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Forbes LA, Nuthivana N, Morales R. Successful Management of Spontaneous Unilateral Twin Ectopic Pregnancy With Two-Step Dose of Methotrexate. Case Rep Obstet Gynecol 2024; 2024:5543780. [PMID: 39188358 PMCID: PMC11347029 DOI: 10.1155/2024/5543780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/17/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024] Open
Abstract
The incidence of unilateral tubal twin pregnancy is 1/20,000-1/250,000 with about 100 reported cases. Four of the six cases that were medically managed were successful. A 24-year-old female presented to the emergency department (ED) with vaginal bleeding and abdominal cramping. She was hemodynamically stable without signs of an acute abdomen. Laboratory evaluation revealed she was pregnant with a serum beta-human chorionic gonadotropin (b-hCG) of 798 mIU/mL. Transvaginal ultrasound (TVUS) revealed a single left tubal pregnancy with a yolk sac. The patient elected medical management with body surface area (BSA)-based intramuscular (IM) methotrexate (MTX). On Day 4, the patient returned to the ED; her b-hCG was 727 mIU/mL. TVUS revealed twin left tubal pregnancies with yolk sacs and fetal poles without cardiac activity. The patient elected to continue medical management with a second dose of BSA-based IM MTX. On Day 6, the patient returned to the ED with abdominal and rectal pain. She was hemodynamically stable without signs of an acute abdomen. Her b-hCG was 533 mIU/mL. TVUS showed persistent twin left tubal pregnancies-one at 5 weeks gestational age and the other at 6 weeks gestational age-without evidence of rupture. The patient continued serial b-hCGs. Thirty-one days after the first dose of MTX, her b-hCG was < 1 mIU/mL. TVUS showed resolution of tubal pregnancies. The patient consented to the publication of this case report. This case documents the successful treatment of spontaneous, unilateral tubal twin pregnancies with two-step dosing of IM MTX.
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Affiliation(s)
- Lauren A. Forbes
- Department of Obstetrics and GynecologyEastern Virginia Medical School at Old Dominion University, Norfolk, Virginia, USA
| | - Navya Nuthivana
- Department of Obstetrics and GynecologyEastern Virginia Medical School at Old Dominion University, Norfolk, Virginia, USA
| | - Renee Morales
- Department of Obstetrics and GynecologyEastern Virginia Medical School at Old Dominion University, Norfolk, Virginia, USA
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Piróg MM, Pulka A, Urbaniec P, Jach R. Comparison of single- and double-dose methotrexate protocols for treatment of pregnancy of unknown location. Eur J Obstet Gynecol Reprod Biol 2024; 298:171-174. [PMID: 38762953 DOI: 10.1016/j.ejogrb.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 04/12/2024] [Accepted: 05/15/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE The use of various methotrexate (MTX) protocols for the treatment of ectopic pregnancy is well established. This study aimed to evaluate the efficacy of single- and double-dose MTX protocols for the treatment of pregnancy of unknown location (PUL). STUDY DESIGN This retrospective study was conducted in the Department of Gynaecological Endocrinology, University Hospital, Krakow, Poland. Haemodynamically stable women with PUL were enrolled between January 2014 and September 2023. Demographics, gestational age and treatment outcomes were compared between women in the single-dose MTX group and women in the double-dose MTX group. The primary outcome was the success rate, measured as the number of women treated without surgical intervention. The secondary outcome was the number of days of MTX needed to achieve an appropriate decrease in beta-human chorionic gonadotrophin (β-hCG). RESULTS Two hundred and eleven women (mean age 33 ± 1.8 years) with PUL were enrolled in the study, with an overall success rate of 89.1 %. Single- and double-dose MTX protocols were found to have comparable treatment success rates (93 % and 95 %, respectively). Women with lower initial serum β-hCG (<2000 mIU/ml) had higher treatment efficacy compared with women with higher initial serum β-hCG (96.5 % vs 71.4 %), regardless of protocol type. The length of hospital stay for the women treated with the single-dose MTX protocol was 1 day shorter compared with that for the women treated with the double-dose MTX protocol. CONCLUSION Single- and double-dose MTX protocols have comparable efficacy and safety, and should be equally considered in women with PUL with initial β-hCG < 2000 mIU/ml.
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Affiliation(s)
- Magdalena M Piróg
- Department of Gynaecological Endocrinology, Jagiellonian University Medical College, Krakow, Poland.
| | - Anna Pulka
- Department of Gynaecological Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - Przemysław Urbaniec
- Department of Gynaecological Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - Robert Jach
- Department of Gynaecological Endocrinology, Jagiellonian University Medical College, Krakow, Poland
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Shen HH, Zhang YY, Wang XY, Wang CJ, Wang Y, Ye JF, Li MQ. Potential Causal Association between Plasma Metabolites, Immunophenotypes, and Female Reproductive Disorders: A Two-Sample Mendelian Randomization Analysis. Biomolecules 2024; 14:116. [PMID: 38254716 PMCID: PMC10813709 DOI: 10.3390/biom14010116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND While extensive research highlighted the involvement of metabolism and immune cells in female reproductive diseases, causality remains unestablished. METHODS Instrumental variables for 486 circulating metabolites (N = 7824) and 731 immunophenotypes (N = 3757) were derived from a genome-wide association study (GWAS) meta-analysis. FinnGen contributed data on 14 female reproductive disorders. A bidirectional two-sample Mendelian randomization study was performed to determine the relationships between exposures and outcomes. The robustness of results, potential heterogeneity, and horizontal pleiotropy were examined through sensitivity analysis. RESULTS High levels of mannose were found to be causally associated with increased risks of gestational diabetes (GDM) (OR [95% CI], 6.02 [2.85-12.73], p = 2.55 × 10-6). A genetically predicted elevation in the relative count of circulating CD28-CD25++CD8+ T cells was causally related to increased female infertility risk (OR [95% CI], 1.26 [1.14-1.40], p = 1.07 × 10-5), whereas a high absolute count of NKT cells reduced the risk of ectopic pregnancy (OR [95% CI], 0.87 [0.82-0.93], p = 5.94 × 10-6). These results remained consistent in sensitivity analyses. CONCLUSIONS Our study supports mannose as a promising GDM biomarker and intervention target by integrating metabolomics and genomics.
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Affiliation(s)
- Hui-Hui Shen
- Laboratory for Reproductive Immunology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai 200080, China
| | - Yang-Yang Zhang
- Laboratory for Reproductive Immunology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai 200080, China
- Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Xuan-Yu Wang
- College of Traditional Chinese Medicine, Tianjin University of Traditional Chinese Medicine, No. 10, Poyang Lake Road, Tuanpo Xinchengxi District, Jinghai District, Tianjin 301617, China
| | - Cheng-Jie Wang
- Department of Obstetrics and Gynecology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai 200011, China
| | - Ying Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Ji’nan 250012, China
| | - Jiang-Feng Ye
- Institute for Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore 138632, Singapore
| | - Ming-Qing Li
- Laboratory for Reproductive Immunology, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai 200080, China
- Shanghai Medical College, Fudan University, Shanghai 200032, China
- Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Hospital of Obstetrics and Gynecology, Fudan University, Shanghai 200080, China
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Hao HJ, Feng L, Dong LF, Zhang W, Zhao XL. Reproductive outcomes of ectopic pregnancy with conservative and surgical treatment: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e33621. [PMID: 37115078 PMCID: PMC10145868 DOI: 10.1097/md.0000000000033621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 04/01/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Ectopic pregnancy (EP), one of the most common gynecological emergencies, is the major cause of maternal death in the first trimester and increases the incidence of infertility and repeat ectopic pregnancy (REP). The aim of this study was to compare the effects of different treatment methods for tubal EP on natural pregnancy outcomes. METHODS We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials for observational studies on EP (published until October 30,2022 in English) comparing methotrexate (MTX) versus surgery, MTX versus salpingostomy, MTX versus salpingectomy, salpingostomy versus salpingectomy, and MTX versus expectant treatment. Our main endpoints included subsequent natural intrauterine pregnancy (IUP) and REP. We assessed the pooled data using Review Manager software (version 5.3) with a random effects model. RESULTS Of 1274 identified articles, 20 were eligible and 3530 participants were included in our analysis. There was a significant difference in the odds of subsequent IUP in tubal EP patients who underwent MTX compared with those who were treated with surgery [odds ratios (OR) = 1.52, 95% confidence interval (CI):1.20-1.92]. No significant difference was found in the odds of REP between the 2 groups (OR = 1.12, 95% confidence interval [CI]: 0.84-1.51). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared to those after salpingostomy (OR = 1.04,95% CI: 0.79-1.38; OR = 1.10, 95% CI: 0.64-1.90). There was a significant difference in the odds of subsequent IUP in patients after MTX compared with those after salpingectomy (OR = 2.11, 95% CI: 1.52-2.93). No significant difference was found in the odds of REP between the 2 groups (OR = 0.98, 95% CI: 0.57-1.71). There was a significant difference in the odds of subsequent IUP between patients who underwent salpingostomy and those who underwent salpingectomy (OR = 1.61, 95% CI: 1.29-2.01). No significant difference was found in the odds of REP between the 2 groups (OR = 1.21, 95% CI: 0.62-2.37). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared with those after expectant treatment (OR = 1.25, 95% CI: 0.64-2.45; OR = 0.69, 95% CI: 0.09-5.55). CONCLUSION For hemodynamically stable tubal EP patients, MTX has advantages over surgery, particularly salpingectomy, in improving natural pregnancy outcomes. However, MTX is not inferior to salpingostomy and expectant treatment.
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Affiliation(s)
- Hong-Juan Hao
- Department of Gynecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Li Feng
- Department of Gynecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Li-Fei Dong
- Department of Gynecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Wei Zhang
- Department of Gynecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
| | - Xiao-Li Zhao
- Department of Gynecology, The Fourth Hospital of Shijiazhuang, Shijiazhuang, Hebei, China
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Caroff A, Ramanah R, Nallet C, Pretalli JB, Roux C. [Embryo stage impact on the risk of ectopic pregnancy after In Vitro Fecondation]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:721-728. [PMID: 36055463 DOI: 10.1016/j.gofs.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/31/2022] [Accepted: 08/03/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Ectopic pregnancies are still the first mortality cause of the first semestre of pregnancy. They are much more frequent in IVF (2-5%) than in the standard population (1-2%). The aim of this study was to compare the rate of ectopic pregnancies following a fresh embryo transfer done whether at an clived embryo stage (day 2 or 3 of the embryo development) or at a blastocyst stage (day 5 or 6 of the embryo development). METHODS This is a monocentric retrospective study including all 18 to 43 year-old patients getting pregnant (ßHCG>100 UI/L) after a fresh embryo transfer from In Vitro Fecondation with or without Intra-Cytoplasmic Sperm Injection, between January 1st 2014 and December 30th 2020 in the Hospital of Besançon (France). This population has been divided into 2 groups according to the embryo stage on the day of transfer. RESULTS Nine hundred and twenty two patients have been included. There were statistically more ectopic pregnancies after a blastocyst transfer (n=4; 5.4%) than after a clived embryo transfer (n=14; 1.7%). (P=0.049) CONCLUSION: In our population, there were more ectopic pregnancies from blastocyst(s) transfers than from clived embryo(es).
