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Zeng F, Lai Y, Huang Y, Zhu F, Gao J, Chen Z, Zeng L, Feng M, Qiu P, Yuan S, Deng G. Shikonin from lithospermum erythrorhizon induces pyroptosis in trophoblast cells by activating the CTSB-NLRP3 inflammasome. Ann Med 2024; 56:2394584. [PMID: 39183455 PMCID: PMC11348813 DOI: 10.1080/07853890.2024.2394584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/26/2024] [Accepted: 03/26/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND With the decline of global fertility, drug therapeutic of ectopic pregnancy is of great significance. Lithospermum erythrorhizon is using for embryo killing as herbal medicine. Shikonin is the critical nucleus of Lithospermum erythrorhizon; however, the mechanism is still unclear. The study aimed to explore the mechanism of shikonin against ectopic pregnancy. MATERIAL AND METHODS In this study, we examined the viability and LDH release of HTR-8/SVneo cells by assays, observed pore formation in cell membranes by microscopy imaging and PI staining, and IL-1β release by WB and ELISA assay kit. Then, we used network pharmacology to analyse the potential interaction between shikonin, ectopic pregnancy and pyroptosis and used molecular docking techniques to verify interactions between shikonin and core common targets. Finally, western blotting and immunofluorescence assay were used to explore the mechanism of shikonin-inducing pyroptosis of HTR-8/SVneo cells. RESULTS Shikonin could cause a significant inhibition of HTR-8/SVneo cell viability in a concentration- and time-dependent manner. In HTR-8/SVneo cells, shikonin-induced cell swelling, bubble formation, an increase in the release of lactate dehydrogenase (LDH) and up-regulation of several pyroptosis-associated factors. And network pharmacology showed that The main targets of shikonin-ectopic pregnancy-pyroptosis were IL-1β and caspase-1, and molecular docking results showed that shikonin can closely bind to IL-1β, caspase-1 and GSDMD. Additionally, the necroptosis inhibitor GSK'872 could not suppress the expression of mature-IL-1β and prevent the pyroptosis phenotype from developing. However, the nucleotide oligomerization domain-like receptor family pyrin domain containing 3 (NLRP3) inhibitor MCC-950 could downregulate the expression of pyroptosis-associated factors and prevent the pyroptosis phenotype from developing. Shikonin led to an elevation in the expression of cathepsin B (CTSB), and the CTSB inhibitor CA-074 abolished pyroptosis induced by shikonin; however, the NLRP3 inhibitor MCC-950 could not inhibit the expression of CTSB. CONCLUSIONS Our results suggest that shikonin activates CTSB to induce NLRP3-dependent pyroptosis in HTR-8/SVneo cells. This study has important clinical implications for the treatment of ectopic pregnancy.
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Affiliation(s)
- Fuling Zeng
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Gynecology, Guangzhou Baiyun District Maternal and Child Health Hospital, Guangzhou, China
| | - Yuling Lai
- Department of Sports Medicine, Guangzhou Sport University, Guangzhou, China
| | - Yanxi Huang
- Department of Gynecology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Fangfang Zhu
- Department of Gynecology, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Jie Gao
- Department of Gynecology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhenyue Chen
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Lihua Zeng
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Min Feng
- The First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Pin Qiu
- Department of Gynecology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shuo Yuan
- Department of Gynecology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Gaopi Deng
- Department of Gynecology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Jeffers K, Koyfman A, Long B. Updates in emergency medicine: Ectopic pregnancy. Am J Emerg Med 2024; 85:90-97. [PMID: 39244808 DOI: 10.1016/j.ajem.2024.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 08/24/2024] [Accepted: 09/01/2024] [Indexed: 09/10/2024] Open
Abstract
INTRODUCTION Ectopic pregnancy is a serious condition that can have significant morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of ectopic pregnancy, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Ectopic pregnancy is a pregnancy that implants outside the normal uterine cavity. It most commonly presents with vaginal bleeding, abdominal or pelvic pain, and amenorrhea. Risk factors for ectopic pregnancy include abnormalities of the fallopian tube, prior ectopic pregnancy, and age over 35 years, but a significant number of patients with confirmed ectopic pregnancy will not have an identifiable risk factor. In patients with suspected ectopic pregnancy, evaluation includes quantitative serum hCG, blood type, and ultrasound. Ultrasound is necessary regardless of the hCG level. If the patient is hemodynamically unstable, resuscitation with blood products and early consultation of obstetrics/gynecology is necessary. Patients with confirmed ectopic pregnancy but who are otherwise stable may be managed medically or surgically. If a yolk sac or fetal pole is not seen in the uterus on ultrasound, this is considered a pregnancy of unknown location (PUL), which may represent an early, failed, or ectopic pregnancy. Stable patients with a PUL who can reliably follow up are managed with close specialist follow up and repeat 48 h HCG level. These patients need to have an hCG level repeated every 48 h until diagnosed with a viable pregnancy, failed pregnancy, or ectopic pregnancy. CONCLUSIONS Knowledge of the latest advances in managing ectopic pregnancy will help clinicians more quickly and accurately diagnose patients presenting with this potentially fatal condition.
