Prognostic value of human chorionic gonadotropin changes after methotrexate injection for ectopic pregnancy

Do the change in β-hCG values between the 0th and 4th days in tubal ectopic pregnancy treatment with a single-dose methotrexate (MTX) protocol predict the need for a second dose of MTX?

AIM

The single-dose methotrexate (MTX) regimen is effective and minimizes side effects but an additional second dose is needed in case of failure in an ectopic pregnancy (EP). We aimed to predict the additional MTX dose by evaluating the change in β-hCG values between day 0 and day 4 in EPs with administered single-dose MTX regimen.

METHOD

A total of 454 tubal EPs between 2013 and 2019 were evaluated retrospectively. Cases cured with a single dose of MTX without an additional dose were accepted as the control group, and cases under a single-dose regimen were cured by applying a second dose of MTX on the 7th day were accepted as the study group. Obstetric and demographic characteristics and the change in β-hCG values compared in both groups.

RESULTS

Age, body mass index (BMI), gravida, smoking, abdominal surgery, presence of IUDs, initial β-hCG levels (0th day), and EP size were similar in both groups, but the presence of previous EP history was significantly higher in the study group. The change of β-hCG from days 0 and 4 determined that a 20% increase predicts the need for a second dose of MTX with 72.4% sensitivity, and 87.8% negative predictive value (NPV).

CONCLUSION

The single-dose MTX protocol is successful in 83.3% of convenient cases (as the control group), but an increase of 20% in β-hCG between days 0 and 4 predicts the patients who need to be administered second-dose MTX, and thus, a double-dose MTX protocol will be achieved early.

Evaluation of the parameters in predicting single-dose methotrexate therapy success for ectopic pregnancy

AIM

Methotrexate has demonstrated efficacy in treating ectopic pregnancies. This study explores factors influencing treatment success, focusing on laboratory and ultrasonographic findings, particularly the day 4 to day 1 β-hCG level ratio.

METHODS

Retrospective cohort study was conducted within patients diagnosed with tubal ectopic pregnancy. Patients' characteristics, ultrasound findings, laboratory data, and β-hCG levels (days 1, 4, 7), and operation findings were reviewed. Women's characteristics were investigated who were treated with single dose of MTX (50 mg/m2). Patients who were performed surgery after MTX treatment were identified as MTX treatment failure.

RESULTS

Among 439 women, 259 underwent surgery due to acute symptoms. Of those treated with MTX, 143 experienced treatment success, while 37 underwent surgery after MTX (MTX failure). Comparative analysis revealed significant differences in β-hCG levels on admission (1128 and 4125 mIU/mL) and the day 4 to day 1 β-hCG ratio (0.91 and 1.25). The overall MTX success rate was 79%, reaching 93% and 89% for β-hCG levels <1000 mIU/mL and <2000 mIU/mL, respectively. Success dropped to 50% with levels exceeding 5000 mIU/mL. ROC analysis identified a crucial 2255 mIU/mL cut-off for β-hCG (sensitivity 70.3% and specificity 68.5%) and a day 4 to day 1 β-hCG ratio of 95.5% (sensitivity 84.7%, specificity 72.5%, positive predictive value 75.4%) for predicting MTX success.

CONCLUSION

Establishing a β-hCG cutoff can reduce hospital stay. The day 4 to day 1 β-hCG ratio holds promise as a widely applicable predictor for MTX success or for determining MTX administration on day 4.

Early prediction of the failure of methotrexate treatment by Days 1-4 serum β-hCG change and 48-hour pre-treatment increment inβ-hCG

To determine whether the change of serum β-hCG levels between Days 1 and 4 and 48-h pre-treatment increment in β-hCG can early predict treatment failure of single-dose methotrexate (MTX) in tubal ectopic pregnancies (EP), a retrospective study of 1120 ectopic pregnancies treated with a regimen of a single dose of MTX was conducted in the Department of Obstetrics and Gynaecology, Shanghai First Maternity and Infant Hospital. Treatment failure was defined by an obligation to proceed to surgery or have an additional doses of methotrexate.1350 files were reviewed, with 1120 included for final analysis .64% (722/1120) had β-hCG levels increase on Day 4 after MTX treatment, while 36% (398/1120) had β-hCG levels fall. In this cohort, the treatment failure rate with a single dose of MTX was 15.7% (113/722), and the significant features in the logistic regression model of diagnosing the results of MTX treatment were the ratio of Day 1 to Day 48-h pre-treatment β-hCG values (Odds Ratio (OR) 1.221, 95% Confidence interval (CI) 1.159-1.294), the ratio of Day 4 to Day 1 β-hCG serum values (OR 1.098, 95% CI 1.014-1.226), and β-hCG values on Day 1 (OR 1.070, 95% CI 1.016-1.156). The decision tree model was developed by using increment of β-hCG in 48 h before treatment > =19%, the ratio of Day 4 to Day 1 β-hCG serum values > =36%, and β-hCG values on Day 1> =728 mIU/L to predict the failure of MTX treatment. The diagnostic accuracy, sensitivity and specificity in the test group were 97.22%, 100%, and 96.9%, respectively.IMPACT STATEMENTWhat is already known on this subject? A decrease of 15% β-hCG levels between Days 4 and 7 is a common protocol for predicting the success of a single-dose methotrexate therapy of an ectopic pregnancy.What do the results of this study add? This clinical study offers the cut-off values points for prediction of single-dose methotrexate treatment failure.What are the implications of these findings for clinical practice and/or further research? We identified the importance of β-hCG increase between Days 1 and 4 and β-hCG increment in 48 h pre-treatment for predicting the failure of single-dose methotrexate therapy. It can be used to aid the clinician to optimise the selection of the most appropriate treatment methods during a follow-up evaluation after MTX treatment.

