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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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Pape J, Bajka A, Seifert B, Asmis L, Imesch P, Metzler J, Burkhardt T, Condous G, Samartzis EP, Bajka M. Judging Urgency in 343 Ectopic Pregnancies Prior to Surgery - The Importance of Transvaginal Sonographic Diagnosis of Intraabdominal Free Blood. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:614-622. [PMID: 36657460 DOI: 10.1055/a-1967-2134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Assessing urgency in ectopic pregnancies (ECP) remains controversial since the disorder covers a large clinical spectrum. Severe conditions such as acute abdomen or hemodynamic instability are mostly related to intra-abdominal blood loss diagnosed as free fluid (FF) on transvaginal sonography (TVS). The aims of the current study were to investigate the value of FF and to assess other potentially predictive parameters for judging urgency. METHODS Retrospective cohort analysis on prospectively collected cases of proven ECP (n = 343). Demographics, clinical and laboratory parameters, and findings on TVS and laparoscopy (LSC) were extracted from the digital patient file. FF on TVS and free blood (FB) in LSC were evaluated. Low urgency was defined as FB (LSC) < 100 ml and high urgency as FB (LSC) ≥ 300 ml. The best subset of variables for the prediction of FB was selected and predictors of urgency were evaluated using receiver operator characteristic (ROC) curves. RESULTS Clinical symptoms, age, β-HCG, hemoglobin (HB) preoperative, and FF were examined in multivariate analysis for the cutoff values of 100 ml and 300 ml. FF was the only independent predictor for low and high urgency; HB preoperative was only significant for high urgency offering marginal improvement. ROC analysis revealed FF as an excellent discriminatory parameter for defining low (AUC 0.837, 95% CI 0.794-0.879) and high urgency (AUC 0.902, 95 % CI 0.860-0.945). CONCLUSION Single assessment of FF on TVS is most valuable for judging urgency. However, the exact cutoff values for a low- and high-risk situation must still be defined.
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Affiliation(s)
- Janna Pape
- Gynecology, University Hospital Zurich, Zurich, Switzerland
- Gynecologic Endocrinology and Reproductive Medicine, Inselspital University Hospital Bern, Bern, Switzerland
| | - Anahita Bajka
- Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Burkhardt Seifert
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Lars Asmis
- Center for perioperative thrombosis and hemostasis, University of Zurich, Zurich, Switzerland
| | - Patrick Imesch
- Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Julian Metzler
- Gynecology, University Hospital Zurich, Zurich, Switzerland
| | - Tilo Burkhardt
- Obstetrics, University Hospital Zurich, Zurich, Switzerland
| | - George Condous
- Acute Gynecology, Early Pregnancy & Advanced Endoscopic Surgery Unit, University of Sydney - Sydney Medical School Nepean, Sydney, Australia
| | - Eleftherios Pierre Samartzis
- Gynecology, University Hospital Zurich, Zurich, Switzerland
- Gynecology, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Michael Bajka
- Gynecology, University Hospital Zurich, Zurich, Switzerland
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Shulman Y, Cohen A, Bercovich O, Cohen Y, Gil Y, Levin I. Prognostic factors for spontaneous resolution of an ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2023; 291:235-239. [PMID: 37925893 DOI: 10.1016/j.ejogrb.2023.10.036] [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: 06/25/2023] [Revised: 10/18/2023] [Accepted: 10/30/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To identify factors that can accurately predict the spontaneous resolution of an ectopic pregnancy. STUDY DESIGN This retrospective cohort analysis was conducted in the Department of Gynecology of a tertiary, university-affiliated medical center. Patients admitted to the center from January 2015 to July 2022 with a tubal ectopic pregnancy who met the criteria for expectant management were included. Beta-human chorionic gonadotropin (ß-hCG) levels were assessed at admission and at subsequent 24-hour intervals. Patients with declining levels were discharged for routine ambulatory ß-hCG follow-up until levels became undetectable. Patients who achieved a successful outcome were designated as the "spontaneous resolution group," while patients who underwent further hospitalization for methotrexate or surgery constituted the" failure group". Demographic, clinical, laboratory, and ultrasound parameters collected at first admission were compared between groups. RESULTS Among the initial group of 210 eligible patients, 7 were lost to follow-up, 161 achieved spontaneous resolution, and 42 were readmitted for active intervention. Multivariate logistic regression analysis revealed that the last ß-hCG level before discharge (last ß-hCG) and the ratio between ß-hCG at discharge to ß-hCG at admission were the only independent parameters to predict outcomes. Patients with ß-hCG < 650 IU/L at discharge and a decline of 50% or more in ß-hCG level during hospitalization, had a 97% success rate with expectant management. Patients with ß-hCG discharge levels ≥ 1,000 IU/L had a 50% chance of success, regardless of whether their ß-hCG levels had declined. For all other patients, a 76% success rate was found. CONCLUSION Short-term, serial ß-hCG follow-up at the initial presentation can help predict the spontaneous resolution of an ectopic pregnancy.
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Affiliation(s)
- Yael Shulman
- Department of Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Aviad Cohen
- Department of Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Or Bercovich
- Department of Obstetrics and Gynecology, Rabin Medical Center, Petah Tikva, Israel
| | - Yoni Cohen
- Department of Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaron Gil
- Department of Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ishai Levin
- Department of Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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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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ÇETİN F, BAYRAMOĞLU TEPE N, SUCU S, BADEMKIRAN MH, KUTLAR İ. Analysis of multiple-dose methotrexate therapy in tubal ectopic pregnancies. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1037172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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6
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Barnhart KT, Hansen KR, Stephenson MD, Usadi R, Steiner AZ, Cedars MI, Jungheim ES, Hoeger KM, Krawetz SA, Mills B, Alston M, Coutifaris C, Senapati S, Sonalkar S, Diamond MP, Wild RA, Rosen M, Sammel MD, Santoro N, Eisenberg E, Huang H, Zhang H. Effect of an Active vs Expectant Management Strategy on Successful Resolution of Pregnancy Among Patients With a Persisting Pregnancy of Unknown Location: The ACT or NOT Randomized Clinical Trial. JAMA 2021; 326:390-400. [PMID: 34342619 PMCID: PMC8335579 DOI: 10.1001/jama.2021.10767] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Women with an early nonviable pregnancy of unknown location are at high risk of ectopic pregnancy and its inherent morbidity and mortality. Successful and timely resolution of the gestation, while minimizing unscheduled interventions, are important priorities. OBJECTIVE To determine if active management is more effective in achieving pregnancy resolution than expectant management and whether the use of empirical methotrexate is noninferior to uterine evacuation followed by methotrexate if needed. DESIGN, SETTING, AND PARTICIPANTS This multicenter randomized clinical trial recruited 255 hemodynamically stable women with a diagnosed persisting pregnancy of unknown location between July 25, 2014, and June 4, 2019, in 12 medical centers in the United States (final follow up, August 19, 2019). INTERVENTIONS Eligible patients were randomized in a 1:1:1 ratio to expectant management (n = 86), active management with uterine evacuation followed by methotrexate if needed (n = 87), or active management with empirical methotrexate using a 2-dose protocol (n = 82). MAIN OUTCOMES AND MEASURES The primary outcome was successful resolution of the pregnancy without change from initial strategy. The primary hypothesis tested for superiority of the active groups combined vs expectant management, and a secondary hypothesis tested for noninferiority of empirical methotrexate compared with uterine evacuation with methotrexate as needed using a noninferiority margin of -12%. RESULTS Among 255 patients who were randomized (median age, 31 years; interquartile range, 27-36 years), 253 (99.2%) completed the trial. Ninety-nine patients (39%) declined their randomized allocation (26.7% declined expectant management, 48.3% declined uterine evacuation, and 41.5% declined empirical methotrexate) and crossed over to a different group. Compared with patients randomized to receive expectant management (n = 86), women randomized to receive active management (n = 169) were significantly more likely to experience successful pregnancy resolution without change in their initial management strategy (51.5% vs 36.0%; difference, 15.4% [95% CI, 2.8% to 28.1%]; rate ratio, 1.43 [95% CI, 1.04 to 1.96]). Among active management strategies, empirical methotrexate was noninferior to uterine evacuation followed by methotrexate if needed with regard to successful pregnancy resolution without change in management strategy (54.9% vs 48.3%; difference, 6.6% [1-sided 97.5% CI, -8.4% to ∞]). The most common adverse event was vaginal bleeding for all of the 3 management groups (44.2%-52.9%). CONCLUSIONS AND RELEVANCE Among patients with a persisting pregnancy of unknown location, patients randomized to receive active management, compared with those randomized to receive expectant management, more frequently achieved successful pregnancy resolution without change from the initial management strategy. The substantial crossover between groups should be considered when interpreting the results. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02152696.
