1
|
Abdelfattah-Arafa E, Abdussalam HF, Omar Saad M, El Ansari W. The predictors of successful methotrexate treatment of tubal ectopic pregnancy. J OBSTET GYNAECOL 2024; 44:2361456. [PMID: 38864434 DOI: 10.1080/01443615.2024.2361456] [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: 08/07/2023] [Accepted: 05/23/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND The pre-treatment characteristics of the patient and ectopic pregnancy to determine the patients who are likely to successfully respond to methotrexate (MTX) therapy remain controversial. This study investigated the outcomes of ectopic pregnancy after one and two MTX doses and their independent predictors. METHODS Retrospective cross-sectional study of women who consented to MTX treatment in 2017-2018 at our institution (N = 317). Of these, patients with Caesarean scar pregnancies were excluded because they require different treatment protocols (n = 25). All patients were treated according to our institution's protocol based on international guidelines and standardised across the three hospitals included in the current study. We retrieved patients' demographics, laboratory, ultrasonography, and clinical characteristics from our hospital database. Serum β-human chorionic gonadotropin (β-hCG) was measured using electrochemiluminescence immunoassay; ectopic pregnancy was diagnosed using ultrasonography (transvaginal probe). RESULTS Two ninety-two patients were included in the current analysis. Age, pre-treatment β-hCG levels, sonographic presence of yolk sac, presence of foetal cardiac activity, and pelvic pain were significantly different between patients with successful and unsuccessful outcomes. Younger age (adjusted odds ratio [aOR] 2.33, 95% confidence interval (CI) 1.16-4.66, p = .017), no pelvic pain (aOR 2.65, 95%CI 1.03-6.83, p = .043), lower initial β-hCG level (aOR 1.32, 95%CI 1.08-1.59, p = .005), and absence of foetal cardiac activity (aOR 12.63; 95% CI 1.04-153.6; p = .047) were independently associated with success. Treatment failure odds were >2 folds higher for each 10-year age increase (p = .017), 32% higher for each 1000 IU/L increase in initial β-hCG level (p = .005), and >2 folds higher in presence of pelvic pain (p = .043). CONCLUSIONS MTX is effective in most patients, averting invasive surgery, which might affect fertility. Pre-treatment β-hCG levels, age, pelvic pain, and foetal cardiac activity was independently associated with outcomes. Research should assess the relationship between the ectopic pregnancy size and treatment outcomes and refine β-hCG titres where treatment would be ineffective.
Collapse
Affiliation(s)
| | | | | | - Walid El Ansari
- Department of Surgery, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
| |
Collapse
|
2
|
Cavalari CAA, Mehrtash H, Brizuela V, Baguiya A, Adu-Bonsaffoh K, Cecatti JG, Bahamondes L, Charles CM, Govule P, Dossou JP, Souza RT, Leão LH, Filippi V, Tunçalp Ö, Baccaro LF. Prevalence and management of ectopic and molar pregnancies in 17 countries in Africa and Latin America and the Caribbean: a secondary analysis of the WHO multi-country cross-sectional survey on abortion. BMJ Open 2024; 14:e086723. [PMID: 39401964 PMCID: PMC11474897 DOI: 10.1136/bmjopen-2024-086723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 09/16/2024] [Indexed: 10/17/2024] Open
Abstract
INTRODUCTION There are limited global data on ectopic pregnancy (EP) and molar pregnancy (MP), making it important to understand their epidemiology and management across different regions. Our study aimed to describe their prevalence for both conditions, severity of their complications and management among women in selected health facilities across 17 countries in Africa and Latin America and the Caribbean (LAC). METHODS This is a secondary analysis of the WHO multi-country survey on abortion. Data were collected from 280 healthcare facilities across 11 countries in Africa and 6 in LAC. Sociodemographic information, signs and symptoms, management and clinical outcomes were extracted from medical records. Facility-level data on post-abortion care (PAC) capabilities were also collected, and facilities were classified accordingly. χ2 or Fisher's exact tests were used to compare categorical data. RESULTS The total number of women with EP and MP across both regions was 9.9% (2 415/24 424) where EP accounted for 7.8% (1 904/24 424) and MP for 2.1% (511/24 424). EP presented a higher severity of complications than MP. At admission, 49.8% of EP had signs of peritoneal irritation. The most common surgical management for EP was laparotomy (87.2%) and for MP, uterine evacuation (89.8%). Facilities with higher scores in infrastructure and capability to provide PAC more frequently provided minimal invasive management using methotrexate/other medical treatment (34.9%) and laparoscopy (5.1%). CONCLUSION In Africa and LAC, EP and MP cause significant maternal morbidity and mortality. The disparity in the provision of good quality care highlights the need to strengthen the implementation of evidence-based recommendations in the clinical and surgical management of EP and MP.
Collapse
Affiliation(s)
- Camila Ayume Amano Cavalari
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Hedieh Mehrtash
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Vanessa Brizuela
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Adama Baguiya
- Kaya Health and Demographic Surveillance System (Kaya-HDSS), Ouagadougou, Burkina Faso
| | - Kwame Adu-Bonsaffoh
- Department of Obstetrics and Gynecology, Korle Bu Teaching Hospital, Accra, Greater Accra, Ghana
| | - Jose Guilherme Cecatti
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Luis Bahamondes
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Charles M'poca Charles
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Philip Govule
- Epidemiology and Disease Control, University of Ghana College of Health Sciences, Accra, Greater Accra, Ghana
- Health Sciences, Uganda Martyrs University Faculty of Health Sciences, Kampala, Uganda
| | - Jean-Paul Dossou
- CNHU-HKM Centre de Recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
- Public Health, Instituut voor Tropische Geneeskunde, Antwerpen, Flanders, Belgium
| | - Renato T Souza
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | - Luis Henrique Leão
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| | | | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, World Health Organization, Geneve, Switzerland
| | - Luiz Francisco Baccaro
- Departamento de Tocoginecologia, Universidade Estadual de Campinas Faculdade de Ciencias Medicas, Campinas, Sao Paulo, Brazil
| |
Collapse
|
3
|
Tarafdari A, Keikha F, Asadi F, Hantoushzadeh S, Gargari OK, Forouzin M, Ghaemi M. The Effectiveness of Letrozole Alone or in Combination with Methotrexate in the Management of Ectopic Pregnancy, A Systematic Review and Meta-Analysis. Reprod Sci 2024:10.1007/s43032-024-01712-7. [PMID: 39384737 DOI: 10.1007/s43032-024-01712-7] [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: 04/20/2024] [Accepted: 09/23/2024] [Indexed: 10/11/2024]
Abstract
This systematic review and meta-analysis aimed to investigate the effect of letrozole alone or in combination with Methotrexate on the management of ectopic pregnancy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were applied for reporting. The EMBASE, PubMed, Scopus, and Web of Science databases were searched for relevant studies focused on women diagnosed with ectopic pregnancy and managed non-surgically with letrozole alone or in combination with methotrexate (MTX) until April 2024. The success rate, laboratory findings, and complications were analyzed and reported. Meta-analysis was done using RevMan 5.4.1 software. Out of 129 unique studies obtained, 7 of them were found eligible for final review; of which, 3 were nonrandomized prospective cohort studies, 2 were randomized clinical trials, and 2 study were case studies. In 5 studies letrozole was used as monotherapy. While in another study letrozole was used with MTX. The meta-analysis showed a significantly lower level of β-HCG in the letrozole group compared to MTX, 7 days after initiation of treatment (Fixed effect model, MD = -92.22, 95%CI: [-159.39, -25.04], P = 0.007, I2 = 0%). There was no significant difference in the level of anti-mullerian hormone (AMH) between groups (Fixed effect model, MD = 0.18, 95%CI: [-0.09, 0.45], P = 0.20, I2 = 0%). Success rate, platelet count, and level of liver enzymes seemed to be better or similar among patients receiving Letrozole compared to patients receiving Methotrexate. Letrozole exhibits potential as a therapeutic option for ectopic pregnancies; however, further randomized clinical trials are necessary to establish strong evidence.
Collapse
Affiliation(s)
- Azadeh Tarafdari
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Keikha
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Asadi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sedigheh Hantoushzadeh
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Kohandel Gargari
- Student Research Committee, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran
| | | | - Marjan Ghaemi
- Vali-E-Asr Reproductive Health Research Center, Family Health Research Institute, Tehran University of Medical Sciences, Tehran, Iran.
| |
Collapse
|
4
|
Lutfi A, Hayes-Ryan D, Cottrell E, Greene RA. Systemic methotrexate (MTX) in early pregnancy: a retrospective study of a tertiary maternity hospital. Ir J Med Sci 2024; 193:2389-2395. [PMID: 38980553 PMCID: PMC11457575 DOI: 10.1007/s11845-024-03748-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 06/30/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Methotrexate (MTX) is used in clinical practice as a medical treatment option in patients with early pregnancy complications like ectopic pregnancy. AIMS To review systemic MTX therapy use in the first trimester of pregnancy in our hospital and to examine subsequent clinical outcomes. METHODS Retrospective review of all women treated with systemic MTX in early pregnancy identified from electronic prescription records from 1 January 2018 to 31 December 2020 at Cork University Maternity Hospital, Ireland. Relevant data was transcribed from electronic health records. RESULTS Indications for treatment were tubal ectopic pregnancy (70%, n = 51), persistent pregnancy of unknown location (22%, n = 16) and caesarean scar pregnancy (7%, n = 5). Treatment was successful in 88% (n = 44) of tubal ectopic pregnancies with 73% (n = 37) and 14% (n = 7) of women receiving a single dose and repeated doses, respectively. Only 8% (n = 4) of tubal ectopic pregnancies required emergency surgery for subsequent tubal rupture. In 93% (n = 15) of cases of persistent pregnancy of unknown location, treatment was successful with one patient requiring uterine evacuation. Women with caesarean scar pregnancy were treated with combined MTX and uterine evacuation without complication. CONCLUSIONS The efficacy of medical treatment with systemic MTX for confirmed tubal ectopic pregnancy in our hospital is in line with national and international standards. Careful consideration should be given to treating caesarean scar pregnancy and persistent pregnancy of unknown location with systemic MTX. Systemic MTX use guided by clinicians specialised in early pregnancy complications and safe medication practices may improve treatment success and reduce adverse events.