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Affiliation(s)
- Kristine Jeffers
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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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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Kugelman N, Cohen B, Yossef F, Margieh N, Regev N, Shani U, Bart Y. Expectant management of tubal pregnancies with human chorionic gonadotropin up to 2000 mIU/mL. Int J Gynaecol Obstet 2024; 164:1094-1100. [PMID: 37776069 DOI: 10.1002/ijgo.15162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/16/2023] [Accepted: 09/12/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE To describe outcomes of expectant management (EM) versus methotrexate (MTX) treatment in tubal pregnancies with pretreatment human chorionic gonadotropin (hCG) less than 2000 mIU/mL. METHODS This retrospective cohort from two tertiary hospitals included women with confirmed tubal pregnancies and pretreatment hCG <2000 mIU/mL. Exclusion criteria were unrecorded pregnancy site, unconfirmed diagnosis, and surgical treatment upon diagnosis. The primary outcome was eventual rate of surgical treatment. RESULTS Between December 2009 and June 2021, 545 of 2114 (25.8%) women diagnosed with a tubal pregnancy met our inclusion criteria. We compared women who underwent EM (N = 201) with women who received MTX (N = 344). All women in the EM group had a declining trend of hCG. The MTX group had higher pretreatment hCG and higher rates of yolk sac or embryo presence on ultrasound. Eventual surgical treatment rate was higher in the MTX group compared with the EM group (39 [11.3%] vs. 9 [4.5%], P = 0.006), with no difference in the treatment failure rate or tubal rupture rate. In a subgroup analysis of women with pretreatment hCG between 1000 and 2000 mIU/mL, eventual surgical treatment, treatment failure, and tubal rupture rates did not differ between groups. Logistic regression analysis revealed that eventual surgical treatment was independently associated with hCG levels less than 1000 mIU/mL (adjusted odds ratio [aOR] 0.28, 95% confidence interval [CI] 0.14-0.56) and endometriosis (aOR 9.20, 95% CI 3.55-23.81). CONCLUSION Expectant management of tubal pregnancies with pretreatment hCG levels less than 2000 mIU/mL and even between 1000 and 2000 mIU/mL and with a declining trend of hCG demonstrated lower or comparable rates of eventual surgical treatment, when compared with MTX treatment.
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Affiliation(s)
- Nir Kugelman
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Bracha Cohen
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Fayrooz Yossef
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- Department of Obstetrics and Gynecology, Bnai Zion Medical Center, Haifa, Israel
| | - Nadine Margieh
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Noam Regev
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Uria Shani
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yossi Bart
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
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Karol D, Williamson M, Pereira N. Successful Expectant Management of a Tubal Ectopic Pregnancy. J Minim Invasive Gynecol 2024; 31:92-94. [PMID: 38042476 DOI: 10.1016/j.jmig.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 12/04/2023]
Affiliation(s)
- Dalia Karol
- Department of Obstetrics and Gynecology (Drs. Karol and Williamson), University of Toronto, Toronto, Ontario
| | - Monica Williamson
- Department of Obstetrics and Gynecology (Drs. Karol and Williamson), University of Toronto, Toronto, Ontario
| | - Nigel Pereira
- University of Toronto, Toronto, Ontario, Mount Sinai Fertility (Dr. Pereira), Toronto, Ontario; Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology (Dr. Pereira), University of Toronto, Toronto, Ontario.
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Alanwar A, Khalaf WM, Alfussaily E, Salem MA, Taema MI, Ali I. The impact of systemic methotrexate and surgical management on fertility preservation in tubal ectopic pregnancy among Saudi women. J Matern Fetal Neonatal Med 2023; 36:2241106. [PMID: 37500183 DOI: 10.1080/14767058.2023.2241106] [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: 09/30/2022] [Revised: 07/06/2023] [Accepted: 07/21/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND The impact of various management plans on subsequent fertility after tubal ectopic pregnancy (EP) is not well known. The objective of the present study was an evaluation of the subsequent fertility outcome among women with EP managed either surgical or medical with systemic methotrexate or medical management followed by surgical one. PATIENTS AND METHODS A retrospective cohort study was done by reviewing of medical records of all women diagnosed with EP at King Faisal Military Hospital, Southern Region, Saudi Arabia throughout the period from January 2015 to December 2016 provided that they were hemodynamic stable, with starting βhCG level less than 10000 IU/L, and adnexal mass less than 5 cm. These cases were followed for four years from January 2017 to December 2020. RESULTS The study included 85 women with EP. Their mean age was 31.3 ± 6.7 years. Medical management (systemic Methotrexate) was followed in 48.2% of cases whereas surgical management was applied for 43.5% of them while medical management followed by surgical one was seen in 8.2% of cases. Complete follow-up throughout 2017-2020 was available for 52 women. A history of recurrent EP was observed among 3 women (5.8%). Most of them (75%) had a viable pregnancy. There was no statistically significant association between the method of management of EP and subsequent fertility, although the rate of normal pregnancy (intrauterine viable pregnancy ≥ 24 weeks which is the age of viability at our hospital) was higher among those managed surgically or by medical followed by surgical management than those managed medical only (84.6% and 100% vs. 62.5%). CONCLUSION Although the normal pregnancy rate was higher among those managed surgically or by medical followed by surgical management than those managed medically only, this was not statistically significant.