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Affiliation(s)
- Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Mary D Stephenson
- Department of Obstetrics and Gynecology, University of Illinois at Chicago
| | - Rebecca Usadi
- Department of Obstetrics and Gynecology, Atrium Health, Charlotte, North Carolina
| | - Anne Z Steiner
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill
| | - Marcelle I Cedars
- Department of Obstetrics and Gynecology, University of California at San Francisco
| | - Emily S Jungheim
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Kathleen M Hoeger
- Department of Obstetrics and Gynecology, University of Rochester, Rochester, New York
| | - Stephen A Krawetz
- Department of Obstetrics and Gynecology and Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Benjie Mills
- Department of Obstetrics & Gynecology, Prisma Health, University of South Carolina School of Medicine-Greenville
| | - Meredith Alston
- Department of Obstetrics and Gynecology, University of Colorado and Denver Health Medical Center, Denver
| | - Christos Coutifaris
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Suneeta Senapati
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarita Sonalkar
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael P Diamond
- Department of Obstetrics and Gynecology, Augusta University, Augusta, Georgia
| | - Robert A Wild
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Mitchell Rosen
- Department of Obstetrics and Gynecology, University of California at San Francisco
| | - Mary D Sammel
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver
| | - Esther Eisenberg
- Fertility and Infertility Branch, National Institute of Child Health and Human Development, Rockville, Maryland
| | - Hao Huang
- Department of Biostatistics, Yale University, New Haven, Connecticut
| | - Heping Zhang
- Department of Biostatistics, Yale University, New Haven, Connecticut
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Po L, Thomas J, Mills K, Zakhari A, Tulandi T, Shuman M, Page A. Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:614-630.e1. [PMID: 33453378 DOI: 10.1016/j.jogc.2021.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. TARGET POPULATION All patients of reproductive age. BENEFITS, HARMS, AND COSTS The implementation of this guideline aims to benefit patients with positive β-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. EVIDENCE The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES) RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
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8
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Soewondo W, Kusumaningrum S, Putro PS, Indriyani I, Maryetty IP, Rosati A, Yuliantara EE. The use of FIESTA sequence MRI in successful management of abdominal pregnancy. Clin Imaging 2021; 77:117-121. [PMID: 33667944 DOI: 10.1016/j.clinimag.2021.01.005] [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: 10/31/2020] [Revised: 12/30/2020] [Accepted: 01/06/2021] [Indexed: 11/19/2022]
Abstract
Identification of fetal location and its relations to abdominal organs is extremely important in reducing fetal and maternal morbidity in rare cases of abdominal pregnancy. Ultrasound examination is inadequate for helping to successfully manage such cases. In this case report, FIESTA sequence MRI is used to provide high-resolution, better contrast, and higher signal-to-noise ratio fetal and abdominal images. A case of advanced abdominal pregnancy with a live fetus is reported. The surgery was conducted successfully on 34 weeks of gestation.
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Affiliation(s)
- Widiastuti Soewondo
- Department of Radiology, Dr. Moewardi Public Hospital, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia.
| | - Sulistyani Kusumaningrum
- Department of Radiology, Dr. Moewardi Public Hospital, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
| | - Prasetyo Sarwono Putro
- Department of Radiology, Dr. Moewardi Public Hospital, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
| | - Ifada Indriyani
- Department of Radiology, Dr. Moewardi Public Hospital, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
| | - Ida Prista Maryetty
- Department of Radiology, Dr. Moewardi Public Hospital, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
| | - Ari Rosati
- Department of Radiology, Dr. Moewardi Public Hospital, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
| | - Eric Edwin Yuliantara
- Department of Obstetrics, Dr. Moewardi Public Hospital, Faculty of Medicine, Universitas Sebelas Maret, Surakarta, Indonesia
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9
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Po L, Thomas J, Mills K, Zakhari A, Tulandi T, Shuman M, Page A. Directive clinique n o 414 : Prise en charge des grossesses de localisation indéterminée et des grossesses ectopiques tubaires et non tubaires. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:631-649.e1. [PMID: 33453377 DOI: 10.1016/j.jogc.2021.01.001] [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: 10/22/2022]
Abstract
OBJECTIF Fournir un algorithme fondé sur des données probantes pour orienter le diagnostic et la prise en charge de la grossesse de localisation indéterminée et de la grossesse ectopique tubaire ou non tubaire. POPULATION CIBLE Toutes les patientes en âge de procréer. BéNéFICES, RISQUES ET COûTS: La mise en œuvre de la présente directive a pour objectif de bénéficier aux patientes ayant obtenu un résultat positif pour la sous-unité bêta de la gonadotrophine chorionique et de fournir aux médecins un algorithme normalisé pour l'expectative et le traitement pharmacologique ou chirurgical en cas de grossesse de localisation indéterminée et de grossesse ectopique tubaire ou non tubaire. DONNéES PROBANTES: Les termes de recherche suivants ont été entrés dans les bases de données PubMed-Medline et Cochrane en 2018 : cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography et prenatal. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des études observationnelles et des études de cas. Des publications supplémentaires ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la solidité des recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PUBLIC VISé: Obstétriciens-gynécologues, médecins de famille, urgentologues, sages-femmes, infirmières autorisées, infirmières praticiennes, étudiants en médecine, résidents et moniteurs cliniques. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).
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10
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Recurrent Tubal Ectopic Pregnancy Management and the Risk of a Third Ectopic Pregnancy. J Minim Invasive Gynecol 2020; 28:1497-1502.e1. [PMID: 33310167 DOI: 10.1016/j.jmig.2020.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the rate of a third ectopic pregnancy according to the modality of treatment of the second ectopic pregnancy. DESIGN Retrospective cohort study. SETTING University-affiliated tertiary medical center. PATIENTS One hundred eleven women who had 2 ectopic pregnancies and a third consecutive pregnancy between 2003 and 2018. INTERVENTIONS Surgery or medical treatment as required. MEASUREMENTS AND MAIN RESULTS With regard to the modality of treatment of the second ectopic pregnancy, the patients were divided into 3 groups: expectant management, medical treatment with methotrexate, and laparoscopic salpingectomy. Univariate and multivariate analyses were conducted to assess the association of various parameters of the second ectopic pregnancy with the occurrence of a third ectopic pregnancy in the consecutive pregnancy. Twenty women (18.0%) were managed expectantly, 55 (49.6%) were treated with methotrexate, and 36 (32.4%) underwent surgery. Expectant management resulted in significantly higher rates of a third ectopic pregnancy compared with treatment with methotrexate or surgical intervention (50.0% vs 18.2% and 13.8%, respectively; p = .005). In the cases of 2 ipsilateral ectopic pregnancies, the interventional approach (medical or surgical treatment) resulted in lower recurrence rates compared with expectant management (25.7% vs 60.0%, respectively; p = .043). CONCLUSION The risk of a third episode of an ectopic pregnancy after expectant management of a second ectopic pregnancy is extremely high. An interventional approach by treatment with methotrexate or salpingectomy is therefore preferred for recurrent ectopic pregnancy management, especially in ipsilateral recurrences.
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Memtsa M, Goodhart V, Ambler G, Brocklehurst P, Keeney E, Silverio S, Anastasiou Z, Round J, Khan N, Hall J, Barrett G, Bender-Atik R, Stephenson J, Jurkovic D. Variations in the organisation of and outcomes from Early Pregnancy Assessment Units: the VESPA mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08460] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background
Early pregnancy complications are common and account for the largest proportion of emergency work in gynaecology. Although early pregnancy assessment units operate in most UK acute hospitals, recent National Institute of Health and Care Excellence guidance emphasised the need for more research to identify configurations that provide the optimal balance between cost-effectiveness, clinical effectiveness and service- and patient-centred outcomes [National Institute for Health and Care Excellence (NICE). Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management. URL: http://guidance.nice.org.uk/CG154 (accessed 23 March 2016)].
Objectives
The primary aim was to test the hypothesis that the rate of hospital admissions for early pregnancy complications is lower in early pregnancy assessment units with high consultant presence than in units with low consultant presence. The key secondary objectives were to assess the effect of increased consultant presence on other clinical outcomes, to explore patient satisfaction with the quality of care and to make evidence-based recommendations about the future configuration of UK early pregnancy assessment units.
Design
The Variations in the organisations of Early Pregnancy Assessment Units in the UK and their effects on clinical, Service and PAtient-centred outcomes (VESPA) study employed a multimethods approach and included a prospective cohort study of women attending early pregnancy assessment units to measure clinical outcomes, an economic evaluation, a patient satisfaction survey, qualitative interviews with service users, an early pregnancy assessment unit staff survey and a hospital emergency care audit.
Setting
The study was conducted in 44 early pregnancy assessment units across the UK.
Participants
Participants were pregnant women (aged ≥ 16 years) attending the early pregnancy assessment units or other hospital emergency services because of suspected early pregnancy complications. Staff members directly involved in providing early pregnancy care completed the staff survey.
Main outcome measure
Emergency hospital admissions as a proportion of women attending the participating early pregnancy assessment units.
Methods
Data sources – demographic and routine clinical data were collected from all women attending the early pregnancy assessment units. For women who provided consent to complete the questionnaires, clinical data and questionnaires were linked using the women’s study number. Data analysis and results reporting – the relationships between clinical outcomes and consultant presence, unit volume and weekend opening hours were investigated using appropriate regression models. Qualitative interviews with women, and patient and staff satisfaction, health economic and workforce analyses were also undertaken, accounting for consultant presence, unit volume and weekend opening hours.
Results
We collected clinical data from 6606 women. There was no evidence of an association between admission rate and consultant presence (p = 0.497). Health economic evaluation and workforce analysis data strands indicated that lower-volume units with no consultant presence were associated with lower costs than their alternatives.
Limitations
The relatively low level of direct consultant involvement could explain the lack of significant impact on quality of care. We were also unable to estimate the potential impact of factors such as scanning practices, level of supervision, quality of ultrasound equipment and clinical care pathway protocols.
