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Ishida R, Ohbe H, Izumi G, Shigemi D, Matsui H, Koga K, Yasunaga H, Osuga Y. National trends in treatments for ectopic pregnancy in Japan from 2010 to 2020: a retrospective observational study. J OBSTET GYNAECOL 2024; 44:2373938. [PMID: 39007782 DOI: 10.1080/01443615.2024.2373938] [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: 04/10/2024] [Accepted: 06/23/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Ectopic pregnancy (EP) can be treated surgically or nonsurgically. In many countries, methotrexate is frequently used as a first-line medical treatment, and its effect is similar to that of surgery in selected patients. We aimed to investigate national trends in the treatment of EP in Japan. METHODS We conducted a retrospective observational analysis between 2010 and 2020 using a nationwide claims database that included inpatient data. We identified female inpatients with EP aged 15 to 49 years old. We analysed year-to-year treatment trends for EP, as well as year-to-year trends in methotrexate administration, with a focus on the site of the pregnancy. Patients who received methotrexate were divided into two groups: Those with and those without surgery after methotrexate use. We compared the characteristics of these groups and calculated the methotrexate success rate. RESULTS We identified 53,653 patients with EP. The proportion of patients undergoing surgery increased from 79% in 2010 to 83% in 2020, whereas the proportion of methotrexate therapy decreased from 8.1% in 2010 to 5.1% in 2020. Regarding methotrexate use for the site of the pregnancy, there was a significant downward trend in methotrexate therapy for tubal pregnancies. Notably, the methotrexate success rate was 84% during the study period. CONCLUSIONS Surgery showed an increasing tendency over time, whereas methotrexate therapy showed a decreasing tendency for EP treatment in Japan. The efficacy of methotrexate in Japan was comparable to that observed in other countries.
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Affiliation(s)
- Risa Ishida
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Gentaro Izumi
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
| | - Daisuke Shigemi
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
- Department of Reproductive Medicine, Chiba University, Chiba, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, The University of Tokyo, Tokyo, Japan
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Cavalari CAA, Mehrtash H, Brizuela V, Baguiya A, Adu-Bonsaffoh K, Cecatti JG, Bahamondes L, Charles CM, Govule P, Dossou JP, Souza RT, Leão LH, Filippi V, Tunçalp Ö, Baccaro LF. Prevalence and management of ectopic and molar pregnancies in 17 countries in Africa and Latin America and the Caribbean: a secondary analysis of the WHO multi-country cross-sectional survey on abortion. BMJ Open 2024; 14:e086723. [PMID: 39401964 PMCID: PMC11474897 DOI: 10.1136/bmjopen-2024-086723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 09/16/2024] [Indexed: 10/17/2024] Open
Abstract
INTRODUCTION There are limited global data on ectopic pregnancy (EP) and molar pregnancy (MP), making it important to understand their epidemiology and management across different regions. Our study aimed to describe their prevalence for both conditions, severity of their complications and management among women in selected health facilities across 17 countries in Africa and Latin America and the Caribbean (LAC). METHODS This is a secondary analysis of the WHO multi-country survey on abortion. Data were collected from 280 healthcare facilities across 11 countries in Africa and 6 in LAC. Sociodemographic information, signs and symptoms, management and clinical outcomes were extracted from medical records. Facility-level data on post-abortion care (PAC) capabilities were also collected, and facilities were classified accordingly. χ2 or Fisher's exact tests were used to compare categorical data. RESULTS The total number of women with EP and MP across both regions was 9.9% (2 415/24 424) where EP accounted for 7.8% (1 904/24 424) and MP for 2.1% (511/24 424). EP presented a higher severity of complications than MP. At admission, 49.8% of EP had signs of peritoneal irritation. The most common surgical management for EP was laparotomy (87.2%) and for MP, uterine evacuation (89.8%). Facilities with higher scores in infrastructure and capability to provide PAC more frequently provided minimal invasive management using methotrexate/other medical treatment (34.9%) and laparoscopy (5.1%). CONCLUSION In Africa and LAC, EP and MP cause significant maternal morbidity and mortality. The disparity in the provision of good quality care highlights the need to strengthen the implementation of evidence-based recommendations in the clinical and surgical management of EP and MP.
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Affiliation(s)
- Camila Ayume Amano Cavalari
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Hedieh Mehrtash
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Vanessa Brizuela
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Adama Baguiya
- Kaya Health and Demographic Surveillance System (Kaya-HDSS), Ouagadougou, Burkina Faso
| | - Kwame Adu-Bonsaffoh
- Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Greater Accra, Ghana
| | - Jose Guilherme Cecatti
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Luis Bahamondes
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Charles M'poca Charles
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Philip Govule
- Epidemiology and Disease Control, University of Ghana College of Health Sciences, Accra, Greater Accra, Ghana
- Health Sciences, Uganda Martyrs University Faculty of Health Sciences, Kampala, Uganda
| | - Jean-Paul Dossou
- CNHU-HKM Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
- Public Health, Instituut voor Tropische Geneeskunde, Antwerpen, Flanders, Belgium
| | - Renato T Souza
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Luis Henrique Leão
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | | | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Luiz Francisco Baccaro
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
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Huddleston EM, Saag KG. Methotrexate: Use in the Post Dobbs v. Jackson Era. J Clin Rheumatol 2024; 30:S2-S4. [PMID: 39325119 DOI: 10.1097/rhu.0000000000002130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
ABSTRACT Methotrexate is one of the most frequently used medications for the treatment of rheumatic diseases. Although initially developed for use as chemotherapy for both solid and hematologic malignancies, it was used as early as the 1960s with success for rheumatoid arthritis (RA) and psoriatic arthritis, ultimately being approved by the US Food and Drug Administration for the treatment of RA in 1988. Beyond RA and psoriatic arthritis, methotrexate is used in the treatment of systemic lupus erythematosus, idiopathic inflammatory myopathies, and other inflammatory conditions. Methotrexate is cytotoxic to the trophoblast and has been used to treat both ectopic pregnancy and gestational trophoblastic neoplasia, leading to studies in the early 1990s that showed it was effective and safe for early abortion in combination with prostaglandin E1 analog misoprostol. Methotrexate is also a teratogen, causing serious birth defects in 6%-10% of patients taking it while pregnant. Additionally, women are more likely to be affected by both RA at SLE, as compared with males, thus worsening the burden of these adverse effects. Both methotrexate's history of use as an abortifacient and its teratogenic properties make its use more complicated in the current era of abortion policy in the United States following the Dobbs v. Jackson Women's Health Organization ruling. Recently published data suggest that this ruling has affected both provider perspectives and patient experiences as it relates to methotrexate use. In the post-Dobbs era, the role of the rheumatologist as it relates to patients' sexual and reproductive health is likely to expand.
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Affiliation(s)
- Edward M Huddleston
- From the Division of Clinical Immunology and Rheumatology, University of Alabama Birmingham, Birmingham, Alabama
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Jeffers K, Koyfman A, Long B. Updates in emergency medicine: Ectopic pregnancy. Am J Emerg Med 2024; 85:90-97. [PMID: 39244808 DOI: 10.1016/j.ajem.2024.09.005] [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: 06/27/2024] [Revised: 08/24/2024] [Accepted: 09/01/2024] [Indexed: 09/10/2024] Open
Abstract
INTRODUCTION Ectopic pregnancy is a serious condition that can have significant morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of ectopic pregnancy, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Ectopic pregnancy is a pregnancy that implants outside the normal uterine cavity. It most commonly presents with vaginal bleeding, abdominal or pelvic pain, and amenorrhea. Risk factors for ectopic pregnancy include abnormalities of the fallopian tube, prior ectopic pregnancy, and age over 35 years, but a significant number of patients with confirmed ectopic pregnancy will not have an identifiable risk factor. In patients with suspected ectopic pregnancy, evaluation includes quantitative serum hCG, blood type, and ultrasound. Ultrasound is necessary regardless of the hCG level. If the patient is hemodynamically unstable, resuscitation with blood products and early consultation of obstetrics/gynecology is necessary. Patients with confirmed ectopic pregnancy but who are otherwise stable may be managed medically or surgically. If a yolk sac or fetal pole is not seen in the uterus on ultrasound, this is considered a pregnancy of unknown location (PUL), which may represent an early, failed, or ectopic pregnancy. Stable patients with a PUL who can reliably follow up are managed with close specialist follow up and repeat 48 h HCG level. These patients need to have an hCG level repeated every 48 h until diagnosed with a viable pregnancy, failed pregnancy, or ectopic pregnancy. CONCLUSIONS Knowledge of the latest advances in managing ectopic pregnancy will help clinicians more quickly and accurately diagnose patients presenting with this potentially fatal condition.
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Affiliation(s)
- Kristine Jeffers
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Bart Y, Regev N, Shani U, Cohen B, Yossef F, Margieh N, Kugelman N. Readmission following methotrexate treatment for tubal pregnancy. Int J Gynaecol Obstet 2024; 166:1297-1303. [PMID: 38523535 DOI: 10.1002/ijgo.15498] [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: 07/02/2023] [Revised: 12/18/2023] [Accepted: 03/10/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE To identify risk factors for readmission following methotrexate treatment for tubal pregnancy. METHODS A retrospective study undertaken in two tertiary medical centers, including all individuals with medically treated tubal pregnancy (N = 511), between December 2009 and June 2021. Individuals with and without readmission following methotrexate treatment were compared. The primary outcome was the readmission rate. Secondary outcomes included the rate of post-discharge gynecological emergency department visits, tubal rupture rate, and the eventual need for surgical treatment. RESULTS Readmission following methotrexate treatment occurred in 224/511 patients (43.8%). Most readmissions were due to abdominal pain or suspicion of treatment failure. Readmitted individuals were more likely to have a history of pelvic inflammatory disease and pretreatment serum human chorionic gonadotropin (hCG) >2000 mIU/mL. Both factors remained significantly associated with higher readmission rates in a logistic regression analysis (adjusted odds ratio [OR] 6.28, 95% confidence interval [CI] 1.30-30.45, and adjusted OR 2.73, 95% CI 1.83-4.07, respectively) after adjustment for age, endometriosis, tubal pathology, abdominal pain, and presence of yolk sac or embryo at diagnosis. A dose-dependent association was observed between pretreatment serum hCG levels and readmission rate (P < 0.001). Pretreatment hCG levels were also associated with tubal rupture and the eventual need for surgical treatment (P < 0.001 for both). A prediction model using hCG was not sufficiently accurate to predict readmission risk. CONCLUSION Readmission following methotrexate treatment for tubal pregnancy was independently associated with previous pelvic inflammatory disease and pretreatment serum hCG levels. The latter was also associated with surgical intervention rate.
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Affiliation(s)
- Yossi Bart
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Noam Regev
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Uria Shani
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Bracha Cohen
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
| | - Fayrooz Yossef
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
- Department of Obstetrics and Gynecology, Bnai Zion Medical Center, Haifa, Israel
| | - Nadine Margieh
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
| | - Nir Kugelman
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
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May B, Friedlander H, Schust D, Bollig KJ. Pregnancies at the Uterotubal Junction: A Review of Terminology (Interstitial, Cornual, and Angular) and Recommendations for Management. Reprod Sci 2024; 31:2576-2587. [PMID: 38653861 DOI: 10.1007/s43032-024-01539-2] [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: 11/20/2023] [Accepted: 04/02/2024] [Indexed: 04/25/2024]
Abstract
Ectopic pregnancies are one of the most common causes of obstetric mortality worldwide. Interstitial ectopic pregnancies, defined as an extracavitary pregnancy within the portion of the Fallopian tube that transverses the myometrium, have reported mortality rates approximately seven times higher than all types of ectopic pregnancy combined. In contrast, intracavitary eccentric gestations, often labeled as "cornual" or "angular" pregnancies, have reportedly high rates of live birth. Unfortunately, the terms "interstitial," "cornual," and "angular" have long been used with varying diagnostic criteria and often interchangeably to describe a pregnancy near the uterotubal junction. The inconsistency in nomenclature and lack of clear diagnostic criteria to distinguish among these pregnancies has resulted in a paucity of data to provide accurate prognostic information and guide appropriate management. This review article aims to provide historical context for the terms "interstitial," "cornual," and "angular;" discuss previous and more recent innovations of diagnostic methods; and provide recommendations for concise terminology and inform management.
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Affiliation(s)
- Bobby May
- Department of Obstetrics & Gynecology, Duke University Hospital, Durham, NC, USA.
- Duke University School of Medicine, DUMC 3084, 203 Baker House, 27710, Durham, NC, USA.
| | - Hilary Friedlander
- Department of Reproductive Endocrinology & Infertility, Duke University Hospital, Durham, NC, USA
| | - Danny Schust
- Department of Reproductive Endocrinology & Infertility, Duke University Hospital, Durham, NC, USA
| | - Kassie J Bollig
- Reproductive Medicine Associates, Basking Ridge, NJ, USA
- Department of Obstetrics, Gynecology and Reproductive Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Akbari EA. Evaluating Medical and Surgical Treatments for Ectopic Pregnancy at a Tertiary Hospital in Dubai. Cureus 2024; 16:e69216. [PMID: 39398689 PMCID: PMC11469796 DOI: 10.7759/cureus.69216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2024] [Indexed: 10/15/2024] Open
Abstract
INTRODUCTION The current data about ectopic pregnancy in the UAE is limited, including the incidence, method of management, and its effectiveness. This study aimed to determine the frequency of medical and surgical management in the treatment of ectopic pregnancy and the efficacy of each modality used. METHOD Two hundred and nine patients were diagnosed with ectopic pregnancies in the years 2018 and 2019 in Latifa Hospital and were included in this study. The patients were treated with either intramuscular injection of methotrexate (single or two doses) or surgical management. RESULTS Methotrexate was administered to 101 patients (48%). In 77 patients (76%), a single dose of methotrexate was administered, and in 24 patients (24%), two doses of methotrexate were administered. In the single-dose group, 75.3% (58 out of 77 patients) were successfully treated and completely recovered. While in the two-dose group, the success rate was 58.3% (14 out of 24 patients). On the other hand, among patients who underwent surgical management, the success rate was 97.2% (105 out of 108 patients). The difference in the success rates was statistically significant. CONCLUSION The results of the study showed that medical and surgical management were used almost equally in managing patients with ectopic pregnancy (48% vs. 52%, respectively). Furthermore, it was shown that single-dose methotrexate treatment was more successful than two doses. However, surgical management had the highest success rate among the three modalities.