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Affiliation(s)
- Ahmed Alanwar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Mouwasat Hospital, Saudi Arabia
| | - Waleed M Khalaf
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Mouwasat Hospital, Saudi Arabia
| | - Eman Alfussaily
- King Faisal Military hospital (Armed forces Hospitals), Saudi Arabia
| | - Marwa A Salem
- King Faisal Military hospital, Imam Abdulrahman Al Faisal hospital, NGH, Dammam, Saudi Arabia
| | - Mohamed I Taema
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Ibrahim Ali
- Department of Obstetrics and Gynecology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- King Faisal Military hospital (Armed forces Hospitals), Saudi Arabia
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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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Solangon SA, Van Wely M, Van Mello N, Mol BW, Ross JA, Jurkovic D. Methotrexate vs expectant management for treatment of tubal ectopic pregnancy: An individual participant data meta-analysis. Acta Obstet Gynecol Scand 2023; 102:1159-1175. [PMID: 37345445 PMCID: PMC10407021 DOI: 10.1111/aogs.14617] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Ectopic pregnancy is an important health condition which affects up to 1 in 100 women. Women who present with mild symptoms and low serum human chorionic gonadotrophin (hCG) are often treated with methotrexate (MTX), but expectant management with close monitoring is a feasible alternative. Studies comparing the two treatments have not shown a statistically significant difference in uneventful resolution of ectopic pregnancy, but these studies were too small to define whether certain subgroups could benefit more from either treatment. MATERIAL AND METHODS We performed a systematic review and individual participant data meta-analysis (IPD-MA) of randomized controlled trials comparing systemic MTX and expectant management in women with tubal ectopic pregnancy and low hCG (<2000 IU/L). A one-stage IPD-MA was performed to assess overall treatment effects of MTX and expectant management to generate a pooled intervention effect. Subgroup analyses and exploratory multivariable analyses were undertaken according to baseline serum hCG and progesterone levels. Primary outcome was treatment success, defined as resolution of clinical symptoms and decline in level of serum hCG to <20 IU/L, or a negative urine pregnancy test by the initial intervention strategy, without any additional treatment. Secondary outcomes were need for blood transfusion, surgical intervention, additional MTX side-effects and hCG resolution times. TRIAL REGISTRATION NUMBER PROSPERO: CRD42021214093. RESULTS 1547 studies reviewed and 821 remained after duplicates removed. Five studies screened for eligibility and three IPD requested. Two randomized controlled trials supplied IPD, leading to 153 participants for analysis. Treatment success rate was 65/82 (79.3%) after MTX and 48/70 (68.6%) after expectant management (IPD risk ratio [RR] 1.16, 95% confidence interval [CI] 0.95-1.40). Surgical intervention rates were not significantly different: 8/82 (9.8%) vs 13/70 (18.6%) (RR 0.65, 95% CI 0.23-1.14). Mean time to success was 19.7 days (95% CI 17.4-22.3) after MTX and 21.2 days (95% CI 17.8-25.2) after expectant management (P = 0.25). MTX specific side-effects were reported in 33 MTX compared to four in the expectant group. CONCLUSIONS Our IPD-MA showed no statistically significant difference in treatment efficacy between MTX and expectant management in women with tubal ectopic pregnancy with low hCG. Initial expectant management could be the preferred strategy due to fewer side-effects.
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Affiliation(s)
| | - Madelon Van Wely
- Center for Reproductive MedicineAmsterdam University Medical CenterAmsterdamthe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Norah Van Mello
- Amsterdam Reproduction and Development Research InstituteAmsterdam University Medical CenterAmsterdamthe Netherlands
- Obstetrics and GynecologyAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Ben W. Mol
- The Ritchie Centre, Department of Obstetrics and GynecologyMonash UniversityClaytonVictoriaAustralia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and NutritionUniversity of AberdeenAberdeenUK
| | - Jackie A. Ross
- Early Pregnancy and Gynaecology Assessment UnitKing's College London HospitalLondonUK
| | - Davor Jurkovic
- Institute for Women's HealthUniversity College LondonLondonUK
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Time to resolution of tubal ectopic pregnancy following methotrexate treatment: A retrospective cohort study. PLoS One 2022; 17:e0268741. [PMID: 35609041 PMCID: PMC9129037 DOI: 10.1371/journal.pone.0268741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/06/2022] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To determine the time to resolution of tubal ectopic pregnancy after methotrexate treatment. METHODS A 14-year retrospective cohort study was performed from 2004-2018 and assessed 216 women treated with single-dose methotrexate for tubal ectopic pregnancy. Women were treated using a single-dose protocol of intramuscular methotrexate (50mg/m2) for confirmed tubal ectopic pregnancy on ultrasound. Ectopic pregnancies were included if the ectopic pregnancy mass was <35mm, no evidence of rupture and no embryonic cardiac activity. Serum hCG was measured on day 1, 4 and 7 of treatment and then at standard weekly intervals until resolution. Where there was not a ≥15% decline in hCG from day 4 and day 7, a second dose of methotrexate was administered. The primary outcome was time to resolution (days), with serum hCG <5 IU/L considered resolved. The secondary outcome was need for rescue surgery. RESULTS Among women who did not proceed to surgery, the median time to resolution was 22 days (IQR 14,34). Time to resolution and need for rescue surgery increased with baseline hCG. When hCG was <1000 IU/L, the median was 20 days (IQR 13,29) but 34.5 days (IQR 22,48) with hCG >2000 IU/L. Early hCG trends were predictive of time to resolution and likelihood of rescue surgery; a hCG rise of >1000 IU/L between Days 1-4 increased time to resolution to 61 days (IQR 35,80) and an odds ratio of rescue surgery of 28.6 (95% C.I. 5.3,155.4). CONCLUSION The median time to resolution for ectopic pregnancies treated with methotrexate is 22 days and associated with baseline hCG levels. The predictive value of baseline hCG may be useful in clinical decision making and counselling women considering methotrexate for ectopic pregnancy.
