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Piróg MM, Pulka A, Urbaniec P, Jach R. Comparison of single- and double-dose methotrexate protocols for treatment of pregnancy of unknown location. Eur J Obstet Gynecol Reprod Biol 2024; 298:171-174. [PMID: 38762953 DOI: 10.1016/j.ejogrb.2024.05.016] [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: 02/03/2024] [Revised: 04/12/2024] [Accepted: 05/15/2024] [Indexed: 05/21/2024]
Abstract
OBJECTIVE The use of various methotrexate (MTX) protocols for the treatment of ectopic pregnancy is well established. This study aimed to evaluate the efficacy of single- and double-dose MTX protocols for the treatment of pregnancy of unknown location (PUL). STUDY DESIGN This retrospective study was conducted in the Department of Gynaecological Endocrinology, University Hospital, Krakow, Poland. Haemodynamically stable women with PUL were enrolled between January 2014 and September 2023. Demographics, gestational age and treatment outcomes were compared between women in the single-dose MTX group and women in the double-dose MTX group. The primary outcome was the success rate, measured as the number of women treated without surgical intervention. The secondary outcome was the number of days of MTX needed to achieve an appropriate decrease in beta-human chorionic gonadotrophin (β-hCG). RESULTS Two hundred and eleven women (mean age 33 ± 1.8 years) with PUL were enrolled in the study, with an overall success rate of 89.1 %. Single- and double-dose MTX protocols were found to have comparable treatment success rates (93 % and 95 %, respectively). Women with lower initial serum β-hCG (<2000 mIU/ml) had higher treatment efficacy compared with women with higher initial serum β-hCG (96.5 % vs 71.4 %), regardless of protocol type. The length of hospital stay for the women treated with the single-dose MTX protocol was 1 day shorter compared with that for the women treated with the double-dose MTX protocol. CONCLUSION Single- and double-dose MTX protocols have comparable efficacy and safety, and should be equally considered in women with PUL with initial β-hCG < 2000 mIU/ml.
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Affiliation(s)
- Magdalena M Piróg
- Department of Gynaecological Endocrinology, Jagiellonian University Medical College, Krakow, Poland.
| | - Anna Pulka
- Department of Gynaecological Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - Przemysław Urbaniec
- Department of Gynaecological Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - Robert Jach
- Department of Gynaecological Endocrinology, Jagiellonian University Medical College, Krakow, Poland
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Chitzios D, Balaouras D, Papasozomenou P, Balaouras G, Mikos T, Daniilidis A, Zafrakas M. Sonographic vascularity indices' study in ectopic pregnancies, after methotrexate treatment. Eur J Obstet Gynecol Reprod Biol X 2024; 22:100316. [PMID: 38778876 PMCID: PMC11109317 DOI: 10.1016/j.eurox.2024.100316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 04/28/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
Objectives Ectopic pregnancy is a crucial problem in Gynaecology. Previous studies concerning the medical treatment of ectopic pregnancies, have used only β-hCG (beta- human chorionic gonadotropin) values, to monitor the successful response to treatment. The current study was a PhD (Doctorate of Philosophy) thesis research, which has evaluated the vascularity indices' changes. The values of vascularity indices could be used, in combination with β-hCG values and the gestational sac dimensions, in every medically treated ectopic pregnancy. The results could be used, for monitoring the course of all medically treated ectopic pregnancies. Study design 72 women of reproductive age have taken part in the study. They have been admitted due to secondary amenorrhea, positive β-hCG test, with or without vaginal bleeding. The participants took part voluntarily and were allocated in two groups. The first group consisted of 37 women, who were possible normal or threatened intrauterine pregnancies (control group). The second group consisted of 35 women, whose sonographic findings suggested ectopic pregnancy, and qualified for methotrexate treatment (study group). Sonographic control and measurement of the vascularity indices (PI - RI) (Pulsatility index - Resistance index) of the ectopic pregnancy was conducted, in combination with β-hCG values for every admitted or outpatient woman.The dimensions of the gestational sac of both groups were measured during four consecutive periods of time. The control group has shown progressively increasing sac dimensions, whereas, in the study group sac dimensions were more stable or growing gradually smaller. The exception where those ectopic pregnancies that ruptured, which have also shown a gradual enlargement of the sac. Results The endometrial thickness of the study group was gradually decreasing up to 76 % per day, and the more eminent, but not statistically significant decrease, was observed in the single dose regiment of methotrexate. Moreover, the quantitative PI and RI were evaluated, and the main finding was that there were no statistically significant decreases in any of the two groups. Concerning the study group, methotrexate treatment was successful, since there was a decrease of up to 80 %, whereas a clearly significant correlation was found between the β-hCG levels and the RI. Conclusion The vascularity indices could be used safely, in combination with β-hCG levels and the decrease of the gestational sac dimensions, as criteria for the evaluation of response to medical treatment of ectopic pregnancies.
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Affiliation(s)
- Dimitrios Chitzios
- International Hellenic University, Health Sciences School, Midwifery Department, PO Box 141, 57400 Sindos, Greece
- Private Obstetric and Gynaecological Practice “Delfys”, Profiti Ilia 27, 55535 Pylaia, Greece
| | - Dimitrios Balaouras
- International Hellenic University, Health Sciences School, Midwifery Department, PO Box 141, 57400 Sindos, Greece
- Private Obstetric and Gynaecological Practice “Delfys”, Profiti Ilia 27, 55535 Pylaia, Greece
| | - Panayiota Papasozomenou
- International Hellenic University, Health Sciences School, Midwifery Department, PO Box 141, 57400 Sindos, Greece
| | - Georgios Balaouras
- General Hospital of Chalkidiki, Polygyros, Medical Biopathology Laboratory, Ippokratous 5, 63100 Polygyros, Greece
| | - Themistoklis Mikos
- Aristotle University of Thessaloniki, 1st Obstetrics and Gynaecology Department, Papageorgiou General Hospital of Thessaloniki, Ring Road, 56403 N.Efkarpia, Greece
| | - Angelos Daniilidis
- Aristotle University of Thessaloniki, 1st Obstetrics and Gynaecology Department, Papageorgiou General Hospital of Thessaloniki, Ring Road, 56403 N.Efkarpia, Greece
| | - Menelaos Zafrakas
- International Hellenic University, Health Sciences School, Midwifery Department, PO Box 141, 57400 Sindos, Greece
- Aristotle University of Thessaloniki, 1st Obstetrics and Gynaecology Department, Papageorgiou General Hospital of Thessaloniki, Ring Road, 56403 N.Efkarpia, Greece
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Solangon SA, Van Wely M, Van Mello N, Mol BW, Ross JA, Jurkovic D. Methotrexate vs expectant management for treatment of tubal ectopic pregnancy: An individual participant data meta-analysis. Acta Obstet Gynecol Scand 2023; 102:1159-1175. [PMID: 37345445 PMCID: PMC10407021 DOI: 10.1111/aogs.14617] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Ectopic pregnancy is an important health condition which affects up to 1 in 100 women. Women who present with mild symptoms and low serum human chorionic gonadotrophin (hCG) are often treated with methotrexate (MTX), but expectant management with close monitoring is a feasible alternative. Studies comparing the two treatments have not shown a statistically significant difference in uneventful resolution of ectopic pregnancy, but these studies were too small to define whether certain subgroups could benefit more from either treatment. MATERIAL AND METHODS We performed a systematic review and individual participant data meta-analysis (IPD-MA) of randomized controlled trials comparing systemic MTX and expectant management in women with tubal ectopic pregnancy and low hCG (<2000 IU/L). A one-stage IPD-MA was performed to assess overall treatment effects of MTX and expectant management to generate a pooled intervention effect. Subgroup analyses and exploratory multivariable analyses were undertaken according to baseline serum hCG and progesterone levels. Primary outcome was treatment success, defined as resolution of clinical symptoms and decline in level of serum hCG to <20 IU/L, or a negative urine pregnancy test by the initial intervention strategy, without any additional treatment. Secondary outcomes were need for blood transfusion, surgical intervention, additional MTX side-effects and hCG resolution times. TRIAL REGISTRATION NUMBER PROSPERO: CRD42021214093. RESULTS 1547 studies reviewed and 821 remained after duplicates removed. Five studies screened for eligibility and three IPD requested. Two randomized controlled trials supplied IPD, leading to 153 participants for analysis. Treatment success rate was 65/82 (79.3%) after MTX and 48/70 (68.6%) after expectant management (IPD risk ratio [RR] 1.16, 95% confidence interval [CI] 0.95-1.40). Surgical intervention rates were not significantly different: 8/82 (9.8%) vs 13/70 (18.6%) (RR 0.65, 95% CI 0.23-1.14). Mean time to success was 19.7 days (95% CI 17.4-22.3) after MTX and 21.2 days (95% CI 17.8-25.2) after expectant management (P = 0.25). MTX specific side-effects were reported in 33 MTX compared to four in the expectant group. CONCLUSIONS Our IPD-MA showed no statistically significant difference in treatment efficacy between MTX and expectant management in women with tubal ectopic pregnancy with low hCG. Initial expectant management could be the preferred strategy due to fewer side-effects.