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Rodgers SK, Horrow MM, Doubilet PM, Frates MC, Kennedy A, Andreotti R, Brandi K, Detti L, Horvath SK, Kamaya A, Koyama A, Lema PC, Maturen KE, Morgan T, Običan SG, Olinger K, Sohaey R, Senapati S, Strachowski LM. A Lexicon for First-Trimester US: Society of Radiologists in Ultrasound Consensus Conference Recommendations. Am J Obstet Gynecol 2024:S0002-9378(24)00811-1. [PMID: 39198135 DOI: 10.1016/j.ajog.2024.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/09/2024] [Accepted: 06/14/2024] [Indexed: 09/01/2024]
Abstract
The Society of Radiologists in Ultrasound convened a multisociety panel to develop a first-trimester US lexicon based on scientific evidence, societal guidelines, and expert consensus that would be appropriate for imagers, clinicians, and patients. Through a modified Delphi process with consensus of at least 80%, agreement was reached for preferred terms, synonyms, and terms to avoid. An intrauterine pregnancy (IUP) is defined as a pregnancy implanted in a normal location within the uterus. In contrast, an ectopic pregnancy (EP) is any pregnancy implanted in an abnormal location, whether extrauterine or intrauterine, thus categorizing cesarean scar implantations as EPs. The term pregnancy of unknown location is used in the setting of a pregnant patient without evidence of a definite or probable IUP or EP at transvaginal US. Since cardiac development is a gradual process and cardiac chambers are not fully formed in the first trimester, the term cardiac activity is recommended in lieu of 'heart motion' or 'heartbeat.' The terms 'living' and 'viable' should also be avoided in the first trimester. 'Pregnancy failure' is replaced by early pregnancy loss (EPL). When paired with various modifiers, EPL is used to describe a pregnancy in the first trimester that may or will not progress, is in the process of expulsion, or has either incompletely or completely passed.
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Affiliation(s)
- Shuchi K Rodgers
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pa
| | - Mindy M Horrow
- Department of Radiology, Einstein Healthcare Network/Jefferson Health, Philadelphia, Pa
| | - Peter M Doubilet
- Department of Radiology, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Mary C Frates
- Department of Radiology, Brigham and Women's Hospital/Harvard Medical School, Boston, Mass
| | - Anne Kennedy
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, Utah
| | - Rochelle Andreotti
- Department of Radiology and Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt University, Nashville, Tenn
| | - Kristyn Brandi
- American College of Obstetricians and Gynecologists, Newark, NJ
| | - Laura Detti
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Tex
| | - Sarah K Horvath
- Department of Obstetrics and Gynecology, Pennsylvania State University, University Park, Pa
| | - Aya Kamaya
- Department of Radiology, Stanford University, Stanford, Calif
| | - Atsuko Koyama
- Division of Child Health, University of Arizona College of Medicine Phoenix, Phoenix, Ariz
| | | | - Katherine E Maturen
- Department of Radiology and Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich
| | - Tara Morgan
- Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz
| | - Sarah G Običan
- Department of Obstetrics and Gynecology, University of South Florida, Tampa, Fla
| | - Kristen Olinger
- Department of Radiology, University of North Carolina, Chapel Hill, NC
| | - Roya Sohaey
- Department of Diagnostic Radiology, Oregon Health & Sciences University, Portland, Ore
| | - Suneeta Senapati
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pa
| | - Lori M Strachowski
- Department of Radiology and Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San Francisco, CA 94110.
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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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Hollier LM, Busacker A, Njie F, Syverson C, Goodman DA. Pregnancy-Related Deaths Due to Hemorrhage: Pregnancy Mortality Surveillance System, 2012-2019. Obstet Gynecol 2024; 144:252-255. [PMID: 38815264 PMCID: PMC11257829 DOI: 10.1097/aog.0000000000005628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 04/18/2024] [Indexed: 06/01/2024]
Abstract
Hemorrhage has been a leading cause of pregnancy-related death in the Centers for Disease Control and Prevention Pregnancy Mortality Surveillance System since 1987 when reporting began. Pregnancy Mortality Surveillance System data from 2012 to 2019 were analyzed to describe pregnancy-related deaths from hemorrhage. Pregnancy-related mortality ratios were estimated for hemorrhage overall and by hemorrhage subclassifications. Specific subclassifications of hemorrhage-related deaths were analyzed by sociodemographic characteristics. Overall, there were 606 deaths due to hemorrhage. The pregnancy-related mortality ratio for hemorrhage overall was 1.94 per 100,000 live births. Ruptured ectopic pregnancy was the most frequent subclassification (22.9%) of pregnancy-related hemorrhage deaths, followed by postpartum hemorrhage (21.2%). There were no significant trends in the pregnancy-related mortality ratio, overall or among any subclassification of hemorrhage deaths, from 2012 to 2019. Reporting subclassifications of pregnancy-related hemorrhage deaths could improve the ability to focus interventions and assess progress over time.
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Affiliation(s)
- Lisa M Hollier
- Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, and the CDC Foundation, Atlanta, Georgia; and Tanaq Support Services, LLC, St. George Island, Alaska
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11
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Rodgers SK, Horrow MM, Doubilet PM, Frates MC, Kennedy A, Andreotti R, Brandi K, Detti L, Horvath SK, Kamaya A, Koyama A, Lema PC, Maturen KE, Morgan T, Običan SG, Olinger K, Sohaey R, Senapati S, Strachowski LM. A Lexicon for First-Trimester US: Society of Radiologists in Ultrasound Consensus Conference Recommendations. Radiology 2024; 312:e240122. [PMID: 39189906 PMCID: PMC11366677 DOI: 10.1148/radiol.240122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/09/2024] [Accepted: 06/14/2024] [Indexed: 08/28/2024]
Abstract
The Society of Radiologists in Ultrasound convened a multisociety panel to develop a first-trimester US lexicon based on scientific evidence, societal guidelines, and expert consensus that would be appropriate for imagers, clinicians, and patients. Through a modified Delphi process with consensus of at least 80%, agreement was reached for preferred terms, synonyms, and terms to avoid. An intrauterine pregnancy (IUP) is defined as a pregnancy implanted in a normal location within the uterus. In contrast, an ectopic pregnancy (EP) is any pregnancy implanted in an abnormal location, whether extrauterine or intrauterine, thus categorizing cesarean scar implantations as EPs. The term pregnancy of unknown location is used in the setting of a pregnant patient without evidence of a definite or probable IUP or EP at transvaginal US. Since cardiac development is a gradual process and cardiac chambers are not fully formed in the first trimester, the term cardiac activity is recommended in lieu of 'heart motion' or 'heartbeat.' The terms 'living' and 'viable' should also be avoided in the first trimester. 'Pregnancy failure' is replaced by early pregnancy loss (EPL). When paired with various modifiers, EPL is used to describe a pregnancy in the first trimester that may or will not progress, is in the process of expulsion, or has either incompletely or completely passed. © RSNA and Elsevier, 2024 Supplemental material is available for this article. This article is a simultaneous joint publication in Radiology and American Journal of Obstetrics & Gynecology. All rights reserved. The articles are identical except for minor stylistic and spelling differences in keeping with each journal's style. Either version may be used in citing this article. See also the editorial by Scoutt and Norton in this issue.
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Affiliation(s)
- Shuchi K. Rodgers
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Mindy M. Horrow
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Peter M. Doubilet
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Mary C. Frates
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Anne Kennedy
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Rochelle Andreotti
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Kristyn Brandi
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Laura Detti
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Sarah K. Horvath
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Aya Kamaya
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Atsuko Koyama
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Penelope Chun Lema
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Katherine E. Maturen
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Tara Morgan
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Sarah G. Običan
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Kristen Olinger
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Roya Sohaey
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Suneeta Senapati
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
| | - Lori M. Strachowski
- From the Department of Radiology, Thomas Jefferson University,
Philadelphia, Pa (S.K.R.); Department of Radiology, Einstein Healthcare
Network/Jefferson Health, Philadelphia, Pa (M.M.H.); Department of Radiology,
Brigham and Women’s Hospital/Harvard Medical School, Boston, Mass
(P.M.D., M.C.F.); Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah (A. Kennedy); Department of Radiology and
Radiological Sciences and Department of Obstetrics and Gynecology, Vanderbilt
University, Nashville, Tenn (R.A.); American College of Obstetricians and
Gynecologists, Newark, NJ (K.B.); Department of Obstetrics and Gynecology,
Baylor College of Medicine, Houston, Tex (L.D.); Department of Obstetrics and
Gynecology, Pennsylvania State University, University Park, Pa (S.K.H.);
Department of Radiology, Stanford University, Stanford, Calif (A. Kamaya);
Division of Child Health, University of Arizona College of Medicine Phoenix,
Phoenix, Ariz (A. Koyama); Department of Emergency Medicine, Columbia
University, New York, NY (P.C.L.); Department of Radiology and Department of
Obstetrics and Gynecology, University of Michigan, Ann Arbor, Mich (K.E.M.);
Department of Radiology, Mayo Clinic Arizona, Phoenix, Ariz (T.M.); Department
of Obstetrics and Gynecology, University of South Florida, Tampa, Fla (S.G.O.);
Department of Radiology, University of North Carolina, Chapel Hill, NC (K.O.);
Department of Diagnostic Radiology, Oregon Health & Sciences University,
Portland, Ore (R.S.); Department of Obstetrics and Gynecology, University of
Pennsylvania, Philadelphia, Pa (S.S.); and Department of Radiology and
Biomedical Imaging and Department of Obstetrics, Gynecology and Reproductive
Sciences, University of California San Francisco, 1001 Potrero Ave, 1X57, San
Francisco, CA 94110 (L.M.S.)
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12
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Hoorshad N, Tarafdari A, Zamani N, Hasani SS, Pasikhani MD. Bilateral tubal ectopic pregnancy following induction ovulation can be missed in emergent ultrasonography: Case report. Int J Surg Case Rep 2024; 121:109863. [PMID: 38945015 PMCID: PMC11261411 DOI: 10.1016/j.ijscr.2024.109863] [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: 04/25/2024] [Revised: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 07/02/2024] Open
Abstract
INTRODUCTION Bilateral tubal ectopic pregnancy (BTP) is a rare and potentially life-threatening condition that is, often challenging to diagnose preoperatively. PRESENTATION OF CASE We present a case of BTP in a 25-year-old primigravid woman with a history of infertility due to polycystic ovarian syndrome. She was receiving letrozole when she presented with severe abdominal pain and vaginal bleeding. Initial evaluation revealed a ruptured ectopic pregnancy in the right fallopian tube, prompting an emergency laparotomy. During surgery, a second intact ectopic mass was discovered in the left fallopian tube, highlighting the diagnostic complexity of BTP. Management involved a salpingectomy on the right side and salpingostomy on the left to preserve fertility. DISCUSSION This case underscores the importance of considering BTP in the differential diagnosis of ectopic pregnancies and the necessity for thorough preoperative imaging studies, namely ultrasonography and surgical exploration, to prevent missed diagnoses. CONCLUSION BTP is a rare and challenging clinical entity that requires a comprehensive approach to diagnosis and management. Early recognition, prompt intervention, and close surveillance are essential to mitigate the risk of maternal morbidity and mortality associated with this condition.
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Affiliation(s)
- Niloofar Hoorshad
- Department of Obstetrics & Gynecology, Imam Khomeini Hospital complex, Tehran University of Medical sciences, Tehran, Iran.
| | - Azadeh Tarafdari
- Department of Obstetrics & Gynecology, Imam Khomeini Hospital complex, Tehran University of Medical sciences, Tehran, Iran
| | - Narges Zamani
- Department of Gynecology Oncology, Vali-e-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Sheikh Hasani
- Department of Gynecology Oncology, Vali-e-Asr Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Deldar Pasikhani
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics & Gynecology, Imam Khomeini Hospital complex, Tehran University of Medical sciences, Tehran, Iran
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13
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Kerestes C, Tschann M, Pearlman Shapiro M, Berry E, Gawron L, Soon R, Kaneshiro B. Self-Determination of Eligibility for Medication Abortion Without Ultrasonography Using a History-Based Tool: LMP-SURE. Obstet Gynecol 2024:00006250-990000000-01117. [PMID: 39053008 DOI: 10.1097/aog.0000000000005675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 05/23/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE To evaluate a self-screening eligibility tool for medication abortion without an ultrasonogram. METHODS We designed a patient-administered, five-question screening tool (LMP-SURE) that assesses gestational age plus factors associated with misdating or ectopic pregnancy. We recruited participants without prior ultrasonograms from family planning clinics in Alaska, Hawai'i, Idaho, and Utah to complete a brief survey including LMP-SURE and then obtained ultrasound dating by chart review. We compared eligibility for medication abortion by ultrasonogram with eligibility by the LMP-SURE screening tool. RESULTS We consented 1,026 participants; 781 met eligibility requirements and completed the tool. Using the LMP-SURE tool, we identified 493 participants (65.1%) eligible for medication abortion without an ultrasonogram. The LMP-SURE tool sensitivity (ability to correctly identify a patient ineligible for medication abortion) was 83.8% (95% CI, 73.1-90.8), specificity (ability to correctly identify a patient eligible for medication abortion) was 70.0% (95% CI, 66.4-73.3), likelihood ratio (-) (probability of someone eligible by LMP-SURE to be ineligible by ultrasonogram vs eligible by ultrasonogram) was 0.23 (95% CI, 0.13-0.40), and percentage of false-negatives was 1.5%. Only 11 patients (1.5%) who met eligibility for medication abortion without an ultrasonogram by the LMP-SURE tool were found ineligible for medication abortion by their ultrasonogram. Of those with conflicts, six (0.8%) had a gestational age beyond 77 days. The two participants (0.3%) diagnosed with ectopic pregnancies both required ultrasonograms by LMP-SURE. CONCLUSION This patient-facing, brief, history-based screening tool can safely minimize the need for ultrasonogram before medication abortion.