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Xiao C, Shi Q, Cheng Q, Xu J. Non-surgical management of tubal ectopic pregnancy: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27851. [PMID: 34918633 PMCID: PMC8677977 DOI: 10.1097/md.0000000000027851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 11/02/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Ectopic pregnancy (EP) is a common cause of acute abdominal pain in the field of gynecology. Because the majority of women with EP are hemodynamically stable, non-surgical therapy is a viable option. The goal of this study was to determine the most effective non-surgical therapy for hemodynamically stable EP. METHODS We performed a systematic review and meta-analysis. We searched PubMed, LILACS, SciELO, CINAHL, Embase, and the Cochrane library in May 2020, with no starting date restrictions.Studies were restricted to randomized controlled trials, which were included if the target population contained women with tubal EP and the intervention was non-surgical management. The primary outcome measure was treatment success defined by a decrease in serum hCG to a level ranging from five mIU/mL to 50 mIU/mL. Secondary outcome measures were side effects, time needed to treat, number of injections and operative rate. RESULTS We conducted a meta-analysis of 15 studies that included 1573 women who were diagnosed with EP and managed non-surgically. There was no significant difference in treatment success in the matched groups; however, single-dose MTX was associated with fewer side effects than multiple-dose (relative risk 0.48, 95% confidence interval 0.28-0.80, P = .006) and two-dose therapies (relative risk 0.74, 95% confidence interval 0.55-1.00, P = .05). CONCLUSIONS We highly recommend that single-dose MTX without mifepristone be used first-line in patients who require conservative therapy due to the inherent negative effects of mifepristone. An EP woman with a low -hCG level that is falling or plateauing should receive expectant treatment to reduce adverse effects.
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Affiliation(s)
- Chao Xiao
- Department of Obstetrics and Gynecology, Zigong First People's Hospital, Zigong, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan Province, China
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Qingquan Shi
- Center of Reproductive Medicine, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan Province, China
| | - Qijun Cheng
- Department of Obstetrics and Gynecology, Zigong First People's Hospital, Zigong, China
| | - Jianli Xu
- Department of Obstetrics and Gynecology, Zigong First People's Hospital, Zigong, China
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Valdera Simbrón CJ, Hernández Rodríguez C, Llanos Jiménez L, Pérez García L, Plaza Arranz J, Albi González M. Management of early gestations with low beta-human chorionic gonadotropin conceived by assisted reproductive technologies: performance of M4 predictive model. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:616-624. [PMID: 33656199 DOI: 10.1002/uog.23625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 02/01/2021] [Accepted: 02/19/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To assess the safety and performance of the M4 model for classifying as high risk or low risk for ectopic pregnancy (EP) pregnancies conceived by assisted reproductive technologies (ART) that present with low beta-human chorionic gonadotropin (β-hCG) concentration in early gestation. METHODS This was a prospective cohort study of 243 pregnancies conceived by ART with low β-hCG levels (5-50 IU/L) at 4 + 0 to 4 + 2 weeks' gestation. After subsequent β-hCG testing at 48 h, pregnancies were classified according to the M4 model into the following categories: (i) high risk, probable EP/persistent pregnancy of unknown location (PPUL), when the risk for EP was ≥ 5%; (ii) low risk, probable intrauterine pregnancy (IUP), when the risk of EP was < 5% and the likelihood of IUP was greater than that of a failed pregnancy of unknown location (FPUL); and (iii) low risk, probable FPUL, when the risk of EP was < 5% and the likelihood of a FPUL was greater than that of an IUP. The predictive performance of the M4 model for EP and its ability to discriminate between high- and low-risk pregnancies was assessed using the final pregnancy outcome at 11 to 13 weeks of gestation as reference, which was classified as EP/PPUL, FPUL or IUP. RESULTS The sensitivity and specificity of the M4 model in detecting a high-risk pregnancy (EP/PPUL) were 60.0% (95% CI, 43.6-74.4%) and 79.8% (95% CI, 73.8-84.7%), respectively. The area under the receiver-operating-characteristics curve of the M4 model for discriminating between high-risk and low-risk (FPUL/IUI) pregnancies was 0.72 (95% CI, 0.62-0.81). The model had a positive likelihood ratio of 2.97 (95% CI, 2.03-4.36) and a negative likelihood ratio of 0.50 (95% CI, 0.33-0.76). The kappa index was 0.30 (95% CI, 0.16-0.43), indicating a low degree of agreement