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Abstract
Peripartum hemorrhage is a leading cause of maternal morbidity and mortality. Anesthesiologists must be familiar with conditions associated with hemorrhage that are unique to labor and delivery and not seen elsewhere in their practice. Regardless of etiology, early recognition and timely treatment of obstetric hemorrhage is necessary to prevent significant blood loss. Massive transfusion protocols are crucial to successful resuscitation, and providers should also consider use of cell salvage, uterine artery embolization, and anti-fibrinolytics. Because more than half the deaths due to hemorrhage are preventable, multidisciplinary care bundles should be used on every labor and delivery unit.
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Affiliation(s)
- Joy L Hawkins
- University of Colorado School of Medicine, 12631 East 17th Avenue, Mail Stop 8202, Aurora, CO 80045, USA.
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102
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Flynn AN, Schreiber CA, Roe A, Shorter JM, Frarey A, Barnhart K, Sonalkar S. Prioritizing Desiredness in Pregnancy of Unknown Location: An Algorithm for Patient-Centered Care. Obstet Gynecol 2020; 136:1001-1005. [PMID: 33030869 DOI: 10.1097/aog.0000000000004124] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patient-centered care is one of the six aims for improvement in health care quality outlined by the National Academy of Medicine (previously known as the Institute of Medicine). We propose an algorithm for patients who are presenting with a pregnancy of unknown location that emphasizes pregnancy desiredness to improve patient-centered care. Health care professionals should assess pregnancy desiredness at a patient's initial consultation for evaluation of pregnancy of unknown location; desiredness, along with other clinical criteria, should guide management. For women with an undesired pregnancy, health care professionals should offer expedient active management. Uterine aspiration will allow for quick clinical diagnosis and resolution of the pregnancy. Alternatively, for women with a desired pregnancy or for those who are ambivalent, we recommend careful conservative management. Adopting this algorithm will recenter the patient in the complex management of pregnancy of unknown location.
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Affiliation(s)
- Anne N Flynn
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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103
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Abstract
OBJECTIVE To evaluate outpatient opioid dispensing and the incidence of persistent opioid use after ectopic pregnancy. METHODS This cohort study used U.S. employer-based claims data to identify opioid-naïve individuals experiencing ectopic pregnancy from November 1, 2008, to September 30, 2015. Treatment was categorized as surgical, medical (using methotrexate), or unknown. New opioid prescriptions were defined as prescriptions filled from 1 week before to 1 week after an ectopic pregnancy treatment. For those who filled a new opioid prescription, we calculated the incidence and risk factors for persistent opioid use, defined as having filled at least one opioid prescription both from 8 to 90 days after treatment and from 91 to 365 days after treatment. RESULTS Of the 15,338 individuals in our study, 7,047 (45.9%, 95% CI 45.2-46.7%) filled an opioid prescription at the time of treatment, of whom 4.1% (95% CI 3.6-4.6%) developed persistent opioid use. The risk of persistent opioid use was lower among those who had surgical compared with medical treatment (3.7% and 6.8%, respectively; relative risk [RR] 0.54, 95% CI 0.38-0.77). Variables most strongly associated with persistent opioid use were a history of benzodiazepine use (RR 1.99; 95% CI 1.43-2.78; adjusted relative risk [aRR] 1.57, 95% CI 1.11-2.22), antidepressant use (RR 1.91, 95% CI 1.45-2.53; aRR 1.53, 95% CI 1.08-2.18), and a pre-existing pain disorder (RR 1.58, 95% CI 1.26-1.99; aRR 1.47, 95% CI 1.16-1.85) in the year before treatment. CONCLUSION New opioid use is common after an ectopic pregnancy; approximately 4% of those with new opioid use develop persistent opioid use, with the rate higher in those treated medically. New pain-management guidelines need to be developed to prevent persistent opioid use after ectopic pregnancy.
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104
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Abstract
This review highlights proposed pandemic-adjusted modifications in obstetric care, with discussion of risks and benefits based on available evidence. We suggest best practices for balancing community-mitigation efforts with appropriate care of obstetric patients.
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105
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Jones DD, Kummer T, Schoen JC. Ruptured Ectopic Pregnancy with an Intrauterine Device: Case Report and Sonographic Considerations. Clin Pract Cases Emerg Med 2020; 4:559-563. [PMID: 33217272 PMCID: PMC7676810 DOI: 10.5811/cpcem.2020.7.48258] [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: 05/17/2020] [Revised: 07/17/2020] [Accepted: 07/24/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Ectopic pregnancy carries a high morbidity and mortality; patients are at risk for rupture and life-threatening hemorrhage. CASE REPORT We present a rare case of ruptured abdominal ectopic pregnancy in a patient with a well-positioned intrauterine device (IUD) and discuss the diagnostic utility that transabdominal point-of-care ultrasound (POCUS) can have when performed at the bedside. CONCLUSION While pregnancy with an IUD in place is rare, when it is encountered the emergency provider should maintain a high degree of suspicion for extrauterine pregnancy and perform prompt evaluation for hemorrhagic shock using diagnostic POCUS.
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Affiliation(s)
- Derick D. Jones
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
- Mayo Clinic Health System Albert Lea and Austin, Department of Emergency Medicine, Austin, Minnesota
| | - Tobias Kummer
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - Jessica C. Schoen
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
- Mayo Clinic Health System Albert Lea and Austin, Department of Emergency Medicine, Austin, Minnesota
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106
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Colombo GE, Leonardi M, Armour M, Di Somma H, Dinh T, da Silva Costa F, Wong L, Armour S, Condous G. Efficacy and safety of expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis. Hum Reprod Open 2020; 2020:hoaa044. [PMID: 33134560 PMCID: PMC7585644 DOI: 10.1093/hropen/hoaa044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/27/2020] [Indexed: 12/29/2022] Open
Abstract
STUDY QUESTION Is expectant management (EM) of tubal ectopic pregnancy (EP) an effective and safe treatment strategy when compared to alternative interventions? SUMMARY ANSWER There is insufficient evidence to conclude EM yields a difference in the resolution of tubal EP, the avoidance of surgery or time to resolution of tubal EP when compared to intramuscular methotrexate in stable patients with β-hCG <1500 IU/l. WHAT IS ALREADY KNOWN The utilisation of medical and surgical management for EP is well established. EM aims to allow spontaneous resolution of the EP without intervention. STUDY DESIGN SIZE AND DURATION We performed a systematic review and meta-analysis, searching Ovid MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, OpenGrey.eu, Google Scholar, cross-referencing citations and trial registries to 15 December 2019. There were no limitations placed on language or publication date. Search terms included tubal EP and EM as well as variations of these terms. PARTICIPANTS/MATERIALS SETTING AND METHOD We considered studies that included patients with tubal EP, EM as a comparator, and that were randomised controlled trials (RCTs). The primary outcome was resolution of tubal EP. Secondary outcomes included avoidance of surgery and the time to resolution of EP. Two reviewers independently selected the studies, assessed bias and extracted data. Relative risk (RR) and mean difference with 95% CI were assessed using a random effects model. The certainty of evidence was scored according to Grading of Recommendations Assessment, Development and Evaluation guidelines. MAIN RESULTS AND THE ROLE OF CHANCE In total, 920 studies were screened. Five studies were eligible for inclusion in the systematic review. Two RCTs comparing methotrexate to EM were identified as being eligible for inclusion in meta-analysis. No RCTs comparing surgery to EM were identified. Compared with EM, there was insufficient evidence that methotrexate yields a difference on resolution of tubal EP (RR 1.04, 95% CI 0.88-1.23, P = 0.67; two RCTs, moderate-certainty evidence), avoiding surgery (RR 1.10, 95% CI 0.94-1.29, P = 0.25; two RCTs, low-certainty evidence) or the time to resolution of tubal EP (-2.56 days (favouring EM), 95% CI -7.93-2.80, P = 0.35; two RCTs, low-certainty evidence). LIMITATIONS REASONS FOR CAUTION Only two RCTs with a total of 103 patients were eligible for inclusion in this meta-analysis. Further RCTs comparing EM to medical and surgical management are needed and these should also report adverse events. Patient preference should also be evaluated. WIDER IMPLICATIONS OF THE FINDINGS We found insufficient evidence of differences in terms of resolution, avoidance of surgery and time to resolution between expectant and medical management. Given the imprecision in the effect estimates as demonstrated by the wide CIs, resulting in the downgrading of certainty of evidence for all outcomes in this meta-analysis, larger RCTs comparing interventions for tubal EP are needed. Caution should be exercised when trying to decide between EM and methotrexate to treat tubal EP. STUDY FUNDING/COMPETING INTERESTS There was no funding for this study. NICM receives funding from various sources; none specifically supported this research. M.L. reports grants from Australian Women and Children's Research Foundation, outside the submitted work. M.A.: As a medical research institute, NICM Health Research Institute receives research grants and donations from foundations, universities, government agencies and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of the Institute. This systematic review was not specifically supported by donor or sponsor funding to NICM. M.A. reports a partnership grant with Metagenetics outside the submitted work. G.C. reports grants from Australian Women and Children's Research Foundation, personal fees from Roche and GE Healthcare, outside the submitted work. The remaining authors report no conflicts of interest. PROSPERO REGISTRATION NUMBER CRD42020142736.