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Affiliation(s)
- Courtney Kerestes
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio; the Department of Obstetrics, Gynecology, and Women's Health, University of Hawai'i, Honolulu, Hawai'i; the Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, California; Planned Parenthood Great Northwest, Hawai'i, Alaska, Indiana, Kentucky, Seattle, Washington; and the Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah
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14
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Hou L, Liang X, Zeng L, Wang Q, Chen Z. Conventional and modern markers of pregnancy of unknown location: Update and narrative review. Int J Gynaecol Obstet 2024. [PMID: 39022869 DOI: 10.1002/ijgo.15807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/08/2024] [Indexed: 07/20/2024]
Abstract
Pregnancy of unknown location (PUL) is a temporary pathologic or physiologic phenomenon of early pregnancy that requires follow up to determine the final pregnancy outcome. Evidence indicated that PUL patients suffer a remarkably higher rate of adverse pregnancy outcomes, represented by ectopic gestation and early pregnancy loss, than the general population. In the past few decades, discussion about PUL has never stopped, and a variety of markers have been widely investigated for the early and accurate evaluation of PUL, including serum biomarkers, ultrasound imaging features, multivariate analysis, and the diagnosis of ectopic pregnancy based on risk stratification. So far, machine learning (ML) methods represented by M4 and M6 logistic regression have gained a level of recognition and are continually improving. Nevertheless, the heterogeneity of PUL markers, mainly caused by the limited sample size, the differences in population and technical maturity, etc., have hampered the management of PUL. With the advancement of multidisciplinary integration and cutting-edge technologies (e.g. artificial intelligence, prediction model development, and telemedicine), novel markers, and strategies for the management of PUL are expected to be developed. In this review, we summarize both conventional and novel markers (represented by artificial intelligence) for PUL assessment and management, investigate their advancements, limitations and challenges, and propose insights on future research direction and clinical application.
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Affiliation(s)
- Likang Hou
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- The First Affiliated Hospital, Medical Imaging Center, Hengyang Medical School, University of South China, Hengyang, China
| | - Xiaowen Liang
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- Key Laboratory of Medical Imaging Precision Theranostics and Radiation Protection, College of Hunan Province, Department of Medical Imaging, the Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Changsha, China
| | - Lingqing Zeng
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- The First Affiliated Hospital, Medical Imaging Center, Hengyang Medical School, University of South China, Hengyang, China
| | - Qian Wang
- The First Affiliated Hospital, Center for Reproductive Medicine, Hengyang Medical School, University of South China, Hengyang, China
| | - Zhiyi Chen
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- Key Laboratory of Medical Imaging Precision Theranostics and Radiation Protection, College of Hunan Province, Department of Medical Imaging, the Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Changsha, China
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15
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Flynn AN, McAllister A, Jen A, Gutman S, Allen A, Kete C, Seth N, Koelper N, Sonalkar S. Exploring Reasons for Loss to Follow-up in Pregnancy of Unknown Location: A Mixed-Methods Study. J Womens Health (Larchmt) 2024. [PMID: 38959225 DOI: 10.1089/jwh.2023.1146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
Objective: To quantify proportions of loss to follow-up in patients presenting with a pregnancy of unknown location and explore patients' perspectives on follow-up for pregnancy of unknown location. A pregnancy of unknown location is a scenario in which a patient has a positive pregnancy test but the pregnancy is not visualized on transvaginal ultrasound. Study Design: We conducted a retrospective cohort study of patients with pregnancy of unknown location who presented to an urban academic emergency department or complex family planning outpatient office. We sought to calculate the proportion of patients lost to follow-up, defined as inability to contact the patient within 2 weeks. We then conducted focus groups of patients diagnosed with a pregnancy of unknown location. We used thematic analysis to identify themes related to follow-up. Results: We reviewed 464 charts of patients diagnosed with pregnancy of unknown location. The median age in this cohort was 27 with most patients identifying as Black (80%, n = 370) and using public insurance (67%, n = 315). When looking at loss to follow-up rates, Black patients experienced loss to follow-up (20%, n = 72) more often than White patients (4%, n = 2; p = 0.003). Focus group participants had a mean age of 31.8+/-4.8, and the majority were of Black race (n = 16, 72.7%). Participants identified barriers to follow-up including the long duration of management, general inconvenience, and poor communication with their health care team. Participants felt a burden of responsibility to learn about their condition and to self-advocate for their follow-up and communication of results. Conclusions: These data indicate that Black patients are more likely to experience loss to follow-up compared with White patients during monitoring for pregnancy of unknown location. Patients identified many barriers to follow-up and felt that successful follow-up required substantial self-efficacy.
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Affiliation(s)
- Anne N Flynn
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Arden McAllister
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alicia Jen
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarah Gutman
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Antoinette Allen
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Corinne Kete
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natasha Seth
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nathanael Koelper
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sarita Sonalkar
- Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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16
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Gaiday A, Tussupkaliyev A, Nurken A, Gaiday A, Primbetova A, Dossimbetova M, Yeszhanova A, Karimsakova B, Ablakimova N. Successful Management of Cervical and Tubal Stump Double Pregnancy after Assisted Reproductive Technologies Using Multiple High Doses of Methotrexate: A Case Report. IRANIAN JOURNAL OF MEDICAL SCIENCES 2024; 49:461-466. [PMID: 39114638 PMCID: PMC11300944 DOI: 10.30476/ijms.2024.102119.3487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 05/20/2024] [Accepted: 05/25/2024] [Indexed: 08/10/2024]
Abstract
The incidence of ectopic pregnancy (EP) has increased in recent years, owing to causes such as pelvic inflammatory diseases and assisted reproductive technologies (ART). The present study reported a case of a 33-year-old nulliparous woman with a history of previous ectopic pregnancies, who underwent pelvic ultrasound in August 2022, which revealed a double EP including a cervical pregnancy and a tubal stump pregnancy. Despite known risk factors and elevated beta-human chorionic gonadotropin (β-hCG) levels, a conservative approach, utilizing multiple doses of systemic methotrexate (MTX) injections, was employed to preserve fertility at the Regional Perinatal Center in Aktobe, Kazakhstan. Treatment efficacy was monitored through β-hCG levels and ultrasound imaging, with successful resolution of both EPs and preservation of reproductive function. The present case highlighted the safety and efficacy of MTX therapy in managing complex EP presentations, emphasizing the necessity of individualized treatment approaches in reproductive medicine, particularly in terms of preserving fertility in patients undergoing ART. Multiple high doses of MTX injections were beneficial for pregnancy with two distinct regions, fetal cardiac activity, and elevated serum β-hCG level. Further research is required to explore optimal treatment strategies for EP, considering patient-specific factors and treatment goals.
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Affiliation(s)
- Andrey Gaiday
- Department of Obstetrics and Gynecology, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Akylbek Tussupkaliyev
- Department of Obstetrics and Gynecology, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Abay Nurken
- Department of Gynecology, Regional Perinatal Center, Aktobe, Kazakhstan
| | - Assel Gaiday
- Department of Gynecology, Regional Perinatal Center, Aktobe, Kazakhstan
| | - Ainur Primbetova
- Department of Gynecology, Regional Perinatal Center, Aktobe, Kazakhstan
| | - Moldir Dossimbetova
- Department of Obstetrics and Gynecology, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | | | - Bibigul Karimsakova
- Department of General Medical Practice, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
| | - Nurgul Ablakimova
- Department of Pharmacology, West Kazakhstan Marat Ospanov Medical University, Aktobe, Kazakhstan
- Department of Hospital Pharmacy, Regional Perinatal Center, Aktobe, Kazakhstan
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17
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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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18
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Akdaş Reis Y, Akay A, Özkan M, Fıratlıgil FB, Dereli ML, Kınay T, Erkaya S. Do the change in β-hCG values between the 0th and 4th days in tubal ectopic pregnancy treatment with a single-dose methotrexate (MTX) protocol predict the need for a second dose of MTX? Arch Gynecol Obstet 2024; 309:2585-2590. [PMID: 37493778 DOI: 10.1007/s00404-023-07116-3] [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: 04/15/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023]
Abstract
AIM The single-dose methotrexate (MTX) regimen is effective and minimizes side effects but an additional second dose is needed in case of failure in an ectopic pregnancy (EP). We aimed to predict the additional MTX dose by evaluating the change in β-hCG values between day 0 and day 4 in EPs with administered single-dose MTX regimen. METHOD A total of 454 tubal EPs between 2013 and 2019 were evaluated retrospectively. Cases cured with a single dose of MTX without an additional dose were accepted as the control group, and cases under a single-dose regimen were cured by applying a second dose of MTX on the 7th day were accepted as the study group. Obstetric and demographic characteristics and the change in β-hCG values compared in both groups. RESULTS Age, body mass index (BMI), gravida, smoking, abdominal surgery, presence of IUDs, initial β-hCG levels (0th day), and EP size were similar in both groups, but the presence of previous EP history was significantly higher in the study group. The change of β-hCG from days 0 and 4 determined that a 20% increase predicts the need for a second dose of MTX with 72.4% sensitivity, and 87.8% negative predictive value (NPV). CONCLUSION The single-dose MTX protocol is successful in 83.3% of convenient cases (as the control group), but an increase of 20% in β-hCG between days 0 and 4 predicts the patients who need to be administered second-dose MTX, and thus, a double-dose MTX protocol will be achieved early.
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Affiliation(s)
- Yıldız Akdaş Reis
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey.
| | - Arife Akay
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
- Bingol maternity and children's hospital, Bingöl, Turkey
| | - Merve Özkan
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
- Ankara Etlik City Hospital, Ankara Etlik City Hospital, Ankara, Türkiye
| | - Fahri Burçin Fıratlıgil
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
- Ankara Etlik City Hospital, Ankara Etlik City Hospital, Ankara, Türkiye
| | - Murat Levent Dereli
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
- Ankara Etlik City Hospital, Ankara Etlik City Hospital, Ankara, Türkiye
| | - Tuğba Kınay
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Salim Erkaya
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
- Ankara Bilkent City Hospital, Ankara Bilkent City Hospital, Ankara, Türkiye
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19
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Chaves LT, Maia R, Borges Peixoto A, Araujo E, Elito J. Tubal ectopic pregnancy: comparative management between pre and Covid-19 pandemic periods. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2024; 46:e-rbgo64. [PMID: 39381345 PMCID: PMC11460413 DOI: 10.61622/rbgo/2024rbgo64] [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: 03/14/2023] [Accepted: 05/13/2023] [Indexed: 10/10/2024] Open
Abstract
Objective To evaluate whether there were differences in the presentation of patients with tubal ectopic pregnancy (EP) during the first year of the COVID-19 pandemic. Methods We performed a retrospective cohort study of all cases of tubal EP between March 2019 and March 2020 (pre-pandemic) and between March 2020 and March 2021 (pandemic). We compared between these two groups the risk factors, clinical characteristics, laboratory data, sonographic aspects, treatment applied and complications. Results We had 150 EP diagnoses during the two years studied, of which 135 were tubal EP. Of these, 65 were included in the pre-pandemic and 70 in the pandemic period. The prevalence of lower abdominal pain was significantly higher in the pandemic compared to the pre-pandemic period (91.4% vs. 78.1%, p=0.031). There was no significant difference in shock index, initial beta-hCG level, hemoglobin level at diagnosis, days of menstrual delay, aspect of the adnexal mass, amount of free fluid on ultrasound, and intact or ruptured presentation between the groups. Expectant management was significantly higher during the pandemic period (40.0% vs. 18.5%, p=0.008), surgical management was lower during the pandemic period (47.1% vs. 67.7%, p=0.023), and number of days hospitalized was lower in the pandemic period (1.3 vs. 2.0 days, p=0.003). Conclusion We did not observe a significant difference in patient history, laboratory and ultrasound characteristics. Abdominal pain was more common during the pandemic period. Regarding treatment, we observed a significant increase in expectant and a decrease in surgical cases during the pandemic period.
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Affiliation(s)
- Lumi Tomishige Chaves
- Universidade Federal de São PauloEscola Paulista de MedicinaDepartment of ObstetricsSão PauloSPBrazilDepartment of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Rafael Maia
- Universidade Federal de São PauloEscola Paulista de MedicinaDepartment of ObstetricsSão PauloSPBrazilDepartment of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Alberto Borges Peixoto
- Universidade de UberabaMário Palmério University HospitalGynecology and Obstetrics ServiceUberabaMGBrazilGynecology and Obstetrics Service, Mário Palmério University Hospital, Universidade de Uberaba, Uberaba, MG, Brazil.
