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Zabad K, Tarakji M, Arafat R, Al-Douni Y, Nakhleh M, Kurdi B. Unruptured tubal ectopic pregnancy concurrent with trophoblastic tissue spread to the rectum: a case report. Ann Med Surg (Lond) 2024; 86:4161-4164. [PMID: 38989230 PMCID: PMC11230750 DOI: 10.1097/ms9.0000000000002141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/24/2024] [Indexed: 07/12/2024] Open
Abstract
Introduction and importance Ectopic pregnancy is a term used to describe pregnancies outside of the uterus. If ruptured, persistent trophoblastic tissue can be present at the site of an ectopic pregnancy, which is an unusual complication. In rare cases, the patients may present with primary implants. Case presentation A 23-year-old woman who was pregnant for the first time complained of abdominal pain and was diagnosed with a 10-week tubal ectopic pregnancy. During laparotomy, trophoblastic implants were discovered in the rectum; however, the pregnancy did not rupture. Clinical discussion The presented case report highlights a rare and late diagnosis of ectopic pregnancy in a 23-year-old primigravida woman with no known risk factors. The patient experienced sudden abdominal pain in the tenth week of gestation, leading to the surgical approach of salpingectomy. Notably, trophoblastic tissue was found in the rectum, indicating local invasion. It was then treated with methotrexate therapy. However, the low-resource setting in Syria limited the use of laparoscopy and resulted in the use of laparotomy. Conclusion This case emphasizes the importance of considering trophoblastic implantation in the management plan for ectopic pregnancies, even in cases in which the pregnancy has not ruptured. It is crucial to evaluate all possible complications of this disease to ensure proper treatment and care of the patient.
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Affiliation(s)
| | | | | | | | | | - Bashar Kurdi
- Faculty of Medicine, Damascus University
- University Hospital of Obstetrics and Gynecology
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Hamid AAA, Yousry A, El Radi SA, Shabaan OM, Mazen E, Nabil H. Clinical audit of ectopic pregnancy. Electron Physician 2017; 9:4009-4013. [PMID: 28461878 PMCID: PMC5407236 DOI: 10.19082/4009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 10/27/2016] [Indexed: 11/20/2022] Open
Abstract
Objective The aim of this study was to determine the risk factors of ectopic pregnancy in cases presented to the Woman’s Health Hospital (WHH) in Assuit University, and to perform clinical audit on strategies for management of ectopic pregnancy in the WHH. Methods This descriptive hospital based study was conducted at the Woman’s Health Hospital (WHH) of Assuit University (Egypt). There were 210 patients who were admitted to the WHH with the diagnosis of ectopic pregnancy in the period between February 1, 2015 through the end of October 2015. Data were analyzed by SPSS version 21, using descriptive statistics, Mann-Whitney U test, and Chi square. Results Ectopic pregnancy affects woman in the reproductive age. There are many risk factors that increase the chance of its occurrence; however, it may also occur in the absence of any risk factors (14.0%). Internal VD (72.5%) is the most frequent risk factor; other risk factors include history of abortion, previous CS, ovulation induction, history of infertility, or previous history of EP. Conclusion Clinical audit is an important item of any adequate health care. As regards to the clinical audit of EP management, we are not adhering to the guidelines.
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Affiliation(s)
| | - Almraghy Yousry
- Assistant Professor of Obstetrics and Gynecology, Faculty of Medicine, Assuit Al-Azhar University, Egypt
| | - Safwat Abd El Radi
- Professor of Obstetrics & Gynecology Faculty of Medicine, Assuit University, Egypt
| | - Omar Mamdouh Shabaan
- Professor of Obstetrics & Gynecology Faculty of Medicine, Assuit University, Egypt
| | - Elzahry Mazen
- Assistant Professor of Obstetrics and Gynecology, Faculty of Medicine, Assuit Al-Azhar University, Egypt
| | - Halal Nabil
- Lecturer of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Egypt
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Kutuk MS, Subasioglu A, Uludag S, Tascioglu N, Ozgun MT, Dundar M. The effect of parental 5,10-methylenetetrahydrofolate reductase 677C/T and 1298A/C gene polymorphisms on response to single-dose methotrexate in tubal ectopic pregnancy. J Matern Fetal Neonatal Med 2016; 30:1232-1237. [PMID: 27379466 DOI: 10.1080/14767058.2016.1209652] [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: 10/21/2022]
Abstract
OBJECT The aim of this study was to assess the effect of parental 5,10-methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms (677C/T and 1298A/C) on response to single-dose methotrexate (MTX) treatment in tubal ectopic pregnancy (TEP). MATERIALS AND METHODS In this prospective cohort study, cases with unruptured TEPs were grouped into two according to their response to single-dose MTX treatment (Group 1: responsive, n:88; Group 2: unresponsive, n:21). The groups were compared with regard to baseline demographic and clinical parameters. As a main outcome measure, the independent effects of parental MTHFR gene polymorphisms on response to single dose MTX treatment were evaluated. RESULTS One hundred and nine unruptured TEP were included in the final analysis. The mean maternal age was 29.30 ± 5.21 years, gravity 2 (min-max: 1-5), parity 1 (min-max: 0-4). The median serum beta-human chorionic gonadotropin (β-hCG) was 1403.35 MI/I (Q1-Q3: 517-2564). The overall response rate was 81% (88/109). The groups were similar with respect to basic baseline demographic data and serum β-hCG level. Binary logistic regression analysis showed that the presence of parental MTHFR677C/T and 1298A/C polymorphism were not independent factor predicting treatment success (p > 0.05). The only independent factor for resistance to single dose MTX was the previous TEP (OR: 4.47 (1.18-16.9)). CONCLUSION Parental MTHFR 677C/T and 1298A/C mutations do not predict the outcome of single dose intramuscular MTX treatment in unruptured TEP.
