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Akdaş Reis Y, Akay A, Özkan M, Fıratlıgil FB, Dereli ML, Kınay T, Erkaya S. Do the change in β-hCG values between the 0th and 4th days in tubal ectopic pregnancy treatment with a single-dose methotrexate (MTX) protocol predict the need for a second dose of MTX? Arch Gynecol Obstet 2024; 309:2585-2590. [PMID: 37493778 DOI: 10.1007/s00404-023-07116-3] [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: 04/15/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023]
Abstract
AIM The single-dose methotrexate (MTX) regimen is effective and minimizes side effects but an additional second dose is needed in case of failure in an ectopic pregnancy (EP). We aimed to predict the additional MTX dose by evaluating the change in β-hCG values between day 0 and day 4 in EPs with administered single-dose MTX regimen. METHOD A total of 454 tubal EPs between 2013 and 2019 were evaluated retrospectively. Cases cured with a single dose of MTX without an additional dose were accepted as the control group, and cases under a single-dose regimen were cured by applying a second dose of MTX on the 7th day were accepted as the study group. Obstetric and demographic characteristics and the change in β-hCG values compared in both groups. RESULTS Age, body mass index (BMI), gravida, smoking, abdominal surgery, presence of IUDs, initial β-hCG levels (0th day), and EP size were similar in both groups, but the presence of previous EP history was significantly higher in the study group. The change of β-hCG from days 0 and 4 determined that a 20% increase predicts the need for a second dose of MTX with 72.4% sensitivity, and 87.8% negative predictive value (NPV). CONCLUSION The single-dose MTX protocol is successful in 83.3% of convenient cases (as the control group), but an increase of 20% in β-hCG between days 0 and 4 predicts the patients who need to be administered second-dose MTX, and thus, a double-dose MTX protocol will be achieved early.
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Affiliation(s)
- Yıldız Akdaş Reis
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey.
| | - Arife Akay
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
- Bingol maternity and children's hospital, Bingöl, Turkey
| | - Merve Özkan
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
- Ankara Etlik City Hospital, Ankara Etlik City Hospital, Ankara, Türkiye
| | - Fahri Burçin Fıratlıgil
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
- Ankara Etlik City Hospital, Ankara Etlik City Hospital, Ankara, Türkiye
| | - Murat Levent Dereli
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
- Ankara Etlik City Hospital, Ankara Etlik City Hospital, Ankara, Türkiye
| | - Tuğba Kınay
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
| | - Salim Erkaya
- Obstetrics-Gynecology Department, Etlik Zübeyde Hanım Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey
- Ankara Bilkent City Hospital, Ankara Bilkent City Hospital, Ankara, Türkiye
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Abuduxukuer R, Chen X, Ni J, Li S, Lu W. Day 4 and day 0 neutrophil-to-lymphocyte ratios as predictors of treatment failure with single-dose methotrexate for ectopic pregnancies. Int J Gynaecol Obstet 2024; 165:131-137. [PMID: 38031149 DOI: 10.1002/ijgo.15248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE To evaluate changes in the neutrophil-to-lymphocyte ratio (NLR) between day 4 and day 0 in ectopic pregnancy (EP) patients treated with single-dose methotrexate (MTX) and investigate its predictive value for treatment outcome. METHODS A total of 406 EP patients receiving single-dose MTX therapy at Shanghai First Maternity and Infant Hospital from January 10, 2013 to September 30, 2019 were studied. A multivariate model was constructed to predict treatment outcome. RESULTS Among the 406 patients, 281 were treated successfully. Treatment success declined significantly when NLR decreased by less than 23% (74.8% vs 58.5%, P = 0.004). Multivariate regression analysis identified NLR reduction of less than 23% on day 4 (odds ratio [OR] 2.09, 95% confidence interval [CI] 1.27-3.44), a human chorionic gonadotropin (hCG) decrease of 15% or less (OR 3.17, 95% CI 1.62-6.34), and an hCG increase of more than 15% on day 4 (OR 5.47, 95% CI 3.05-10.22) as independent risk factors for single-dose MTX treatment failure. The final predictive model had a sensitivity of 0.768 and a specificity of 0.569, using a cut-off value of 3. The area under the receiver operating characteristic curve was 0.712. Patients with a predictive score of ≥3 were more likely to fail single-dose MTX therapy. CONCLUSION The present study concluded that an NLR decrease of less than 23% on day 4, a plateau or increase in serum hCG on day 4, and an hCG value greater than 1000 mIU/mL on day 0 were predictors of single-dose MTX treatment failure in EP patients.