- Universidade Federal do Triângulo MineiroDepartment of Obstetrics and GynecologyUberabaMGBrazilDepartment of Obstetrics and Gynecology, Universidade Federal do Triângulo Mineiro, Uberaba, MG, Brazil.
| | - Edward Araujo
- Universidade Federal de São PauloEscola Paulista de MedicinaDepartment of ObstetricsSão PauloSPBrazilDepartment of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Júlio Elito
- Universidade Federal de São PauloEscola Paulista de MedicinaDepartment of ObstetricsSão PauloSPBrazilDepartment of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
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20
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Ntiyakunze G, Gidion D, Kyejo W, Moshi B, Jaiswal S, Moshi L, Muzo J, Chuwa H, Abeid M. Medical management of ectopic pregnancy: Case series at a private tertiary hospital, Tanzania. SAGE Open Med Case Rep 2024; 12:2050313X241252348. [PMID: 38773989 PMCID: PMC11107306 DOI: 10.1177/2050313x241252348] [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: 09/18/2023] [Accepted: 04/15/2024] [Indexed: 05/24/2024] Open
Abstract
Ectopic pregnancy is a pregnancy in which the developing blastocyst implants outside the endometrial cavity. An estimated 1.3%-2.4% of pregnancies end up outside the uterus. With prompt diagnosis and efficient treatment, the risks of morbidity and mortality associated with ectopic pregnancy can be reduced. For the treatment of carefully chosen ectopic pregnancies, methotrexate therapy, a folic acid antagonist that is highly toxic to rapidly replicating tissues, produces outcomes comparable to surgery. We describe six cases of ectopic pregnancy which were successfully treated with methotrexate and on follow-up two of them successfully conceived to term delivery. For patients who are physically fit enough, medical management of an ectopic pregnancy with methotrexate should be the first line of treatment to lower surgical morbidity and mortality. Following the administration of the medication, the patient is monitored with a clinical symptom interview and weekly plasma human chorionic gonadotrophin levels checks. When initial human chorionic gonadotrophin levels are extremely high, complete resolution of an ectopic pregnancy can take 6-8 weeks instead of the usual 2-3 weeks. Early diagnosis of ectopic pregnancies is necessary to improve their prognosis. Ectopic pregnancies can be managed medically with methotrexate to preserve fertility. Compared to surgical management, methotrexate therapy appears to have more advantages.
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Affiliation(s)
- Gregory Ntiyakunze
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Daudi Gidion
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Willbroad Kyejo
- Department of Family Medicine, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Brenda Moshi
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Shweta Jaiswal
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Lynn Moshi
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Jane Muzo
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
| | - Harrison Chuwa
- Department of Oncology, The Aga Khan Hospital, Dar Es Salaam, Tanzania
| | - Muzdalifat Abeid
- Department of Obstetrics and Gynecology, The Aga Khan University, Dar Es Salaam, Tanzania
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21
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Fontenot M, Valentine J. Pseudogestational Sac Delaying Diagnosis of Ectopic Pregnancy: A Case Report. J Emerg Med 2024; 66:e642-e644. [PMID: 38702245 DOI: 10.1016/j.jemermed.2023.12.009] [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: 10/25/2023] [Revised: 11/25/2023] [Accepted: 12/08/2023] [Indexed: 05/06/2024]
Abstract
BACKGROUND Diagnosis of ectopic pregnancy can be complicated by nonspecific laboratory and radiographic findings. The multiple alternative diagnoses must be weighed against each other based on the entire clinical presentation. CASE REPORT We present a case of a 20-year-old woman who arrived to the Emergency Department (ED) with abdominal pain and ended up being transferred for an Obstetrics evaluation of a possible heterotopic pregnancy. Her radiology-performed ultrasound had revealed an "intrauterine gestational sac" along with an adnexal mass near the right ovary. The patient was not undergoing assisted-reproductive fertilization, nor did she have meaningful risk factors for heterotopic pregnancy. The patient was managed expectantly over the ensuing week to see whether the intrauterine fluid was a true gestational sac. After multiple repeat ED visits, the diagnosis of ectopic pregnancy was made. Ultimately, the patient elected for surgical management of her ectopic pregnancy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case offers a reminder of the subtleties of radiographic identification of intrauterine pregnancies and the ever-present need to "clinically correlate."
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Affiliation(s)
- Maya Fontenot
- University of Houston Tilman J. Fertitta Family College of Medicine, Houston, Texas
| | - Jake Valentine
- University of Houston Tilman J. Fertitta Family College of Medicine, Houston, Texas; HCA Houston Healthcare Kingwood, Kingwood, Texas
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22
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Wei S, Gao T, Wu Y, Wang G, Chen Y, Tao X, Liang Y, Zhou Z, Sun L, Liu M, Li H, Bao Y. The relationship between expression of Tspan5 mRNA in maternal-fetal interface and tubal pregnancy. Eur J Obstet Gynecol Reprod Biol 2024; 296:91-98. [PMID: 38422804 DOI: 10.1016/j.ejogrb.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Shiyuan Wei
- The Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Tianyang Gao
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China.
| | - Yihua Wu
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Guiming Wang
- Department of Pathology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Yao Chen
- The Department of Reproductive Medicine Center, Foshan Women and Children Hospital, Foshan, Guangdong, China
| | - Xinli Tao
- The Department of Gynecology, Xiangzhou District People's Hospital, Xiangyang, Hubei, China
| | - Yingqiu Liang
- Shijiazhuang Obstetrics and Gynecology Hospital, Shijiazhuang, Henan, China
| | - Zijun Zhou
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Liyan Sun
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Minyin Liu
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Haiyan Li
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Yanjing Bao
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
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23
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Yeniocak AS, Tercan C, Dagdeviren E, Arabacı O, Genc EE. Evaluation of a scoring system to predict treatment success with single-dose methotrexate in ectopic pregnancy. Arch Gynecol Obstet 2024; 309:2047-2055. [PMID: 38488896 DOI: 10.1007/s00404-024-07458-6] [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: 01/09/2024] [Accepted: 03/04/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE This study sought to assess the efficacy of a newly developed scoring system in predicting treatment outcomes for ectopic pregnancy among patients undergoing single-dose methotrexate therapy. The primary research question centered on the reliability and predictive accuracy of objective parameters in determining methotrexate therapy success. METHODS Conducted as a retrospective single-center cohort study, data from 172 ectopic pregnancy patients treated with methotrexate between January 2021 and January 2023 were analyzed. Parameters including adnexal mass size, peritoneal fluid presence, yolk sac identification, endometrial thickness, ectopic pregnancy location, and initial B-hCG levels were meticulously evaluated for their association with treatment outcomes. RESULTS Following the exclusion of 21 emergency surgery cases, the final analysis comprised 151 patients. Notable associations were observed between specific parameters (fetal cardiac activity, adnexal mass size > 3.5 cm, peritoneal fluid presence, yolk sac identification, endometrial thickness > 10 mm, and initial B-hCG levels) and treatment outcomes (p < 0.001). Additionally, the novel scoring system demonstrated promising predictive performance. At a cutoff of 2.50, it achieved a sensitivity of 91.7% and a specificity of 59.7%. Increasing the cutoff to 3.50 resulted in a sensitivity of 94.0%, with a specificity of 46.3%. CONCLUSION Objective parameters, particularly those integrated into the developed scoring system, exhibited substantial associations with methotrexate therapy outcomes in ectopic pregnancy. These findings underscore the potential of an objective scoring model to significantly influence clinical decision-making in therapy, offering avenues for enhanced prognostication and patient care in treatment outcomes.
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Affiliation(s)
- Ali Selcuk Yeniocak
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey.
| | - Can Tercan
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Emrah Dagdeviren
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Onur Arabacı
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Emine Elif Genc
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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24
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Deniz S, Ali B, Canan U, Yılmaz AH, Olcay I, Burcu D, Fatma GK. Evaluation of the parameters in predicting single-dose methotrexate therapy success for ectopic pregnancy. J Obstet Gynaecol Res 2024; 50:856-863. [PMID: 38476034 DOI: 10.1111/jog.15923] [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: 11/03/2023] [Accepted: 03/01/2024] [Indexed: 03/14/2024]
Abstract
AIM Methotrexate has demonstrated efficacy in treating ectopic pregnancies. This study explores factors influencing treatment success, focusing on laboratory and ultrasonographic findings, particularly the day 4 to day 1 β-hCG level ratio. METHODS Retrospective cohort study was conducted within patients diagnosed with tubal ectopic pregnancy. Patients' characteristics, ultrasound findings, laboratory data, and β-hCG levels (days 1, 4, 7), and operation findings were reviewed. Women's characteristics were investigated who were treated with single dose of MTX (50 mg/m2). Patients who were performed surgery after MTX treatment were identified as MTX treatment failure. RESULTS Among 439 women, 259 underwent surgery due to acute symptoms. Of those treated with MTX, 143 experienced treatment success, while 37 underwent surgery after MTX (MTX failure). Comparative analysis revealed significant differences in β-hCG levels on admission (1128 and 4125 mIU/mL) and the day 4 to day 1 β-hCG ratio (0.91 and 1.25). The overall MTX success rate was 79%, reaching 93% and 89% for β-hCG levels <1000 mIU/mL and <2000 mIU/mL, respectively. Success dropped to 50% with levels exceeding 5000 mIU/mL. ROC analysis identified a crucial 2255 mIU/mL cut-off for β-hCG (sensitivity 70.3% and specificity 68.5%) and a day 4 to day 1 β-hCG ratio of 95.5% (sensitivity 84.7%, specificity 72.5%, positive predictive value 75.4%) for predicting MTX success. CONCLUSION Establishing a β-hCG cutoff can reduce hospital stay. The day 4 to day 1 β-hCG ratio holds promise as a widely applicable predictor for MTX success or for determining MTX administration on day 4.
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Affiliation(s)
- Simsek Deniz
- Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Bahadırlı Ali
- Ministry of Health Bursa City Hospital, Bursa, Turkey
| | - Urun Canan
- Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | | | - Ilhan Olcay
- Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Dincgez Burcu
- Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Gencer Ketenci Fatma
- Istanbul Gaziosmanpasa Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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25
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Yazawa H, Yazawa R, Matsuoka R, Ohara M. Surgical Outcomes and Trends in Incidence of Ectopic Pregnancy. Gynecol Minim Invasive Ther 2024; 13:111-118. [PMID: 38911310 PMCID: PMC11192286 DOI: 10.4103/gmit.gmit_53_23] [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: 04/08/2023] [Revised: 08/24/2023] [Accepted: 09/08/2023] [Indexed: 06/25/2024] Open
Abstract
Objectives We aimed to evaluate the surgical results for ectopic pregnancy (EP) treated at Fukushima Red Cross Hospital for over a 20-year period from 2002 to 2021. Materials and Methods We evaluated the incidence, surgical procedures, site of implantation, amount of hemoperitoneum, and the proportion of cases with risk factors of EP. Results Two hundred and fifty-nine cases of EP were treated surgically. The incidence of EP seemed to be gradually decreasing in recent years. By pregnancy site, 235 (90.7%) of EPs were tubal pregnancies (TPs), 13 in interstitial pregnancies (IPs), 7 in ovarian pregnancies, and 4 in peritoneal pregnancies. For IPs, human chorionic gonadotropin (hCG) levels were statistically higher than with TP and intraperitoneal bleeding was less than with other EP sites. Thirty-nine patients (15.0%) were with massive hemoperitoneum (>500 mL), and laparoscopic surgery was performed in all patients with massive hemoperitoneum except in two patients. The proportion of cases with risk factors for EP such as Chlamydia trachomatis infection or history of smoking was 5.4% and 40.6%, respectively. Epidemiological research shows that the number of patients with chlamydia infection, rates of smokers, or the occurrence of EP with assisted reproductive technology has been decreasing in recent years in Japan. Conclusion Appropriate surgical intervention should be selected while considering such as facility capabilities, context, and surgeon skill, especially in critical cases, such as cases involving massive hemoperitoneum and hemorrhagic shock. The recent presumed decrease in the occurrence of EP may partly be associated with the decrease in the occurrence of risk factors.
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Affiliation(s)
- Hiroyuki Yazawa
- Department of Obstetrics and Gynecology, Fukushima Red Cross Hospital, Fukushima Medical University, Fukushima, Japan
| | - Riho Yazawa
- Department of Obstetrics and Gynecology, Fukushima Red Cross Hospital, Fukushima Medical University, Fukushima, Japan
| | - Ryo Matsuoka
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima, Japan
| | - Miki Ohara
- Department of Obstetrics and Gynecology, Fukushima Red Cross Hospital, Fukushima Medical University, Fukushima, Japan
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26
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Tremmel E, Starrach T, Buschmann C, Trillsch F, Kolben T, Mahner S, Burges A, Kost B, Ehmann L, Burgmann DM. Management of non-tubal ectopic pregnancies analysis of a large tertiary center case series. Arch Gynecol Obstet 2024; 309:1227-1236. [PMID: 38078931 PMCID: PMC10894165 DOI: 10.1007/s00404-023-07290-4] [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: 07/08/2023] [Accepted: 11/06/2023] [Indexed: 02/25/2024]
Abstract
PURPOSE Ectopic pregnancies include cesarean scar (CSP), cornual and cervical pregnancies. Various treatment modalities have been- described, but no standardized procedure has been defined so far. The aim of our analysis was to evaluate the diagnostics and treatment at the Department of Obstetrics and Gynecology, LMU University Hospital, Munich. METHODS In this retrospective, single-center analysis, 24 patients treated between 2015 and 2020 were analyzed. After verification of the diagnosis by imaging and HCG-analysis, the treatment was individually determined: therapy with methotrexate (MTX) locally with or without simultaneous systemic treatment, surgical treatment via curettage, excision with uterine reconstruction even hemi hysterectomy. RESULTS Ten patients presented with CSP, six with cervical and eight with cornual pregnancies. Median age was 34.6 years. CSP was treated with local MTX in six cases; five required additional treatment with systemic MTX or curettage. Primary curettage or surgery was performed in four cases. In cervical pregnancies the primary therapy with local MTX injection and systemic treatment was performed in 50%. One patient was treated with MTX and insertion of a Bakri balloon. Trachelectomy was required in one case. 50% of cornual pregnancies were treated with MTX locally and intramuscularly and 50% received surgery. CONCLUSION Treatment strategies were based on the patient's individual risk parameters. The results of this study show, that simultaneous treatment with local and systemic MTX had good outcomes and could avoid surgeries.