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Affiliation(s)
- A Caroff
- Service de gynécologie obstétrique, Centre Hospitalo-Universitaire Jean Minjoz, 3, boulevard Alexandre Flemming, 25000 Besançon, France.
| | - R Ramanah
- Service de gynécologie obstétrique, Centre Hospitalo-Universitaire Jean Minjoz, 3, boulevard Alexandre Flemming, 25000 Besançon, France
| | - C Nallet
- Service de gynécologie obstétrique, Centre Hospitalo-Universitaire Jean Minjoz, 3, boulevard Alexandre Flemming, 25000 Besançon, France
| | - J-B Pretalli
- Service de biologie de la reproduction, Centre Hospitalo-Universitaire Jean Minjoz, 3, boulevard Alexandre Flemming, 25000 Besançon, France
| | - C Roux
- Service de biologie de la reproduction, Centre Hospitalo-Universitaire Jean Minjoz, 3, boulevard Alexandre Flemming, 25000 Besançon, France
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Wenjing L, Haibo L. Therapeutic effect of laparoscopic salpingotomy vs. salpingectomy on patients with ectopic pregnancy: A systematic review and meta-analysis. Front Surg 2022; 9:997490. [PMID: 36303847 PMCID: PMC9592917 DOI: 10.3389/fsurg.2022.997490] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aim Laparoscopic treatment of ectopic pregnancy mainly includes laparoscopic salpingotomy and salpingectomy. We aimed to assess the therapeutic effect of laparoscopic salpingotomy and salpingectomy on patients with tubal pregnancy. Methods From January 2000 through June 2022, the Cochrane Library, Medline, PubMed, Web of Science, EMBASE, and the Chinese Biomedicine Database were searched for studies that compared the therapeutic effect of laparoscopic salpingotomy vs. salpingectomy in the treatment of tubal pregnancy. Results Twenty-four randomized clinical trials (RCTs) studies were incorporated into this analysis. No statistical differences were found between the two groups in terms of operation duration and postoperative hospitalize length, but the volume of intraoperative blood loss in patients with laparoscopic salpingotomy was less than that in salpingectomy. Importantly, the natural intrauterine pregnancy rate after laparoscopic salpingotomy was significantly higher than those who underwent salpingectomy. In addition, laparoscopic salpingotomy can better protect the ovarian reserve function and endocrine function and provide favorable conditions for the second pregnancy. Conclusion Patients with ectopic tubal pregnancy should give priority to laparoscopic salpingotomy for embryo extraction.
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Yu Y, Li Y, Yang X, Fan Q, Cao D, Wang Y. Daily variations and levels of human chorionic gonadotropin before methotrexate treatment as predictors of treatment success. J Obstet Gynaecol Res 2022; 48:3128-3136. [PMID: 36056536 DOI: 10.1111/jog.15413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/11/2022] [Accepted: 08/20/2022] [Indexed: 12/01/2022]
Abstract
AIM The aim of this study is to investigate the role of human chorionic gonadotropin (hCG) daily variations and levels prior to methotrexate treatment as predictors for treatment outcome. METHODS This retrospective study included patients who had a sonographically confirmed ectopic pregnancy at the International Peace Maternity and Child Health Hospital between November 2015 and June 2020. The associations of hCG levels and daily variations with the treatment success were evaluated by multivariable logistic regression and receiver operator characteristic (ROC) curve. Establish a nomogram that predicts how methotrexate (MTX) therapy will turn out. The performance of the model was assessed utilizing concordance index, receiver operating characteristic curves, and calibration plots. RESULTS The median serum hCG levels before treatment and hCG daily variation in the failure group were higher than those in the success group (487.8 vs. 270.7 IU/L, -1.86% vs. 7.29%, both p < 0.01). According to the ROC curve analysis, the cutoff values of serum hCG level before treatment and daily variations were 617.35 IU/L and 1.76%/day. By multivariable logistic regression analysis, serum hCG levels before treatment (odds ratio [OR]: 1.001, 95% confidence interval [CI]: 1.000 ~ 1.001) and hCG daily variations were independently associated with the treatment success (OR: 1.033, 95% CI: 1.015 ~ 1.052). The nomogram was effective at predicting the outcome of MTX treatment with a receiver operating characteristic area under the curve of 0.717 (p < 0.001). The nomogram's calibration curve was almost parallel to the ideal diagonal line. CONCLUSION We successfully created a nomogram based on serum hCG levels before treatment and hCG daily changes to anticipate the result of MTX therapy, which could assist medical professionals in selecting therapeutic schedule for patients with tubal pregnancies.
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Affiliation(s)
- Yuchong Yu
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuhong Li
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoming Yang
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiong Fan
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dan Cao
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yudong Wang
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Time to pregnancy in women with previous ectopic pregnancy undergoing in vitro fertilization treatment: a retrospective cohort study. Sci Rep 2022; 12:8820. [PMID: 35614336 PMCID: PMC9133082 DOI: 10.1038/s41598-022-13027-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 05/16/2022] [Indexed: 11/30/2022] Open
Abstract
We aimed to investigate the difference in the time to pregnancy (TTP) between women with previous ectopic pregnancy (EP) and control women following in vitro fertilization (IVF) treatment and the association between TTP and the number of oocytes retrieved and embryos available. A retrospective study involving 1097 women, 547 of which had previous EP and 550 were control women whose previous pregnancy were abortion, was conducted. Women in the EP group had significantly longer median TTP than those in the control group (36; range, 12–252 vs 28; range, 12–220; P = 0.019). For women with previous EP, > 48 months TTP was most likely associated with low numbers of oocytes retrieved and embryos available compared to TTP of ≤ 24 months or 25–48 months, and women with younger age had a shorter TTP, higher numbers of oocytes retrieved and embryos available. A Cox proportional hazards model showed that maternal age was significantly related to the pregnancy over the TTP (adjusted hazard ratio, 0.934; P < 0.001). In conclusion, women with previous EP have a significantly increased TTP than control women with previous abortion. For women with previous EP, TTP is negatively associated with the numbers of oocytes retrieved and embryos available.
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Wu Q, Lin Y, Zhang J, Zhou Y, Chen L, Lin T. Preliminary hysteroscopic tubal hydrotubation improves fertility outcomes after laparoscopic salpingotomy for tubal ampullary pregnancy. BMC Surg 2022; 22:53. [PMID: 35151301 PMCID: PMC8841113 DOI: 10.1186/s12893-021-01367-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 10/10/2021] [Indexed: 11/23/2022] Open
Abstract
Background Salpingotomy may change the anatomical structure and patency of the fallopian tube, which may affect the fallopian function. This study is to investigate the clinical efficacy of preliminary hysteroscopic tubal hydrotubation (HTH) after laparoscopic salpingotomy for tubal ampullary pregnancy. Methods A retrospective study was carried out, 140 women underwent laparoscopic salpingotomy for ampullary pregnancy from March 2013 to March 2017. Some patients received HTH in the 1st month and hysterosalpingography (HSG) in the 3rd month after salpingotomy (HTH group; n = 95), and some patients only received HSG in the 3rd month after salpingotomy (control group; n = 45). Clinical data, tubal patency and fertility outcome were evaluated after follow-up of 15 months. Results The tubal patency rate of the operated side was significantly higher in the HTH group than that in the control group (89.47% vs 68.89%, P < 0.05). The intrauterine pregnancy (IUP) rate was significantly higher in the HTH group (76.47% vs 51.11%, P < 0.05), and the recurrent ectopic pregnancy rate in the operated side was significantly lower in the HTH group than in the control group (9.41% vs 22.22%, P < 0.05). Logistic regression analysis showed that the positive factor for IUP was HTH (OR = 3.109, 95% CI 1.439–6.714, P = 0.004), while the negative factors were history of pelvic inflammatory disease (PID) (OR = 0.167, 95% CI 0.074–0.377, P < 0.001) and history of tubal infertility (OR = 0.286, 95% CI 0.113–0.723, P < 0.05). Conclusion Preliminary HTH after laparoscopic salpingotomy for ampullary pregnancy could improve reproductive function and lead to a better fertility outcome. Patients without history of PID or tubal infertility may be the most suitable ones for HTH after salpingotomy.
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Tang S, Du T, Huang J, Ye H, Zhao M, Lin J, Kuang Y. Effect of previous wedge resection for interstitial pregnancy on pregnancy and neonatal outcomes following frozen-thawed embryo transfer (FET) cycles of IVF/ICSI: a retrospective study. Reprod Biol Endocrinol 2022; 20:23. [PMID: 35105356 PMCID: PMC8805226 DOI: 10.1186/s12958-022-00896-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/17/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The present study aimed to evaluate pregnancy and neonatal outcomes in women, with a previous history of wedge resection for interstitial pregnancy, in frozen-thawed embryo transfer (FET) cycles of IVF/ICSI. METHODS The present study involved a retrospective case-control assessment of 75 cases and 375 control subjects over 6 years in a single center. To compare pregnancy and neonatal outcomes between cases, treated using wedge resection, and controls without any previous history of ectopic pregnancy, propensity score matching (1:5) was utilized. The study also compared subgroups in the case group. RESULTS Women with previous wedge resection exhibited higher rates of ectopic pregnancy and uterine rupture rate as compared to control subjects (9.1% vs 1.3%, P = 0.025 and 4.5% vs 0%, P = 0.035, respectively). No statistically significant differences were recorded between the two cohorts with regard to clinical pregnancy rate, live birth rate, and neonatal outcomes. For pregnancy type subgroup analysis, Z-score and rates of large for gestational age were recorded to be significantly lower in twin pregnancy subgroup when compared with singleton pregnancy subgroup (0.10 (- 0.59, 0.25) vs 0.50 (- 0.97, 1.39), P = 0.005; 4.5% vs 26.1%, P = 0.047, respectively). CONCLUSION The results of the present study indicated that previous wedge resection correlated to a higher risk of ectopic pregnancy and uterine rupture. However, it might not be related to an increased risk of adverse neonatal outcomes. The study recommended cesarean section in these patients. Further studies are required to verify the validity of current recommendations.
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Affiliation(s)
- Shengluan Tang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Tong Du
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Jialyu Huang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China
| | - Hongjuan Ye
- Department of Reproductive Medicine Center, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ming Zhao
- Shanghai Towako Hospital, No. 477, Fute West 1st Road, Shanghai, China
| | - Jiaying Lin
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China.
| | - Yanping Kuang
- Department of Assisted Reproduction, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, 639 Zhizaoju Rd, Shanghai, 200011, China.