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Affiliation(s)
| | - Madelon Van Wely
- Center for Reproductive MedicineAmsterdam University Medical CenterAmsterdamthe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Norah Van Mello
- Amsterdam Reproduction and Development Research InstituteAmsterdam University Medical CenterAmsterdamthe Netherlands
- Obstetrics and GynecologyAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Ben W. Mol
- The Ritchie Centre, Department of Obstetrics and GynecologyMonash UniversityClaytonVictoriaAustralia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and NutritionUniversity of AberdeenAberdeenUK
| | - Jackie A. Ross
- Early Pregnancy and Gynaecology Assessment UnitKing's College London HospitalLondonUK
| | - Davor Jurkovic
- Institute for Women's HealthUniversity College LondonLondonUK
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Xiao C, Shi Q, Cheng Q, Xu J. Non-surgical management of tubal ectopic pregnancy: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e27851. [PMID: 34918633 PMCID: PMC8677977 DOI: 10.1097/md.0000000000027851] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 11/02/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Ectopic pregnancy (EP) is a common cause of acute abdominal pain in the field of gynecology. Because the majority of women with EP are hemodynamically stable, non-surgical therapy is a viable option. The goal of this study was to determine the most effective non-surgical therapy for hemodynamically stable EP. METHODS We performed a systematic review and meta-analysis. We searched PubMed, LILACS, SciELO, CINAHL, Embase, and the Cochrane library in May 2020, with no starting date restrictions.Studies were restricted to randomized controlled trials, which were included if the target population contained women with tubal EP and the intervention was non-surgical management. The primary outcome measure was treatment success defined by a decrease in serum hCG to a level ranging from five mIU/mL to 50 mIU/mL. Secondary outcome measures were side effects, time needed to treat, number of injections and operative rate. RESULTS We conducted a meta-analysis of 15 studies that included 1573 women who were diagnosed with EP and managed non-surgically. There was no significant difference in treatment success in the matched groups; however, single-dose MTX was associated with fewer side effects than multiple-dose (relative risk 0.48, 95% confidence interval 0.28-0.80, P = .006) and two-dose therapies (relative risk 0.74, 95% confidence interval 0.55-1.00, P = .05). CONCLUSIONS We highly recommend that single-dose MTX without mifepristone be used first-line in patients who require conservative therapy due to the inherent negative effects of mifepristone. An EP woman with a low -hCG level that is falling or plateauing should receive expectant treatment to reduce adverse effects.
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Affiliation(s)
- Chao Xiao
- Department of Obstetrics and Gynecology, Zigong First People's Hospital, Zigong, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan Province, China
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Qingquan Shi
- Center of Reproductive Medicine, West China Second University Hospital, Sichuan University, Chengdu, Sichuan Province, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, Sichuan Province, China
| | - Qijun Cheng
- Department of Obstetrics and Gynecology, Zigong First People's Hospital, Zigong, China
| | - Jianli Xu
- Department of Obstetrics and Gynecology, Zigong First People's Hospital, Zigong, China
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Methotrexate versus expectant management in ectopic pregnancy: a meta-analysis. Arch Gynecol Obstet 2021; 305:547-553. [PMID: 34524502 DOI: 10.1007/s00404-021-06236-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 09/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Ectopic pregnancy (EP) affects 1-2% of all pregnant females'(Barnhart et al., Expert Opin Pharmacother 2(3):409-417, 2001) that can require emergent surgical intervention. Noninvasive diagnostic tests like transvaginal ultrasound (TVUS), and serial β-hCG levels have enabled early diagnosis and allowed medical therapy to be tried. Methotrexate (MTX) versus expectant management, both have been considered safe but superiority of one over the other is lacking. METHODS We searched for RCT that have shown efficacy of MTX versus expectant management in hemodynamically stable patients. Our primary outcome was whether one modality is superior to the other. RESULTS Four RCT were included in the meta-analysis after review. Our pooled analysis when comparing MTX and expectant management showed us that the difference between the uneventful decline in β-hCG levels (treatment success) was statistically insignificant (RR = 1.06, 95% CI 0.93-1.21) with no significant heterogeneity between trials (I2 = 0.0%, P = 0.578). The difference between need for surgical intervention between methotrexate and expectant management was also statistically insignificant (RR = 0.77, 95% CI 0.43-1.40) with no significant heterogeneity between trials (I2 = 0.0%, P = 0.552). CONCLUSION We conclude that expectant management is not inferior to MTX in hemodynamically stable patients with ectopic pregnancy that have declining or low β-hCG levels.
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Case Report of Spontaneous Bilateral Ovarian Pregnancy in a Nulliparous Lady. Case Rep Obstet Gynecol 2021; 2021:6670763. [PMID: 34055434 PMCID: PMC8143897 DOI: 10.1155/2021/6670763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Accepted: 05/02/2021] [Indexed: 11/23/2022] Open
Abstract
Nontubal ectopic pregnancies, especially ovarian ones, are rare. Here, we report a case of spontaneous bilateral ovarian pregnancy in a 23-year-old nulliparous lady who presented with a three-day history of abdominal pain localized to the right iliac fossa. Laboratory investigations and pelvic US and transvaginal US findings were suggestive of a right ovarian ectopic pregnancy and left ovarian cyst. Following the patient's consent, the gynaecologist laparoscopically removed the right ovarian ectopic pregnancy and performed a left ovarian cystectomy. Histopathology revealed findings of trophoblastic tissue and chorionic villi with products of conception in both ovaries leading to the diagnosis of bilateral spontaneous ectopic pregnancy. Physicians must be mindful in cases that have a similar clinical presentation because an early diagnosis leads to a reduction in the morbidity and mortality of this specific patient population and helps to improve their overall prognosis.
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Mitwally MF, Hozayen WG, Hassanin KMA, Abdalla KA, Abdalla NK. Aromatase inhibitor letrozole: a novel treatment for ectopic pregnancy. Fertil Steril 2020; 114:361-366. [PMID: 32622660 DOI: 10.1016/j.fertnstert.2020.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To study the use of the aromatase inhibitor letrozole for treatment of ectopic pregnancy compared with methotrexate. DESIGN Nonrandomized prospective cohort study. SETTING University hospital. PATIENT(S) A series of 42 consecutive patients with undisturbed ectopic pregnancy. INTERVENTION(S) Counseling on treatment options, including surgical treatment (control group) versus medical treatment with methotrexate (group 1) or letrozole (group 2). MAIN OUTCOME MEASURE(S) Primary outcome: complete resolution of ectopic pregnancy determined by serum human chorionic gonadotropin (β-hCG) levels below laboratory immunoassay detection. SECONDARY OUTCOMES changes in the biochemical parameter of ovarian reserve, antimüllerian hormone (AMH), and hematologic changes associated with the two medical treatments compared with surgical treatment. RESULT(S) Each treatment group included 14 patients, and each patient made her own treatment choice. Complete resolution of ectopic pregnancy occurred in an equal number of patients: 12 out of 14 (86%) in each of the two medical treatment groups. Methotrexate treatment was associated with statistically significantly higher liver enzymes and lower blood platelets count. The decline in β-hCG levels was faster in the letrozole group when compared with the methotrexate group. Three months after treatment, AMH levels were lower in the methotrexate group when compared with the letrozole and the surgery groups. However, the decline in β-hCG and AMH levels was not statistically significant. CONCLUSION(S) To our knowledge, this is the first report in the literature on the success of letrozole for the medical treatment of ectopic pregnancy. The promisingly high resolution rate and better safety profile that letrozole has compared with a chemotherapeutic agent such as methotrexate should encourage further studies.