Conclusions
We have shown that consultant presence in the early pregnancy assessment unit has no significant impact on key outcomes, such as the proportion of women admitted to hospital as an emergency, pregnancy of unknown location rates, ratio of new to follow-up visits, negative laparoscopy rate and patient satisfaction. All data strands indicate that low-volume units run by senior or specialist nurses and supported by sonographers and consultants may represent the optimal early pregnancy assessment unit configuration.
Future work
Our results show that further research is needed to assess the potential impact of enhanced clinical and ultrasound training on the performance of all disciplines working in early pregnancy assessment units.
Trial registration
Current Controlled Trials ISRCTN10728897.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Maria Memtsa
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Venetia Goodhart
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sergio Silverio
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
- Department of Women and Children’s Health, King’s College London, St Thomas’ Hospital, London, UK
| | | | - Jeff Round
- Institute of Health Economics, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Nazim Khan
- Modelling and Analytical Systems Solutions Ltd, Edinburgh, UK
| | - Jennifer Hall
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Geraldine Barrett
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | | | - Judith Stephenson
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
| | - Davor Jurkovic
- Elizabeth Garrett Anderson Institute for Women’s Health, University College London, London, UK
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12
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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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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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Evaluation of maternal serum biomarkers in predicting outcome of successful expectant management of tubal ectopic pregnancies. Eur J Obstet Gynecol Reprod Biol 2020; 250:61-65. [PMID: 32387894 DOI: 10.1016/j.ejogrb.2020.04.009] [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: 01/09/2020] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To assess the value of multiple serum biomarkers for the prediction of successful outcome of expectant management in women with tubal ectopic pregnancy (TEP). STUDY DESIGN Women with a conclusive ultrasound diagnosis of TEP had a blood test to measure β-human chorionic gonadotropin (β-hCG), progesterone, inhibin A, activin A and high sensitivity C-reactive protein (hsCRP) at the initial visit. Women presenting with pain, serum β-hCG ≥ 1500 IU, evidence of a live ectopic pregnancy or a significant haemoperitoneum were advised to have emergency surgery. Women eligible for expectant management were followed-up prospectively until serum β-hCG declined to non-pregnant level or surgical treatment was required. RESULTS A total of 93 women with a TEP were included in the final cohort. Emergency surgery was carried out in 42/93 (45 %) of women whilst 51/93 (55 %) were managed expectantly. Of the latter group, 42/51 (82 %) had successful expectant management and 9/51(18 %) required surgical procedure after a period of follow up. On multi-variable analysis, only higher values of serum β-hCG and progesterone at the initial visit were associated with a lower chance of successful expectant management of TEP. A one-unit increase in either variable on the log-scale was associated with an approximate 20-fold reduction in the odds of a successful outcome. CONCLUSION(S) Serum β-hCG and progesterone were significantly lower in women who had successful expectant management of TEP. Other biomarkers under consideration were not significantly different in women with successful and failed expectant management.
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Leonardi M, Allison E, Lu C, Nadim B, Condous G. Prognostic accuracy of a novel methotrexate protocol for the resolution of tubal ectopic pregnancies. Eur J Obstet Gynecol Reprod Biol 2020; 247:186-190. [DOI: 10.1016/j.ejogrb.2020.02.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/12/2020] [Accepted: 02/17/2020] [Indexed: 10/25/2022]
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Dooley W, De Braud L, Memtsa M, Thanatsis N, Jauniaux E, Jurkovic D. Physical resolution of tubal ectopic pregnancy on ultrasound imaging following successful expectant management. Reprod Biomed Online 2020; 40:880-886. [PMID: 32414664 DOI: 10.1016/j.rbmo.2020.02.006] [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: 11/17/2019] [Revised: 01/19/2020] [Accepted: 02/11/2020] [Indexed: 11/29/2022]
Abstract
RESEARCH QUESTION What is the time required for complete physical resolution of tubal ectopic pregnancies diagnosed on ultrasound imaging in women undergoing successful expectant management? DESIGN A prospective observational cohort study of 177 women who had successful expectant management of tubal ectopic pregnancy, who attended a single Early Pregnancy Unit between January 2014 and December 2018. All participants were monitored until their serum beta-human chorionic gonadotrophin (beta-HCG) dropped to non-pregnant concentrations and with 2-weekly follow-up ultrasound scans until resolution of the pregnancy. RESULTS A total of 112/177 (63.3%, 95% confidence interval [CI] 55.7-70.4) of tubal ectopic pregnancies were indiscernible on ultrasound 2 weeks after serum beta-HCG had returned to non-pregnant concentrations. In 8/177 (4.5%, 95% CI 2.0-8.7), physical resolution took longer than 78 days. There was a positive correlation between biochemical and physical resolution of tubal ectopic pregnancy (r = 0.21, P = 0.006). CONCLUSIONS Physical resolution of tubal ectopic pregnancy is often prolonged and is positively correlated with initial and maximum beta-HCG concentrations. Results of this study indicate that beta-HCG resolution cannot be used as the end-point of expectant management of tubal ectopic pregnancy, which should be considered when counselling women and planning for future pregnancies.
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Affiliation(s)
- William Dooley
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Lucrezia De Braud
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Maria Memtsa
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Nikolaos Thanatsis
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Eric Jauniaux
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Davor Jurkovic
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK.
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Nadim B, Leonardi M, Infante F, Lattouf I, Reid S, Condous G. Rationalizing the management of pregnancies of unknown location: Diagnostic accuracy of human chorionic gonadotropin ratio‐based decision tree compared with the risk prediction model M4. Acta Obstet Gynecol Scand 2019; 99:381-390. [DOI: 10.1111/aogs.13752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 06/26/2019] [Accepted: 10/14/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Batool Nadim
- Acute Gynecology Early Pregnancy and Advanced Endosurgery Unit Nepean Hospital Sydney NSW Australia
| | - Mathew Leonardi
- Acute Gynecology Early Pregnancy and Advanced Endosurgery Unit Nepean Hospital Sydney NSW Australia
| | - Fernando Infante
- Department of Obstetrics and Gynecology Northern Beaches Hospital Sydney NSW Australia
| | - Ihab Lattouf
- Acute Gynecology Early Pregnancy and Advanced Endosurgery Unit Nepean Hospital Sydney NSW Australia
| | - Shannon Reid
- Department of Obstetrics and Gynecology Liverpool Hospital Liverpool NSW Australia
| | - George Condous
- Acute Gynecology Early Pregnancy and Advanced Endosurgery Unit Nepean Hospital Sydney NSW Australia
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18
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Dooley WM, Chaggar P, De Braud LV, Bottomley C, Jauniaux E, Jurkovic D. Effect of morphological type of extrauterine ectopic pregnancy on accuracy of preoperative ultrasound diagnosis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:538-544. [PMID: 30937982 DOI: 10.1002/uog.20274] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/01/2019] [Accepted: 03/23/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To assess the overall accuracy of transvaginal ultrasound (TVS) for diagnosis of all types of extrauterine ectopic pregnancy (EUEP) in a large group of women who were managed surgically. We also aimed to assess the positive predictive value (PPV) of TVS for each of the different ultrasound morphological types of EUEP. METHODS This was a retrospective observational study of all pregnant women who underwent emergency surgery following ultrasound diagnosis of EUEP at a single early pregnancy unit between January 2009 and December 2017. The preoperative TVS findings were recorded, including the exact location and morphological type (Type I-V; defined using ultrasound criteria) of EUEP. TVS findings were compared with operative and histological findings. The performance of ultrasound in diagnosing EUEP overall and according to morphological type was assessed, using visual confirmation of ectopic pregnancy at surgery as the reference standard. RESULTS A total of 26 401 women presented with early-pregnancy complications during the study period, including 1241 (4.7%; 95% CI, 4.5-5.0%) women with a conclusive diagnosis of EUEP on TVS or a presumed diagnosis based on severe pain and significant hemoperitoneum. Surgery was performed in 721/1241 (58.1%; 95% CI, 55.3-60.8%) cases, of which 710 (98.5%; 95% CI, 97.6-99.4%) had a conclusive diagnosis of EUEP on preoperative TVS. The remaining 11 women had severe pain and significant hemoperitoneum and were managed surgically on clinical grounds as an emergency, without an ectopic pregnancy having been identified on ultrasound examination. At laparoscopy, the diagnosis of EUEP was confirmed in 706/710 (99.4%; 95% CI, 98.6-99.8%) women with a positive ultrasound diagnosis and in all 11 women with a presumed ultrasound diagnosis of EUEP. The PPV of preoperative ultrasound for the diagnosis of EUEP was 99.4% (95% CI, 98.6-99.8%) with sensitivity of 98.5% (95% CI, 97.3-99.1%). There was no statistically significant difference in the accuracy of preoperative ultrasound diagnosis between the five morphological types (P = 0.76). CONCLUSIONS The accuracy of preoperative ultrasound for diagnosis of EUEP is high. The morphological type of EUEP on TVS had no significant effect on the accuracy of preoperative diagnosis. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- W M Dooley
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - P Chaggar
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - L V De Braud
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - C Bottomley
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - E Jauniaux
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - D Jurkovic
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
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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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Nadim B, Lu C, Infante F, Reid S, Condous G. Relationship Between Ultrasonographic and Biochemical Markers of Tubal Ectopic Pregnancy and Success of Subsequent Management. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:2899-2907. [PMID: 29675930 DOI: 10.1002/jum.14652] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 11/24/2017] [Accepted: 11/29/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To determine whether there is an association between morphologic types of tubal ectopic pregnancy (EP), 0-hour human chorionic gonadotropin (hCG) levels, and subsequent management success. METHODS We conducted a prospective study (November 2006-December 2015). Women had a diagnosis of EP by transvaginal ultrasonography if they had an inhomogeneous mass adjacent to the ovary and moving separately from it ("blob" sign), a mass with a hyperechoic ring around the gestational sac ("bagel" sign), or a gestational sac with an embryonic pole with or without a yolk sac with or without cardiac activity. The morphologic type, EP size, and 0-hour hCG level were analyzed. A multivariate analysis determined any correlation between these variables and nonsurgical management success. RESULTS A total of 7350 consecutive women underwent transvaginal ultrasonography, of whom 301 (4.2%) had a diagnosis of tubal EP; 181 (60.1%) had the blob sign; 90 (29.9%) had the bagel sign; and 23 (7.6%) were noted to have an embryo (14 viable and 9 nonviable). Eighty-three of 301(27.5%) women had expectant management; 67 of 301(22.2%) were given methotrexate; and 151 of 301 (50%) had surgery. Success rates for the groups were 77%, 75%, and 100%, respectively. No difference between the morphologic type and success rate of treatment was noted. Although there was a significant correlation between the EP mass size and 0-hour hCG level, the mass size itself was not correlated with the success rate of either medical or expectant management. Overall higher 0-hour hCG levels were associated with management failure. In the expectant group, median hCG level for failure was 589 IU/L versus 366 IU/L for success, whereas in the medical group, the median for failure was 1244 IU/L versus 7629 IU/L for success. CONCLUSIONS There is no significant correlation between the morphologic type and size of EP with a nonsurgical management outcome. A likely successful outcome is related to a lower level of serum hCG at presentation.