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Ayenew A. Prevalence and determinants of ectopic pregnancy in Ethiopia: Systematic review and meta-analysis. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2022. [DOI: 10.1177/22840265211062010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Ectopic pregnancy is a life-threatening obstetric emergency, and is a major health problem for women of fertile age. Therefore, the aim of this systematic review and meta-analysis was to estimate the prevalence, determinant factors, and outcomes of ectopic pregnancy among fertile age women in Ethiopia. Method: International databases (MEDLINE/Pub Med, Hinari, Scopus, Google scholar, African journals, and literatures were searched and nine eligible cross sectional and two case control studies were included in this systematic review and meta-analysis. Eggers test and funnel plot were computed to check publication bias across the studies. Publication bias was computed using a funnel plot and eggers test. Heterogeneity of the studies was checked using Cochrane Q-test and I2 statistic. Results: The pooled prevalence of ectopic pregnancy in Ethiopia was 3.61% (95%CI: 2.24–4.98, I2 = 89.2.0%, p < 0.001). Having cesarean section scar (AOR = 7.44, 95%CI: 5.48–10.09), single marital status (AOR = 5.71, 95%CI: 4.76–6.85), history of sexually transmitted infection (AOR = 4.68, 95%CI: 3.04–7.19), history of abortion (AOR = 3.89, 95%CI: 3.35–4.52), history of ectopic pregnancy (AOR = 5.74, 95%CI: 3.81–8.65), and emergency contraceptive use (AOR = 8.72, 95%CI: 2.90–26.20) were the determinant factors for the occurrence of ectopic pregnancy. Conclusion: This systematic review and meta-analysis showed that the prevalence of ectopic pregnancy was high in Ethiopia. Thus, educating women to limit the number of sexual partners, smoking cessation, using a condom during sex helps prevent sexually transmitted infections and the risk of pelvic inflammatory disease is crucial.
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Affiliation(s)
- Asteray Ayenew
- Midwifery Department, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Asgari Z, Chegini V, Hosseini R, Mohajeri M, Ansari I. Fertility outcomes subsequent to medical and surgical treatment for ectopic pregnancy: A retrospective cohort study in Iran. Int J Reprod Biomed 2021; 19:881-888. [PMID: 34805728 PMCID: PMC8595907 DOI: 10.18502/ijrm.v19i10.9820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/19/2020] [Accepted: 01/03/2021] [Indexed: 11/24/2022] Open
Abstract
Background Ectopic pregnancy (EP) and its treatment methods may affect subsequent fertility outcomes. Objective To compare methotrexate (MTX), laparoscopic salpingostomy, and salpingectomy methods of EP treatment and their effects on fertility outcomes. Materials and Methods This retrospective cohort study was performed on women receiving a definitive diagnosis of tubular EP from 2014 to 2017 at Arash Medical Center, Tehran, Iran. In total, 194 women were studied, of which 64 were treated with MTX, 52 underwent salpingostomy, and 78 underwent salpingectomy, depending on their clinical status. Basic information, obstetrics history, and major outcomes of the treatment after an 18-month follow-up, including recurrence of EP, miscarriage, and successful intrauterine pregnancy (IUP), were recorded and variables were compared among the three groups. Results There was no significant difference in fertility outcomes among the three groups. Among the studied variables, predictors of successful IUP after EP treatment were multiparity (Hazard Ratio (HR): 1.37; 95%CI: 1.06-1.77), no history of miscarriage (HR: 2.37; 95%CI: 1.01-5.56), and a higher number of live births (HR: 1.54; 95%CI: 1.01-2.37). On the other hand, predictors of EP recurrence included nulliparity (HR: 1.61; 95%CI: 1.02-2.53) and a lower number of live births (HR: 3.84; 95%CI: 1.43-10.98). The effect of other factors, including the utilized therapeutic modalities, was not statistically significant. Conclusion The current study results demonstrated that after an 18-month follow-up, fertility outcomes, including recurrence of EP and successful IUP, were not significantly different among the subjects with EP treated with MTX, salpingostomy, or salpingectomy. Further studies with long-term follow-ups are recommended.
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Affiliation(s)
- Zahra Asgari
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Venus Chegini
- Department of Obstetrics and Gynecology, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Reihaneh Hosseini
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Mohajeri
- Department of Obstetrics and Gynecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Iman Ansari
- Medical Students Research Committee, Shahed University, Tehran, Iran
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Diagnosis and Management of Ectopic Pregnancy: A Comparative Review of Major National Guidelines. Obstet Gynecol Surv 2021; 75:611-623. [PMID: 33111962 DOI: 10.1097/ogx.0000000000000832] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Ectopic pregnancies (EPs) represent a severe early pregnancy complication that is associated with increased risks of maternal morbidity and mortality. Over the years, there has been a significant reduction in the mortality from this complication by improving the diagnostic tools and the treatment options. Objective The aim of this study was to review and compare the recommendations from published guidelines on this potentially fatal condition. Evidence Acquisition A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence on EP was carried out. Results All the guidelines point out the crucial role of sonography in the prompt diagnosis of EP and describe similar sonographic findings. There is a consensus on the indications and contraindications to the use of methotrexate, the post-treatment surveillance, and the criteria of expectant management. The indications for a surgical approach are not well established, although the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence agree that a laparoscopy is preferred to laparotomy for hemodynamically stable patients. The latter is considered a better option only in emergency conditions. However, there is controversy in the recommended methotrexate protocols and the evaluation of β-human chorionic gonadotrophin and progesterone levels. Conclusion It is of paramount importance to build consistent international protocols, so as to help clinicians all over the world diagnose EPs in the most timely and accurate way and subsequently treat them effectively as a nonurgent medical condition, with the intention to lower the mortality and morbidity rate.
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Chromopertubation of an Ectopic Pregnancy. Obstet Gynecol 2021; 137:123-125. [PMID: 33278295 DOI: 10.1097/aog.0000000000004187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/01/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND An ectopic pregnancy is a nonviable pregnancy located outside of the endometrial cavity of the uterus, which can be managed medically or surgically. CASE A 35-year-old woman with a prior ectopic pregnancy, who reported tubal surgery of unknown location and extent, presented with a recurrent ectopic pregnancy. Ultrasound imaging showed a complex cystic lesion adjacent to the ovary, moderate complex free fluid, and no intrauterine pregnancy. She underwent an urgent diagnostic laparoscopy. Chromopertubation was performed to demonstrate absence of the left fallopian tube. The ectopic pregnancy was incidentally noted to be mobile and was expelled from the right fallopian tube. CONCLUSION Chromopertubation offers a minimally invasive technique for management of ectopic pregnancy that may reduce injury as a result of less surgical manipulation of the fallopian tube.
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Recurrent Tubal Ectopic Pregnancy Management and the Risk of a Third Ectopic Pregnancy. J Minim Invasive Gynecol 2020; 28:1497-1502.e1. [PMID: 33310167 DOI: 10.1016/j.jmig.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the rate of a third ectopic pregnancy according to the modality of treatment of the second ectopic pregnancy. DESIGN Retrospective cohort study. SETTING University-affiliated tertiary medical center. PATIENTS One hundred eleven women who had 2 ectopic pregnancies and a third consecutive pregnancy between 2003 and 2018. INTERVENTIONS Surgery or medical treatment as required. MEASUREMENTS AND MAIN RESULTS With regard to the modality of treatment of the second ectopic pregnancy, the patients were divided into 3 groups: expectant management, medical treatment with methotrexate, and laparoscopic salpingectomy. Univariate and multivariate analyses were conducted to assess the association of various parameters of the second ectopic pregnancy with the occurrence of a third ectopic pregnancy in the consecutive pregnancy. Twenty women (18.0%) were managed expectantly, 55 (49.6%) were treated with methotrexate, and 36 (32.4%) underwent surgery. Expectant management resulted in significantly higher rates of a third ectopic pregnancy compared with treatment with methotrexate or surgical intervention (50.0% vs 18.2% and 13.8%, respectively; p = .005). In the cases of 2 ipsilateral ectopic pregnancies, the interventional approach (medical or surgical treatment) resulted in lower recurrence rates compared with expectant management (25.7% vs 60.0%, respectively; p = .043). CONCLUSION The risk of a third episode of an ectopic pregnancy after expectant management of a second ectopic pregnancy is extremely high. An interventional approach by treatment with methotrexate or salpingectomy is therefore preferred for recurrent ectopic pregnancy management, especially in ipsilateral recurrences.
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Zhang J, Zhang Y, Gan L, Liu XY, Du SP. Predictors and clinical features of methotrexate (MTX) therapy for ectopic pregnancy. BMC Pregnancy Childbirth 2020; 20:654. [PMID: 33121473 PMCID: PMC7597060 DOI: 10.1186/s12884-020-03350-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 10/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ectopic pregnancy is a major life- and fertility-threatening women's health concern. As a result of advances in examination technology, an increasing number of ectopic pregnancies can be diagnosed early and treated with medical methods instead of surgery. The aim of this study was to summarize the clinical features and identify the predictors of success of methotrexate (MTX) treatment of ectopic pregnancy. METHODS This was a retrospective study of 238 ectopic pregnancies treated with MTX in the Department of Gynecology of Shaanxi Provincial People's Hospital from January 2017 to December 2017. RESULTS Patients were divided into two groups: the successful treatment group (n = 166) and the failed treatment group (n = 72). The overall success rate of MTX therapy for ectopic pregnancy was 69.75%. The mean initial beta-human chorionic gonadotropin (β-hCG) level was significantly lower in the successful treatment group than in the failed treatment group (2538.08 IU/L versus 3533.17 IU/L, P = 0.000). The treatment success rate of the group with an initial β-hCG concentration less than 4000 IU/L was significantly higher than that of the group with an initial β-hCG concentration greater than 4000 IU/L. However, the success rate of the group with an initial β-hCG concentration greater than 4000 IU/L was still relatively high (54.55%). β-hCG levels were significantly increased on the 4th day in the failed treatment group (P = 0.000). Compared to the initial β-hCG level, the day-4 β-hCG level increased by more than 8.21%, indicating that the treatment was effective. The diagnostic sensitivity was 88.6%, the specificity was 74.5%, and the area under the receiver operating characteristic (ROC) curve was 0.863 (95% confidence interval (CI): 0.805-0.920). CONCLUSIONS MTX therapy as a treatment option is safe and effective for asymptomatic, hemodynamically stable patients with ectopic pregnancies who are interested in conservative treatment, regardless of the serum β-hCG level or adnexal mass size. The change in the β-hCG level between the initial day and the 4th day is an effective and early predictive tool for the success of MTX therapy for ectopic pregnancy.
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Affiliation(s)
- Jing Zhang
- Shaanxi Provincial People's Hospital, Xian, 710068, Shaanxi, China
| | - Yu Zhang
- Shaanxi Provincial People's Hospital, Xian, 710068, Shaanxi, China
| | - Lu Gan
- Shaanxi Provincial People's Hospital, Xian, 710068, Shaanxi, China
| | - Xiao-Ying Liu
- Shaanxi Provincial People's Hospital, Xian, 710068, Shaanxi, China
| | - Shan-Ping Du
- Shaanxi Provincial People's Hospital, Xian, 710068, Shaanxi, China.