between the model classification and the final diagnosis. No serious adverse events related directly to the application of the M4 model were observed, although 14 pregnancies classified ultimately as high risk had been categorized initially as low risk by the M4 model. Of these, seven resolved with expectant management, five with methotrexate (MTX) and two required laparoscopic surgery (one after failure of medical treatment with MTX and one after deviation from the follow-up protocol). There were no cases of EP/PPUL with additional complications or need for blood or other blood product transfusion. Of the 243 ART pregnancies with low β-hCG concentration in early gestation, only 47 (19.3%) had an IUP, half (24/47) of which had an early miscarriage, resulting in only 9.5% (23/243) cases having an ongoing pregnancy. CONCLUSIONS Application of the M4 model in pregnancies conceived by ART with low β-hCG concentration in early gestation showed limited capacity in classifying them as being at low or high risk for EP, therefore, its use in pregnancies of this type is not recommended. No serious adverse events or complications related to the use of the model were observed. These pregnancies have a low probability of ending in an IUP as well as a high rate of early miscarriage. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C J Valdera Simbrón
- Assisted Reproduction Unit, Fundación Jiménez Díaz, Madrid, Spain
- Department of Obstetrics and Gynaecology, Fundación Jiménez Díaz, Madrid, Spain
| | - C Hernández Rodríguez
- Assisted Reproduction Unit, Fundación Jiménez Díaz, Madrid, Spain
- Department of Obstetrics and Gynaecology, Fundación Jiménez Díaz, Madrid, Spain
| | | | - L Pérez García
- Department of Obstetrics and Gynaecology, Fundación Jiménez Díaz, Madrid, Spain
| | - J Plaza Arranz
- Department of Obstetrics and Gynaecology, Fundación Jiménez Díaz, Madrid, Spain
| | - M Albi González
- Department of Obstetrics and Gynaecology, Fundación Jiménez Díaz, Madrid, Spain
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Millan NM, Morano J, Florez L, Carugno J, Medina CA. Management of tubal ectopic pregnancy with methotrexate in the setting of symptomatic Coronavirus disease 2019 (COVID-19): A case report. Facts Views Vis Obgyn 2021; 13:273-277. [PMID: 34555882 PMCID: PMC8823271 DOI: 10.52054/fvvo.13.3.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background Coronavirus Disease 2019 (COVID-19) represents a complex therapeutic challenge. As the pandemic progresses, patients are presenting with ectopic pregnancies (EPs) and symptomatic COVID-19. Objective We present the management of a patient with multiple medical comorbidities and tubal EP in the setting of severe symptomatic COVID-19 infection where all management options were precluded. Methods Case report with literature review of management of tubal EP in the setting of severe symptomatic COVID-19 infection. Result After careful consideration of options, the patient underwent successful medical management with methotrexate while receiving supportive care for COVID-19. Conclusions Methotrexate proved to be the safest therapeutic option in this patient. Management of patients with severe COVID-19 and gynaecologic emergencies should be individualised and carefully reviewed with evolving knowledge of COVID-19.
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Interstitial Ectopic Pregnancy: The Role of Mifepristone in the Medical Treatment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189781. [PMID: 34574706 PMCID: PMC8472240 DOI: 10.3390/ijerph18189781] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 09/15/2021] [Indexed: 02/04/2023]
Abstract
Interstitial pregnancy is defined as the presence of a gestational sac in the most proximal section of the fallopian tube. Management of interstitial pregnancy remains a debated topic. Depending on hemodynamic stability, size of pregnancy, depth of surrounding myometrium, and desires for future fertility, interstitial pregnancy can be managed medically or surgically. We reviewed the literature in December 2020 using keywords “interstitial pregnancy”, “medical treatment”, “methotrexate”, and “mifepristone”. Articles published from January 1991 until 2020 were obtained from databases EMBASE, SCOPUS, and PUBMED. We describe the case of a patient with an interstitial pregnancy that was managed with a total medical approach in August 2020 at Burlo Garofolo Hospital. The patient was asymptomatic and hemodynamically stable, with a high level of serum β-hCG (22,272 mUi/mL). We used the combination of methotrexate (MTX) and mifepristone. Medical therapy was effective leading to interstitial pregnancy resolution in 51 days without collateral effects for the patient. We found seven previous cases reported in the literature. Our purpose is to underline the efficacy of medical therapy with systemic multidose MTX associated with a single oral dose of mifepristone and also folinic acid when is present a viable fetus and a high serum β-hCG level.