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Affiliation(s)
- G E Colombo
- School of Medicine, Medical Sciences, and Nutrition, University of Aberdeen, Aberdeen AB24 3FX, UK
- Acute Gynaecology, Early Pregnancy, and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, 2747 NSW, Australia
| | - M Leonardi
- Acute Gynaecology, Early Pregnancy, and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, 2747 NSW, Australia
- Sydney Medical School Nepean, University of Sydney, Sydney, NSW 2006, Australia
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON, L8N 3Z5, Canada
| | - M Armour
- NICM Health Research Institute, Western Sydney University, Penrith, NSW 2145, Australia
- Translational Health Research Institute (THRI), Western Sydney University, Penrith, NSW 2145, Australia
| | - H Di Somma
- Acute Gynaecology, Early Pregnancy, and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, 2747 NSW, Australia
- School of Medicine, University of Auckland, Auckland 1010, New Zealand
| | - T Dinh
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, ON K1N 6N5, Canada
| | - F da Silva Costa
- Department of Obstetrics and Gynaecology, Monash University Faculty of Medicine, Nursing, and Health Sciences, Clayton, VIC 3800, Australia
- Department of Gynecology and Obstetrics, University of São Paulo, Faculdade de Medicina Ribeirão Preto, Ribeirão Preto, São Paulo 14049-900, Brazil
| | - L Wong
- Department of Obstetrics and Gynaecology, Monash Medical Centre, Clayton, VIC 3168, Australia
| | - S Armour
- Translational Health Research Institute (THRI), Western Sydney University, Penrith, NSW 2145, Australia
| | - G Condous
- Acute Gynaecology, Early Pregnancy, and Advanced Endosurgery Unit, Nepean Hospital, Kingswood, 2747 NSW, Australia
- Sydney Medical School Nepean, University of Sydney, Sydney, NSW 2006, Australia
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107
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Karadağ B, Aykan Yüksel B, Gürses C, Karataş S. Spontaneous unilateral quadruplet tubal ectopic pregnancy. Turk J Obstet Gynecol 2020; 17:146-148. [PMID: 32850192 PMCID: PMC7406898 DOI: 10.4274/tjod.galenos.2020.64624] [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: 12/11/2019] [Accepted: 02/17/2020] [Indexed: 12/01/2022] Open
Abstract
Ectopic pregnancy (EP) is defined as the implantation of the fertilized ovum outside the uterine cavity. Importantly, the implantation site is tubal in 95% of the cases. Multiple EPs are extremely rare. We present a case of a 25-year-old patient, gravida 2 para 1, with amenorrhea accompanied by the complaints of vaginal bleeding and abdominal pain. She was admitted to the emergency department. Trans-vaginal ultrasound revealed a left ovarian anechoic cyst of 30 mm and four embryos in the right tube with positive cardiac activities. An emergency laparotomy found the rupture of tubal pregnancy on the right side, which ultimately led to hemo-peritoneum. Therefore, we performed right salpingectomy. This is the first well-documented case of a patient with spontaneous unilateral quadruplet tubal EP.
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Affiliation(s)
- Burak Karadağ
- University of Health Sciences Turkey, Antalya Training and Research Hospital, Clinic of Obstetrics and Gynecology, Antalya, Turkey
| | - Burcu Aykan Yüksel
- University of Health Sciences Turkey, Antalya Training and Research Hospital, Clinic of Obstetrics and Gynecology, Antalya, Turkey
| | - Cemil Gürses
- University of Health Sciences Turkey, Antalya Training and Research Hospital, Clinic of Radiology, Antalya, Turkey
| | - Selim Karataş
- University of Health Sciences Turkey, Antalya Training and Research Hospital, Clinic of Obstetrics and Gynecology, Antalya, Turkey
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108
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Ectopic Pregnancy During Coronavirus Disease 2019 (COVID-19): To Operate, or Not to Operate. Obstet Gynecol 2020; 136:288-290. [PMID: 32459700 DOI: 10.1097/aog.0000000000003995] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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109
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Petrini A, Spandorfer S. Recurrent Ectopic Pregnancy: Current Perspectives. Int J Womens Health 2020; 12:597-600. [PMID: 32801937 PMCID: PMC7414932 DOI: 10.2147/ijwh.s223909] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/17/2020] [Indexed: 11/25/2022] Open
Abstract
Ectopic pregnancy represents a potentially life-threatening diagnosis. The risk factors for recurrent ectopic pregnancy have been enumerated but are not yet clearly defined. Understanding which risk factors are perhaps more common may allow providers to counsel and manage patients with a higher level of scrutiny.
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Affiliation(s)
- Allison Petrini
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Steven Spandorfer
- The Ronald O. Perelman and Claudia Cohen Center for Reproductive Medicine, Weill Cornell Medical College, New York, NY, USA
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110
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Managing Ectopic Pregnancies by Targeting Chorionic Villi with a Transvaginal Injection of Ethanol into the Lacunar Space. Biomedicines 2020; 8:biomedicines8070202. [PMID: 32659901 PMCID: PMC7400639 DOI: 10.3390/biomedicines8070202] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/05/2020] [Accepted: 07/06/2020] [Indexed: 11/17/2022] Open
Abstract
Methotrexate has been the main mode of non-surgical treatment for ectopic pregnancies. However, we have developed an easier, repeatable method that can be applied even to patients with a high beta-human chorionic gonadotropin (β-hCG) level and/or positive fetal heartbeat, by targeting chorionic villi with a transvaginal injection of absolute ethanol (AE) into the lacunar space (intervillous space). The efficacy and safety of this method were examined in 242 cases of ectopic pregnancy, including 103 with positive fetal heartbeat. Serum β-hCG level was measured at frequent intervals, and transvaginal ultrasonography was performed to observe the gestational sac and hyperechoic inner ring. Of the 242 patients, 222 (91.7%) were successfully treated. The average number of AE injection(s) required was 1.6 (range: 1-5), and the average dose was 3.2 mL. After the treatment, many of the patients tried to conceive again, and 63 of the traceable 145 patients (43.4%), who had fallopian tube pregnancy, and 7 of the traceable 12 patients (58.3%), who had cervical or cesarean scar pregnancies, successfully conceived and delivered babies with no observed side effects. Therefore, this method could be an effective treatment for ectopic pregnancy with the potential to replace conventional surgical interventions and medical treatment using methotrexate.