Early (Days 1-4) post-treatment serum hCG level changes predict single-dose methotrexate treatment success in tubal ectopic pregnancy

STUDY QUESTION

What is the capacity of the change between Day 1 and Day 4 post-treatment serum human chorionic gonadotropin (hCG) levels for predicting single-dose methotrexate treatment success in tubal ectopic pregnancy?

SUMMARY ANSWER

Any fall in Days 1-4 serum hCG signified an 85% (95% CI 76.8-90.6) likelihood of treatment success for women with tubal ectopic pregnancy (initial hCG of ≥1000 and ≤5000 IU/l) managed with single-dose methotrexate.

WHAT IS KNOWN ALREADY

For those with tubal ectopic pregnancy managed by single-dose methotrexate, current guidelines advocate intervention if Days 4-7 hCG fails to fall by >15%. The trajectory of hCG over Days 1-4 has been proposed as an early indicator that predicts treatment success, allowing early reassurance for women. However, almost all prior studies of Days 1-4 hCG changes have been retrospective.

STUDY DESIGN, SIZE, DURATION

This was a prospective cohort study of women with tubal ectopic pregnancy (pre-treatment hCG of ≥1000 and ≤5000 IU/l) managed with single-dose methotrexate. The data were derived from a UK multicentre randomized controlled trial of methotrexate and gefitinib versus methotrexate and placebo for treatment of tubal ectopic pregnancy (GEM3). For this analysis, we include data from both treatment arms.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were categorized according to single-dose methotrexate treatment success or failure. Treatment success for this analysis was defined as complete and uneventful resolution of tubal ectopic pregnancy to serum hCG <30 IU/l following single-dose methotrexate treatment without additional treatment. Patient characteristics of the treatment success and failure groups were compared. Changes in Days 1-4, 1-7, and 4-7 serum hCG were evaluated as predictors of treatment success through receiver operating characteristic curve analysis. Test performance characteristics were calculated for percentage change ranges and thresholds including optimal classification thresholds.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 322 women with tubal ectopic pregnancy were treated with single-dose methotrexate. The overall single-dose methotrexate treatment success rate was 59% (n = 189/322). For any fall in serum hCG on Days 1-4, likelihood ratios were >3, while for any fall of serum hCG >20% on Days 1-7, likelihood ratios reached 5. Any rise of serum hCG on Days 1-7 and 4-7 strongly reduced the chance of success. Any fall in Days 1-4 hCG predicted single-dose methotrexate treatment success with a sensitivity of 58% and specificity 84%, resulting in positive and negative predictive values of 85% and 57%, respectively. Any rise in Days 1-4 serum hCG <18% was identified as an optimal test threshold that predicted treatment success with 79% sensitivity and 74% specificity, resulting in 82% positive predictive value and 69% negative predictive value.

LIMITATIONS, REASONS FOR CAUTION

Our findings may be limited by intervention bias resulting from existing guidelines which influences evaluation of hCG changes reliant on Day 7 serum hCG levels.

WIDER IMPLICATIONS OF THE FINDINGS

Examining a large prospective cohort, we show the value of Days 1-4 serum hCG changes in predicting single-dose methotrexate treatment success in tubal ectopic pregnancy. We recommend that clinicians provide early reassurance to women who have a fall or only a modest (<18%) rise in Days 1-4 serum hCG levels, that their treatment will likely be effective.

STUDY FUNDING/COMPETING INTEREST(S)

This project was supported by funding from the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership (grant reference number 14/150/03). A.W.H. has received honoraria for consultancy for Ferring, Roche, Nordic Pharma and AbbVie. W.C.D. has received honoraria from Merck and Guerbet and research funding from Galvani Biosciences. L.H.R.W. has received research funding from Roche Diagnostics. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437). B.W.M. also reports consultancy for ObsEva and Merck and travel support from Merck. The other authors declare no competing interests.

TRIAL REGISTRATION NUMBER

This study is a secondary analysis of the GEM3 trial (ISRCTN Registry ISRCTN67795930).

Predictors and clinical features of methotrexate (MTX) therapy for ectopic pregnancy

BACKGROUND

Ectopic pregnancy is a major life- and fertility-threatening women's health concern. As a result of advances in examination technology, an increasing number of ectopic pregnancies can be diagnosed early and treated with medical methods instead of surgery. The aim of this study was to summarize the clinical features and identify the predictors of success of methotrexate (MTX) treatment of ectopic pregnancy.

