PAPP-A is a large glycoprotein with alpha2-electrophoretic mobility that is produced by the placenta during pregnancy. In this thesis a biochemical and molecular characterisation of PAPP-A was performed. The polyclonal antiserum (DAKO) directed against PAPP-A has been shown to also interact with proteins other than PAPP-A. These non-specific interactions were abolished by performing Western blotting immunodetection at a high salt concentration (0.6M NaCl). At this salt concentration a single band of 195 kDa was immunodetected and this corresponded to the monomeric PAPP-A molecule. It was also discovered that a subset of paratopes in this antiserum reacted, under the described high salt concentration conditions, with the glycan component of PAPP-A. A placental cDNA library was screened using this antibody for the PAPP-A cDNA but this did not yield a clone for PAPP-A. A possible explanation is that the interaction with this antibody requires carbohydrate components to be present on the PAPP-A molecule. It is known that proteins expressed in bacterial systems are not post-translationally modified. Therefore another approach to the isolation of the PAPP-A cDNA clone was adopted, but this required some primary amino acid sequence of this protein that was unavailable at the time. To generate this information, PAPP-A was purified using its previously unpublished affinity for L-arginine in combination with the already described procedures of ammonium sulphate precipitation, ion exchange and gel filtration. Final purification of PAPP-A was achieved by SDS-PAGE electrophoresis. The isolated monomeric PAPP-A gave a unique single N-terminal amino acid sequence: N-EARGATEEPS. The N terminal sequence combined with the sequence obtained from limited proteolytic digestion of PAPP-A were used to design oligonucleotide primers specific for PAPP-A. These primers were used in a PCR reaction that produced 500 and >1200 bp fragments using the cDNA library as DNA template; thus demonstrating that PAPP-A is synthesised in the placenta. PAPP-A was shown to have O and N-linked carbohydrate chains. Enzymatic deglycosylation demonstrated that the N-linked chains were 8% (w/w) of the molecule. The O-linked groups were extensively modified with the presence of oligomers of N-acetyl-glucosamine. It was also shown that it was these groups the PAPP-A antibodies bind to at high salt concentration. A physical interaction of PAPP-A with endoproteinase Arg-C (EGF-BP) was observed. It was seen that they form a 1:1 (PAPP-A: endoproteinase) sub-unit complex that was stable in SDS. A further investigation revealed that PAPP-A interacted with the endoproteinase Arg-C and this resulted in a 30% inhibition of the esterolytic activity of this enzyme.

OBJECTIVE: To evaluate the incidence of chromosomal abnormalities in ectopic pregnancy chorionic villi. METHODS: A prospective study of patients with the diagnosis of ectopic pregnancy was conducted, with chorionic villi obtained at the time of surgical therapy cultured and analyzed for karyotype. Review of the patient's medical record and ultrasound evaluation was then completed and findings correlated with karyotype results. RESULTS: Twenty- two patients undergoing surgery for the diagnosis of ectopic pregnancy yielded chorionic villi for culture. Successful culture was performed in 21 patients, with 3 (14%) revealing abnormal karyotypes. Review of the medical record showed ultrasound results consistent with fetal development or a gestational sac in 15 of 18 patients with normal chromosomal analysis. Three of 6 patients without fetal development yielded abnormal chromosomal findings. CONCLUSION: Our results confirm that a high degree of success can be achieved in the karyotype analysis of ectopic pregnancy chorionic villi and that these conceptuses have a rate of abnormality similar to that reported for intrauterine gestations. Our data further suggest that when a gestational sac or fetal pole is identified by ultrasound, there is usually a normal karyotype.