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Affiliation(s)
- Rukeyemu Abuduxukuer
- Department of Gynecology, School of Medicine, Shanghai First Maternity and Infant Hospital, Tong Ji University, Shanghai, P.R. China
- Shanghai Key Laboratory of Maternal and Fetal Medicine, Shanghai First Maternity and Infant Hospital, Shanghai, P.R. China
| | - Xiaoyue Chen
- Department of Gynecology, School of Medicine, Shanghai First Maternity and Infant Hospital, Tong Ji University, Shanghai, P.R. China
- Shanghai Key Laboratory of Maternal and Fetal Medicine, Shanghai First Maternity and Infant Hospital, Shanghai, P.R. China
| | - Jingyi Ni
- Department of Clinical Research Center, School of Medicine, Shanghai First Maternity and Infant Hospital, Tong Ji University, Shanghai, P.R. China
| | - Shuangdi Li
- Department of Gynecology, School of Medicine, Shanghai First Maternity and Infant Hospital, Tong Ji University, Shanghai, P.R. China
- Shanghai Key Laboratory of Maternal and Fetal Medicine, Shanghai First Maternity and Infant Hospital, Shanghai, P.R. China
| | - Wen Lu
- Department of Gynecology, School of Medicine, Shanghai First Maternity and Infant Hospital, Tong Ji University, Shanghai, P.R. China
- Shanghai Key Laboratory of Maternal and Fetal Medicine, Shanghai First Maternity and Infant Hospital, Shanghai, P.R. China
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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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Barbier M, Pivano A, Tourette C, Poizac S, Cravello L, Boubli L, Agostini A. Evaluation of a follow-up customized strategy for women treated with methotrexate for an ectopic pregnancy: An observational study. Eur J Obstet Gynecol Reprod Biol 2019; 236:32-35. [PMID: 30877908 DOI: 10.1016/j.ejogrb.2019.02.037] [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: 02/18/2019] [Accepted: 02/26/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate a follow-up customized strategy used in women treated with methotrexate for tubal ectopic pregnancy. STUDY DESIGN This observational monocentric study took place from November 2009 to December 2015 in the emergency unit at La Conception University Hospital in Marseille, France. 440 women were treated by methotrexate for tubal ectopic pregnancy. Women were assigned in a classic follow up protocol with a weekly hCG evaluation (conventional protocol) if the drop in hCG between D1 and D4 was inferior to 20% or in an alternative follow up (streamlined protocol) with a hCG evaluation at one month. The main outcome measures were the success rate, the proportion of women requiring several methotrexate injections, and the mean number of consultations per women and duration of the follow-up. RESULTS During this period, the success rate was 348/440 (79.1%). The rate of women requiring 1, 2, or 3 injections and of women lost to follow-up were comparable between the two protocols. The mean number of consultations per woman was 3.6 ± 1.33 vs. 5.95 ± 2.25 days (p < 0.0001), and the follow-up was 27.5 ± 12 vs. 28.1 ± 15.4 (p = 0.6) respectively in the conventional protocol group and the streamlined. CONCLUSION Our customized strategy allows for a decrease in the number of consultations per woman without changing the success rate or the need for methotrexate injection. hCG count drop between D1 and D4 allows for the selection of a low-risk group that can benefit from appropriate aftercare.