METHODS

This was a retrospective study of 238 ectopic pregnancies treated with MTX in the Department of Gynecology of Shaanxi Provincial People's Hospital from January 2017 to December 2017.

RESULTS

Patients were divided into two groups: the successful treatment group (n = 166) and the failed treatment group (n = 72). The overall success rate of MTX therapy for ectopic pregnancy was 69.75%. The mean initial beta-human chorionic gonadotropin (β-hCG) level was significantly lower in the successful treatment group than in the failed treatment group (2538.08 IU/L versus 3533.17 IU/L, P = 0.000). The treatment success rate of the group with an initial β-hCG concentration less than 4000 IU/L was significantly higher than that of the group with an initial β-hCG concentration greater than 4000 IU/L. However, the success rate of the group with an initial β-hCG concentration greater than 4000 IU/L was still relatively high (54.55%). β-hCG levels were significantly increased on the 4th day in the failed treatment group (P = 0.000). Compared to the initial β-hCG level, the day-4 β-hCG level increased by more than 8.21%, indicating that the treatment was effective. The diagnostic sensitivity was 88.6%, the specificity was 74.5%, and the area under the receiver operating characteristic (ROC) curve was 0.863 (95% confidence interval (CI): 0.805-0.920).

CONCLUSIONS

MTX therapy as a treatment option is safe and effective for asymptomatic, hemodynamically stable patients with ectopic pregnancies who are interested in conservative treatment, regardless of the serum β-hCG level or adnexal mass size. The change in the β-hCG level between the initial day and the 4th day is an effective and early predictive tool for the success of MTX therapy for ectopic pregnancy.

Day 1 to day 4 serum hCG change in predicting single-dose methotrexate treatment failure for tubal ectopic pregnancies

OBJECTIVE

To determine if changes in Day 1 to Day 4 serum human chorionic gonadotropin (hCG) levels can predict treatment failure of single-dose methotrexate (MTX) in medical management of tubal ectopic pregnancies (EP).

STUDY DESIGN

This retrospective cohort study was conducted at a tertiary level hospital. Files were reviewed for all women who received at least one dose of 50 mg/m² intramuscular MTX for treatment of ultrasound-confirmed tubal EPs between 2013 and 2018. "Treatment failure" is defined as needing additional MTX or surgery to manage the EP. The primary purpose is to establish a threshold percentage change in Day 1 to Day 4 (Day 1/4) hCG that best predicts treatment failure, with clinically and statistically significant sensitivity and specificity, based on receiver-operator characteristic (ROC) analysis.

RESULTS

252 files were reviewed, with 108 included for final analysis. 17% of cases required a second dose of MTX and 12% required surgery to manage the EP. Women in the treatment failure group had significantly higher median hCG levels on Day 1, 4 and 7, but were otherwise similar to women who were successful in age, parity, history of previous EP, and EP size. ROC curve analysis of Day 1/4 hCG demonstrates that ≥5% rise best predicts treatment failure with sensitivity 68% (95% confidence interval [CI] 49-83%), specificity 69% (95%CI 56-78%), and AUC 0.77 (95%CI 0.68-0.86, p < 0.001). The positive predictive value is 46% (95%CI 36-56%) and negative predictive value is 84% (95%CI 75-90%). In comparison, ROC analysis of Day 4 to Day 7 hCG demonstrates that a drop of ≤17% best predicted failure, with sensitivity 83% (95%CI 64-94%), specificity 82% (95%CI 71-90%), and AUC 0.90 (95%CI 0.84-0.96), p < 0.001.

CONCLUSION

This study suggests that ≥5% rise in Day 1/4 serum hCG levels could potentially predict treatment failure of single-dose MTX for tubal EPs, and that conversely, <5% rise or any drop in Day 1/4 hCG levels can reliably predict treatment success. Clinicians could consider factoring-in Day 1/4 hCG changes during the course of medically managing patients. They must bear in mind, however, that acting on the Day 1/4 hCG change would lead to increased interventions.

Early prediction of methotrexate treatment outcome in tubal ectopic pregnancy based on days 0 and 4 human chorionic gonadotropin levels

AIM

Methotrexate (MTX) is an efficient treatment for ectopic pregnancy, used according to 'single-dose' protocol. Treatment success is evaluated on days 4 and 7 after dose administration, and defined as a decline of ≥15% in beta-human chorionic gonadotropin (β-hCG) levels, with a positive predictive value of 93%. A decrease on day 4 β-hCG levels was determined to be a good predictor for treatment success. We retrospectively examined changes in β-hCG levels between days 0 and 4 after MTX treatment as an early predictor for treatment outcome.

METHODS

The 'success group' consisted of patients with resolved ectopic pregnancy after a single MTX dose and 'failure group' included patients who required additional MTX doses or underwent surgery after the first dose. For each group, demographic and pregnancy data were analyzed as well as initial (admission day), days 0, 4 and 7 β-hCG levels.