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Affiliation(s)
- Mehmet Serdar Kutuk
- a Department of Obstetrics and Gynecology , Erciyes University , Kayseri , Turkey and
| | - Asli Subasioglu
- b Department of Medical Genetics , Faculty of Medicine, Erciyes University , Kayseri , Turkey
| | - Semih Uludag
- a Department of Obstetrics and Gynecology , Erciyes University , Kayseri , Turkey and
| | - Nazife Tascioglu
- b Department of Medical Genetics , Faculty of Medicine, Erciyes University , Kayseri , Turkey
| | - Mahmut Tuncay Ozgun
- a Department of Obstetrics and Gynecology , Erciyes University , Kayseri , Turkey and
| | - Munis Dundar
- b Department of Medical Genetics , Faculty of Medicine, Erciyes University , Kayseri , Turkey
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Demirdag E, Guler I, Abay S, Oguz Y, Erdem M, Erdem A. The impact of expectant management, systemic methotrexate and surgery on subsequent pregnancy outcomes in tubal ectopic pregnancy. Ir J Med Sci 2016; 186:387-392. [PMID: 26895299 DOI: 10.1007/s11845-016-1419-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The most common treatment modalities of ectopic pregnancy may influence long-term subsequent fertility outcomes in women who previously treated for ectopic pregnancy. AIMS Our objective was to compare long-term subsequent fertility outcomes after treatment with expectant management, systemic methotrexate (MTX) and surgery in tubal ectopic pregnancy. METHODS We searched our database for all women diagnosed with tubal ectopic pregnancy between January 2007 and January 2011 who were managed expectantly, with systemic MTX and with surgery. Treatment success and spontaneous pregnancy rates were compared in patients who desire to conceive following a tubal pregnancy. RESULTS One hundred twelve of 151 women desired to conceive following tubal ectopic pregnancy. Twenty-seven of 112 (24.1 %) patients were managed expectantly. Fifty-three (47.3 %) and 32 (28.5 %) patients were managed with systemic MTX or surgery, respectively. All patients in expectant and surgery groups were managed successfully. Two (3.7 %) patients had surgery after failed treatment with systemic MTX. Spontaneous intrauterine pregnancy rates were 62.9 % in expectantly managed women, 58.4 % in women with systemic MTX and 68.7 % in women with surgery (p > 0.05). CONCLUSIONS Treatment of ectopic pregnancy with either expectant management or systemic MTX is equally effective as compared to surgery. Spontaneous intrauterine pregnancy rates were comparable in expectant management, systemic methotrexate and surgery.
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Affiliation(s)
- E Demirdag
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - I Guler
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey.
| | - S Abay
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - Y Oguz
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - M Erdem
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - A Erdem
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
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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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Abstract
PURPOSE Ectopic pregnancy (EP) presents a major health problem for women of child-bearing age. EP refers to the pregnancy occurring outside the uterine cavity that constitutes 1.2-1.4 % of all reported pregnancies. All identified risk factors are maternal: pelvic inflammatory disease, Chlamydia trachomatis infection, smoking, tubal surgery, induced conception cycle, and endometriosis. These developments have provided the atmosphere for trials using methotrexate as a non-surgical treatment for EP. The diagnosis measure of EP is serum human chorionic gonadotropin, urinary hCGRP/i-hCG, progesterone measurement, transvaginal ultrasound scan, computed tomography, vascular endothelial growth factor, CK, disintegrin and metalloprotease-12 and hysterosalpingography. The treatment option of EP involves surgical treatment by laparotomy or laparoscopy, medical treatment is usually systemic or through local route, or by expectant treatment. RESULTS It was concluded that review data reflect a decrease in surgical treatment and not an actual decline in EP occurrence so that further new avenues are needed to explore early detection of the EP.