published_or_final_version / Obstetrics and Gynaecology / Doctoral / Doctor of Philosophy

OBJECTIVE: To describe the patient profile, clinical features, risk factors, management options and complications in women with ectopic pregnancy. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: King Edward VIII Hospital, Congella, Durban from July 2005 – June 2006. MATERIALS AND METHODS: 130 case notes of women with the final diagnosis with ectopic pregnancy were examined retrospectively. Data was retrieved through a structured proforma. The variables studied included age, parity, signs and symptoms, treatment, management, complications and associated maternal morbidity and mortality. RESULTS: One hundred and twenty women diagnosed with ectopic pregnancy were included in this study. Ten patients were excluded due to failure to obtain clinical records. Women’s ages ranged from 17-40 years with 32 patients (26.7%) being nulliparous and 88 patients (73.3%) between parity 1-4. Twelve patients (10%) had a history of previous ectopic pregnancy. The commonest presenting symptom was abdominal pain in 106 (88.3%) patients whereas amenorrhoea and vaginal bleeding were found in 88 (73.3%) and 84 (70%) patients respectively. The most common physical sign was tenderness: Adnexal tenderness in 99 (82.5%) and pelvic tenderness in 91 (75.8%) of women. Fourteen women (11.7%) presented to the gynaecological outpatient’s department in acute shock with a blood pressure < 90/60 mmHg. The commonest ultrasound findings were the presence of an adnexal mass and an empty uterus in 82 (68.3%) and 80 (66.7%) women respectively. The most frequent risk factors were previous genital infection in 34 patients (28.3%) and multiple sexual partners in 32 patients (26.7%). One hundred and eleven 92.4%) women were managed by laparotomy: One hundred and four (87.4%) women via emergency laparotomy and 6 women (5%) had an elective laparotomy. One patient (0.8%) had a diagnostic laparoscopy which was converted to laparotomy. Only 8 patients (6.7%) were managed laparoscopically. Surgical treatment consisted of salpingectomy 101/120 (84.9%) and salpingotomy in 4 (3.4%) patients. Post- operation complications were minimal however the one maternal death was probably due to a pulmonary embolus. CONCLUSION: Risk factors may not always be present, hence ectopic pregnancy should be suspected in every women of reproductive age who present with unexplained abdominal pain, amenorrhoea and vaginal bleeding. Most women presented with ruptured ectopic pregnancies at King Edward VIII Hospital warranting emergency laparotomy. / Thesis (M.Med.)-University of KwaZulu-Natal, Durban, 2011.

Thesis (MMed (Obstetrics and Gynaecology))--University of Stellenbosch, 2010. / ENGLISH ABSTRACT: Study objective: To investigate whether an educational intervention in the Gynaecology Department of Tygerberg Hospital (TBH) was effective in improving the accuracy of the diagnosis and appropriateness of treatment options offered to women with suspected Ectopic Pregnancy (EP). Methods: A retrospective cross-sectional before-and-after study was performed, including 335 consecutive patients with suspected EP before (1/3 - 30/6/2008) and after (1/9 - 31/12/2008) “the intervention”. From the gynaecological admissions register all pregnant patients with symptoms potentially compatible with EP were selected and these were cross referenced with beta-hCG requests, entries in the theatre register for surgery for possible EP and methotrexate prescriptions for EP in these time periods. “The intervention” consisted of a formal lecture presented to the registrars and consultants regarding the latest evidence-based guidelines concerning the diagnosis and management of EP. An algorithm based on this information was introduced in the emergency unit and ultrasound unit together with a