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Agbal T, Erturk Aksakal S, Pay RE, Erkaya S. Comparison of the success rates of a single dose and an additional dose of methotrexate on the 4th day in patients whose β-hCG values do not fall after a single dose of methotrexate (Day 0-4). J Gynecol Obstet Hum Reprod 2024; 53:102811. [PMID: 38844087 DOI: 10.1016/j.jogoh.2024.102811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 06/11/2024]
Abstract
INTRODUCTION This study's aim is to investigate whether the rise in β-hCG levels between days 0 and 4 in patients with tubal ectopic pregnancy who have received a single dose of methotrexate has prognostic value in treatment success, and to investigate whether administering a second dose on day 4 enhances treatment success. MATERIAL AND METHODS Patients diagnosed with ectopic pregnancy and experiencing an increase in β- hCG levels on day 4 after initiation of methotrexate treatment were included in our study. Patients treated with a single dose Methotrexate (MTX) protocol until December 2019 were retrospectively screened from January 2018 to December 2019. Patients receiving a second dose on day 4 until September 2021 were prospectively enrolled from January 2020 to September 2021. A decrease of over 15 % in the β-hCG value after the 4th dose was considered as treatment success. RESULTS Treatment success rates were compared between these two groups. 115 patients with ectopic pregnancy were included in the study. A single dose methotrexate protocol was applied in 67 of the patients (Group 1), while an additional dose methotrexate was applied in 48 (Group 2). The treatment was successful in 40 patients (59.7 %) in Group 1 and in 39 patients (81.3 %) in Group 2. The success rate of the treatment was significantly higher in patients who received an additional dose methotrexate protocol (p = 0.014). DISCUSSION This study shows that; it is possible to increase success rates by applying an additional MTX dose on the 4th day in cases with an increase in β-hCG on the 4th day.
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Affiliation(s)
- Tugba Agbal
- Department of Gynaecology, University of Health Sciences, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey.
| | - Sezin Erturk Aksakal
- Department of Gynaecology, University of Health Sciences, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
| | - Ramazan Erda Pay
- Department of Gynaecology, University of Health Sciences, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
| | - Salim Erkaya
- Department of Perinatology, University of Health Sciences, Etlik Zubeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey
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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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Zhang J, Zhang Y, Gan L, Liu XY, Du SP. Predictors and clinical features of methotrexate (MTX) therapy for ectopic pregnancy. BMC Pregnancy Childbirth 2020; 20:654. [PMID: 33121473 PMCID: PMC7597060 DOI: 10.1186/s12884-020-03350-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 10/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ectopic pregnancy is a major life- and fertility-threatening women's health concern. As a result of advances in examination technology, an increasing number of ectopic pregnancies can be diagnosed early and treated with medical methods instead of surgery. The aim of this study was to summarize the clinical features and identify the predictors of success of methotrexate (MTX) treatment of ectopic pregnancy. METHODS This was a retrospective study of 238 ectopic pregnancies treated with MTX in the Department of Gynecology of Shaanxi Provincial People's Hospital from January 2017 to December 2017. RESULTS Patients were divided into two groups: the successful treatment group (n = 166) and the failed treatment group (n = 72). The overall success rate of MTX therapy for ectopic pregnancy was 69.75%. The mean initial beta-human chorionic gonadotropin (β-hCG) level was significantly lower in the successful treatment group than in the failed treatment group (2538.08 IU/L versus 3533.17 IU/L, P = 0.000). The treatment success rate of the group with an initial β-hCG concentration less than 4000 IU/L was significantly higher than that of the group with an initial β-hCG concentration greater than 4000 IU/L. However, the success rate of the group with an initial β-hCG concentration greater than 4000 IU/L was still relatively high (54.55%). β-hCG levels were significantly increased on the 4th day in the failed treatment group (P = 0.000). Compared to the initial β-hCG level, the day-4 β-hCG level increased by more than 8.21%, indicating that the treatment was effective. The diagnostic sensitivity was 88.6%, the specificity was 74.5%, and the area under the receiver operating characteristic (ROC) curve was 0.863 (95% confidence interval (CI): 0.805-0.920). CONCLUSIONS MTX therapy as a treatment option is safe and effective for asymptomatic, hemodynamically stable patients with ectopic pregnancies who are interested in conservative treatment, regardless of the serum β-hCG level or adnexal mass size. The change in the β-hCG level between the initial day and the 4th day is an effective and early predictive tool for the success of MTX therapy for ectopic pregnancy.