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Affiliation(s)
- Batool Nadim
- Acute Gynecology, Early Pregnancy, and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
| | - Chuan Lu
- Department of Computer Sciences, Aberystwyth University, Aberystwyth, Wales
| | - Fernando Infante
- Acute Gynecology, Early Pregnancy, and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
| | - Shannon Reid
- Department of Obstetrics and Gynecology Wollongong Hospital, Wollongong, New South Wales, Australia
| | - George Condous
- Acute Gynecology, Early Pregnancy, and Advanced Endoscopy Surgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Penrith, New South Wales, Australia
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May J, Duncan C, Mol B, Bhattacharya S, Daniels J, Middleton L, Hewitt C, Coomarasamy A, Jurkovic D, Bourne T, Bottomley C, Peace-Gadsby A, Doust A, Tong S, Horne AW. A multi-centre, double-blind, placebo-controlled, randomised trial of combination methotrexate and gefitinib versus methotrexate alone to treat tubal ectopic pregnancies (GEM3): trial protocol. Trials 2018; 19:643. [PMID: 30458863 PMCID: PMC6247635 DOI: 10.1186/s13063-018-3008-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/20/2018] [Indexed: 11/12/2022] Open
Abstract
Background Tubal ectopic pregnancy (tEP) is the most common life-threatening condition in gynaecology. Treatment options include surgery and medical management. Stable women with tEPs with pre-treatment serum human chorionic gonadotrophin (hCG) levels < 1000 IU/L respond well to outpatient medical treatment with intramuscular methotrexate. However, tEPs with hCG > 1000 IU/L can take significant time to resolve with methotrexate and require multiple outpatient monitoring visits. In pre-clinical studies, we found that tEP implantation sites express high levels of epidermal growth factor receptor. In early-phase trials, we found that combination therapy with gefitinib, an orally active epidermal growth factor receptor antagonist, and methotrexate resolved tEPs without the need for surgery in over 70% of cases, did not cause significant toxicities, and was well tolerated. We describe the protocol of a randomised trial to assess the efficacy of combination gefitinib and methotrexate, versus methotrexate alone, in reducing the need for surgical intervention for tEPs. Methods and analysis We propose to undertake a multi-centre, double-blind, placebo-controlled, randomised trial (around 70 sites across the UK) and recruit 328 women with tEPs (with pre-treatment serum hCG of 1000–5000 IU/L). Women will be randomised in a 1:1 ratio by a secure online system to receive a single dose of intramuscular methotrexate (50 mg/m2) and either oral gefitinib or matched placebo (250 mg) daily for 7 days. Participants and healthcare providers will remain blinded to treatment allocation throughout the trial. The primary outcome is the need for surgical intervention for tEP. Secondary outcomes are the need for further methotrexate treatment, time to resolution of the tEP (serum hCG ≤ 15 IU/L), number of hospital visits associated with treatment (until resolution or scheduled/emergency surgery), and the return of menses by 3 months after resolution. We will also assess adverse events and reactions until day of resolution or surgery, and participant-reported acceptability at 3 months. Discussion A medical intervention that reduces the need for surgery and resolves tEP faster would be a favourable treatment alternative. If effective, we believe that gefitinib and methotrexate could become standard care for stable tEPs. Trial registration ISRCTN Registry ISRCTN67795930. Registered 15 September 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-3008-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James May
- Simpsons Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Colin Duncan
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Ben Mol
- Monash Health, Monash Medical Centre, Melbourne, Australia
| | - Siladitya Bhattacharya
- Obstetrics and Gynaecology, Division of Applied Clinical Sciences, University of Aberdeen, Aberdeen Maternity Hospital, Aberdeen, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen's Medical Centre, Nottingham, UK
| | - Lee Middleton
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Catherine Hewitt
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Birmingham Women's Hospital, Birmingham, UK
| | - Davor Jurkovic
- Gynaecology Diagnostic and Treatment Unit, University College Hospital, London, UK
| | - Tom Bourne
- Obstetrics and Gynaecology, Chelsea and Westminster NHS Hospital Foundation Trust, London, UK
| | | | | | - Ann Doust
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Stephen Tong
- University of Melbourne, Mercy Hospital for Women, Melbourne, Australia
| | - Andrew W Horne
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4SA, UK.
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Rajah K, Goodhart V, Zamora KP, Amin T, Jauniaux E, Jurkovic D. How to measure size of tubal ectopic pregnancy on ultrasound. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 52:103-109. [PMID: 29143993 DOI: 10.1002/uog.18958] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 10/16/2017] [Accepted: 11/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To identify the preoperative ultrasound parameters for assessing the size of tubal ectopic pregnancy that correlate best with findings at surgery. METHODS This was a prospective study of all women attending our center who had a conclusive transvaginal ultrasound diagnosis of tubal ectopic pregnancy over a 10-month period. In each case, the total size of the ectopic pregnancy was measured by placing the calipers on the outer edges of the visible trophoblastic tissue. In ectopic pregnancies presenting with a well-defined gestational sac, the size of the celomic (chorionic) cavity was also measured using the inner borders of the trophoblastic ring as reference points. In women with signs of intra-abdominal bleeding, the size of the hematosalpinx and/or hemoperitoneum was measured. Surgeons were blinded to the ultrasound measurements and were asked to estimate the size of the ectopic pregnancy and the amount of hemoperitoneum intraoperatively. RESULTS A total of 105 women were diagnosed with a tubal ectopic pregnancy on ultrasound examination, of whom 71 (67.6%) were managed surgically. A significant (P < 0.01) positive correlation was found between all ultrasound measurements and the size of the tubal ectopic pregnancy as reported during surgery. In the absence of hematosalpinx, the mean total outer diameter of the ectopic pregnancy had the highest positive correlation with the size of the tubal ectopic pregnancy at surgery (r = 0.65, P < 0.001). In cases complicated by hematosalpinx, the mean diameter of the tube was the only variable that correlated significantly with the estimated size of the ectopic pregnancy at surgery (P < 0.001). There was a significant positive association between the amount of hemoperitoneum on ultrasound and the estimated volume of intraperitoneal blood at surgery (P < 0.001). CONCLUSIONS The mean size of a hematosalpinx and the total outer mean diameter of an ectopic pregnancy on ultrasound correlate better with the surgical findings than does the size of the celomic cavity. Our findings show that the standard approach of measuring the size of an intrauterine pregnancy on ultrasound should be adapted to include these additional measurements in women diagnosed with a tubal ectopic pregnancy. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- K Rajah
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
| | - V Goodhart
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
| | - K P Zamora
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
| | - T Amin
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
| | - E Jauniaux
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
| | - D Jurkovic
- Early Pregnancy Unit, Institute for Women's Health, University College Hospital, London, UK