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Ozcan MCH, Wilson JR, Frishman GN. A Systematic Review and Meta-analysis of Surgical Treatment of Ectopic Pregnancy with Salpingectomy versus Salpingostomy. J Minim Invasive Gynecol 2020; 28:656-667. [PMID: 33198948 DOI: 10.1016/j.jmig.2020.10.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/20/2020] [Accepted: 10/22/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the fertility outcomes of salpingectomy compared with those of salpingostomy among patients treated for tubal ectopic pregnancies, including a separate analysis of women with risk factors along with a review of the surgical technique. DATA SOURCES Systematic review and meta-analysis from 1990 to the present through PubMed, Embase, CINAHL, and Ovid MEDLINE. The search string included "tubal pregnancy" or "ectopic" as well as "salpingectomy" and various terms describing salpingotomy. METHODS OF STUDY SELECTION Articles studying women who underwent surgical management of an ectopic pregnancy and the contrasted outcomes of salpingectomy vs salpingostomy were reviewed. The primary outcomes included subsequent intrauterine pregnancy (IUP) and repeat ectopic pregnancy (REP). TABULATION, INTEGRATION, AND RESULTS Two randomized controlled trials (RCTs), which consisted mostly of patients classified as low risk, and patients from 16 cohort studies were included. In the RCTs, there was no significant difference in the odds of subsequent IUP in patients who underwent a salpingectomy compared with those who were treated with salpingotomy (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.71-1.33). However, a significant and clinically meaningful difference was noted in the cohort studies, with the patients having a lower chance of IUP after salpingectomy (OR 0.45; 95% CI, 0.39-0.52). No significant difference was noted in the OR for a REP in the randomized trials (OR 0.77; 95% CI, 0.41-1.47), but the patients followed in the cohort studies had a cumulatively higher risk of REP after a salpingostomy (OR 0.73; 95% CI, 0.60-0.90). The subgroup analysis examining women within the studies with risk factors for tubal pathology found an even more impressive lowering in the odds of a subsequent IUP in patients classified as at-risk who were treated with salpingectomy (OR 0.30; 95% CI, 0.17-0.54), with a change in the direction of the odds for an REP rate favoring those who were treated with salpingostomy (OR 1.96; 95% CI, 0.88-4.35). CONCLUSION Salpingectomy has clear advantages over salpingostomy, and RCTs consisting mainly of patients classified as low risk show no difference in outcomes between salpingectomy and salpingostomy. However, in cohort studies inclusive of all patients, the likelihood of a subsequent spontaneous IUP is decreased in patients treated with salpingectomy, and salpingostomies may be especially underused in women with risk factors for tubal disease.
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Affiliation(s)
- Meghan C H Ozcan
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island (Drs. Ozcan and Frishman).
| | - Jeffrey R Wilson
- W.P. Carey School of Business, Arizona State University, Tempe, Arizona (Dr. Wilson)
| | - Gary N Frishman
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island (Drs. Ozcan and Frishman)
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Effect of Methotrexate on Salpingostomy Completion Rate for Tubal Ectopic Pregnancy: A Retrospective Cohort Study. J Minim Invasive Gynecol 2020; 28:1334-1342.e3. [PMID: 32911090 DOI: 10.1016/j.jmig.2020.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To determine whether completion rates of salpingostomy for tubal ectopic pregnancy are compromised by initial medical management with methotrexate (MTX). DESIGN Retrospective cohort study. SETTING Single academic hospital system. PATIENTS Patients requiring surgery for ectopic pregnancy between 2006 and 2017. INTERVENTIONS A subset of patients who went directly to surgery, and all patients who failed MTX before requiring surgery underwent detailed chart review. Salpingostomy plan and success rate and salpingostomy failure reasons were compared between patients pretreated with MTX and those who were MTX-untreated. MEASUREMENTS AND MAIN RESULTS Among 94 ectopic pregnancies requiring surgery after failed MTX treatment, 55 (59%) underwent planned salpingostomy. From 693 ectopic pregnancies managed without MTX, 166 were analyzed in detail, of which 80 (48%) underwent planned salpingostomy. The patients who underwent planned salpingostomy were thinner (body mass index 27.3 ± 7.2 kg/m2 vs 29.3 ± 8.3 kg/m2; p = .048), less frequently African American (33% vs 47%; p = .017), and more likely to have a visualized adnexal lesion (70% vs 52%; p = .004) than those undergoing planned salpingectomy. Preoperative ultrasound identified fetal cardiac activity and hemoperitoneum at comparable rates. MTX exposure was not associated with age, body mass index, race, ectopic risk factors, human chorionic gonadotropin levels, or gestational age at diagnosis, but the patients treated with MTX underwent surgery later than those who were untreated (gestational age 53.4 ± 11.2 days vs 43.5 ± 11 days; p <.001). The differences between the adnexal lesion size and rates of fetal cardiac activity and hemoperitoneum on ultrasound related to MTX exposure did not meet significance. Planned salpingostomy was completed in 22 (40%) of the patients treated with MTX vs 34 (42%) of those who were untreated. The reasons for failure, surgery time, and rates of hemoperitoneum or ectopic rupture were not associated with MTX exposure. Body mass index, race, tubal anastomosis history, visualization of the adnexal lesion, and MTX exposure were not significantly associated with the salpingostomy rate in a multivariate logistic regression model, but having a subspecialist surgeon (odds ratio 2.70; 95% confidence interval, 1.08-6.76; p = .033) and tubal rupture at surgery (odds ratio 0.23; 95% confidence interval, 0.09-0.54; p = .001) were. CONCLUSION The initial medical management of an ectopic pregnancy with MTX is not associated with a decreased salpingostomy success rate.
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Baggio S, Garzon S, Russo A, Ianniciello CQ, Santi L, Laganà AS, Raffaelli R, Franchi M. Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant management. Arch Gynecol Obstet 2020; 303:259-268. [PMID: 32852572 PMCID: PMC7854461 DOI: 10.1007/s00404-020-05749-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 08/13/2020] [Indexed: 12/18/2022]
Abstract
Purpose To compare fertility and reproductive outcome after surgical, medical, and expectant management for tubal ectopic pregnancy (EP). Methods 133 of 228 patients, who were managed between January 2012 and December 2017 for a tubal EP, tried to conceive immediately after treatment: 86 out of 173 (49.7%) underwent surgical treatment; 38 (21.9%) were treated with methotrexate (MTX), and 49 (28.3%) had expectant management. Clinical data were retrieved by medical records, fertility outcomes were obtained by phone follow-up. The cumulative incidence (CI) of intrauterine clinical pregnancy (CP), miscarriage, live birth (LB), and recurrent EP, and the time between treatment and first intrauterine CP were compared between women treated with MTX, surgery and expectant management. Results The CI of intrauterine CP starting from 12 months after the EP was 65.3% for the expectant management, 55.3% for the MTX group, and 39.5% for surgery (p = 0.012). Post-hoc analysis showed expectant management having higher intrauterine CP and LB, and shorter time between treatment and first intrauterine CP compared to surgery (p < 0.05). The CI of recurrent EP was comparable between the 3 groups. The analysis stratified per βhCG cut-off of 1745 mUI/mL and EP mass cut-off of 25 mm reported consistent results. Conclusions Women successfully managed by expectation appear to have better reproductive outcomes compared to women who underwent surgery, with the shortest time to achieve a subsequent intrauterine CP. Therefore, if safely applicable the expectant management should be considered in the case of tubal EP. The fact that the chosen treatment was primarily guided by the βhCG value and EP mass diameter based on the protocol, which is intrinsically related to the characteristics of the EP, represents the main limitation of the present study. Indeed, we cannot completely exclude that the observed differences between treatments are related to the EP itself instead of the treatment.
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Affiliation(s)
- Silvia Baggio
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy. .,Department of Obstetrics and Gynecology, "Sacro Cuore" Hospital, Negrar Di Valpolicella, Verona, Italy.
| | - Simone Garzon
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Anna Russo
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | | | - Lorenza Santi
- Department of Endocrinology, Diabetes and Metabolism, AOUI Verona, University of Verona, Verona, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Ricciarda Raffaelli
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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Mitwally MF, Hozayen WG, Hassanin KMA, Abdalla KA, Abdalla NK. Aromatase inhibitor letrozole: a novel treatment for ectopic pregnancy. Fertil Steril 2020; 114:361-366. [PMID: 32622660 DOI: 10.1016/j.fertnstert.2020.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To study the use of the aromatase inhibitor letrozole for treatment of ectopic pregnancy compared with methotrexate. DESIGN Nonrandomized prospective cohort study. SETTING University hospital. PATIENT(S) A series of 42 consecutive patients with undisturbed ectopic pregnancy. INTERVENTION(S) Counseling on treatment options, including surgical treatment (control group) versus medical treatment with methotrexate (group 1) or letrozole (group 2). MAIN OUTCOME MEASURE(S) Primary outcome: complete resolution of ectopic pregnancy determined by serum human chorionic gonadotropin (β-hCG) levels below laboratory immunoassay detection. SECONDARY OUTCOMES changes in the biochemical parameter of ovarian reserve, antimüllerian hormone (AMH), and hematologic changes associated with the two medical treatments compared with surgical treatment. RESULT(S) Each treatment group included 14 patients, and each patient made her own treatment choice. Complete resolution of ectopic pregnancy occurred in an equal number of patients: 12 out of 14 (86%) in each of the two medical treatment groups. Methotrexate treatment was associated with statistically significantly higher liver enzymes and lower blood platelets count. The decline in β-hCG levels was faster in the letrozole group when compared with the methotrexate group. Three months after treatment, AMH levels were lower in the methotrexate group when compared with the letrozole and the surgery groups. However, the decline in β-hCG and AMH levels was not statistically significant. CONCLUSION(S) To our knowledge, this is the first report in the literature on the success of letrozole for the medical treatment of ectopic pregnancy. The promisingly high resolution rate and better safety profile that letrozole has compared with a chemotherapeutic agent such as methotrexate should encourage further studies.
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Affiliation(s)
| | - Walaa G Hozayen
- Biochemistry Division,Chemistry Department, Faculty of Science, Beni-Suef University, Beni-Suef, Egypt
| | - Kamel M A Hassanin
- Biochemistry Department, Faculty of Veterinary Medicine, Minia University, El-Minia, Egypt
| | - Kamal A Abdalla
- Department of Obstetrics & Gynecology, Faculty of Medicine, Minia University, El-Minia, Egypt
| | - Noha K Abdalla
- Biotechnology and Life Sciences Department, Faculty of Postgraduate Studies for Advanced Sciences, Beni-Suef University, Beni-Suef, Egypt
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Perlman BE, Guerrero K, Karsalia R, Heller DS. Reproductive outcomes following a ruptured ectopic pregnancy. EUR J CONTRACEP REPR 2020; 25:206-208. [PMID: 32343158 DOI: 10.1080/13625187.2020.1755032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Purpose: To determine the effect of ruptured ectopic pregnancies on the rate of future intrauterine pregnancies.Materials and Methods: This was a retrospective study of patients at a University-affiliated hospital with a history of an ectopic pregnancy between January 1991 to December 2016. All patients that underwent a salpingectomy for a tubal ectopic pregnancy were considered for this study. Intrauterine pregnancy rates for patients with a history of a ruptured ectopic pregnancy were compared to those with non-ruptured ectopic pregnancies. Fisher's exact test was used for analysis.Results: During the study period, 77 patients met the inclusion criteria. In this cohort, 14 patients with a history of a tubal ruptured ectopic pregnancy had achieved pregnancy within 12 months, compared to 24 patients in the non-ruptured group (52% vs 48%, p = 0.81). The rate of intrauterine pregnancies, compared to repeat ectopic pregnancy, in both the ruptured and non-ruptured group, was 71% (p > 0.99).Conclusion(s): Ruptured ectopic pregnancies did not adversely affect the rate of intrauterine pregnancy within 12 months of rupture when compared to non-ruptured ectopic pregnancies.