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Affiliation(s)
- Magalie Barbier
- Department of Gynaecology and Obstetrics, Conception University Hospital, 147 Boulevard Baille, 13005, Marseille, France.
| | - Audrey Pivano
- Department of Gynaecology and Obstetrics, Conception University Hospital, 147 Boulevard Baille, 13005, Marseille, France.
| | - Claire Tourette
- Department of Gynaecology and Obstetrics, Conception University Hospital, 147 Boulevard Baille, 13005, Marseille, France.
| | - Sabine Poizac
- Department of Gynaecology and Obstetrics, Conception University Hospital, 147 Boulevard Baille, 13005, Marseille, France.
| | - Ludovic Cravello
- Department of Gynaecology and Obstetrics, Conception University Hospital, 147 Boulevard Baille, 13005, Marseille, France.
| | - Leon Boubli
- Department of Gynaecology and Obstetrics, Conception University Hospital, 147 Boulevard Baille, 13005, Marseille, France.
| | - Aubert Agostini
- Department of Gynaecology and Obstetrics, Conception University Hospital, 147 Boulevard Baille, 13005, Marseille, France.
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Kovaleva A, Irishina N, Pereira A, Cuesta-Guardiola T, Ortiz-Quintana L. Methotrexate-treated ectopic pregnancy: beta human chorionic gonadotropin serum changes as a success predictor using a mathematical model validation. Eur J Obstet Gynecol Reprod Biol 2016; 210:35-38. [PMID: 27936449 DOI: 10.1016/j.ejogrb.2016.10.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 09/04/2016] [Accepted: 10/18/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Surgical rescue of methotrexate-treated ectopic pregnancy is necessary when tubal rupture or medical therapy failure is detected during post-therapeutic monitoring. It is known that an increased beta human chorionic gonadotropin (β-hCG) concentration is the most important factor associated with treatment failure. Therefore, we suggested that relative changes in serum β-hCG could predict a successful result of medical treatment, leading to facilitation of the decision to forgo the prospect of possible surgical rescue. METHODS A retrospective observational study of 115 patients with an ectopic pregnancy who were treated with a single dosage protocol of 50mg/m2 of methotrexate injected intramuscularly was performed at Puerta de Hierro University Hospital and Gregorio Marañón University General Hospital. Standard statistical tests were applied in order to evaluate the relative changes in β-hCG concentration between the 1st and the 4th days following methotrexate injection. RESULTS Methotrexate treatment has a 95% probability to be successful if the relative change of β-hCG from the 1st to the 4th day of monitoring is within the following interval: [-1.02; 0.15]. Moreover, if the values of β-hCG-relative change from 1st to 4th day of monitoring are within [0.54; 1.2], it assures a negative result of treatment with 95% probability. Therefore, the value 0.15 (15%) of β-hCG relative change can be considered a cut-off value for a positive result to treatment. CONCLUSIONS Our data support that negative β-hCG relative changes on the 4th day of treatment likely predict a successful result of methotrexate therapy, with a cut-off point of 0.15. Expectant management should be carried out in these cases if no clinical indications of surgery are presented.