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Nadim B, Infante F, Lu C, Sathasivam N, Condous G. Morphological ultrasound types known as 'blob' and 'bagel' signs should be reclassified from suggesting probable to indicating definite tubal ectopic pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:543-549. [PMID: 28195383 DOI: 10.1002/uog.17435] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 02/03/2017] [Accepted: 02/03/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE In a recent consensus statement on early pregnancy nomenclature by Barnhart, a definite ectopic pregnancy (EP) was defined morphologically on transvaginal sonography (TVS) as an extrauterine gestational sac with yolk sac and/or embryo, with or without cardiac activity, whilst a probable EP was defined as an inhomogeneous adnexal mass ('blob' sign) or extrauterine sac-like structure ('bagel' sign). This study aims to determine whether these ultrasound markers used to define probable EP can be used to predict a definite tubal EP. METHODS This was a retrospective cohort study of women presenting to the Early Pregnancy Unit (EPU) at Nepean Hospital, Sydney, Australia between November 2006 and June 2016. Women classified with a probable EP or a pregnancy of unknown location (PUL), i.e. with no signs of extra- or intrauterine pregnancy (IUP), at their first TVS were included, whilst those with a definite tubal EP, IUP or non-tubal EP were excluded from the final analysis. The gold standard for tubal EP was histological confirmation of chorionic villi in Fallopian tube removed at laparoscopy. The performance of blob or bagel sign on TVS in the prediction of definite tubal EP was evaluated in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). This was compared with the performance of extrauterine gestational sac with yolk sac and/or embryo on TVS to predict definite tubal EP. RESULTS During the study period, 7490 consecutive women attended the EPU, of whom 849 were analyzed. At primary TVS, 240/849 were diagnosed with probable EP, of which 174 (72.5%) were classified as blob sign and 66 (27.5%) as bagel sign. The remaining 609/849 were diagnosed with PUL, of which 47 had a final diagnosis of EP (including 24 blob sign, 19 bagel sign and four gestational sac with embryo/yolk sac). 101 of all 198 (51%) blob sign cases and 50 of all 85 (59%) bagel sign cases underwent laparoscopy and salpingectomy; histology proved a tubal EP in 98 (97%) of these blob-sign cases and 48 (96.0%) of the bagel-sign cases. The sensitivity for the blob and bagel signs in the prediction of definite tubal EP was 89.8% and 83.3%, respectively, the specificity was 99.5% and 99.6%, PPV was 96.7% and 95.2% and NPV was 98.3% and 98.6%. This was comparable to the sensitivity of extrauterine gestational sac with yolk sac and/or embryo on TVS in the prediction of definite tubal EP (sensitivity, 84.0%; specificity, 99.9%; PPV, 97.7%; NPV, 99.3% (P = 0.5)). CONCLUSIONS Blob and bagel signs seem to be the most common presentations of a tubal EP on TVS. Although they cannot be considered as a definitive sign of EP, their PPV is very high (> 95%); such women should therefore be considered at very high risk for having a tubal EP and should be treated as such. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- B Nadim
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Medical School, Nepean Hospital, University of Sydney, Kingswood, NSW, Australia
| | - F Infante
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Medical School, Nepean Hospital, University of Sydney, Kingswood, NSW, Australia
| | - C Lu
- Department of Computer Sciences, Aberystwyth University, Aberystwyth, Wales, UK
| | - N Sathasivam
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Medical School, Nepean Hospital, University of Sydney, Kingswood, NSW, Australia
| | - G Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Medical School, Nepean Hospital, University of Sydney, Kingswood, NSW, Australia
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Hübener C, Bidlingmaier M, Wu Z, Diebold J, Strasburger CJ, Mahner S, Hasbargen U, Delius M. Human placental growth hormone in ectopic pregnancy: Detection in maternal blood, immunohistochemistry and potential clinical implication. Growth Horm IGF Res 2017; 37:13-18. [PMID: 29073481 DOI: 10.1016/j.ghir.2017.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 10/11/2017] [Accepted: 10/12/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate human placental growth hormone (hGH-V) in ectopic pregnancy (EP): detection in maternal blood, correlation with immunohistochemistry and possible role as a marker for the course of EP. DESIGN Women presenting in the outpatient or emergency department of a tertiary care university hospital with a positive pregnancy test and strong suspicion of EP by ultrasound and/or symptoms were eligible for the study (n=70). Tissue specimens from the surgically treated patients (n=50) were examined by histopathology as well as by a hGH-V specific immohistochemistry set-up. A highly sensitive hGH-V specific immunoassay was used to analyse serum samples collected before treatment, day 1 post surgery samples and serial samples for medical treatment. RESULT(S) In EP patients' sera hGH-V was shown to be measurable for the first time (n=18). HGH-V however could not be detected in all patients' sera. HCG levels were significantly higher in the hGH-V serum positive group (p 0.001). HGH-V was localized to the syncytiotrophoblast in all specimens of EP examined by immunohistochemistry (n=10) regardless of the detection in the patient's blood. CONCLUSION(S) Placental growth hormone (hGH-V) was shown to be present both in ectopic pregnancy patients' sera and tissue. It may serve as a biomarker for monitoring the course and treatment of EP.
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Affiliation(s)
- Christoph Hübener
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany.
| | - Martin Bidlingmaier
- Endocrine Laboratory, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Ziemssenstraße 1, 80336 München, Germany
| | - Zida Wu
- Klinik für Endokrinologie, Diabetes und Ernährungsmedizin, Charité Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Joachim Diebold
- Pathologisches Institut, Kantonsspital Luzern, Luzerner Kantonsspital, 6000 Luzern 16, Switzerland
| | - Christian J Strasburger
- Klinik für Endokrinologie, Diabetes und Ernährungsmedizin, Charité Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Sven Mahner
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany
| | - Uwe Hasbargen
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany
| | - Maria Delius
- Klinik und Poliklinik für Frauenheilkunde und Geburtshilfe, Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377 München, Germany
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Farahani L, Sinha A, Lloyd J, Islam M, Ross JA. Negative histology with surgically treated tubal ectopic pregnancies - A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2017; 213:98-101. [PMID: 28441571 DOI: 10.1016/j.ejogrb.2017.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 03/19/2017] [Accepted: 04/01/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To determine the outcome of histological examinations of surgical specimens obtained from treatment of tubal ectopic pregnancy and to correlate with clinical findings, pre-operative ultrasound scans and the type of surgery. STUDY DESIGN A retrospective cohort study of 941 women diagnosed with a tubal ectopic pregnancy in the Early Pregnancy Unit and having surgical treatment at King's College Hospital, London. Clinical and ultrasound data had been entered contemporaneously on our electronic early pregnancy database and hospital clinical records over an 11year period from 2004 to 2014. Demographic data, clinical history, ultrasound scan parameters, type of surgical management and histological diagnosis were recorded. The primary outcome measure was the presence or absence of chorionic villi in the surgical specimen. Data were analysed using Mann Whitney U test for non-parametric data, relative risk for categorical data and binomial logistic regression. RESULTS A surgical specimen was obtained in 925 cases. Of these, 881/925 (95.2%) were positive for the presence of chorionic villi on histological examination. Patients with negative histology had a lower median gestational age, smaller ectopic pregnancies and lower serum human chorionic gonadotrophin levels. The relative risk of negative histology was significantly higher with a solid ectopic pregnancy on ultrasound (RR1.91, 95% CI 1.07-3.4) and with conservative surgery (RR 3.68, 95% CI 1.25-10.77). The relative risk was significantly lower with the presence of embryonic cardiac activity (RR 0.12, 95% CI 0.02-0.85). Only the serum hCG level was a significant predictor of negative histology on logistic regression analysis (p=0.048). In 39/44 women with negative histology, the human chorionic gonadotrophin level declined after surgery with no further intervention. Five of the 44 required a second surgical procedure as the ectopic pregnancy had been missed at the initial surgery and did not resolve. CONCLUSION There is lack of histological confirmation of sonographically diagnosed and surgically confirmed ectopic pregnancies in approximately 5% of cases, making this a relatively common finding following surgical treatment of tubal ectopic pregnancy. Clinicians should be aware of this when counselling women with tubal ectopic pregnancies about to undergo surgery, include this risk in the consent process and plan post-surgical follow up with this in mind.