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Affiliation(s)
| | - Walaa G Hozayen
- Biochemistry Division,Chemistry Department, Faculty of Science, Beni-Suef University, Beni-Suef, Egypt
| | - Kamel M A Hassanin
- Biochemistry Department, Faculty of Veterinary Medicine, Minia University, El-Minia, Egypt
| | - Kamal A Abdalla
- Department of Obstetrics & Gynecology, Faculty of Medicine, Minia University, El-Minia, Egypt
| | - Noha K Abdalla
- Biotechnology and Life Sciences Department, Faculty of Postgraduate Studies for Advanced Sciences, Beni-Suef University, Beni-Suef, Egypt
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8
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Levin G, Meyer R, Dior U, Gilad R, Benshushan A, Shushan A, Rottenstreich A. Outcome of methotrexate treatment for ectopic pregnancies among obese women. J Gynecol Obstet Hum Reprod 2020; 49:101790. [PMID: 32413523 DOI: 10.1016/j.jogoh.2020.101790] [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: 04/02/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Single dose administration of methotrexate (MTX) is considered the first line of treatment in selected patients with an ectopic pregnancy (EP). However, data regarding MTX efficacy among obese patients is limited. We sought to investigate the efficacy of MTX single dose regimen among obese patients MATERIAL AND METHODS: A retrospective cohort study conducted at a gynecology department in a tertiary teaching hospital, between January 2010 and December 2018, including women diagnosed with an EP and treated by a single-dose regimen of MTX. We compared success rate and gestation characteristics between obese and non-obese women. RESULTS Overall, 195 women were treated with single-dose intramuscular MTX for EP during the study period. Of those, 31 women (15.9%) were obese (BMI ≥ 30 kg/m2) and the rest 164 (84.1%) were of normal body weight. Median MTX dosage for the obese group was 95 milligrams (IQR 91-104) vs. 83 milligrams (IQR 78-87) for the non-obese group. Treatment success rate of the overall cohort was 66.6% (130/195) and treatment success rate of single-dose MTX was comparable between the obese and non-obese groups (64.5% vs. 67.0%, p = 0.78). Obese patients were older as compared to non-obese (median age 33 vs. 29, p = 0.03). In multivariate logistic regression analysis, percentage hCG change from day 1 to day 4 was the only factor associated with treatment success (aOR 1.02; 95%CI 1.01, 1.04, p < 0.001). CONCLUSION Single-dose MTX treatment among obese patients diagnosed with ectopic pregnancy led to similar success rates as compared to non-obese patients.
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Affiliation(s)
- Gabriel Levin
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Raanan Meyer
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.
| | - Uri Dior
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronit Gilad
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Avi Benshushan
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Asher Shushan
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amihai Rottenstreich
- The Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Elci E, Elci G, Sayan S. Primary ovarian ectopic pregnancy case report. J OBSTET GYNAECOL 2019; 40:883-884. [PMID: 31478430 DOI: 10.1080/01443615.2019.1634023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Erkan Elci
- Department of Obstetrics and Gynecology, Van Training and Research Hospital, Van, Turkey
| | - Gulhan Elci
- Department of Obstetrics and Gynecology, Van Training and Research Hospital, Van, Turkey
| | - Sena Sayan
- Department of Obstetrics and Gynecology, Van Training and Research Hospital, Van, Turkey
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Alur-Gupta S, Cooney LG, Senapati S, Sammel MD, Barnhart KT. Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis. Am J Obstet Gynecol 2019; 221:95-108.e2. [PMID: 30629908 DOI: 10.1016/j.ajog.2019.01.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/18/2018] [Accepted: 01/02/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the treatment success and failure rates, as well as side effects and surgery rates, between methotrexate protocols. DATA SOURCES PubMed, Embase, and the Cochrane library searched up to July 2018. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared women with ectopic pregnancies receiving the single-dose, two-dose, or multi-dose methotrexate protocols. STUDY APPRAISAL AND SYNTHESIS METHODS Odds of treatment success, treatment failure, side effects, and surgery for tubal rupture, as well as length of follow-up until treatment success, were compared using random and fixed effects meta-analysis. Sensitivity analyses compared treatment success in the groups with high human chorionic gonadatropin (hCG) values and a large adnexal mass, as defined by individual studies. The Cochrane Collaboration tool was used to assess risk of bias. RESULTS The 2-dose protocol was associated with higher treatment success compared to the single-dose protocol (odds ratio [OR], 1.84; 95% CI, 1.13, 3.00). The 2-dose protocol was more successful in women with high hCG (OR, 3.23; 95% CI, 1.53, 6.84) and in women with a large adnexal mass (OR, 2.93; 95% CI, 1.23, 6.9). The odds of surgery for tubal rupture were lower in the 2-dose protocol (OR, 0.65; 95% CI, 0.26, 1.63), but this was not statistically significant. The length of follow-up was 7.9 days shorter for the 2-dose protocol (95% CI, -12.2, -3.5). The odds of side effects were higher in the 2-dose protocol (OR, 1.53; 95% CI, 1.01, 2.30). Compared to the single-dose protocol, the multi-dose protocol was associated with a nonsignificant reduction in treatment failure (OR, 0.56; 95% CI, 0.28, 1.13) and a higher chance of side effects (OR, 2.10; 95% CI, 1.24, 3.54). The odds of surgery for tubal rupture (OR, 1.62; 95% CI, 0.41, 6.49) and time to follow-up (OR, -1.3; 95% CI, -5.4, 2.7) were similar. CONCLUSION The 2-dose methotrexate protocol is superior to the single-dose protocol for the treatment of ectopic pregnancy in terms of treatment success and time to success. Importantly, these findings hold true in patients thought to be at a lower likelihood of responding to medical management, such as those with higher hCGs and a large adnexal mass.
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Affiliation(s)
- Snigdha Alur-Gupta
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA.
| | - Laura G Cooney
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA
| | - Suneeta Senapati
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA
| | - Mary D Sammel
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Kurt T Barnhart
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA
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11
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Levin G, Dior UP, Shushan A, Gilad R, Benshushan A, Rottenstreich A. Success rate of methotrexate treatment for recurrent vs. primary ectopic pregnancy: a case-control study. J OBSTET GYNAECOL 2019; 40:507-511. [DOI: 10.1080/01443615.2019.1621819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Uri P. Dior
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Asher Shushan
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronit Gilad
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Avi Benshushan
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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12
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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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Betti M, Vergani P, Damiani GR, Pellegrino A, Di Naro E, Trojano G, Pirovano C, Stomati M, Loverro M. Unilateral twin tubal pregnancy: a case report and review of the literature. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:423-427. [PMID: 30333471 PMCID: PMC6502111 DOI: 10.23750/abm.v89i3.6915] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/15/2018] [Indexed: 11/23/2022]
Abstract
Background:Unilateral twin tubal pregnancy is an extremely rare condition, occurring in 1/20.000-250.000 pregnancies and represents a major health risk for reproductive-aged women, leading to even life-threatening complications. Aim:We present a case of a 31-year-old woman with unilateral twin tubal pregnancy, treated with methotrexate and then surgically because of failure, followed by review of the literature. Methods: Researches for relevant data were conducted utilizing multiple databases, including PubMed and Ovid. Results: The most common type of twin ectopic pregnancy is the heterotopic (1/7000 pregnancies) in which in which both ectopic and intrauterine pregnancy occur simultaneously. Expectant, medical and surgical therapy have similar success rates in correctly selected patients. Two prospective randomized trials did not identify any statistically significant differences between groups receiving MTX as a single dose or in multiple doses. Among the 106 cases reported in literature, methotrexate was tried just in 4 patients (3 unilateral and 1 bilateral) before ours. Details are reported in the table 1. Conclusion: The recent shift in the treatment of singleton ectopic pregnancies to the less invasive medical therapy might apply even in the case of twin implants. (www.actabiomedica.it)
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Affiliation(s)
- Marta Betti
- Department of Obstetrics and Gynaecology, ASTT Lecco, Ospedale Alessandro Manzoni, Lecco, Italy.