Collapse
Affiliation(s)
- Ahmed Lutfi
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland.
| | - Deirdre Hayes-Ryan
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- Department of Obstetrics and Gynaecology, National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | | | - Richard A Greene
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
- Department of Obstetrics and Gynaecology, National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| |
Collapse
|
5
|
Zeevi G, Bercovich O, Haring Y, Nahum S, Romano A, Houri O, Yeoshoua E, Eitan R, Peled Y, Krissi H. Nomogram to predict methotrexate treatment success in ectopic pregnancy. Int J Gynaecol Obstet 2024. [PMID: 39324483 DOI: 10.1002/ijgo.15927] [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: 07/06/2024] [Revised: 08/28/2024] [Accepted: 09/11/2024] [Indexed: 09/27/2024]
Abstract
OBJECTIVE To evaluate clinical factors prior to methotrexate (MTX) treatment for tubal ectopic pregnancy and to apply the data to a prediction model for treatment success. METHODS A retrospective cohort study was conducted during 2014-2022. Of the 808 patients with a tubal ectopic pregnancy, 372 with a β-hCG level less than 5000 IU/L were treated with a single dose of MTX and were included in this study. Pretreatment factors, including patient characteristics, initial β-hCG level, and sonographic parameters, were compared between those who achieved complete resolution and those who needed additional MTX or surgical intervention. A logistic regression model and multivariable analysis were used to predict success. A graphic nomogram was generated to represent the model. RESULTS Complete resolution of the ectopic pregnancy was achieved in 290 (77.9%) patients after a single dose of MTX. A second dose or surgical intervention was required for 82 (22.0%): 49 (13.2%) received a second dose of MTX and 33 (8.9%) underwent laparoscopic salpingectomy. In the MTX Success group compared to the MTX Failure group, the median β-hCG levels were lower (746 vs 1347 IU/L, P < 0.001) and the presence of a yolk sac and a fetal pole were less frequent. The predictive model, based on significant variables, includes initial β-hCG concentration and the visibility of a yolk sac or fetal pole. Analysis with cross-validation techniques revealed that the model was both accurate and discriminative. CONCLUSION A predictive nomogram was developed to predict the success of single-dose MTX treatment for tubal ectopic pregnancy.
Collapse
Affiliation(s)
- Gil Zeevi
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medical Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Or Bercovich
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medical Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Yael Haring
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medical Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Shir Nahum
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medical Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Asaf Romano
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medical Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ohad Houri
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medical Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Effi Yeoshoua
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medical Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ram Eitan
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medical Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Peled
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medical Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Haim Krissi
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
- Faculty of Medical Health Sciences, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
6
|
Bart Y, Regev N, Shani U, Cohen B, Yossef F, Margieh N, Kugelman N. Readmission following methotrexate treatment for tubal pregnancy. Int J Gynaecol Obstet 2024; 166:1297-1303. [PMID: 38523535 DOI: 10.1002/ijgo.15498] [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: 07/02/2023] [Revised: 12/18/2023] [Accepted: 03/10/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE To identify risk factors for readmission following methotrexate treatment for tubal pregnancy. METHODS A retrospective study undertaken in two tertiary medical centers, including all individuals with medically treated tubal pregnancy (N = 511), between December 2009 and June 2021. Individuals with and without readmission following methotrexate treatment were compared. The primary outcome was the readmission rate. Secondary outcomes included the rate of post-discharge gynecological emergency department visits, tubal rupture rate, and the eventual need for surgical treatment. RESULTS Readmission following methotrexate treatment occurred in 224/511 patients (43.8%). Most readmissions were due to abdominal pain or suspicion of treatment failure. Readmitted individuals were more likely to have a history of pelvic inflammatory disease and pretreatment serum human chorionic gonadotropin (hCG) >2000 mIU/mL. Both factors remained significantly associated with higher readmission rates in a logistic regression analysis (adjusted odds ratio [OR] 6.28, 95% confidence interval [CI] 1.30-30.45, and adjusted OR 2.73, 95% CI 1.83-4.07, respectively) after adjustment for age, endometriosis, tubal pathology, abdominal pain, and presence of yolk sac or embryo at diagnosis. A dose-dependent association was observed between pretreatment serum hCG levels and readmission rate (P < 0.001). Pretreatment hCG levels were also associated with tubal rupture and the eventual need for surgical treatment (P < 0.001 for both). A prediction model using hCG was not sufficiently accurate to predict readmission risk. CONCLUSION Readmission following methotrexate treatment for tubal pregnancy was independently associated with previous pelvic inflammatory disease and pretreatment serum hCG levels. The latter was also associated with surgical intervention rate.
Collapse
Affiliation(s)
- Yossi Bart
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Noam Regev
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Uria Shani
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Bracha Cohen
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
| | - Fayrooz Yossef
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
- Department of Obstetrics and Gynecology, Bnai Zion Medical Center, Haifa, Israel
| | - Nadine Margieh
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
| | - Nir Kugelman
- Department of Obstetrics and Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion- Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
7
|
Hou L, Liang X, Zeng L, Wang Q, Chen Z. Conventional and modern markers of pregnancy of unknown location: Update and narrative review. Int J Gynaecol Obstet 2024. [PMID: 39022869 DOI: 10.1002/ijgo.15807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 07/08/2024] [Indexed: 07/20/2024]
Abstract
Pregnancy of unknown location (PUL) is a temporary pathologic or physiologic phenomenon of early pregnancy that requires follow up to determine the final pregnancy outcome. Evidence indicated that PUL patients suffer a remarkably higher rate of adverse pregnancy outcomes, represented by ectopic gestation and early pregnancy loss, than the general population. In the past few decades, discussion about PUL has never stopped, and a variety of markers have been widely investigated for the early and accurate evaluation of PUL, including serum biomarkers, ultrasound imaging features, multivariate analysis, and the diagnosis of ectopic pregnancy based on risk stratification. So far, machine learning (ML) methods represented by M4 and M6 logistic regression have gained a level of recognition and are continually improving. Nevertheless, the heterogeneity of PUL markers, mainly caused by the limited sample size, the differences in population and technical maturity, etc., have hampered the management of PUL. With the advancement of multidisciplinary integration and cutting-edge technologies (e.g. artificial intelligence, prediction model development, and telemedicine), novel markers, and strategies for the management of PUL are expected to be developed. In this review, we summarize both conventional and novel markers (represented by artificial intelligence) for PUL assessment and management, investigate their advancements, limitations and challenges, and propose insights on future research direction and clinical application.
Collapse
Affiliation(s)
- Likang Hou
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- The First Affiliated Hospital, Medical Imaging Center, Hengyang Medical School, University of South China, Hengyang, China
| | - Xiaowen Liang
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- Key Laboratory of Medical Imaging Precision Theranostics and Radiation Protection, College of Hunan Province, Department of Medical Imaging, the Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Changsha, China
| | - Lingqing Zeng
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- The First Affiliated Hospital, Medical Imaging Center, Hengyang Medical School, University of South China, Hengyang, China
| | - Qian Wang
- The First Affiliated Hospital, Center for Reproductive Medicine, Hengyang Medical School, University of South China, Hengyang, China
| | - Zhiyi Chen
- Institute of Medical Imaging, Hengyang Medical School, University of South China, Hengyang, China
- Key Laboratory of Medical Imaging Precision Theranostics and Radiation Protection, College of Hunan Province, Department of Medical Imaging, the Affiliated Changsha Central Hospital, Hengyang Medical School, University of South China, Changsha, China
| |
Collapse
|
8
|
Başkıran Y, Uçkan K, Çeleğen İ. Can failure be predicted in methotrexate treatment with the modified parameter? Arch Gynecol Obstet 2024; 310:477-483. [PMID: 38714561 DOI: 10.1007/s00404-024-07433-1] [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: 03/26/2023] [Accepted: 02/14/2024] [Indexed: 05/10/2024]
Abstract
OBJECTIVE The objective of the study was to increase the prediction of success of single-dose methotrexate therapy in ectopic pregnancy patients with modified parameters obtained from complete blood count and beta-human chorionic gonadotropin (β-hCG) parameters. In this way, it was aimed to predict patients whose methotrexate treatment may fail and rupture, to avoid unnecessary methotrexate treatment, to shorten the duration of hospital stay and to reduce patient mortality. MATERIALS AND METHODS 233 patients diagnosed with ectopic pregnancy between January 1, 2017, and March 01, 2022, in the obstetrics and gynecology service of a tertiary center were included in the study. RESULTS The mean of β-hCG was 1976 in the methotrexate group and 2358 in the surgery group (p < 0.05). The ROC curve determined the effect of BW (β-hCGxWBC/1000) and BP (β-hCGx1000/PLT) markers in diagnosing patients who will need surgery in ectopic pregnancy. The areas under the ROC curve for β-hCG, BW and BP were 0.86, 0.99 and 0.94, respectively (p < 0.05). β-hCG > 2139.03, BW > 30.96 and BP > 10.17 values were significantly associated with the need for surgery in ectopic pregnancy patients (p < 0.05). Logistic regression analysis revealed that a 1-unit increase in BP caused a statistically significant 1.77-fold increase in surgical need in patients with ectopic pregnancy. In contrast, a 1-unit increase in BW caused a 2.34-fold increase in surgical need (p < 0.05). CONCLUSION The study results showed that BW and BP values together with β-hCG are effective in predicting ectopic pregnancy patients who may undergo surgery.