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Affiliation(s)
- E Tremmel
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany.
| | - T Starrach
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - C Buschmann
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - F Trillsch
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - T Kolben
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - S Mahner
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - A Burges
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - B Kost
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - L Ehmann
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
| | - D M Burgmann
- Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Marchioninistraße 15, 81377, Munich, Germany
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Larraín D, Caradeux J. β-Human Chorionic Gonadotropin Dynamics in Early Gestational Events: A Practical and Updated Reappraisal. Obstet Gynecol Int 2024; 2024:8351132. [PMID: 38486788 PMCID: PMC10940029 DOI: 10.1155/2024/8351132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/06/2024] [Accepted: 03/01/2024] [Indexed: 03/17/2024] Open
Abstract
In the last decade, the widespread use of transvaginal ultrasound and the availability of highly specific serum assays of human chorionic gonadotropin (hCG) have become mainstays in the evaluation of early pregnancy. These tests have revolutionized the management of pregnancies of unknown location and markedly reduced the morbidity and mortality associated with the misdiagnosis of ectopic pregnancy. However, despite several advances, their misuse and misinterpretations are still common, leading to an increased use of healthcare resources, patient misinformation, and anxiety. This narrative review aims to succinctly summarize the β-hCG dynamics in early gestation and provide general gynecologists a practical approach to patients with first-trimester symptomatic pregnancy.
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Affiliation(s)
- Demetrio Larraín
- Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile
| | - Javier Caradeux
- Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile
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28
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Elshamy E, Zakaria Y, Alajami F, Fathy M. Expectant management versus systemic methotrexate in the management of persistent pregnancy of unknown location, a seven-year retrospective analysis. Arch Gynecol Obstet 2024; 309:1035-1041. [PMID: 38194091 DOI: 10.1007/s00404-023-07332-x] [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: 10/02/2023] [Accepted: 12/01/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE To compare Expectant management to systemic methotrexate in the management of persistent pregnancy of unknown location with beta-hCG levels below the discrimination zone. METHODS A retrospective cohort study was conducted on 71 women with persistent pregnancy of unknown location. They were divided into two groups according to the applied management; Group 1, (n = 40) who were managed expectantly and Group 2 (n = 31) who were given a single dose of methotrexate. Data variables were collected and analyzed to evaluate whether expectant management was as effective as methotrexate. RESULTS There was no significant difference between the two groups regarding age, parity, gestational age, body mass index and day seven beta-hCG. Success rates were (32 patients (80%) and 28 patients (90.3%) in expectant management and methotrexate groups, respectively (P > 0.05). The mean values for day zero and day four beta-hCG were significantly higher and the mean duration for complete recovery was statistically shorter in the methotrexate group (P < 0.05). There were no significant differences between the two groups regarding prior ectopic, percentage of beta-hCG level drop on day four and day seven, success rate, occurrence of sequelae and patient satisfaction that area under the curve (AUC) for group 1 (expectant management) is 0.566 at 95% Confidence Interval of (0.388: 0.745). CONCLUSION Expectant management is an effective and safe alternative to single-dose methotrexate for persistent PUL with beta-hCG levels below the discrimination zone.
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Affiliation(s)
- Elsayed Elshamy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Menoufia University, Shibin El-Kom, Egypt.
- Department of Obstetrics and Gynecology, King Abdul-Aziz Airbase Hospital, 041/9 Prince Sattam Street, Al-Khobar, Saudi Arabia.
| | - Yahya Zakaria
- Department of Obstetrics and Gynecology, King Abdul-Aziz Airbase Hospital, 041/9 Prince Sattam Street, Al-Khobar, Saudi Arabia
- Department of Obstetrics and Gynecology, Faculty of Medicine, Fayoum University, Faiyum, Egypt
| | - Feryal Alajami
- Department of Obstetrics and Gynecology, King Abdul-Aziz Airbase Hospital, 041/9 Prince Sattam Street, Al-Khobar, Saudi Arabia
| | - Mahmoud Fathy
- Department of Obstetrics and Gynecology, King Abdul-Aziz Airbase Hospital, 041/9 Prince Sattam Street, Al-Khobar, Saudi Arabia
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain-Shams University, Cairo, Egypt
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29
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Kugelman N, Cohen B, Yossef F, Margieh N, Regev N, Shani U, Bart Y. Expectant management of tubal pregnancies with human chorionic gonadotropin up to 2000 mIU/mL. Int J Gynaecol Obstet 2024; 164:1094-1100. [PMID: 37776069 DOI: 10.1002/ijgo.15162] [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: 06/23/2023] [Revised: 08/16/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE To describe outcomes of expectant management (EM) versus methotrexate (MTX) treatment in tubal pregnancies with pretreatment human chorionic gonadotropin (hCG) less than 2000 mIU/mL. METHODS This retrospective cohort from two tertiary hospitals included women with confirmed tubal pregnancies and pretreatment hCG <2000 mIU/mL. Exclusion criteria were unrecorded pregnancy site, unconfirmed diagnosis, and surgical treatment upon diagnosis. The primary outcome was eventual rate of surgical treatment. RESULTS Between December 2009 and June 2021, 545 of 2114 (25.8%) women diagnosed with a tubal pregnancy met our inclusion criteria. We compared women who underwent EM (N = 201) with women who received MTX (N = 344). All women in the EM group had a declining trend of hCG. The MTX group had higher pretreatment hCG and higher rates of yolk sac or embryo presence on ultrasound. Eventual surgical treatment rate was higher in the MTX group compared with the EM group (39 [11.3%] vs. 9 [4.5%], P = 0.006), with no difference in the treatment failure rate or tubal rupture rate. In a subgroup analysis of women with pretreatment hCG between 1000 and 2000 mIU/mL, eventual surgical treatment, treatment failure, and tubal rupture rates did not differ between groups. Logistic regression analysis revealed that eventual surgical treatment was independently associated with hCG levels less than 1000 mIU/mL (adjusted odds ratio [aOR] 0.28, 95% confidence interval [CI] 0.14-0.56) and endometriosis (aOR 9.20, 95% CI 3.55-23.81). CONCLUSION Expectant management of tubal pregnancies with pretreatment hCG levels less than 2000 mIU/mL and even between 1000 and 2000 mIU/mL and with a declining trend of hCG demonstrated lower or comparable rates of eventual surgical treatment, when compared with MTX treatment.
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Affiliation(s)
- Nir Kugelman
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Bracha Cohen
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Fayrooz Yossef
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Obstetrics and Gynecology, Bnai Zion Medical Center, Haifa, Israel
| | - Nadine Margieh
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Noam Regev
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Uria Shani
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yossi Bart
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
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Ji JS, Liu L, Huang H, Chen HW, Xiao L, Lu XY, Ni YY, Jia WJ, Huang L. The body mass index and the risk of ectopic pregnancy: a 5-year retrospective case-control study. BMC Pregnancy Childbirth 2024; 24:143. [PMID: 38368325 PMCID: PMC10873945 DOI: 10.1186/s12884-024-06319-z] [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: 03/13/2023] [Accepted: 02/04/2024] [Indexed: 02/19/2024] Open
Abstract
PURPOSE Acknowledging the associated risk factors may have a positive impact on reducing the incidence of ectopic pregnancy (EP). In recent years, body mass index (BMI) has been mentioned in research. However, few studies are available and controversial on the relationship between EP and BMI. METHODS We retrospectively studied the EP women as a case group and the deliveries as a control group in the central hospital of Wuhan during 2017 ~ 2021. χ2 test of variables associated with ectopic pregnancy was performed to find differences. Univariate and multivariate binary logistic regression analysis was conducted to analyze the association of the variables of age, parity, history of induced abortion, history of ectopic pregnancy, history of spontaneous abortion, history of appendectomy surgery and BMI (< 18.5 kg/m2, 18.5 ~ 24.9 kg/m2, 25 kg/m2 ~ 29.9 kg/m2, ≥ 30 kg /m2) with EP. RESULTS They were 659 EP and 1460 deliveries. The variables of age, parity, history of induced abortion, history of ectopic pregnancy and BMI were different significantly(P < 0.05). Multivariate analysis showed that the variables of age > 35 years old [(OR (Odds Ratio), 5.415; 95%CI (Confidence Interval), 4.006 ~ 7.320, P < 0.001], history of ectopic pregnancy (OR, 3.944; 95%CI, 2.405 ~ 6.467; P < 0.001), history of induced abortion(OR, 3.365; 95%CI, 2.724 ~ 4.158, P < 0.001) and low BMI (< 18.5 kg/m2) (OR, 1.929; 95%CI, 1.416 ~ 2.628, P < 0.001])increased the risk of EP. CONCLUSION The history of ectopic pregnancy, history of induced abortion and age > 35 years old were the risk factors with EP. In addition to these traditional factors, we found low BMI (< 18.5 kg/m2) with women may increase the risk to EP.
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Affiliation(s)
- Jin-Shuang Ji
- Department of Gynecology & Obstetrics, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China
| | - Ling Liu
- The Diagnosis and Therapy Center of Pelvic Floor Rehabilitation and Electrophysiology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China
| | - Huan Huang
- Department of Gynecology & Obstetrics, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China
| | - Hong-Wei Chen
- Department of Gynecology & Obstetrics, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China
| | - Li Xiao
- Department of Gynecology & Obstetrics, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China
- The Diagnosis and Therapy Center of Pelvic Floor Rehabilitation and Electrophysiology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China
| | - Xiang-Yi Lu
- Department of Gynecology & Obstetrics, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China
| | - Yang-Yang Ni
- Department of Gynecology & Obstetrics, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China
| | - Wen-Juan Jia
- Department of Gynecology & Obstetrics, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China
| | - Lei Huang
- Department of Gynecology & Obstetrics, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China.
- The Diagnosis and Therapy Center of Pelvic Floor Rehabilitation and Electrophysiology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, Hubei, China.
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Kaplan O, Ertürk Aksakal S, Fidan BB, Engin-Üstün Y, Çelebier M. Plasma metabolomics for diagnostic biomarkers on ectopic pregnancy. Scand J Clin Lab Invest 2024; 84:44-52. [PMID: 38402583 DOI: 10.1080/00365513.2024.2317763] [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: 02/08/2023] [Accepted: 01/14/2024] [Indexed: 02/27/2024]
Abstract
Metabolomics is a relatively novel omics tool to provide potential biomarkers for early diagnosis of the diseases and to insight the pathophysiology not having discussed ever before. In the present study, an ultra-performance liquid chromatography-quadrupole time-of-flight mass spectrometry (UPLC-Q-TOF-MS) was employed to the plasma samples of Group T1: Patients with ectopic pregnancy diagnosed using ultrasound, and followed-up with beta-hCG level (n = 40), Group T2: Patients with ectopic pregnancy diagnosed using ultrasound, underwent surgical treatment and confirmed using histopathology (n = 40), Group P: Healthy pregnant women (n = 40) in the first prenatal visit of pregnancy, Group C: Healthy volunteers (n = 40) scheduling a routine gynecological examination. Metabolite extraction was performed using 3 kDa pores - Amicon® Ultra 0.5 mL Centrifugal Filters. A gradient elution program (mobile phase composition was water and acetonitrile consisting of 0.1% formic acid) was applied using a C18 column (Agilent Zorbax 1.8 μM, 100 x 2.1 mm). Total analysis time was 25 min when the flow rate was 0.2 mL/min. The raw data was processed through XCMS - R program language edition where the optimum parameters detected using Isotopologue Parameter Optimization (IPO). The potential metabolites were identified using MetaboAnalyst 5.0 and finally 27 metabolites were evaluated to be proposed as potential biomarkers to be used for the diagnosis of ectopic pregnancy.