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A risk prediction model for medical treatment failure in tubal pregnancy. Eur J Obstet Gynecol Reprod Biol 2018; 225:148-154. [PMID: 29727784 DOI: 10.1016/j.ejogrb.2018.04.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 04/11/2018] [Accepted: 04/15/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Methotrexate is an alternative treatment for tubal pregnancy. However, despite initial treatment, ∼15% of women eventually require surgery. This study aimed to identify the risk factors for medical treatment failure in tubal pregnancy and apply them to a risk prediction model. STUDY DESIGN This single-center retrospective cohort study included 123 participants initially treated medically for tubal pregnancy between January 2006 and December 2015. Logistic regression analysis was used to construct a risk prediction model (visually presented as a nomogram) for medical treatment failure. Model performance was assessed using discrimination and calibration. The medical treatment failure rate was 36.6%. The prediction model integrated the presence of a gestational sac, ectopic mass size, and follow-up β-human chorionic gonadotropin levels above cut-off values on days 4 and 7. The model used the following cut-off values: increased β-human chorionic gonadotropin levels by 1028.6 mIU/mL, 1.0457-fold higher than baseline level on day 4; and increased β-human chorionic gonadotropin levels by 1233 mIU/mL, 1.3025-fold higher than baseline level on day 7. RESULTS The corresponding areas under the receiver-operating characteristic curves were 0.8135 (95% confidence interval, 0.733-0.893) for the day 4 model and 0.8600 for the day 7 model (95% confidence interval, 0.788-0.932). Comparison of the day 4 and 7 models revealed no significant difference in their predictive abilities (P = 0.4318). CONCLUSIONS This model identified a substantial proportion of the participants who experienced medical treatment failure for tubal pregnancy. It was visualized as a nomogram, facilitating clinical application.
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Yuk JS, Lee JH, Park WI, Ahn HS, Kim HJ. Systematic review and meta-analysis of single-dose and non-single-dose methotrexate protocols in the treatment of ectopic pregnancy. Int J Gynaecol Obstet 2018; 141:295-303. [PMID: 29485731 DOI: 10.1002/ijgo.12473] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 10/14/2017] [Accepted: 02/23/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND It remains unclear which methotrexate protocol for the treatment of ectopic pregnancy has a higher success rate or a higher adverse effect rate. OBJECTIVE To compare the treatment success rates and adverse effect rates of single-dose and non-single-dose (two-dose and multi-dose) methotrexate protocols in the treatment of ectopic pregnancy. SEARCH STRATEGY Various databases including Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched on July 1, 2017, using search terms including "methotrexate" and "pregnancy." SELECTION CRITERIA Randomized controlled trials comparing different methotrexate protocols for the treatment of ectopic pregnancy were included. DATA COLLECTION AND ANALYSIS Relative risks (RRs) and 95% confidence intervals (CIs) were calculated to compare treatment success rates and adverse effect rates. MAIN RESULTS The single-dose and non-single-dose protocols had similar success rates (RR 1.00, 95% CI 0.96-1.04; 11 trials, 1121 patients, I2 =18%). The non-single-dose protocols had a higher adverse effect rate than did the single-dose protocol (RR 0.73, 95% CI 0.59-0.91; nine trials, 934 patients, I2 =0%). CONCLUSIONS The single-dose methotrexate protocol was the optimal protocol for the medical treatment of ectopic pregnancy.
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Affiliation(s)
- Jin-Sung Yuk
- Department of Obstetrics and Gynecology, College of Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University, Changwon, Korea
| | - Jung Hun Lee
- Department of Obstetrics and Gynecology, College of Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University, Changwon, Korea
| | - Won I Park
- Department of Obstetrics and Gynecology, Hangang Sacred Heart Hospital, School of Medicine, Hallym University, Seoul, Korea
| | - Hyeong Sik Ahn
- Institute for Evidence-Based Medicine, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea
| | - Hyun Jung Kim
- Institute for Evidence-Based Medicine, Department of Preventive Medicine, College of Medicine, Korea University, Seoul, Korea
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16
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Inal ZO, Inal HA. Comparison of Four Methods of Treating Ectopic Pregnancy: A Retrospective Cohort Study. Geburtshilfe Frauenheilkd 2018; 78:70-77. [PMID: 29375148 PMCID: PMC5778193 DOI: 10.1055/s-0043-122151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 10/29/2017] [Accepted: 11/01/2017] [Indexed: 12/27/2022] Open
Abstract
Objective
To compare the results of expectant management, single and multidose methotrexate (MTX) and surgical management of ectopic pregnancy (EP).
Materials and Methods
In this retrospective cohort study, the original files of 233 patients who were treated for EP between May 2009 and December 2016 were analyzed. The patients were assigned to the following groups based on the applied treatment methods: Group 1, expectant management (n = 24), Group 2, single-dose MTX (n = 144), Group 3, multiple-dose MTX (n = 25), and Group 4, surgical intervention (n = 40). The following parameters were recorded and assessed: sociodemographic characteristics, pelvic ultrasonography findings (gestational sac, ectopic mass appearance, positive fetal cardiac activity), serum beta-human chorionic gonadotropin (β-hCG) levels on Day 0, Day 4, and Day 7, and surgical procedures in women that underwent surgical interventions.
Results
The sociodemographic characteristics were similar in all four groups. The percentage of ectopic mass and positive fetal cardiac activity was greater and the diameter of the mass was larger in Group 4 than in the other groups. The β-hCG values on Day 0, Day 4, and Day 7 were statistically different between the groups (p < 0.001). The cutoff value for the β-hCG change for EP resolution was 18% between Day 0 and Day 4 (AUC = 0.726, p < 0.001) and 15% between Day 4 and Day 7 (AUC = 0.874, p < 0.001). The probability of the requirement for an additional dose of MTX was 0.78 (95% CI 0.71 – 0.87; p < 0.001) times lower in patients who had a > 18% decrease in β-hCG levels from Day 0 to Day 4 in comparison to those who had a decrease < 18% from Day 0 to Day 4. The probability of the requirement for an additional dose of MTX was 1.64 (95% CI 1.25 – 2.16; p < 0.001) times greater in patients whose reduction in β-hCG levels from Day 4 to Day 7 was < 15% in comparison to those who had > 15% reduction from Day 4 to Day 7.
Conclusions
Additional dose requirements for patients with EP may be predicted early in the changes in β-hCG levels between Day 0 and Day 4. Further prospective studies are required to elucidate this issue.
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Affiliation(s)
- Zeynep Ozturk Inal
- Konya Education and Research Hospital, Department of Gynecology, Konya, Turkey
| | - Hasan Ali Inal
- Konya Education and Research Hospital, Department of Gynecology, Konya, Turkey
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17
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Hsu JY, Chen L, Gumer AR, Tergas AI, Hou JY, Burke WM, Ananth CV, Hershman DL, Wright JD. Disparities in the management of ectopic pregnancy. Am J Obstet Gynecol 2017; 217:49.e1-49.e10. [PMID: 28288792 PMCID: PMC5484775 DOI: 10.1016/j.ajog.2017.03.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/26/2017] [Accepted: 03/02/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ectopic pregnancy is common among young women. Treatment can consist of either surgery with salpingectomy or salpingostomy or medical management with methotrexate. In addition to acute complications, treatment of ectopic pregnancy can result in long-term sequelae that include decreased fertility. Little is known about the patterns of care and predictors of treatment in women with ectopic pregnancy. Similarly, data on outcomes for various treatments are limited. OBJECTIVE We examined the patterns of care and outcomes for women with ectopic pregnancy. Specifically, we examined predictors of medical (vs surgical) management of ectopic pregnancy and tubal conservation (salpingostomy vs salpingectomy) among women who underwent surgery. STUDY DESIGN The Perspective database was used to identify women with a diagnosis of tubal ectopic pregnancy treated from 2006-2015. Perspective is an all-payer database that collects data on patients at hospitals from throughout the United States. Women were classified as having undergone medical treatment, if they received methotrexate, and surgical treatment, if treatment consisted of salpingostomy or salpingectomy. Multivariable models were developed to examine predictors of medical treatment and of tubal conserving salpingostomy among women who were treated surgically. RESULTS Among the 62,588 women, 49,090 women (78.4%) were treated surgically, and 13,498 women (21.6%) received methotrexate. Use of methotrexate increased from 14.5% in 2006 to 27.3% by 2015 (P<.001). Among women who underwent surgery, salpingostomy decreased over time from 13.0% in 2006 to 6.0% in 2015 (P<.001). Treatment in more recent years, at a teaching hospital and at higher volume centers, were associated with the increased use of methotrexate (P<.05 for all). In contrast, Medicaid recipients (adjusted risk ratio, 0.92; 95% confidence interval, 0.87-0.98) and uninsured women (adjusted risk ratio, 0.87; 95% confidence interval, 0.82-0.93) were less likely to receive methotrexate than commercially insured patients. Among those who underwent surgery, black (adjusted risk ratio, 0.76; 95% confidence interval, 0.69-0.85) and Hispanic (adjusted risk ratio, 0.80; 95% confidence interval, 0.66-0.96) patients were less likely to undergo tubal conserving surgery than white women and Medicaid recipients (adjusted risk ratio, 0.69; 95% confidence interval, 0.64-0.75); uninsured women (adjusted risk ratio, 0.60; 95% confidence interval, 0.55-0.66) less frequently underwent salpingostomy than commercially insured patients. CONCLUSION There is substantial variation in the management of ectopic pregnancy. There are significant race- and insurance-related disparities associated with treatment.