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Affiliation(s)
- Barry E Perlman
- Departments of Obstetrics, Gynecology and Women's Health, Rutgers-New Jersey Medical School, Newark NJ, USA
| | - Kerly Guerrero
- Departments of Obstetrics, Gynecology and Women's Health, Rutgers-New Jersey Medical School, Newark NJ, USA
| | - Ruchi Karsalia
- Departments of Obstetrics, Gynecology and Women's Health, Rutgers-New Jersey Medical School, Newark NJ, USA
| | - Debra S Heller
- Departments of Obstetrics, Gynecology and Women's Health, Rutgers-New Jersey Medical School, Newark NJ, USA.,Pathology, Immunology and Laboratory Medicine, New Jersey Medical School, Rutgers-New Jersey Medical School, Newark NJ, USA
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Wang X, Huang L, Yu Y, Xu S, Lai Y, Zeng W. Risk factors and clinical characteristics of recurrent ectopic pregnancy: A case-control study. J Obstet Gynaecol Res 2020; 46:1098-1103. [PMID: 32281241 PMCID: PMC7384140 DOI: 10.1111/jog.14253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To compare signs and symptoms between patients with recurrent ectopic pregnancies (REP) and primary ectopic pregnancies (PEP) and to identify potential risk factors of REP. MATERIALS AND METHODS Data from 2014 to 2016 were analyzed. The study included 81 women each diagnosed with REP and PEP with no recurrence of ectopic pregnancy (EP) before January 2019. Information, including historical factors and findings at presentation of both group were collected. Data were compared between the two groups. Associations between REP and the risk factors were analyzed by logistic regression. RESULTS The findings revealed that compared to the patients in the PEP group, REP patients had significantly lower education (P = 0.001), higher proportion of previous infertility (P < 0.001) and different methods of PEP treatment (P = 0.001). Clinical data of the last operation revealed significantly higher occurrences of pelvic and peritubal adhesions (P < 0.05). Further multiple regression analysis showed that lower educational background (odds ratio [OR] = 4.183 95% confidence interval [CI] 1.311-13.344 P = 0.016), nulliparity (OR = 12.312 95% CI 3.382-44.824 P < 0.001), history of salpingotomy (OR = 7.129 95% CI 1.022-49.748 P < 0.05) and abortion (OR for one abortion = 21.576, P = 0.001; OR for two abortions =36.794, P < 0.001; OR for three abortions or more = 119.013, P < 0.001) were significant risk factors for REP. CONCLUSION Active education on contraception is required for patients with lower educational level and history of abortion. Different plans should be formulated for patients with EP. For EP patients wanting fertility, the risk between fertility preservation and REP needs to be evaluated as reproductive function cannot be pursued blindly while ignoring the risk of recurrence.
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Affiliation(s)
- Xinyan Wang
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Lu Huang
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Yan Yu
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Sheng Xu
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Yucheng Lai
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Wenjie Zeng
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
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Levin G, Dior UP, Shushan A, Gilad R, Benshushan A, Rottenstreich A. Success rate of methotrexate treatment for recurrent vs. primary ectopic pregnancy: a case-control study. J OBSTET GYNAECOL 2019; 40:507-511. [DOI: 10.1080/01443615.2019.1621819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Uri P. Dior
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Asher Shushan
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronit Gilad
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Avi Benshushan
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Ectopic pregnancy and outcomes of future intrauterine pregnancy. Fertil Steril 2019; 112:112-119. [DOI: 10.1016/j.fertnstert.2019.03.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/27/2019] [Accepted: 03/11/2019] [Indexed: 01/09/2023]
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Ranji GG, Usha Rani G, Varshini S. Ectopic Pregnancy: Risk Factors, Clinical Presentation and Management. J Obstet Gynaecol India 2018; 68:487-492. [PMID: 30416277 DOI: 10.1007/s13224-017-1075-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/04/2017] [Indexed: 11/25/2022] Open
Abstract
Background Ectopic pregnancy is increasing in incidence. Nevertheless, there is wide availability of tools for early diagnosis and advances in management. Though it is not a leading cause of maternal mortality, it significantly causes morbidity and jeopardizes reproductive outcome in women desirous of fertility. Aims To determine incidence, risk factors, symptoms, signs, type of ectopic pregnancy and management. Settings and Design This is a one-year prospective, descriptive study conducted in Department of Obstetrics and Gynaecology, Sri Ramachandra Medical College and Research Institute, Porur, Chennai. Results There were 119 ectopic pregnancies during the study period. The incidence of ectopic pregnancy is 2.81/100 deliveries. Ectopic pregnancy was common in 26-30 years, the minimum age at diagnosis was 18 years and maximum age was 40 years. Fourteen women had previous one ectopic pregnancy. Four had previous two ectopic pregnancies. Previous cesarean and treatment for infertility were the commonest risk factors. The classic triad was present in only 27.7% of patients. Fourteen patients presented with shock. Five women were diagnosed even before they missed their periods. Success rate of medical treatment with methotrexate is 83.33%. Tubal pregnancy was the commonest type, and ampulla was the commonest site. Right side was affected more than left side. Thirty-three patients (27.7%) required blood transfusion. Seven developed morbidity. After 1-year follow-up of 68 women who were desirous of fertility, five women have become pregnant subsequently with intrauterine gestation.
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Affiliation(s)
- G Geovin Ranji
- Department of Obstetrics and Gynaecology, Sri Ramachandra Medical College and Research Institute, Chennai, 600097 India
| | - G Usha Rani
- Department of Obstetrics and Gynaecology, Sri Ramachandra Medical College and Research Institute, Chennai, 600097 India
| | - Sri Varshini
- Department of Obstetrics and Gynaecology, Sri Ramachandra Medical College and Research Institute, Chennai, 600097 India
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Factors Predicting Persistent Ectopic Pregnancy After Laparoscopic Salpingostomy or Salpingotomy for Tubal Pregnancy: A Retrospective Cohort Study. J Minim Invasive Gynecol 2018; 26:1036-1043. [PMID: 30312675 DOI: 10.1016/j.jmig.2018.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/20/2018] [Accepted: 10/04/2018] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To identify factors predictive of persistent ectopic pregnancy (PEP) in women who have undergone laparoscopic salpingostomy or salpingotomy for tubal pregnancy. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING Tertiary referral center. PATIENTS Ninety-nine women who underwent laparoscopic tubal preservation surgery for ectopic pregnancy. INTERVENTIONS Seventy women underwent laparoscopic salpingostomy, and the remaining 29 women underwent laparoscopic salpingotomy. MEASUREMENTS AND MAIN RESULTS Factors predicting PEP were evaluated. The change in serum beta human chorionic gonadotropin (β-hCG) levels from baseline observed between postoperative days 5 and 10 (ChCGD5-10) was a predictor of PEP (odds ratio [OR], 0.80; p = .01). Based on receiver operating characteristic (ROC) curve analysis, a cutoff value of 93.1% was determined, with an area under the ROC curve of 0.95 (sensitivity, 85.7%; specificity, 100%). Nonetheless, when considering perioperative variables only, body mass index (BMI) was identified as a predictor of PEP (OR, 0.71; p = .03). Based on the ROC analysis, a BMI cutoff value of ≤22 kg/m2 was determined, with an ROC area of 0.73 (sensitivity, 43.2%; specificity, 100%). In addition, a higher baseline β-hCG level (hazard ratio [HR], 1.0002; p = .009) and left tubal pregnancy (HR, 6.46; p = .03) were predictive of recurrent ectopic pregnancy. There were no differences in the perioperative outcomes, PEP rates, or subsequent intrauterine pregnancy rates between the salpingostomy and salpingotomy groups. In addition, surgical method was not a predictor of recurrent ectopic pregnancy. CONCLUSIONS ChCGD5-10 was identified as a predictor for PEP, suggesting that it might be more clinically useful for the follow-up of PEP. When considering perioperative variables only, BMI was a predictor for PEP. In addition, there was no significant difference in clinical outcomes between the salpingostomy and salpingotomy groups.
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Nicolaus K, Jimenez-Cruz J, Bräuer DM, Lehmann T, Mothes AR, Runnebaum IB. Endometriosis and Beta-hCG > 775 IU/l Increase the Risk of Non-tube-preserving Surgery for Tubal Pregnancy. Geburtshilfe Frauenheilkd 2018; 78:690-696. [PMID: 30057425 PMCID: PMC6059851 DOI: 10.1055/a-0635-8453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/23/2018] [Accepted: 05/28/2018] [Indexed: 11/28/2022] Open
Abstract
Introduction
Tubal pregnancy is the most clinically relevant form of ectopic pregnancy. Surgery consisting of laparoscopic salpingotomy is the therapeutic gold standard. This study looked at risk factors for non-tube-preserving surgery. The aim was to determine a cut-off value for beta-hCG levels, which could be used to predict the extent of tubal surgery.
Materials and Method
97 patients with tubal pregnancy who underwent primary salpingotomy in the Department of Gynecology and Obstetrics of Jena University Hospital between 2010 and 2016 were retrospectively analyzed. A prior medical history of risk factors such as adnexitis, ectopic pregnancy, tubal surgery, treatment for infertility and intrauterine pessary was included in the analysis. The study population was divided into two subgroups: (1) a group which underwent laparoscopic linear salpingotomy, and (2) a group which had laparoscopic partial tubal resection or salpingectomy. Risk factors for salpingectomy were determined using binary logistic regression analysis. Statistical analysis was done using SPSS, version 24.0, to identify risk factors for non-tube-preserving surgery.
Results
68 patients (70.1%) underwent laparoscopic salpingotomy and 29 patients (29.9%) had laparoscopic salpingectomy. The two groups differed with regard to age (p = 0.01) but not with regard to the parameters ‘gestational age’, ‘viability and rupture status of the ectopic pregnancy’ or ‘symptoms at presentation’. Patients who were known to have endometriosis prior to surgery or who were diagnosed with endometriosis intraoperatively were more likely to undergo salpingectomy (OR: 3.28; 95% CI: 0.9 – 10.8; p = 0.05). Calculated mean beta-hCG levels were higher in the salpingectomy group compared to the group who had tube-preserving salpingotomy (3277.8 IU/l vs. 9338.3 IU/l, p = 0.01). A cut-off beta-hCG value of 775 IU/l prior to surgery was predictive for salpingectomy with a true positive rate of 86.2% and increased the probability that salpingectomy would be necessary (OR: 5.23; 95% CI: 0.229 – 0.471; p = 0.005).
Conclusion
Endometriosis and a beta-hCG value of more than 775 IU/l significantly increased the risk for non-tube-preserving surgery in women with tubal pregnancy.