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Affiliation(s)
- Linda Farahani
- Early Pregnancy Unit, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Anjita Sinha
- Early Pregnancy Unit, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Jilly Lloyd
- Early Pregnancy Unit, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Melissa Islam
- Early Pregnancy Unit, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Jackie A Ross
- Early Pregnancy Unit, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
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Jurkovic D, Memtsa M, Sawyer E, Donaldson ANA, Jamil A, Schramm K, Sana Y, Otify M, Farahani L, Nunes N, Ambler G, Ross JA. Single-dose systemic methotrexate vs expectant management for treatment of tubal ectopic pregnancy: a placebo-controlled randomized trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:171-176. [PMID: 27731538 DOI: 10.1002/uog.17329] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 10/04/2016] [Accepted: 10/05/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Methotrexate is used routinely worldwide for the medical treatment of clinically stable women with a tubal ectopic pregnancy. This is despite the lack of robust evidence to show its superior effectiveness over expectant management. The aim of our multicenter randomized controlled trial was to compare success rates of methotrexate against placebo for the conservative treatment of tubal ectopic pregnancy. METHODS This study took place in two early-pregnancy units in the UK between August 2005 and June 2014. Inclusion criteria were clinically stable women with a conclusive ultrasound diagnosis of a tubal ectopic pregnancy, presenting with a low serum beta human chorionic gonadotropin (β-hCG) level of < 1500 IU/L. Women were assigned randomly to a single systemic injection of either 50 mg/m2 methotrexate or placebo. The primary outcome was a binary indicator for success of conservative management, defined as resolution of clinical symptoms and decline of serum β-hCG to < 20 IU/L or a negative urine pregnancy test without the need for any additional medical intervention. An intention-to-treat analysis was followed. RESULTS We recruited a total of 80 women, 42 of whom were assigned to methotrexate and 38 to placebo. The arms of the study were matched in terms of age, ethnicity, obstetric history, pregnancy characteristics and serum levels of β-hCG and progesterone. The rates of success were similar for the two study arms: 83% with methotrexate and 76% with placebo. On univariate analysis, this difference was not statistically significant (χ2 (1 degree of freedom) = 0.53; P = 0.47). On multivariate logistic regression, the serum level of β-hCG was the only covariate found to be significantly associated with outcome. The odds of failure increased by 0.15% for each unit increase in β-hCG (odds ratio, 1.0015 (95% CI, 1.0002-1.003); P = 0.02). In 14 women presenting with serum β-hCG of 1000-1500 IU/L, the success rate was 33% in those managed expectantly compared with 62% in those receiving methotrexate. This difference was not statistically significant and a larger sample size would be needed to give sufficient power to detect a difference in the subgroup of women with higher β-hCG. In women with successful conservative treatment, there was no significant difference in median β-hCG resolution times between study arms (17.5 (interquartile range (IQR), 14-28.0) days (n = 30) in the methotrexate group vs 14 (IQR, 7-29.5) days (n = 25) in the placebo group; P = 0.73). CONCLUSIONS The results of our study do not support the routine use of methotrexate for the treatment of clinically stable women diagnosed with tubal ectopic pregnancy presenting with low serum β-hCG (< 1500 IU/L). Further work is required to identify a subgroup of women with tubal ectopic pregnancy and β-hCG ≥ 1500 IU/L in whom methotrexate may offer a safe and cost-effective alternative to surgery. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Comparación entre una sola dosis de metotrexate sistémico y la conducta expectante en el tratamiento de casos de embarazo ectópico tubárico: un ensayo aleatorio controlado con placebo RESUMEN OBJETIVO: El metotrexate se utiliza de modo rutinario en todo el mundo para el tratamiento de las mujeres clínicamente estables con un embarazo ectópico tubárico. Esto sucede a pesar de la falta de evidencia rigurosa que demuestre que su eficacia es superior a la conducta expectante. El objetivo de este ensayo controlado aleatorio multicéntrico fue comparar las tasas de éxito del metotrexate con las de un placebo para el tratamiento cauteloso del embarazo ectópico tubárico. MÉTODOS: Este estudio se llevó a cabo en dos clínicas de control de gestación temprana en el Reino Unido entre agosto de 2005 y junio de 2014. Los criterios de inclusión fueron mujeres clínicamente estables con un diagnóstico ecográfico concluyente de embarazo ectópico tubárico, las cuáles presentaban una concentración sérica baja de la β hormona coriónica gonadotrópica (β-hCG) inferior a 1500 UI/L. Las mujeres fueron asignadas aleatoriamente a una sola inyección sistémica de 50 mg/m2 de metotrexate o a placebo. El resultado primario fue un indicador binario del éxito del tratamiento conservador, definido como la resolución de los síntomas clínicos y la disminución en el suero de la β-hCG a <20 UI/L o una prueba de embarazo negativa en orina sin la necesidad de ninguna intervención médica adicional. Se hizo un análisis por intención de tratar. RESULTADOS Se reclutó un total de 80 mujeres; a 42 de ellas se les asignó el metotrexate y a 38 el placebo. Los grupos del estudio se realizaron en función de la edad, el origen étnico, los antecedentes obstétricos, las características del embarazo y los niveles séricos de la β-hCG y la progesterona. Las tasas de éxito fueron similares para los dos grupos de estudio: 83% con metotrexate y 76% con placebo. En el análisis univariante, esta diferencia no fue estadísticamente significativa (χ2 (1 grado de libertad) = 0,53; P = 0,47). En la regresión logística multivariante, el nivel sérico de la β-hCG fue la única covariable que se encontró significativamente asociada con el resultado. Las probabilidades de fracaso aumentaron en un 0,15% por cada unidad de aumento de la β-hCG (cociente de probabilidad 1,0015 (IC 95%, 1,0002-1,003); P = 0,02). La tasa de éxito en las 14 mujeres con un nivel sérico de la β-hCG de 1000-1500 UI/L fue del 33% en las tratadas con conducta expectante frente al 62% en las que recibieron metotrexate. Esta diferencia no fue estadísticamente significativa, por lo que se necesitaría un tamaño de muestra mayor, lo suficiente como para poder detectar diferencias en el subgrupo de mujeres con una β-hCG más elevada. En las mujeres en las que el tratamiento conservador tuvo éxito, no hubo una diferencia significativa en la mediana de los tiempos de resolución de la ß-hCG entre los grupos del estudio (17,5 (amplitud intercuartílica (IQR), 14-28,0) días (n = 30) en el grupo de metotrexate frente a 14 (IQR, 7-29.5) días (n = 25) en el grupo de placebo; P = 0,73). CONCLUSIONES Los resultados de este estudio no apoyan el uso rutinario de metotrexate para el tratamiento de las mujeres clínicamente estables diagnosticadas con un embarazo ectópico tubárico que presenta un nivel sérico bajo la β-hCG (<1500 UI/L). Serán necesarios estudios adicionales para identificar un subgrupo de mujeres con embarazo ectópico tubárico y β-hCG ≥1500 UI/L para quienes el metotrexate puede ofrecer una alternativa segura y rentable en comparación con la cirugía. : : ,,。。 : 2005820146,2。,,β(beta human chorionic gonadotropin,β-hCG)<1500 IU/L。,(50 mg/m2 )。,β-hCG<20 IU/L,。。 : 80,42,38。2、、、β-hCG。2:83%,76%。,[χ2 (1)=0.53;P=0.47]。logistic,β-hCG。β-hCG,0.15%[,1.0015(95% CI,1.0002~1.003);P=0.02]。14β-hCG1000~1500 IU/L,33%,62%。,β-hCG。,2β-hCG(P=0.73),17.5[(interquartile range,IQR),14~28.0](n=30),14 (IQR,7~29.5)(n=25)。 : 、、β-hCG(<1500 IU/L)。,β-hCG>1500 IU/L、。.
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Affiliation(s)
- D Jurkovic
- Institute for Women's Health, University College Hospital, London, UK
| | - M Memtsa
- Institute for Women's Health, University College Hospital, London, UK
| | - E Sawyer
- Early Pregnancy Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
| | - A N A Donaldson
- Applied Mathematics & Statistics Department, State University of New York, Stony Brook, NY, USA
| | - A Jamil
- Institute for Women's Health, University College Hospital, London, UK
| | - K Schramm
- Early Pregnancy Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
| | - Y Sana
- Early Pregnancy Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
| | - M Otify
- Early Pregnancy Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
| | - L Farahani
- Institute for Women's Health, University College Hospital, London, UK
| | - N Nunes
- Institute for Women's Health, University College Hospital, London, UK
| | - G Ambler
- Department of Statistical Science, University College London, London, UK
| | - J A Ross
- Early Pregnancy Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
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Yasumoto K, Sato Y, Ueda Y, Ito T, Kawaguchi H, Nakajima M, Muneshige A. Expectant management for abdominal pregnancy. Gynecol Minim Invasive Ther 2016; 6:82-84. [PMID: 30254883 PMCID: PMC6113971 DOI: 10.1016/j.gmit.2016.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 09/18/2016] [Accepted: 11/09/2016] [Indexed: 12/25/2022] Open
Abstract
This is the first English language report describing the expectant management for abdominal pregnancy. The patient was a 31-year-old multiparous woman who was transferred to our hospital on suspicion of ectopic pregnancy. Her serum human chorionic gonadotropin was positive, and a poorly-vascularized mass measuring about 4 cm was visualized in the Douglas pouch by transvaginal ultrasonography, as well as by pelvic magnetic resonance imaging. Because the bilateral adnexa were apparently intact, she was diagnosed with abdominal pregnancy, and expectant management was commenced. Unexpectedly, the mass remained in situ for nearly 3 years after her serum human chorionic gonadotropin tested negative. Laparoscopic removal of the mass was finally required because of persistent defecation pain. This case illustrates that some abdominal pregnancies can be managed expectantly, as is the case with tubal pregnancies. During the expectant management, however, it should be considered that the abdominal pregnancy mass may persist for a longer period and cause moderate symptoms necessitating surgical removal.