RESULTS

Of 159 women included in the study, MTX treatment was successful in 117 patients (73.6%) while 42 patients (26.4%) were defined as treatment failure. In the success group, most patients (58.9%) demonstrated a decrease in β-hCG values between days 0 and 4 as opposed to the failure group in which an increase in β-hCG values was observed (76.2%). Decrease of >18% in β-hCG levels was predictive of treatment success (positive predictive value 92%). Increase in β-hCG values is less predictive of treatment failure with positive predictive value of 54%.

CONCLUSION

Differences in β-hCG levels between days 0 and 4 may serve as an early predictor for treatment outcome.

Comparative study of low-dose versus standard single-dose methotrexate: A novel approach for medical treatment of ectopic pregnancy

AIM

Methotrexate (MTX) treatment at a dose of 50 mg/m² of body surface area (BSA) is an effective and widely used treatment method in ectopic pregnancy. However, there is a limited number of studies investigating lower MTX doses. In this study, we aimed to investigate the efficacy of lower MTX doses in the treatment of ectopic pregnancy.

METHODS

This retrospective study included a total of 112 patients who were hospitalized due to ectopic pregnancy and administered single-dose MTX. The patients were divided into three groups according to the dose given as 22-40 mg/m² of BSA (n = 17), 41-49 mg/m² of BSA (n = 81) and ≥ 50 mg/m² of BSA (n = 14). Data including demographic characteristics of the patients, previous history of ectopic pregnancy, previous gynecological surgeries, the use of in vitro fertilization techniques, ultrasonographic findings, beta-human chorionic gonadotropin hormone (β-hCG) levels, pre-treatment endometrial sampling, MTX doses applied, and the need for a surgical intervention during follow-up were retrieved from the hospital records.

RESULTS

Of the patients, 16.96% (n = 19) were operated at the end of treatment, irrespective of the pre-treatment β-hCG levels with a success rate of 83% (n = 93). Fourteen (12.5%) of the patients received the second dose of MTX. The overall success rate was 89.2% in patients with a β-hCG level of ≤5000 mIU/mL.

CONCLUSION

This study shows that lower MTX doses than 50 mg/m² , which has been considered standard treatment and widely used in the treatment of ectopic pregnancy for nearly three decades, are effective with similar success rates.

Evaluation of a follow-up customized strategy for women treated with methotrexate for an ectopic pregnancy: An observational study

OBJECTIVE

To evaluate a follow-up customized strategy used in women treated with methotrexate for tubal ectopic pregnancy.

STUDY DESIGN

This observational monocentric study took place from November 2009 to December 2015 in the emergency unit at La Conception University Hospital in Marseille, France. 440 women were treated by methotrexate for tubal ectopic pregnancy. Women were assigned in a classic follow up protocol with a weekly hCG evaluation (conventional protocol) if the drop in hCG between D1 and D4 was inferior to 20% or in an alternative follow up (streamlined protocol) with a hCG evaluation at one month. The main outcome measures were the success rate, the proportion of women requiring several methotrexate injections, and the mean number of consultations per women and duration of the follow-up.

RESULTS

During this period, the success rate was 348/440 (79.1%). The rate of women requiring 1, 2, or 3 injections and of women lost to follow-up were comparable between the two protocols. The mean number of consultations per woman was 3.6 ± 1.33 vs. 5.95 ± 2.25 days (p < 0.0001), and the follow-up was 27.5 ± 12 vs. 28.1 ± 15.4 (p = 0.6) respectively in the conventional protocol group and the streamlined.

CONCLUSION

Our customized strategy allows for a decrease in the number of consultations per woman without changing the success rate or the need for methotrexate injection. hCG count drop between D1 and D4 allows for the selection of a low-risk group that can benefit from appropriate aftercare.

Early prediction of the success of methotrexate treatment success by 24-hour pretreatment increment in HCG and day 1-4 change in HCG

RESEARCH QUESTION

Several studies have tried to identify early markers of treatment outcome after methotrexate (MTX) treatment for ectopic pregnancy, including pretreatment and day 4 human chorionic gonadotrophin (HCG) concentrations and their corresponding changes, and the increment in HCG during the initial 24 h after treatment. There have, however, been conflicting results. This study aimed to re-evaluate the role of these markers in the earlier identification of treatment success in a large cohort of women.

DESIGN

This was a retrospective cohort study including women diagnosed with an ectopic pregnancy and treated with a regimen of a single dose of MTX. A comparison of maternal and gestation characteristics was made between groups in whom treatment was successful or failed.

RESULTS

A total of 292 women treated with single-dose intramuscular MTX for ectopic pregnancy were included in this study. In the overall cohort, the treatment success rate with a single dose of MTX was 62.7% (183/292). Only two independent determinants were significantly associated with treatment success: the initial 24-h percentage increase in HCG (adjusted odds ratio [OR] 1.82, 95% confidence interval [CI] 1.26-2.63; P < 0.001) and the percentage change in HCG from day 1 to day 4 (adjusted OR 1.12, 95% CI 1.04-1.21; P < 0.001). The optimal cut-off points for prediction of treatment success were an increment of less than 17% in the 24 h before treatment and a decrease of more than 22% between the day 1 and day 4 HCG concentrations.

