- Email: [email protected]
Ectopic pregnancy after caesarean section sterilisation
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 147 (2009) 111–115
114
References [1] World Health Organization. Neonatal and perinatal mortality. Geneva: World Health Organization; 2006. [2] Matturri L, Lavezzi AM. Pathology of the central autonomic nervous system in stillbirth. Open Ped Med J 2007;1:1–8. [3] Matturri L, Ottaviani G, Lavezzi AM. Guidelines for neuropathologic diagnostics of perinatal unexpected loss and sudden infant death sindrome (SIDS). A technical protocol. Virchows Arch 2008;452:19–25. [4] Fulcheri E, Bulfamante G, Resta L, Taddei GL. Embryo and fetal pathology in routine diagnostics what has changed and what need to be changed. Patologica 2006;98:1–36. [5] Folkerth RD, Zanoni S, Andiman SE, Billiards SS. Neuronal cell death in arcuate nucleus of the medulla oblongata in stillbirth. Int J Devl Neurosci 2008;26: 133–40.
with two endoloops (Vicryl) for haemostasis. The ectopic pregnancy was removed via the left iliac fossa 10 mm port via an endoscopic bag, and the port fascia was closed with Vicryl 1/0 on a J-shaped needle while the skin was closed for all ports with Monocryl 2/0. She recovered well with a postoperative haemoglobin of 9.0 g/dl and was discharged the next day with a follow-up appointment for 2 months.
Rosaria Mingronea, Ezio Fulcherib, Anna Maria Lavezzia,* Luigi Matturria a ‘‘Lino Rossi’’ Research Center for the Study and Prevention of Unexpected Perinatal Death and SIDS, Department of Surgical, Reconstructive and Diagnostic Sciences, University of Milan, Italy b Department of Pathology, San Martino Hospital, University of Genova, Italy *Corresponding author at: ‘‘Lino Rossi’’ Research Center, Department of Surgical, Reconstructive and Diagnostic Sciences, University of Milan, Via della Commenda, 19, 20122 Milan, Italy. Tel.: +39 02 50320821; fax: +39 02 50320823 E-mail address: [email protected] (A.M. Lavezzi) 24 March 2009 doi:10.1016/j.ejogrb.2009.07.004
Ectopic pregnancy after caesarean section sterilisation Dear Editor, A 39-year-old woman presented to the acute gynaecology admission unit complaining of sudden onset constant left iliac fossa pain with dizziness. Her last menstrual period had been six weeks before and a pregnancy test was positive. There was no vaginal bleeding or shoulder tip pain. She had five children, four by spontaneous vaginal deliveries and one by caesarean section in 2003, when she had bilateral tubal ligation. On admission her observations were stable. On palpation she had guarding in the left iliac fossa and cervical excitation tenderness in the left adnexae. Transabdominal and transvaginal scan showed a ‘‘single anechoic area within the left ovary measuring 23 mm 23 mm ‘dominant follicle’ cyst. No free fluid in the Pouch of Douglas or obvious adnexal masses were seen. No evidence of an ectopic pregnancy was seen, however, this could not be fully excluded’’. Blood results showed a serum bHcG 15,346 mIU/ml; progesterone 41.8 ng/ml and haemoglobin 10.6 g/dl. She gave consent for laparoscopy and a 7 mm subumbilical laparoscopic port was established. Inspection of the peritoneal cavity identified bilateral complete tubal transection. The uterus was bulky, consistent with a six-week gestation size. A bleeding left distal ectopic pregnancy was noted, with blood collected in the Pouch of Douglas (see picture). A right iliac fossa 5 mm port and a left iliac fossa 10 mm port were inserted to perform a salpingectomy. A clear pedicle for the ectopic was treated with diathermy dissection