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Affiliation(s)
- Koji Yasumoto
- Department of Obstetrics and Gynecology, Nagahama Red Cross Hospital, Nagahama, Japan
| | - Yukiyasu Sato
- Department of Obstetrics and Gynecology, Otsu Red Cross Hospital, Otsu, Japan
| | - Yusuke Ueda
- Department of Obstetrics and Gynecology, Nagahama Red Cross Hospital, Nagahama, Japan
| | - Takuma Ito
- Department of Obstetrics and Gynecology, Nagahama Red Cross Hospital, Nagahama, Japan
| | - Hiromi Kawaguchi
- Department of Obstetrics and Gynecology, Nagahama Red Cross Hospital, Nagahama, Japan
| | - Masataka Nakajima
- Department of Obstetrics and Gynecology, Nagahama Red Cross Hospital, Nagahama, Japan
| | - Akira Muneshige
- Department of Obstetrics and Gynecology, Nagahama Red Cross Hospital, Nagahama, Japan
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Hoyos LR, Malik M, Najjar M, Rodriguez-Kovacs J, Abdallah M, Vilchez G, Awonuga AO. Morbid obesity and outcome of ectopic pregnancy following capped single-dose regimen methotrexate. Arch Gynecol Obstet 2016; 295:375-381. [DOI: 10.1007/s00404-016-4229-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
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Ayim F, Tapp S, Guha S, Ameye L, Al-Memar M, Sayasneh A, Bottomley C, Gould D, Stalder C, Timmerman D, Bourne T. Can risk factors, clinical history and symptoms be used to predict risk of ectopic pregnancy in women attending an early pregnancy assessment unit? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:656-662. [PMID: 27854390 DOI: 10.1002/uog.16007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 06/14/2016] [Accepted: 06/21/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To examine whether risk factors and symptoms may be used to predict the likelihood of ectopic pregnancy (EP) in women attending early pregnancy assessment units in the UK. METHODS This was an observational cohort study of pregnant women under 12 weeks' gestation who were recruited from three London university hospitals between August 2012 and April 2013. One hospital continued recruitment between January and June 2015. A standardized information sheet incorporating patient demographics, medical history and symptoms was completed by patients and confirmed by examining clinicians. The outcome measure was final pregnancy location. RESULTS There were 1320 eligible patients included in the analysis, with a total of 72 EPs (rate of 6%). Pelvic pain and diarrhea > three times in the previous 24 h were independent symptoms that increased the risk of EP, with relative risks of 2.4 (95% CI, 1.4-4.0; P = 0.002) and 2.2 (95% CI, 1.08-4.5; P = 0.03), respectively. The only other independent marker of risk of EP was duration of vaginal bleeding; the risk of EP increased by 20% (95% CI, 14%-27%) for every 1-day increment in duration (P < 0.001). A logistic regression model incorporating these factors demonstrated an area under the receiver-operating characteristics curve of 0.73 (95% CI, 0.67-0.79). The prevalence of EP was low when there was no pelvic pain, no diarrhea and the duration of bleeding was ≤ 3 days, with an EP rate of 2% (6/391). In the presence of a single risk factor, the EP rate increased to 5% (29/631) when only pelvic pain was present, 8% (1/12) when only diarrhea > three times in the previous 24 h was reported and 9% (9/103) when there was only vaginal bleeding with a duration > 3 days. Women with pelvic pain and vaginal bleeding of any severity for > 3 days had a high EP rate of 16% (23/146). In the nine women who also reported diarrhea > three times in the previous 24 h, two had EP. CONCLUSIONS Only the presence of pelvic pain, diarrhea > three times in the previous 24 h and duration of bleeding were symptoms that significantly increased the risk for EP in women attending early pregnancy assessment units. Risk factors and symptoms alone could not be used to predict reliably an EP. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- F Ayim
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK
| | - S Tapp
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK
| | - S Guha
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK
| | - L Ameye
- Department of Development and Regeneration, Campus Gasthuisberg, KU Leuven, Leuven, Belgium
| | - M Al-Memar
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK
| | - A Sayasneh
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK
| | - C Bottomley
- Chelsea and Westminster Hospital, London, UK
| | - D Gould
- St Mary's Hospital, Imperial College, London, UK
| | - C Stalder
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK
| | - D Timmerman
- Department of Development and Regeneration, Campus Gasthuisberg, KU Leuven, Leuven, Belgium
| | - T Bourne
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College, London, UK
- Department of Development and Regeneration, Campus Gasthuisberg, KU Leuven, Leuven, Belgium
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Odejinmi F, Huff KO, Oliver R. Individualisation of intervention for tubal ectopic pregnancy: historical perspectives and the modern evidence based management of ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2016; 210:69-75. [PMID: 27940397 DOI: 10.1016/j.ejogrb.2016.10.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/21/2016] [Indexed: 11/30/2022]
Abstract
Historically, ectopic pregnancy was a life-threatening condition where diagnosis was possible only at post mortem or laparotomy and maternal mortality was up to 90%. The evolution in the management of ectopic pregnancy has meant that diagnosis can be made using non-invasive techniques with an aim to identify the ectopic gestation before tubal rupture. This enables health care professionals to offer management options that consider not only maternal mortality, but morbidity and fertility outcomes as well. In spite of this, diagnostic techniques and management options are not without limitations. Research is currently focused on new tests with a single diagnostic capability, diagnostic and treatment algorithms and safe methods of triaging patients. This article aims to review the current literature on the diagnosis and management of ectopic pregnancy and to formulate a pathway to help individualise care and achieve the best possible outcome.
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Affiliation(s)
- Funlayo Odejinmi
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK.
| | - Keren O Huff
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK
| | - Reeba Oliver
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK
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Fistouris J, Bergh C, Strandell A. Classification of pregnancies of unknown location according to four different hCG-based protocols. Hum Reprod 2016; 31:2203-11. [DOI: 10.1093/humrep/dew202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/20/2016] [Indexed: 11/13/2022] Open
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Berry J, Davey M, Hon MS, Behrens R. A 5-year experience of the changing management of ectopic pregnancy. J OBSTET GYNAECOL 2016; 36:631-4. [DOI: 10.3109/01443615.2015.1133578] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Janet Berry
- Wessex Deanery Rotation, Department of Obstetrics and Gynaecology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Southampton, UK,
| | - Mark Davey
- Wessex Deanery Rotation, Department of Obstetrics and Gynaecology, Princess Anne Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK,
| | - Mei-See Hon
- Department of Obstetrics and Gynaecology, Worthing Hospital, Western Sussex Hospitals NHS Foundation Trust, Worthing, UK, and
| | - Renée Behrens
- Department of Obstetrics and Gynaecology, Hampshire Hospitals Foundation Trust, Winchester, UK
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35
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Demirdag E, Guler I, Abay S, Oguz Y, Erdem M, Erdem A. The impact of expectant management, systemic methotrexate and surgery on subsequent pregnancy outcomes in tubal ectopic pregnancy. Ir J Med Sci 2016; 186:387-392. [PMID: 26895299 DOI: 10.1007/s11845-016-1419-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The most common treatment modalities of ectopic pregnancy may influence long-term subsequent fertility outcomes in women who previously treated for ectopic pregnancy. AIMS Our objective was to compare long-term subsequent fertility outcomes after treatment with expectant management, systemic methotrexate (MTX) and surgery in tubal ectopic pregnancy. METHODS We searched our database for all women diagnosed with tubal ectopic pregnancy between January 2007 and January 2011 who were managed expectantly, with systemic MTX and with surgery. Treatment success and spontaneous pregnancy rates were compared in patients who desire to conceive following a tubal pregnancy. RESULTS One hundred twelve of 151 women desired to conceive following tubal ectopic pregnancy. Twenty-seven of 112 (24.1 %) patients were managed expectantly. Fifty-three (47.3 %) and 32 (28.5 %) patients were managed with systemic MTX or surgery, respectively. All patients in expectant and surgery groups were managed successfully. Two (3.7 %) patients had surgery after failed treatment with systemic MTX. Spontaneous intrauterine pregnancy rates were 62.9 % in expectantly managed women, 58.4 % in women with systemic MTX and 68.7 % in women with surgery (p > 0.05). CONCLUSIONS Treatment of ectopic pregnancy with either expectant management or systemic MTX is equally effective as compared to surgery. Spontaneous intrauterine pregnancy rates were comparable in expectant management, systemic methotrexate and surgery.
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Affiliation(s)
- E Demirdag
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - I Guler
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey.
| | - S Abay
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - Y Oguz
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - M Erdem
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - A Erdem
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
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Al-Memar M, Kirk E, Bourne T. The role of ultrasonography in the diagnosis and management of early pregnancy complications. ACTA ACUST UNITED AC 2015. [DOI: 10.1111/tog.12201] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Maya Al-Memar
- Early Pregnancy & Acute Gynaecology Unit; Queen Charlotte's & Chelsea Hospital, Imperial College; Du Cane Road London W12 0HS UK
| | - Emma Kirk
- North Middlesex University Hospital; Sterling Way London N18 1QX UK
| | - Tom Bourne
- Queen Charlotte's & Chelsea Hospital, Imperial College; Du Cane Road London W12 0HS
- Imperial College; London
- KU Leuven; Belgium
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Mavrelos D, Memtsa M, Helmy S, Derdelis G, Jauniaux E, Jurkovic D. β-hCG resolution times during expectant management of tubal ectopic pregnancies. BMC WOMENS HEALTH 2015; 15:43. [PMID: 25994203 PMCID: PMC4443555 DOI: 10.1186/s12905-015-0200-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 05/08/2015] [Indexed: 11/16/2022]
Abstract
Background A subset of women with a tubal ectopic pregnancy can be safely managed expectantly. Expectant management involves a degree of disruption with hospital visits to determine serum β-hCG (β-human chorionic gonadotrophin) concentration until the pregnancy test becomes negative and expectant management is considered complete. The length of time required for the pregnancy test to become negative and the parameters that influence this interval have not been described. Information on the likely length of follow up would be useful for women considering expectant management of their tubal ectopic pregnancy. Methods This was a retrospective study at a tertiary referral center in an inner city London Hospital. We included women who were diagnosed with a tubal ectopic pregnancy by transvaginal ultrasound between March 2009 and March 2014. During the study period 474 women were diagnosed with a tubal ectopic pregnancy and 256 (54 %) of them fulfilled our management criteria for expectant management. A total of 158 (33 %) women had successful expectant management and in those cases we recorded the diameter of the ectopic pregnancy (mm), the maximum serum β-hCG (IU/L) and levels during follow up until resolution as well as the interval to resolution (days). Results The median interval from maximum serum β-hCG concentration to resolution was 18.0 days (IQR 11.0–28.0). The maximum serum β-hCG concentration and the rate of decline of β-hCG were independently associated with the length of follow up. Women’s age and size of ectopic pregnancy did not have significant effects on the length of follow up. Conclusion Women undergoing expectant management of ectopic pregnancy can be informed that the likely length of follow up is under 3 weeks and that it positively correlates with initial β-hCG level at the time of diagnosis.