CONCLUSIONS

A small increase in HCG concentration 24 h before treatment with MTX, alongside a decline in HCG concentration from day 1 to day 4, may predict the success of medical treatment for an ectopic pregnancy.

Evaluation of Tubal Pregnancy After Treatment With Methotrexate by Ultrasound Elastography

OBJECTIVES

The purpose of this study was to evaluate the application of ultrasound elastography in the assessment of methotrexate (MTX) treatment for tubal pregnancy and the association with the elasticity score and human chorionic gonadotropin (hCG) concentration.

METHODS

A total of 73 cases of unruptured tubal pregnancy were diagnosed and treated systemically with MTX. The sonographic characters of conventional transvaginal sonography and elastography and serum hCG concentrations before and after MTX therapy were retrospectively reviewed and analyzed.

RESULTS

The mean elasticity score was statistically significantly lower for the ectopic tubal masses of the success group (mean ± SD, 2.58 ± 0.68) than for the failure group (3.33 ± 0.47) on day 7 (P < .001) and similar on day 0. The median elasticity score for the success group on day 7 was 3, and for the failure group, it was 4. When elasticity scores of 3 and 2 were used for the criterion of successful MTX treatment, the elastography had 94.5% sensitivity, 61.1% specificity, 88.1% positive predictive value, and 78.6% negative predictive value. Elastography of the ectopic masses and subsequent hCG concentration at 1 week after the MTX injection in the success group had a strong relationship.

CONCLUSIONS

Our results suggest that transvaginal elastography was a useful tool in the evaluation of tubal pregnancy after pharmacologic management.

Comparison of Four Methods of Treating Ectopic Pregnancy: A Retrospective Cohort Study

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.

Trends in serum human chorionic gonadotropin levels 0-4 days after methotrexate administration for predicting tubal ectopic pregnancy treatment success

OBJECTIVE

To evaluate serum human chorionic gonadotropin (HCG) levels 0-4 days after single-dose methotrexate administration for tubal ectopic pregnancy.

METHODS

The present retrospective study included women with tubal ectopic pregnancy treated by methotrexate at a tertiary hospital in Hong Kong, China, between January 1, 2007, and December 31, 2016. Patients were stratified serum HCG levels rose or fell from day 0-4 post-administration. Trends in day 0-4 serum HCG to predict treatment success were compared with that of day 4-7 serum HCG. The optimal drop in HCG was identified by receiver operating characteristic curve analysis.

RESULTS

There were 102 patients included. The positive predictive value (PPV) of day 0-4 serum HCG for treatment success was 91% (95% confidence interval [CI] 82-96), which is comparable to the current criterion of a 15% drop in day 4-7 serum HCG (PPV 91%, 95% CI 84-95). A 6% drop in day 0-4 serum HCG was the best predictor of treatment success (PPV 96%, 95% CI 86-99).

CONCLUSION

A drop in day 0-4 serum HCG provided earlier prognostic information and was not inferior to the current criterion.

Predictors of failure of the commonly used single-dose methotrexate protocol for treating tubal ectopic pregnancies

OBJECTIVES

This study identified patients who would benefit from an earlier additional medical intervention and/or continuing close surveillance even if commonly used parameters indicated sufficient medical treatment to determine markers of treatment failure.

MATERIALS AND METHODS

A retrospective analysis of patients with a preliminary diagnosis of ectopic pregnancy treated with the single-dose methotrexate protocol. Group 1: cases cured with a single dose of methotrexate; Group 2: cases who required more than one dose of methotrexate or surgery following the first dose. Demographics, clinical/sonographic findings, observation period, and β-human chorionic gonadotropin (hCG) levels were compared among the two groups. Thresholds were defined and a regression analysis was performed to define independent predictors of failure.

RESULTS

Data from 120 patients were analyzed: Group 1 (n = 92); Group 2 (n = 28). β-hCG levels measured at all time points, and day (0-4) and day (4-7) changes, presence of adnexial masses, and infertility were significantly different among the two groups. Only the day (0-4) and day (4-7) changes in β-hCG levels were independent predictors of failure.

CONCLUSION

Day (0-4) thresholds or newly defined day (4-7) thresholds were not more sensitive than the conventional day (4-7) criteria. Day (0-4) β-hCG levels increased by more than 9.7% in half the patients who required additional methotrexate doses or surgery despite fulfillment of the conventional day (4-7) criteria. In contrast, no cases of treatment failure were observed if the day (0-4) decrease was >26.6%.

Predictive factors for the methotrexate treatment outcome in ectopic pregnancy: A comparative study of 400 cases

OBJECTIVE

We sought to evaluate the global success rate of intramuscular methotrexate for the treatment of ectopic pregnancy, identify factors predictive of treatment success or failure, and study methotrexate tolerability in a large patient cohort.

STUDY DESIGN

For this single-center retrospective observational study, we retrieved the records of all women who had a clinically or echographically confirmed ectopic pregnancy with a Fernandez score <13 and who were treated according to a 1mg/kg intramuscular single-dose methotrexate protocol. Medical treatment failure was defined by an obligation to proceed to laparoscopy. Needing a second injection was not considered to be medical treatment failure.

