**2.5.3 Rp/v-HCG for predicting the active tubal hemorrhage of EPs**

No apparent Rp/v-HCG cut-off value for predicting the active tubal hemorrhage is shown when the HCG level of venous serum is more than 1500U/L. When the HCG level of venous serum is less than 1500U/L, however, few patients have the active tubal hemorrhage. It seems that the Rp/v-HCG is higher; the incidence rate of active tubal hemorrhage is lower. It is very important for gynecological emergency doctor to predict the presence of tubal hemorrhage in EPs. No ideal marker for tubal hemorrhage of EPs, however, has been founded in the present medical procedure till to now.

#### **2.5.4 Rp/v-HCG> 1.0 for diagnosing the abdominal prengancy during surgery**

Abdominal pregnancy is an extremely rare form of ectopic pregnancy (EP) with potentially life-threatening complications both to mother and the fetus, which is historically defined as an implantation in the peritoneal cavity, exclusive of tubal, ovarian or intraligamentary pregnancy.

Due to infrequency of abdominal pregnancy, it is often unsuspected and remains a diagnostic challenge despite improvements in imaging techniques (Dassah, et al., 2009.). A retrospective analysis show there were 20 cases of abdominal pregnancy out of 58, 000

Clinical Application of One-Step Diagnosis for

**3. Conclusion** 

Mol, et al., 2008.).

initiation of either medical or surgical intervention.

Ectopic Pregnancy by HCG Ratio: Hemoperitoneum Versus Venous Serum 145

Fig. 4. Contrast enhancement scan of computerized tomography (CT) for splenic pregnancy. One SEP whose Rp/v-HCG = 2.2 (22286 IU/L /9974.9 IU/L) showed intact fallopian and ovary during laparoscopy and then was performed by D &C. Twelve days after operation, CT showed the embryo sac (white arrow) and hematoma under splenic capsule (black arrow).

Early diagnosis of ectopic pregnancy is the key to optimal treatment, especially is essential in order to minimize the morbidity and to assess the need for urgent surgical intervention. Intervention prior to rupture prevents hemorrhage, potentially enhances fertility, and allows for nonsurgical methods (Segal, et al., 2010.). Observational studies indicate that among women treated with salpingostomy as compared with those treated with salpingectomy, rates of subsequent intrauterine pregnancy are higher (73% vs. 57%) though the rates of subsequent ectopic pregnancy are also higher (15% vs. 10%) (Seeber, et al., 2006;

Though the advent of β-HCG measurements and improved transvaginal ultrasound techniques has made laparoscopic diagnosis of ectopic pregnancy almost redundant and allowed for both expectant and medical management options, combing transvaginal ultrasonography with gonadotropin quantification could not give the most satisfactory results since it takes an average of 36 h to diagnose EP, not including the resources devoted to collecting blood samples (Garcia, et al., 2001.). Hence, additional new tests or diagnostic methods are necessary to be established for a rapid and accurate diagnosis of EP prior to

Besides laparoscopy and transvaginal sound, serum biomarkers (including HCG) may be helpful for the early diagnosis of EPs. Over 20 serum biomarkers have been identified to date in an attempt to permit earlier diagnosis of ectopic pregnancy, the instigation of earlier management and reduce healthcare costs (Cartwright, et al., 2009; Pedersen, et al., 1991.). The ideal marker for the diagnosis of ectopic pregnancy would be specific for tubal damage or present only after endometrial implantation. Various markers have been assessed, including creatinine kinase (Lavie, et al., 1993.) and fetal fibronectin (Ness, et al., 1998.), but

Certain serum biomarkers have been shown initially to be of discriminatory value but then subsequent studies have found them to be of limited use (such as placental protein 14) (Daponte, et al., 2008; Mantzavinos, et al., 1991.). A number of biomarkers (such as estradiol, pregnancy associated plasma protein A, cancer antigen 125) can distinguish a tubal ectopic from a viable intrauterine pregnancy but are unable to distinguish the former from a nonviable intrauterine pregnancy (miscarriage) (Mueller, et al., 2004; Katsikis, et al., 2006).

none is sufficiently sensitive or specific for the diagnosis of ectopic pregnancy.

Fig. 3. Scatter diagram of the Rp/v-HCG levels for active bleeding group and without active bleeding (No) group when HCG of venous serum was more than 1500U/L or less than 1500U/L. No suggested Rp/v-HCG cut-off value for the distribution of the active tubal hemorrhage was shown when HCG of venous serum was more than 1500U/L.

deliveries, giving an incidence of 0.34 per 1, 000 deliveries. The diagnoses were missed in 10 cases and there was one maternal death. The rate of 50% missed diagnosis in this analysis highlights the need for a high index of suspicion in the diagnosis of abdominal pregnancies as the clinical features are varied. The maternal and fetal outcomes relate to early diagnosis and skilled management, which calls for vigilance on the part of the obstetrician (Sunday-Adeoye, et al., 2011.).

In this study, two SEPs whose Rp/v-HCG was of > 1.0 showed normal fallopian tube and ovary but hemoperitoneum during the laparotomy. They were both diagnosed as abdominal pregnancy (one was splenic pregnancy) finally after thorough pelvic and abdominal exploration. One of the splenic pregnancy suffered second exploration and splenectomy because it is mistaken as hemorrhagic corpus luteum combined with pregnancy by the gynecologist who ignored of Rp/v-HCG was of > 1.0. Hence, the criteria of diagnosis for abdominal pregnancy may be considered: 1) No evidence of gestational sac or chorionic villi in the adnexa is seen during the surgery, 2) Rp/v-HCG, however, is of > 1.0.

Transvaginal ultrasound and serial β-hCG level are of little use for the differential diagnosis between hemoperitoneum with intrauterine pregnancy and ectopic pregnancy including abdominal pregnancy, however, the overall specificity of Rp/v-HCG> 1.0 in the diagnosis of ectopic pregnancy is 100 % (95% CI: 93.0–100), a PPV of 100 % (95% CI: 98.5–100). Therefore, we may consider the definitive diagnosis of ectopic pregnancy when preoperative Rp/v-HCG is of > 1.0 and consider the diagnosis of abdominal pregnancy when preoperative or intraoperative Rp/v-HCG is of > 1.0, however, the adnexa sees no evidence of gestational sac. It is useful for gynecologists to reduce omission diagnostic rate of abdominal pregnancy, especially during the emergency surgery without enough preoperative preparation. Due to the rare case, further study with more data of abdominal pregnancy is needed.

Fig. 4. Contrast enhancement scan of computerized tomography (CT) for splenic pregnancy. One SEP whose Rp/v-HCG = 2.2 (22286 IU/L /9974.9 IU/L) showed intact fallopian and ovary during laparoscopy and then was performed by D &C. Twelve days after operation, CT showed the embryo sac (white arrow) and hematoma under splenic capsule (black arrow).