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Affiliation(s)
- Kristin Nicolaus
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Jorge Jimenez-Cruz
- Abteilung für Geburtshilfe und Pränatalmedizin, Universitatsklinikum Bonn, Bonn, Germany
| | - Dominik Michael Bräuer
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Thomas Lehmann
- Institut für Medizinische Statistik, Informatik und Dokumentation, Universitätsklinikum Jena, Jena, Germany
| | - Anke Regina Mothes
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Ingo B Runnebaum
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
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Kontomanolis EN, Kalagasidou S, Fasoulakis Z. MicroRNAs as Potential Serum Biomarkers for Early Detection of Ectopic Pregnancy. Cureus 2018; 10:e2344. [PMID: 29796356 PMCID: PMC5959728 DOI: 10.7759/cureus.2344] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Diagnosis of ectopic pregnancy relies on both ultrasound findings and human chorionic gonadotropin (hCG) measurements but due to the need for serial tests, tubal rupture and death represent major maternal and fetal risks. Early detection of ectopic pregnancy is essential and thus a noninvasive diagnostic tool seems crucial for the prevention of adverse effects since studies suggest there is a specific relationship between ectopic pregnancy and increasing microRNA factors. Human fluids in women with ectopic pregnancy reveal a particular change in comparison to healthy women. In addition to certain placental microRNAs circulating through plasma that present a specific concentration and serum profile, microRNAs seem to be possible biomarkers for the detection of pregnancy complications linked to placental pathologies. The aim of this study is to review current literature considering the expression levels of several circulating microRNAs that have shown to be novel potential biomarkers for the diagnosis of tubal ectopic pregnancy.
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Affiliation(s)
- Emmanuel N Kontomanolis
- Obstetrics and Gynecology, Democritus University of Thrace, University Hospital of Alexandroupolis
| | - Sofia Kalagasidou
- Department of Obstetrics and Gynecology, Bodosakio General Hospital of Ptolemaida
| | - Zacharias Fasoulakis
- Obstetrics and Gynecology, Democritus University of Thrace, University Hospital of Alexandroupolis
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Hoyos LR, Vilchez G, Allsworth JE, Malik M, Rodriguez-Kovacs J, Adekola H, Awonuga AO. Outcomes in subsequent pregnancies after wedge resection for interstitial ectopic pregnancy: a retrospective cohort study. J Matern Fetal Neonatal Med 2018; 32:2354-2360. [DOI: 10.1080/14767058.2018.1437411] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Luis R. Hoyos
- Department of Obstetrics & Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI, USA
| | - Gustavo Vilchez
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, University of Missouri – Kansas City School of Medicine, Kansas City, MO, USA
| | | | - Mokerrum Malik
- Department of Obstetrics & Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI, USA
| | - Javier Rodriguez-Kovacs
- Department of Obstetrics & Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI, USA
| | - Henry Adekola
- Division of Maternal–Fetal Medicine, Department of Obstetrics & Gynecology, Hurley Medical Center, Michigan State University, Flint Campus, Detroit, MI, USA
| | - Awoniyi O. Awonuga
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics & Gynecology, Wayne State University/Hutzel Women’s Hospital, Detroit, MI, USA
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Hastie R, Lim E, Sluka P, Campbell L, Horne AW, Ellett L, Hannan NJ, Brownfoot F, Kaitu'u-Lino TJ, Tong S. Vinorelbine Potently Induces Placental Cell Death, Does Not Harm Fertility and is a Potential Treatment for Ectopic Pregnancy. EBioMedicine 2018; 29:166-176. [PMID: 29429891 PMCID: PMC5925452 DOI: 10.1016/j.ebiom.2018.01.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/15/2018] [Accepted: 01/31/2018] [Indexed: 11/30/2022] Open
Abstract
Ectopic pregnancies complicate 1–2 pregnancies and are a leading cause of maternal death. An effective oral drug therapy that replaces surgery might make its treatment safer, cheaper, simpler and therefore more widely accessible. The only current medical treatment offered to women is intramuscular methotrexate, but this only reliably resolves smaller ectopic pregnancies. As such, many ectopic pregnancies require surgical excision. We show that vinorelbine, an orally available chemotherapeutic agent, potently induced placental cell death but did not harm fertility in mice. Vinorelbine was 100–1000 times more potent than methotrexate in inducing placental cell death in vitro, and more potent than combination methotrexate and gefitinib (another proposed treatment for ectopic pregnancy being evaluated in phase III trials). Mechanistically, it caused microtubule condensation, blocked mitosis and activated the apoptosis cascade in placental cells. Vinorelbine was more efficacious than methotrexate ± gefitinib in reducing the volume of placental cell tumors xenografted subcutaneously in SCID mice. Mice exposed to vinorelbine and allowed to breed, following a four week washout period, displayed normal fertility, however long-term fertility was not assessed. Human Fallopian tubes treated with vinorelbine did not exhibit up-regulation of apoptosis molecules. Our findings show that placental cells appear sensitive to vinorelbine and it has potential as a tablet-only approach to treat ectopic pregnancy. We have identified vinorelbine, a well tolerated chemotherapeutic, as a potential therapeutic for ectopic pregnancy. Vinorelbine potently reduced placental cell viability in-vitro and in-vivo and proved more efficacious than the current medical therapeutic. Vinorelbine did not impact upon subsequent fertility in a mouse breeding model.
Ectopic pregnancy occurs when a conceptus implants outside of the womb. They are life threating and are a leading cause of maternal death in early pregnancy. Currently, the large majority of ectopic pregnancies are removed surgical, partly owing to the limited efficacy of the only available medical therapeutic, methotrexate. Here, we have identified a potential new medical therapeutic for ectopic pregnancy, vinorelbine. Vinorelbine, which is orally available chemotherapeutic, reduced placental cell viability both in-vitro and in-vivo and did not impact upon mice fertility in a breeding model. As such, vinorelbine may be an efficacious treatment for ectopic pregnancy and further human studies into its application are warranted.
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Affiliation(s)
- Roxanne Hastie
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia.
| | - Elgene Lim
- Connie Johnson Breast Cancer Research Group, Garvan Institute of Medical Research, Sydney, Australia
| | - Pavel Sluka
- Uro-Oncology Laboratory, Monash University, Eastern Health Clinical School, Melbourne, Australia
| | - Lisa Campbell
- MRC Centre for Reproductive Health, The University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | - Andrew W Horne
- MRC Centre for Reproductive Health, The University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK
| | | | - Natalie J Hannan
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
| | - Fiona Brownfoot
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
| | - Tu'uhevaha J Kaitu'u-Lino
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, Victoria 3084, Australia; Mercy Perinatal, Mercy Hospital for Women, Victoria, Australia
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31
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Mikhail E, Salemi JL, Schickler R, Salihu HM, Plosker S, Imudia AN. National rates, trends and determinants of inpatient surgical management of tubal ectopic pregnancy in the United States, 1998-2011. J Obstet Gynaecol Res 2018; 44:730-738. [PMID: 29359520 DOI: 10.1111/jog.13588] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/18/2017] [Indexed: 11/30/2022]
Abstract
AIM To describe the frequency and temporal trends of inpatient hospitalization for tubal ectopic pregnancy as well as patients' characteristics, determinants and the current national trends in surgical management of ectopic pregnancy. METHODS We conducted a retrospective, cross-sectional analysis of patients who were treated for tubal ectopic pregnancy in an inpatient hospital setting in the United States from 1998 to 2011 using data from the Nationwide Inpatient Sample databases. National frequency and significant changes in the rate of surgical management of tubal ectopic pregnancy in the inpatient setting are described. RESULTS The study included 334 639 tubal ectopic pregnancies for women aged 18-50 in the United States from 1998 to 2011. The rate of tubal ectopic pregnancy (per 10 000 maternal admissions) decreased from 77.2 in 1998 to 40.5 in 2011. The proportion of tubal ectopic pregnancies for which salpingostomy was performed decreased from 17.0% in 1998 to 7.0% in 2011, while the rate of salpingectomy increased from 69.3% in 1998 to 80.9% in 2011. The temporal change in surgical choice was not different in states with comprehensive in vitro fertilization insurance mandates. CONCLUSION The rate of tubal ectopic pregnancy managed in the inpatient setting in the United States decreased 5% annually between 1998 and 2011. The rate of salpingectomies performed annually increased whereas that of salpingostomy decreased over time. The surgical approach selected for the management of tubal ectopic pregnancies was not influenced by a state's in vitro fertilization mandate status.
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Affiliation(s)
- Emad Mikhail
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Robyn Schickler
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Hamisu M Salihu
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Shayne Plosker
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Anthony N Imudia
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
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Phillips CH, Wortman JR, Ginsburg ES, Sodickson AD, Doubilet PM, Khurana B. First-trimester emergencies: a radiologist's perspective. Emerg Radiol 2017; 25:61-72. [PMID: 28948411 DOI: 10.1007/s10140-017-1556-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 09/13/2017] [Indexed: 12/27/2022]
Abstract
The purpose of this article is to help the practitioner ensure early diagnosis and response to emergencies in the first trimester by reviewing anatomy of the developing embryo, highlighting the sonographic appearance of common first-trimester emergencies, and discussing key management pathways for treating emergent cases. First-trimester fetal development is a stepwise process that can be challenging to evaluate in the emergency department (ED) setting. This is due, in part, to the complex anatomy of early pregnancy, subtlety of the sonographic findings, and the fact that fewer than half of patients with ectopic pregnancy present with the classic clinical findings of a positive pregnancy test, vaginal bleeding, pelvic pain, and tender adnexa. Ultrasound (US) has been the primary approach to diagnostic imaging of first-trimester emergencies, with magnetic resonance imaging (MRI) and computed tomography (CT) playing a supportive role in a small minority of cases. Familiarity with the sonographic findings diagnostic of and suspicious for early pregnancy failure, ectopic pregnancy, retained products of conception, gestational trophoblastic disease, failed intrauterine devices, and complications associated with assisted reproductive technology (ART) is critical for any emergency radiologist. Evaluation of first-trimester emergencies is challenging, and knowledge of key imaging findings and familiarity with management pathways are needed to ensure early diagnosis and response.
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Affiliation(s)
- Catherine H Phillips
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Jeremy R Wortman
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Elizabeth S Ginsburg
- Department of Infertility and Reproductive Surgery, Obstetrics and Gynecology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Aaron D Sodickson
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Peter M Doubilet
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Bharti Khurana
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Hsu JY, Chen L, Gumer AR, Tergas AI, Hou JY, Burke WM, Ananth CV, Hershman DL, Wright JD. Disparities in the management of ectopic pregnancy. Am J Obstet Gynecol 2017; 217:49.e1-49.e10. [PMID: 28288792 PMCID: PMC5484775 DOI: 10.1016/j.ajog.2017.03.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/26/2017] [Accepted: 03/02/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ectopic pregnancy is common among young women. Treatment can consist of either surgery with salpingectomy or salpingostomy or medical management with methotrexate. In addition to acute complications, treatment of ectopic pregnancy can result in long-term sequelae that include decreased fertility. Little is known about the patterns of care and predictors of treatment in women with ectopic pregnancy. Similarly, data on outcomes for various treatments are limited. OBJECTIVE We examined the patterns of care and outcomes for women with ectopic pregnancy. Specifically, we examined predictors of medical (vs surgical) management of ectopic pregnancy and tubal conservation (salpingostomy vs salpingectomy) among women who underwent surgery. STUDY DESIGN The Perspective database was used to identify women with a diagnosis of tubal ectopic pregnancy treated from 2006-2015. Perspective is an all-payer database that collects data on patients at hospitals from throughout the United States. Women were classified as having undergone medical treatment, if they received methotrexate, and surgical treatment, if treatment consisted of salpingostomy or salpingectomy. Multivariable models were developed to examine predictors of medical treatment and of tubal conserving salpingostomy among women who were treated surgically. RESULTS Among the 62,588 women, 49,090 women (78.4%) were treated surgically, and 13,498 women (21.6%) received methotrexate. Use of methotrexate increased from 14.5% in 2006 to 27.3% by 2015 (P<.001). Among women who underwent surgery, salpingostomy decreased over time from 13.0% in 2006 to 6.0% in 2015 (P<.001). Treatment in more recent years, at a teaching hospital and at higher volume centers, were associated with the increased use of methotrexate (P<.05 for all). In contrast, Medicaid recipients (adjusted risk ratio, 0.92; 95% confidence interval, 0.87-0.98) and uninsured women (adjusted risk ratio, 0.87; 95% confidence interval, 0.82-0.93) were less likely to receive methotrexate than commercially insured patients. Among those who underwent surgery, black (adjusted risk ratio, 0.76; 95% confidence interval, 0.69-0.85) and Hispanic (adjusted risk ratio, 0.80; 95% confidence interval, 0.66-0.96) patients were less likely to undergo tubal conserving surgery than white women and Medicaid recipients (adjusted risk ratio, 0.69; 95% confidence interval, 0.64-0.75); uninsured women (adjusted risk ratio, 0.60; 95% confidence interval, 0.55-0.66) less frequently underwent salpingostomy than commercially insured patients. CONCLUSION There is substantial variation in the management of ectopic pregnancy. There are significant race- and insurance-related disparities associated with treatment.