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Methotrexate versus expectant management in ectopic pregnancy: a meta-analysis. Arch Gynecol Obstet 2021; 305:547-553. [PMID: 34524502 DOI: 10.1007/s00404-021-06236-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Ectopic pregnancy (EP) affects 1-2% of all pregnant females'(Barnhart et al., Expert Opin Pharmacother 2(3):409-417, 2001) that can require emergent surgical intervention. Noninvasive diagnostic tests like transvaginal ultrasound (TVUS), and serial β-hCG levels have enabled early diagnosis and allowed medical therapy to be tried. Methotrexate (MTX) versus expectant management, both have been considered safe but superiority of one over the other is lacking. METHODS We searched for RCT that have shown efficacy of MTX versus expectant management in hemodynamically stable patients. Our primary outcome was whether one modality is superior to the other. RESULTS Four RCT were included in the meta-analysis after review. Our pooled analysis when comparing MTX and expectant management showed us that the difference between the uneventful decline in β-hCG levels (treatment success) was statistically insignificant (RR = 1.06, 95% CI 0.93-1.21) with no significant heterogeneity between trials (I2 = 0.0%, P = 0.578). The difference between need for surgical intervention between methotrexate and expectant management was also statistically insignificant (RR = 0.77, 95% CI 0.43-1.40) with no significant heterogeneity between trials (I2 = 0.0%, P = 0.552). CONCLUSION We conclude that expectant management is not inferior to MTX in hemodynamically stable patients with ectopic pregnancy that have declining or low β-hCG levels.
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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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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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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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Lee TH, Chou CC, Chang CF, Lin YR, Chen WL. A Rare Case of Ruptured Ectopic Pregnant Woman Present With Double Negative Pregnant Test. J Acute Med 2020; 10:126-128. [PMID: 33209571 PMCID: PMC7667254 DOI: 10.6705/j.jacme.202009_10(3).0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/06/2020] [Accepted: 01/31/2020] [Indexed: 11/14/2022]
Abstract
The urine pregnancy test is one of the most useful methods for initially excluding pregnancy emergencies in the emergency department (ED). Although most urine pregnancy tests are regarded to be up to 99% accurate, false-negative results may lead ED physicians toward considering incorrect diagnoses, mask critical conditions, and even influence patient safety. Therefore, blood pregnancy tests (quantitative measurements) are clinically used for second-line screening. A double false-negative result from two pregnancy tests is very rare and has scarcely been reported for life-threatening ruptured ectopic pregnancy patients. In this report, for the first time, we describe a rare case of a 32-year-old female who suffered a life-threatening ruptured ectopic pregnancy and who had a double pregnancy test (both urine and blood) that was a false negative.
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Affiliation(s)
- Tsung-Han Lee
- Changhua Christian Hospital Department of Emergency Medicine Changhua Taiwan
- National Chiao Tung University Department of Biological Science and Technology Hsinchu Taiwan
| | - Chu-Chung Chou
- Changhua Christian Hospital Department of Emergency Medicine Changhua Taiwan
- Chung Shan Medical University School of Medicine Taichung Taiwan
- Kaohsiung Medical University School of Medicine Kaohsiung Taiwan
| | - Chin-Fu Chang
- Changhua Christian Hospital Department of Emergency Medicine Changhua Taiwan
| | - Yan-Ren Lin
- Changhua Christian Hospital Department of Emergency Medicine Changhua Taiwan
- Chung Shan Medical University School of Medicine Taichung Taiwan
- Kaohsiung Medical University School of Medicine Kaohsiung Taiwan
| | - Wen-Liang Chen
- National Chiao Tung University Department of Biological Science and Technology Hsinchu Taiwan
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Baggio S, Garzon S, Russo A, Ianniciello CQ, Santi L, Laganà AS, Raffaelli R, Franchi M. Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant management. Arch Gynecol Obstet 2020; 303:259-268. [PMID: 32852572 PMCID: PMC7854461 DOI: 10.1007/s00404-020-05749-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 08/13/2020] [Indexed: 12/18/2022]
Abstract
Purpose To compare fertility and reproductive outcome after surgical, medical, and expectant management for tubal ectopic pregnancy (EP). Methods 133 of 228 patients, who were managed between January 2012 and December 2017 for a tubal EP, tried to conceive immediately after treatment: 86 out of 173 (49.7%) underwent surgical treatment; 38 (21.9%) were treated with methotrexate (MTX), and 49 (28.3%) had expectant management. Clinical data were retrieved by medical records, fertility outcomes were obtained by phone follow-up. The cumulative incidence (CI) of intrauterine clinical pregnancy (CP), miscarriage, live birth (LB), and recurrent EP, and the time between treatment and first intrauterine CP were compared between women treated with MTX, surgery and expectant management. Results The CI of intrauterine CP starting from 12 months after the EP was 65.3% for the expectant management, 55.3% for the MTX group, and 39.5% for surgery (p = 0.012). Post-hoc analysis showed expectant management having higher intrauterine CP and LB, and shorter time between treatment and first intrauterine CP compared to surgery (p < 0.05). The CI of recurrent EP was comparable between the 3 groups. The analysis stratified per βhCG cut-off of 1745 mUI/mL and EP mass cut-off of 25 mm reported consistent results. Conclusions Women successfully managed by expectation appear to have better reproductive outcomes compared to women who underwent surgery, with the shortest time to achieve a subsequent intrauterine CP. Therefore, if safely applicable the expectant management should be considered in the case of tubal EP. The fact that the chosen treatment was primarily guided by the βhCG value and EP mass diameter based on the protocol, which is intrinsically related to the characteristics of the EP, represents the main limitation of the present study. Indeed, we cannot completely exclude that the observed differences between treatments are related to the EP itself instead of the treatment.