Sterilisation is a common method of contraception chosen by women of child-bearing age whose families are complete. As with all methods of contraception there is a risk of failure and a further risk that the subsequent pregnancy will be ectopic [1]. A lifetime risk of pregnancy of 1 in 200 after laparoscopic sterilisation and 1 in 100 after tubal ligation at caesarean section is quoted. Women need to be carefully counselled regarding these failure rates in view of possible litigation. The Pomeroy technique of ligation involves removing part of the fallopian tube and is reported to fail due to recanalisation or tuboperitoneal fistulae formation. The opening is not large enough for a fertilized ovum to pass, resulting in distal segment implantation [2]. An alternative theory suggests that the likelihood of an ectopic is increased due to space or pouch formation in the altered tubal lumen [2]. A multicentre prospective cohort study by Peterson et al. reported the postpartum salpingectomy failure rate as 2 ectopic pregnancies in 1637 women (0.12%) [1]. A study by Brenner et al. in Los Angeles reported 7 previous tubal sterilisations in 100 cases of ectopic pregnancy. In a review of 100 consecutive cases with a confirmed diagnosis of ectopic pregnancy, seven were found to have had tubal sterilisation 17 months to 8 years previously. In three cases, bilateral tubal fulguration had been done, and in four cases, bilateral tubal ligation was performed [3]. There does not appear a clear set of risk factors for an ectopic pregnancy following sterilisation in the literature. Specialist gynaecologists as well as general medical practitioners should not forget that a history of sterilisation does not exclude the possibility of ectopic pregnancy. These women might be at an increased risk and an extrauterine pregnancy can occur several years after surgery. References [1] Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilisation Working Group. N Engl J Med 1997;336(March (11)):796–7. [2] Shah JP, Parulekar SV, Hinduja IN. Ectopic pregnancy after tubalsterilisation. J Postgrad Med 1991;37(January (1)):17–20. [3] Brenner PF, Benedetti T, Mishell Jr DR. Ectopic pregnancy following tubal sterilization surgery. Obstet Gynecol 1977;49(3):323–4.
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 147 (2009) 111–115
115
Aisha Janjua*, Joanne Beasley1 Princess of Wales Maternity Unit, Birmingham Heartlands Hospital, Bordesley Green East, Bordesley Green, Birmingham B9 5SS, United Kingdom *Corresponding author. Tel.: +44 7812566623; fax: +44 1214240066 E-mail addresses: [email protected] (A. Janjua) [email protected] (J. Beasley) 1 Tel.: +44 7894647224; fax: +44 1214240066. 13 November 2008 doi:10.1016/j.ejogrb.2009.07.014
Excess risk of stillbirth during the 1918–1920 influenza pandemic in Japan Dear Editor, Infection with the influenza A virus (H5N1) causes a higher risk of death among young adults than among older adults. Given this observation, a full clarification of pregnancy outcomes during the ‘Spanish’ influenza pandemic of 1918–1920 is of fundamental importance [1]. During this pandemic, the frequency of pregnancy termination by abortion, stillbirth or prematurity among pregnant pneumonia cases was 51.6% (302/585) [2]. Another study gave a similar estimate (51.0%, 25/49) among hospitalized pregnant women [3]. Despite the clear causal relationship between pandemic influenza and stillbirth, historical estimates are confounded by misclassification and their reliance on only hospitalized cases [2–4], and it is difficult to apply the estimate to predict the impact of future pandemics. This letter reports an estimate of the excess risk of stillbirth during the 1918–1920 pandemic in Japan. The monthly counts of live births and stillbirths from 1913 to 1920 were obtained for Kanagawa prefecture and the city of Osaka, Japan, whose respective populations were 1,344,609 and 1,557,986. In Japan, pandemic impact was not limited to winter 1918–1919, and continued during winter 1919–1920. The risk of stillbirth during the pandemic period (i.e. the first wave from October 1918 to March 1919 and the second wave from October 1919 to March 1920) was