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Affiliation(s)
- Ozan Kaplan
- Department of Analytical Chemistry, Faculty of Pharmacy, Hacettepe University, Ankara, Turkiye
| | - Sezin Ertürk Aksakal
- Department of Obstetrics and Gynecology, University of Health Sciences, Etlik Zubeyde Women's Health Training and Research Hospital, Ankara, Turkiye
| | - Bilge Başak Fidan
- Department of Analytical Chemistry, Faculty of Pharmacy, Hacettepe University, Ankara, Turkiye
| | - Yaprak Engin-Üstün
- Department of Obstetrics and Gynecology, University of Health Sciences, Etlik Zubeyde Women's Health Training and Research Hospital, Ankara, Turkiye
| | - Mustafa Çelebier
- Department of Analytical Chemistry, Faculty of Pharmacy, Hacettepe University, Ankara, Turkiye
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Mraihi F, Buzzaccarini G, D’Amato A, Laganà AS, Basly J, Mejri C, Hafsi M, Chelli D, Ghali Z, Bianco B, Barra F, Etrusco A. Cornual Pregnancy: Results of a Single-Center Retrospective Experience and Systematic Review on Reproductive Outcomes. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:186. [PMID: 38276065 PMCID: PMC10819158 DOI: 10.3390/medicina60010186] [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: 12/16/2023] [Revised: 01/14/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
Background and Objectives: Cornual pregnancies (CPs) are rare forms of ectopic pregnancy. When abortion does not occur, it can be a life-threatening condition for the mother and can also impair future fertility. We present our experience in the diagnosis and management of CPs. A systematic review was also conducted to investigate the reproductive outcomes after treatment. Materials and Methods: Between January 2010 and December 2022, we performed a retrospective, cross-sectional, single-center, and descriptive data collection and analysis (ClinicalTrial ID: NCT06165770). The search for suitable articles published in English was carried out using the following databases (PROSPERO ID: CRD42023484909): MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register), Health Technology Assessment Database, Web of Science, and search register such as ClinicalTrial. Only studies describing the impact of CP treatment on fertility were selected. Results: Two studies were included in the systematic review. Seventeen patients suffering from CPs were selected. In our series, a pelvic ultrasound allowed for the diagnosis of a cornual localization in 35.30% of cases. Thirteen women (76.47%) underwent immediate surgical management. The laparoscopic approach was the most used (76.92%), with a laparotomic conversion rate of 30%. Four patients (23.52%) received medical treatment with methotrexate. After treatment, two patients managed to achieve pregnancy. Conclusions: CP is a rare form of ectopic pregnancy that can quickly become life-threatening for the mother. Ultrasound does not lead to a precise diagnosis in all cases. In the absence of complications and emergencies, laparoscopy is an approach that could be considered valid. For selected asymptomatic patients, medical treatment may be a valid alternative. The data from the studies included in the systematic review, although demonstrating a superiority of medical treatment in terms of future pregnancies, are heterogeneous and do not allow us to reach a definitive conclusion.
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Affiliation(s)
- Fathi Mraihi
- Gynecology and Obstetrics Unit “D”, Maternity and Neonatology Center, Tunis University Hospital, Tunis 1001, Tunisia; (F.M.); (J.B.); (C.M.); (M.H.); (D.C.); (Z.G.)
| | - Giovanni Buzzaccarini
- Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, 20132 Milan, Italy;
| | - Antonio D’Amato
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine, University of Bari, 70124 Bari, Italy;
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | - Jihene Basly
- Gynecology and Obstetrics Unit “D”, Maternity and Neonatology Center, Tunis University Hospital, Tunis 1001, Tunisia; (F.M.); (J.B.); (C.M.); (M.H.); (D.C.); (Z.G.)
| | - Chaima Mejri
- Gynecology and Obstetrics Unit “D”, Maternity and Neonatology Center, Tunis University Hospital, Tunis 1001, Tunisia; (F.M.); (J.B.); (C.M.); (M.H.); (D.C.); (Z.G.)
| | - Montasar Hafsi
- Gynecology and Obstetrics Unit “D”, Maternity and Neonatology Center, Tunis University Hospital, Tunis 1001, Tunisia; (F.M.); (J.B.); (C.M.); (M.H.); (D.C.); (Z.G.)
| | - Dalenda Chelli
- Gynecology and Obstetrics Unit “D”, Maternity and Neonatology Center, Tunis University Hospital, Tunis 1001, Tunisia; (F.M.); (J.B.); (C.M.); (M.H.); (D.C.); (Z.G.)
| | - Zaineb Ghali
- Gynecology and Obstetrics Unit “D”, Maternity and Neonatology Center, Tunis University Hospital, Tunis 1001, Tunisia; (F.M.); (J.B.); (C.M.); (M.H.); (D.C.); (Z.G.)
| | - Bianca Bianco
- Discipline of Sexual and Reproductive Health and Populational Genetics, Department of Collective Health, Faculdade de Medicina do ABC/Centro Universitário FMABC, Santo André 09060-870, SP, Brazil;
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. “Ospedale del Tigullio”-ASL4, Via G. B. Ghio 9, Metropolitan Area of Genoa, 16043 Chiavari, Italy;
- Department of Health Sciences (DISSAL), University of Genoa, Via Antonio Pastore 1, 16132 Genova, Italy
| | - Andrea Etrusco
- Unit of Obstetrics and Gynecology, “Paolo Giaccone” Hospital, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy;
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Wang L, Cai C, Huang L, Shi D, Chen Q, Chen Y, Yu W. Safety profile of methotrexate used off-label in ectopic pregnancy: an active monitoring study based on a Chinese hospital pharmacovigilance system. Curr Med Res Opin 2024; 40:35-42. [PMID: 37975718 DOI: 10.1080/03007995.2023.2285375] [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: 06/24/2023] [Accepted: 11/15/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Methotrexate (MTX) is characterized as first-line therapy although its indication of ectopic pregnancy is off-label use. We aimed to conduct a retrospective cohort study to investigate the incidence, characteristics of adverse drug reactions (ADRs) of MTX, provide valuable insights for medical workers. METHODS Basing on China Hospital Pharmacovigilance System (CHPS), a retrospective analysis was performed to evaluate the safety of MTX (n = 672). An active monitoring model was set to detect ADR signals from the hospital information system. Frequency, Common Terminology Criteria for Adverse Events (CTCAE) grade proportion and association of dose exposure with ADRs were presented as outcomes. RESULTS The total incidence of ADRs was 54.0%. Anaemia (37.6%) was the most frequent ADR, followed by hepatic function abnormal (11.3%), hyperuricemia (6.1%), neutropenia (4.6%), leukopenia (4.0%), and dyslipidaemia (2.5%). For the composition of all ADRs, CTCAE grade one, two and three dominated for 86.3%, 12.1% and 1.6%, respectively. The severity of hepatic function abnormal was more serious in the two-dose exposed group (p = .021), while other types of ADRs had no statistical or clinical differences. Logistic regression analysis showed the incidence of any ADRs (OR 1.87 [1.31-2.64]; p = .001), hepatic function abnormal (OR 2.75 [1.69-4.48]; p < .001), dyslipidaemia (OR 5.15 [1.87-14.13]; p = .001) were significantly higher in the two-dose exposed group. After adjusted, the positive associations were still maintained. CONCLUSIONS MTX is quite safe in ectopic pregnancy, despite its mild to moderate hematotoxicity, hepatotoxicity and nephrotoxicity. Taking CHPS can present the accurate denominator of the incidence of adverse drug reactions into account, our study advocates that it may have great potential to be used as an active monitoring tool for off-label drug use risk management.
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Affiliation(s)
- Lingsong Wang
- Scientific Research and Innovation Center, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Can Cai
- Scientific Research and Innovation Center, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Lurong Huang
- Department of Gynecology, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Danni Shi
- Scientific Research and Innovation Center, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Quanyao Chen
- Scientific Research and Innovation Center, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Yao Chen
- Scientific Research and Innovation Center, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Weiwei Yu
- Department of Obstetrics, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
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Cárdenas-Suárez N, Urrutia-Villamil P, Reyes-Jimenez T, Pereira-Diaz O. Hydrodissection as a Novel Alternative After Failed Management of a Cervical Pregnancy With Methotrexate: Case Report and Literature Review. Cureus 2024; 16:e52556. [PMID: 38249658 PMCID: PMC10798570 DOI: 10.7759/cureus.52556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 01/23/2024] Open
Abstract
Cervical ectopic pregnancies (CEPs) are rare and life-threatening diagnoses. Risk factors have been associated with CEPs, yet their etiology and pathogenesis remain unknown. Timely intervention is vital for successful outcomes, yet it is challenged as there is no standardized approach to treatment. We present the case of a 42-year-old woman diagnosed with CEP following five weeks and one day of amenorrhea. The patient was treated with a two-dose regimen of intramuscular methotrexate (MTX) but failed to respond. Ultrasound-guided intrasac MTX injection was considered a secondary treatment. However, spontaneous expulsion was observed after administering lidocaine at different cervical points. Hydrodissection following systemic MTX could present a novel alternative for treating CEP. Expulsion of pregnancy after hydrodissection could be associated with tissue necrosis and/or destabilized implantation of pregnancy, secondary to the effects of MTX. Further research is vital for evaluating the underlying mechanisms for expulsion and the role of hydrodissection following MTX in treating CEP.
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Affiliation(s)
- Natalia Cárdenas-Suárez
- Department of Obstetrics and Gynecology, University of Puerto Rico Medical Sciences Campus, San Juan, PRI
| | | | | | - Olga Pereira-Diaz
- Department of Obstetrics and Gynecology, San Juan City Hospital, San Juan, PRI
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Bo W, Qianyu Z, Mo L. Global, Regional, and National Burden of Ectopic Pregnancy: A 30-Year Observational Database Study. Int J Clin Pract 2023; 2023:3927337. [PMID: 38146347 PMCID: PMC10749725 DOI: 10.1155/2023/3927337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 12/27/2023] Open
Abstract
Objective To estimate global, regional, and national trends due to ectopic pregnancy as part of the 2019 Global Burden of Disease study. Methods We systematically reviewed trends in ectopic pregnancy burden using data from the Global Burden of Disease (GBD) database, including 21 regions, 195 countries, and territories over the past 30 years. The trends of ectopic pregnancy-related incidence, mortality, and disability-adjusted life years (DALYs) attributable to all known risk factors were also analyzed. Age-standardized rates (ASRs) and their estimated annual percentage changes (EAPCs) were also calculated. Results Incident cases, deaths, and DALYs of ectopic pregnancy increased worldwide in the past 30 years. The age-standardized incidence rate (ASIR) was decreasing (EAPC = -1.14, 95% confidence interval (CI): -1.29 to -0.98), and the age-standardized death (EAPC = -0.9, 95% CI: -1.03 to -0.76) and DALY rate decreased generally (EAPC = -0.83, 95% CI: -0.98 to -0.68). In addition, the burden of ectopic pregnancy is lower in areas with higher socioeconomic development, and significant positive correlations between ASRs and sociodemographic index (SDI) were observed, especially among low-middle SDI, and low SDI quintiles carried the majority burden of ectopic pregnancy. Conclusion Globally, the incidence, mortality, and DALY rate of ectopic pregnancy had been decreasing from 1990 to 2019. Compared with lower and decreasing ASIR in the high SDI region, ASIR in the low SDI region was always high, indicating the need for ectopic pregnancy treatment improvement and the establishment of more targeted and specific strategies in low SDI countries to reduce the incidence of ectopic pregnancy.
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Affiliation(s)
- Wang Bo
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, China
| | - Zhang Qianyu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, China
| | - Li Mo
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrical and Gynecological Diseases, Wuhan, China
- Key Laboratory of Cancer Invasion and Metastasis, Ministry of Education, Wuhan, China
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Fleurant E, McCloskey L. Medication Abortion: A Comprehensive Review. Clin Obstet Gynecol 2023; 66:706-724. [PMID: 37910067 DOI: 10.1097/grf.0000000000000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
This chapter provides an overview of evidence-based guidelines for medication abortion in the first trimester. We discuss regimens, both FDA-approved and other clinical-based protocols, and will briefly discuss novel self-managed abortion techniques taking place outside the formal health care system. Overview of patient counseling and pain management are presented with care to include guidance on "no touch" regimens that have proven both feasible and effective. We hope that this comprehensive review helps the health care community make strides to increase access to abortion in a time when reproductive health care is continuously restricted.
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Affiliation(s)
- Erin Fleurant
- Department of Obstetrics and Gynecology, Northwestern McGaw Medical Center, Chicago, Illinois
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Valdés-Martínez OH, Sordia-Hernández LH, Sordia-Piñeyro MO, Guerra-Leal JD, García-Luna SM, Morales-Martínez FA. Intrasaccular methotrexate treatment of cervical pregnancies maintains fertility: a case series. J OBSTET GYNAECOL 2023; 43:2130207. [PMID: 36240120 DOI: 10.1080/01443615.2022.2130207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Otto Hugo Valdés-Martínez
- Centro Universitario de Medicina Reproductiva, Departamento de Ginecología y Obstetricia, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, N.L., México
| | - Luis Humberto Sordia-Hernández
- Centro Universitario de Medicina Reproductiva, Departamento de Ginecología y Obstetricia, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, N.L., México
| | - María Ofelia Sordia-Piñeyro
- Centro Universitario de Medicina Reproductiva, Departamento de Ginecología y Obstetricia, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, N.L., México
| | - Jesús Dante Guerra-Leal
- Centro Universitario de Imagen Diagnostica, Departamento de Radiología e Imagen, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González". Universidad Autónoma de Nuevo León, Monterrey, N.L., México
| | - Selene M García-Luna
- Centro Universitario de Medicina Reproductiva, Departamento de Ginecología y Obstetricia, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, N.L., México
| | - Felipe Arturo Morales-Martínez
- Centro Universitario de Medicina Reproductiva, Departamento de Ginecología y Obstetricia, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Universidad Autónoma de Nuevo León, Monterrey, N.L., México
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Gilmore E, Gutman S, Kim HT, Roe AH. Diagnosis and Management of an Intramyometrial Ectopic Pregnancy Within a Septate Uterus. Obstet Gynecol 2023; 142:1244-1247. [PMID: 37562025 DOI: 10.1097/aog.0000000000005312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/22/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND An intramyometrial pregnancy is a rare form of ectopic pregnancy, making up an estimated 1% of all ectopic pregnancies. Previously described management options have included surgical excision in the emergency setting. CASE A 32-year-old woman, gravida 4 para 0, at 6 0/7 weeks of gestation by last menstrual period, was noted to have a gestational sac implanted entirely within the uterine myometrium. Ultrasonography and magnetic resonance imaging confirmed the presence of an intramyometrial ectopic pregnancy within a septate uterus. The patient's abnormal pregnancy was successfully treated with multidose methotrexate. CONCLUSION Intramyometrial pregnancy is a rare entity that should be considered when it is suggested by ultrasonography or if an intrauterine pregnancy is surgically inaccessible from the endometrial cavity. In a stable patient, multidose systemic methotrexate may be a feasible management strategy.