Collapse
Affiliation(s)
- Yusuf Başkıran
- Istinye University Faculty of Medicine, Istanbul, Turkey.
| | - Kazım Uçkan
- Van Yuzuncu Yil University Faculty of Medicine, Van, Turkey
| | - İzzet Çeleğen
- Van Yuzuncu Yil University Faculty of Medicine, Van, Turkey
| |
Collapse
|
9
|
Jin CS, Uzuner C, Condous G. Safety of methotrexate administration in women with pregnancy of unknown location at high risk of ectopic pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:97-103. [PMID: 38279942 DOI: 10.1002/uog.27593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 12/22/2023] [Accepted: 01/02/2024] [Indexed: 01/29/2024]
Abstract
OBJECTIVES To evaluate the safety of current guidelines on methotrexate (MTX) administration in women with pregnancy of unknown location (PUL) who are considered to have a high risk of underlying ectopic pregnancy (EP), and to investigate whether implementation of these guidelines would result in inadvertent exposure to MTX of viable intrauterine pregnancies (IUPs). METHODS This was a retrospective observational study of consecutive clinically stable women who were classified with PUL at the early pregnancy unit of Nepean Hospital, Sydney, Australia, between 2007 and 2021. PUL was defined as a positive pregnancy test in the absence of signs of IUP or EP on transvaginal ultrasound. Patients with a PUL that behaved biochemically like an EP, but for which the location of pregnancy was not confirmed on ultrasound, were eligible for MTX to minimize the risk of subsequent tubal rupture. Criteria discussed in the guidelines of the American College of Obstetricians and Gynecologists (ACOG), American Society for Reproductive Medicine (ASRM), Royal College of Obstetricians and Gynaecologists (RCOG) and National Institute for Health and Care Excellence (NICE) were applied to the PUL database. The number of patients eligible to receive MTX and the number with an underlying viable IUP who would be inadvertently prescribed MTX were calculated. RESULTS A total of 816 women with PUL were reviewed, of whom 724 had complete data and were included in the final analysis. Six patients had persistent PUL and the remaining 718 had a diagnosis of viable IUP, non-viable IUP, EP or failed PUL. According to the ACOG, ASRM, RCOG and NICE guidelines, the rate of MTX administration among patients with PUL would have been 2.76%, 4.56%, 0.41% and 35.36%, respectively. However, no persistent PUL would have received MTX according to the ACOG, ASRM and RCOG protocols (the NICE protocol identified patients with persistent PUL with a sensitivity of 100%), and the majority of MTX treatments were unnecessary because those patients were later classified as having non-viable IUP or failed PUL. Application of ACOG and ASRM guidance could result theoretically in inadvertent MTX administration to women with an underlying viable IUP at a rate of 4.1/1000 (3/724). CONCLUSIONS Current guidelines used to predict high risk of EP in the PUL population lead to inadvertent MTX administration to women with an underlying viable IUP. These guidelines should be used wisely to ensure that no wanted pregnancy is exposed to MTX. Women with PUL should be monitored carefully, and MTX should be used judiciously when the location of pregnancy is yet to be confirmed. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- C S Jin
- Nepean Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia
| | - C Uzuner
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Sydney, NSW, Australia
| | - G Condous
- Nepean Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Sydney Medical School Nepean, University of Sydney, Nepean Hospital, Sydney, NSW, Australia
| |
Collapse
|
10
|
Saadia Z, Nasralla K, Iqbal J, Elamin E. Prevalence, Determinants, and Management Options of Scar Site Pregnancy in Women With Previous Cesarean Section: A Study From the Al-Qassim Region. Cureus 2024; 16:e65874. [PMID: 39219911 PMCID: PMC11364361 DOI: 10.7759/cureus.65874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2024] [Indexed: 09/04/2024] Open
Abstract
INTRODUCTION Pregnancy located outside the uterine cavity following a cesarean section has become more prevalent in recent years due to the increase in cesarean section delivery. This study sought to investigate the prevalence, determinants, and treatment options of scar site pregnancy among women who sought maternal and child health services in a hospital in Buraydah, Al-Qassim region, Saudi Arabia. METHODS Utilizing a quantitative retrospective case-control design, 50 women were recruited and assigned to the two groups evenly. Demographic data and risk factors were assessed using a questionnaire, and data were analyzed using SPSS version 27 at a 95% confidence interval and presented in tables and figures. RESULTS Fifty-eight percent of the participants were aged 35 years and above, with 38% reporting a parity of 1-3. Logistic regression revealed that parity (odds ratio (OR) = 10.975, 95% confidence interval (CI) = 0.887-135.861, and p-value = 0.062), the interval between the last and present pregnancies (OR = 0.056, 95% CI = 0.005-0.668, p-value = 0.023), intrauterine contraceptive device (IUCD) use in the last year (OR = 0.070, 95% CI = 0.006 -0.780, p-value = 0.031) were statistically significant in predicting cesarean scar pregnancy. Combined methotrexate and aspiration were the most prevalent treatment options for scar site pregnancy in this study. CONCLUSION Scar site pregnancy is a maternal health complication that affects women across all healthcare settings, and its prevalence is not clear due to underdiagnosis and underreporting. The risk of scar site pregnancy increased with an increase in the number of childbirths (parity) and the interval between the last and current pregnancies.
Collapse
Affiliation(s)
- Zaheera Saadia
- Obstetrics and Gynecology, Qassim University, College of Medicine, Buraydah, SAU
| | - Khalid Nasralla
- Obstetrics and Gynecology, Qassim University, College of Medicine, Buraydah, SAU
| | - Javed Iqbal
- Obstetrics and Gynecology, Maternity and Children Hospital, Buraydah, SAU
| | - Ebtihal Elamin
- Obstetrics and Gynecology, Maternity and Children Hospital, Buraydah, SAU
| |
Collapse
|
11
|
Wei S, Gao T, Wu Y, Wang G, Chen Y, Tao X, Liang Y, Zhou Z, Sun L, Liu M, Li H, Bao Y. The relationship between expression of Tspan5 mRNA in maternal-fetal interface and tubal pregnancy. Eur J Obstet Gynecol Reprod Biol 2024; 296:91-98. [PMID: 38422804 DOI: 10.1016/j.ejogrb.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Shiyuan Wei
- The Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Tianyang Gao
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China.
| | - Yihua Wu
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Guiming Wang
- Department of Pathology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Yao Chen
- The Department of Reproductive Medicine Center, Foshan Women and Children Hospital, Foshan, Guangdong, China
| | - Xinli Tao
- The Department of Gynecology, Xiangzhou District People's Hospital, Xiangyang, Hubei, China
| | - Yingqiu Liang
- Shijiazhuang Obstetrics and Gynecology Hospital, Shijiazhuang, Henan, China
| | - Zijun Zhou
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Liyan Sun
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Minyin Liu
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Haiyan Li
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Yanjing Bao
- The Department of Reproductive Medicine Center, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| |
Collapse
|
12
|
Yeniocak AS, Tercan C, Dagdeviren E, Arabacı O, Genc EE. Evaluation of a scoring system to predict treatment success with single-dose methotrexate in ectopic pregnancy. Arch Gynecol Obstet 2024; 309:2047-2055. [PMID: 38488896 DOI: 10.1007/s00404-024-07458-6] [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: 01/09/2024] [Accepted: 03/04/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE This study sought to assess the efficacy of a newly developed scoring system in predicting treatment outcomes for ectopic pregnancy among patients undergoing single-dose methotrexate therapy. The primary research question centered on the reliability and predictive accuracy of objective parameters in determining methotrexate therapy success. METHODS Conducted as a retrospective single-center cohort study, data from 172 ectopic pregnancy patients treated with methotrexate between January 2021 and January 2023 were analyzed. Parameters including adnexal mass size, peritoneal fluid presence, yolk sac identification, endometrial thickness, ectopic pregnancy location, and initial B-hCG levels were meticulously evaluated for their association with treatment outcomes. RESULTS Following the exclusion of 21 emergency surgery cases, the final analysis comprised 151 patients. Notable associations were observed between specific parameters (fetal cardiac activity, adnexal mass size > 3.5 cm, peritoneal fluid presence, yolk sac identification, endometrial thickness > 10 mm, and initial B-hCG levels) and treatment outcomes (p < 0.001). Additionally, the novel scoring system demonstrated promising predictive performance. At a cutoff of 2.50, it achieved a sensitivity of 91.7% and a specificity of 59.7%. Increasing the cutoff to 3.50 resulted in a sensitivity of 94.0%, with a specificity of 46.3%. CONCLUSION Objective parameters, particularly those integrated into the developed scoring system, exhibited substantial associations with methotrexate therapy outcomes in ectopic pregnancy. These findings underscore the potential of an objective scoring model to significantly influence clinical decision-making in therapy, offering avenues for enhanced prognostication and patient care in treatment outcomes.
Collapse
Affiliation(s)
- Ali Selcuk Yeniocak
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey.
| | - Can Tercan
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Emrah Dagdeviren
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Onur Arabacı
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Emine Elif Genc
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| |
Collapse
|
13
|
Deniz S, Ali B, Canan U, Yılmaz AH, Olcay I, Burcu D, Fatma GK. Evaluation of the parameters in predicting single-dose methotrexate therapy success for ectopic pregnancy. J Obstet Gynaecol Res 2024; 50:856-863. [PMID: 38476034 DOI: 10.1111/jog.15923] [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: 11/03/2023] [Accepted: 03/01/2024] [Indexed: 03/14/2024]
Abstract
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.