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111
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The association between mitochondrial DNA copy number, telomere length, and tubal pregnancy. Placenta 2020; 97:108-114. [PMID: 32792056 DOI: 10.1016/j.placenta.2020.06.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 06/02/2020] [Accepted: 06/22/2020] [Indexed: 01/10/2023]
Abstract
Growing evidence has demonstrated association between the occurrence of tubal ectopic pregnancy (TP) and oxidative stress (OS) status, in which mitochondria and telomeres play important roles. However, little is known about the underlying correlation between TP and the mitochondrial DNA copy number (mtDNAcn) or telomere length (TL) abnormalities. In this study, we found OS level was elevated in TP patients. We hierarchically detected the relative mtDNAcn and TL of villi from normal pregnancy (NP) and TP samples according to different gestational age, fetal sex, maternal age, and BMI. The results revealed that the relative mtDNAcn was significantly lower in the villi in the TP group compared with the NP cohort, which was negatively correlated with OS status. In the NP group, the mtDNAcn in the female subgroup was apparently lower than that in the male subgroup, while no statistical difference was found in the mtDNAcn in the TP group between the female and male subgroups. Moreover, the relative TL in the TP group was at a similar level to the NP group, and no statistical correlation was observed between relative TL and OS level. In summary, our findings indicate that the abnormal level of mtDNAcn rather than TL is correlated with TP, which provides new insights into the mechanism of TP.
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112
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Zheng Q, Xu S, Mo M, You J, Zeng Y. A live birth with unexpectedly low serum human chorionic gonadotropin level on day 11 after blastocyst embryo transfer: a case report. F S Rep 2020; 1:48-50. [PMID: 34223212 PMCID: PMC8244353 DOI: 10.1016/j.xfre.2020.04.005] [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: 03/13/2020] [Revised: 04/18/2020] [Accepted: 04/28/2020] [Indexed: 11/26/2022] Open
Abstract
Objective To report a very rare case of live birth with unexpectedly low serum hCG level on day 11 after blastocyst embryo transfer. Design Case report. Setting Private infertility center. Patients A 30-year-old nulliparous woman presented with PCOS and 1 year of infertility. Interventionss Conventional IVF was scheduled and a long-acting agonist protocol was selected. Main Outcome Measures Maternal serum hCG levels and transvaginal ultrasound exams for the embryo's well-being. Results The hCG level was 11.6 IU/L on day 11 after the transfer of two blastocyst embryos, which was considered as either failing or extrauterine pregnancy. After blood titration, there were delayed hCG increases. A series of transvaginal ultrasounds also indicated a delayed but normal-appearing intrauterine pregnancy. A healthy baby boy was delivered at term by means of cesarean section. Conclusions A low initial serum hCG level may be associated with certain maternal or fetal characteristics and IVF treatment variables. Close conservative observation is warranted before undertaking any therapeutic intervention.
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Affiliation(s)
- Qizhen Zheng
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Shenzhen Zhongshan Urology Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Shiru Xu
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Shenzhen Zhongshan Urology Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Meilan Mo
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Shenzhen Zhongshan Urology Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Jing You
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Shenzhen Zhongshan Urology Hospital, Shenzhen, Guangdong, People's Republic of China
| | - Yong Zeng
- Shenzhen Key Laboratory of Reproductive Immunology for Peri-implantation, Shenzhen Zhongshan Institute for Reproduction and Genetics, Shenzhen Zhongshan Urology Hospital, Shenzhen, Guangdong, People's Republic of China
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113
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Li J, Luo X, Yang J, Chen S. Treatment of tubal heterotopic pregnancy with viable intrauterine pregnancy: Analysis of 81 cases from one tertiary care center. Eur J Obstet Gynecol Reprod Biol 2020; 252:56-61. [PMID: 32563925 DOI: 10.1016/j.ejogrb.2020.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/03/2020] [Accepted: 06/06/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The aim of our study was to analyze the treatment and pregnancy outcome of tubal heterotopic pregnancy (HP) patients with a viable intrauterine pregnancy (IUP) in our center. STUDY DESIGN This was a retrospective analysis of 81 patients with tubal HP and a viable IUP. Patients were divided into either an expectant treatment group (29 patients) or a surgical treatment group (52 patients, 36 laparoscopy and 16 laparotomy). Data related to the basal clinical characteristic of all patients, rescue treatment and ectopic pregnancy (EP) rupture rate in the expectant treatment group, operation details in the surgical treatment group and pregnancy outcomes were collected and analyzed. Subgroup analyses were also performed. RESULTS In the expectant treatment group, the abortion rate, EP rupture rate and rescue treatment rate were 10.34 % (3/29), 21.14 % (7/29) and 34.48 % (10/29), respectively; subgroup analysis revealed that the rescue treatment rate in patients with EP mass enlargement ≥50 % was 71.43 % (5/7), which was significantly higher than that in patients with EP mass enlargement <50 % (15.00 %, 3/20), with P = 0.011. In the surgical treatment group, the abortion rate of all patients was 15.38 % (8/52); the abortion rate was 22.22 % (8/36) in the laparoscopy subgroup, which was significantly higher than that in the laparotomy subgroup (0.00 %, 0/16), with P = 0.038. CONCLUSIONS Surgical treatment is a safe treatment option for tubal HP with a viable IUP, and laparoscopic surgery may be a potential risk factor for abortion. A high risk of failure exists for expectant management of tubal HP with a viable IUP, and EP mass enlargement ≥50 % may be a potential predictor of rescue treatment.
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Affiliation(s)
- JinBo Li
- Department of Gynecology and Obstetrics, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong, Guangzhou, 510080, PR China
| | - XiaoChan Luo
- Department of Gynecology and Obstetrics, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong, Guangzhou, 510080, PR China
| | - JianBo Yang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong, Guangzhou, 510080, PR China
| | - ShuQin Chen
- Department of Gynecology and Obstetrics, The First Affiliated Hospital, Sun Yat-Sen University, Guangdong, Guangzhou, 510080, PR China.
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114
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Levin G, Meyer R, Dior U, Gilad R, Benshushan A, Shushan A, Rottenstreich A. Outcome of methotrexate treatment for ectopic pregnancies among obese women. J Gynecol Obstet Hum Reprod 2020; 49:101790. [PMID: 32413523 DOI: 10.1016/j.jogoh.2020.101790] [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: 04/02/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Single dose administration of methotrexate (MTX) is considered the first line of treatment in selected patients with an ectopic pregnancy (EP). However, data regarding MTX efficacy among obese patients is limited. We sought to investigate the efficacy of MTX single dose regimen among obese patients MATERIAL AND METHODS: A retrospective cohort study conducted at a gynecology department in a tertiary teaching hospital, between January 2010 and December 2018, including women diagnosed with an EP and treated by a single-dose regimen of MTX. We compared success rate and gestation characteristics between obese and non-obese women. RESULTS Overall, 195 women were treated with single-dose intramuscular MTX for EP during the study period. Of those, 31 women (15.9%) were obese (BMI ≥ 30 kg/m2) and the rest 164 (84.1%) were of normal body weight. Median MTX dosage for the obese group was 95 milligrams (IQR 91-104) vs. 83 milligrams (IQR 78-87) for the non-obese group. Treatment success rate of the overall cohort was 66.6% (130/195) and treatment success rate of single-dose MTX was comparable between the obese and non-obese groups (64.5% vs. 67.0%, p = 0.78). Obese patients were older as compared to non-obese (median age 33 vs. 29, p = 0.03). In multivariate logistic regression analysis, percentage hCG change from day 1 to day 4 was the only factor associated with treatment success (aOR 1.02; 95%CI 1.01, 1.04, p < 0.001). CONCLUSION Single-dose MTX treatment among obese patients diagnosed with ectopic pregnancy led to similar success rates as compared to non-obese patients.