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Affiliation(s)
- Emma Gilmore
- Department of Obstetrics and Gynecology and the Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Traisrisilp K, Sethasathien S. Large unruptured tubal pregnancy mimicking abdominal pregnancy. BMJ Case Rep 2023; 16:e256090. [PMID: 37816580 PMCID: PMC10565280 DOI: 10.1136/bcr-2023-256090] [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] [Indexed: 10/12/2023] Open
Abstract
Ectopic pregnancy accounts for 1-2% of all pregnancies. Ultrasound is the primary diagnostic tool to locate pregnancy outside the uterus and identify complications such as haemoperitoneum. In inconclusive cases, MRI is an adjunctive imaging modality offering more precise tissue differentiation and helpful to location identification. Presented is an unusual case of tubal pregnancy. The patient in her 30s, who was 14 weeks into her first pregnancy, had a suspected abdominal pregnancy. Both transabdominal ultrasound and an MRI indicated an ectopic pregnancy, likely originating from the right fallopian tube. A successful laparotomy and right salpingectomy were performed without complications. Rarely, as in this case, large unruptured and advanced tubal pregnancies can mimic an abdominal pregnancy, underscoring the importance of disease recognition and familiarity with uncommon image findings. An accurate diagnosis of pregnancy location is crucial for effective case management.
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Affiliation(s)
- Kuntharee Traisrisilp
- Obstetric and Gynecology, Chiang Mai University, Faculty of Medicine, Chiang Mai, Thailand
| | - Sethawat Sethasathien
- Obstetric and Gynecology, Chiang Mai University, Faculty of Medicine, Chiang Mai, Thailand
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Banwarth-Kuhn B, McQuade M, Krashin JW. Vaginal Bleeding Before 20 Weeks Gestation. Obstet Gynecol Clin North Am 2023; 50:473-492. [PMID: 37500211 DOI: 10.1016/j.ogc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Conditions that often present with vaginal bleeding before 20 weeks are common and can cause morbidity and mortality. Clinically stable patients can choose their management options. Clinically unstable patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy. Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids. Available data on prognosis with expectant management of pre-viable rupture of membranes in the United States are poor for mothers and fetuses.
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Affiliation(s)
| | | | - Jamie W Krashin
- Department of Obstetrics & Gynecology, University of New Mexico Health Sciences Center, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
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Solangon SA, Van Wely M, Van Mello N, Mol BW, Ross JA, Jurkovic D. Methotrexate vs expectant management for treatment of tubal ectopic pregnancy: An individual participant data meta-analysis. Acta Obstet Gynecol Scand 2023; 102:1159-1175. [PMID: 37345445 PMCID: PMC10407021 DOI: 10.1111/aogs.14617] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Ectopic pregnancy is an important health condition which affects up to 1 in 100 women. Women who present with mild symptoms and low serum human chorionic gonadotrophin (hCG) are often treated with methotrexate (MTX), but expectant management with close monitoring is a feasible alternative. Studies comparing the two treatments have not shown a statistically significant difference in uneventful resolution of ectopic pregnancy, but these studies were too small to define whether certain subgroups could benefit more from either treatment. MATERIAL AND METHODS We performed a systematic review and individual participant data meta-analysis (IPD-MA) of randomized controlled trials comparing systemic MTX and expectant management in women with tubal ectopic pregnancy and low hCG (<2000 IU/L). A one-stage IPD-MA was performed to assess overall treatment effects of MTX and expectant management to generate a pooled intervention effect. Subgroup analyses and exploratory multivariable analyses were undertaken according to baseline serum hCG and progesterone levels. Primary outcome was treatment success, defined as resolution of clinical symptoms and decline in level of serum hCG to <20 IU/L, or a negative urine pregnancy test by the initial intervention strategy, without any additional treatment. Secondary outcomes were need for blood transfusion, surgical intervention, additional MTX side-effects and hCG resolution times. TRIAL REGISTRATION NUMBER PROSPERO: CRD42021214093. RESULTS 1547 studies reviewed and 821 remained after duplicates removed. Five studies screened for eligibility and three IPD requested. Two randomized controlled trials supplied IPD, leading to 153 participants for analysis. Treatment success rate was 65/82 (79.3%) after MTX and 48/70 (68.6%) after expectant management (IPD risk ratio [RR] 1.16, 95% confidence interval [CI] 0.95-1.40). Surgical intervention rates were not significantly different: 8/82 (9.8%) vs 13/70 (18.6%) (RR 0.65, 95% CI 0.23-1.14). Mean time to success was 19.7 days (95% CI 17.4-22.3) after MTX and 21.2 days (95% CI 17.8-25.2) after expectant management (P = 0.25). MTX specific side-effects were reported in 33 MTX compared to four in the expectant group. CONCLUSIONS Our IPD-MA showed no statistically significant difference in treatment efficacy between MTX and expectant management in women with tubal ectopic pregnancy with low hCG. Initial expectant management could be the preferred strategy due to fewer side-effects.
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Affiliation(s)
| | - Madelon Van Wely
- Center for Reproductive MedicineAmsterdam University Medical CenterAmsterdamthe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Norah Van Mello
- Amsterdam Reproduction and Development Research InstituteAmsterdam University Medical CenterAmsterdamthe Netherlands
- Obstetrics and GynecologyAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Ben W. Mol
- The Ritchie Centre, Department of Obstetrics and GynecologyMonash UniversityClaytonVictoriaAustralia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and NutritionUniversity of AberdeenAberdeenUK
| | - Jackie A. Ross
- Early Pregnancy and Gynaecology Assessment UnitKing's College London HospitalLondonUK
| | - Davor Jurkovic
- Institute for Women's HealthUniversity College LondonLondonUK
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Ghanaie MM, Hoshyarmanesh S, Asgari SM, Galebin SMA, Fakor F. Predictive value of serum βHCG level in ectopic pregnancy: A cross sectional study. Health Sci Rep 2023; 6:e1442. [PMID: 37680207 PMCID: PMC10480407 DOI: 10.1002/hsr2.1442] [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: 04/08/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 09/09/2023] Open
Abstract
Background and Aims Ectopic pregnancy (EP) is a potentially life-threatening emergency. We investigate the predictive value of serum βHCG level and it's changes from the baseline to the 4th and 7th days after single dose (SD) methotrexate (MTX) treatment in successful treatment of tubal EP. It is important for early diagnosis of EP. Methods In this cross-sectional study, 690 women with tubal EP and under treatment with SD MTX were evaluated. Successful and failed groups were analyzed on the baseline, 4th and 7th days of MTX treatment. Data were analyzed using SPSS22 software. All p values of less than 0/05 were considered satistically significant. Results SD MTX treatment was successful in 584 (84.7%) patients. The mean baseline ßHCG value was 882.35 ± 430.76 in the successful group and 1083.99 ± 1080.25 in the failed group. There was a 19.53% decrease in ßHCG values between the baseline and 4th days in the successful group and a 12.94% increase in the failed group (p < 0.001). On days baseline, 4 and 7; receiver operating characteristic curve analysis's value was 504.5, 429, 279 for cut off; 58%, 73%, 81% for sensitivity and 51%, 52%, 55% for specificity, respectively. Conclusion A decrease in the ßHCG value and/or a cut-off decrease of 59.9% on the baseline, 4th day and 81.6% between the baseline and 7th days, can predict the successful treatment of tubal EP with SD MTX.
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Affiliation(s)
- Mandana Mansour Ghanaie
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Alzahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | - Sanaz Hoshyarmanesh
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Alzahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
| | | | | | - Fereshteh Fakor
- Department of Obstetrics & Gynecology, Reproductive Health Research Center, Alzahra Hospital, School of MedicineGuilan University of Medical SciencesRashtIran
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Reis YA, Akay A, Diktaş EG, Özkan M, Öztürk N, Özkan D, Çakır BT, Erkaya S. Prediction of Rupture by Complete Blood Count in Tubal Ectopic Pregnancies Treated with a Single-Dose Methotrexate Protocol. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:e503-e510. [PMID: 37846182 PMCID: PMC10579924 DOI: 10.1055/s-0043-1772485] [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: 03/16/2023] [Accepted: 05/05/2023] [Indexed: 10/18/2023] Open
Abstract
OBJECTIVE The availability of reliable and inexpensive markers that can be used to determine the risk of rupture during methotrexate (MTX) treatment in ectopic pregnancies (EPs) is considerable. The aim of the present study is to investigate the role of systemic inflammatory markers such as leukocytes (or white blood cells, WBCs), the neutrophil-to-lymphocyte ratio (NLR), and platelet distribution width (PDW), which are among the parameters of the complete blood count (CBC), in the prediction of rupture of EPs under MTX treatment. MATERIALS AND METHODS A total of 161 patients with tubal EP who underwent a single-dose methotrexate (MTX) protocol were retrospectively analyzed, and the control group (n = 83) included patients cured by MTX, while the ruptured group (n = 78) included patients who were operated on for tubal rupture during the MTX treatment. The features of EP, beta-human chorionic gonadotropin (β-hCG) levels, sonographic findings, and CBC-derived markers such as WBC, NLR, and PDW, were investigated by comparing both groups. RESULTS The NLR was found to be higher in the ruptured group, of 2.92 ± 0.86%, and significantly lower in the control group, of 2.09 ± 0.6%. Similarly, the PDW was higher (51 ± 9%) in the ruptured group, and it was significantly lower a (47 ± 13%) in the control group (p < 0.05). Other CBC parameters were similar in both groups (p > 0.05). CONCLUSION Systemic inflammation markers derived from CBC can be easily applied to predict the risk of tubal rupture in Eps, since the CBC is an inexpensive and easy-to-apply test, which is first requested from each patient during hospitalization.
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Affiliation(s)
- Yıldız Akdaş Reis
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Arife Akay
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Elif Gülşah Diktaş
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Merve Özkan
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Neslihan Öztürk
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Doğukan Özkan
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Betül Tokgöz Çakır
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Salim Erkaya
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
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Fu Y, Zhang W, Wang Q, Hu C, Li Q, Huang J. Evaluation of Guidelines and Consensus on Ectopic Pregnancy Based by AGREE II Method. Int J Womens Health 2023; 15:1367-1374. [PMID: 37667774 PMCID: PMC10475285 DOI: 10.2147/ijwh.s421956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023] Open
Abstract
Introduction To evaluate the methodological quality of diagnosis and treatment guidelines/consensus related to ectopic pregnancy. Materials and methods Use the "Appraisal of Guidelines and Research and Evaluation" (AGREE II) method to evaluate the differences among the guideline/consensus. Results We appraised 9 clinical practice guidelines for ectopic pregnancy (9 clinical practice guidelines from 5 countries) including the United States, United Kingdom, Ireland, Canada, and China. The guidelines received the highest scores for clarity of presentation (82.72%) and lowest scores for editorial independence (30.56%). The comprehensive recommendations of the 7 guidelines were Grade B, the other 2 guidelines were Grade C. Conclusion The overall quality of the ectopic pregnancy guidelines had room for improvement. It is recommended to supplement and improve the four fields of "independence", "rigor", "participants" and "application", especially the "independence" and "application" fields.
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Affiliation(s)
- Yiran Fu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Weishe Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
- Hunan Engineering Research Center of Early Life Development and Disease Prevention, Changsha, People’s Republic of China
| | - Qi Wang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Caihong Hu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Qi Li
- Reproductive Medicine Center, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Jingrui Huang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
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Orsi M, Janneh FM, Sesay A, Bah AK, Tiru NA. A Clinical and Ethical Dilemma: Expectant Management for Ectopic Pregnancy with a Vital Fetus in a Low-Resource Setting. J Clin Med 2023; 12:5642. [PMID: 37685709 PMCID: PMC10488410 DOI: 10.3390/jcm12175642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/20/2023] [Accepted: 08/28/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Guidelines recommend the prompt surgical removal of any ectopic pregnancy (EP) in the presence of a vital embryo. This treatment impacts future fertility, particularly in low-resource settings where access to assisted reproductive techniques is limited. In addition, growing evidence is reporting live births after conservative management of initially undiagnosed abdominal pregnancies. Therefore, the discussion on the acceptability of expectant management in selected cases has been recently raised. CASE We present and discuss the case of a woman with vital first trimester EP who refused surgical treatment at Princess Christian Maternity Hospital, Freetown, Sierra Leone. She was initially diagnosed with a 12 week pregnancy located in the left adnexal region without hemoperitoneum. She refused both surgical treatment and hospital admission and did not come back to the hospital for antenatal care until 26 weeks of gestational age. Therefore, she was admitted and finally delivered, at 34 weeks of gestation, a 1.9 kg healthy baby which was alive. To disentangle the potential conflict between the ethical principles of medical treatment's beneficence and the patient's autonomy, we provide an update on counselling for a patient with early vital EP in a resource-limited setting and discuss the knowledge gap in this area. CONCLUSIONS Limited access to fertility treatment in low- and middle-income countries may justify the discussion of expectant management as an option in selected cases of uncomplicated vital EP.