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Affiliation(s)
- Jennifer Y Hsu
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Ling Chen
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Arielle R Gumer
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Ana I Tergas
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; New York Presbyterian Hospital, New York, NY
| | - June Y Hou
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Hospital, New York, NY
| | - William M Burke
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Hospital, New York, NY
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Dawn L Hershman
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; New York Presbyterian Hospital, New York, NY
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Hospital, New York, NY.
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18
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Pretreatment serum human chorionic gonadotropin cutoff value for medical treatment success with single-dose and multi-dose regimen of methotrexate in tubal ectopic pregnancy. Obstet Gynecol Sci 2017; 60:79-86. [PMID: 28217676 PMCID: PMC5313368 DOI: 10.5468/ogs.2017.60.1.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/11/2016] [Accepted: 08/14/2016] [Indexed: 11/23/2022] Open
Abstract
Objective To investigate individual pretreatment serum human chorionic gonadotropin (hCG) cutoff value for medical treatment success with single-dose and multi-dose regimen of methotrexate in tubal ectopic pregnancy. Methods Eighty-five women who received methotrexate for the treatment of tubal ectopic pregnancy during 2003 to 2015 were selected. Fifty-three women received a single-dose regimen and 32 women received a multi-dose regimen. Medical treatment failure was defined as necessity of surgical treatment. The medical treatment success rate was estimated in both regimens and the pretreatment serum hCG titer to predict the success was assessed by receiver operating characteristics curve analysis. Results Pretreatment clinical and laboratory parameters were similar between group of single-dose regimen and multi-dose regimen. Treatment success rate was 64.2% in the single-dose regimen group and 71.9% in the multi-dose regimen group (P>0.05). Pretreatment serum hCG titer was an independent prognostic factor for treatment success in each regimen. Serum hCG cutoff value to predict the treatment success was 3,026 IU/L in single-dose regimen group and 3,711 IU/L in multi-dose regimen group. Conclusion We recommend use of single-dose regimen when pretreatment serum hCG <3,026 IU/L but multi-dose regimen may be favored when initial serum hCG level between 3,026 and 3,711 IU/L.
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Yang C, Cai J, Geng Y, Gao Y. Multiple-dose and double-dose versus single-dose administration of methotrexate for the treatment of ectopic pregnancy: a systematic review and meta-analysis. Reprod Biomed Online 2017; 34:383-391. [PMID: 28131495 DOI: 10.1016/j.rbmo.2017.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 01/01/2017] [Accepted: 01/04/2017] [Indexed: 01/01/2023]
Abstract
In this systematic review and meta-analysis, the effectiveness and safety among different dosage of methotrexate protocols for the treatment of unruptured tubal ectopic pregnancy was evaluated. Six studies of randomized contorlled trials were identified through searches conducted on PubMed, Embase and Cochrane Library between January 1974 and March 2016. The overall success rate of multiple-dose protocol was similar to the single-dose protocol (RR 1.07, 95% CI 0.99 to 1.17, I2 = 0%). The difference between double-dose and single-dose groups was not significant (RR 1.09, 95% CI 0.98 and 1.20, I2 = 0%). The incidence of side-effects of double-dose regimen was similar with single-dose regimen. Side-effects, however, are more common in multiple-dose regimen (RR 1.64, 95% CI 1.15 to 2.34, P = 0.006, I2 = 0%). This meta-analysis indicated that the incidence of side-effects of multiple-dose protocol was significantly higher than single-dose protocol, and the success rates between them were similar. The double-dose regimen was an efficient and safe alternative to the single-dose protocol. Further high-quality researches are needed to confirm our findings and to develop the optimal protocol.
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Affiliation(s)
- Chun Yang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jing Cai
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yuhong Geng
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ying Gao
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Yang J, Na YJ, Song YJ, Choi OH, Lee SK, Kim HG. The effectiveness of laparoendoscopic single-site surgery (LESS) compared with conventional laparoscopic surgery for ectopic pregnancy with hemoperitoneum. Taiwan J Obstet Gynecol 2016; 55:35-9. [PMID: 26927245 DOI: 10.1016/j.tjog.2015.02.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2015] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE The purpose of this study was to compare clinical outcomes of conventional laparoscopic surgery and laparoendoscopic single-site surgery (LESS) in the surgical treatment of tubal ectopic pregnancy. MATERIAL AND METHODS A total of 156 patients were diagnosed with ectopic pregnancies by ultrasonography and serum β-human chorionic gonadotrophin (β-hCG) levels at Pusan National University Yangsan Hospital from January 2009 through December 2013. We excluded 28 patients who only received medical treatment, 15 patients who underwent surgery by laparotomy for severe hypovolemic shock, and 30 patients who presented with less than 1 L of hemoperitoneum. Of the 83 patients with massive hemoperitoneum, 38 patients had LESS performed while the remaining 45 patients underwent conventional laparoscopic surgery. RESULTS In this study, there were no statistically significant differences in clinical outcomes in either surgical method except for operative time. Operative time of LESS was significantly shorter than conventional surgery for patients with more than 500 mL of hemoperitoneum. CONCLUSION LESS is a safe and feasible surgical approach in the treatment of tubal ectopic pregnancy. At the same time, LESS has been shown to be more effective than conventional laparoscopic surgery in handling massive hemoperitoneum of more than 1 L, which is a common complication of ectopic pregnancy.
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Affiliation(s)
- Juseok Yang
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, South Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea
| | - Yong Jin Na
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, South Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea
| | - Yong Jung Song
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, South Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea
| | - Ook Hwan Choi
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, South Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea
| | - Sun Kyung Lee
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, South Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea
| | - Hwi Gon Kim
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, South Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea.
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Song T, Kim MK, Kim ML, Jung YW, Yun BS, Seong SJ. Single-dose versus two-dose administration of methotrexate for the treatment of ectopic pregnancy: a randomized controlled trial. Hum Reprod 2015; 31:332-8. [PMID: 26701971 DOI: 10.1093/humrep/dev312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/20/2015] [Indexed: 12/27/2022] Open
Abstract
STUDY QUESTION Can a two-dose methotrexate treatment protocol improve the treatment success rate compared with a single-dose protocol in women with an ectopic pregnancy? SUMMARY ANSWER The two-dose protocol was not superior to the single-dose protocol for the treatment of ectopic pregnancy. WHAT IS KNOWN ALREADY Although the two-dose methotrexate protocol for ectopic pregnancy was recently introduced to combine the efficacy and convenience of the fixed multi-dose and single-dose protocols, studies comparing the success rates, treatment satisfaction and acceptability of the single-dose and two-dose treatment protocols for ectopic pregnancy are currently lacking. STUDY DESIGN, SIZE, DURATION A randomized trial was conducted on 92 participants with tubal ectopic pregnancy, between May 2013 and April 2015. PARTICIPANT/MATERIALS, SETTING, METHODS Patients who were diagnosed with tubal ectopic pregnancy and who elected to undergo systemic methotrexate treatment were randomly assigned to follow either the single-dose (n = 46) or two-dose protocol (n = 46). The primary outcome measure was treatment success without surgical intervention. The secondary outcome measures were the incidence of methotrexate-associated side effects, β-human chorionic gonadotrophin (β-hCG) resolution time, cost of care received and treatment satisfaction. MAIN RESULTS AND THE ROLE OF CHANCE There were no differences in baseline characteristics between the groups. The success rates between the single-dose and two-dose groups did not show a significant difference [82.6 versus 87.0%; relative risk (RR) 0.95; 95% confidence interval (CI) 0.80-1.13]. However, the success rate in a subgroup of participants with a pretreatment β-hCG level of >5000 mIU/ml appeared to be higher in the two-dose group than in the single-dose group (80.0 versus 58.8%), although the difference was not statistically significant. No significant differences in methotrexate-associated side effects, cost or treatment satisfaction were observed between the groups. The two-dose group required a lower number of days for the β-hCG level to decrease to <5 mIU/ml than the single-dose group (25.7 ± 13.6 versus 31.9 ± 14.1 days; P = 0.025). LIMITATIONS, REASONS FOR CAUTION Some caution is warranted in interpreting the results due to an overoptimistic sample size calculation on the basis of the biggest difference as reported in literature between the success rates of two protocols. WIDER IMPLICATIONS OF THE FINDINGS The single-dose protocol with the option to elaborate to a second dose in the case of treatment failure could stand as the treatment for most cases of ectopic pregnancy. STUDY FUNDING/COMPLETING OF INTERESTS None. TRIAL REGISTRATION NUMBER www.clinicaltrials.gov, no. NCT01855568. TRIAL REGISTRATION DATE 10 May 2013. DATE OF FIRST PATIENT'S ENROLMENT 26 May 2013.