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Affiliation(s)
- Silvia Baggio
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy. .,Department of Obstetrics and Gynecology, "Sacro Cuore" Hospital, Negrar Di Valpolicella, Verona, Italy.
| | - Simone Garzon
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Anna Russo
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | | | - Lorenza Santi
- Department of Endocrinology, Diabetes and Metabolism, AOUI Verona, University of Verona, Verona, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Ricciarda Raffaelli
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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Chen S, Zhu F, Zhang Y, Li J, Gao J, Deng G. A Model to Predict Treatment Failure of Single‑Dose Methotrexate in Patients with Tubal Pregnancy. Med Sci Monit 2020; 26:e920079. [PMID: 32383438 PMCID: PMC7236588 DOI: 10.12659/msm.920079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Background In China, approximately 15% of tubal pregnancy patients treated with MTX eventually required surgery because the ectopic mass was ruptured; therefore, it is essential to develop a model to predict the risk of failure with methotrexate treatment in tubal pregnancy. Material/Methods In this research, 168 patients met the eligibility criteria, and 29 candidate risk factors for treatment failure were collected. Multivariable logistic regression analysis was used to analyze the factors, and a full model was developed. We used a multiple fractional polynomial model and a stepwise model to increase the reliability. Bootstrap resampling for 500 times was used to internally test the prediction model. The integral performance of the model depends on the evaluation of the nomogram, the discriminative performance by receiver operating characteristic (ROC) curve analysis, and calibration. Results The model showed excellent discrimination and calibration. The area under the ROC curve for the prediction model, mfp model, and stepwise model were 0.879 (95% CI: 0.812–0.942), 0.872 (95% CI: 0.805–0.931), and 0.880 (95% CI: 0.817–0.949), respectively. At a cutoff value of ≥0.40, sensitivity was 60%, specificity was 91%, positive predictive value (PPV) was 81%, and negative predictive value (NPV) was 77%. The model provides a net benefit when clinical decision thresholds are between 0% and 40% of predicted risk. Conclusion This model indicated good accuracy in predicting methotrexate treatment failure for tubal pregnancy patients.
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Affiliation(s)
- Si Chen
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Fangfang Zhu
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Yingxuan Zhang
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Jing Li
- First Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Jie Gao
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
| | - Gaopi Deng
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China (mainland)
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The quality and utility of research in ectopic pregnancy in the last three decades: An analysis of the published literature. Eur J Obstet Gynecol Reprod Biol 2020; 245:134-142. [DOI: 10.1016/j.ejogrb.2019.12.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/14/2019] [Accepted: 12/23/2019] [Indexed: 12/14/2022]
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Davis AA, Lata K, Panwar A, Kriplani A. Unexpected rupture of an expectantly managed tubal ectopic pregnancy: a reminder for enhanced diligence. BMJ Case Rep 2019; 12:e230876. [PMID: 31888919 PMCID: PMC6936481 DOI: 10.1136/bcr-2019-230876] [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] [Accepted: 12/16/2019] [Indexed: 11/03/2022] Open
Abstract
Expectant management of tubal ectopic pregnancies is a feasible and possibly preferable method of management in asymptomatic women with low serum β-human chorionic gonadotropin (hCG). This involves serial monitoring of β-hCG until negative, after which it is deemed as spontaneously resolved ectopic pregnancy. We describe a case of tubal ectopic pregnancy which was expectantly managed with an initial β-hCG of 585 mIU/mL until undetectable. This patient presented with ruptured ectopic pregnancy 8 weeks after the original diagnosis, at the level of 5 mIU/mL. This highlights the importance of close monitoring in the expectant management of tubal ectopic pregnancies, with the incorporation of imaging, even when serial β-hCG shows a persistently reducing trend.
