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Rohini S, Sharma UR, Vinutha M, Shreelaxmi D, Vada S, Janandri S, Haribabu T, Taj N, Gayathri SV, Ghara A, Mudagal MP. Rheumatoid arthritis-associated complications during pregnancy and its effect on offspring: comprehensive review. Inflammopharmacology 2024; 32:1-17. [PMID: 38691248 DOI: 10.1007/s10787-024-01482-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/05/2024] [Indexed: 05/03/2024]
Abstract
This study comprehensively explores the complexities of rheumatoid arthritis during pregnancy and its impact on offspring. Through an extensive review of existing literature, we investigate maternal and fetal risks, including adverse pregnancy outcomes and developmental issues in offspring. Utilizing reputable databases such as PubMed, Google Scholar, and Science Direct, we meticulously examined studies exploring the connection between rheumatoid arthritis and pregnancy complications, with a focus on outcomes for offspring. We excluded studies lacking sufficient data or peer review. Synthesizing findings from selected studies, we identified common themes and patterns, presenting results in a clear, organized manner. Our examination reveals a heightened likelihood of preterm birth and preeclampsia among pregnant individuals with rheumatoid arthritis, often correlated with disease activity. Furthermore, we highlight the impact on fetal and neonatal outcomes, such as low birth weight, underscoring the importance of meticulous disease management throughout pregnancy. Balancing the necessity of disease-modifying agents with potential risks, and consideration of medication safety is paramount. A multidisciplinary approach involving rheumatologists and obstetricians is crucial for optimizing outcomes. In conclusion, this synthesis underscores the nuanced challenges of rheumatoid arthritis in pregnancy. A comprehensive understanding and personalized, multidisciplinary approach to an organization is essential for informed decision-making in clinical practice. Our review contributes to ongoing discourse, providing insights for enhanced patient care and guiding future research endeavors.
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Affiliation(s)
- S Rohini
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Uday Raj Sharma
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India.
| | - M Vinutha
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - D Shreelaxmi
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Surendra Vada
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Suresh Janandri
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - T Haribabu
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Nageena Taj
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - S V Gayathri
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Abhishek Ghara
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
| | - Manjunatha P Mudagal
- Department of Pharmacology, Acharya & BM Reddy College of Pharmacy, Acharya Dr. Sarvepalli Radhakrishna Road, Achit Nagar (Post), Soldevanahalli, Bengaluru, 560090, India
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Weber-Schoendorfer C, Diav-Citrin O. Methotrexate in pregnancy: still many unanswered questions. RMD Open 2023; 9:rmdopen-2022-002899. [PMID: 36921981 PMCID: PMC10030667 DOI: 10.1136/rmdopen-2022-002899] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 03/05/2023] [Indexed: 03/17/2023] Open
Affiliation(s)
| | - Orna Diav-Citrin
- The Israeli Teratology Information Service, State of Israel Ministry of Health, Jerusalem, Israel
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3
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Distal Tibial Hemimelia in Fetal Methotrexate Syndrome: A Case Study and Literature Review. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020228. [PMID: 36832357 PMCID: PMC9954531 DOI: 10.3390/children10020228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/20/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
Methotrexate (MTX), a folate antagonist, is used in various fields, including malignancies and rheumatoid or inflammatory autoimmune diseases. MTX is used for the non-surgical treatment of ectopic pregnancies and the elective termination of pregnancy. The teratogenic effects of MTX have been recognized since the 1960s. Fetal methotrexate syndrome (FMS) was established based on the study of congenital anomalies. Generally, there is a risk of FMS when MTX is used between four and six weeks after conception. Here, we reviewed the literature regarding MTX usage and described a case of FMS that was born with a rare anomaly, such as tibial hemimelia, in a mother who had received MTX 4 months before conception for the management of an ectopic pregnancy.
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Phillips CH, Benson CB, Durfee SM, Heller HT, Doubilet PM. "Pseudogestational Sac" and Other 1980s-Era Concepts in Early First-Trimester Ultrasound: Are They Still Relevant Today? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1547-1551. [PMID: 32045016 DOI: 10.1002/jum.15243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 01/10/2020] [Accepted: 01/21/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To determine whether an intrauterine round or oval fluid collection ("saclike structure") can prove to be either an intrauterine pregnancy or intrauterine fluid in conjunction with an ectopic pregnancy (sometimes termed "pseudogestational sac") and whether ultrasound features, including the presence or absence of an echogenic rim, "double sac sign" (DSS), or "intradecidual sign" (IDS), are helpful for establishing the diagnosis or predicting the prognosis. METHODS We identified all sonograms obtained from women with positive serum human chorionic gonadotropin results at our institution between January 1, 2012, and June 30, 2018, meeting the following criteria: presence of an intrauterine saclike structure without a yolk sac or embryo; no extraovarian adnexal mass; and follow-up information identifying the location of the pregnancy as intrauterine or ectopic. Study authors reviewed sonograms in all cases and recorded the following information: presence or absence of each of an echogenic rim around the collection, a DSS, and an IDS, as well as the mean sac diameter. The indications for the initial ultrasound examinations were recorded. RESULTS A total of 649 sonograms met the inclusion criteria. Of these, 598 fluid collections showed an echogenic rim, 182 a DSS, and 347 an IDS (findings not mutually exclusive). In all 649 cases, a subsequent sonogram or other clinical follow-up confirmed that the patient had an intrauterine pregnancy. That is, none of the fluid collections proved to be a pseudogestational sac. In total, 41.2% were live at the end of the first trimester, and 58.8% miscarried. The prognosis was better in cases with, compared to without, an IDS (P = .01, χ2 ), but no ultrasound feature was clinically useful for ruling in or excluding a good prognosis. CONCLUSIONS In a woman with positive human chorionic gonadotropin results and no extraovarian adnexal mass, the ultrasound finding of an intrauterine saclike structure is virtually certain to be a gestational sac. Ultrasound features of the structure are of no diagnostic or clinically useful prognostic value. Concepts introduced 30 to 40 years ago when ultrasound equipment had far lower resolution than currently, including a DDS, an IDS, and a pseudogestational sac, have no role today in assessing early pregnancy.