estimated. First, observations during the non-pandemic period from October 1913 to September 1918 were used to generate the baseline (i.e. the expected number of stillbirths). Second, the excess risk of stillbirths was calculated as the observed minus the expected proportion of stillbirths during the two pandemic periods. Detailed methodology can be found in the online appendix (http://ees.elsevier.com/euro/). Fig. 1A and B compares the observed and expected monthly counts of stillbirth in Kanagawa and Osaka, respectively. The expected baseline proportions of stillbirth during the pandemic periods (i.e. based on the non-pandemic period) were 8.01% and 7.88% for Kanagawa and 8.17% and 7.86% for Osaka, for 1918–1919 and 1919–1920 respectively. During the pandemic periods, the observed proportion of stillbirth in Kanagawa was 8.12% (95% confidence interval (CI): 7.80, 8.44) for 1918–1919 and 8.46% (95% CI: 7.99, 8.93) for 1919–1920. In Osaka the proportions were 8.72% (95% CI: 8.33, 9.11) for 1918–1919 and 8.54% (95% CI: 8.09, 8.98) for 1919–1920. In Kanagawa, the risk ratios (RR) were estimated as 1.10 (95% CI: 1.08, 1.11) and 1.23 (95% CI: 1.21, 1.25) for 1918–1919 and 1919–1920 respectively. In Osaka, the RR were 1.30 (95% CI: 1.26, 1.33) for 1918–1919 and 1.24 (95% CI: 1.21, 1.27) for 1919–1920.
Fig. 1. Observed and expected monthly number of stillbirths in (A) Kanagawa and (B) Osaka, Japan, for the period October 1913 to June 1920. Each circle represents the observed number of stillbirths in a given month. The continuous line represents the expected number of stillbirths (i.e. the baseline) in the absence of the influenza pandemic from 1918 to 1920, generated by records from the non-pandemic period from October 1913 to September 1918. The excess number of stillbirths during the first (October 1918–March 1919) and second (October 1919–March 1920) pandemic waves was calculated as the observed minus the expected number of stillbirths during the pandemic periods. The label of each year corresponds to January of that year. The horizontal arrows indicate pandemic and non-pandemic periods.
This study is the first to precisely estimate the risk of stillbirth during the 1918–1920 influenza pandemic, addressing the epidemiological problems of misclassification and observing only hospitalized cases. The estimates are in concordance with previous suggestions [1–4], including a crude RR estimate of stillbirth of 1.3 that did not account for misclassification [5]. The RR of stillbirth during the pandemic periods was measured for the entire population, and the estimates (1.1–1.3) are not trivial. Considering that 30,000 stillbirths are reported per year among 1.1 million pregnant women in the current Japanese population (2.7%), a pandemic might elevate the proportion to 3.0–3.5%, causing an additional 3000–9000 stillbirths per year. These figures call for effective preparedness plans among healthcare providers. This study provides a population-level estimate that is free from the above-mentioned confounding factors. This method could be applied to the estimation of other influenza-associated risks among pregnant women (e.g. early pregnancy loss and neonatal outcomes).
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ejogrb.2009.07.009. References [1] Mortimer P. Influenza-related death rates for pregnant women. Emerg Infect Dis 2006;12:1805–6. [2] Harris JW. Influenza occurring in pregnant women: a statistical study of thirteen hundred and fifty cases. JAMA 1919;72:978–80. [3] Bland PB. Influenza in its relation to pregnancy and labor. Am J Obstet Dis Women Child 1919;79:184–97. [4] Woolston WJ, Conley DO. Epidemic pneumonia (Spanish influenza) in pregnancy: effect in one hundred and one cases. JAMA 1918;71:1898–9. [5] Reid A. Neonatal mortality and stillbirths in early twentieth century Derbyshire, England. Popul Stud 2001;55:213–32.