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Affiliation(s)
- Taejong Song
- Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Mi-La Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Yong Wook Jung
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Bo Seong Yun
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
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Saadati N, Najafian M, Masihi S, Safiary S, Abedi P. Comparison of Two Different Protocols of Methotrexate Therapy in Medical Management of Ectopic Pregnancy. IRANIAN RED CRESCENT MEDICAL JOURNAL 2015; 17:e20147. [PMID: 26756008 PMCID: PMC4706730 DOI: 10.5812/ircmj.20147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 07/15/2014] [Accepted: 08/13/2014] [Indexed: 11/30/2022]
Abstract
Background: Ectopic pregnancy (EP) is one of the most dangerous complications of pregnancy and without prompt diagnosis and treatment, it could become a major cause of maternal morbidity and mortality. Objectives: In this randomized controlled study, we compared single and double dose of methotrexate (MTX) therapy in the treatment of ectopic pregnancy. Patients and Methods: This study was performed on 76 patients who were admitted to Obstetrics Ward with primary diagnosis of ectopic pregnancy based on their medical history, physical examination, beta subunit (β-HCG) level, and transvaginal ultrasonography. Using random block allocation, the patients were classified in two groups of single dose and double dose administration of MTX. In single dose group, 50 mg/m2 of MTX was given at day 0 and in double dose group, the patients received two doses of MTX at day 0 and 4. The level of β-HCG was measured at day 0, 4, 7 in both groups. The successful treatment was defined as 15% reduction in β-HCG level between day 4 and 7. The two groups were compared with each other with regard to their need for operation, or extra dose of MTX; duration of hospitalization; and MTX complications. Results: Results showed that the rate of success in double dose method was more than single dose one (79% versus 69%) but the difference was not significant (P = 0.29). Although the need for operation and extra dose of MTX were lower in the double dose group (15.8% vs. 18.8% and 5.26% vs. 13.2%, respectively), these differences were not significant too. Duration of hospitalization was significantly lower in double dose compared to the single dose (11.55 d vs. 14.76 d, P < 0.001). Conclusions: Single dose therapy of MTX has sufficient power and efficacy in the treatment of ectopic pregnancy, however in patients with higher serum level of β-HCG, the successful treatment increases by using double dose method. Using double dose also could decrease the necessity of operation, re-administration of MTX, and duration of hospitalization.
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Affiliation(s)
- Najmieh Saadati
- Obstetrics and Gynecology Department, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
| | - Mahin Najafian
- Obstetrics and Gynecology Department, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
- Corresponding Author: Mahin Najafian, Obstetrics and Gynecology Department, Fertility Infertility and Perinatology Research Center, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran. Tel: +98-9161188801, Fax: +98-6113738333, E-mail:
| | - Sara Masihi
- Obstetrics and Gynecology Department, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
| | - Sara Safiary
- Obstetrics and Gynecology Department, Fertility Infertility and Perinatology Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
| | - Parvin Abedi
- Midwifery Department, Reproductive Health Promotion Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran
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Panelli DM, Phillips CH, Brady PC. Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. FERTILITY RESEARCH AND PRACTICE 2015; 1:15. [PMID: 28620520 PMCID: PMC5424401 DOI: 10.1186/s40738-015-0008-z] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 09/29/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar. FINDINGS Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality. CONCLUSION This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.
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Affiliation(s)
- Danielle M. Panelli
- Department of Obstcpetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115 USA
| | - Catherine H. Phillips
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Paula C. Brady
- Department of Obstcpetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115 USA
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Randomized comparison of health-related quality of life in women with ectopic pregnancy or pregnancy of unknown location treated with systemic methotrexate or expectant management. Eur J Obstet Gynecol Reprod Biol 2015; 192:1-5. [DOI: 10.1016/j.ejogrb.2015.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 05/31/2015] [Accepted: 06/03/2015] [Indexed: 11/20/2022]
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Predictors of success of different treatment modalities for management of ectopic pregnancy. Obstet Gynecol Int 2014; 2014:423708. [PMID: 25580127 PMCID: PMC4279122 DOI: 10.1155/2014/423708] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2014] [Accepted: 11/26/2014] [Indexed: 11/23/2022] Open
Abstract
Aim. The purpose of this study was to investigate factors affecting the success of different treatment modalities for the management of ectopic pregnancy (EP).
Methods. One hundred and ninety-seven patients with EP, were included in the study. Patients were treated with either intramuscular methotrexate (Mtx) or surgical treatment. Results. Mtx was applied in 97 (49.2%) patients. In 67 patients (69.1%), a single dose of Mtx and in 30 patients (30.9%) a multiple dose of Mtx was applied. Forty-seven (70.14%) patients were successfully treated with a single-dose Mtx. In the multiple-dose group, the success rate was 70% (21/30 patients). The difference between the success rates was not statistically significant. When the initial serum βhCG value was <1000 mIU/mL, the overall success rate of Mtx treatment was determined to be 86.11%; however, the rate decreased to 42.3% when the βhCG value was >3000 mIU/mL. On the other hand, if the EP mass diameter was <25 mm, the success rate was 89.28% and decreased to 52.63% when it was ≥25 mm. Conclusion. The results of the study showed that single-dose treatment with Mtx could be as successful as multiple doses. Overall success of Mtx treatment depended on initial βhCG value and EP mass diameter.
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Kim MK, Kim JJ, Choi JS, Eom JM, Lee JH. Prospective comparison of single port versus conventional laparoscopic surgery for ectopic pregnancy. J Obstet Gynaecol Res 2014; 41:590-5. [DOI: 10.1111/jog.12595] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 08/12/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Min Kyung Kim
- Department of Obstetrics and Gynecology; Kangbuk Samsung Hospital; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Jeong Jin Kim
- Department of Obstetrics and Gynecology; Kangbuk Samsung Hospital; Sungkyunkwan University School of Medicine; Seoul Korea
| | - Joong Sub Choi
- Department of Obstetrics and Gynecology; College of Medicine; Hanyang University; Seoul Korea
| | - Jeong Min Eom
- Department of Obstetrics and Gynecology; National Medical Center; Seoul Korea
| | - Jung Hun Lee
- Department of Obstetrics and Gynecology; MizMedi Hospital, Eulji University School of Medicine; Seoul Korea
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27
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Cecchino GN, Araujo Júnior E, Elito Júnior J. Methotrexate for ectopic pregnancy: when and how. Arch Gynecol Obstet 2014; 290:417-23. [DOI: 10.1007/s00404-014-3266-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 04/17/2014] [Indexed: 11/24/2022]
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28
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Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril 2013; 100:638-44. [DOI: 10.1016/j.fertnstert.2013.06.013] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 06/07/2013] [Indexed: 10/26/2022]
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29
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Yasutake N, Tsunematsu R, Oishi H, Yahata H, Uchida S, Kobayashi H, Kato K. Successfully treated abdominal pregnancy causing hemoperitoneum using combined surgical and systemic methotrexate therapy: a case report and review of cases treated at Kyushu University Hospital. Gynecol Obstet Invest 2013; 76:188-92. [PMID: 23969319 DOI: 10.1159/000353980] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 06/19/2013] [Indexed: 11/19/2022]
Abstract
Abdominal pregnancy is a rare condition that accounts for only 1% of all ectopic pregnancies but results in high maternal morbidity and mortality. We present a case of abdominal pregnancy with massive peritoneal bleeding successfully treated using systemic methotrexate (MTX). A 34-year-old woman with amenorrhea for 8 weeks and a positive pregnancy test was referred for evaluation of ectopic pregnancy. Transvaginal ultrasonographic scan showed a gestational sac measuring 25 mm in diameter containing a viable embryo in the cul-de-sac and a considerable amount of free fluid in the patient's lower abdomen and pelvis. Laboratory parameters showed that her hemoglobin concentration was 5.8 g/dl and serum human chorionic gonadotropin concentration was 13,195 mIU/ml. Emergency surgery revealed an abdominal pregnancy in the cul-de-sac and a massive intra-abdominal hemorrhage. After a hemostasis procedure, the patient was successfully treated using systemic MTX. We also present the review of abdominal pregnancy cases treated using systemic MTX at our institution over 10 years. Systemic MTX treatment for abdominal pregnancy is safe and effective and makes it possible to avoid the risk of excessive bleeding by surgical resection of the implantation site.