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Affiliation(s)
- Catherine H Phillips
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Carol B Benson
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sara M Durfee
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Howard T Heller
- Department of Radiology, Memorial Healthcare System, Hollywood, Florida, USA
| | - Peter M Doubilet
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Lim JA, Sheng KL, Chong SE. A Narrow Escape From Methotrexate: The Importance of Correlating Ultrasound Findings With Discriminatory Level of β-hCG and the β-hCG Ratio. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2237-2238. [PMID: 30536687 DOI: 10.1002/jum.14899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 10/09/2018] [Indexed: 06/09/2023]
Affiliation(s)
- Jo Anne Lim
- Department of Internal Medicine, Hospital Sultan Abdul Halim, Kedah, Malaysia
| | - Kun Leng Sheng
- Department of Obstetrics and Gynecology, Hospital Sultan Abdul Halim, Kedah, Malaysia
| | - Soon Eu Chong
- Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, Penang, Malaysia
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Verberne EA, de Haan E, van Tintelen JP, Lindhout D, van Haelst MM. Fetal methotrexate syndrome: A systematic review of case reports. Reprod Toxicol 2019; 87:125-139. [PMID: 31181251 DOI: 10.1016/j.reprotox.2019.05.066] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 05/24/2019] [Accepted: 05/29/2019] [Indexed: 12/27/2022]
Abstract
Methotrexate is a folic acid antagonist known to be teratogenic in humans. Several cases of congenital malformations after fetal exposure to methotrexate have been published, resulting in the establishment of the 'fetal methotrexate syndrome'. However, it is unclear which congenital anomalies can truly be attributed to methotrexate exposure. The objective of this review is to delineate a consistent phenotype of the fetal methotrexate syndrome. We performed a systematic review that yielded 29 cases of (congenital) anomalies after in utero exposure to methotrexate and compared their malformation pattern to that of children and fetuses with congenital anomalies in general. Statistically significant higher proportions of microcephaly, craniosynostosis, tetralogy of Fallot, pulmonary valve atresia, limb reduction defects and syndactyly were found in the methotrexate group, indicating that these congenital anomalies are truly part of the fetal methotrexate syndrome. These results aid clinicians with diagnosing fetal methotrexate syndrome.
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Affiliation(s)
- Eline A Verberne
- Department of Clinical Genetics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Emma de Haan
- Department of Clinical Genetics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J Peter van Tintelen
- Department of Clinical Genetics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands; Department of Genetics, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Dick Lindhout
- Department of Genetics, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Mieke M van Haelst
- Department of Clinical Genetics, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Fridman D, Hawkins E, Dar P, Chudnoff S, Rotenberg O, Chong W, Xie X, Mehta S, Levie M. Methotrexate Administration to Patients With Presumed Ectopic Pregnancy Leads to Methotrexate Exposure of Intrauterine Pregnancies. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:675-684. [PMID: 30244479 DOI: 10.1002/jum.14751] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 06/10/2018] [Accepted: 07/14/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To report clinical experience with methotrexate (MTX) treatment for suspected but not definite ectopic pregnancy (EP). METHODS This was a retrospective cohort study. All patients treated with MTX for presumed EP between 2000 and 2016 were included. Demographic, clinical, sonographic, and outcome data were collected and analyzed. RESULTS A total of 820 patients were treated with MTX, 692 (84.4%) of which were lacking definitive features of EP; 155 (22.4%) failed to follow up until complete resolution and were excluded. Retrospective sonographic categorization was applied to 537 patients; of those patients, 393 (73.2%) were categorized as probable EPs, 136 (25.3%) pregnancies of unknown location (PULs), and 8 (1.5%) probable intrauterine pregnancies (IUPs). Sixteen were eventually diagnosed with IUP: 6 from the probable EPs, 9 from the PULs, and 1 from the probable IUP group. Patients with final diagnosis of IUP had higher values of β-human chorionic gonadotropin as well as lower prevalence of adnexal mass (38% versus 74%; P = .003), higher prevalence of intracavitary fluid (44% versus 9%; P = .0004) and thicker endometrium (17.1 ± 11.8 versus 9.7 ± 5.6; P = .04). None of the sonographic parameters were able to distinguish patients with IUP. One patient of the 16 with IUP was diagnosed with a viable pregnancy, and 7 additional patients had a possible viable pregnancy. None of them elected to continue the pregnancy. CONCLUSIONS Most patients with suspected EP who are eligible for medical treatment lack definitive sonographic features of EP. Treatment with MTX in such cases should be delayed, as clinically reasonable, to improve the diagnosis and prevent inadvertent administration of MTX to patients with a viable IUP.
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Affiliation(s)
- Dmitry Fridman
- Department of Obstetrics, Gynecology, and Women's Health, Montefiore Medical Center, Bronx, New York, USA
| | - Eleanor Hawkins
- Department of Obstetrics, Gynecology, and Women's Health, Montefiore Medical Center, Bronx, New York, USA
| | - Peer Dar
- Department of Obstetrics, Gynecology, and Women's Health, Montefiore Medical Center, Bronx, New York, USA
| | - Scott Chudnoff
- Department of Obstetrics, Gynecology, and Women's Health, Montefiore Medical Center, Bronx, New York, USA
| | - Ohad Rotenberg
- Department of Obstetrics, Gynecology, and Women's Health, Montefiore Medical Center, Bronx, New York, USA
| | - Woojin Chong
- Department of Obstetrics, Gynecology, and Women's Health, Montefiore Medical Center, Bronx, New York, USA
| | - Xianhong Xie
- Department of Obstetrics, Gynecology, and Women's Health, Montefiore Medical Center, Bronx, New York, USA
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Sukrant Mehta
- Department of Obstetrics, Gynecology, and Women's Health, Montefiore Medical Center, Bronx, New York, USA
| | - Mark Levie
- Department of Obstetrics, Gynecology, and Women's Health, Montefiore Medical Center, Bronx, New York, USA
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8
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Abstract
Pregnancy of unknown location is a situation in which a positive pregnancy test occurs, but a transvaginal ultrasound does not show intrauterine or ectopic gestation. One great concern of pregnancy of unknown location is that they are cases of ectopic pregnancy whose diagnosis might be postponed. Transvaginal ultrasound is able to identify an ectopic pregnancy with a sensitivity ranging from 87% to 94% and a specificity ranging from 94% to 99%. A patient with pregnancy of unknown location should be followed up until an outcome is obtained. The only valid biomarkers with clinical application and validation are serum levels of the beta fraction of hCG and progesterone. A single serum dosage of hCG is used only to determine whether the value obtained is above or below the discriminatory zone, that means the value of serum hCG above which an intrauterine gestational sac should be visible on ultrasound. Serum progesterone levels are a satisfactory marker of pregnancy viability, but they are unable to predict the location of a pregnancy of unknown location: levels below 5 ng/mL are associated with nonviable gestations, whereas levels above 20 ng/mL are correlated with viable intrauterine pregnancies. Most cases are low risk and can be monitored by expectant management with transvaginal ultrasound and serial serum hCG levels, in addition to the serum progesterone levels. To minimize diagnostic error and intervene during progressive intrauterine gestation, protocol indicates active treatment only in situations when progressive intrauterine pregnancy is excluded and a high possibility of ectopic pregnancy exists.