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Affiliation(s)
- D Mavrelos
- Institute of Women's Health, University College London, London, UK.
| | - M Memtsa
- Gynaecological Diagnostic and Outpatient Treatment Unit, University College London Hospital, Lower Ground Floor, Elizabeth Garrett Anderson Wing, 250 Euston Road, London, NW1 6BU, UK.
| | - S Helmy
- University Hospital, Vienna, Austria.
| | - G Derdelis
- Gynaecological Diagnostic and Outpatient Treatment Unit, University College London Hospital, Lower Ground Floor, Elizabeth Garrett Anderson Wing, 250 Euston Road, London, NW1 6BU, UK.
| | - E Jauniaux
- Institute of Women's Health, University College London, London, UK.
| | - D Jurkovic
- Gynaecological Diagnostic and Outpatient Treatment Unit, University College London Hospital, Lower Ground Floor, Elizabeth Garrett Anderson Wing, 250 Euston Road, London, NW1 6BU, UK.
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Refaat B, Dalton E, Ledger WL. Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies. Reprod Biol Endocrinol 2015; 13:30. [PMID: 25884617 PMCID: PMC4403912 DOI: 10.1186/s12958-015-0025-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/03/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Ectopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment. METHODS The scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected. RESULTS A history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence. CONCLUSIONS EP/HP are tragic events in a couple's reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.
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Affiliation(s)
- Bassem Refaat
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-Abdiyah Campus, PO Box 7607, Makkah, KSA.
| | - Elizabeth Dalton
- School of Women's & Children's Health, University of New South Wales, Sydney, NSW, 2031, Australia.
| | - William L Ledger
- School of Women's & Children's Health, University of New South Wales, Sydney, NSW, 2031, Australia.
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Bourne T. A missed opportunity for excellence: the NICE guideline on the diagnosis and initial management of ectopic pregnancy and miscarriage. THE JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2014; 41:13-9. [PMID: 25512352 DOI: 10.1136/jfprhc-2014-101025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Tom Bourne
- Adjunct Professor and Consultant Gynaecologist, Queen Charlotte's & Chelsea Hospital, Imperial College, London, UK and Visiting Professor, Department of Development and Regeneration, KU Leuven, Belgium
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Silva PM, Araujo Júnior E, Cecchino GN, Elito Júnior J, Camano L. Effectiveness of expectant management versus methotrexate in tubal ectopic pregnancy: a double-blind randomized trial. Arch Gynecol Obstet 2014; 291:939-43. [PMID: 25315383 DOI: 10.1007/s00404-014-3513-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 10/07/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE To compare the effectiveness of expectant management versus methotrexate in selected cases of tubal ectopic pregnancy. METHODS A double-blind randomized trial included 23 selected patients with a confirmed diagnosis of tubal pregnancy who met the inclusion criteria (hemodynamic stability, initial serum β-hCG concentration <2,000 mIU/mL, declining titers of β-hCG 48 h prior to treatment, visible tubal pregnancy on transvaginal ultrasound, a tubal mass <5.0 cm and fertility desire). The patients were divided into two groups: 10 patients in the methotrexate group (MTX 50 mg/m(2) administered as a single intramuscular dose) and 13 patients in the placebo group (saline solution administered in a single intramuscular dose). Quantitative variables were expressed as means ± standard deviations and compared by Student's t test or Mann-Whitney test. Dichotomous variables (success/treatment failure) were presented as proportions and compared by the Fisher exact test. RESULTS Successful treatment with negative titers of β-hCG occurred in 9 cases (90.0%) of the methotrexate group and in 12 (92.3%) of the placebo group (p > 0.999). The β-hCG values became undetectable at 22 ± 15.4 days in the methotrexate group and 20.6 ± 8.4 days in the placebo group (p = 0.80). CONCLUSION This study showed no statistically significant difference between the treatment with methotrexate and placebo, with similar success rates and similar time interval for β-hCG to become undetectable.
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Affiliation(s)
- Priscila Matthiesen Silva
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), Rua Carlos Weber 956, apto. 113 Visage, Vila Leopoldina, São Paulo, SP, CEP 05303-000, Brazil
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Nonsurgical Management of Live Tubal Ectopic Pregnancy by Ultrasound-Guided Local Injection and Systemic Methotrexate. J Minim Invasive Gynecol 2014; 21:642-9. [DOI: 10.1016/j.jmig.2014.01.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 01/10/2014] [Accepted: 01/12/2014] [Indexed: 11/18/2022]
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Guha S, Ayim F, Ludlow J, Sayasneh A, Condous G, Kirk E, Stalder C, Timmerman D, Bourne T, Van Calster B. Triaging pregnancies of unknown location: the performance of protocols based on single serum progesterone or repeated serum hCG levels. Hum Reprod 2014; 29:938-45. [DOI: 10.1093/humrep/deu045] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Trophoblastic infiltration in tubal pregnancy evaluated by immunohistochemistry and correlation with variation of Beta-human chorionic gonadotropin. PATHOLOGY RESEARCH INTERNATIONAL 2014; 2014:302634. [PMID: 24523985 PMCID: PMC3913197 DOI: 10.1155/2014/302634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/23/2013] [Accepted: 12/08/2013] [Indexed: 11/21/2022]
Abstract
Objective. To evaluate trophoblastic cell proliferation and angiogenesis in tubal pregnancy assessed by immunohistochemical study and their correlation with an average variation of β-hCG in an interval of 48 hours before surgery. Methods. A prospective study was conducted on 18 patients with a diagnosis of tubal pregnancy. The patients were divided into two groups of ectopic pregnancy of which 11 showed rise of β-hCG levels and 7 patients showed declining β-hCG levels in an interval of 48 hours prior to surgery. Trophoblastic cell proliferation and angiogenesis were assessed by Ki-67 and VEGF, respectively. Trophoblastic cell proliferation was assessed by Ki-67 and was classified into three groups (grade I: less than 1/3 of stained nuclei, grade II: 1/3 to 2/3 of the stained nuclei, and grade III: more than 2/3 of the nuclei stained). The cases analyzed for VEGF were divided into three groups (grade I: less than 1/3 of the stained cytoplasm; grade II: 1/3 to 2/3 of the stained cytoplasm; grade III: more than 2/3 of the stained cytoplasm). Statistical analysis was performed using the chi-square, ANOVA, and Kruskal-Wallis tests. Results. The mean variation in the serum β-hCG levels in 48 hours in tubal pregnancy patients correlated with trophoblastic cell proliferation assessed by Ki-67 and showed a decline of 13.46% in grade I, a rise of 45.99% in grade II, and ascension of 36.68% in grade III (P = 0.030). The average variation in the serum β-hCG in 48 hours, where angiogenesis was evaluated by VEGF, showed a decline of 18.35% in grade I, a rise of 32.95% in grade II, and ascension of 37.55% in grade III (P = 0.047). Conclusions. Our observations showed a direct correlation of increased levels of serum β-hCG in 48h period prior to surgery with higher trophoblastic cell proliferation assessed by Ki-67 and angiogenesis assessed by VEGF in tubal pregnancy.
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Horne AW, Skubisz MM, Doust A, Duncan WC, Wallace E, Critchley HOD, Johns TG, Norman JE, Bhattacharya S, Mollison J, Rassmusen M, Tong S. Phase II single arm open label multicentre clinical trial to evaluate the efficacy and side effects of a combination of gefitinib and methotrexate to treat tubal ectopic pregnancies (GEM II): study protocol. BMJ Open 2013; 3:bmjopen-2013-002902. [PMID: 23872290 PMCID: PMC3717468 DOI: 10.1136/bmjopen-2013-002902] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Tubal ectopic pregnancy (tEP) is the most common life-threatening condition in gynaecology. tEPs with pretreatment serum human chorionic gonadotrophin (hCG) levels <1000 IU/L respond well to outpatient medical treatment with intramuscular methotrexate (MTX). TEPs with hCG >1000 IU/L take a significant time to resolve with MTX and require multiple outpatient monitoring visits. Gefitinib is an orally active epidermal growth factor receptor (EGFR) antagonist. In preclinical studies, we found that EP implantation sites express high levels of EGFR and that gefitinib augments MTX-induced regression of pregnancy-like tissue. We performed a phase I toxicity study administering oral gefitinib and intramuscular MTX to 12 women with tEPs. The combination therapy did not cause significant toxicities and was well tolerated. We noted that combination therapy resolved the tEPs faster than MTX alone. We now describe the protocol of a larger single arm trial to estimate the efficacy and side effects of combination gefitinib and MTX to treat stable tEPs with hCG 1000-10 000 IU/L METHODS AND ANALYSIS: We propose to undertake a single-arm multicentre open label trial (in Edinburgh and Melbourne) and recruit 28 women with tEPs (pretreatment serum hCG 1000-10 000 IU/L). We intend to give a single dose of intramuscular MTX (50 mg/m(2)) and oral gefitinib (250 mg) daily for 7 days. Our primary outcome is the resolution of EP to non-pregnant hCG levels <15 IU/L without requirement of surgery. Our secondary outcomes are comparison of time to resolution against historical controls given MTX only, and safety and tolerability as determined by clinical/biochemical assessment. ETHICS AND DISSEMINATION Ethical approval has been obtained from Scotland A Research Ethics Committee (MREC 11/AL/0350), Southern Health Human Research Ethics Committee B (HREC 11180B) and the Mercy Health Human Research Ethics Committee (R12/25). Data will be presented at international conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ACTRN12611001056987.
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Affiliation(s)
- Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
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