prescribed ultrasound reporting form containing all the pertinent information required to follow the algorithm. Clinical decisions were left to the registrar and consultant on duty. Primary outcomes: Time from presentation to treatment, number and appropriateness of special investigations, surgical procedures or medical management. Secondary outcomes: Number of in-patient days and visits, adherence to the algorithm. Results: There was a non-significant trend towards improved reporting of the uterine content and significantly less reports of definite signs of an intrauterine pregnancy (IUP) (p<0.001, RR 0.46, 95% CI 0.31-0.70) due to stricter ultrasound criteria being followed. There was a significant change in the spectrum of uterine findings (p=0.001), the spectrum of adnexal findings (p=0.006) and the spectrum of free fluid noted (p=0.05). There was a reduction in the total number of beta-hCG levels requested at presentation (patients with no beta-hCG: 24 vs 34, p=0.05, RR 1.60, 95% CI 0.99-2.59) with a significant reduction in the number of inappropriate beta-hCG requests (77 vs 40, p<0.001, RR 0.60, 95% CI 0.43-0.81). There was a significant difference in the spread of the number of beta-hCG tests per patient with less repeat tests in the study group (p=0.021). Significantly less manual vacuum aspirations (MVAs) were performed (47 vs 21, p=0.003, RR 0.51, 95% CI 0.32-0.81) but there was no change in the other treatment modalities offered nor in the time from presentation to treatment, number of visits or in-patient days. Adherence to the algorithm was poor (59 %). Conclusions: Except for a significant decrease in the MVAs performed, with possibly less interrupted early intrauterine pregnancies, the improvement in the use of special investigations after “the intervention” did not translate into fewer inappropriate diagnoses and management. This could be due to frequent non-adherence to the algorithm, and widespread implementation of the algorithm as well as continuous audits would be necessary before a future study could be attempted to assess the efficacy of the algorithm. / AFRIKAANSE OPSOMMING: Studiedoelwit: Die hoofdoel van hierdie studie is om te ondersoek of „n opvoedkundige intervensie in die Ginekologiese afdeling van Tygerberg Hospitaal (TBH) doeltreffend sou wees in die verbetering van die akkuraatheid van diagnose en die gepastheid van behandelingsopsies wat aan vroue gebied word met „n vermoedelike ektopiese swangerskap (ES). Metodes: „n Retrospektiewe, kruisdeursnee voor-en-na studie rakende 335 opeenvolgende pasiënte wat ‟n vermoedelike ES het voor (1/3/2008 – 30/6/2008) en na (1/9/2008 – 31/12/2008) “die intervensie”. Swanger pasiënte is uit die ginekologiese toelatingsregister geselekteer indien hulle simptome gehad het wat moontlik verbind kon word met ES. Hulle is kruisverwys met die beta-hCG‟s aangevra, inskrywings in die teaterregister vir chirurgie vir moontlike ES en ginekologie-pasiënte wat metotrexate vir ES binne hierdie tydperke ontvang het. “Die intervensie” het bestaan uit „n formele lesing aan die kliniese assistente en konsultante ten opsigte van die jongste bewysgebaseerde riglyne rakende die diagnose en hantering van ES. „n Algoritme gegrond op hierdie inligting is in die noodeenheid en ultraklank-afdeling ten toon gestel asook „n voorgeskrewe ultraklank rapporteringsvorm met al die toepaslike inligting wat vereis word om die algoritme te volg. Kliniese besluite is aan die kliniese assistent en konsultant aan diens oorgelaat. Primêre uitkomste: Tydsduur vanaf aanmelding tot behandeling, aantal en gepastheid van spesiale ondersoeke, chirurgiese prosedures en mediese hantering. Sekondêre uitkomste: Die aantal binnepasiëntdae en besoeke, nakoming van die algoritme. Resultate: Daar was „n nie-betekenisvolle neiging tot beter rapportering van die uteriene-inhoud