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Affiliation(s)
| | | | - Augusto Pereira
- Department of Obstetrics and Gynecology, University Hospital of Gregorio Marañón, Madrid, Spain
| | | | - Luis Ortiz-Quintana
- Department of Obstetrics and Gynecology, University Hospital of Gregorio Marañón, Madrid, Spain
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Falling in serum β human chorionic gonadotropin levels between days 1 and 7 as a new protocol to predict successful single-dose of methotrexate therapy for ectopic pregnancy. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2015. [DOI: 10.1016/j.mefs.2014.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Second-dose methotrexate in ectopic pregnancies: the role of beta human chorionic gonadotropin. Fertil Steril 2014; 102:1646-9. [PMID: 25241368 DOI: 10.1016/j.fertnstert.2014.08.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/15/2014] [Accepted: 08/11/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the role of β-hCG levels on days 1, 4, and 7 after methotrexate as predictors for second-dose requirement and success. DESIGN Retrospective cohort study. SETTING Tertiary university-affiliated hospital. PATIENT(S) A total of 1,703 patients were admitted because of ectopic pregnancy. Four hundred nine received methotrexate, of whom 73 women required a second dose. INTERVENTION(S) The "single-dose" methotrexate protocol with 50 mg/m(2) was administered to patients with progressing ectopic pregnancy. Surgical intervention was performed in cases of methotrexate second-dose treatment failure. MAIN OUTCOME MEASURE(S) Methotrexate second-dose requirement and success according to β-hCG levels on days 1, 4 and 7. RESULT(S) Second-dose methotrexate was successful in 58 patients (79.4%, success group), whereas 15 patients (20.6%) failed treatment and required surgical intervention (failure group). The medians of β-hCG levels on days 1, 4, and 7 were significantly higher in the "failure group" (1,601 vs. 2,844, 2,164 vs. 3,225, and 1,915 vs. 3,745 mIU/mL, respectively). Logistic regression analysis demonstrated that day-1 β-hCG levels were the only significant independent variable for second-dose treatment outcome. The receiver operating characteristic curve for β-hCG levels on day 1 was 0.727, and at a cutoff value of 2,234 mIU/mL the sensitivity and specificity reached the optimum for treatment success (77.5% and 73.3%, respectively). CONCLUSION(S) Day-1 β-hCG levels were the only predictors for methotrexate second-dose requirement and treatment success. The cutoff value of β-hCG on day 1 with the optimal treatment results was found to be 2,234 mIU/mL.
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van Mello NM, Mol F, Ankum WM, Mol BW, van der Veen F, Hajenius PJ. Ectopic pregnancy: how the diagnostic and therapeutic management has changed. Fertil Steril 2013; 98:1066-73. [PMID: 23084008 DOI: 10.1016/j.fertnstert.2012.09.040] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Revised: 09/21/2012] [Accepted: 09/24/2012] [Indexed: 11/16/2022]
Abstract
Nowadays ectopic pregnancy often can be diagnosed before the woman's condition has deteriorated, which has altered the former clinical picture of a life-threatening disease into a more benign condition. This review describes the historical developments in the diagnostic and therapeutic management of ectopic pregnancy leading up to current clinical practice. The first attempts to diagnose ectopic pregnancy originate from the beginning of the 20th century.
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Affiliation(s)
- Norah M van Mello
- Department of Obstetrics and Gynecology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.
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Thurman AR, Cornelius M, Korte JE, Fylstra DL. An alternative monitoring protocol for single-dose methotrexate therapy in ectopic pregnancy. Am J Obstet Gynecol 2010; 202:139.e1-6. [PMID: 19962125 DOI: 10.1016/j.ajog.2009.09.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Revised: 07/04/2009] [Accepted: 09/24/2009] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We sought to determine the sensitivity and specificity of alternative monitoring regimens in predicting the need for a second methotrexate (MTX) dose in women undergoing medical therapy for ectopic pregnancy. STUDY DESIGN We reviewed 187 women who received MTX for ectopic pregnancy. RESULTS We defined MTX treatment success as a clinically stable patient whose day-7 beta human chorionic gonadotropin (beta-hCG) level decreased by > or = 50%, compared with the day-of-treatment (DOT) beta-hCG. In comparison to the standard MTX monitoring protocol, this model was 100% sensitive and 57.4% specific in predicting the need for a second MTX dose in women whose DOT beta-hCG was <2000 mIU/mL and was 100% sensitive and 37.9% specific in women whose DOT beta-hCG was > or = 2000 mIU/mL. CONCLUSION This model is an alternative to the traditional MTX monitoring regimen.
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Affiliation(s)
- Andrea Ries Thurman
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, CONRAD Clinical Research Center, 601 Colley Ave., Norfolk, VA 23507, USA.