Collapse
Affiliation(s)
- Simsek Deniz
- Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Bahadırlı Ali
- Ministry of Health Bursa City Hospital, Bursa, Turkey
| | - Urun Canan
- Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | | | - Ilhan Olcay
- Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Dincgez Burcu
- Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Gencer Ketenci Fatma
- Istanbul Gaziosmanpasa Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| |
Collapse
|
14
|
Yazawa H, Yazawa R, Matsuoka R, Ohara M. Surgical Outcomes and Trends in Incidence of Ectopic Pregnancy. Gynecol Minim Invasive Ther 2024; 13:111-118. [PMID: 38911310 PMCID: PMC11192286 DOI: 10.4103/gmit.gmit_53_23] [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: 04/08/2023] [Revised: 08/24/2023] [Accepted: 09/08/2023] [Indexed: 06/25/2024] Open
Abstract
Objectives We aimed to evaluate the surgical results for ectopic pregnancy (EP) treated at Fukushima Red Cross Hospital for over a 20-year period from 2002 to 2021. Materials and Methods We evaluated the incidence, surgical procedures, site of implantation, amount of hemoperitoneum, and the proportion of cases with risk factors of EP. Results Two hundred and fifty-nine cases of EP were treated surgically. The incidence of EP seemed to be gradually decreasing in recent years. By pregnancy site, 235 (90.7%) of EPs were tubal pregnancies (TPs), 13 in interstitial pregnancies (IPs), 7 in ovarian pregnancies, and 4 in peritoneal pregnancies. For IPs, human chorionic gonadotropin (hCG) levels were statistically higher than with TP and intraperitoneal bleeding was less than with other EP sites. Thirty-nine patients (15.0%) were with massive hemoperitoneum (>500 mL), and laparoscopic surgery was performed in all patients with massive hemoperitoneum except in two patients. The proportion of cases with risk factors for EP such as Chlamydia trachomatis infection or history of smoking was 5.4% and 40.6%, respectively. Epidemiological research shows that the number of patients with chlamydia infection, rates of smokers, or the occurrence of EP with assisted reproductive technology has been decreasing in recent years in Japan. Conclusion Appropriate surgical intervention should be selected while considering such as facility capabilities, context, and surgeon skill, especially in critical cases, such as cases involving massive hemoperitoneum and hemorrhagic shock. The recent presumed decrease in the occurrence of EP may partly be associated with the decrease in the occurrence of risk factors.
Collapse
Affiliation(s)
- Hiroyuki Yazawa
- Department of Obstetrics and Gynecology, Fukushima Red Cross Hospital, Fukushima Medical University, Fukushima, Japan
| | - Riho Yazawa
- Department of Obstetrics and Gynecology, Fukushima Red Cross Hospital, Fukushima Medical University, Fukushima, Japan
| | - Ryo Matsuoka
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima, Japan
| | - Miki Ohara
- Department of Obstetrics and Gynecology, Fukushima Red Cross Hospital, Fukushima Medical University, Fukushima, Japan
| |
Collapse
|
15
|
Larraín D, Caradeux J. β-Human Chorionic Gonadotropin Dynamics in Early Gestational Events: A Practical and Updated Reappraisal. Obstet Gynecol Int 2024; 2024:8351132. [PMID: 38486788 PMCID: PMC10940029 DOI: 10.1155/2024/8351132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 02/06/2024] [Accepted: 03/01/2024] [Indexed: 03/17/2024] Open
Abstract
In the last decade, the widespread use of transvaginal ultrasound and the availability of highly specific serum assays of human chorionic gonadotropin (hCG) have become mainstays in the evaluation of early pregnancy. These tests have revolutionized the management of pregnancies of unknown location and markedly reduced the morbidity and mortality associated with the misdiagnosis of ectopic pregnancy. However, despite several advances, their misuse and misinterpretations are still common, leading to an increased use of healthcare resources, patient misinformation, and anxiety. This narrative review aims to succinctly summarize the β-hCG dynamics in early gestation and provide general gynecologists a practical approach to patients with first-trimester symptomatic pregnancy.
Collapse
Affiliation(s)
- Demetrio Larraín
- Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile
| | - Javier Caradeux
- Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile
| |
Collapse
|
16
|
Karol D, Williamson M, Pereira N. Successful Expectant Management of a Tubal Ectopic Pregnancy. J Minim Invasive Gynecol 2024; 31:92-94. [PMID: 38042476 DOI: 10.1016/j.jmig.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 12/04/2023]
Affiliation(s)
- Dalia Karol
- Department of Obstetrics and Gynecology (Drs. Karol and Williamson), University of Toronto, Toronto, Ontario
| | - Monica Williamson
- Department of Obstetrics and Gynecology (Drs. Karol and Williamson), University of Toronto, Toronto, Ontario
| | - Nigel Pereira
- University of Toronto, Toronto, Ontario, Mount Sinai Fertility (Dr. Pereira), Toronto, Ontario; Division of Gynecologic Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology (Dr. Pereira), University of Toronto, Toronto, Ontario.
| |
Collapse
|
17
|
Capmas P, Panjo H, Artignan J, Babelhadj A, Benoist I, Decouzon J, Jarrige C, Leglise M, Renoncet V, Pelletier-Fleury N. Women's preferences for less active ectopic pregnancy treatment: A discrete choice experiment. Eur J Obstet Gynecol Reprod Biol 2024; 292:175-181. [PMID: 38035866 DOI: 10.1016/j.ejogrb.2023.11.032] [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: 09/06/2023] [Revised: 11/14/2023] [Accepted: 11/23/2023] [Indexed: 12/02/2023]
Abstract
RESEARCH QUESTION Shared decision-making has become a hallmark of quality care and is increasingly spotlighted in practice guidelines. Little is known about women's views for treatment of less active ectopic pregnancy. What are the preferences of women for less active ectopic pregnancy treatment-related attributes? DESIGN A discrete choice model with 8 attributes depicting ectopic pregnancy treatment including varying levels of first-line treatment effectiveness, length of hospitalization, cost, length of sick leave, of convalescence, need for surgical management, for emergency care during convalescence and for tube removal was used. Childbearing aged women, i.e. those who might experience an ectopic pregnancy in the future, were recruited. They were asked to choose between hypothetical treatments in 18 choice tasks with different levels of all treatment attributes. A conditional logit McFadden's choice model was performed. The main outcome measure was preference weights for less active ectopic pregnancy treatment-related attributes. RESULTS A total of 5770 observations from 178 women were analysed. The attributes displaying the highest marginal impacts on women's decisions included: higher rate of first-line treatment effectiveness, lower rate of tube removal, lower rate of surgical management, shorter length of hospitalization and, to a lesser extent, but still significant, shorter length of convalescence, absence of risk of emergency care during convalescence and lower cost. CONCLUSIONS Trade-offs made by women between the attributes of less active ectopic pregnancy treatment suggest that no treatment option, either medical or surgical, is an obvious preferred option. These results encourage the promotion of shared decision-making.
Collapse
Affiliation(s)
- Perrine Capmas
- Centre of Research in Epidemiology and Population Health (CESP), UMR1018, Inserm, Paris Saclay University, Hôpital Paul Brousse, 16 Avenue Paul Vaillant Couturier F-94816 Villejuif, France; Gynecology and Obstetrics Department, Bicetre Hospital, GHU Sud, AP-HP, 78 avenue du Général Leclerc, F-94276 Le Kremlin Bicetre, France; GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France.
| | - Henri Panjo
- Centre of Research in Epidemiology and Population Health (CESP), UMR1018, Inserm, Paris Saclay University, Hôpital Paul Brousse, 16 Avenue Paul Vaillant Couturier F-94816 Villejuif, France
| | - Juliette Artignan
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Aicha Babelhadj
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Inès Benoist
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Julie Decouzon
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Claire Jarrige
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Mylène Leglise
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Valérie Renoncet
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Nathalie Pelletier-Fleury
- Centre of Research in Epidemiology and Population Health (CESP), UMR1018, Inserm, Paris Saclay University, Hôpital Paul Brousse, 16 Avenue Paul Vaillant Couturier F-94816 Villejuif, France; GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| |
Collapse
|
18
|
Alabiad MA, Elhasadi I, Alnasser SM, Alorini M, Alshaikh ABA, Jaber FA, Shalaby AM, Samy W, Heraiz AI, Mohammed Albakoush KM, Khairy DA. Effect of Aromatase Inhibitor Letrozole on the Placenta of Adult Albino Rats: A Histopathological, Immunohistochemical, and Biochemical Study. IRANIAN JOURNAL OF MEDICAL SCIENCES 2024; 49:46-56. [PMID: 38322160 PMCID: PMC10839141 DOI: 10.30476/ijms.2023.96905.2853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/23/2023] [Accepted: 03/04/2023] [Indexed: 02/08/2024]
Abstract
Background Letrozole, an aromatase inhibitor, has recently been introduced as the preferred treatment option for ectopic pregnancy. To date, no study has investigated the effect of letrozole alone on placental tissue. The present study aimed to evaluate the effect of different doses of letrozole on the placenta of rats and to clarify the underlying mechanism. Methods Sixty pregnant female rats were equally divided into three groups, namely the control group (GI), low-dose (0.5 mg/Kg/day) letrozole group (GII), which is equivalent to the human daily dose (HED) of 5 mg, and high-dose (1 mg/Kg/day) letrozole group (GIII), equivalent to the HED of 10 mg. Letrozole was administered by oral gavage daily from day 6 to 16 of gestation. Data were analyzed using a one-way analysis of variance followed by Tukey's post hoc test and Chi square test. P<0.05 was considered statistically significant. Results Compared to the GI and GII groups, high-dose letrozole significantly increased embryonic mortality with a high post-implantation loss rate (P<0.001) and significantly reduced the number of viable fetuses (P<0.001) and placental weight (P<0.001) of pregnant rats. Moreover, it significantly reduced placental estrogen receptor (ER) and progesterone receptor (PR) (P<0.001) and the expression of vascular endothelial growth factor (P<0.001), while increasing the apoptotic index of cleaved caspase-3 (P<0.001). Conclusion Letrozole inhibited the expression of ER and PR in rat placenta. It interrupted stimulatory vascular signals causing significant apoptosis and placental vascular dysfunction. Letrozole in an equivalent human daily dose of 10 mg caused a high post-implantation loss rate without imposing severe side effects.