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Affiliation(s)
- Jennifer Y Hsu
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Ling Chen
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Arielle R Gumer
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Ana I Tergas
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; New York Presbyterian Hospital, New York, NY
| | - June Y Hou
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Hospital, New York, NY
| | - William M Burke
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Hospital, New York, NY
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Dawn L Hershman
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; New York Presbyterian Hospital, New York, NY
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Hospital, New York, NY.
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Zhang B, Cao L, Ding L, Yan L, Chen ZJ. Effect of different ectopic pregnancy treatments on cryopreserved embryo transfer outcomes: A retrospective cohort study. Gynecol Minim Invasive Ther 2017; 6:103-107. [PMID: 30254890 PMCID: PMC6135176 DOI: 10.1016/j.gmit.2017.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 01/02/2017] [Accepted: 01/03/2017] [Indexed: 11/19/2022] Open
Abstract
Objective To evaluate the effects of different treatment methods for previous ectopic pregnancies (EP) on cryopreserved embryo transfer (CET) outcomes. Materials and Methods This was a retrospective cohort study. Patients with EP histories were divided into four groups based on their previous EP treatments: Group 1-unilateral tubal removal; Group: 2-bilateral tubal removal or unilateral tubal removal with contralateral tubal ligation; Group: 3-conservative surgery group; and Group 4-conservative medication group. A total of 1333 women with previous histories of being admitted to the hospital for CET treatment were consecutively enrolled between January 2009 and December 2014. Results Patients who underwent bilateral tubal ligation or removal had a lower miscarriage rate [8.88% vs. 3.46%, p = 0.006, odds ratio = 2.718, 95% confidence interval (CI) = 1.301-5.677] than those who underwent unilateral tubal removal. No significant difference was observed in the rate of EP after CET in the four groups in women with EP histories. (p1 = 0.258, 95%CI = 0.113-1.836; p2 = 0.137, 95%CI = 0.975-0.997; p3 = 0.314, 95%CI = 0.987-1.001; p4 = 0.198, 95%CI = 0.987-1.001). The groups were not different with regard to other pregnancy outcomes. Conclusion There was no significant difference among EP treatment methods with regard to their impacts on CET outcomes in women with EP histories. Bilateral tubal ligation or removal surgery can decrease the miscarriage rate after CET.
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Affiliation(s)
- Bingqian Zhang
- Center for Reproductive Medicine, Shandong University, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Jinan, China
- The Key laboratory for Reproductive Endocrinology of Ministry of Education, Jinan, China
- Shandong Provincial Key Laboratory of Reproductive Medicine, Jinan, China
| | - Lianbao Cao
- Center for Reproductive Medicine, Shandong University, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Jinan, China
- The Key laboratory for Reproductive Endocrinology of Ministry of Education, Jinan, China
- Shandong Provincial Key Laboratory of Reproductive Medicine, Jinan, China
| | - Lingling Ding
- Center for Reproductive Medicine, Shandong University, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Jinan, China
- The Key laboratory for Reproductive Endocrinology of Ministry of Education, Jinan, China
- Shandong Provincial Key Laboratory of Reproductive Medicine, Jinan, China
| | - Lei Yan
- Center for Reproductive Medicine, Shandong University, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Jinan, China
- The Key laboratory for Reproductive Endocrinology of Ministry of Education, Jinan, China
- Shandong Provincial Key Laboratory of Reproductive Medicine, Jinan, China
- Corresponding authors. Centre for Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan 250021, China. E-mail addresses: (L. Yan), (Z.-J. Chen)
| | - Zi-Jiang Chen
- Center for Reproductive Medicine, Shandong University, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Jinan, China
- The Key laboratory for Reproductive Endocrinology of Ministry of Education, Jinan, China
- Shandong Provincial Key Laboratory of Reproductive Medicine, Jinan, China
- Corresponding authors. Centre for Reproductive Medicine, Shandong Provincial Hospital Affiliated to Shandong University, 157 Jingliu Road, Jinan 250021, China. E-mail addresses: (L. Yan), (Z.-J. Chen)
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Irani M, Robles A, Gunnala V, Spandorfer SD. Unilateral Salpingectomy and Methotrexate Are Associated With a Similar Recurrence Rate of Ectopic Pregnancy in Patients Undergoing In Vitro Fertilization. J Minim Invasive Gynecol 2017; 24:777-782. [PMID: 28285056 DOI: 10.1016/j.jmig.2017.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 02/28/2017] [Accepted: 03/01/2017] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVE To determine whether different treatment approaches of ectopic pregnancy (EP), particularly unilateral salpingectomy and methotrexate, affect its recurrence rate in patients undergoing in vitro fertilization (IVF). DESIGN A retrospective cohort study (Canadian Task Force classification II-2). SETTING An academic medical center. PATIENTS Patients with a history of a previous EP who achieved pregnancy after IVF cycles between January 2004 and August 2015 were included. The recurrence rate of EP was compared between patients who underwent different treatment approaches for a previous EP. INTERVENTIONS IVF. MEASUREMENTS AND MAIN RESULTS A total of 594 patients were included. Seventeen patients had a recurrence of EP (2.9%). Patients with a history of ≥2 EPs were associated with a significantly higher recurrence rate of EP than those with 1 previous EP (8.5% vs. 1.8%; p = .01; odds ratio [OR] = 2.2; 95% confidence interval [CI], 1.2-4.4). Patients who underwent unilateral salpingectomy (n = 245) had a comparable recurrence rate of EP after IVF with those who received methotrexate (n = 283) (3.6% vs. 2.8%; p = .5; OR = 1.3; 95% CI, 0.4-3.4). This OR remained unchanged after adjusting for patient's age, number of previous EPs, number of transferred embryos, and peak estradiol level during stimulation (adjusted OR = 1.4; 95% CI, 0.5-3.8). None of the patients who underwent bilateral salpingectomy (n = 45) or salpingostomy (n = 21) had a recurrence of EP after IVF. CONCLUSION The recurrence rate of EP significantly correlates with the number of previous EPs. Treatment of EP with methotrexate has a comparable recurrence rate of EP after IVF with unilateral salpingectomy. Therefore, the risk of recurrence should not be a reason to favor salpingectomy over methotrexate in this population.
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Affiliation(s)
- Mohamad Irani
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York
| | - Alex Robles
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, New York
| | - Vinay Gunnala
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York
| | - Steven D Spandorfer
- Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medicine, New York, New York.
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Brady PC, Ginsburg ES. An Updated Review of Ectopic Pregnancies Resulting from Assisted Reproduction. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0196-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Park EHG, Mohammadi-Zaniani G, Pronin S, Elderfield CHJ, Duncan WC. Subsequent pregnancy outcome of tubal ectopic pregnancies treated by methotrexate and salpingectomy. Eur J Obstet Gynecol Reprod Biol 2017; 212:192-193. [PMID: 28238473 DOI: 10.1016/j.ejogrb.2017.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/14/2017] [Accepted: 02/15/2017] [Indexed: 10/20/2022]
Affiliation(s)
| | | | - Savva Pronin
- University of Edinburgh Medical School, Edinburgh, UK
| | | | - W Colin Duncan
- University of Edinburgh Medical School, Edinburgh, UK; Pregnancy Support Centre, The Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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Kudesia R, Talib HJ, Pollack SE. Fertility Awareness Counseling for Adolescent Girls; Guiding Conception: The Right Time, Right Weight, and Right Way. J Pediatr Adolesc Gynecol 2017; 30:9-17. [PMID: 27486027 DOI: 10.1016/j.jpag.2016.07.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 07/25/2016] [Accepted: 07/25/2016] [Indexed: 11/28/2022]
Abstract
STUDY OBJECTIVE To provide a detailed summary of fertility awareness counseling pearls for healthy teens and those with fertility-relevant comorbidities, and to assist providers in offering such counseling to adolescents and young adult women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Comprehensive literature review of English-language studies relating to fertility in pediatric and adolescent female patients (ages 13-21 years), and evidence-based dialogue guide. RESULTS The literature indicates that although adolescents are interested in discussing sexuality and reproduction, this is commonly overlooked during the standard office medical visit. As a result, adolescents often turn to less reliable sources and hold a variety of reproductive misconceptions and a sense of lack of control over future fertility. We found no studies that examined the routine provision of fertility awareness counseling with healthy adolescents. There are a multitude of specific gynecologic and medical conditions that have ramifications for fertility. We detail these comprehensively, and provide a dialogue guide to assist with fertility awareness counseling for the female adolescent, containing specific information and indications for referral. CONCLUSION Providers caring for adolescent girls have the opportunity to enhance fertility awareness as part of a larger reproductive health conversation that adolescents desire, and from which they might benefit. Identifying potential future fertility issues, understanding age-related fertility decline, and aiding in health optimization before future conception might empower the adolescent to make informed reproductive decisions. We provide an algorithm to use with adolescents to discuss the "right time, right weight, right way" to pursue childbearing.
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Affiliation(s)
- Rashmi Kudesia
- Division of Reproductive Endocrinology and Infertility, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Hina J Talib
- Division of Adolescent Medicine, Department of Pediatrics, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Staci E Pollack
- Division of Reproductive Endocrinology and Infertility, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Kallner HK, Danielsson KG. Prevention of unintended pregnancy and use of contraception-important factors for preconception care. Ups J Med Sci 2016; 121:252-255. [PMID: 27646655 PMCID: PMC5098489 DOI: 10.1080/03009734.2016.1208310] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Preservation of fertility and optimizing health before pregnancy is becoming increasingly important in societies where childbirth often is postponed. Research shows that as women postpone childbirth they achieve higher levels of education and higher incomes. This leads to advantages for their children and for society. However, as women postpone childbearing they are at risk for contracting conditions which may affect fertility and/or pregnancies, pregnancy outcome, and the newborn child. Preconception counseling is therefore becoming increasingly important. Women are often unaware of the added health benefits of contraception and have the right to be well informed so they can make decisions to fulfill their reproductive desires. Contraception can reduce the risk of unintended pregnancies, ectopic and molar pregnancies, and sexually transmitted infections. In addition, hormonal contraceptives reduce the risk of some types of cancer, dysmenorrhea, heavy menstrual bleeding, and anemia and are a treatment for endometriosis. Contraception should increasingly be looked upon as a means of preserving fertility and optimizing health status before a planned pregnancy. Thus, effective contraception can provide women with a possibility of achieving their long-term reproductive goals, although childbearing is actually postponed. The most effective contraceptive methods are the long-acting reversible contraceptives, which have been shown to be highly effective especially in young women who have difficulties with adherence to user-dependent methods. Therefore, these methods should increasingly be promoted in all age groups.