en betekenisvol minder rapportering van definitiewe tekens van „n intra-uteriene swangerskap (IUS) (p<0.001, RR 0.46, 95% CI 0.31-0.70) as gevolg van strenger ultraklankstandaarde gevolg. Daar was „n betekenisvolle verandering in die spektrum van uteriene bevindinge (p=0.001), die spektrum van die adneksale bevindinge (p=0.006) en die spektrum van die vrye vog aangeteken (p=0.05). Daar was „n vermindering in die totale aantal beta-hCG-vlakke aangevra met aanmelding (pasiënte met geen hCG: 24 vs 34, p=0.05, RR 1.60, 95% CI 0.99-2.59) met „n betekenisvolle vermindering in die aantal onvanpaste beta-hCGs aangevra (77 vs 40, p<0.001, RR0.60, 95% CI 0.43-0.81). Daar was „n betekenisvolle verskil in die verspreiding van die aantal beta-hCG-toetse per pasiënt, met minder herhalende toetse in die studiegroep (p=0.021). Betekenisvol minder manuele vakuum aspirasies (MVAs) is uitgevoer (47 vs 21, p=0.003, RR 0.51, 95% CI 0.32-0.81), maar geen verskil in ander behandelingsmodaliteite is aangebied nie, asook geen verskil in die tydsduur vanaf aanmelding, die aantal besoeke of die aantal binnepatiëntdae nie. Nakoming van die algoritme was swak (59%). Gevolgtrekkings: Behalwe vir „n betekenisvolle afname in die MVAs uitgevoer, met moontlik minder onderbroke vroeë IUS, het die verbetering in die gebruik van spesiale ondersoeke ná “die intervensie” nie minder onvanpaste diagnoses en hantering tot gevolg gehad nie. Dit kan die gevolg wees van gereelde nie-nakoming van die algoritme, en uitgebreide implementering van die algoritme asook voortdurende oudits sal nodig wees voor „n verdere studie aangepak kan word om die doeltreffendheid van die algoritme te bepaal.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第22724号 / 医博第4642号 / 新制||医||1045(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 戸井 雅和, 教授 小川 修, 教授 黒田 知宏 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Graviditetsförlust i form av tidiga missfall är en vanlig diagnos i sjukvården. En mer sällsynt diagnos är utomkvedshavandeskap som kan ha ett dramatiskt förlopp och vara direkt livshotande. Sjuksköterskan kan inom flera olika områden i sjuk-vården träffa på kvinnor som har råkat ut för någon av dessa förluster och behöver omvårdnad. Syftet med litteraturöversikten var att ta reda på vad eventuell forsk-ning visade angående kvinnors känslomässiga upplevelser vid graviditetsförlust samt att ur ett omvårdnadsperspektiv belysa kvinnors reaktioner på vården. För att uppnå syftet gjordes en litteraturöversikt enligt Friberg (2006). Resultatet ledde fram till tre teman; Känslomässiga upplevelser, Hur dessa hanterades och Reak-tioner på omvårdnaden. Kvinnorna upplevde graviditetsförlusten olika men gemensamt för dem var att bemötandet från vårdpersonalen hade betydelse för hur de känslomässigt hanterade situationen. Om vårdpersonalen var sympatisk, enga-gerad och hade tid för dem klarade de av att hantera situationen på ett bättre sätt än när personalens bemötande upplevdes känslokallt och rutinmässigt. Resultatet diskuterades i förhållande till Travelbees omvårdnadsfilosofi. Kvinnorna behöver ges omvårdnad utgående från varje enskild individs unika situation. Det är en patientkategori som oftast har kort vårdtid vilket gör det till en utmaning för sjuk-sköterskor att i omvårdnaden hinna bemöta dem individuellt och uppfatta deras behov. / Pregnancy loss and early miscarriage are common adverse outcome in pregnancy. A more rare diagnosis is ectopic pregnancy that can be very dramatic and life-threatening. Nurses from different areas in hospitals meet women in need of care after such a loss. The purpose of this literature review was to find out what the research show about women’s emotional experience of pregnancy loss and from a nursing view find out how the women experienced the care they received. To reach the purpose, a literature review