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Affiliation(s)
- Gabriel Levin
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Raanan Meyer
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.
| | - Uri Dior
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronit Gilad
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Avi Benshushan
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Asher Shushan
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amihai Rottenstreich
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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115
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Chen S, Zhu F, Zhang Y, Li J, Gao J, Deng G. A Model to Predict Treatment Failure of Single‑Dose Methotrexate in Patients with Tubal Pregnancy. Med Sci Monit 2020; 26:e920079. [PMID: 32383438 PMCID: PMC7236588 DOI: 10.12659/msm.920079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background In China, approximately 15% of tubal pregnancy patients treated with MTX eventually required surgery because the ectopic mass was ruptured; therefore, it is essential to develop a model to predict the risk of failure with methotrexate treatment in tubal pregnancy. Material/Methods In this research, 168 patients met the eligibility criteria, and 29 candidate risk factors for treatment failure were collected. Multivariable logistic regression analysis was used to analyze the factors, and a full model was developed. We used a multiple fractional polynomial model and a stepwise model to increase the reliability. Bootstrap resampling for 500 times was used to internally test the prediction model. The integral performance of the model depends on the evaluation of the nomogram, the discriminative performance by receiver operating characteristic (ROC) curve analysis, and calibration. Results The model showed excellent discrimination and calibration. The area under the ROC curve for the prediction model, mfp model, and stepwise model were 0.879 (95% CI: 0.812–0.942), 0.872 (95% CI: 0.805–0.931), and 0.880 (95% CI: 0.817–0.949), respectively. At a cutoff value of ≥0.40, sensitivity was 60%, specificity was 91%, positive predictive value (PPV) was 81%, and negative predictive value (NPV) was 77%. The model provides a net benefit when clinical decision thresholds are between 0% and 40% of predicted risk. Conclusion This model indicated good accuracy in predicting methotrexate treatment failure for tubal pregnancy patients.
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Affiliation(s)
- Si Chen
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Fangfang Zhu
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Yingxuan Zhang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Jing Li
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Jie Gao
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Gaopi Deng
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
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A rare cause of surgical abdomen: Heterotopic pregnancy rupture. JOURNAL OF SURGERY AND MEDICINE 2020. [DOI: 10.28982/josam.702768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Wang X, Huang L, Yu Y, Xu S, Lai Y, Zeng W. Risk factors and clinical characteristics of recurrent ectopic pregnancy: A case-control study. J Obstet Gynaecol Res 2020; 46:1098-1103. [PMID: 32281241 PMCID: PMC7384140 DOI: 10.1111/jog.14253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To compare signs and symptoms between patients with recurrent ectopic pregnancies (REP) and primary ectopic pregnancies (PEP) and to identify potential risk factors of REP. MATERIALS AND METHODS Data from 2014 to 2016 were analyzed. The study included 81 women each diagnosed with REP and PEP with no recurrence of ectopic pregnancy (EP) before January 2019. Information, including historical factors and findings at presentation of both group were collected. Data were compared between the two groups. Associations between REP and the risk factors were analyzed by logistic regression. RESULTS The findings revealed that compared to the patients in the PEP group, REP patients had significantly lower education (P = 0.001), higher proportion of previous infertility (P < 0.001) and different methods of PEP treatment (P = 0.001). Clinical data of the last operation revealed significantly higher occurrences of pelvic and peritubal adhesions (P < 0.05). Further multiple regression analysis showed that lower educational background (odds ratio [OR] = 4.183 95% confidence interval [CI] 1.311-13.344 P = 0.016), nulliparity (OR = 12.312 95% CI 3.382-44.824 P < 0.001), history of salpingotomy (OR = 7.129 95% CI 1.022-49.748 P < 0.05) and abortion (OR for one abortion = 21.576, P = 0.001; OR for two abortions =36.794, P < 0.001; OR for three abortions or more = 119.013, P < 0.001) were significant risk factors for REP. CONCLUSION Active education on contraception is required for patients with lower educational level and history of abortion. Different plans should be formulated for patients with EP. For EP patients wanting fertility, the risk between fertility preservation and REP needs to be evaluated as reproductive function cannot be pursued blindly while ignoring the risk of recurrence.
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Affiliation(s)
- Xinyan Wang
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Lu Huang
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Yan Yu
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Sheng Xu
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Yucheng Lai
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Wenjie Zeng
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
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Scibetta EW, Han CS. Ultrasound in Early Pregnancy: Viability, Unknown Locations, and Ectopic Pregnancies. Obstet Gynecol Clin North Am 2020; 46:783-795. [PMID: 31677754 DOI: 10.1016/j.ogc.2019.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Ultrasound is essential in the evaluation and management of pregnancies of unknown location. Differential diagnoses include early pregnancy loss, pregnancy of unknown location, and ectopic pregnancies. Both transabdominal and transvaginal routes should be available, in addition to physical examination, for complete evaluation. Diagnostic criteria for early pregnancy loss have expanded in recent years to ensure false positive results do not lead to inappropriate evacuation of desired pregnancies.
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Affiliation(s)
- Emily W Scibetta
- Department of Obstetrics and Gynecology, Harbor-UCLA, 1000 W Carson St, Torrance, CA 90509, USA.
| | - Christina S Han
- Division of Maternal-Fetal Medicine, University of California at Los Angeles, 10833 Le Conte Avenue, Room 27-139 CHS, Los Angeles, CA 90095-1740, USA; Center for Fetal Medicine and Women's Ultrasound, 6310 San Vicente Boulevard, Suite 520, Los Angeles, CA 90048, USA
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119
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Beyan E, Kanmaz AG, Budak A, Emirdar V, Tutar SO, Inan AH. Uterine manipulator requirement in laparoscopic surgery of Ectopic Pregnancy. Pak J Med Sci 2020; 36:105-110. [PMID: 32063941 PMCID: PMC6994866 DOI: 10.12669/pjms.36.2.1294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: The advantages of laparoscopic surgery used in the treatment of ectopic pregnancy is well-known; however, the efficacy of uterine manipulators remains unknown. In this study, we aimed to investigate the efficacy of uterine manipulators in the laparoscopic treatment of ectopic pregnancy. Methods: Overall, 118 patients who underwent laparoscopy due to ectopic pregnancy in Department of Obstetrics and Gynaecology at Tepecik Education and Research Hospital between January 2010 and January 2018 and who met the inclusion criteria were included in the study. Groups of patients undergoing surgery with or without the use of a uterine manipulator were compared in terms of demographic data, operative and postoperative results. Results: No difference was noted between the groups in terms of age, parity, body mass index, smoking, side of ectopic pregnancy mass, previous operations and pregnancy type. However, the size of ectopic pregnancy mass measured by ultrasonography was significantly larger (p = 0.006) and the operation time was significantly shorter (p<0.001) in the group where uterine manipulators were not used than in the uterine manipulator group. Conclusion: We concluded that not using a uterine manipulator in laparoscopic procedures for ectopic pregnancy did not increase operative complications and that operation time was higher in procedures using uterine manipulators.
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Affiliation(s)
- Emrah Beyan
- Dr. Emrah Beyan, MD. Department of Obstetrics and Gynecology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Ahkam Goksel Kanmaz
- Dr. Ahkam Goksel Kanmaz, MD. Department of Obstetrics and Gynecology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Adnan Budak
- Dr. Adnan Budak, MD. Department of Obstetrics and Gynecology, Tepecik Education and Research Hospital, Izmir, Turkey
| | - Volkan Emirdar
- Dr. Volkan Emirdar, MD. Department of Obstetrics and Gynecology, Medical Park Hospital, Izmir, Turkey
| | - Sadettin Oguzhan Tutar
- Dr. Sadettin Oguzhan Tutar, MD. Department of Obstetrics and Gynecology, Ardahan State Hospital, Ardahan, Turkey
| | - Abdurrahman Hamdi Inan
- Dr. Abdurrahman Hamdi Inan, MD. Department of Obstetrics and Gynecology, Bornova Turkan Ozilhan State Hospital, Izmir, Turkey
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120
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Sabbioni L, Carossino E, Severi FM, Luisi S. From β-hCG values to counseling in tubal pregnancy: what do women want? Gynecol Endocrinol 2019; 35:1021-1026. [PMID: 31322446 DOI: 10.1080/09513590.2019.1640201] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Tubal pregnancy represents an entity that every gynecologist will encounter during professional life. Because of the high prevalence among the pregnant population, standardized protocols are needed in order to choose the optimal strategy for each case. Accurate ultrasound pictures are supporting a more precise diagnosis of ectopic tubal pregnancy, the evolution of which should be closely monitored in follow-up with serial β-hCG values. Laparoscopy, intramuscular methotrexate, and active expectant management are all involved, however, tailoring the best treatment to the patient's needs is the challenge to focus on. This manuscript describes how in routinary practice an evidence-based diagnostic process should be the key factor to go for the best possible management. When possible, a longsighted less invasive approach should be preferred, aiming to preserve the patient's fertility for years to come. An optimal choice of the management should involve the patient or the couple in the decision-making process to reach the ultimate goal of compliance.