Hiroshi Nishiura* Theoretical Epidemiology, University of Utrecht, 3584 CL Utrecht, The Netherlands *Tel.: +31 30 253 1233; fax: +31 30 252 1887 E-mail address: [email protected] 4 March 2009 doi:10.1016/j.ejogrb.2009.07.009
114
References [1] World Health Organization. Neonatal and perinatal mortality. Geneva: World Health Organization; 2006. [2] Matturri L, Lavezzi AM. Pathology of the central autonomic nervous system in stillbirth. Open Ped Med J 2007;1:1–8. [3] Matturri L, Ottaviani G, Lavezzi AM. Guidelines for neuropathologic diagnostics of perinatal unexpected loss and sudden infant death sindrome (SIDS). A technical protocol. Virchows Arch 2008;452:19–25. [4] Fulcheri E, Bulfamante G, Resta L, Taddei GL. Embryo and fetal pathology in routine diagnostics what has changed and what need to be changed. Patologica 2006;98:1–36. [5] Folkerth RD, Zanoni S, Andiman SE, Billiards SS. Neuronal cell death in arcuate nucleus of the medulla oblongata in stillbirth. Int J Devl Neurosci 2008;26: 133–40.
with two endoloops (Vicryl) for haemostasis. The ectopic pregnancy was removed via the left iliac fossa 10 mm port via an endoscopic bag, and the port fascia was closed with Vicryl 1/0 on a J-shaped needle while the skin was closed for all ports with Monocryl 2/0. She recovered well with a postoperative haemoglobin of 9.0 g/dl and was discharged the next day with a follow-up appointment for 2 months.
Rosaria Mingronea, Ezio Fulcherib, Anna Maria Lavezzia,* Luigi Matturria a ‘‘Lino Rossi’’ Research Center for the Study and Prevention of Unexpected Perinatal Death and SIDS, Department of Surgical, Reconstructive and Diagnostic Sciences, University of Milan, Italy b Department of Pathology, San Martino Hospital, University of Genova, Italy *Corresponding author at: ‘‘Lino Rossi’’ Research Center, Department of Surgical, Reconstructive and Diagnostic Sciences, University of Milan, Via della Commenda, 19, 20122 Milan, Italy. Tel.: +39 02 50320821; fax: +39 02 50320823 E-mail address: [email protected] (A.M. Lavezzi) 24 March 2009 doi:10.1016/j.ejogrb.2009.07.004
Ectopic pregnancy after caesarean section sterilisation Dear Editor, A 39-year-old woman presented to the acute gynaecology admission unit complaining of sudden onset constant left iliac fossa pain with dizziness. Her last menstrual period had been six weeks before and a pregnancy test was positive. There was no vaginal bleeding or shoulder tip pain. She had five children, four by spontaneous vaginal deliveries and one by caesarean section in 2003, when she had bilateral tubal ligation. On admission her observations were stable. On palpation she had guarding in the left iliac fossa and cervical excitation tenderness in the left adnexae. Transabdominal and transvaginal scan showed a ‘‘single anechoic area within the left ovary measuring 23 mm 23 mm ‘dominant follicle’ cyst. No free fluid in the Pouch of Douglas or obvious adnexal masses were seen. No evidence of an ectopic pregnancy was seen, however, this could not be fully excluded’’. Blood results showed a serum bHcG 15,346 mIU/ml; progesterone 41.8 ng/ml and haemoglobin 10.6 g/dl. She gave consent for laparoscopy and a 7 mm subumbilical laparoscopic port was established. Inspection of the peritoneal cavity identified bilateral complete tubal transection. The uterus was bulky, consistent with a six-week gestation size. A bleeding left distal ectopic pregnancy was noted, with blood collected in the Pouch of Douglas (see picture). A right iliac fossa 5 mm port and a left iliac fossa 10 mm port were inserted to perform a salpingectomy. A clear pedicle for the ectopic was treated with diathermy dissection