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Conservative management of tubal ectopic pregnancy. Best Pract Res Clin Obstet Gynaecol 2009; 23:509-18. [PMID: 19299204 DOI: 10.1016/j.bpobgyn.2008.12.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Accepted: 12/15/2008] [Indexed: 11/22/2022]
Abstract
In this chapter an overview is given of the best available evidence on the conservative treatment for tubal ectopic pregnancy, i.e., expectant management and medical treatment with systemic methotrexate. From the two randomized controlled trials on expectant management, no conclusions can be drawn yet. It may be that women with low serum hCG levels need not be treated at all, but more research needs to be done in this subgroup of women to reach firm conclusions. Systemic methotrexate in a fixed multiple-dose i/m regimen can be recommended for hemodynamically stable women with an unruptured tubal ectopic pregnancy and no signs of active bleeding presenting with serum hCG concentrations<3,000 IU/l. In women with serum hCG concentrations<1,500 IU/l, a single-dose methotrexate regimen can be considered.
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van Mello NM, Mol F, Adriaanse AH, Boss EA, Dijkman AB, Doornbos JPR, Emanuel MH, Friederich J, Leeuw-Harmsen LVD, Lips JP, van Santbrink EJP, Verhoeve HR, Visser H, Ankum WM, Veen FVD, Mol BW, Hajenius PJ. The METEX study: methotrexate versus expectant management in women with ectopic pregnancy: a randomised controlled trial. BMC Womens Health 2008; 8:10. [PMID: 18565217 PMCID: PMC2453103 DOI: 10.1186/1472-6874-8-10] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Accepted: 06/19/2008] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Patients with ectopic pregnancy (EP) and low serum hCG concentrations and women with a pregnancy of unknown location (PUL) and plateauing serum hCG levels are commonly treated with systemic methotrexate (MTX). However, there is no evidence that treatment in these particular subgroups of women is necessary as many of these early EPs may resolve spontaneously. The aim of this study is whether expectant management in women with EP or PUL and with low but plateauing serum hCG concentrations is an alternative to MTX treatment in terms of treatment success, future pregnancy, health related quality of life and costs. METHODS/DESIGN A multicentre randomised controlled trial in The Netherlands. Hemodynamically stable patients with an EP visible on transvaginal ultrasound and a plateauing serum hCG concentration < 1,500 IU/L or with a persisting PUL with plateauing serum hCG concentrations < 2,000 IU/L are eligible for the trial. Patients with a viable EP, signs of tubal rupture/abdominal bleeding, or a contra-indication for MTX will not be included. Expectant management is compared with systemic MTX in a single dose intramuscular regimen (1 mg/kg) in an outpatient setting. Serum hCG levels are monitored weekly; in case of inadequately declining, systemic MTX is installed or continued. In case of hemodynamic instability and/or signs of tubal rupture, surgery is performed. The primary outcome measure is an uneventful decline of serum hCG to an undetectable level by the initial intervention. Secondary outcomes are (re)interventions (additional systemic MTX injections and/or surgery), treatment complications, health related quality of life, financial costs, and future fertility. Analysis is performed according to the intention to treat principle. Quality of life is assessed by questionnaires before and at three time points after randomisation. Costs are expressed as direct costs with data on costs and used resources in the participating centres. Fertility is assessed by questionnaires after 6, 12, 18 and 24 months. Patients' preferences will be assessed using a discrete choice experiment. DISCUSSION This trial will provide guidance on the present management dilemmas in women with EPs and PULs with low and plateauing serum hCG concentrations. TRIAL REGISTRATION Current Controlled Trials ISRCTN 48210491.