Collapse
Affiliation(s)
- Mohamed Ali Alabiad
- Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ibtesam Elhasadi
- Department of Pathology, Faculty of Medicine, University of Benghazi, Benghazi, Libya
| | - Sulaiman Mohammed Alnasser
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim, University, Buraydah, Saudi Arabia
| | - Mohammed Alorini
- Department of Basic Medical Sciences, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Kingdom of Saudi Arabia
| | - Ahmed Baker A Alshaikh
- Department of Obstetrics and Gynecology, College of Medicine, Jouf University, Sakaka, Kingdom of Saudi Arabia
| | - Fatima A Jaber
- Department of Biology, College of Science, University of Jeddah, Jeddah, Kingdom of Saudi Arabia
| | - Amany Mohamed Shalaby
- Department of Histology and Cell Biology, School of Medicine, Tanta University, Tanta, Egypt
| | - Walaa Samy
- Department of Medical Biochemistry and Molecular Biology Department, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Ahmed Ismail Heraiz
- Department of Gynecology and Obstetrics, School of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Dina Ahmed Khairy
- Department of Pathology, School of Medicine, Beni-Suef University, Beni-Suef, Egypt
| |
Collapse
|
19
|
Cao G, Liu R, Liu J, Liu J, Liu Y, Li L, Zhao X, Li H, Cao H. Association of menstrual blood volume and reproductive outcomes in patients with caesarean scar pregnancy managed using uterine artery embolization and curettage. HUM FERTIL 2023; 26:1491-1496. [PMID: 37154620 DOI: 10.1080/14647273.2023.2207746] [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: 08/02/2022] [Accepted: 04/11/2023] [Indexed: 05/10/2023]
Abstract
This study aimed to assess the association of menstrual blood volumes (MBV) and reproductive outcomes in patients after uterine artery embolization (UAE) combined with curettage for caesarean scar pregnancy (CSP). This retrospective observational study enrolled women who underwent UAE plus curettage for CSP at the Interventional Department of Henan Provincial People's Hospital between December 2012 and December 2017. The primary outcome was pregnancy rate and the secondary outcomes were live birth rate (LBR) and interpregnancy interval. This study finally included 37 women (16 women with normal MBV and 21 women with decreased MBV) with pregnancy intention after UAE plus curettage for CSP. The pregnancy rate in women with normal MBV was higher than those with decreased MBV (81.3% vs. 47.6%; P = 0.048). There were no differences between the two groups regarding the interpregnancy interval (18.4 ± 8.7 vs. 22.2 ± 10.0 months, P = 0.233), and LBR (63% vs. 38%, P = 0.191). In conclusion, Women with normal MBV after UAE combined with curettage for CSP management might have a higher pregnancy rate compared with patients with decreased MBV, but there were no differences in LBR between the two groups.
Collapse
Affiliation(s)
- Guangshao Cao
- Department of Intervention, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou City, P.R. China
| | - Ruiqing Liu
- Department of Intervention, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou City, P.R. China
| | - Jianwen Liu
- Department of Intervention, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou City, P.R. China
| | - Jian Liu
- Department of Intervention, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou City, P.R. China
| | - Yuyan Liu
- Department of Intervention, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou City, P.R. China
| | - Lupeng Li
- Department of Intervention, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou City, P.R. China
| | - Xiaoyang Zhao
- Department of Intervention, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou City, P.R. China
| | - Hui Li
- Department of Gynaecology, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou City, P.R. China
| | - Huicun Cao
- Department of Intervention, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, Henan University People's Hospital, Zhengzhou City, P.R. China
| |
Collapse
|
20
|
Tavares BVG, Delfino LS, Ignarro IS, Baccaro LF. Adaptation of a Brazilian university hospital to clinical treatment of ectopic pregnancy: Lessons learned over 17 years. Int J Gynaecol Obstet 2023; 162:1091-1097. [PMID: 37177821 DOI: 10.1002/ijgo.14835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 03/15/2023] [Accepted: 04/16/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To describe and compare the annual success rates of medical treatment in the analyzed period and to evaluate the associated factors. METHODS Retrospective study with 158 women with tubal pregnancy followed up over 17 years. Statistical analysis was performed using the Cochran-Armitage test, the χ2 test, Mann-Whitney test, and multiple logistic regression. RESULTS The success rate was 47.4%. There was a trend of significant change in the success rate of clinical treatment over time (Z = 2.01, P = 0.044); it was associated to undergoing treatment between 2012 and 2017 (P = 0.028), the absence of abdominal pain (P = 0.020), receiving a higher dose of methotrexate (P < 0.001), and less time hospitalized (P < 0.001). In the final statistical model, we observed that receiving a higher dose of methotrexate (P = 0.025, odds ratio [OR] 1.03, 95% confidence interval [CI] 1.00-1.06), having a low serum β-HCG concentration before treatment (P = 0.003, OR 0.87, 95% CI 0.79-0.95), and not having abdominal pain (P = 0.004, OR 4.26, 95% CI 1.61-11.28) were factors associated with a higher chance of successful clinical treatment for tubal pregnancy. CONCLUSION A greater chance of success was observed among women undergoing clinical treatment from 2012 onwards, who used higher doses of methotrexate, were asymptomatic at admission, and had low concentrations of β-hCG.
Collapse
Affiliation(s)
- Bárbara V G Tavares
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP) School of Medicine, Campinas, Brazil
| | - Letícia S Delfino
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP) School of Medicine, Campinas, Brazil
| | - Isabella S Ignarro
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP) School of Medicine, Campinas, Brazil
| | - Luiz F Baccaro
- Department of Obstetrics and Gynecology, University of Campinas (UNICAMP) School of Medicine, Campinas, Brazil
| |
Collapse
|
21
|
Banwarth-Kuhn B, McQuade M, Krashin JW. Vaginal Bleeding Before 20 Weeks Gestation. Obstet Gynecol Clin North Am 2023; 50:473-492. [PMID: 37500211 DOI: 10.1016/j.ogc.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Conditions that often present with vaginal bleeding before 20 weeks are common and can cause morbidity and mortality. Clinically stable patients can choose their management options. Clinically unstable patients require urgent procedural management: uterine aspiration, dilation and evacuation, or surgical removal of an ectopic pregnancy. Septic abortion requires prompt procedural management, intravenous antibiotics, and intravenous fluids. Available data on prognosis with expectant management of pre-viable rupture of membranes in the United States are poor for mothers and fetuses.
Collapse
Affiliation(s)
| | | | - Jamie W Krashin
- Department of Obstetrics & Gynecology, University of New Mexico Health Sciences Center, MSC 10 5580, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA.
| |
Collapse
|
22
|
Fu Y, Zhang W, Wang Q, Hu C, Li Q, Huang J. Evaluation of Guidelines and Consensus on Ectopic Pregnancy Based by AGREE II Method. Int J Womens Health 2023; 15:1367-1374. [PMID: 37667774 PMCID: PMC10475285 DOI: 10.2147/ijwh.s421956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/19/2023] [Indexed: 09/06/2023] Open
Abstract
Introduction To evaluate the methodological quality of diagnosis and treatment guidelines/consensus related to ectopic pregnancy. Materials and methods Use the "Appraisal of Guidelines and Research and Evaluation" (AGREE II) method to evaluate the differences among the guideline/consensus. Results We appraised 9 clinical practice guidelines for ectopic pregnancy (9 clinical practice guidelines from 5 countries) including the United States, United Kingdom, Ireland, Canada, and China. The guidelines received the highest scores for clarity of presentation (82.72%) and lowest scores for editorial independence (30.56%). The comprehensive recommendations of the 7 guidelines were Grade B, the other 2 guidelines were Grade C. Conclusion The overall quality of the ectopic pregnancy guidelines had room for improvement. It is recommended to supplement and improve the four fields of "independence", "rigor", "participants" and "application", especially the "independence" and "application" fields.
Collapse
Affiliation(s)
- Yiran Fu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Weishe Zhang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
- Hunan Engineering Research Center of Early Life Development and Disease Prevention, Changsha, People’s Republic of China
| | - Qi Wang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Caihong Hu
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Qi Li
- Reproductive Medicine Center, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| | - Jingrui Huang
- Department of Obstetrics, Xiangya Hospital Central South University, Changsha, People’s Republic of China
| |
Collapse
|
23
|
Noël L, Chantraine F. Methotrexate for CSPs. Best Pract Res Clin Obstet Gynaecol 2023; 89:102364. [PMID: 37354647 DOI: 10.1016/j.bpobgyn.2023.102364] [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: 04/07/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/26/2023]
Abstract
Expectant management of a cesarean scar pregnancy (CSP) is associated with a high risk of severe maternal morbidity. Therefore, most experts recommend immediate termination after the diagnosis of a CSP. However, there is no consensus about the optimal management of a CSP in terms of efficacy, safety, and preservation of future fertility. Methotrexate (MTX) is a folic acid antagonist that has been largely used to treat tubal ectopic pregnancies. This review summarizes the current knowledge and uncertainties about the administration of MTX as a medical or non-invasive option to terminate a CSP; the preferred injection route (systemic or local/intragestational), the comparison with other treatment modalities, and the prognostic factors for MTX success will be discussed, as well as the recommendations from scientific societies.