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Affiliation(s)
- Amenda Ann Davis
- Obstetrics and Gynaecology, Paras Hospitals, Gurgaon, Haryana, India
| | - Kusum Lata
- Obstetrics and Gynaecology, Paras Hospitals, Gurgaon, Haryana, India
| | - Akshita Panwar
- Obstetrics and Gynaecology, Paras Hospitals, Gurgaon, Haryana, India
| | - Alka Kriplani
- Obstetrics and Gynaecology, Paras Hospitals, Gurgaon, Haryana, India
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Abstract
Early in pregnancy women frequently experience nausea, vomiting, and vaginal bleeding. Nausea and vomiting can be mild, managed by dietary modifications and medications, or severe, requiring intravenous fluids and medications. Care should be used when selecting medications for nausea to avoid additional side effects or potential harm to the developing fetus. When evaluating vaginal bleeding in early pregnancy, ectopic pregnancy must be ruled out. If an intrauterine pregnancy is seen, threatened miscarriage should be considered and the patient appropriately counseled. If neither intrauterine pregnancy nor ectopic pregnancy can be established, a management algorithm for pregnancy of unknown location is presented.
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Affiliation(s)
- Elizabeth Pontius
- Department of Emergency Medicine, Georgetown University School of Medicine, MedStar Georgetown University Hospital, MedStar Washington Hospital Center, 110 Irving Street, Northwest, NA 1177, Washington, DC 20010, USA
| | - Julie T Vieth
- Department of Emergency Medicine, Canton-Potsdam Hospital, 50 Leroy Street, Potsdam, NY 13676, USA.
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Abstract
Early diagnosis of an extrauterine pregnancy is important for safe and effective management. However, a pregnancy's location often cannot be easily determined with abnormal implantations or prior to 5-6 weeks' gestation. Multiple testing strategies exist to diagnose an abnormal pregnancy when location is unknown, but caution needs to be used to avoid a false diagnosis. Medical treatment is optimal when an abnormal pregnancy is diagnosed early. Because most of these pregnancies are intrauterine, additional testing to localize the pregnancy will allow the correct choice of therapy and avoids unnecessary exposure to a toxic therapy. This testing strategy should be reserved for patients with significant concern for ectopic pregnancy, based on either risk factors or clinical findings. Overuse of this approach can lead to interruption of normal pregnancies.
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Affiliation(s)
- Daniela Carusi
- Department of Obstetrics & Gynecology, Brigham & Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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Pınar N, Kaplan M, Özgür T, Özcan O. Ameliorating effects of tempol on methotrexate-induced liver injury in rats. Biomed Pharmacother 2018; 102:758-764. [DOI: 10.1016/j.biopha.2018.03.147] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/19/2018] [Accepted: 03/23/2018] [Indexed: 02/01/2023] Open
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Inal ZO, Inal HA. Comparison of Four Methods of Treating Ectopic Pregnancy: A Retrospective Cohort Study. Geburtshilfe Frauenheilkd 2018; 78:70-77. [PMID: 29375148 PMCID: PMC5778193 DOI: 10.1055/s-0043-122151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 10/29/2017] [Accepted: 11/01/2017] [Indexed: 12/27/2022] Open
Abstract
Objective
To compare the results of expectant management, single and multidose methotrexate (MTX) and surgical management of ectopic pregnancy (EP).
Materials and Methods
In this retrospective cohort study, the original files of 233 patients who were treated for EP between May 2009 and December 2016 were analyzed. The patients were assigned to the following groups based on the applied treatment methods: Group 1, expectant management (n = 24), Group 2, single-dose MTX (n = 144), Group 3, multiple-dose MTX (n = 25), and Group 4, surgical intervention (n = 40). The following parameters were recorded and assessed: sociodemographic characteristics, pelvic ultrasonography findings (gestational sac, ectopic mass appearance, positive fetal cardiac activity), serum beta-human chorionic gonadotropin (β-hCG) levels on Day 0, Day 4, and Day 7, and surgical procedures in women that underwent surgical interventions.
Results
The sociodemographic characteristics were similar in all four groups. The percentage of ectopic mass and positive fetal cardiac activity was greater and the diameter of the mass was larger in Group 4 than in the other groups. The β-hCG values on Day 0, Day 4, and Day 7 were statistically different between the groups (p < 0.001). The cutoff value for the β-hCG change for EP resolution was 18% between Day 0 and Day 4 (AUC = 0.726, p < 0.001) and 15% between Day 4 and Day 7 (AUC = 0.874, p < 0.001). The probability of the requirement for an additional dose of MTX was 0.78 (95% CI 0.71 – 0.87; p < 0.001) times lower in patients who had a > 18% decrease in β-hCG levels from Day 0 to Day 4 in comparison to those who had a decrease < 18% from Day 0 to Day 4. The probability of the requirement for an additional dose of MTX was 1.64 (95% CI 1.25 – 2.16; p < 0.001) times greater in patients whose reduction in β-hCG levels from Day 4 to Day 7 was < 15% in comparison to those who had > 15% reduction from Day 4 to Day 7.
Conclusions
Additional dose requirements for patients with EP may be predicted early in the changes in β-hCG levels between Day 0 and Day 4. Further prospective studies are required to elucidate this issue.
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Affiliation(s)
- Zeynep Ozturk Inal
- Konya Education and Research Hospital, Department of Gynecology, Konya, Turkey
| | - Hasan Ali Inal
- Konya Education and Research Hospital, Department of Gynecology, Konya, Turkey
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