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Ustunyurt E, Duran M, Coskun E, Ustunyurt ÖB, Simşek H. Role of initial and day 4 human chorionic gonadotropin levels in predicting the outcome of single-dose methotrexate treatment in women with tubal ectopic pregnancy. Arch Gynecol Obstet 2013; 288:1149-52. [PMID: 23666603 DOI: 10.1007/s00404-013-2879-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Accepted: 05/02/2013] [Indexed: 11/27/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the initial and day 4 beta-human chorionic gonadotropin (β-hCG) levels as a predictor of methotrexate (MTX) therapy success for ectopic pregnancy. METHODS Retrospective study of 87 patients with tubal ectopic pregnancy treated with a single dose of 50 mg/m(2) MTX at Bursa Şevket Yılmaz Research and Education Hospital between January 2011 and July 2012 was performed. RESULTS The overall success rate is measured as 72.4 %. The two groups of patients, successfully treated patients (n = 63) and unsuccessfully treated patients (n = 24), were compared. The mean initial β-hCG level was significantly lower in the treatment success group than in the treatment failure group (1,417 mIU/mL versus 5,995 mIU/mL, p < 0.001). The number of cases with decreasing β-hCG level on day 4 was significantly more in the success group compared to the failure group (61.9 and 37.5 %, respectively, p = 0.04). The success rate was 90 % when β-hCG levels were <1,000 mIU/mL, 85.7 % when the levels were between 1,000 and 1,999 mIU/mL, and 76.5 % when the levels were between 2,000 and 2,999 mIU/mL, 54.5 % when the levels were between 3,000 and 3,999 mIU/mL. CONCLUSION Single-dose MTX therapy is a safe and effective treatment modality for tubal ectopic pregnancies with the β-hCG serum concentration below 3,000 mIU/mL, and β-hCG level changes between days 0 and 4 after MTX therapy are important in predicting the outcome of treatment.
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Affiliation(s)
- Emın Ustunyurt
- The Department of Obstetrics and Gynecology, Bursa Şevket Yılmaz Research and Education Hospital, Bursa, Turkey,
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Dueñas-Garcia OF, Young C, Mikhail M, Salafia C. Compliance with follow-up in an inner-city population treated with intramuscular methotrexate for suspected ectopic pregnancy. Int J Gynaecol Obstet 2012; 120:254-6. [DOI: 10.1016/j.ijgo.2012.10.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/02/2012] [Accepted: 11/27/2012] [Indexed: 11/25/2022]
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Ectopic pregnancy: when is expectant management safe? ACTA ACUST UNITED AC 2012; 9:421-426. [PMID: 23144641 PMCID: PMC3491186 DOI: 10.1007/s10397-012-0736-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 02/11/2012] [Indexed: 10/28/2022]
Abstract
This study was conducted to evaluate expectant management in asymptomatic patients with an initial serum beta-hCG titer of <2,500 IU/l and to determine the independent ability of initial serum beta-hCG titers and trend of serum beta-hCG to predict successful expectant management. A cohort of patients (N = 418) with suspected ectopic pregnancy (EP) between January 1991 and July 2008 is described. Three groups were defined: group I (n = 182), immediate surgical intervention (<24 h); group IIa (n = 130), unsuccessful expectant management (surgical intervention during follow-up), and group IIb (n = 99), successful expectant management (spontaneous regression of trophoblast). Hospital protocol was not complied in 35 cases (Table 1). Beta-hCG levels >3,000 IU/l occur in our expectant management group; however, none of these cases were successful. Unnecessary surgery was prevented in 14% (n = 7) of asymptomatic patients with initial beta-hCG of >2,000 IU/l. The success rate of expectant management was 49%, without a rise in complication rate or number of acute cases. In conclusion, the initial serum beta-hCG cutoff level of 2,000 IU/l is not a rigid upper limit for accepting expectant management in suspected EP and best practice is case specific. In asymptomatic patients, the serum beta-hCG cutoff level of at least 2,500 IU/l can be used for expectant management. This cutoff could be higher, but interpretation is limited due to censure in follow-up inherent to the predefined clinical protocol. There is no gain in including patients for expectant management with initial serum beta-hCG level >3,000 IU/l.