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Affiliation(s)
- Lorenzo Sabbioni
- Local Health Authority of Reggio Emilia, Division of Obstetrics and Gynecology, Cesare Magati Hospital, Scandiano, Italy
| | - Emanuela Carossino
- Local Health Authority of Reggio Emilia, Division of Obstetrics and Gynecology, Cesare Magati Hospital, Scandiano, Italy
| | - Filiberto Maria Severi
- Division of Obstetrics and Gynecology, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
| | - Stefano Luisi
- Division of Obstetrics and Gynecology, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
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Shah JS, Nasab S, Papanna R, Chen HY, Promecene P, Berens P, Johnson A, Bhalwal A. Management and reproductive counseling in cervical, caesarean scar and interstitial ectopic pregnancies over 11 years: identifying the need for a modern management algorithm. Hum Reprod Open 2019; 2019:hoz028. [PMID: 31777762 PMCID: PMC6870555 DOI: 10.1093/hropen/hoz028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 08/11/2019] [Indexed: 12/12/2022] Open
Abstract
STUDY QUESTION Do management strategies (treatment type and order), including provision of reproductive counseling, differ in patients with non-tubal pregnancies? SUMMARY ANSWER Medical and surgical treatment strategies varied widely for each type of non-tubal pregnancy and reproductive counseling in this patient population is lacking. WHAT IS KNOWN ALREADY Owing to the rarity of non-tubal pregnancies, there is no consensus regarding treatment strategies or protocol. Furthermore, there is limited data on how patients with a non-tubal pregnancy are counseled about future fertility. STUDY DESIGN SIZE DURATION This is a descriptive retrospective study. Data were collected from January 2006 to December 2017. A total of 50 patients were included in the study. PARTICIPANTS/MATERIALS SETTING METHODS Patients with an ultrasound diagnosis of a non-tubal ectopic pregnancy (e.g. cervical ectopic pregnancy [CEP], Caesarean scar pregnancy [CSP] or interstitial ectopic pregnancy [IEP]) were included. This study was performed at a university-based institution tertiary referral center. Demographic and clinical characteristics, treatment type and order, reproductive counseling and outcomes were collected. Descriptive statistics were used for analyses. MAIN RESULTS AND THE ROLE OF CHANCE Of the 50 patients identified, 13 were CEP (26%), 8 were CSP (16%) and 29 were IEP (58%). Patients with a CSP had a higher parity (median = 3, P = 0.02) and number of prior Caesarean deliveries (mean = 2.1, P < 0.001). A total of 66% (23/35) of patients expressed a desire for future fertility prior to treatment and only 56% (28/50) of patients received reproductive counseling according to the electronic medical records. Among all non-tubal pregnancies, there were variations in the type and the order of treatments that patients received. LIMITATIONS REASONS FOR CAUTION This study was performed in a tertiary referral center therefore the management strategy could have been influenced by the prior interventions and patient response. The descriptive retrospective design precluded any assumption of causation. WIDER IMPLICATIONS OF THE FINDINGS The management for non-tubal pregnancies has wide variations. Reproductive counseling in this patient population is lacking. The findings highlight the need for the development of a treatment algorithm and a reproductive counseling protocol for each non-tubal pregnancy to better standardize treatment strategy. STUDY FUNDING/COMPETING INTERESTS There was no funding for this study. The authors have no conflict of interest to report.
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Affiliation(s)
- Jaimin S Shah
- Department of Obstetrics & Gynecology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Susan Nasab
- Department of Obstetrics & Gynecology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Ramesha Papanna
- Department of Fetal Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Han-Yang Chen
- Department of Obstetrics & Gynecology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Pamela Promecene
- Department of Obstetrics & Gynecology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Pamela Berens
- Department of Obstetrics & Gynecology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Anthony Johnson
- Department of Fetal Surgery, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Asha Bhalwal
- Department of Obstetrics & Gynecology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
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Conservative management of Caesarean scar pregnancies with systemic multidose methotrexate: predictors of treatment failure and reproductive outcomes. Reprod Biomed Online 2019; 39:827-834. [DOI: 10.1016/j.rbmo.2019.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/29/2019] [Accepted: 05/22/2019] [Indexed: 11/22/2022]
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123
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Deng J, Chen L, Xue H, Zeng FX, Niu PG, Shi DH. Contribution of genetic polymorphism of methylene tetrahydrofolate reductase on the effect of methotrexate in ectopic pregnancy patients. J Clin Lab Anal 2019; 34:e23030. [PMID: 31502727 PMCID: PMC6977338 DOI: 10.1002/jcla.23030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/13/2019] [Accepted: 08/13/2019] [Indexed: 01/22/2023] Open
Abstract
Background Methotrexate (MTX) is the prior drug in ectopic pregnancy (EP). However, approximately 10% of patients suffer from failure by MTX therapy. Reduced folate carrier 1 (RFC1), methylene tetrahydrofolate reductase (MTHFR), and dihydrofolate reductase (DHFR) are involved in the transport and effects of MTX in vivo. In the present study, we aim to investigate the relationship between the genetic polymorphisms of RFC1, MTHFR, and DHFR and the clinical efficacy of MTX in tubal pregnancies. Methods 100 patients of EP were enrolled in this study. Polymorphisms of RFC1 G80A, MTHFR C677T, and DHFR A‐317G were genotyped. β‐hCG level was detected in day 0, 4, and 7 after MTX injection. Association of MTX efficacy and genetic polymorphisms was analyzed. Results Methylene tetrahydrofolate reductase C677T was associated with MTX treatment (P = .017). The success rate of first MTX injection was superior in patients with harboring mutation allele of MTHFR gene than that in patients with wild‐type gene (P = .001). However, there was no significant association between the polymorphisms of RFC1 G80A, DHFR A‐317G, and surgical treatment (P = .709 and .476, respectively). In addition, β‐hCG level decrement was not significantly changed by MTX injection with different polymorphisms of RFC1, MTHFR, and DHFR on either day 4 (P = .214, 0.197 and 0.270, respectively) or day 7 (P = .172, .554, and .726, respectively). Conclusion Our results suggested that the reliable indicator was polymorphism of MTHFR C677T in failure by MTX injection.