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Affiliation(s)
- Pedro Paulo Pereira
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Úrsula Trovato Gomez
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
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Parks MA, Barnhart KT, Howard DL. Trends in the Management of Nonviable Pregnancies of Unknown Location in the United States. Gynecol Obstet Invest 2018; 83:552-557. [PMID: 29874639 DOI: 10.1159/000488760] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 03/23/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND When managing a nonviable pregnancy of unknown location (PUL), a debate has emerged in the literature whether to perform uterine curettage for definitive diagnosis of pregnancy location or administer methotrexate for a presumed ectopic pregnancy. The purpose of this study is to describe the treatment patterns when managing a PUL. METHODS A prospective, anonymous Internet based-electronic survey of PUL case scenarios was administered to a random sample of physicians across the United States. RESULTS A total of 214 physicians responded. When presented with a PUL by ultrasound and a βhCG measurement of 3,270 mIU/mL, which is above the discriminatory level, 88.3% (188) would choose an additional βhCG measurement before recommending any intervention. When presented with a PUL by ultrasound and serial βhCG measurements demonstrating an inappropriate trend for a viable gestation, 36.5% would offer uterine curettage and 31.3% would offer methotrexate. Resident and private clinicians had a fourfold lower adjusted odds of choosing uterine curettage compared to academic physicians. CONCLUSIONS Based on our findings, there does not appear to be a consensus regarding the management of a PUL.
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Affiliation(s)
- Melissa A Parks
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia,
| | - Kurt T Barnhart
- Department of Reproductive Endocrinology and Infertility, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
| | - David L Howard
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, USA
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10
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Puget C, Joueidi Y, Bauville E, Laviolle B, Bendavid C, Lavoué V, Le Lous M. Serial hCG and progesterone levels to predict early pregnancy outcomes in pregnancies of uncertain viability: A prospective study. Eur J Obstet Gynecol Reprod Biol 2018; 220:100-105. [DOI: 10.1016/j.ejogrb.2017.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/21/2017] [Accepted: 11/26/2017] [Indexed: 12/17/2022]
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11
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Svirsky R, Ben-Ami I, Berkovitch M, Halperin R, Rozovski U. Outcomes of conception subsequent to methotrexate treatment for an unruptured ectopic pregnancy. Int J Gynaecol Obstet 2017; 139:170-173. [DOI: 10.1002/ijgo.12264] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 05/28/2017] [Accepted: 07/12/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Ran Svirsky
- Department of Obstetrics and Gynecology; Assaf Harofeh Medical Center; Zerifin Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Ido Ben-Ami
- Department of Obstetrics and Gynecology; Assaf Harofeh Medical Center; Zerifin Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Matitiahu Berkovitch
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
- Clinical Pharmacology Unit; Assaf Harofeh Medical Center; Zerifin Israel
| | - Reuvit Halperin
- Department of Obstetrics and Gynecology; Assaf Harofeh Medical Center; Zerifin Israel
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
| | - Uri Rozovski
- Sackler School of Medicine; Tel-Aviv University; Tel-Aviv Israel
- Institute of Hematology; Davidoff Cancer Center; Beilinson Hospital; Petah Tikva Israel
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12
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Dauti A, Gerstl B, Chong S, Chisholm O, Anazodo A. Improvements in Clinical Trials Information Will Improve the Reproductive Health and Fertility of Cancer Patients. J Adolesc Young Adult Oncol 2017; 6:235-269. [PMID: 28207285 DOI: 10.1089/jayao.2016.0084] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
There are a number of barriers that result in cancer patients not being referred for oncofertility care, which include knowledge about reproductive risks of antineoplastic agents. Without this information, clinicians do not always make recommendations for oncofertility care. The objective of this study was to describe the level of reproductive information and recommendations that clinicians have available in clinical trial protocols regarding oncofertility management and follow-up, and the information that patients may receive in clinical trials patient information sheets or consent forms. A literature review of the 71 antineoplastic drugs included in the 68 clinical trial protocols showed that 68% of the antineoplastic drugs had gonadotoxic animal data, 32% had gonadotoxic human data, 83% had teratogenic animal data, and 32% had teratogenic human data. When the clinical trial protocols were reviewed, only 22% of the protocols reported the teratogenic risks and 32% of the protocols reported the gonadotoxic risk. Only 56% of phase 3 protocols had gonadotoxic information and 13% of phase 3 protocols had teratogenic information. Nine percent of the protocols provided fertility preservation recommendations and 4% provided reproductive information in the follow-up and survivorship period. Twenty-six percent had a section in the clinical trials protocol, which identified oncofertility information easily. When gonadotoxic and teratogenic effects of treatment were known, they were not consistently included in the clinical trial protocols and the lack of data for new drugs was not reported. Very few protocols gave recommendations for oncofertility management and follow-up following the completion of cancer treatment. The research team proposes a number of recommendations that should be required for clinicians and pharmaceutical companies developing new trials.