Sterilisation is a common method of contraception chosen by women of child-bearing age whose families are complete. As with all methods of contraception there is a risk of failure and a further risk that the subsequent pregnancy will be ectopic [1]. A lifetime risk of pregnancy of 1 in 200 after laparoscopic sterilisation and 1 in 100 after tubal ligation at caesarean section is quoted. Women need to be carefully counselled regarding these failure rates in view of possible litigation. The Pomeroy technique of ligation involves removing part of the fallopian tube and is reported to fail due to recanalisation or tuboperitoneal fistulae formation. The opening is not large enough for a fertilized ovum to pass, resulting in distal segment implantation [2]. An alternative theory suggests that the likelihood of an ectopic is increased due to space or pouch formation in the altered tubal lumen [2]. A multicentre prospective cohort study by Peterson et al. reported the postpartum salpingectomy failure rate as 2 ectopic pregnancies in 1637 women (0.12%) [1]. A study by Brenner et al. in Los Angeles reported 7 previous tubal sterilisations in 100 cases of ectopic pregnancy. In a review of 100 consecutive cases with a confirmed diagnosis of ectopic pregnancy, seven were found to have had tubal sterilisation 17 months to 8 years previously. In three cases, bilateral tubal fulguration had been done, and in four cases, bilateral tubal ligation was performed [3]. There does not appear a clear set of risk factors for an ectopic pregnancy following sterilisation in the literature. Specialist gynaecologists as well as general medical practitioners should not forget that a history of sterilisation does not exclude the possibility of ectopic pregnancy. These women might be at an increased risk and an extrauterine pregnancy can occur several years after surgery. References [1] Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilisation Working Group. N Engl J Med 1997;336(March (11)):796–7. [2] Shah JP, Parulekar SV, Hinduja IN. Ectopic pregnancy after tubalsterilisation. J Postgrad Med 1991;37(January (1)):17–20. [3] Brenner PF, Benedetti T, Mishell Jr DR. Ectopic pregnancy following tubal sterilization surgery. Obstet Gynecol 1977;49(3):323–4.
Letters to the Editor / European Journal of Obstetrics & Gynecology and Reproductive Biology 147 (2009) 111–115
115
Aisha Janjua*, Joanne Beasley1 Princess of Wales Maternity Unit, Birmingham Heartlands Hospital, Bordesley Green East, Bordesley Green, Birmingham B9 5SS, United Kingdom *Corresponding author. Tel.: +44 7812566623; fax: +44 1214240066 E-mail addresses: [email protected] (A. Janjua) [email protected] (J. Beasley) 1 Tel.: +44 7894647224; fax: +44 1214240066. 13 November 2008 doi:10.1016/j.ejogrb.2009.07.014
Excess risk of stillbirth during the 1918–1920 influenza pandemic in Japan Dear Editor, Infection with the influenza A virus (H5N1) causes a higher risk of death among young adults than among older adults. Given this observation, a full clarification of pregnancy outcomes during the ‘Spanish’ influenza pandemic of 1918–1920 is of fundamental importance [1]. During this pandemic, the frequency of pregnancy termination by abortion, stillbirth or prematurity among pregnant pneumonia cases was 51.6% (302/585) [2]. Another study gave a similar estimate (51.0%, 25/49) among hospitalized pregnant women [3]. Despite the clear causal relationship between pandemic influenza and stillbirth, historical estimates are confounded by misclassification and their reliance on only hospitalized cases [2–4], and it is difficult to apply the estimate to predict the impact of future pandemics. This letter reports an estimate of the excess risk of stillbirth during the 1918–1920 pandemic in Japan. The monthly counts of live births and stillbirths from 1913 to 1920 were obtained for Kanagawa prefecture and the city of Osaka, Japan, whose respective populations were 1,344,609 and 1,557,986. In Japan, pandemic impact was not limited to winter 1918–1919, and continued during winter 1919–1920. The risk of stillbirth during the pandemic period (i.e. the first wave from October 1918 to March 1919 and the second wave from October 1919 to March 1920) was estimated. First, observations during the non-pandemic period from October 1913 to September 1918 were used to