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Affiliation(s)
- Jie Deng
- Department of Pharmacy, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Li Chen
- Department of Gynecology, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Heng Xue
- Laboratory Medicine, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Fan-Xiang Zeng
- Department of Pharmacy, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Pei-Guang Niu
- Department of Pharmacy, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Dao-Hua Shi
- Department of Pharmacy, Fujian Provincial Maternity and Children's Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
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124
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Judge-Golden CP, Smith KJ, Mor MK, Borrero S. Financial Implications of 12-Month Dispensing of Oral Contraceptive Pills in the Veterans Affairs Health Care System. JAMA Intern Med 2019; 179:1201-1208. [PMID: 31282923 PMCID: PMC6618816 DOI: 10.1001/jamainternmed.2019.1678] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The Veterans Affairs (VA) health care system is the largest integrated health care system in the United States. Like most US health plans, the VA currently stipulates a 3-month maximum dispensing limit for all medications, including oral contraceptive pills (OCPs). However, 12-month OCP dispensing has been shown to improve continuation of use, decrease coverage gaps, and reduce unintended pregnancy in other practice settings. OBJECTIVE To estimate the financial and reproductive health implications for the VA of implementing a 12-month OCP dispensing option, with the goal of informing policy change. DESIGN, SETTING, AND PARTICIPANTS A decision model from the VA payer perspective was developed to estimate incremental costs to the health care system of allowing the option to receive a 12-month supply of OCPs up front, compared with the standard 3-month maximum, during a 1-year time horizon. A model cohort of 24 309 reproductive-aged, heterosexually active, female VA enrollees who wish to avoid pregnancy for at least 1 year was assumed. Probabilities of continuation of OCP use, coverage gaps, pregnancy, and pregnancy outcomes were drawn from published data. Costs of OCP provision and pregnancy-related care and the number of women using OCPs were drawn from VA administrative data. One-way and probabilistic sensitivity analyses were performed to assess model robustness. MAIN OUTCOMES AND MEASURES Incremental per-woman and total costs to the VA of allowing for 12-month dispensing of OCPs compared with standard 3-month dispensing. RESULTS The 12-month OCP dispensing option, modeled from the VA health system perspective using a cohort of 24 309 women, resulted in anticipated VA annual cost savings of $87.12 per woman compared with the cost of 3-month dispensing, or an estimated total savings of $2 117 800 annually. Cost savings resulted from an absolute reduction of 24 unintended pregnancies per 1000 women per year with 12-month dispensing, or 583 unintended pregnancies averted annually. Expected cost savings with 12-month dispensing were sensitive to changes in the probability of OCP coverage gaps with 3-month dispensing, the probability of pregnancy during coverage gaps, and the proportion of pregnancies paid for by the VA. When simultaneously varying all variables across plausible ranges, the 12-month strategy was cost saving in 95.4% of model iterations. CONCLUSIONS AND RELEVANCE Adoption of a 12-month OCP dispensing option is expected to produce substantial cost savings for the VA while better supporting reproductive autonomy and reducing unintended pregnancy among women veterans.
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Affiliation(s)
- Colleen P Judge-Golden
- Medical Scientist Training Program, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kenneth J Smith
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sonya Borrero
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Health Care System, Pittsburgh, Pennsylvania.,Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania
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125
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Alur-Gupta S, Cooney LG, Senapati S, Sammel MD, Barnhart KT. Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis. Am J Obstet Gynecol 2019; 221:95-108.e2. [PMID: 30629908 DOI: 10.1016/j.ajog.2019.01.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/18/2018] [Accepted: 01/02/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the treatment success and failure rates, as well as side effects and surgery rates, between methotrexate protocols. DATA SOURCES PubMed, Embase, and the Cochrane library searched up to July 2018. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared women with ectopic pregnancies receiving the single-dose, two-dose, or multi-dose methotrexate protocols. STUDY APPRAISAL AND SYNTHESIS METHODS Odds of treatment success, treatment failure, side effects, and surgery for tubal rupture, as well as length of follow-up until treatment success, were compared using random and fixed effects meta-analysis. Sensitivity analyses compared treatment success in the groups with high human chorionic gonadatropin (hCG) values and a large adnexal mass, as defined by individual studies. The Cochrane Collaboration tool was used to assess risk of bias. RESULTS The 2-dose protocol was associated with higher treatment success compared to the single-dose protocol (odds ratio [OR], 1.84; 95% CI, 1.13, 3.00). The 2-dose protocol was more successful in women with high hCG (OR, 3.23; 95% CI, 1.53, 6.84) and in women with a large adnexal mass (OR, 2.93; 95% CI, 1.23, 6.9). The odds of surgery for tubal rupture were lower in the 2-dose protocol (OR, 0.65; 95% CI, 0.26, 1.63), but this was not statistically significant. The length of follow-up was 7.9 days shorter for the 2-dose protocol (95% CI, -12.2, -3.5). The odds of side effects were higher in the 2-dose protocol (OR, 1.53; 95% CI, 1.01, 2.30). Compared to the single-dose protocol, the multi-dose protocol was associated with a nonsignificant reduction in treatment failure (OR, 0.56; 95% CI, 0.28, 1.13) and a higher chance of side effects (OR, 2.10; 95% CI, 1.24, 3.54). The odds of surgery for tubal rupture (OR, 1.62; 95% CI, 0.41, 6.49) and time to follow-up (OR, -1.3; 95% CI, -5.4, 2.7) were similar. CONCLUSION The 2-dose methotrexate protocol is superior to the single-dose protocol for the treatment of ectopic pregnancy in terms of treatment success and time to success. Importantly, these findings hold true in patients thought to be at a lower likelihood of responding to medical management, such as those with higher hCGs and a large adnexal mass.
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Affiliation(s)
- Snigdha Alur-Gupta
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA.
| | - Laura G Cooney
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA
| | - Suneeta Senapati
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA
| | - Mary D Sammel
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Kurt T Barnhart
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA
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Abstract
PURPOSE OF REVIEW Work-related musculoskeletal disorders (WMSDs) are prevalent among surgeons and result in significant disability. We aimed to review the English-language literature regarding ergonomic risk, prevalence of WMSDs, and unique ergonomic considerations of gynecologic surgery. RECENT FINDINGS Surgeon WMSDs are prevalent, with rates ranging from 66 to 94% for open surgery, 73-100% for conventional laparoscopy, 54-87% for vaginal surgery, and 23-80% for robotic-assisted surgery. Risk factors for injury in open surgery include use of loupes, headlamps, and microscopes. Unique risks in laparoscopic surgery include table and monitor position, long-shafted instruments, and poor instrument handle design. In vaginal surgery, improper table height and twisted trunk position create injury risk. Although robotic surgery offers some advantages in neck and shoulder strain, it remains associated with trunk, wrist, and finger strain. SUMMARY WMSDs are prevalent among surgeons but have received little attention because of under-reporting of injury and logistical constraints of studying surgical ergonomics. Future research must aim to develop objective surgical ergonomics instruments and guidelines and to correlate ergonomics assessments with pain and tissue-level damage in surgeons with WMSDs. Ergonomics training should be developed and implemented in order to protect surgeons from preventable, potentially career-altering injuries.
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127
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Levin G, Dior UP, Shushan A, Gilad R, Benshushan A, Rottenstreich A. Success rate of methotrexate treatment for recurrent vs. primary ectopic pregnancy: a case-control study. J OBSTET GYNAECOL 2019; 40:507-511. [DOI: 10.1080/01443615.2019.1621819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Uri P. Dior
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Asher Shushan
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronit Gilad
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Avi Benshushan
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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128
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Levin G, Rottenstreich A. Earlier predictors for treatment outcome among single dose methotrexate for an ectopic pregnancy. Arch Gynecol Obstet 2019; 300:793. [PMID: 31321492 DOI: 10.1007/s00404-019-05250-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/10/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel.