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Affiliation(s)
- Jing Zhang
- Shaanxi Provincial People's Hospital, Xian, 710068, Shaanxi, China
| | - Yu Zhang
- Shaanxi Provincial People's Hospital, Xian, 710068, Shaanxi, China
| | - Lu Gan
- Shaanxi Provincial People's Hospital, Xian, 710068, Shaanxi, China
| | - Xiao-Ying Liu
- Shaanxi Provincial People's Hospital, Xian, 710068, Shaanxi, China
| | - Shan-Ping Du
- Shaanxi Provincial People's Hospital, Xian, 710068, Shaanxi, China.
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Goh A, Karine P, Kirby A, Williams C, Kapurubandara S. Day 1 to day 4 serum hCG change in predicting single-dose methotrexate treatment failure for tubal ectopic pregnancies. Eur J Obstet Gynecol Reprod Biol 2020; 255:105-110. [PMID: 33113399 DOI: 10.1016/j.ejogrb.2020.10.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/12/2020] [Accepted: 10/14/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine if changes in Day 1 to Day 4 serum human chorionic gonadotropin (hCG) levels can predict treatment failure of single-dose methotrexate (MTX) in medical management of tubal ectopic pregnancies (EP). STUDY DESIGN This retrospective cohort study was conducted at a tertiary level hospital. Files were reviewed for all women who received at least one dose of 50 mg/m2 intramuscular MTX for treatment of ultrasound-confirmed tubal EPs between 2013 and 2018. "Treatment failure" is defined as needing additional MTX or surgery to manage the EP. The primary purpose is to establish a threshold percentage change in Day 1 to Day 4 (Day 1/4) hCG that best predicts treatment failure, with clinically and statistically significant sensitivity and specificity, based on receiver-operator characteristic (ROC) analysis. RESULTS 252 files were reviewed, with 108 included for final analysis. 17% of cases required a second dose of MTX and 12% required surgery to manage the EP. Women in the treatment failure group had significantly higher median hCG levels on Day 1, 4 and 7, but were otherwise similar to women who were successful in age, parity, history of previous EP, and EP size. ROC curve analysis of Day 1/4 hCG demonstrates that ≥5% rise best predicts treatment failure with sensitivity 68% (95% confidence interval [CI] 49-83%), specificity 69% (95%CI 56-78%), and AUC 0.77 (95%CI 0.68-0.86, p < 0.001). The positive predictive value is 46% (95%CI 36-56%) and negative predictive value is 84% (95%CI 75-90%). In comparison, ROC analysis of Day 4 to Day 7 hCG demonstrates that a drop of ≤17% best predicted failure, with sensitivity 83% (95%CI 64-94%), specificity 82% (95%CI 71-90%), and AUC 0.90 (95%CI 0.84-0.96), p < 0.001. CONCLUSION This study suggests that ≥5% rise in Day 1/4 serum hCG levels could potentially predict treatment failure of single-dose MTX for tubal EPs, and that conversely, <5% rise or any drop in Day 1/4 hCG levels can reliably predict treatment success. Clinicians could consider factoring-in Day 1/4 hCG changes during the course of medically managing patients. They must bear in mind, however, that acting on the Day 1/4 hCG change would lead to increased interventions.
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Affiliation(s)
- Amy Goh
- Department of Obstetrics and Gynaecology, Westmead Hospital, Hawkesbury Rd, Westmead, New South Wales, 2145, Australia; Sydney West Advanced Pelvic Surgery Unit, 6 Kempsey St, Blacktown, New South Wales, 2148, Australia.
| | - Priyanka Karine
- Department of Obstetrics and Gynaecology, Westmead Hospital, Hawkesbury Rd, Westmead, New South Wales, 2145, Australia.
| | - Adrienne Kirby
- NHMRC Clinical Trials Centre at The University of Sydney, The University of Sydney, Sydney, New South Wales, 2006, Australia.
| | - Corey Williams
- Department of Obstetrics and Gynaecology, Westmead Hospital, Hawkesbury Rd, Westmead, New South Wales, 2145, Australia.
| | - Supuni Kapurubandara
- Department of Obstetrics and Gynaecology, Westmead Hospital, Hawkesbury Rd, Westmead, New South Wales, 2145, Australia; Sydney West Advanced Pelvic Surgery Unit, 6 Kempsey St, Blacktown, New South Wales, 2148, Australia; The University of Sydney School of Medicine, Sydney, New South Wales, 2006, Australia.