was done according to Friberg (2006). The results showed three different themes; Emotional experiences, How the women coped with the emotional experiences and How the women reacted to the care given. The women experienced the pregnancy loss differently but they had one thing in common: The way they handled the situation depended on how the health professional treated them. If the caregivers were sympathetic, compassionate and gave time to the women they coped a lot better than if the caregivers were insensi-tive, callous and showed a matter of fact attitude. The result is discussed in rela-tion to Travelbees nursing philosophy. The women need to be provided with targeted care. The care must be based on every woman’s individual needs. These patients often spend a very short time at the hospital with short time for treatment witch leads the nurses to a challenge of how to get the time to treat every woman individually. This would lead to a better understanding for the women’s needs

Identifikační záznam: ŠEBESTOVÁ, Marcela. Náhlé příhody břišní v gynekologii pohledem sestry v intenzivní péči. [Acute Severe Abdominal Pain in Gynaecology from the Point of View of a Nurse in the Intensive Care Unit]. Praha, 2011. 68 s., 10 příl. Diplomová práce (Mgr.). Univerzita Karlova v Praze, 1. lékařská fakulta, Ústav teorie a praxe v ošetřovatelství. Vedoucí práce Mgr. Kulhavá, Miluše. Abstrakt Diplomová práce je zaměřena na náhlé příhody břišní v gynekologii pohledem sestry intenzivní péče. Teoretická část je věnována anatomii a fyziologii ženského reprodukčního systému. Velkou část práce zaujímají náhlé příhody břišní v gynekologii a to především mimoděložní těhotenství, tedy stav, se kterým se může setkat každá žena ve svém reprodukčním období. Empirická část práce je věnována kvalitativnímu výzkumu se zaměřením na zjištění spokojenosti respondentek s poskytovanou ošetřovatelskou péčí po operaci mimoděložního těhotenství. Pohled na hospitalizaci ze strany pacientek je velice cenný, protože dokládá výsledky zdravotnické, v tomto případě ošetřovatelské práce jinak, než běžné statistiky. Výzkumný soubor je tvořen pěti ženami v reprodukčním věku, které byly hospitalizovány na gynekologicko-porodnické klinice s diagnózou ektopická gravidita. Práce shromažďuje co nejvíce informací o mimoděložním...

INTRODUÇÃO: A definição de fatores preditivos de lesão morfológica e funcional da tuba uterina poderia colaborar na escolha do tratamento de pacientes com gestação ectópica. O objetivo deste estudo foi verificar o comportamento do tecido trofoblástico em relação à sua penetração na parede da tuba uterina em gestações ampulares, relacionar a profundidade dessa penetração com idade gestacional, concentração de beta-hCG, tipo de imagem ultra-sonográfica e dimensão da massa ectópica à ultra-sonografia e avaliar a possibilidade de predição dessa invasão pelos parâmetros estudados. MÉTODOS: realizou-se estudo retrospectivo, entre 1° de janeiro de 2000 a 31 de março de 2004, com 105 pacientes com gestação tubária ampular submetidas à salpingectomia. As imagens ectópicas foram classificadas pelo aspecto ultra-sonográfico em anel tubário, massa complexa e embrião com atividade cardíaca e sua dimensão foi obtida pela medida do maior eixo. Histologicamente a invasão trofoblástica na parede tubária foi classificada em grau I: quando limitada à mucosa da tuba uterina; grau II: até a camada muscular; grau III: invasão de toda a espessura da tuba uterina. RESULTADOS: 29 pacientes tiveram infiltração tubária grau I, 30 pacientes infiltração grau II e 46 pacientes infiltração grau III. Os graus de invasão trofoblástica não estiveram associados à idade gestacional (p = 0,53) nem ao maior diâmetro da imagem à ultra-sonografia (p = 0,43). Os diferentes graus de invasão trofoblástica apresentaram diferença significativa da beta-hCG (p < 0,001). O grau I apresentou valores menores que os graus II e III (p < 0,05) e o grau II valores menores que o grau III (p < 0,05). Houve associação entre o grau de invasão trofoblástica e a descrição do tipo de imagem identificada à ultra-sonografia (p = 0,001). Embrião com atividade cardíaca foi mais prevalente nos casos de invasão grau III. O valor de 2 400 mUI/ml apresentou sensibilidade de 82,8%, especificidade de 85,5%, valor preditivo positivo de 68,6% e valor preditivo negativo de 92,7% (acurácia de 84,8%) para determinar invasão trofoblástica grau I. beta-hCG de 5 990 mUI/ml foi o melhor ponto de corte para predição de invasão trofoblástica grau III: sensibilidade de 82,6%, especificidade de 74,6%, valor preditivo positivo de 71,7% e valor preditivo negativo de 84,6% (acurácia de 78,1%). CONCLUSÕES: Em gestações ampulares, o tecido trofoblástico se desenvolve a partir de sua penetração na parede tubária, a profundidade da penetração do trofoblasto na tuba uterina relaciona-se às concentrações séricas de beta-hCG e ao tipo de imagem ultra-sonográfica, sendo que a concentração sérica da beta-hCG é a melhor preditora da profundidade da invasão na tuba uterina. / INTRODUCTION: The definition of predictive factors of morphologic and functional damage to the Fallopian tube may help in the choice of treatment for patients with ectopic pregnancy. The objective of the present study was to verify the presence of trophoblastic invasion into the tubal wall in ampular pregnancies, correlate the depth of penetration of trophoblastic tissue into the tubal wall with gestational age, beta-hCG concentration, type of ultrasonographic image and dimension of the ectopic mass upon ultrasound, and to evaluate the possible prediction of this invasion based on the parameters studied. METHODS: A retrospective study was conducted on 105 patients with ampular pregnancy submitted to salpingectomy between January 1, 2000 and March 31, 2004. Ectopic images were classified based on ultrasonographic findings in tubal ring, complex mass and embryonic heart activity. The dimension of the mass was determined by measuring the major axis. Histologically, trophoblastic invasion into the tubal wall was classified as grade I when limited to the tubal mucosa, grade II when reaching the muscle layer, and grade III when comprising the full thickness of the Fallopian tube. RESULTS: Twenty-nine patients had tubal infiltration grade I, 30 had grade II and 46 had grade III. The level of trophoblastic invasion was associated neither with gestational age (p = 0.53) nor with a greater diameter of the ultrasound image (p = 0.43). The different levels of trophoblastic invasion were significantly associated with beta-hCG concentration (p < 0.001), with lower concentrations being observed for grade I compared to grades II and III (p < 0.05) and for grade II compared to grade III (p < 0.05). There was an association between the level of trophoblastic invasion and the type of ultrasonographic image (p = 0.001). Embryos with heart activity were more prevalent in cases of grade III invasion. beta-hCG levels of 2 400 mIU/ml showed 82.8% sensitivity, 85.5% specificity, a positive predictive value of 68.6% and a negative predictive value of 92.7% (84.8% accuracy) for the diagnosis of grade I trophoblastic invasion. A beta-hCG titer of 5990 mIU/ml was the best cut-off for the prediction of grade III trophoblastic invasion: 82.6% sensitivity, 74.6% specificity, positive predictive value of 71.7% and negative predictive value of 84.6% (78.1% accuracy). CONCLUSIONS: trophoblastic tissue penetrate tubal wall in ampular pregnancies, the depth of penetration of trophoblastic tissue is correlated with beta-hCG concentration and type of ultrasonographic image and beta-hCG titer is the best predictor of the depth of penetration into tubal wall.