generate the baseline (i.e. the expected number of stillbirths). Second, the excess risk of stillbirths was calculated as the observed minus the expected proportion of stillbirths during the two pandemic periods. Detailed methodology can be found in the online appendix (http://ees.elsevier.com/euro/). Fig. 1A and B compares the observed and expected monthly counts of stillbirth in Kanagawa and Osaka, respectively. The expected baseline proportions of stillbirth during the pandemic periods (i.e. based on the non-pandemic period) were 8.01% and 7.88% for Kanagawa and 8.17% and 7.86% for Osaka, for 1918–1919 and 1919–1920 respectively. During the pandemic periods, the observed proportion of stillbirth in Kanagawa was 8.12% (95% confidence interval (CI): 7.80, 8.44) for 1918–1919 and 8.46% (95% CI: 7.99, 8.93) for 1919–1920. In Osaka the proportions were 8.72% (95% CI: 8.33, 9.11) for 1918–1919 and 8.54% (95% CI: 8.09, 8.98) for 1919–1920. In Kanagawa, the risk ratios (RR) were estimated as 1.10 (95% CI: 1.08, 1.11) and 1.23 (95% CI: 1.21, 1.25) for 1918–1919 and 1919–1920 respectively. In Osaka, the RR were 1.30 (95% CI: 1.26, 1.33) for 1918–1919 and 1.24 (95% CI: 1.21, 1.27) for 1919–1920.
Fig. 1. Observed and expected monthly number of stillbirths in (A) Kanagawa and (B) Osaka, Japan, for the period October 1913 to June 1920. Each circle represents the observed number of stillbirths in a given month. The continuous line represents the expected number of stillbirths (i.e. the baseline) in the absence of the influenza pandemic from 1918 to 1920, generated by records from the non-pandemic period from October 1913 to September 1918. The excess number of stillbirths during the first (October 1918–March 1919) and second (October 1919–March 1920) pandemic waves was calculated as the observed minus the expected number of stillbirths during the pandemic periods. The label of each year corresponds to January of that year. The horizontal arrows indicate pandemic and non-pandemic periods.
This study is the first to precisely estimate the risk of stillbirth during the 1918–1920 influenza pandemic, addressing the epidemiological problems of misclassification and observing only hospitalized cases. The estimates are in concordance with previous suggestions [1–4], including a crude RR estimate of stillbirth of 1.3 that did not account for misclassification [5]. The RR of stillbirth during the pandemic periods was measured for the entire population, and the estimates (1.1–1.3) are not trivial. Considering that 30,000 stillbirths are reported per year among 1.1 million pregnant women in the current Japanese population (2.7%), a pandemic might elevate the proportion to 3.0–3.5%, causing an additional 3000–9000 stillbirths per year. These figures call for effective preparedness plans among healthcare providers. This study provides a population-level estimate that is free from the above-mentioned confounding factors. This method could be applied to the estimation of other influenza-associated risks among pregnant women (e.g. early pregnancy loss and neonatal outcomes).
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ejogrb.2009.07.009. References [1] Mortimer P. Influenza-related death rates for pregnant women. Emerg Infect Dis 2006;12:1805–6. [2] Harris JW. Influenza occurring in pregnant women: a statistical study of thirteen hundred and fifty cases. JAMA 1919;72:978–80. [3] Bland PB. Influenza in its relation to pregnancy and labor. Am J Obstet Dis Women Child 1919;79:184–97. [4] Woolston WJ, Conley DO. Epidemic pneumonia (Spanish influenza) in pregnancy: effect in one hundred and one cases. JAMA 1918;71:1898–9. [5] Reid A. Neonatal mortality and stillbirths in early twentieth century Derbyshire, England. Popul Stud 2001;55:213–32.
Hiroshi Nishiura* Theoretical Epidemiology, University of Utrecht, 3584 CL Utrecht, The Netherlands *Tel.: +31 30 253 1233; fax: +31 30 252 1887 E-mail address: [email protected] 4 March 2009 doi:10.1016/j.ejogrb.2009.07.009