Collapse
Affiliation(s)
- Laure Noël
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Liège, Citadelle Hospital, 4000 Liège, Belgium.
| | - Frédéric Chantraine
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Liège, Citadelle Hospital, 4000 Liège, Belgium.
| |
Collapse
|
24
|
Aiob A, Yousef H, Abu Shqara R, Mustafa Mikhail S, Odeh M, Lowenstein L. Risk factors and prediction of ectopic pregnancy rupture following methotrexate treatment: A retrospective cohort study. Eur J Obstet Gynecol Reprod Biol 2023; 285:181-185. [PMID: 37146508 DOI: 10.1016/j.ejogrb.2023.04.030] [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: 02/27/2023] [Revised: 04/21/2023] [Accepted: 04/28/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVE Ectopic pregnancy (EP) rupture after methotrexate (MTX) treatment can have severe consequences. We examined clinical characteristics and beta-hCG trends that may predict EP rupture after MTX treatment. STUDY DESIGN In this 10-year retrospective study of 277 women with an EP, we compared clinical, sonographic and beta-hCG trends, before and after MTX treatment, between those who did and did not have an EP rupture after MTX treatment. RESULTS EP rupture was diagnosed in 41 women (15.1%) within 25 days of MTX treatment, and was correlated with higher parity and advanced pregnancy age: 2(0-5) vs. 1(0-6), P = 0.027 and 6.6(4.2-9.8) vs. 6.1(4-9.5), P = 0.045. EP rupture was also correlated with higher beta-hCG levels on days 0, 4 and 7 of MTX treatment: (2063 vs. 920 mIU/ml), (3221 vs. 921 mIU/ml) and (2368 vs. 703 mIU/ml), respectively, P < 0.001, for all. An increase of beta-hCG by>14% during days 0-4 showed a sensitivity of 71.4% CI 95% [55.4%-84.3%] and a specificity of 67.5% CI 95% [61.1%-73.6%] for predicting EP rupture after MTX treatment. Beta-hCG > 910 mIU/ml on day 0 showed a sensitivity of 80.9% CI 95% [66.7%-90.8%] and a specificity of 70.4% CI 95% [64.1%-76.3%] for predicting EP rupture after MTX treatment. A beta-hCG increase by>14% during days 0-4, and a beta-hCG value > 910 mUI/mL on day 0 were associated with increased risks of EP rupture after MTX treatment; the odds ratios were 6.4 and 10.5, respectively. Odds ratios were 8.06 [CI 95% (3.70-17.56)], P < 0.001 for every percent rise in beta-hCG during days 0-4; 1.37 [CI 95% (1.06-1.86)], P = 0.046 for every week change in gestational age; and 1.001 [CI 95% (1.000-1.001)], P < 0.001 for every unit rise in beta-hCG at day 0. CONCLUSION Beta-hCG > 910 mIU/ml at day 0, a rise in beta-hCG by>14% during days 0-4, and more advanced gestational age were associated with EP rupture after MTX treatment.
Collapse
Affiliation(s)
- Ala Aiob
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel.
| | - Haddad Yousef
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel
| | - Raneen Abu Shqara
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Susana Mustafa Mikhail
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Marwan Odeh
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Lior Lowenstein
- Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel; Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| |
Collapse
|
25
|
Ge I, Geißler C, Geffroy A, Juhasz-Böss I, Wiehle P, Asberger J. Treatment of Cesarean Scar and Cervical Pregnancies Using the Ovum Aspiration Set for Intrachorial Methotrexate Injection as a Conservative, Fertility-Preserving Procedure. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040761. [PMID: 37109719 PMCID: PMC10143318 DOI: 10.3390/medicina59040761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Cesarean scar and cervical pregnancies are rare forms of ectopic pregnancies, occurring in 1 in 2000 and 1 in 9000 pregnancies, respectively. Both entities are medically challenging due to their high morbidity and mortality potential. Materials and Methods: In this retrospective study, we analyzed all cesarean scar and cervical pregnancies from 2010 to 2019 in the Department of Gynecology and Obstetrics of the University Hospital Freiburg, treated with both intrachorial (using the ovum aspiration set) and systemic methotrexate application. Results: We identified seven patients with a cesarean scar and four patients with cervical pregnancies. At diagnosis, the median gestational age was 7 + 1 (range: 5 + 5-9 + 5) weeks and the mean value of ß-hCG was 43,536 (range: 5132-87842) mlU/mL. On average, one dose of intrachorial and two doses of systemic methotrexate were administered per patient. The efficacy rate was 72.7% with three patients (27.3%) needing an additional surgical or interventional procedure. The uterus was preserved in 100% of the patients. Out of the eight patients with follow-up data, five reported subsequent pregnancies (62.5%) that resulted in six live births. None had recurrent cesarean scars or cervical pregnancies. In the subgroup analyses, when comparing cesarean scar pregnancies to cervical pregnancies, patient characteristics, treatment modality, and the outcome did not differ significantly, except for parity (2 versus 0, p = 0.02) and the duration since the last pregnancy (3 vs. 0.75 years, p = 0.048). When comparing cases with successful and failed methotrexate-only treatments, the maternal age was significantly higher in the successful group (34 vs. 27 years, p = 0.02). Localization of the gestation, gestational and maternal age, ß-hCG, and history of preceding pregnancies were non-predictive for the efficacy of the treatment. Conclusions: The combined application of intrachorial and systemic methotrexate for the treatment of cesarean scar and cervical pregnancies has been proven effective, well-tolerated, organ- and fertility-conserving with a low complication rate.
Collapse
Affiliation(s)
- Isabell Ge
- Department of Obstetrics and Gynaecology, University Hospital of Basel, 4056 Basel, Switzerland
- Breast Center, University Hospital Basel, University of Basel, 4056 Basel, Switzerland
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Carmen Geißler
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Alexandra Geffroy
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Philipp Wiehle
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Jasmin Asberger
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| |
Collapse
|
26
|
Natarajan A, Chivukula N, Dhanakoti GB, Sahoo AK, Ravichandran J, Samal A. EPEK: Creation and analysis of an Ectopic Pregnancy Expression Knowledgebase. Comput Biol Chem 2023; 104:107866. [PMID: 37030102 DOI: 10.1016/j.compbiolchem.2023.107866] [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: 12/28/2022] [Revised: 03/04/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023]
Abstract
Ectopic pregnancy (EP) is one of the leading causes of maternal mortality, where the fertilized embryo grows outside of the uterus. Recent experiments on mice have uncovered the importance of genetic factors in the transport of embryos inside the uterus. In the past, efforts have been made to identify possible gene or protein markers in EP in humans through multiple expression studies. Although there exist comprehensive gene resources for other maternal health disorders, there is no specific resource that compiles the genes associated with EP from such expression studies. Here, we address that knowledge gap by creating a computational resource, Ectopic Pregnancy Expression Knowledgebase (EPEK), that involves manual compilation and curation of expression profiles of EP in humans from published articles. In EPEK, we compiled information on 314 differentially expressed genes, 17 metabolites, and 3 SNPs associated with EP. Computational analyses on the gene set from EPEK showed the implication of cellular signaling processes in EP. We also identified possible exosome markers that could be clinically relevant in the diagnosis of EP. In a nutshell, EPEK is the first and only dedicated resource on the expression profile of EP in humans. EPEK is accessible at https://cb.imsc.res.in/epek.
Collapse
Affiliation(s)
- Ananya Natarajan
- Indian Institute of Science Education and Research (IISER) Mohali, Punjab, India
| | - Nikhil Chivukula
- The Institute of Mathematical Sciences (IMSc), Chennai, India; Homi Bhabha National Institute (HBNI), Mumbai, India
| | | | - Ajaya Kumar Sahoo
- The Institute of Mathematical Sciences (IMSc), Chennai, India; Homi Bhabha National Institute (HBNI), Mumbai, India
| | - Janani Ravichandran
- The Institute of Mathematical Sciences (IMSc), Chennai, India; Homi Bhabha National Institute (HBNI), Mumbai, India.
| | - Areejit Samal
- The Institute of Mathematical Sciences (IMSc), Chennai, India; Homi Bhabha National Institute (HBNI), Mumbai, India.
| |
Collapse
|
27
|
Levin G, Ohayon A, Weissbach T, Burke YZ, Meyer R. Ectopic first pregnancy treated by methotrexate versus salpingectomy-Maternal and perinatal outcomes in a subsequent pregnancy: A retrospective study. Int J Gynaecol Obstet 2023; 160:823-828. [PMID: 35871755 PMCID: PMC10087190 DOI: 10.1002/ijgo.14365] [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: 03/11/2022] [Revised: 06/30/2022] [Accepted: 07/17/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To study obstetric outcomes of a second pregnancy among women with a first ectopic pregnancy (EP) treated with methotrexate compared with laparoscopic salpingectomy. METHODS A retrospective cohort study including all women with a first EP and a following pregnancy that concluded by delivery at ≥24 weeks of gestation between March 2011 and April 2021. Second pregnancy outcomes were compared between women treated with methotrexate and those treated with salpingectomy in their first pregnancy. RESULTS Overall, 125 women were included, of which 64 (51.2%) were treated with methotrexate and 61 (48.8%) were treated with salpingectomy. In women treated with salpingectomy, the proportion of women conceiving by in vitro fertilization and those with measured gestational sac diameter or β-subunit human chorionic gonadotropin was higher. The proportion of women conceiving by in vitro fertilization in their second pregnancy was higher in the salpingectomy group (55.2% versus 18.0%, P < 0.001). All maternal and neonatal outcomes were similar in both groups. The rate of low birth weight < 2500 g was 7.8% in the methotrexate group versus 18% in the salpingectomy group (P = 0.111). CONCLUSION Maternal and neonatal outcomes of a second pregnancy among women treated for EP in their first pregnancy are similar in women treated by methotrexate and those treated by salpingectomy.