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Affiliation(s)
- Nobuko Yasutake
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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The importance of gestational sac size of ectopic pregnancy in response to single-dose methotrexate. ISRN OBSTETRICS AND GYNECOLOGY 2013; 2013:269425. [PMID: 23762575 PMCID: PMC3666270 DOI: 10.1155/2013/269425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 02/05/2013] [Indexed: 11/18/2022]
Abstract
This retrospective cohort study was designed in a selective group of 185 patients diagnosed with and treated for ectopic pregnancy. Intramuscular administration of a single dose of methotrexate (50 mg/m2) was performed to measure predictors of failure or resistance to treatment necessitating surgical intervention. During the time of treatment with a single dose of MTX, 20 patients (10.8%) failed to response, in which 6 of 20 (30%) indicated side effects to MTX and rupture of the ectopic pregnancy. Remaining cases (n = 14) showed resistance to the drug; the level of β-hCG did not fall at least 15% during 7 days after treatment and necessitated laparotomy. In backward-step analysis by multiple logistic regressions of various types of predictor factors, size of gestational sac (coefficient = 1.91, OR = 6.78, 95% confidence interval = 3.18–8.22) and baseline level β-hCG (coefficient = 1.60, OR = 5.0, 95% confidence interval = 4.26–6.72) had significant correlation with leading EP patients failing to response to MTX. This study suggests that further investigation for finding relative contraindications of MTX treatment in EP women should be considered on the gestational sac size because other variables are in the causal pathway of this variable.
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31
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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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32
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A pragmatic and evidence-based management of ectopic pregnancy. J Minim Invasive Gynecol 2013; 20:446-54. [PMID: 23587907 DOI: 10.1016/j.jmig.2013.02.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Revised: 02/08/2013] [Accepted: 02/08/2013] [Indexed: 01/14/2023]
Abstract
The incidence of ectopic pregnancy is approximately 2% of all pregnancies, and it remains the leading cause of death in early pregnancy. Over 95% of ectopic pregnancies are tubal pregnancies, and the remainders are nontubal pregnancies. The highest risk factor for ectopic pregnancy is a previous tubal pregnancy followed by previous tubal surgery, tubal sterilization, tubal pathology, and current intrauterine device use. The apparent increase in the incidence of nontubal ectopic pregnancy including heterotopic pregnancy may be attributed to the increasing number of pregnancies because of in vitro fertilization treatment. In most cases, an ectopic pregnancy can be treated medically with a single dose of methotrexate. Surgical treatment is still needed in women who are hemodynamically unstable and in those who do not fulfill the criteria for methotrexate treatment. Usually surgical treatment can be performed by laparoscopy and in some cases by hysteroscopy. Laparotomy is rarely needed even in women with intraperitoneal bleeding.
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33
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Patil M. Ectopic pregnancy after infertility treatment. J Hum Reprod Sci 2012; 5:154-65. [PMID: 23162353 PMCID: PMC3493829 DOI: 10.4103/0974-1208.101011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 03/14/2012] [Accepted: 03/15/2012] [Indexed: 12/27/2022] Open
Abstract
Early pregnancy complications are more common in women who conceive after infertility treatment. Most of these occur before 12 weeks of gestation and include miscarriage, vaginal bleeding, intrauterine hematoma, vanishing twin, and ectopic pregnancy (EP). The incidence of EPs following infertility treatment is much higher compared with that in spontaneous pregnancies. The occurrence of an EP is very distressing to an infertile couple, who has lots of hopes pinned on the treatment outcome, especially because of the cost incurred and the physical and mental trauma both have gone through during the treatment process. The association between infertility and EP is complex, as it can be a consequence of infertility as well as a cause. The two principal risk factors for an EP are genital tract infections and tubal surgeries. Though several etiologies are proposed, but patients with tubal factor infertility are at an increased risk of an EP. Earlier diagnosis of EP helps to improve prognosis and optimize subsequent fertility. It is pivotal to evaluate the likelihood of subsequent occurrence of an EP and be too vigilant when treating. The correct choice of the treatment modality should be made to prevent the recurrence. The early prediction of the pregnancy outcome therefore has great importance for both the couple and clinician. Today with the help of sensitive beta human chorionic gonadotropin (β-hCG) assays and transvaginal sonography, one can diagnose an EP prior to symptoms, and conservative treatment for the preservation of the fallopian tube is possible. Conservative management in the form of expectant and medical management should be considered as a first-line treatment modality, provided that the overall clinical picture suggests that it is safe to do so. If not, laparoscopic management of EPs appears to be the favored approach of management as compared to laparotomy.
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Affiliation(s)
- Madhuri Patil
- Dr. Patil's Fertility and Endoscopy Clinic, Bangalore, Karnataka, India
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34
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van Mello NM, Mol F, Verhoeve HR, van Wely M, Adriaanse AH, Boss EA, Dijkman AB, Bayram N, Emanuel MH, Friederich J, van der Leeuw-Harmsen L, Lips JP, Van Kessel MA, Ankum WM, van der Veen F, Mol BW, Hajenius PJ. Methotrexate or expectant management in women with an ectopic pregnancy or pregnancy of unknown location and low serum hCG concentrations? A randomized comparison. Hum Reprod 2012; 28:60-7. [PMID: 23081873 DOI: 10.1093/humrep/des373] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What is the treatment success rate of systemic methotrexate (MTX) compared with expectant management in women with an ectopic pregnancy or a pregnancy of unknown location (PUL) with low and plateauing serum hCG concentrations? SUMMARY ANSWER In women with an ectopic pregnancy or a PUL and low and plateauing serum hCG concentrations, expectant management is an alternative to medical treatment with single-dose systemic MTX. WHAT IS KNOWN AND WHAT THIS PAPER ADDS MTX is often used in asymptomatic women with an ectopic pregnancy or a PUL with low and plateauing serum hCG concentrations. These pregnancies may be self-limiting and watchful waiting is suggested as an alternative, but evidence from RCTs is lacking. The results of this RCT show that expectant management is an alternative to treatment with systemic MTX in a single-dose regimen in these women. STUDY DESIGN, SIZE, DURATION A multicentre RCT women were assigned to systemic MTX (single dose) treatment or expectant management, using a web-based randomization program, block randomization with stratification for hospital and serum hCG concentration (<1000 versus 1000-2000 IU/l). The primary outcome measure was an uneventful decline of serum hCG to an undetectable level (<2 IU/l) by the initial intervention strategy. Secondary outcome measures included additional treatment, side effects and serum hCG clearance time. PARTICIPANTS, SETTING, METHODS From April 2007 to January 2012, we performed a multicentre study in The Netherlands. All haemodynamically stable women >18 years old with both an ectopic pregnancy visible on transvaginal sonography and a plateauing serum hCG concentration <1500 IU/l or with a PUL and a plateauing serum hCG concentration <2000 IU/l were eligible for the trial. MAIN RESULTS We included 73 women of whom 41 were allocated to single-dose MTX and 32 to expectant management. There was no difference in primary treatment success rate of single-dose MTX versus expectant management, 31/41 (76%) and 19/32 (59%), respectively [relative risk (RR) 1.3 95% confidence interval (CI) 0.9-1.8]. In nine women (22%), additional MTX injections were needed, compared with nine women (28%) in whom systemic MTX was administered after initial expectant management (RR 0.8; 95% CI 0.4-1.7). One woman (2%) from the MTX group underwent surgery compared with four women (13%) in the expectant management group (RR 0.2; 95% CI 0.02-1.7), all after experiencing abdominal pain within the first week of follow-up. In the MTX group, nine women reported side effects versus none in the expectant management group. No serious adverse events were reported. Single-dose systemic MTX does not have a larger treatment effect compared with expectant management in women with an ectopic pregnancy or a PUL and low and plateauing serum hCG concentrations. WIDER IMPLICATIONS OF THE FINDINGS Sixty percent of women after expectant management had an uneventful clinical course with steadily declining serum hCG levels without any intervention, which means that MTX, a potentially harmful drug, can be withheld in these women. BIAS, LIMITATION AND GENERALISABILITY: A limitation of this RCT is that it was an open (not placebo controlled) trial. Nevertheless, introduction of bias was probably limited by the strict criteria to be fulfilled for treatment with MTX. STUDY FUNDING This trial is supported by a grant of the Netherlands Organization for Health Research and Development (ZonMw Clinical fellow grant 90700154). TRIAL REGISTRATION ISRCTN 48210491.