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Affiliation(s)
- Norah M van Mello
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Femke Mol
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert H Adriaanse
- Department of Obstetrics and Gynaecology, Medical Centre Alkmaar, Alkmaar, The Netherlands
| | - Erik A Boss
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Antonius B Dijkman
- Department of Obstetrics and Gynaecology, Boven IJ Hospital, Amsterdam, The Netherlands
| | - Johannes PR Doornbos
- Department of Obstetrics and Gynaecology, Zaans Medical Centre, Zaandam, The Netherlands
| | - Mark Hans Emanuel
- Department of Obstetrics and Gynaecology, Spaarne Hospital, Hoofddorp, The Netherlands
| | - Jaap Friederich
- Department of Obstetrics and Gynaecology, Gemini Hospital, Den Helder, The Netherlands
| | | | - Jos P Lips
- Department of Obstetrics and Gynaecology, Kennemer Gasthuis, Haarlem, The Netherlands
| | - Evert JP van Santbrink
- Department of Obstetrics and Gynaecology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Harold R Verhoeve
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Harry Visser
- Department of Obstetrics and Gynaecology, Tergooi Hospital, Blaricum, The Netherlands
| | - Willem M Ankum
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Fulco van der Veen
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Petra J Hajenius
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Hajenius PJ, Mol F, Mol BWJ, Bossuyt PMM, Ankum WM, van der Veen F. Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev 2007; 2007:CD000324. [PMID: 17253448 PMCID: PMC7043290 DOI: 10.1002/14651858.cd000324.pub2] [Citation(s) in RCA: 127] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Treatment options for tubal ectopic pregnancy are; (1) surgery, e.g. salpingectomy or salpingo(s)tomy, either performed laparoscopically or by open surgery; (2) medical treatment, with a variety of drugs, that can be administered systemically and/or locally by various routes and (3) expectant management. OBJECTIVES To evaluate the effectiveness and safety of surgery, medical treatment and expectant management of tubal ectopic pregnancy in view of primary treatment success, tubal preservation and future fertility. SEARCH STRATEGY The Cochrane Menstrual Disorders and Subfertility Group's Specialised Register, Cochrane Controlled Trials Register (up to February 2006), Current Controlled Trials Register (up to October 2006), and MEDLINE (up to October 2006) were searched. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing treatments in women with tubal ectopic pregnancy. DATA COLLECTION AND ANALYSIS Data extraction and quality assessment was done independently by two reviewers. Differences were resolved by discussion with all reviewers. MAIN RESULTS Thirty five studies have been analysed on the treatment of tubal ectopic pregnancy, describing 25 different comparisons. SURGERY Laparoscopic salpingostomy is significantly less successful than the open surgical approach in the elimination of tubal ectopic pregnancy (2 RCTs, n=165, OR 0.28, 95% CI 0.09, 0.86) due to a significant higher persistent trophoblast rate in laparoscopic surgery (OR 3.5, 95% CI 1.1, 11). However, the laparoscopic approach is significantly less costly than open surgery (p=0.03). Long term follow-up (n=127) shows no evidence of a difference in intra uterine pregnancy rate (OR 1.2, 95% CI 0.59, 2.5) but there is a non significant tendency to a lower repeat ectopic pregnancy rate (OR 0.47, 95% 0.15, 1.5). Salpingostomy alone is significantly less successful than when combined with a prophylactic single shot methotrexate (2 RCTs, n=163, OR 0.25, 95% CI 0.08-0.76) to prevent persistent trophoblast. MEDICAL TREATMENT Systemic methotrexate in a fixed multiple dose intramuscular regimen has a non significant tendency to a higher treatment success than laparoscopic salpingostomy (1 RCT, n=100, OR 1.8, 95% CI 0.73, 4.6). No significant differences are found in long term follow-up (n=74): intra uterine pregnancy (OR 0.82, 95% CI 0.32, 2.1) and repeat ectopic pregnancy (OR 0.87, 95% CI 0.19, 4.1). One single dose intramuscular methotrexate is significantly less successful than laparoscopic salpingostomy (4 RCTs, n=265, OR 0.38, 95% CI 0.20, 0.71). With a variable dose regimen treatment success rises, but shows no evidence of a difference compared to laparoscopic