RESULTS

Between February 2008 and November 2013 (69 months), 400 women received methotrexate for ectopic pregnancy. The medical treatment protocol was effective for 314 patients, i.e., an overall success rate of 78.5%. A single methotrexate dose was sufficient for 63.5% of the women and a second dose was successful for 73.2% of the remaining women. The medical treatment success rate fell as initial hCG levels climbed. The main factors associated with methotrexate failure included day (D) 0, D4 and D7 hCG levels, pretherapeutic blood progesterone, hematosalpinx at D0 and pain at D7. Early favorable kinetics of hCG levels was predictive of success. Methotrexate treatment was successful in 90% of women who had D0 hCG <1000IU/l. Methotrexate tolerability was good, with only 9% of the women reporting non-severe adverse effects. The fertility rate with delivery after medical treatment for ectopic pregnancy was 80.7%.

CONCLUSION

In this study, we showed that an initial hCG value <1000IU/l and favorable early HCG kinetics were predictive factors for the successful medical treatment of ectopic pregnancy by methotrexate, and hematosalpinx and pretherapeutic blood progesterone >5ng/ml at diagnosis were predictive of its failure. We also confirmed good tolerability for single-dose methotrexate protocols.

Methotrexate treatment in progressive tubal ectopic pregnancies and hCG-related clinicosurgical implications

Our aim was to evaluate the relationship between the success of methotrexate treatment and β-hCG levels in progressive tubal ectopic pregnancies. We defined a retrospective cohort of 394 progressive tubal ectopic pregnancy patients treated with methotrexate. A single-dose methotrexate protocol using 50 mg/m(2) was administered to patients with progressive tubal ectopic pregnancy. Surgery was performed in patients who exhibited signs of acute abdomen due to tubal rupture. Of 394 patients that received methotrexate treatment, 335 (84.6%) responded to medical treatment, while the remaining 59 (15.36%) underwent surgery due to treatment failure. β-hCG levels in the failure group were significantly higher as compared with the success group at Day 1, Day 4, and Day 7 (2116±3157 vs. 4178±3422, 2062±3551 vs. 4935±4103, and 1532±3007 vs. 3900±4783, respectively). The receiver operating characteristics curve for β-hCG levels at Day 1 was 0.738, with a cutoff value of 1418 mIU/mL, while sensitivity and specificity values reached the optimum for treatment success (83.1% and 59.4%, respectively). Medical treatment with methotrexate achieved an 85.02% success rate for the treatment of progressive tubal ectopic pregnancy, while success rates for medical treatment decreased significantly when initial β-hCG levels were >1418 mIU/mL.

Single-dose methotrexate treatment for ectopic pregnancy and pregnancy of unknown location and progesterone as a predictor of success

BACKGROUND

The use of single-dose intramuscular administration of methotrexate in the treatment of ectopic pregnancies (EP) is a well-established practice. This study evaluates its use at a novel dose of 40 mg/m(2) body surface area (BSA).

OBJECTIVE

To evaluate the efficacy and safety of single-dose methotrexate treatment 40 mg/m(2) for tubal EP and persistent pregnancies of unknown location (PUL) and determine whether serum progesterone is a predictor of treatment success.

MATERIALS AND METHODS

Retrospective cohort study of patients receiving intramuscular methotrexate 40 mg/m(2) for the treatment of EP or PUL at Royal Prince Alfred Hospital over five years.

RESULTS

One hundred and eighteen women received single-dose methotrexate with an overall success of 84%. Surgical intervention was needed in 16.6%. Pretreatment beta-hCG level and ectopic diagnosis were independent variables predictive of the need for surgery (P = 0.003 and 0.02, respectively). Serum progesterone level was not predictive of the need for a second dose or surgery. The sensitivity and specificity at pretreatment beta-hCG of 1202 IU/L were 84% and 74%, respectively. Commonly reported side effects included nausea, abdominal pain and heavy vaginal bleeding. Significant treatment-related adverse effects were rare.

CONCLUSION

Single-dose IM methotrexate at a novel dose of 40 mg/m(2) is a safe and effective treatment for selected EP and persistent PUL. The risk of surgery was positively correlated to serum beta-hCG level and the diagnosis of EP. Progesterone was not a risk factor for surgery. Further studies are required to confirm the efficacy of this dose regimen and explore the safety of expectant management as an alternative to methotrexate treatment.

Second-dose methotrexate in ectopic pregnancies: the role of beta human chorionic gonadotropin

OBJECTIVE

To evaluate the role of β-hCG levels on days 1, 4, and 7 after methotrexate as predictors for second-dose requirement and success.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university-affiliated hospital.

PATIENT(S)

A total of 1,703 patients were admitted because of ectopic pregnancy. Four hundred nine received methotrexate, of whom 73 women required a second dose.

INTERVENTION(S)

The "single-dose" methotrexate protocol with 50 mg/m(2) was administered to patients with progressing ectopic pregnancy. Surgical intervention was performed in cases of methotrexate second-dose treatment failure.