Collapse
Affiliation(s)
- Gabriel Levin
- Department of Gynecologic Oncology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Aviran Ohayon
- Faculty of Medicine, St. George's University of London, London, UK
| | - Tal Weissbach
- Faculty of Medicine, Tel-Aviv-Hebrew University, Tel-Aviv, Israel.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Yechiel Z Burke
- Faculty of Medicine, Tel-Aviv-Hebrew University, Tel-Aviv, Israel.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Raanan Meyer
- Faculty of Medicine, Tel-Aviv-Hebrew University, Tel-Aviv, Israel.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel.,The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Ramat-Gan, Israel
| |
Collapse
|
28
|
Zhao X, Yan L, Ji S, Zhang Y, Ha L, He C, Tian Y, Chen L, Zhu Q, Li M, Zhang J. Colnoy-stimulating factor 1 positive (CSF1 + ) secretory epithelial cells induce excessive trophoblast invasion in tubal pregnancy rupture. Cell Prolif 2023:e13408. [PMID: 36721079 DOI: 10.1111/cpr.13408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/10/2023] [Accepted: 01/11/2023] [Indexed: 02/02/2023] Open
Abstract
Tubal ectopic pregnancy (TEP) occurs when an embryo aberrantly implants in the fallopian tube, leading to abortive or ruptured tubal ectopic pregnancy (AEP or REP). Poor outcomes of REP include maternal infertility or mortality. Current studies on the prevention and treatment of ruptured tubal ectopic pregnancy (REP) are unfortunately hampered by a lack of the cell spectrum and cell-cell communications in the maternal-foetal interface. Here, we investigate the mechanisms of tubal rupture through single-cell transcriptome profiling of the fallopian tube-trophoblast interface in REP, AEP and intrauterine pregnancy patients. In REP, extravillous trophoblast (EVTs) cells form a dominant cell population, displaying aggressive invasion and proliferation, with robust differentiation into three subsets. Cell communication analysis identified colony-stimulating factor 1 (CSF1), overexpressed by fallopian tube secretory epithelial cells in REP, with CSF1R on EVTs and macrophages, as a ligand/receptor pair that stimulates EVT invasion and macrophage accumulation. CSF1+ secretory epithelial cells stimulate EVTs migration and invasion, leading to a tubal rupture in REP. These results provide a mechanistic context and cellular milieu leading to tubal rupture, facilitating further study and development of therapeutics for REP in early pregnancy.
Collapse
Affiliation(s)
- Xiaoya Zhao
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Li Yan
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Sifan Ji
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yiqin Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Lisai Ha
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Chuqing He
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yuan Tian
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Luting Chen
- Shanghai Municipal Key Clinical Specialty, Shanghai, China.,Department of Assisted Reproduction, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qian Zhu
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Mingqing Li
- Hospital and Institute of Obstetrics and Gynecology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| |
Collapse
|
29
|
Zippl AL, Aulitzky A, Braun AS, Feil K, Toth B. Gestörte Frühgravidität. GYNAKOLOGISCHE ENDOKRINOLOGIE 2023. [DOI: 10.1007/s10304-022-00486-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
ZusammenfassungEine Schwangerschaft kann intrauterin, ektop oder an einem unklaren Ort liegen und entwicklungsphysiologisch vital oder gestört sein. Die transvaginale Sonographie ermöglicht die Darstellung einer intrauterinen Schwangerschaft ab einem Schwellenwert des humanen Choriongonadotropins (hCG) von 1000 IU/l in der etwa sechsten Schwangerschaftswoche (SSW). Ektope Schwangerschaften sind abhängig von der SSW gegebenenfalls erschwert sonographisch erkennbar. Der Verlauf des hCG-Werts kann hilfreich dabei sein, eine physiologische von einer gestörten Frühschwangerschaft zu unterscheiden, muss aber immer in Zusammenschau mit der Klinik und dem Ultraschallbefund interpretiert werden. Bei einem frühen Abort kann abhängig von der Klinik exspektativ oder medikamentös vorgegangen werden. Die Indikation zur Kürettage sollte insgesamt zurückhaltend gestellt werden. Bei einer ektopen Schwangerschaft sollte abhängig von SSW und Klinik eine operative Therapie oder eine Methotrexattherapie durchgeführt werden.
Collapse
|
30
|
Muacevic A, Adler JR, Sanjaghsaz H, Nichols R. Ectopic Pregnancy in an Adolescent: A Case Report and Review of Literature. Cureus 2022; 14:e32220. [PMID: 36620848 PMCID: PMC9812281 DOI: 10.7759/cureus.32220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 12/12/2022] Open
Abstract
Ectopic pregnancy continues to be the leading cause of death in the first trimester. Here, we report the case of a 17-year-old female who presented with vaginal bleeding and a positive serum beta-human chorionic gonadotropin level. In addition, we review the literature, focusing on the early diagnosis and management with the increasing preference for nonsurgical management of ectopic pregnancy, particularly in adolescents.
Collapse
|
31
|
Clinical Presentation as a Predictor of the Response to Methotrexate Therapy in Patients with Ectopic Pregnancy. J Pregnancy 2022; 2022:5778321. [PMID: 36479045 PMCID: PMC9722302 DOI: 10.1155/2022/5778321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose Ectopic pregnancy can be fatal if not diagnosed and timely treated. There is an increase in ectopic pregnancy rate which attributes in part to fertility medications and procedures and early diagnosis. Methotrexate, a folic acid antagonist, is widely used in the medical treatment of ectopic pregnancy. Many studies examined the safety and success rate of methotrexate looking into factors affecting the success rate, if the patient may present with symptoms such as abdominal pain, and some consider this as impeding rupture and it might affect the success of medical treatment. This study evaluates the success rate of methotrexate treatment outcomes in regard to presentation and looks into other factors that can help choosing a single or multiple dose modality. Methods This is a retrospective review of 154 cases of ectopic pregnancy treated with methotrexate from January 2011 to December 2020 at King Khalid University Hospital (KKUH). Demographic data, clinical presentation, treatment progress, and outcome and failure rate were collected and analyzed. Student's t-test was used for statistical analysis of associations in SPSS. Results 154 patients were treated with MTX; of those patients, 25 received more than one dose. The difference between the responses to MTX treatment in symptomatic and asymptomatic individuals was not significant (p = 0.267). 131 (85%) had successful treatment. There were no associations between patient BMI, ectopic mass size, or ectopic mass site, the presence or absence of pelvic fluid on ultrasound at diagnosis, and the treatment success rate. There was a significant decline in the treatment success rate with increasing β-hCG levels on the presentation day (p = 0.035) and on day 4 (p value <0.001) of treatment. Conclusion MTX treatment can be used to manage symptomatic patients with ectopic pregnancy. The success rate in symptomatic patients is not different from that in asymptomatic patients. β - hCG levels > 5000 IU/L. Pretreatment and on day 4 posttreatment is associated with higher failure rate.
Collapse
|
32
|
Wang C, Xiong Y, Liu F, Qiu L, Zhang CQ. Rectal ectopic pregnancy after in vitro fertilization and embryo transfer: A case report. Medicine (Baltimore) 2022; 101:e31676. [PMID: 36451431 PMCID: PMC9705002 DOI: 10.1097/md.0000000000031676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
RATIONALE Rectal ectopic pregnancy is an extremely rare abdominal pregnancy. This article presents a female underwent an unsuccessful in vitro fertilization which was misdiagnosed by serum beta-human chorionic gonadotropin (β-hCG) test and transvaginal ultrasonography. Twenty days later, a ruptured rectal ectopic pregnancy was confirmed by laparoscopy then the gestational tissue removed successfully. PATIENT CONCERNS A 32-year-old Chinese female was admitted to our hospital with complaining of symptoms, like gradual worsening of lower abdominal pain and dysuria. The abdominal ultrasonography revealed a sac-like mass in the posterior area to the uterus and a moderate amount of free fluid in the pelvic cavity. Forty days ago, she underwent a frozen embryo transfer. Twenty days ago, her serum β-hCG level was <5 mIU/mL and neither intrauterine nor ectopic pregnancy was detected by transvaginal ultrasonography. Then the procedure was thought to have resulted in biochemical pregnancy failure. DIAGNOSIS The primary rectal ectopic pregnancy. INTERVENTIONS The mass was removed laparoscopic surgery. OUTCOMES The patient recovered well. LESSONS When the history of in vitro fertilization combined with an inappropriate rise of serum β-hCG and no visible evidence of an intra-uterine pregnancy, physicians should consider the possibility of abdominal pregnancy. Early diagnosis of abdominal pregnancy can effectively save the life of the pregnant woman.