salpingostomy (OR 1.1, 95% CI 0.52, 2.3). Long term follow-up (n=98) do not differ significantly (intra uterine pregnancy OR 1.0, 95% CI 0.43, 2.4, ectopic pregnancy OR 0.54, 95% CI 0.12, 2.4). The efficacy of systemic single dose methotrexate alone is significantly less successful than when combined with mifepristone (2 RCTs, n=262, OR 0.59, 95% CI 0.35, 1.0). The same goes for the addition of traditional Chinese medicine (1 RCT, n=78, OR 0.08, 95% CI 0.02, 0.39). Local medical treatment administered transvaginally under ultrasound guidance is significantly better than a 'blind' intra-tubal injection under laparoscopic guidance in the elimination of tubal ectopic pregnancy (1 RCT, n=36, methotrexate OR 5.8, 95% CI 1.3, 26; 1 RCT, n=80, hyperosmolar glucose OR 0.38, 95% CI 0.15, 0.93). However, compared to laparoscopic salpingostomy, local injection of methotrexate administered transvaginally under ultrasound guidance is significantly less successful (1 RCT, n=78, OR 0.17, 95% CI 0.04, 0.76) but with positive long term follow up (n=51): a significantly higher intra uterine pregnancy rate (OR 4.1, 95% CI 1.3, 14) and a non significant tendency to a lower repeat ectopic pregnancy rate (OR 0.30, 95% CI 0.05, 1.7). EXPECTANT MANAGEMENT: Expectant management is significantly less successful than prostaglandin therapy (1 RCT, n=23, OR 0.08, 95% CI 0.02-0.39). AUTHORS' CONCLUSIONS In the surgical treatment of tubal ectopic pregnancy laparoscopic surgery is a cost effective treatment. An alternative nonsurgical treatment option in selected patients is medical treatment with systemic methotrexate. Expectant management can not be adequately evaluated yet.
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Affiliation(s)
- P J Hajenius
- Academic Medical Center, University of Amsterdam, Obstetrics and Gynecology (H4-205), Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ.
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Kirk E, Condous G, Van Calster B, Haider Z, Van Huffel S, Timmerman D, Bourne T. A validation of the most commonly used protocol to predict the success of single-dose methotrexate in the treatment of ectopic pregnancy. Hum Reprod 2006; 22:858-63. [PMID: 17088266 DOI: 10.1093/humrep/del433] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Currently, the likely success of single-dose methotrexate (MTX) (50 mg/m(2)) for the treatment of ectopic pregnancy is indicated by a >15% decrease in hCG from days 4-7 after administration. The aim of this study was to assess this protocol and to develop new rules that could be used to predict the outcome at an earlier stage. METHODS Data were collected prospectively. Women receiving MTX for an ectopic pregnancy had serum hCG and progesterone levels checked on days 1, 3, 4, 5 and 7. Other factors including age, gestational age, previous obstetric history and ultrasound findings were recorded. The women were followed up until the outcome of medical management was known. Univariate analysis was performed to determine the benefit of the '15% day 4-7 rule', as well as to develop new rules, which potentially could be used to predict the likelihood of success before 7 days. Historical and ultrasound variables were also analysed to identify the significant variables associated with successful conservative management. RESULTS The success rate of single-dose MTX was 68.1% (47/69). A second dose was required in 18.8% (13/69) of cases, and it was successful in 84.6% (11/13). The 15% day 4-7 rule correctly predicted the outcome in 90.3% of cases [sensitivity 93.0%, specificity 84.2%, positive predictive value (PPV) 93.0% and negative predictive value (NPV) 84.2%, Fisher exact test P-value < 0.0001]. New rules were developed based on the percentage change day 4-5 and logistic regression models incorporating day 5 hCG levels and ultrasound findings. These new rules did not outperform the current 15% day 4-7 rule. CONCLUSIONS We have confirmed that a 15% decrease in serum hCG between day 4 and day 7 is a very good indicator of the likely success of MTX. The development of new rules did not significantly improve our ability to predict a successful outcome at an earlier stage.
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Affiliation(s)
- E Kirk
- Department of Obstetrics & Gynaecology, Early Pregnancy, Gynaecological Ultrasound and MAS Unit, St George's, University of London, London, UK.