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Affiliation(s)
- Angela Dauti
- 1 College of Arts and Sciences, Department of Chemistry, New York University , New York City, New York.,2 Population Sciences Department, Dana-Farber Cancer Institute , Boston, Massachusetts.,3 Department of Women's and Children's Medicine, School of Medical Sciences, University of New South Wales , Sydney, Australia
| | - Brigitte Gerstl
- 4 Kids Cancer Centre, Sydney Children's Hospital , Sydney, Australia
| | - Serena Chong
- 3 Department of Women's and Children's Medicine, School of Medical Sciences, University of New South Wales , Sydney, Australia
| | - Orin Chisholm
- 5 Department of Pharmaceutical Medicine, School of Medical Sciences, University of New South Wales , Sydney, Australia
| | - Antoinette Anazodo
- 3 Department of Women's and Children's Medicine, School of Medical Sciences, University of New South Wales , Sydney, Australia .,4 Kids Cancer Centre, Sydney Children's Hospital , Sydney, Australia .,6 Nelune Comprehensive Cancer Centre, Prince of Wales Hospital , Randwick, Australia
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13
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Rodgers SK, Chang C, DeBardeleben JT, Horrow MM. Normal and Abnormal US Findings in Early First-Trimester Pregnancy: Review of the Society of Radiologists in Ultrasound 2012 Consensus Panel Recommendations. Radiographics 2016; 35:2135-48. [PMID: 26562242 DOI: 10.1148/rg.2015150092] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Since being introduced more than 30 years ago, endovaginal ultrasonography (US) and quantitative testing of serum levels of the beta subunit of human chorionic gonadotropin have become the standard means of establishing the presence of normal intrauterine pregnancy (IUP), failed IUP, and ectopic pregnancy. Appropriate use of these powerful tools requires clear, standardized interpretations based on conservative criteria to protect both the pregnancy and the mother. Since diagnoses are assigned earlier and available medical treatments for ectopic pregnancy and failed IUP are expanding, emphasis must carefully shift toward watchful waiting when the mother is clinically stable and a definitive location for the pregnancy cannot be established with US. To this end and to prevent inadvertent harm to early normal pregnancies, the Society of Radiologists in Ultrasound convened a consensus panel of radiologists, obstetricians, and emergency medicine physicians in 2012 with the goal of reviewing current literature and clinical practices and formulating modern criteria and terminology for the various first-trimester outcomes.
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Affiliation(s)
- Shuchi K Rodgers
- From the Department of Radiology, Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19141
| | - Crystal Chang
- From the Department of Radiology, Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19141
| | - John T DeBardeleben
- From the Department of Radiology, Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19141
| | - Mindy M Horrow
- From the Department of Radiology, Einstein Medical Center, 5501 Old York Rd, Philadelphia, PA 19141
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14
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Lagarce L, Bernard N, Carlier P, Phelipot-Lates S, Perault-Pochat MC, Drablier G, Bourneau-Martin D, Lainé-Cessac P. Méthotrexate pour grossesse extra-utérine : quels risques en cas de nouvelle grossesse ? Therapie 2016; 71:389-94. [DOI: 10.1016/j.therap.2015.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 12/14/2015] [Indexed: 12/27/2022]
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15
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Balaouras D, Chitzios D, Daniilidis A, Tantanasis T, Mavromatidis G, Loufopoulos A, Nasioutziki M, Asimakopoulos E. Endometrial changes after methotrexate treatment: Relation with multiple nabothian cysts and future pregnancies. EUR J INFLAMM 2016. [DOI: 10.1177/1721727x16656861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A clinical study was conducted in order to validate the effect of methotrexate on 30 patients with ectopic pregnancy (EP). A typical ultrasound appearance of multiple cysts of Naboth in the cervix was observed on six cases that are studied below. Endometrial sample with endogyn was retrieved from the six cases after the treatment with methotrexate was complete. The cytological results were studied and there were many changes found in the endometrial cells, in their cores, and some inflammatory cells as well. Two out of the six cases studied show more profound evidence. The cellular appearance of the endometrium after the treatment is discussed, in relation to the presence of multiple Nabothian cysts, as a result of inflammatory reaction, and the possibility of any influence in the capacity for a future pregnancy.
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Affiliation(s)
- Dimitrios Balaouras
- 2nd University Department of Obstetrics and Gynecology, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Greece
| | - Dimitrios Chitzios
- 2nd University Department of Obstetrics and Gynecology, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Greece
| | - Angelos Daniilidis
- 2nd University Department of Obstetrics and Gynecology, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Greece
| | - Theocharis Tantanasis
- 2nd University Department of Obstetrics and Gynecology, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Greece
| | - Georgios Mavromatidis
- 3rd University Department of Obstetrics and Gynecology, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Greece
| | - Aristotelis Loufopoulos
- 2nd University Department of Obstetrics and Gynecology, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Greece
| | - Maria Nasioutziki
- Department of Cytology, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Greece
| | - Efstratios Asimakopoulos
- 2nd University Department of Obstetrics and Gynecology, Hippokrateio General Hospital, Aristotle University of Thessaloniki, Greece
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Gerosa M, Schioppo T, Meroni PL. Challenges and treatment options for rheumatoid arthritis during pregnancy. Expert Opin Pharmacother 2016; 17:1539-47. [DOI: 10.1080/14656566.2016.1197204] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Framarino-dei-Malatesta M, Perrone G, Giancotti A, Ventriglia F, Derme M, Iannini I, Tibaldi V, Galoppi P, Sammartino P, Cascialli G, Brunelli R. Epirubicin: a new entry in the list of fetal cardiotoxic drugs? Intrauterine death of one fetus in a twin pregnancy. Case report and review of literature. BMC Cancer 2015; 15:951. [PMID: 26673573 PMCID: PMC4682214 DOI: 10.1186/s12885-015-1976-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 12/05/2015] [Indexed: 12/28/2022] Open
Abstract
Background Current knowledge indicate that epirubicin administration in late pregnancy is almost devoid of any fetal cardiotoxicity. We report a twin pregnancy complicated by breast cancer in which epirubicin administration was causatively linked to the death of one twin who was small for gestational age (SGA) and in a condition of oligohydramnios and determined the onset of a transient cardiotoxicity of the surviving fetus/newborn. Case presentation A 38-year-old caucasic woman with a dichorionic twin pregnancy was referred to our center at 20 and 1/7 weeks for a suspected breast cancer, later confirmed by the histopathology report. At 31 and 3/7 weeks, after the second chemotherapy cycle, ultrasound examination evidenced the demise of one twin while cardiac examination revealed a monophasic diastolic ventricular filling, i.e. a diastolic dysfunction of the surviving fetus who was delivered the following day due to the occurrence of grade II placental abruption. The role of epirubicin cardiotoxicity in the death of the first twin was supported by post-mortem cardiac and placental examination and by the absence of structural or genomic abnormalities that may indicate an alternative etiology of fetal demise. The occurrence of epirubicin cardiotoxicity in the surviving newborn was confirmed by the report of high levels of troponin and transient left ventricular septal hypokinesia. Conclusion Based on our findings we suggest that epirubicin administration in pregnancy should be preceded by the screening of some fetal conditions like SGA and oligohydramnios that may increase its cardiotoxicity and that, during treatment, the diastolic function of the fetal right ventricle should be specifically monitored by a pediatric cardiologist; also, epirubicin and desamethasone for lung maturation should not be closely administered since placental effects of glucocorticoids may increase epirubicin toxicity.