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Affiliation(s)
- N M van Mello
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, PO Box 22700, 1100 DE Amsterdam, The Netherlands.
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Abstract
The use of medical management of ectopic pregnancy has become an accepted alternative to surgical therapy. Methotrexate, a folic acid antagonist, is the most widely studied agent. The most commonly used protocol consists of methotrexate 50 mg/m of actual body weight. Assessment of human chorionic gonadotropin (hCG) levels is repeated on days 4 and 7. Repeat methotrexate dosing is performed for hCG drops < 15%. Contraindications include hemodynamically unstable patients or those with elevated liver enzymes, low white blood count, or abnormal renal function. hCG levels are most predictive of success. A success rate of above 90% is achievable.
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36
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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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37
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Gungorduk K, Asicioglu O, Yildirim G, Gungorduk OC, Besimoglu B, Ark C. Comparison of single-dose and two-dose methotrexate protocols for the treatment of unruptured ectopic pregnancy. J OBSTET GYNAECOL 2011; 31:330-4. [DOI: 10.3109/01443615.2011.560301] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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38
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Laparoendoscopic Single-Site Salpingectomy in Isthmic and Ampullary Ectopic Pregnancy: Preliminary Report and Technique. J Minim Invasive Gynecol 2011; 18:230-3. [DOI: 10.1016/j.jmig.2010.12.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 12/07/2010] [Accepted: 12/09/2010] [Indexed: 11/22/2022]
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39
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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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40
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Cetin M, Yildiz C, Yenicesu AGI, Cetin A. Spontaneous twin cervico-isthmic pregnancy in a grand multiparous woman. J Obstet Gynaecol Res 2010; 36:1112-5. [PMID: 21058446 DOI: 10.1111/j.1447-0756.2010.01256.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cervico-isthmic pregnancy is a rare form of ectopic pregnancy and is defined as the implantation of a fertilized ovum in the cervico-isthmic portion. The cause is unknown; local pathology related to previous cervical or uterine surgery may play a role, given an apparent association with a prior history of curettage or cesarean delivery. Transvaginal ultrasonography and β-human chorionic gonadotrophin assays are useful for diagnosis. Here we report a case of spontaneous twin cervico-isthmic pregnancy in a grand multiparous patient who was diagnosed early in the first trimester with transvaginal ultrasonography. The pregnancy was terminated successfully with methotrexate. Methotrexate seems to be most successful at early gestational ages.
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Affiliation(s)
- Meral Cetin
- Department of Obstetrics and Gynecology, Cumhuriyet University School of Medicine, Sivas, Turkey
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41
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Dilbaz S, Guven ESG, Yildirim BA, Gelisen O, Karcaaltincaba D, Kurtaran V, Haberal A. Is it necessary to operate on all women with an acute abdomen following medical treatment of tubal ectopic pregnancy? J OBSTET GYNAECOL 2010; 30:496-500. [PMID: 20604655 DOI: 10.3109/01443615.2010.481734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The main objective of this retrospective study is to evaluate the question of whether it is necessary to perform surgery for patients who develop an acute abdomen after methotrexate administration in cases of tubal ectopic pregnancy. A total of 26 women with tubal ectopic pregnancy who required emergency surgical evaluation after a single dose of methotrexate treatment were included. The surgical findings were tubal abortion (10 cases, 38.4%); tubal rupture (12 cases, 46.2%) and tubal haematoma (4 cases, 15.4%). The average time for initiation of severe abdominal pain following single dose methotrexate treatment was 6.12 +/- 2.10 days (range, 2-10). The most common site of implantation was isthmus (50.0%) and 38.5% (five patients) of the patients had tubal abortion from this part of the tube, while 46.1% of women (six patients) with isthmic localisation had a tubal rupture. Following medical treatment of ectopic pregnancy, surgery may be an option in the presence of symptoms/signs of acute abdomen (in the presence or absence of haemodynamic instability) and free pelvic fluid on sonography for only patients with isthmic tubal ectopic pregnancy, or if the isthmic localisation of tubal ectopic pregnancy is suspected on sonography.
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Affiliation(s)
- S Dilbaz
- Department of Obstetrics and Gynecology, Etlik Zubeyde Hanim Womens' Health and Teaching Hospital, Ankara, Turkey
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Gervaise A, Fernandez H. Prise en charge diagnostique et thérapeutique des grossesses extra-utérines. ACTA ACUST UNITED AC 2010; 39:F17-24. [PMID: 20395072 DOI: 10.1016/j.jgyn.2010.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 12/18/2009] [Indexed: 10/19/2022]
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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: 9] [Impact Index Per Article: 0.6] [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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Affiliation(s)
- Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania Medical Center, Philadelphia, PA 19104, USA.
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Darbhamulla A, Bhal K, Lal S. Is routine monitoring of hepatic and renal function beneficial following single-dose methotrexate treatment for ectopic pregnancy? A 4-year review of experience from a teaching hospital. J OBSTET GYNAECOL 2009; 28:434-5. [DOI: 10.1080/01443610802163773] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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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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Surgical treatment of ectopic pregnancy. Best Pract Res Clin Obstet Gynaecol 2009; 23:519-27. [PMID: 19231293 DOI: 10.1016/j.bpobgyn.2008.12.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2008] [Revised: 12/20/2008] [Accepted: 12/22/2008] [Indexed: 11/22/2022]
Abstract
Ectopic pregnancy remains the leading cause of death in the first trimester of pregnancy. Today, serial serum hCG measurements and transvaginal ultrasound examination can provide early detection of most ectopic pregnancies allowing medical treatment with methotrexate. In those who require surgery, the type of procedure depends on the clinical situation and the location of the pregnancy. Most of the cases can and should be performed by laparoscopy. Compared with laparotomy, the laparoscopic approach is associated with many advantages including short hospital stay, low cost and less adhesion formation. In addition, hemoperitoneum is not a contraindication for performing laparoscopy. Linear salpingostomy is the procedure of choice when unruptured tubal pregnancy is found in women who want to preserve their fertility; otherwise, salpingectomy is performed. Fertility performance after salpingostomy and salpingectomy is comparable. Similar to the case with tubal ectopic pregnancy in general, women with non-tubal ectopic pregnancy such as cervical, interstitial, or Caesarean scar pregnancy should be first treated medically with methotrexate. These types of ectopic pregnancies may be associated with massive bleeding during surgery. Precautionary procedures should be considered and these include the placement of an angiographic catheter for possible uterine artery embolization. These pregnancies can also be treated laparoscopically.
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Dadhwal V, Deka D, Ghosh B, Mittal S. Successful management of live ectopic pregnancy with high β-hCG titres by ultrasound-guided potassium chloride injection and systemic methotrexate. Arch Gynecol Obstet 2009; 280:799-801. [DOI: 10.1007/s00404-009-0983-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Accepted: 02/02/2009] [Indexed: 11/28/2022]
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Abstract
The incidence of ectopic pregnancies is increasing, which may be related to better diagnostic tools as well as the increasing use of assisted reproductive technologies. However, the signs and symptoms of ectopic pregnancy can be similar to other complications of early pregnancy such as miscarriage. Diagnosis often requires serial human chorionic gonadotropin levels along with ultrasound and, in some cases, dilation and curettage. Once a diagnosis has been made, treatment options include medical therapy with methotrexate and surgery, which can often be performed via the laparoscope. Fertility rates after therapy are similar for both medically and surgically treated patients.
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Affiliation(s)
- Jennifer L Kulp
- University of Pennsylvania Medical Center, Penn Fertility Care, Department of Obstetrics and Gynecology, 3701 Market St. Suite 810, Philadelphia, PA 19104, USA
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