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Affiliation(s)
- Helena Kopp Kallner
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
- CONTACT Helena Kopp Kallner, MD, PhD Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital, 182 88 Stockholm, Sweden
| | - Kristina Gemzell Danielsson
- Department of Women’s and Children’s Health, Division of Obstetrics and Gynecology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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Odejinmi F, Huff KO, Oliver R. Individualisation of intervention for tubal ectopic pregnancy: historical perspectives and the modern evidence based management of ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2016; 210:69-75. [PMID: 27940397 DOI: 10.1016/j.ejogrb.2016.10.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/21/2016] [Indexed: 11/30/2022]
Abstract
Historically, ectopic pregnancy was a life-threatening condition where diagnosis was possible only at post mortem or laparotomy and maternal mortality was up to 90%. The evolution in the management of ectopic pregnancy has meant that diagnosis can be made using non-invasive techniques with an aim to identify the ectopic gestation before tubal rupture. This enables health care professionals to offer management options that consider not only maternal mortality, but morbidity and fertility outcomes as well. In spite of this, diagnostic techniques and management options are not without limitations. Research is currently focused on new tests with a single diagnostic capability, diagnostic and treatment algorithms and safe methods of triaging patients. This article aims to review the current literature on the diagnosis and management of ectopic pregnancy and to formulate a pathway to help individualise care and achieve the best possible outcome.
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Affiliation(s)
- Funlayo Odejinmi
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK.
| | - Keren O Huff
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK
| | - Reeba Oliver
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK
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Pirot F, Laas E, Girard G. [Can salpingectomy be proposed first line in case of ectopic pregnancy?]. ACTA ACUST UNITED AC 2016; 44:526-7. [PMID: 27568412 DOI: 10.1016/j.gyobfe.2016.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/13/2016] [Indexed: 11/30/2022]
Affiliation(s)
- F Pirot
- Service de gynécologie-obstétrique, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France.
| | - E Laas
- Service de gynécologie-obstétrique, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
| | - G Girard
- Service de gynécologie-obstétrique, hôpital Armand-Trousseau, AP-HP, 26, avenue du Docteur-Arnold-Netter, 75012 Paris, France
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Ding Y, Huang W, Jiang H, Zhu J. A new tubal classification system for fertility prognosis after laparoscopic salpingostomy for tubal pregnancy. Eur J Obstet Gynecol Reprod Biol 2016; 203:136-41. [PMID: 27285304 DOI: 10.1016/j.ejogrb.2016.03.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 03/20/2016] [Accepted: 03/23/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the objectivity and accuracy of a new system that predicts the pregnancy outcomes in patients with tubal pregnancy after laparoscopic salpingostomy. STUDY DESIGN 480 tubal pregnancy patients were retrospectively stratified as mild, moderate, or severe group according to the new tubal classification system in which pelvic adhesions, tubal morphology, structure, and patency were included. The follow-up was performed for 24 months to determine spontaneous pregnancy outcomes. RESULTS The tubal classification was significantly associated with intrauterine pregnancy rates (mild 70.9% vs. moderate 66.0% vs. severe 41.8%, P=0.001) and recurrent ectopic pregnancy rates (mild 2.8% vs. moderate 4.2% vs. severe 10.9%, P=0.047). The 24-month cumulative rate of intrauterine pregnancy was 73.5% in the mild group, 68.5% in the moderate group, and 45.8% in the severe group (P=0.002). The 24-month cumulative repeat ectopic pregnancy rate was 6.6% in the mild group, 9.1% in the moderate group, and 15% in the severe group (P=0.154). In Cox multivariate regression analysis, a lack of a history of infertility [hazard ratio (HR)=0.633, P=0.001] and tubal scoring (mild HR=2.408, P=0.008; moderate HR=2.147, P=0.010) were significantly associated with a higher rate of spontaneous intrauterine pregnancy. Having a history of infertility (HR=0.351, P=0.037) and no prior abdominopelvic surgery (HR=2.907, P=0.014) were significantly associated with a lower ectopic pregnancy rate. CONCLUSION The new tubal classification system significantly correlated with spontaneous pregnancy outcomes in patients with tubal pregnancy following laparoscopic salpingostomy.
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Affiliation(s)
- Yan Ding
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Wen Huang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Hongyuan Jiang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China.
| | - Jin Zhu
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China.
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Hemostatic Techniques for Laparoscopic Management of Cornual Pregnancy: Double-Impact Devascularization Technique. J Minim Invasive Gynecol 2016; 23:1016-7. [PMID: 27117718 DOI: 10.1016/j.jmig.2016.03.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/03/2016] [Indexed: 11/22/2022]
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Comparison of the Fertility Outcome of Salpingotomy and Salpingectomy in Women with Tubal Pregnancy: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0152343. [PMID: 27015601 PMCID: PMC4807767 DOI: 10.1371/journal.pone.0152343] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/11/2016] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To compare the natural fertility outcomes of salpingotomy and salpingectomy among women treated for tubal pregnancy. METHODS An online database search including PubMed, Embase, CENTRAL and Web of Science was performed to identify studies comparing salpingotomy and salpingectomy to treat women with tubal pregnancy. The search included papers published after the databases were established until May 2015. Two reviewers independently screened literature according to the inclusion and exclusion criteria and then extracted data and assessed the methodological quality of all of the included studies. The meta-analysis was conducted using RevMan 5.3 software. The registration number is CRD42015017545 in PROSPERO. RESULTS Two randomized controlled trials (RCTs) and eight cohort studies, including a total of 1,229 patients, were znalyzed. The meta-analysis of the RCT subgroup indicated that there was no statistically significant difference in IUP rates (RR = 1.04, 95% CI = 0.89-1.21, P = 0.61) nor the repeat ectopic pregnancy (REP) rate (RR = 1.30, 95% CI = 0.72-2.38, P = 0.39) between the salpingotomy and salpingectomy group. In contrast, the cohort study subgroup analysis revealed that the IUP rate was higher in the salpingotomy group compared with the salpingectomy group (RR = 1.24, 95% CI = 1.08-1.42, P = 0.002); Salpingotomy also increased the risk of REP rate (RR = 2.27, 95% CI = 1.12-4.58, P = 0.02). The persistent ectopic pregnancy (PEP) occurred more frequently in the salpingotomy group than the salpingectomy group (RR = 11.61, 95% CI = 3.17-42.46, P = 0.0002). An IUP would be more likely to occur after salpingotomy than salpingectomy when the follow-up time was more than 36 months (RR = 1.16, 95% CI = 1.02-1.32, P = 0.03). The IUP rate (RR = 1.13, 95% CI = 1.01-1.26, P = 0.03), and the REP rate (RR = 1.62, 95% CI = 1.02-2.56, P = 0.04) was higher after salpingotomy than salpingectomy among patients from Europe compared with those from America. CONCLUSIONS Based on the available evidence, we believe that for patients with a healthy contralateral tube operated for tubal pregnancy, the subsequent fertility after salpingectomy and salpingotomy are similar in the long term. The fertility prospects will not be improved via salpingotomy compared with salpingectomy.
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Berry J, Davey M, Hon MS, Behrens R. A 5-year experience of the changing management of ectopic pregnancy. J OBSTET GYNAECOL 2016; 36:631-4. [DOI: 10.3109/01443615.2015.1133578] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Janet Berry
- Wessex Deanery Rotation, Department of Obstetrics and Gynaecology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Southampton, UK,
| | - Mark Davey
- Wessex Deanery Rotation, Department of Obstetrics and Gynaecology, Princess Anne Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK,
| | - Mei-See Hon
- Department of Obstetrics and Gynaecology, Worthing Hospital, Western Sussex Hospitals NHS Foundation Trust, Worthing, UK, and
| | - Renée Behrens
- Department of Obstetrics and Gynaecology, Hampshire Hospitals Foundation Trust, Winchester, UK
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Fertilité et risque de récidive après traitement chirurgical d’une grossesse extra-utérine : salpingotomie versus salpingectomie. ACTA ACUST UNITED AC 2016; 45:129-38. [DOI: 10.1016/j.jgyn.2015.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/18/2015] [Accepted: 08/25/2015] [Indexed: 11/24/2022]
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Panelli DM, Phillips CH, Brady PC. Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. FERTILITY RESEARCH AND PRACTICE 2015; 1:15. [PMID: 28620520 PMCID: PMC5424401 DOI: 10.1186/s40738-015-0008-z] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 09/29/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar. FINDINGS Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality. CONCLUSION This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.
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Affiliation(s)
- Danielle M. Panelli
- Department of Obstcpetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115 USA
| | - Catherine H. Phillips
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Paula C. Brady
- Department of Obstcpetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115 USA
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Li J, Jiang K, Zhao F. Fertility outcome analysis after surgical management of tubal ectopic pregnancy: a retrospective cohort study. BMJ Open 2015; 5:e007339. [PMID: 26351180 PMCID: PMC4563265 DOI: 10.1136/bmjopen-2014-007339] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 03/13/2015] [Accepted: 03/18/2015] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To compare the subsequent fertility and risk of recurrence of an ectopic pregnancy (EP) in women who had had an EP, according to the type of surgical treatment they received--that is, salpingectomy, salpingostomy or tubal anastomosis. METHODS A retrospective cohort study was carried out between January 2003 and September 2011 of 618 patients admitted to hospital with tubal EP and who had received surgical treatment (salpingectomy, n=434; salpingostomy, n=112; and tube anastomosis, n=72). Main outcomes included the first intrauterine pregnancy (IUP) and recurrent EP. RESULTS The crude IUP rates up to 24 months after surgery were 55.5% for salpingectomy, 50.9% for salpingostomy and 40.3% for tubal anastomosis treatments. In the multivariate-adjusted model, with the patients receiving salpingectomy as the reference group, HR for patients after salpingostomy and tubal anastomosis treatments for IUP were 0.912 (95% CI 0.762 to 2.017) and 0.619 (95% CI 0.328 to 0.927), respectively. The 2-year cumulative recurrent EP rates were found to be 8.1% for salpingectomy, 6.3% for salpingostomy and 16.7% for tubal anastomosis treatments. Taking the patients receiving salpingectomy as the reference group, the patients who received tubal anastomosis had a positively higher risk of recurrent EP (HR=2.280; 95% CI 1.121 to 4.636) in univariate analysis. Adjustment for other potential confounders only slightly attenuated the HR. CONCLUSIONS The patients with an EP receiving tubal anastomosis treatments appeared to have a lower 2-year rate of IUP and a higher risk of recurrent EP after adjustment for other potential risk factors.
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Affiliation(s)
- Jingwei Li
- Obstetrics and Gynecology Department, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Kailei Jiang
- Department of Pediatric Surgery, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Fujie Zhao
- Obstetrics and Gynecology Department, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
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