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, POB 12000, 91120, Jerusalem, Israel
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Dhombres F, Maurice P, Guilbaud L, Franchinard L, Dias B, Charlet J, Blondiaux E, Khoshnood B, Jurkovic D, Jauniaux E, Jouannic JM. A Novel Intelligent Scan Assistant System for Early Pregnancy Diagnosis by Ultrasound: Clinical Decision Support System Evaluation Study. J Med Internet Res 2019; 21:e14286. [PMID: 31271152 PMCID: PMC6636237 DOI: 10.2196/14286] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 01/26/2023] Open
Abstract
Background Early pregnancy ultrasound scans are usually performed by nonexpert examiners in obstetrics/gynecology (OB/GYN) emergency departments. Establishing the precise diagnosis of pregnancy location is key for appropriate management of early pregnancies, and experts are usually able to locate a pregnancy in the first scan. A decision-support system based on a semantic, expert-validated knowledge base may improve the diagnostic performance of nonexpert examiners for early pregnancy transvaginal ultrasound. Objective This study aims to evaluate a novel Intelligent Scan Assistant System for early pregnancy ultrasound to diagnose the pregnancy location and determine the image quality. Methods Two trainees performed virtual transvaginal ultrasound examinations of early pregnancy cases with and without the system. The ultrasound images and reports were blindly reviewed by two experts using scoring methods. A diagnosis of pregnancy location and ultrasound image quality were compared between scans performed with and without the system. Results Each trainee performed a virtual vaginal examination for all 32 cases with and without use of the system. The analysis of the 128 resulting scans showed higher quality of the images (quality score: +23%; P<.001), less images per scan (4.6 vs 6.3 [without the CDSS]; P<.001), and higher confidence in reporting conclusions (trust score: +20%; P<.001) with use of the system. Further, use of the system cost an additional 8 minutes per scan. We observed a correct diagnosis of pregnancy location in 39 (61%) and 52 (81%) of 64 scans in the nonassisted mode and assisted mode, respectively. Additionally, an exact diagnosis (with precise ectopic location) was made in 30 (47%) and 49 (73%) of the 64 scans without and with use of the system, respectively. These differences in diagnostic performance (+20% for correct location diagnosis and +30% for exact diagnosis) were both statistically significant (P=.002 and P<.001, respectively). Conclusions The Intelligent Scan Assistant System is based on an expert-validated knowledge base and demonstrates significant improvement in early pregnancy scanning, both in diagnostic performance (pregnancy location and precise diagnosis) and scan quality (selection of images, confidence, and image quality).
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Affiliation(s)
- Ferdinand Dhombres
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France.,Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France
| | - Paul Maurice
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France.,Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France
| | - Lucie Guilbaud
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Loriane Franchinard
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Barbara Dias
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Jean Charlet
- Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France.,Direction de la Recherche et de l'Innovation, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Eléonore Blondiaux
- Service de Radiologie, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France
| | - Babak Khoshnood
- Obstetrical, Perinatal and Pediatric Epidemiology Research Team, Center for Biostatistics and Epidemiology, INSERM, Paris, France
| | - Davor Jurkovic
- Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospital and Institute for Women's Health, University College London, London, United Kingdom
| | - Eric Jauniaux
- Gynaecology Diagnostic and Outpatient Treatment Unit, University College Hospital and Institute for Women's Health, University College London, London, United Kingdom
| | - Jean-Marie Jouannic
- Service de Médecine Fœtale, Sorbonne Université, Assistance Publique - Hôpitaux de Paris / Hôpitaux Universitaires Est Parisiens, Hôpital Armand Trousseau, Paris, France.,Medical Informatics and Knowledge Engineering for eHealth Lab, INSERM, Paris, France
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Levin G, Dior UP, Shushan A, Gilad R, Benshushan A, Rottenstreich A. Risk factors for recurrent ectopic pregnancy following single-dose methotrexate treatment. EUR J CONTRACEP REPR 2019; 24:294-298. [PMID: 31204856 DOI: 10.1080/13625187.2019.1625324] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Our study aimed to investigate the predisposing factors for recurrence of an ectopic pregnancy (EP) following single-dose methotrexate (MTX) treatment for a primary EP. Methods: This was a retrospective cohort study performed in a tertiary care medical centre including all patients diagnosed with primary EP and treated with a single-dose regimen of intramuscular MTX. EPs with future recurrence were compared with first time only EPs, to identify risk factors for recurrent EP. Forward stepwise multivariate logistic regression analyses were subsequently carried out. Results: The study included 272 women. Of those, 22 (8.1%) had a recurrent EP. Women in the recurrent EP group had a higher rate of abortions (45.5% vs 32.7%; p = 0.02), previous pelvic surgery (45.5% vs 6.5%; p < 0.001) and both pelvic and uterine surgery (4.5% vs 1.6%; p < 0.001). Conception by assisted reproductive technology (ART) was more common among the non-recurrent EP group (23.0% vs 4.5%; p = 0.04). Success of single-dose MTX treatment was lower in the recurrent EP group compared with the non-recurrent EP group (36.4% vs 65.7%; p = 0.006). A history of pelvic surgery was independently associated with recurrent EP (adjusted odds ratio [OR] 17.6; 95% confidence interval [CI] 4.9, 63.2; p = 0.001). Treatment success of single-dose MTX was independently protective for recurrent EP (adjusted OR 0.25; 95% CI 0.08, 0.76; p = 0.02). Conclusions: Among women with an EP, attention should be paid to those with previous pelvic surgery. Efforts should be made to achieve medical treatment success to prevent recurrent EP.
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Affiliation(s)
- Gabriel Levin
- a Department of Obstetrics and Gynecology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
| | - Uri P Dior
- a Department of Obstetrics and Gynecology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
| | - Asher Shushan
- a Department of Obstetrics and Gynecology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
| | - Ronit Gilad
- a Department of Obstetrics and Gynecology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
| | - Avi Benshushan
- a Department of Obstetrics and Gynecology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
| | - Amihai Rottenstreich
- a Department of Obstetrics and Gynecology , Hadassah-Hebrew University Medical Center , Jerusalem , Israel
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Fermaut M, Fauconnier A, Brossard A, Razafimamonjy J, Fritel X, Serfaty A. Detection of complicated ectopic pregnancies in the hospital discharge database: A validation study. PLoS One 2019; 14:e0217674. [PMID: 31166967 PMCID: PMC6550422 DOI: 10.1371/journal.pone.0217674] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/16/2019] [Indexed: 11/18/2022] Open
Abstract
Objective Complicated ectopic pregnancies with severe bleeding (CEPSB) are life-threatening situations and should be considered maternal near-miss cases. Previous studies have found an association between severe maternal morbidity secondary to CEPSB and substandard care. Almost all women with CEPSB are hospitalized, generating administrative and medical records. The objective of this study was to propose a method to measure the validity of the hospital discharge database (HDD) to detect CEPSB among hospital stays in two gynecological units. Methods We included all hospital stays of women who were 18–45 years old and hospitalized for acute pelvic pain or/and metrorrhagia in the two hospitals. The HDD was compared to medical data (gold standard). Two algorithms constructed from the International Classification of Disease (ICD-10) and Common Classification of Medical Procedures (CCAM), were applied to the HDD: a “predefined algorithm” according to coding guidelines and a “pragmatic algorithm” based on coding practices. Sensitivity, specificity and positive likelihood-ratios were calculated. False negatives and positives were analyzed to describe coding practices. Results Among 370 hospital stays included, 52 were classified as CEPSB cases. The “predefined algorithm” gave a sensitivity of 23.1% (95% CI: 11.6–34.5) and a specificity of 99.1% (95% CI: 98.0–100.0) to identify CEPSB. The “pragmatic algorithm” gave a sensitivity of 63.5% (95% CI: 50.4–76.5) and a specificity of 94.7% (95% CI: 92.2–97.5) to identify CEPSB. Coding errors (77.6%) were due to misuse of diagnosis codes and because complications were not coded. Conclusion HDD is not reliable enough to detect CEPSB due to incorrect coding practices. However, it could be an ideal tool to monitor quality of care if a culture in data quality assessment is developed to improve quality of medical information.