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Affiliation(s)
| | - Giuseppina Perrone
- Department of Gynecologic Obstetrics and Urology Sciences, University of Rome "Sapienza", Rome, Italy.
| | - Antonella Giancotti
- Department of Gynecologic Obstetrics and Urology Sciences, University of Rome "Sapienza", Rome, Italy.
| | - Flavia Ventriglia
- Department of Pediatrics, University of Rome "Sapienza", Rome, Italy.
| | - Martina Derme
- Department of Gynecologic Obstetrics and Urology Sciences, University of Rome "Sapienza", Rome, Italy.
| | - Isabella Iannini
- Department of Gynecologic Obstetrics and Urology Sciences, University of Rome "Sapienza", Rome, Italy.
| | - Valentina Tibaldi
- Department of Gynecologic Obstetrics and Urology Sciences, University of Rome "Sapienza", Rome, Italy.
| | - Paola Galoppi
- Department of Gynecologic Obstetrics and Urology Sciences, University of Rome "Sapienza", Rome, Italy.
| | - Paolo Sammartino
- Department of Surgery "Pietro Valdoni", University of Rome "Sapienza", Rome, Italy.
| | - Gianluca Cascialli
- Department of Gynecologic Obstetrics and Urology Sciences, University of Rome "Sapienza", Rome, Italy.
| | - Roberto Brunelli
- Department of Gynecologic Obstetrics and Urology Sciences, University of Rome "Sapienza", Rome, Italy.
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Leroy C, Rigot JM, Leroy M, Decanter C, Le Mapihan K, Parent AS, Le Guillou AC, Yakoub-Agha I, Dharancy S, Noel C, Vantyghem MC. Immunosuppressive drugs and fertility. Orphanet J Rare Dis 2015; 10:136. [PMID: 26490561 PMCID: PMC4618138 DOI: 10.1186/s13023-015-0332-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 08/30/2015] [Indexed: 12/16/2022] Open
Abstract
Immunosuppressive drugs are used in the treatment of inflammatory and autoimmune diseases, as well as in transplantation. Frequently prescribed in young people, these treatments may have deleterious effects on fertility, pregnancy outcomes and the unborn child. This review aims to summarize the main gonadal side effects of immunosuppressants, to detail the effects on fertility and pregnancy of each class of drug, and to provide recommendations on the management of patients who are seen prior to starting or who are already receiving immunosuppressive treatment, allowing them in due course to bear children. The recommendations for use are established with a rather low level of proof, which needs to be taken into account in the patient management. Methotrexate, mycophenolate, and le- and teri-flunomide, cyclophosphamide, mitoxanthrone are contraindicated if pregnancy is desired due to their teratogenic effects, as well as gonadotoxic effects in the case of cyclophosphamide. Anti-TNF-alpha and mTOR-inhibitors are to be used cautiously if pregnancy is desired, since experience using these drugs is still relatively scarce. Azathioprine, glucocorticoids, mesalazine, anticalcineurins such as cyclosporine and tacrolimus, ß-interferon, glatiramer-acetate and chloroquine can be used during pregnancy, bearing in mind however that side effects may still occur. Experience is limited concerning natalizumab, fingolimod, dimethyl-fumarate and induction treatments. Conclusion: At the time of prescription, patients must be informed of the possible consequences of immunosuppressants on fertility and of the need for contraception. Pregnancy must be planned and the treatment modified if necessary in a pre-conception time period adapted to the half-life of the drug, imperatively in relation with the prescriber of the immunosuppressive drugs.
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Affiliation(s)
- Clara Leroy
- Endocrinology and Metabolism, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
- Andrology, Hôpital Calmette, Lille University Hospital, 59037, Lille Cedex, France.
| | - Jean-Marc Rigot
- Andrology, Hôpital Calmette, Lille University Hospital, 59037, Lille Cedex, France.
| | - Maryse Leroy
- Gynaecology -Obstetrics, Hôpital Jeanne de Flandres, Lille University Hospital, 59037, Lille Cedex, France.
| | - Christine Decanter
- Endocrine Gynaecology, Hôpital Jeanne de Flandres, Lille University Hospital, 59037, Lille Cedex, France.
| | - Kristell Le Mapihan
- Endocrinology and Metabolism, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Anne-Sophie Parent
- Endocrinology and Metabolism, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Anne-Claire Le Guillou
- Endocrinology and Metabolism, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Ibrahim Yakoub-Agha
- Hematology, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Sébastien Dharancy
- Liver Diseases and Gastroenterology, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Christian Noel
- Nephrology Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
| | - Marie-Christine Vantyghem
- Endocrinology and Metabolism, Hôpital Huriez, Lille University Hospital, 59037, Lille Cedex, France.
- InsermU859 Biotherapies of Diabetes, Lille University Hospital, 59037, Lille Cedex, France.