MAIN OUTCOME MEASURE(S)

Methotrexate second-dose requirement and success according to β-hCG levels on days 1, 4 and 7.

RESULT(S)

Second-dose methotrexate was successful in 58 patients (79.4%, success group), whereas 15 patients (20.6%) failed treatment and required surgical intervention (failure group). The medians of β-hCG levels on days 1, 4, and 7 were significantly higher in the "failure group" (1,601 vs. 2,844, 2,164 vs. 3,225, and 1,915 vs. 3,745 mIU/mL, respectively). Logistic regression analysis demonstrated that day-1 β-hCG levels were the only significant independent variable for second-dose treatment outcome. The receiver operating characteristic curve for β-hCG levels on day 1 was 0.727, and at a cutoff value of 2,234 mIU/mL the sensitivity and specificity reached the optimum for treatment success (77.5% and 73.3%, respectively).

CONCLUSION(S)

Day-1 β-hCG levels were the only predictors for methotrexate second-dose requirement and treatment success. The cutoff value of β-hCG on day 1 with the optimal treatment results was found to be 2,234 mIU/mL.

Predictive value of hemoperitoneum for outcome of methotrexate treatment in ectopic pregnancy: an observational comparative study

OBJECTIVE

To assess the predictive value of hemoperitoneum for the outcome of methotrexate (MTX) treatment of ectopic pregnancy (EP).

METHODS

This observational prospective single-center study included women presenting with EP treated with MTX from November 2007 to November 2009. The percentage of women with hemoperitoneum at the beginning of MTX treatment was compared between two groups: those whose treatment was successful and those whose treatment failed. The rate of hemoperitoneum in each group and its value in predicting the outcome of MTX treatment of EP were assessed.

RESULTS

MTX treatment was successful in 69 of 93 (74%) cases. The percentage of women with hemoperitoneum at the beginning of treatment was significantly higher in women in whom MTX treatment failed as compared to those in whom it was successful (15/24 (62.5%) vs 17/69 (24.6%); P = 0.001). The likelihood of requiring surgery following treatment with MTX was higher in women with hemoperitoneum (odds ratio, 5.1; 95% CI, 1.74-15.14). Study of the diagnostic performance of hemoperitoneum in predicting the need for surgical treatment after MTX treatment revealed a sensitivity of 0.63, a specificity of 0.76, a positive predictive value of 0.47 and a negative predictive value of 0.85.

CONCLUSIONS

The presence of hemoperitoneum appears to be a risk factor for MTX treatment failure. It is important to inform women as fully as possible about the risk of such failure. Nonetheless, the predictive value of this sign is insufficient for either routinely excluding women with hemoperitoneum from MTX treatment or omitting post-treatment monitoring.

ß-hCG and prediction of therapeutic success in ectopic pregnancies treated with methotrexate, results from a prospective observational study

OBJECTIVE

To evaluate the diagnostic accuracy of different beta-human chorionic gonadotrophin (ß-hCG) levels measurement, for predicting success of medical treatment in cases diagnosed as tubal ectopic pregnancy (TEP).

DESIGN

Five-year prospective observational study.

SETTING

Prenatal Diagnosis Unit, Vall d'Hebron University Hospital - Barcelona.

PATIENTS

TEP cases fulfilling criteria for medical treatment with Methotrexate.

INTERVENTIONS

ß-hCG levels were measured on d 0, 4 and 7 of treatment. Results were compared by non-parametrical tests. A ROC curve was plotted to define cut-off points. Diagnostic accuracy of the different measurements was evaluated.

MAIN OUTCOME MEASURE

Failure of treatment defined as need for surgical treatment or persistence of high ß-HCG levels despite treatment.

RESULTS

126 women were diagnosed as TEP, eligible for medical treatment. There were no differences in parity, age, previous TEP, or adnexal mass size. Success rate was 88%. ß-HCG decreased significantly more, between days 0-7 and 4-7, in the successful cases. LR for success prediction was 6.2 and 7.8 for ß-HCG levels at days 4 and 7 respectively, 4.02 and 2.47 for decrement between days 0-7 (25%) and 4-7 (20%), respectively.

CONCLUSION

ß-hCG cutoff values have a potential for predicting a successful medical treatment of TEP.

Assessment of early decline in the percentage of β-hCG values between days 0 and 4 after methotrexate therapy in ectopic pregnancy for the prediction of treatment success

OBJECTIVE

To evaluate percentage changes in serum beta-human chorionic gonadotropin (β-hCG) values between days 0-1, 0-4 and 0-7 as an indicator of methotrexate therapy success in extra-uterine pregnancies.

MATERIAL AND METHODS

Women with ectopic pregnancy treated with single-dose methotrexate therapy between January 2011 and August 2012 were assessed. Recorded data were reviewed electronically from patient files. All women (n=93) with an ectopic pregnancy treated medically with intramuscular methotrexate (50 mg/m(2)) were included. The percentage changes in serum β-hCG levels from day 0 to 1, day 0 to 4 and day 0 to 7 were calculated for each case.