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Kanmaz AG, Hamdi İnan A, Beyan E, Budak A. Various BhCG monitoring protocols for predicting the success of single-dose methotrexate in the treatment of ectopic pregnancy. J OBSTET GYNAECOL 2019; 39:811-815. [DOI: 10.1080/01443615.2019.1575344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Ahkam Go¨Ksel Kanmaz
- Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Abdurrahman Hamdi İnan
- Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Emrah Beyan
- Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Adnan Budak
- Department of Obstetrics and Gynecology, Izmir provincial health directorate, Izmir, Turkey
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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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Early prediction of the success of methotrexate treatment success by 24-hour pretreatment increment in HCG and day 1-4 change in HCG. Reprod Biomed Online 2019; 39:149-154. [PMID: 31029556 DOI: 10.1016/j.rbmo.2019.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 01/24/2019] [Accepted: 02/20/2019] [Indexed: 11/24/2022]
Abstract
RESEARCH QUESTION Several studies have tried to identify early markers of treatment outcome after methotrexate (MTX) treatment for ectopic pregnancy, including pretreatment and day 4 human chorionic gonadotrophin (HCG) concentrations and their corresponding changes, and the increment in HCG during the initial 24 h after treatment. There have, however, been conflicting results. This study aimed to re-evaluate the role of these markers in the earlier identification of treatment success in a large cohort of women. DESIGN This was a retrospective cohort study including women diagnosed with an ectopic pregnancy and treated with a regimen of a single dose of MTX. A comparison of maternal and gestation characteristics was made between groups in whom treatment was successful or failed. RESULTS A total of 292 women treated with single-dose intramuscular MTX for ectopic pregnancy were included in this study. In the overall cohort, the treatment success rate with a single dose of MTX was 62.7% (183/292). Only two independent determinants were significantly associated with treatment success: the initial 24-h percentage increase in HCG (adjusted odds ratio [OR] 1.82, 95% confidence interval [CI] 1.26-2.63; P < 0.001) and the percentage change in HCG from day 1 to day 4 (adjusted OR 1.12, 95% CI 1.04-1.21; P < 0.001). The optimal cut-off points for prediction of treatment success were an increment of less than 17% in the 24 h before treatment and a decrease of more than 22% between the day 1 and day 4 HCG concentrations. CONCLUSIONS A small increase in HCG concentration 24 h before treatment with MTX, alongside a decline in HCG concentration from day 1 to day 4, may predict the success of medical treatment for an ectopic pregnancy.
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Brunello J, Guerby P, Cartoux C, Yazigi A, Baujat M, Parant O, Vayssière C, Vaysse C, Chantalat E, Vidal F. Can early βhCG change and baseline progesterone level predict treatment outcome in patients receiving single dose Methotrexate protocol for tubal ectopic pregnancy? Arch Gynecol Obstet 2019; 299:741-745. [DOI: 10.1007/s00404-019-05068-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 01/25/2019] [Indexed: 11/30/2022]
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Ahmed MR, Sayed Ahmed WA, Mohamed TY. Day 1 change in maternal serum β-HCG levels as an early predictor of successful medical therapy in ectopic pregnancies. J Matern Fetal Neonatal Med 2019; 33:2403-2407. [PMID: 30608010 DOI: 10.1080/14767058.2018.1551353] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To evaluate the role of β-HCG level changes between days 0 and 1 as an early predictor of methotrexate success in cases of tubal ectopic pregnancy.Methods: A retrospective study included 86 tubal ectopic pregnancies treated with a single-dose methotrexate protocol of 50 mg/m2 of body surface. β-HCG measurements were taken on days 0, 1, 4 and 7 where day 0 is the day of methotrexate injection. Day 0 β-HCG and the percentage change in β-HCG level between days 0 and 1 (HCG index) were calculated and compared between patients who were successfully or unsuccessfully treated. Receiver operator characteristics (ROC) curves were plotted to identify the best cutoff levels.Results: The average level of β-HCG (1416.8 versus 2502.5 IU/L, p=.001) and its increment after 24 hours (12.9 versus 27.1%, p=.001) were significantly lower in the successful treatment group. ROC curves for β-HCG level and its relative increment revealed that cutoff values of ≤1550 IU/L and ≤13% increment showed a sensitivity of 90 and 70% respectively for successful methotrexate treatment.Conclusion: Day 0 β-HCG level ≤1550 IU/L and an increment of ≤13% after 24 hours are early predictors of successful methotrexate treatment for tubal ectopic pregnancy.
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Affiliation(s)
- Magdy R Ahmed
- Obstetrics and Gynecology Department, Suez Canal University, Ismailia, Egypt
| | | | - Tamer Y Mohamed
- Obstetrics and Gynecology Department, Suez Canal University, Ismailia, Egypt
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