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Kahyaoglu S, Turgay I, Gocmen M, Sut N, Batioglu S. A new predictive scoring system including shock index for unruptured tubal pregnancy patients. Eur J Obstet Gynecol Reprod Biol 2006; 126:99-103. [PMID: 16246482 DOI: 10.1016/j.ejogrb.2005.09.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2004] [Revised: 08/08/2005] [Accepted: 09/21/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Shock index (SI) and predictive score grading system including it for predicting medical treatment failure of tubal pregnancies have been studied. STUDY DESIGN Eighty-eight patients were diagnosed as nonruptured tubal pregnancies. Shock index was calculated as the ratio of heart rate to systolic arterial pressure. A predictive score was used based on four parameters including initial level of beta-human chorionic gonadotropin (betahCG), aspect of the image on ultrasound, size of the ectopic mass and shock index value at admission. RESULTS Forty patients have undergone to surgery because of tubal gestational sac size > or =4 cm and/or presence of fetal heart activity. Nineteen patients were managed expectantly. Twenty-four patients received single dose methotrexate (MTX) and five patients received second dose MTX. Success rate for single dose MTX therapy was 72% (21/29). The cut-off shock index value for tubal rupture was 0.77 with 89% sensitivity and 61% specifity. CONCLUSION In this study, we demonstrated that tubal pregnancy patients who were managed with nonsurgical measures at admission and who had SI values lower than 0.77 and predictive score grades greater and equal to 6.5 did not experience tubal rupture and did not need surgical intervention during nonsurgical management.
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Affiliation(s)
- Serkan Kahyaoglu
- Zekai Tahir Burak Women's Health and Research Hospital, Department of Infertility and Reproductive Medicine, Gn. Dr.Tevfik Saglam Cad. Emlakbankasi Evleri C3/32 Etlik, Ankara, Turkey.
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Cho GJ, Lee SH, Shin JW, Lee NW, Kim T, Kim HJ, Lee KW. Predictors of success of repeated injections of single-dose methotrexate regimen for tubal ectopic pregnancy. J Korean Med Sci 2006; 21:86-9. [PMID: 16479071 PMCID: PMC2733985 DOI: 10.3346/jkms.2006.21.1.86] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The purpose of this study is to evaluate predictors of success of repeated injections of methotrexate in the single-dose regimen for the treatment of tubal ectopic pregnancy. All patients who had ectopic tubal pregnancy and were treated with a single dose regimen were retrospectively identified. 126 patients were treated with methotrexate. Among them, 39 patients were adequate for this study. 33 were treated with the 2nd dose and 27 were successfully cured. Additionally, 6 who were injected with the 3rd dose were all cured as well. Therefore, in our study, the success rate for the repeated injections of methotrexate was found to be 84.6% (33/39). The mean initial beta-hCG level was significantly lower in patients who were successfully treated than in patients who failed (3915.3+/-3281.3 vs. 8379.7+/-2604.4 IU/mL, p<0.05). The success rate is 96% when the beta-hCG level is less than 6,000 IU/mL and is 58% when beta-hCG is greater than 6,000 IU/mL (OR=18.57, 95% CI 1.86-185.89). The initial beta-hCG level is the only factor that has significant meaning as predictor of success of repeated injections of methotrexate in the single-dose regimen. Repeated injections of methotrexate may be particularly effective when the initial beta-hCG level is below 6,000 IU/mL.
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Affiliation(s)
- Geum Joon Cho
- Department of Obstetrics and Gynecology, College of Medicine, Korea University, Seoul, Korea
| | - Sang Hoon Lee
- Department of Obstetrics and Gynecology, College of Medicine, Korea University, Seoul, Korea
| | - Jin Woo Shin
- Department of Obstetrics and Gynecology, College of Medicine, Korea University, Seoul, Korea
| | - Nak Woo Lee
- Department of Obstetrics and Gynecology, College of Medicine, Korea University, Seoul, Korea
| | - Tak Kim
- Department of Obstetrics and Gynecology, College of Medicine, Korea University, Seoul, Korea
| | - Hai Joong Kim
- Department of Obstetrics and Gynecology, College of Medicine, Korea University, Seoul, Korea
| | - Kyu Wan Lee
- Department of Obstetrics and Gynecology, College of Medicine, Korea University, Seoul, Korea
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