RESULTS

The median β-hCG values decreased between days 0 and 4 by 55.8%, and 89.6% of these cases were treatment successes. The median initial serum β-hCG values were lower in women with successful treatment, but this was not statistically significant (p=0.11).

CONCLUSION

A decline in serum β-hCG values between days 0 and 4 appears to be the best predictor. It would be beneficial to determine whether a woman with an ectopic pregnancy treated with single-dose methotrexate administration will be treated successfully.

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

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.

Using a decline in serum hCG between days 0-4 to predict ectopic pregnancy treatment success after single-dose methotrexate: a retrospective cohort study

BACKGROUND

The current measure of treatment efficacy of single-dose methotrexate for ectopic pregnancy, is a fall in serum hCG of ≥15% between days 4-7 of treatment, which has a positive predictive value of 93% for treatment success. Two small studies have proposed a fall in serum hCG between days 0-4 after treatment confers similar, earlier prognostic information, with positive predictive values of 100% and 88% for treatment success. We sought to validate this in a large, independent cohort because of the potentially significant clinical implications.

METHODS

We conducted a retrospective study of women (n=206) treated with single-dose methotrexate for ectopic pregnancy (pre-treatment serum hCG levels ≤3000 IU/L) at Scottish hospitals between 2006-2011. Women were divided into two cohorts based on whether their serum hCG levels rose or fell between days 0-4 after methotrexate. Treatment outcomes of women in each cohort were compared, and the test performance characteristics calculated. This methodology was repeated for the current measure (≥15% fall in serum hCG between days 4-7 of treatment) and an alternate early measure (<20% fall in serum hCG between days 0-4 of treatment), and all three measures were compared for their ability to predict medical treatment success.

RESULTS

In our cohort, the positive predictive value of the current clinical measure was 89% (95% CI 84-94%) (121/136). A falling serum hCG between days 0-4 predicted treatment success in 85% (95% CI 79-92%) of cases (94/110) and a <20% fall in serum hCG between days 0-4 predicted treatment success in 94% (95% CI 88-100%) of cases (59/63). There was no significant difference in the ability of these tests to predict medical treatment success.

CONCLUSIONS

We have verified that a decline in serum hCG between days 0-4 after methotrexate treatment for ectopic pregnancies, with pre-treatment serum hCG levels ≤3000 IU/L, provides an early indication of likelihood of treatment success, and performs just as well as the existing measure, which only provides prognostic information on day 7.

Are early human chorionic gonadotropin levels after methotrexate therapy a predictor of response in ectopic pregnancy?

OBJECTIVE

The purpose of this study was to evaluate beta-human chorionic gonadotropin (beta-hCG) levels between days 0 and 4 as a predictor of methotrexate therapy success for ectopic pregnancy.

STUDY DESIGN

We conducted a retrospective study that evaluated posttreatment beta-hCG levels of 30 patients with ectopic pregnancy who had been treated with single-dose methotrexate therapy.

RESULTS

beta-hCG levels decreased between days 0 and 4 in 40.0% of cases, and 100% of these cases had treatment success. beta-hCG levels increased in 60.0% of cases, and 61.8% of these cases had treatment success. In patients with increasing beta-hCG levels on day 4, we calculated the beta-hCG "difference variable" (beta-hCG level at day 4 minus day 0). The median beta-hCG difference variable between cases of treatment success and failure were statistically significant (P = .035).

CONCLUSION

beta-hCG level changes between days 0 and 4 after methotrexate therapy have clinical significance and predictive value. Decreasing beta-hCG levels is highly predictive of treatment success. The beta-hCG difference variable is a reliable predictor of success in cases with rising beta-hCG levels after methotrexate therapy.

Ultrasound monitoring in patients undergoing in-vitro fertilization after methotrexate treatment for ectopic pregnancy

OBJECTIVES

To compare sonographic characteristics of the endometrium and follicles during in-vitro fertilization (IVF) before and after methotrexate (MTX) treatment for ectopic pregnancy.

METHODS

This retrospective study, conducted at Conception Hospital from January 2000 to July 2007, included all patients diagnosed with an ectopic pregnancy resulting from IVF treatment that was treated with MTX and who then underwent another IVF cycle. We compared the number and size of follicles and the endometrial thickness and quality on the day of human chorionic gonadotropin injection in the cycles before and after the MTX treatment to determine whether MTX had any effect.

RESULTS

Eleven patients were included in the study. The median interval between the IVF cycle resulting in ectopic pregnancy and the first IVF cycle after MTX therapy was 180 (range, 150-900) days. There was no statistically significant difference between the before and after MTX treatment groups with respect to number of follicles (14 (3-20) vs. 9 (4-16), P = 0.12), follicle size (16.5 (14.7-21.7) mm vs. 17.8 (14.9-19.8) mm, P = 0.37), endometrial thickness (10.0 (9.5-12.0) mm vs. 10.0 (7.5-14.0) mm, P = 0.31) or endometrial quality (P = 0.32). Four women became pregnant during the IVF cycle following MTX treatment.

CONCLUSIONS

Ultrasound monitoring showed no modification of the characteristics of the endometrium or follicles during IVF after MTX treatment for ectopic pregnancy.