Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA; Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA.
Am J Obstet Gynecol. 2017 Aug;217(2):185.e1-185.e9. doi: 10.1016/j.ajog.2017.04.023. Epub 2017 Apr 19.
Pregnancies of unknown location with abnormal beta-human chorionic gonadotropin trends are frequently treated as presumed ectopic pregnancies with methotrexate. Preliminary data suggest that outpatient endometrial aspiration may be an effective tool to diagnose pregnancy location, while also sparing women exposure to methotrexate.
The purpose of this study was to evaluate the utility of an endometrial sampling protocol for the diagnosis of pregnancies of unknown location after in vitro fertilization.
A retrospective cohort study of 14,505 autologous fresh and frozen in vitro fertilization cycles from October 2007 to September 2015 was performed; 110 patients were diagnosed with pregnancy of unknown location, defined as a positive beta-human chorionic gonadotropin without ultrasound evidence of intrauterine or ectopic pregnancy and an abnormal beta-human chorionic gonadotropin trend (<53% rise or <15% fall in 2 days). These patients underwent outpatient endometrial sampling with Karman cannula aspiration. Patients with a beta-human chorionic gonadotropin decline ≥15% within 24 hours of sampling and/or villi detected on pathologic analysis were diagnosed with failing intrauterine pregnancy and had weekly beta-human chorionic gonadotropin measurements thereafter. Those patients with beta-human chorionic gonadotropin declines <15% and no villi identified were diagnosed with ectopic pregnancy and treated with intramuscular methotrexate (50 mg/m) or laparoscopy.
Across 8 years of follow up, among women with pregnancy of unknown location, failed intrauterine pregnancy was diagnosed in 46 patients (42%), and ectopic pregnancy was diagnosed in 64 patients (58%). Clinical variables that included fresh or frozen embryo transfer, day of embryo transfer, serum beta-human chorionic gonadotropin at the time of sampling, endometrial thickness, and presence of an adnexal mass were not significantly different between patients with failed intrauterine pregnancy or ectopic pregnancy. In patients with failed intrauterine pregnancy, 100% demonstrated adequate postsampling beta-human chorionic gonadotropin declines; villi were identified in just 46% (n=21 patients). Patients with failed intrauterine pregnancy had significantly shorter time to resolution (negative serum beta-human chorionic gonadotropin) after sampling compared with patients with ectopic pregnancy (12.6 vs 26.3 days; P<.001).
With the use of this safe and effective protocol of endometrial aspiration with Karman cannula, a large proportion of women with pregnancy of unknown location are spared methotrexate, with a shorter time to pregnancy resolution than those who receive methotrexate.
对于人绒毛膜促性腺激素β水平异常升高但位置不明的妊娠，通常采用甲氨蝶呤治疗异位妊娠。初步数据表明，门诊子宫内膜抽吸术可能是一种有效的诊断妊娠位置的方法，同时还可避免妇女接触甲氨蝶呤。
本研究旨在评估在体外受精后使用子宫内膜取样方案诊断不明位置妊娠的效果。
对 2007 年 10 月至 2015 年 9 月期间的 14505 例自体新鲜和冷冻体外受精周期进行回顾性队列研究；110 例患者被诊断为人绒毛膜促性腺激素β水平升高但超声未见宫内或异位妊娠，且人绒毛膜促性腺激素β水平呈异常升高趋势（<53%升高或 2 天内<15%下降），定义为不明位置妊娠。这些患者采用 Karman 套管抽吸行门诊子宫内膜取样。取样后 24 小时内人绒毛膜促性腺激素β下降≥15%和/或病理分析发现绒毛的患者被诊断为宫内妊娠失败，此后每周进行人绒毛膜促性腺激素β测量。如果人绒毛膜促性腺激素β下降<15%且未发现绒毛，则诊断为异位妊娠，采用肌肉注射甲氨蝶呤（50mg/m）或腹腔镜治疗。
在 8 年的随访中，在不明位置妊娠的患者中，46 例（42%）被诊断为宫内妊娠失败，64 例（58%）被诊断为异位妊娠。在宫内妊娠失败或异位妊娠患者中，并无差异的临床变量包括新鲜或冷冻胚胎移植、胚胎移植日、取样时的血清人绒毛膜促性腺激素β水平、子宫内膜厚度和附件包块。在宫内妊娠失败患者中，100%的患者人绒毛膜促性腺激素β下降充分；仅 46%（21 例）患者发现绒毛。与异位妊娠患者相比，宫内妊娠失败患者取样后血清人绒毛膜促性腺激素β恢复正常的时间明显更短（12.6 天 vs 26.3 天；P<.001）。
采用 Karman 套管的安全有效的子宫内膜抽吸术方案，可使很大一部分不明位置妊娠的妇女避免使用甲氨蝶呤，且妊娠恢复时间短于接受甲氨蝶呤治疗的患者。