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Lagarce L, Zenut M, Lainé-Cessac P. Pharmacologie du méthotrexate. ACTA ACUST UNITED AC 2015; 44:203-11. [DOI: 10.1016/j.jgyn.2014.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 12/02/2014] [Indexed: 12/27/2022]
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Yiu ZZN, Warren RB, Mrowietz U, Griffiths CEM. Safety of conventional systemic therapies for psoriasis on reproductive potential and outcomes. J DERMATOL TREAT 2015; 26:329-34. [PMID: 25424052 DOI: 10.3109/09546634.2014.991673] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The effects of conventional systemic therapies for psoriasis on pregnancy outcomes, lactation, male fertility and mutagenicity are common concerns in the clinical setting. There is relatively little evidence to guide clinician and patient. In this study, we review the safety profile of the commonly used conventional systemic therapies used for psoriasis in individuals of reproductive potential. Safety data are derived from large-scale registries, adverse-event reporting databases, clinical trials and case reports. We assess the effect of each therapy on adverse pregnancy outcomes, including congenital malformations, and lactation with maternal administration. We also assess the effect of the therapies on male fertility and potential mutagenicity with paternal administration. We provide applicable guidance to inform clinician and patient before and after conception.
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Affiliation(s)
- Zenas Z N Yiu
- The Dermatology Centre, Salford Royal NHS Foundation Trust, University of Manchester, Manchester Academic Health Science Centre , Manchester , UK and
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22
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Sholapurkar SL. Methotrexate for ectopic pregnancy: success rates and avoidance of embryopathy. Am J Obstet Gynecol 2015; 212:121-2. [PMID: 25284691 DOI: 10.1016/j.ajog.2014.09.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
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23
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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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Gerosa M, Meroni PL, Cimaz R. Safety considerations when prescribing immunosuppression medication to pregnant women. Expert Opin Drug Saf 2014; 13:1591-9. [DOI: 10.1517/14740338.2014.951326] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
In utero exposure to certain drugs early in pregnancy may adversely affect nephrogenesis. Exposure to drugs later in pregnancy may affect the renin-angiotensin system, which could have an impact on fetal or neonatal renal function. Reduction in nephron number and renal function could have adverse consequences for the child several years later. Data are limited on the information needed to guide decisions for patients and providers regarding the use of certain drugs in pregnancy. The study of drug nephroteratogenicity has not been systematized, a large, standardized, global approach is needed to evaluate the renal risks of in utero drug exposures.
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Weber-Schoendorfer C, Chambers C, Wacker E, Beghin D, Bernard N, Shechtman S, Johnson D, Cuppers-Maarschalkerweerd B, Pistelli A, Clementi M, Winterfeld U, Eleftheriou G, Pupco A, Kao K, Malm H, Elefant E, Koren G, Vial T, Ornoy A, Meister R, Schaefer C. Pregnancy Outcome After Methotrexate Treatment for Rheumatic Disease Prior to or During Early Pregnancy: A Prospective Multicenter Cohort Study. Arthritis Rheumatol 2014; 66:1101-10. [DOI: 10.1002/art.38368] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 01/14/2014] [Indexed: 12/27/2022]
Affiliation(s)
- Corinna Weber-Schoendorfer
- Charité-Universitätsmedizin Berlin and Pharmakovigilanz und Beratungszentrum Embryonaltoxikologie; Berlin Germany
| | | | - Evelin Wacker
- Charité-Universitätsmedizin Berlin and Pharmakovigilanz und Beratungszentrum Embryonaltoxikologie; Berlin Germany
| | - Delphine Beghin
- Centre de Référence sur les Agents Tératogènes, Hôpital Universitaires Paris Est, AP-HP; Paris France
| | - Nathalie Bernard
- Hospices Civils de Lyon and Centre Régional de Pharmacovigilance; Lyon France
| | - Svetlana Shechtman
- Israel Ministry of Health and Israeli Teratology Information Service; Jerusalem Israel
| | - Diana Johnson
- University of California at San Diego; La Jolla California
| | | | - Alessandra Pistelli
- Azienda Ospedaliero Universitaria Careggi and Centro di Riferimento Regionale di Tossicologia Perinatale; Florence Italy
| | - Maurizio Clementi
- University of Padua and Servizio di Informazione Teratologica; Padua Italy
| | - Ursula Winterfeld
- University Hospital, Lausanne and Swiss Teratogen Information Service; Lausanne Switzerland
| | - Georgios Eleftheriou
- Ospedali Riuniti and Poison Control Center and Teratology Information Service; Bergamo Italy
| | - Anna Pupco
- Hospital for Sick Children; Toronto, Ontario Canada
| | - Kelly Kao
- University of California at San Diego; La Jolla California
| | - Heli Malm
- HUSLAB and Helsinki University Central Hospital, Teratology Information; Helsinki Finland
| | - Elisabeth Elefant
- Centre de Référence sur les Agents Tératogènes, Hôpital Universitaires Paris Est, AP-HP; Paris France
| | - Gideon Koren
- Hospital for Sick Children; Toronto, Ontario Canada
| | - Thierry Vial
- Hospices Civils de Lyon and Centre Régional de Pharmacovigilance; Lyon France
| | - Asher Ornoy
- Israel Ministry of Health and Israeli Teratology Information Service; Jerusalem Israel
| | | | - Christof Schaefer
- Charité-Universitätsmedizin Berlin and Pharmakovigilanz und Beratungszentrum Embryonaltoxikologie; Berlin Germany
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Knez J, Day A, Jurkovic D. Ultrasound imaging in the management of bleeding and pain in early pregnancy. Best Pract Res Clin Obstet Gynaecol 2014; 28:621-36. [PMID: 24841987 DOI: 10.1016/j.bpobgyn.2014.04.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Revised: 03/16/2014] [Accepted: 04/10/2014] [Indexed: 12/27/2022]
Abstract
Bleeding and pain are experienced by 20% of women during the first trimester of pregnancy. Although most pregnancies complicated by pain and bleeding tend to progress normally, these symptoms are distressing for woman, and they are also associated with an increased risk of miscarriage and ectopic pregnancy. Ultrasound is the first and often the only diagnostic modality that is used to determine location of early pregnancy and to assess its health. Ultrasound is an accurate, safe, painless and relatively inexpensive diagnostic tool, which all contributed to its widespread use in early pregnancy. Pain and bleeding in early pregnancy are sometimes caused by concomitant gynaecological, gastrointestinal, and urological problems, which could also be detected on ultrasound scan. In women with suspected intra-abdominal bleeding, ultrasound scan can be used to detect the presence of blood and provide information about the extent of bleeding. In this chapter, we comprehensively review the use of ultrasound in the diagnosis and management of early pregnancy complications. We include information about the diagnosis of gynaecological and other pelvic abnormalities, which could cause pain or bleeding in pregnancy. We also provide a summary of the current views on the safety of ultrasound in early pregnancy.