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Affiliation(s)
- Michele Orsi
- Unit of Obstetrics, Department of Woman Newborn and Child, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Via della Commenda, 12, 20122 Milan, Italy
| | - Foday Musa Janneh
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospital Complex, Fourah Bay Road, Freetown 00232, Sierra Leone
| | - Amadu Sesay
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospital Complex, Fourah Bay Road, Freetown 00232, Sierra Leone
| | - Abdul Karim Bah
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospital Complex, Fourah Bay Road, Freetown 00232, Sierra Leone
| | - Nitsuh Addis Tiru
- Princess Christian Maternity Hospital, University of Sierra Leone Teaching Hospital Complex, Fourah Bay Road, Freetown 00232, Sierra Leone
- Doctors with Africa CUAMM, Via San Francesco, 126, 35121 Padova, Italy
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Cirucci CA. Self-Managed Medication Abortion: Implications for Clinical Practice. LINACRE QUARTERLY 2023; 90:273-289. [PMID: 37841380 PMCID: PMC10566489 DOI: 10.1177/00243639221128389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Medication abortion represents more than 50 percent of abortions in the United States (US). Since its approval in the US in 2000, the Food and Drug Administration (FDA) has progressively relaxed the prescribing requirements such that currently, no office visit, in-person dispensing, or ultrasound is required. Obtaining medication for abortion online without medical supervision or evaluation is also possible. This article reviews the complications of medication abortion by examining major studies and delineates the risks specific to self-managed abortion to inform clinicians in caring for women. Summary Medication abortion has become the most common abortion method in the United States. This document provides a detailed history of the relaxation requirements on medication abortion and reviews the major studies on medication abortion complications including a discussion of their limitations. Finally, the paper delineates the ease of access to medication abortion without a health care provider and the risks associated with self-managed abortion. This paper is intended to provide information for clinicians who likely will be encountering increasing number of patients with such complications.
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Wang S, Qi L, Liu Y, Shi H, Chen X, Wang N, Su Y. Suitable endometrial thickness on embryo transfer day may reduce ectopic pregnancy rate and improve clinical pregnancy rate. BMC Pregnancy Childbirth 2023; 23:517. [PMID: 37454102 DOI: 10.1186/s12884-023-05837-6] [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: 11/19/2022] [Accepted: 07/09/2023] [Indexed: 07/18/2023] Open
Abstract
BACKGROUND This retrospective study aimed to investigate the most suitable endometrial thickness (EMT) on the day of embryo transfer that could reduce ectopic pregnancy rate (EPR) and improve clinical pregnancy rate (CPR) in fresh embryo transfer patients with early follicular phase long-acting regimen. METHODS A total of 11,738 IVF/ICSI cycles, comprising 4,489 non-clinical pregnancies, 7,121 intrauterine pregnancies, and 128 ectopic pregnancy cycles after fresh embryo transfer, recorded between September 2017 and December 2020. Clinical pregnancy (CP) and ectopic pregnancy (EP) were the primary outcomes. Multivariate logistic regression was used to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI) for EP and CP. Patients were divided into three groups based on the EMT (6-10 mm, 11-15 mm, and 16-20 mm). CPR and EPR per millimeter of EMT were drawn into a line chart, and three groups were analyzed by Chi-square test. RESULTS After controlling for potential confounders, EMT had a significant effect on CP (aOR = 1.07; 95% CI, 1.05-1.08; P = 0.00) and EP (aOR = 0.88; 95% CI, 0.82-0.94; P = 0.00). With the increase of EMT, CPR increased and EPR decreased. Pearson correlation coefficients were r = 0.708 (P = 0.00) and r =-0.558 (P = 0.03), respectively. Significant differenceswere detected in the CPRs and EPRs (all P = 0.00). The CPR in the 6-10 mm group (54.88%) was significantly lower than that in the 11-15 mm group (64.23%) and the 16-20 mm group (64.40%) (P = 0.00). The EPR in the 6-10 mm group (2.72%) was significantly higher than that in the other two groups (1.60% and 0.97%, P = 0.00). The difference in CPR and EPR between the 11-15 mm group and the 16-20 mm group was not statistically significant, which indicated that EMT ≥ 11 mm simultaneously reduced the EPR and increased the CPR. CONCLUSIONS EMT was inversely proportional to EPR and directly proportional to CPR in fresh embryo transfer cycles. The EMT ≥ 11 mm on the day of embryo transfer could simultaneously achieve lower EPR and higher CPR. Accordingly, more attention should be given to the EMT of women who underwent ART treatment.
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Affiliation(s)
- Shiming Wang
- Reproductive Medical Center, Henan Province Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Erqi District, Zhengzhou, China
| | - Lin Qi
- Reproductive Medical Center, Henan Province Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Erqi District, Zhengzhou, China
| | - Yaping Liu
- Reproductive Medical Center, Henan Province Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Erqi District, Zhengzhou, China
| | - Hao Shi
- Reproductive Medical Center, Henan Province Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Erqi District, Zhengzhou, China
| | - Xiaoli Chen
- Reproductive Medical Center, Henan Province Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Erqi District, Zhengzhou, China
| | - Ningning Wang
- Reproductive Medical Center, Henan Province Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Erqi District, Zhengzhou, China
| | - Yingchun Su
- Reproductive Medical Center, Henan Province Key Laboratory of Reproduction and Genetics, The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Erqi District, Zhengzhou, China.
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Mackenzie SC, Moakes CA, Doust AM, Mol BW, Duncan WC, Tong S, Horne AW, Whitaker LHR. Early (Days 1-4) post-treatment serum hCG level changes predict single-dose methotrexate treatment success in tubal ectopic pregnancy. Hum Reprod 2023; 38:1261-1267. [PMID: 37178269 PMCID: PMC10320483 DOI: 10.1093/humrep/dead089] [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: 02/02/2023] [Revised: 04/12/2023] [Indexed: 05/15/2023] Open
Abstract
STUDY QUESTION What is the capacity of the change between Day 1 and Day 4 post-treatment serum human chorionic gonadotropin (hCG) levels for predicting single-dose methotrexate treatment success in tubal ectopic pregnancy? SUMMARY ANSWER Any fall in Days 1-4 serum hCG signified an 85% (95% CI 76.8-90.6) likelihood of treatment success for women with tubal ectopic pregnancy (initial hCG of ≥1000 and ≤5000 IU/l) managed with single-dose methotrexate. WHAT IS KNOWN ALREADY For those with tubal ectopic pregnancy managed by single-dose methotrexate, current guidelines advocate intervention if Days 4-7 hCG fails to fall by >15%. The trajectory of hCG over Days 1-4 has been proposed as an early indicator that predicts treatment success, allowing early reassurance for women. However, almost all prior studies of Days 1-4 hCG changes have been retrospective. STUDY DESIGN, SIZE, DURATION This was a prospective cohort study of women with tubal ectopic pregnancy (pre-treatment hCG of ≥1000 and ≤5000 IU/l) managed with single-dose methotrexate. The data were derived from a UK multicentre randomized controlled trial of methotrexate and gefitinib versus methotrexate and placebo for treatment of tubal ectopic pregnancy (GEM3). For this analysis, we include data from both treatment arms. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants were categorized according to single-dose methotrexate treatment success or failure. Treatment success for this analysis was defined as complete and uneventful resolution of tubal ectopic pregnancy to serum hCG <30 IU/l following single-dose methotrexate treatment without additional treatment. Patient characteristics of the treatment success and failure groups were compared. Changes in Days 1-4, 1-7, and 4-7 serum hCG were evaluated as predictors of treatment success through receiver operating characteristic curve analysis. Test performance characteristics were calculated for percentage change ranges and thresholds including optimal classification thresholds. MAIN RESULTS AND THE ROLE OF CHANCE A total of 322 women with tubal ectopic pregnancy were treated with single-dose methotrexate. The overall single-dose methotrexate treatment success rate was 59% (n = 189/322). For any fall in serum hCG on Days 1-4, likelihood ratios were >3, while for any fall of serum hCG >20% on Days 1-7, likelihood ratios reached 5. Any rise of serum hCG on Days 1-7 and 4-7 strongly reduced the chance of success. Any fall in Days 1-4 hCG predicted single-dose methotrexate treatment success with a sensitivity of 58% and specificity 84%, resulting in positive and negative predictive values of 85% and 57%, respectively. Any rise in Days 1-4 serum hCG <18% was identified as an optimal test threshold that predicted treatment success with 79% sensitivity and 74% specificity, resulting in 82% positive predictive value and 69% negative predictive value. LIMITATIONS, REASONS FOR CAUTION Our findings may be limited by intervention bias resulting from existing guidelines which influences evaluation of hCG changes reliant on Day 7 serum hCG levels. WIDER IMPLICATIONS OF THE FINDINGS Examining a large prospective cohort, we show the value of Days 1-4 serum hCG changes in predicting single-dose methotrexate treatment success in tubal ectopic pregnancy. We recommend that clinicians provide early reassurance to women who have a fall or only a modest (<18%) rise in Days 1-4 serum hCG levels, that their treatment will likely be effective. STUDY FUNDING/COMPETING INTEREST(S) This project was supported by funding from the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership (grant reference number 14/150/03). A.W.H. has received honoraria for consultancy for Ferring, Roche, Nordic Pharma and AbbVie. W.C.D. has received honoraria from Merck and Guerbet and research funding from Galvani Biosciences. L.H.R.W. has received research funding from Roche Diagnostics. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437). B.W.M. also reports consultancy for ObsEva and Merck and travel support from Merck. The other authors declare no competing interests. TRIAL REGISTRATION NUMBER This study is a secondary analysis of the GEM3 trial (ISRCTN Registry ISRCTN67795930).
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Affiliation(s)
- Scott C Mackenzie
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Catherine A Moakes
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Ann M Doust
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - W Colin Duncan
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Lucy H R Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
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Bužinskienė D, Mačionytė M, Dasevičius D, Šilkūnas M. Case report: Ectopic pregnancy in the interstitial part of the fallopian tube. Front Surg 2023; 10:1197036. [PMID: 37470044 PMCID: PMC10352450 DOI: 10.3389/fsurg.2023.1197036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023] Open
Abstract
Ectopic pregnancy remains one of the most common causes of pregnancy-related death in the first trimester. 2.4% of ectopic pregnancies occur in the interstitial part of the fallopian tube. As the symptoms of this condition are non-specific and the localization is associated with a higher risk of bleeding, early diagnosis of interstitial pregnancies is important, based not only on clinical symptoms, but also on additional diagnostic methods. Early diagnosis leads to better treatment-related outcomes. We report a 32-year-old female patient who came to the emergency department because of pain in the lower abdomen and right iliac region and bloody vaginal discharge. During palpation of the abdomen, the pain was localized in the lower part of the abdomen. Human chorionic gonadotropin (hCG) was significantly increased in biochemical tests. Transvaginal ultrasound examination of internal genital organs, abdominal and pelvic computer tomography (CT) were per-formed. An ectopic pregnancy was suspected. Thus, the patient was hospitalized in the gynecology department for surgical treatment. A laparoscopy was performed and an ectopic pregnancy was diagnosed in the interstitial part of the right fallopian tube and in the right uterine corner, which led to right salpingectomy and right uterine angle resection. Thus, interstitial pregnancy is a rare and life-threatening gynecological condition due to the higher risk of bleeding compared to other ectopic pregnancies. However, appropriate diagnosis based on clinical signs, transvaginal ultrasound findings and hCG levels in the blood ensures early diagnosis of interstitial pregnancy, which leads to the choice of medical treatment with methotrexate or minimally invasive surgical techniques.
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Affiliation(s)
- Diana Bužinskienė
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Obstetrics and Gynecology, Institute of Clinical Medicine, Faculty of Medicine Vilnius University, Vilnius, Lithuania
| | | | - Darius Dasevičius
- National Center of Pathology, Affiliate of Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Mindaugas Šilkūnas
- Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Obstetrics and Gynecology, Institute of Clinical Medicine, Faculty of Medicine Vilnius University, Vilnius, Lithuania
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Zheng X, Zhou Y, Sun Z, Yan T, Yang Y, Wang R. Abdominal pregnancy secondary to uterine horn pregnancy: a case report. BMC Pregnancy Childbirth 2023; 23:412. [PMID: 37270533 DOI: 10.1186/s12884-023-05704-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 05/15/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Pregnancy begins with a fertilized ovum that normally attaches to the uterine endometrium. However, an ectopic pregnancy can occur when a fertilized egg implants and grows outside the uterine cavity. Tubal ectopic pregnancy is the most common type (over 95%), with ovarian, abdominal, cervical, broad ligament, and uterine cornual pregnancy being less common. As more cases of ectopic pregnancy are diagnosed and treated in the early stages, the survival rate and fertility retention significantly improve. However, complications of abdominal pregnancy can sometimes be life-threatening and have severe consequences. CASE PRESENTATION We present a case of intraperitoneal ectopic pregnancy with fetal survival. Ultrasound and magnetic resonance imaging showed a right cornual pregnancy with a secondary abdominal pregnancy. In September 2021, we performed an emergency laparotomy, along with additional procedures such as transurethral ureteroscopy, double J-stent placement, abdominal fetal removal, placentectomy, repair of the right uterine horn, and pelvic adhesiolysis, in the 29th week of pregnancy. During laparotomy, we diagnosed abdominal pregnancy secondary to a rudimentary uterine horn. The mother and her baby were discharged eight days and 41 days, respectively, after surgery. CONCLUSIONS Abdominal pregnancy is a rare condition. The variable nature of ectopic pregnancy can cause delays in timely diagnosis, resulting in increased morbidity and mortality, especially in areas with inadequate medical and social services. A high index of suspicion, coupled with appropriate imaging studies, can help facilitate its diagnosis in any suspected case.
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Affiliation(s)
- Xingju Zheng
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Yao Zhou
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Zhucheng Sun
- Department of Vascular Surgery, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Ting Yan
- Department of Gynecology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Yan Yang
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China
| | - Rongpin Wang
- Department of Radiology, Guizhou Provincial People's Hospital, Guiyang, 550002, China.
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