Une grossesse extra-utérine est une grossesse implantée en dehors de la cavité utérine. Il existe quatre thérapeutiques pour leur prise en charge : l’expectative, le traitement médical par méthotrexate, le traitement chirurgical conservateur (salpingotomie) et le traitement chirurgical radical (salpingectomie). Le choix entre ces 4 traitements repose tout d’abord sur des critères de faisabilité (traitement médical et expectative sont par exemple exclus en cas de rupture tubaire). Ces critères de faisabilité peuvent être résumés par la notion d’activité de la GEU. Cette notion permet de différencier les grossesses extra-utérines peu actives pouvant bénéficier d’un traitement médical des grossesses extra-utérines actives requérant un traitement chirurgical.Chaque traitement présente des avantages et des inconvénients et la principale question toujours en suspens concerne la fertilité après prise en charge d’une GEU. L’essai randomisé DEMETER a donc été conçu pour évaluer l’existence éventuelle d’une différence de fertilité de plus de 20% entre traitement médical et traitement chirurgical conservateur d’une part pour les GEU peu actives et entre traitement chirurgical conservateur et radical d’autre part pour les GEU actives.Il n’y a pas de différence significative de plus de 20% de fertilité deux ans après la prise en charge d’une grossesse extra-utérine que ce soit pour les grossesses peu actives entre traitement médical et traitement chirurgical conservateur ou pour les grossesses actives entre traitement chirurgical conservateur et radical. Par ailleurs, cet essai a aussi permis de conclure à la supériorité, en terme d’échec immédiat, du traitement chirurgical conservateur avec injection postopératoire de méthotrexate par rapport au traitement médical pour la prise en charge des GEU peu actives. La plus grande efficacité du traitement chirurgical conservateur est probablement majorée par l’injection postopératoire de méthotrexate. Le taux de conversion d’un traitement chirurgical conservateur vers un traitement chirurgical radical est important : 10% dans le groupe des GEU peu actives et 21% (significativement plus élevé) dans le groupe des GEU actives. Enfin, Le délai de guérison est plus court après traitement chirurgical conservateur qu’après traitement médical.Ces résultats couplés aux données de la littérature permettent d’élaborer des recommandations sur la prise en charge des grossesses extra-utérines. Notamment, pour les GEU peu actives avec un taux d’hCG inférieur à 5000UI/ml sans signe de rupture tubaire ou de défaillance hémodynamique, un traitement médical par méthotrexate doit être proposé sous réserve d’une bonne compliance de la patiente pour le suivi. Une prise en charge par chirurgie conservatrice reste une option valide. Dans ce cas, une injection postopératoire de méthotrexate sera réalisée systématiquement dans les 24 heures suivant l’intervention. Le traitement des GEU actives est chirurgical et la décision entre conservateur et radical a lieu en peropératoire. Enfin, une information aux patientes pourra être délivrée sur l’absence de différence de fertilité 2 ans après le traitement d’une GEU. / An ectopic pregnancy is a pregnancy implanted outside uterine cavity. There are four different treatments to manage tubal ectopic pregnancy: expectation, medical treatment (methotrexate), conservative surgery (salpingotomy) and radical surgery (salpingectomy). The choice between these different treatments is based on feasibility criteria (medical treatment and expectation are not feasible in case of tubal rupture). These feasibility criteria can be summarized by activity of ectopic pregnancy. This activity allowed differentiating less active ectopic pregnancies that can be supported by medical treatment and active ectopic pregnancies that required surgery.All of these treatments present advantages and disadvantages and the major unresolved issue concerns subsequent fertility after management of ectopic pregnancy. Randomized trial DEMETER has thus been designed to evaluate a difference of 20% between medical management and conservative surgery for less active ectopic pregnancy and between conservative and radical surgery for active ectopic pregnancy. Differences for two years subsequent fertility after management of ectopic pregnancy were not more than 20% between medical management and conservative surgery for less active ectopic pregnancy as between conservative and radical surgery for active ectopic pregnancy. This trial also allowed concluding to the superiority of conservative surgery with a systematic postoperative injection of methotrexate compared to medical treatment for management of less active ectopic pregnancy. This superiority might be enhanced by postoperative methotrexate injection. The conversion rate to radical surgery when a conservative surgery is decided is important: 10% for less active ectopic pregnancy and 21% (significantly higher) for active ectopic pregnancy. Recovery time is shorter after conservative surgery compared to medical management.Results of DEMETER trial and literature review allowed giving guidelines for management of ectopic pregnancy. Less active ectopic pregnancy with hCG rate less than 5.000UI/l without tubal rupture or hemodynamic failure can be managed in first intention by medical treatment (methotrexate) if the women is assiduous to a close check. However, conservative surgery for less active ectopic pregnancy is a good option. A systematic postoperative injection of methotrexate in the 24 first hours after surgery should be recommended. Active ectopic pregnancy has to be managed surgically and decision between conservative and radical surgery should be done in the operative room. Finally, women have to be informed about the absence of difference between treatments for subsequent fertility.