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Affiliation(s)
- Jure Knez
- Gynaecology Diagnostic and Outpatient Treatment Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Road, London NW1 2BU, UK
| | - Andrea Day
- Gynaecology Diagnostic and Outpatient Treatment Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Road, London NW1 2BU, UK
| | - Davor Jurkovic
- Gynaecology Diagnostic and Outpatient Treatment Unit, Elizabeth Garrett Anderson Wing, University College Hospital, 235 Euston Road, London NW1 2BU, UK.
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Martín MC, Barbero P, Groisman B, Aguirre MÁ, Koren G. Methotrexate embryopathy after exposure to low weekly doses in early pregnancy. Reprod Toxicol 2014; 43:26-9. [DOI: 10.1016/j.reprotox.2013.10.005] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/07/2013] [Accepted: 10/18/2013] [Indexed: 12/27/2022]
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Kirk E, Bottomley C, Bourne T. Diagnosing ectopic pregnancy and current concepts in the management of pregnancy of unknown location. Hum Reprod Update 2013; 20:250-61. [DOI: 10.1093/humupd/dmt047] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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Doubilet PM, Benson CB. Double sac sign and intradecidual sign in early pregnancy: interobserver reliability and frequency of occurrence. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:1207-1214. [PMID: 23804343 DOI: 10.7863/ultra.32.7.1207] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVES To assess the interobserver agreement, frequency of occurrence, and prognostic importance of the double sac sign (DSS), intradecidual sign (IDS), and other sonographic findings in early intrauterine pregnancies. METHODS We retrospectively identified all sonograms obtained between January 1, 2006, and December 31, 2011, in which: (1) the scan demonstrated an intrauterine fluid collection without a yolk sac or embryo; (2) a follow-up scan confirmed an intrauterine pregnancy; and (3) the first-trimester outcome was known. Each coinvestigator characterized the 199 study sonograms as demonstrating or not demonstrating a DSS or an IDS, based on judgment about whether the scan met published criteria defining these signs. RESULTS Interobserver agreement was poor for the DSS (κ= 0.24) and IDS (κ= 0.23). Scans frequently demonstrated neither sign: 150 cases (75.4%) if we considered a sign to be present when both investigators graded it as present and 69 cases (34.7%) using the looser criterion that either graded it as present. The presence of a DSS or an IDS was unrelated to the β-human chorionic gonadotropin (β-hCG) value (P > .05, t test, all comparisons). An inner echogenic ring was present in 158 cases (79.4%), and the decidua was brighter peripherally than centrally in 102 (51.3%). The first-trimester outcome was unrelated to the presence of a DSS or an IDS, presence of an inner echogenic ring, or decidual appearance (P > .05, χ(2), all comparisons). CONCLUSIONS The sonographic appearance of early gestational sacs, before visualization of a yolk sac or embryo, is highly variable. The DSS and IDS are often absent; there is poor interobserver agreement regarding these signs; and the prognosis is unrelated to their presence or absence. A round or oval intrauterine fluid collection in a woman with positive β-hCG should be treated as a gestational sac until proven otherwise, regardless of whether it demonstrates a DSS or an IDS.
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Affiliation(s)
- Peter M Doubilet
- Department of Radiology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
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Benson CB, Doubilet PM, Peters HE, Frates MC. Intrauterine fluid with ectopic pregnancy: a reappraisal. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2013; 32:389-393. [PMID: 23443178 DOI: 10.7863/jum.2013.32.3.389] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To determine the incidence of intrauterine fluid in patients with ectopic pregnancy and to define the characteristics that distinguish this fluid from an early intrauterine gestational sac. METHODS We identified all patients scanned transvaginally at our institution from July 2008 through August 2011 for suspected ectopic pregnancy, who proved to have ectopic pregnancy based on pathologic, surgical, or adnexal sonographic findings. We reviewed the sonograms to characterize any fluid in the uterus as to shape, contents, and location. Fluid was classified as type A if it was pointy edged, contained echoes, and/or was clearly located within the uterine cavity or type B if it was smooth walled and anechoic and location was in the decidua or uncertain. The appearance of type A fluid is inconsistent with a gestational sac, while the appearance of type B overlaps that of a gestational sac. RESULTS Our study population included 229 women with ectopic pregnancy. In 38 (16.6%), sonography showed fluid in the uterus, which was classified as type A in 31 and type B in 7. Only 2 patients (0.9%) had type B fluid with no adnexal findings suggestive of ectopic pregnancy. Based on these results and the published incidence of ectopic pregnancy (2% of all pregnancies), we calculated that a patient with a positive pregnancy test, an intrauterine smooth-walled anechoic cystic structure, and no adnexal mass has a 0.02% probability of ectopic pregnancy, while the probability of intrauterine pregnancy in such a patient is 99.98%. CONCLUSIONS Fluid can be seen in the uterus in 16.6% of patients with ectopic pregnancy. On transvaginal sonography, it can be distinguished from an early intrauterine gestational sac based on shape, contents, and/or location in most cases. In the remaining cases, the fluid appears indistinguishable from, and is highly likely to represent, an early intrauterine gestation.
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Affiliation(s)
- Carol B Benson
- Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Rubal L, Chung K. Do you need to definitively diagnose the location of a pregnancy of unknown location? The case for "yes". Fertil Steril 2013; 98:1078-84. [PMID: 23084009 DOI: 10.1016/j.fertnstert.2012.09.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 09/17/2012] [Accepted: 09/20/2012] [Indexed: 12/27/2022]
Abstract
Pregnancy of unknown location (PUL) is a common diagnostic challenge. The primary diagnostic goal is to ensure that the PUL is nonviable prior to proceeding with any invasive procedures. In nonviable PUL, there are several diagnostic and treatment strategies, which are generally quite safe. However, the management option that provides the most definite diagnosis is uterine curettage. We advocate use of uterine curettage in all cases of nonviable PUL because it limits exposure to a chemotherapeutic agent to only those who need it and it allows for the most accurate information for counseling the patient on prognosis of future pregnancies.