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Affiliation(s)
- Marion Fermaut
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
- EA 7285, Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
| | - Arnaud Fauconnier
- Department of Gynecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
- EA 7285, Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
| | - Aurélie Brossard
- Department of Gynecology and Obstetrics, University Hospital Center of Poitiers, Poitiers, France
| | - Jimmy Razafimamonjy
- Medical Information Department, Intercommunal Hospital Centre of Poissy-Saint-Germain-en-Laye, Poissy, France
| | - Xavier Fritel
- Department of Gynecology and Obstetrics, University Hospital Center of Poitiers, Poitiers, France
- INSERM CIC 1402, University Hospital Center of Poitiers, Poitiers, France
| | - Annie Serfaty
- EA 7285, Research Unit "Risk and Safety in Clinical Medicine for Women and Perinatal Health", Versailles-Saint-Quentin University (UVSQ), Montigny-le-Bretonneux, France
- Medical Information Department, Armand-Trousseau, La Roche-Guyon, Eastern Parisian University Hospital, Assistance Publique–Hôpitaux de Paris (AP-HP), Paris, France
- Regional Agency of Health for Paris Region, Direction of health promotion and inequality reduction, Paris, France
- * E-mail:
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Early prediction of the success of methotrexate treatment success by 24-hour pretreatment increment in HCG and day 1-4 change in HCG. Reprod Biomed Online 2019; 39:149-154. [PMID: 31029556 DOI: 10.1016/j.rbmo.2019.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/24/2019] [Accepted: 02/20/2019] [Indexed: 11/24/2022]
Abstract
RESEARCH QUESTION Several studies have tried to identify early markers of treatment outcome after methotrexate (MTX) treatment for ectopic pregnancy, including pretreatment and day 4 human chorionic gonadotrophin (HCG) concentrations and their corresponding changes, and the increment in HCG during the initial 24 h after treatment. There have, however, been conflicting results. This study aimed to re-evaluate the role of these markers in the earlier identification of treatment success in a large cohort of women. DESIGN This was a retrospective cohort study including women diagnosed with an ectopic pregnancy and treated with a regimen of a single dose of MTX. A comparison of maternal and gestation characteristics was made between groups in whom treatment was successful or failed. RESULTS A total of 292 women treated with single-dose intramuscular MTX for ectopic pregnancy were included in this study. In the overall cohort, the treatment success rate with a single dose of MTX was 62.7% (183/292). Only two independent determinants were significantly associated with treatment success: the initial 24-h percentage increase in HCG (adjusted odds ratio [OR] 1.82, 95% confidence interval [CI] 1.26-2.63; P < 0.001) and the percentage change in HCG from day 1 to day 4 (adjusted OR 1.12, 95% CI 1.04-1.21; P < 0.001). The optimal cut-off points for prediction of treatment success were an increment of less than 17% in the 24 h before treatment and a decrease of more than 22% between the day 1 and day 4 HCG concentrations. CONCLUSIONS A small increase in HCG concentration 24 h before treatment with MTX, alongside a decline in HCG concentration from day 1 to day 4, may predict the success of medical treatment for an ectopic pregnancy.
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Brancazio S, Saramago I, Goodnight W, McGinty K. Cesarean scar ectopic pregnancy: Case report ☆. Radiol Case Rep 2019; 14:354-359. [PMID: 31007806 PMCID: PMC6457063 DOI: 10.1016/j.radcr.2018.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/02/2018] [Accepted: 12/02/2018] [Indexed: 11/18/2022] Open
Abstract
Cesarean scar ectopic pregnancies are a rare form of extrauterine pregnancies, yet their incidence is increasing given the rise in cesarean deliveries. Similar to other ectopic pregnancies, cesarean scar ectopic pregnancies pose a great risk for maternal hemorrhage and ultimately maternal mortality. This study presents the case of a cesarean scar ectopic pregnancy in a patient with 3 prior cesarean deliveries. Here, we highlight the importance of early diagnosis and treatment of cesarean scar ectopic pregnancies.
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Affiliation(s)
- Sophia Brancazio
- University of North Carolina, School of Medicine, 321 S. Columbia St., Chapel Hill, NC 27516
- Corresponding author.
| | - Israel Saramago
- University of North Carolina, Department of Radiology, 2006 Old Clinic CB#7510, Chapel Hill, NC 27516
| | - William Goodnight
- University of North Carolina, Department of Obstetrics and Gynecology, Maternal Fetal Medicine, 3010 Old Clinic CB # 7516, Chapel Hill, NC 27599
| | - Katrina McGinty
- University of North Carolina, Department of Obstetrics and Gynecology, Maternal Fetal Medicine, 3010 Old Clinic CB # 7516, Chapel Hill, NC 27599
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Benor A, Grazi R, Kulak D. A case report of an abnormal trend in hCG levels in a pregnancy complicated by ovarian hyperstimulation syndrome. Case Rep Womens Health 2019; 21:e00096. [PMID: 30733923 PMCID: PMC6357681 DOI: 10.1016/j.crwh.2019.e00096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 01/22/2019] [Indexed: 12/18/2022] Open
Abstract
Objective To present a case of abnormally trending hCG levels due to ovarian hyperstimulation syndrome (OHSS) and to portray the obscurities of this commonly used method for tracking early pregnancies. Design Case report. Setting Outpatient ART facility. Patient A patient who received controlled ovarian hyperstimulation in an ART cycle. Intervention Supportive care. Main outcome measure hCG level. Result The hCG levels in this patient with OHSS trended in an abnormal fashion, suggesting a failing or ectopic pregnancy, but the patient had a normal intrauterine fetus. Conclusion hCG levels may be falsely low in pregnancies complicated by OHSS. Levels of human chorionic gonadotropin are affected by the fluid dynamics in ovarian hyperstimulation syndrome. In ovarian hyperstimulation syndrome, human chorionic gonadotropin values do not follow normal trends. Caution is warranted before diagnosing an abnormal early pregnancy in patients with ovarian hyperstimulation syndrome.
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Affiliation(s)
- Ariel Benor
- Genesis Fertility, Division of Reproductive Endocrinology & Infertility at Maimonides Medical Center, 6010 Bay Pkwy., Brooklyn, New York, USA
| | - Richard Grazi
- Genesis Fertility, Division of Reproductive Endocrinology & Infertility at Maimonides Medical Center, 6010 Bay Pkwy., Brooklyn, New York, USA
| | - David Kulak
- Genesis Fertility, Division of Reproductive Endocrinology & Infertility at Maimonides Medical Center, 6010 Bay Pkwy., Brooklyn, New York, USA
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Watanabe K, Chigusa Y, Kondoh E, Mogami H, Horie A, Baba T, Mandai M. Human chorionic gonadotropin value and its change prior to methotrexate treatment can predict the prognosis in ectopic tubal pregnancies. Reprod Med Biol 2019; 18:51-56. [PMID: 30655721 PMCID: PMC6332740 DOI: 10.1002/rmb2.12247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/20/2018] [Accepted: 09/19/2018] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To investigate the role of beta-human chorionic gonadotropin (HCG) level and its change prior to methotrexate (MTX) treatment as predictors of treatment success and to access the posttreatment observation period for ectopic tubal pregnancy. METHODS Clinical data of 41 females treated with MTX for tubal pregnancies were reviewed and analyzed retrospectively. RESULTS Among 41 patients, 34 achieved complete resolution without surgery. No statistically significant difference was observed in the presence of hemorrhagic ascites, serum progesterone levels, or diameters of adnexal mass between the MTX success and failure groups. Serum HCG levels on the day of MTX administration (day 1) were significantly lower in the MTX success group. Moreover, % HCG change per day, which represents the increment ratio of HCG prior to MTX treatment, was significantly lower in the MTX success group. Receiver operating characteristic (ROC) curves demonstrated that the treatment success was predicted by % HCG change per day less than +12.6% per day with a sensitivity of 87% and a specificity of 71%. The duration from treatment to complete recovery was strongly correlated with day 1 HCG levels. CONCLUSIONS Pretreatment HCG change is a significant predictor of therapeutic success of MTX treatment, and the treatment period may be predicted from initial HCG levels.
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Affiliation(s)
- Koichi Watanabe
- Department of Gynecology and ObstetricsKyoto UniversityKyotoJapan
| | | | - Eiji Kondoh
- Department of Gynecology and ObstetricsKyoto UniversityKyotoJapan
| | - Haruta Mogami
- Department of Gynecology and ObstetricsKyoto UniversityKyotoJapan
| | - Akihito Horie
- Department of Gynecology and ObstetricsKyoto UniversityKyotoJapan
| | - Tsukasa Baba
- Department of Gynecology and ObstetricsKyoto UniversityKyotoJapan
| | - Masaki Mandai
- Department of Gynecology and ObstetricsKyoto UniversityKyotoJapan
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