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Skubisz MM, Tong S. The evolution of methotrexate as a treatment for ectopic pregnancy and gestational trophoblastic neoplasia: a review. ISRN OBSTETRICS AND GYNECOLOGY 2012; 2012:637094. [PMID: 22462004 PMCID: PMC3302016 DOI: 10.5402/2012/637094] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Accepted: 12/05/2011] [Indexed: 12/01/2022]
Abstract
Methotrexate was developed in 1949 as a synthetic folic acid analogue to compete with folic acid and thus interfere with cell replication. While initially developed as a potential treatment for acute lymphoblastic leukaemia, a serendipitous observation led to methotrexate's use to effect the dramatic cure of a case of advanced choriocarcinoma. This prompted the exploration for the potential of methotrexate to treat other conditions involving disordered trophoblastic tissue. Methotrexate has subsequently revolutionized the treatment of two pregnancy-related conditions—gestational trophoblastic neoplasia and ectopic pregnancy. This article reviews the development of modern treatment protocols that use methotrexate to medically treat these two important gynaecological conditions.
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Affiliation(s)
- Monika M Skubisz
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, Heidelberg, 3084 VIC, Australia
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Abstract
A little more than half a century ago, young women were frequently dying of reproductive sequelae such as ectopic pregnancies and gestational trophoblastic disease. Mortality from these conditions was as high as 90% in the case of metastatic choriocarcinoma. If lives could be saved, it was in the operating theater and often at the expense of future reproductive potential. By the 1940s, however, targeted chemotherapy was starting to be explored, and the development of methotrexate for the treatment of childhood leukemia in 1949 eventually resulted in an unexpected, but nevertheless long and happy association with the field of gynecology. Here we trace the origins of methotrexate and how it came to be an effective medical treatment for two life-threatening gynecologic conditions. It illustrates how the contributions of many clinicians and scientists from many disciplines, over the greater part of a century, come together to improve the care of a single patient today.
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12
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Comparison of double- and single-dose methotrexate protocols for treatment of ectopic pregnancy. Int J Gynaecol Obstet 2011; 116:67-71. [DOI: 10.1016/j.ijgo.2011.08.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Revised: 08/19/2011] [Accepted: 09/30/2011] [Indexed: 11/24/2022]
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Güth U, Sartorius G, Obermann EC. [Successful methotrexate therapy of tubal pregnancy]. DER PATHOLOGE 2011; 32:514-6. [PMID: 21553093 DOI: 10.1007/s00292-011-1429-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pathologists are well acquainted with the histopathologic features of a vital tubal pregnancy; however, tubal pregnancy successfully treated with medication is seen much less often, since these patients do not usually undergo surgery. We report a rare case of this type, in which no trophoblast tissue was found at histopathologic examination. Intratubal granulation tissue represented the remaining non-vital pregnancy tissue.
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Affiliation(s)
- U Güth
- Frauenklinik, Universitätsspital Basel, Basel, Schweiz
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Rabischong B, Tran X, Sleiman AA, Larraín D, Jaffeux P, Aublet-Cuvelier B, Pouly JL, Fernandez H. Predictive factors of failure in management of ectopic pregnancy with single-dose methotrexate: a general population-based analysis from the Auvergne Register, France. Fertil Steril 2011; 95:401-4, 404.e1. [DOI: 10.1016/j.fertnstert.2010.08.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 07/27/2010] [Accepted: 08/13/2010] [Indexed: 11/15/2022]
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Balci O, Ozdemir S, Mahmoud AS, Acar A, Colakoglu MC. The efficacy of multiple-dose methotrexate treatment for unruptured tubal ectopic pregnancy and conversion rate to surgery: a study on 294 cases. Fertil Steril 2010; 93:2415-7. [PMID: 20137786 DOI: 10.1016/j.fertnstert.2009.09.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 08/11/2009] [Accepted: 09/08/2009] [Indexed: 10/19/2022]
Abstract
In this prospective study 294 patients diagnosed with ectopic pregnancy (EP) were treated with multiple-dose methotrexate (MTX) to determine the conversion rate to surgery. We concluded that multiple-dose MTX treatment had a low success rate, and the success rate was not related to initial b-hCG value; it was more related to the size of gestational mass before treatment.
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Affiliation(s)
- Osman Balci
- Department of Obstetrics and Gynecology, Meram Medicine Faculty, Selcuk University, Akyokus, 42080, Konya, Turkey.
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