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Affiliation(s)
- Lauren Rubal
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Southern California Keck School of Medicine, Los Angeles, California, USA
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Barnhart KT. Early pregnancy failure: beware of the pitfalls of modern management. Fertil Steril 2012; 98:1061-5. [PMID: 23084007 PMCID: PMC3479658 DOI: 10.1016/j.fertnstert.2012.09.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 09/17/2012] [Indexed: 12/27/2022]
Abstract
The evolution of the diagnosis and management of women with an early pregnancy loss has been a success story. The mortality from ectopic pregnancy has objectively been decreased in the past few decades. However, modern management has resulted in a new set of issues. Over-interpretation of a single ultrasound, misunderstanding of the utility of serial hCG values, and inappropriate use of methotrexate can result in iatrogenic complications. Modern management has successfully improved the diagnosis of ectopic pregnancy before rupture; it should now also focus on ensuring that an intrauterine pregnancy is not interrupted as a result of diagnosis and treatment. This article reviews some of the pitfalls of the modern management of early pregnancy failure and introduces a series of articles on the subject.
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MESH Headings
- Abortifacient Agents, Nonsteroidal/adverse effects
- Abortion, Spontaneous/blood
- Abortion, Spontaneous/diagnosis
- Abortion, Spontaneous/diagnostic imaging
- Abortion, Spontaneous/mortality
- Abortion, Spontaneous/therapy
- Abortion, Therapeutic/adverse effects
- Abortion, Therapeutic/methods
- Biomarkers/blood
- Chorionic Gonadotropin/blood
- Diagnosis, Differential
- Diagnostic Errors
- Early Diagnosis
- Female
- Humans
- Methotrexate/adverse effects
- Predictive Value of Tests
- Pregnancy
- Pregnancy Outcome
- Pregnancy, Ectopic/blood
- Pregnancy, Ectopic/diagnosis
- Pregnancy, Ectopic/diagnostic imaging
- Pregnancy, Ectopic/mortality
- Pregnancy, Ectopic/therapy
- Prenatal Diagnosis/methods
- Risk Assessment
- Risk Factors
- Treatment Outcome
- Ultrasonography, Prenatal
- Unnecessary Procedures
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Affiliation(s)
- Kurt T Barnhart
- Departments of Obstetrics and Gynecology and Epidemiology, Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Borisow N, Döring A, Pfueller CF, Paul F, Dörr J, Hellwig K. Expert recommendations to personalization of medical approaches in treatment of multiple sclerosis: an overview of family planning and pregnancy. EPMA J 2012; 3:9. [PMID: 22738272 PMCID: PMC3464716 DOI: 10.1186/1878-5085-3-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 06/22/2012] [Indexed: 12/18/2022]
Abstract
Multiple sclerosis is the most common chronic autoimmune disease of the central nervous system which preferentially affects females at childbearing age. For this reason, patients and treating physicians were frequently confronted with questions concerning family planning, pregnancy and birth. Preventive and personalized treatment approaches are considered, because topics as heredity, risk of congenital malformations, influence of pregnancy on MS and aspects of drug therapy during the period of conception, pregnancy, puerperium and lactation have to be discussed. Here, we provide an overview about the current state of knowledge regarding these issues.
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Affiliation(s)
- Nadja Borisow
- NeuroCure Clinical Research Center and Clinical and Experimental Research Center for Multiple Sclerosis, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany.
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Hyoun SC, Običan SG, Scialli AR. Teratogen update: methotrexate. ACTA ACUST UNITED AC 2012; 94:187-207. [PMID: 22434686 DOI: 10.1002/bdra.23003] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 01/09/2012] [Accepted: 01/13/2012] [Indexed: 12/12/2022]
Abstract
Methotrexate and aminopterin are folic acid antagonists that inhibit dihydrofolate reductase, resulting in a block in the synthesis of thymidine and inhibition of DNA synthesis. Methotrexate has been used for the treatment of malignancy, rheumatic disorders, and psoriasis and termination of intrauterine pregnancy. Recently, methotrexate has become a standard treatment for ectopic pregnancy. The misdiagnosis of an intrauterine pregnancy as an ectopic pregnancy can result in exposure of a continuing pregnancy to dose levels of methotrexate of 50 mg/m(2) (maternal body surface area). Experimental animal studies have associated methotrexate therapy with embryo death in mice, rats, rabbits, and monkeys. Structural malformations have been most consistently produced in rabbits at a maternal dose level of 19.2 mg/kg. Abnormalities in rabbits include hydrocephalus, microphthalmia, cleft lip and palate, micrognathia, dysplastic sacral and caudal vertebrate, phocomelia, hemimelia, syndactyly, and ectrodactyly. Based on human case reports of methotrexate exposure during pregnancy, a methotrexate embryopathy has been described that includes growth deficiency, microcephaly, hypoplasia of skull bones, wide fontanels, coronal or lambdoidal craniosynostosis, upswept frontal scalp hair, broad nasal bridge, shallow supraorbital ridges, prominent eyes, low-set ears, maxillary hypoplasia, epicanthal folds, short limbs, talipes, hypodactyly, and syndactyly. This syndrome may be associated with exposures between 6 and 8 weeks after conception and dose levels of 10 mg/week or greater. More recent case reports of methotrexate exposure for the misdiagnosis of ectopic pregnancy involve treatment before 6 weeks after conception and have raised the suggestion of a distinct syndrome due to such early exposures. Tetralogy of Fallot and perhaps other neural crest cell-related abnormalities may be features of this early syndrome. A disproportionality analysis of methotrexate and aminopterin case reports and series provides support for pulmonary atresia, craniosynostosis, and limb deficiencies as reported more often than expected in methotrexate-exposed children. Denominator-based data will be welcome to better define elements of a methotrexate embryopathy and possibly to distinguish an early exposure syndrome from anomalies traditionally associated with methotrexate exposure.
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Affiliation(s)
- Sara C Hyoun
- George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
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Raio C, Ash A, Nelson M, Bramante R, Moore C. Outcome following high-dose methotrexate in pregnancies misdiagnosed as ectopic. Am J Obstet Gynecol 2012; 206:e12-3; author reply e13. [PMID: 22182683 DOI: 10.1016/j.ajog.2011.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Accepted: 11/18/2011] [Indexed: 11/16/2022]
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