Collapse
Affiliation(s)
- Chujun Wang
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yipin Xiong
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fengzhen Liu
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Lijuan Qiu
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chun-Quan Zhang
- Department of Ultrasound, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- * Correspondence: Chun-Quan Zhang, Department of Ultrasound, the Second Affiliated Hospital of Nanchang University, No.1, Minde Road, Donghu District, Nanchang 330006, Jiangxi, China (e-mail: )
| |
Collapse
|
33
|
Bermas BL. The Unintended Consequence of the Overturn of Roe v Wade: Restrictions on Methotrexate Use. J Rheumatol 2022; 49:1284-1285. [DOI: 10.3899/jrheum.220782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
34
|
Muacevic A, Adler JR, Kumari S. Predictors of Successful Medical Management With Methotrexate in Unruptured Tubal Ectopic Pregnancy. Cureus 2022; 14:e31923. [PMID: 36580082 PMCID: PMC9792717 DOI: 10.7759/cureus.31923] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction Medical treatment with methotrexate (MTX) is a safe and effective alternative to surgery in carefully selected cases of ectopic pregnancies diagnosed early prior to rupture. Aim To determine the optimal pre-treatment levels of beta human chorionic gonadotropin (𝛽-hCG) and its changing trends most likely to have a successful outcome with medical management. Material and methods A prospective observational study was conducted in a tertiary teaching hospital from December 2018 to May 2021. "Single-dose" MTX regime was used for medical management of ectopic pregnancy in patients fulfilling the selection criteria. The 𝛽-hCG levels were recorded at baseline and on day 4 and day 7 of MTX injection. Thereafter, at weekly intervals till complete resolution or surgical intervention due to failure of medical management. In addition, receiver operating characteristic (ROC) curve analysis for a pre-treatment 𝛽-hCG cut-off value and changing trends in post-treatment 𝛽- hCG levels most likely to have a successful outcome with MTX treatment were determined. Results Fifty patients fulfilling the inclusion criteria were included in the study, with successful medical management in 33 (66%). The mean pre-treatment 𝛽-hCG levels in women with successful medical management were 3270.97 (+/- 901) compared to 5249.17 (+/-808.02) for those with treatment failure (p=0.00001). The mean 𝛽-hCG level in the failed treatment group was significantly higher on day 4 than the pre-treatment levels (6742.56 +/- 572 vs. 5249.17+/- 808.02; p<0.05). Inadequate reduction of 𝛽-hCG level on day 7 (<15% of day 4 levels) requiring repeat dosage of MTX was more likely to have an unsuccessful outcome (p=0.00001). The area under curve (AUC) value of 0.905 (95% CI: 0.814-0.996) depicted that pre-treatment 𝛽-hCG level of 4000 mIU/ml taken as the cut-off value was able to predict levels ≤4000 mIU/ml had a greater likelihood of successful outcome with MTX, having a sensitivity of 84.5%, specificity of 83.3%, positive predictive value (PPV) of 90.3%, and negative predictive value (NPV) of 75% (p< 0.05). Demographic variables or previous clinical history, considered risk factors for ectopic pregnancy, did not affect the outcome of medical management in this study. Conclusion Medical management of ectopic pregnancy is a viable first-line treatment option in carefully selected patients. In this study, the most important predictors for the successful outcome of medical management were the pre-treatment β-hCG levels and their fall on day 4 and day 7 after MTX therapy.
Collapse
|
35
|
Leziak M, Żak K, Frankowska K, Ziółkiewicz A, Perczyńska W, Abramiuk M, Tarkowski R, Kułak K. Future Perspectives of Ectopic Pregnancy Treatment-Review of Possible Pharmacological Methods. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192114230. [PMID: 36361110 PMCID: PMC9656791 DOI: 10.3390/ijerph192114230] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/22/2022] [Accepted: 10/26/2022] [Indexed: 06/03/2023]
Abstract
Ectopic pregnancy, that is, a blastocyst occurring outside the endometrial cavity of the uterus, affects nearly 2% of pregnancies. The treatment of ectopic pregnancy is surgical or pharmacological. Since surgical management is associated with numerous serious side effects, conservative treatment is sought. The treatment of choice in the majority of cases is based on pharmacotherapy with methotrexate (MTX) in a single- or multi-dose regimen. Although the efficacy of methotrexate reaches between 70 and 90%, its use requires specific conditions regarding both the general condition of the patient and the characteristic features of the ectopic pregnancy. Moreover, MTX can cause severe adverse effects, including stomatitis, hepatotoxicity and myelosuppression. Therefore, clinicians and researchers are still looking for a less toxic, more effective treatment, which could prevent surgeries as a second-choice treatment. Some studies indicate that other substances might constitute a good alternative to methotrexate in the management of ectopic pregnancies. These substances include aromatase inhibitors, especially letrozole. Another promising substance in EP treatment is gefitinib, an inhibitor of EGFR tyrosine domain which, combined with MTX, seems to constitute a more effective alternative in the management of tubal ectopic pregnancies. Other substances for local administration include KCl and absolute ethanol. KCl injections used in combination with MTX may be used when foetal heart function is detected in cervical ectopic pregnancies, as well as in heterotopic pregnancy treatment. Absolute ethanol injections proved successful and safe in caesarean scar pregnancies management. Thus far, little is known about the use of those substances in the treatment of ectopic pregnancies, but already conducted studies seem to be promising.
Collapse
Affiliation(s)
- Milena Leziak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Klaudia Żak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Karolina Frankowska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Aleksandra Ziółkiewicz
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Weronika Perczyńska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Monika Abramiuk
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
| | - Rafał Tarkowski
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
| | - Krzysztof Kułak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
| |
Collapse
|
36
|
Ren F, Liu G, Wang T, Li M, Guo Z. Unruptured ovarian ectopic pregnancy: Two case reports and literature review. Front Physiol 2022; 13:1036365. [PMID: 36388130 PMCID: PMC9641050 DOI: 10.3389/fphys.2022.1036365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/05/2022] [Indexed: 11/26/2022] Open
Abstract
In clinical practice, ovarian pregnancy is extremely rare and is always found to be ruptured. A definitive diagnosis for ruptured ovarian pregnancy is difficult to obtain. We present two cases of unruptured ovarian pregnancies detected during laparoscopy and review existing literature to better understand the clinical characteristics of ectopic pregnancies in this rare site. Intrauterine devices, assisted reproductive technology, and intrauterine operations are all high-risk factors in ovarian pregnancy. Moreover, menopause, abdominal pain, and vaginal bleeding are clinical manifestations. Ovarian pregnancy can be diagnosed using serum hCG, transvaginal ultrasound, and magnetic resonance imaging. Laparoscopy is the treatment of choice for ovarian pregnancy. It is recommended that the intact gestational sac be excised and the ovarian function be protected to the greatest extent possible during the operation. More definitive diagnosis of ovarian pregnancy must be reported in order to gain a better understanding of ovarian pregnancy.
Collapse
Affiliation(s)
- Fang Ren
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Gang Liu
- Department of Urology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Tifang Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Meijun Li
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhiqiang Guo
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Zhiqiang Guo,
| |
Collapse
|
37
|
Alabiad MA, Said WMM, Gad AH, Sharaf ElDin MTA, Khairy DA, Gobran MA, Shalaby AM, Samy W, Abdelsameea AA, Heraiz AI. Evaluation of Different Doses of the Aromatase Inhibitor Letrozole for the Treatment of Ectopic Pregnancy and Its Effect on Villous Trophoblastic Tissue. Reprod Sci 2022; 29:2983-2994. [PMID: 35701686 PMCID: PMC9537218 DOI: 10.1007/s43032-022-00993-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 05/29/2022] [Indexed: 11/26/2022]
Abstract
Letrozole, an aromatase inhibitor, has recently been introduced as a favorable medical treatment for ectopic pregnancy. We aimed at evaluating the effects of different doses of letrozole for termination of ectopic pregnancy and study their effects on villous trophoblastic tissue. Sixty patients with undisturbed ectopic pregnancy were classified into three equal groups. Group I: the control group that contained women who underwent laparoscopic salpingectomy, Group II: patients who received letrozole (5 mg day-1) for 10 days, and Group III: patients who received letrozole (10 mg day-1) for 10 days. Subsequently, the β-hCG levels were determined on the first day and after 11 days of treatment. Group IV consisted of patients of GII and GIII; their β-hCG did not drop below 100 mIU/ml within 11 days, and underwent salpingectomy. Placental tissues from patients undergoing salpingectomy either from the control group or GIV were processed for the evaluation of estrogen (ER) and progesterone (PR) receptors, vascular endothelial growth factor (VEGF), and cleaved caspase 3 (CC-3) expression. Cases exposed to high dose letrozole 10 mg day-1 resulted in a higher ectopic pregnancy resolution rate of 85% (17/20), while the resolution rate of the low dose letrozole-treated group (5 mg day-1) was 65% (13/20), and also showed a significant reduction in β-hCG levels on the 11th day, 25.63 ± 4.29 compared to the low dose letrozole group 37.91 ± 7.18 (P < 0.001), Meanwhile, the letrozole-treated group GIV showed markedly reduced expression of ER, PR, and VEGF and a significant increase in the apoptotic index cleaved caspase-3 compared to the control group (P < 0.001). The utilization of letrozole at a dose of 10 mg day-1 for medical treatment of ectopic pregnancy results in a high-successful rate without any severe side effects. Letrozole depriving the placenta of estrogen that had vascular supporting signals resulted in destroying the vascular network with marked apoptosis.
Collapse
Affiliation(s)
- Mohamed Ali Alabiad
- Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, 44519 Egypt
| | - Warda M. M. Said
- Department of Pathology, Faculty of Medicine, Benghazi University, Benghazi, Libya
| | - Abdalla Hassan Gad
- Department of Gynecology and Obstetrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Dina Ahmed Khairy
- Department of Biomedical Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mai Ahmed Gobran
- Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, 44519 Egypt
| | - Amany Mohamed Shalaby
- Department of Histology and Cell Biology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Walaa Samy
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | | | - Ahmed Ismail Heraiz
- Department of Gynecology and Obstetrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| |
Collapse
|
38
|
Muacevic A, Adler JR. A 10-Year Review of Methotrexate Treatment for Ectopic Pregnancy in a Malaysian Tertiary Referral Hospital. Cureus 2022; 14:e30395. [PMID: 36407144 PMCID: PMC9671276 DOI: 10.7759/cureus.30395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2022] [Indexed: 01/25/2023] Open
Abstract
Background Ectopic pregnancy was recorded as the fourth principal cause of maternal death in Malaysia in 2019. Early diagnosis and use of methotrexate treatment proved to be safe and effective alternatives to surgical treatment. This study investigates the success rate of methotrexate treatment for ectopic pregnancy in a tertiary hospital in Malaysia. Methods This was a retrospective review of 73 patients with ectopic pregnancies treated with methotrexate according to a single-dose protocol from January 2009 until November 2019. The diagnosis of ectopic pregnancy was made using a combination of transvaginal scan and serial serum β-hCG levels. Their clinical and demographic data were reviewed. Serum β-hCG levels were measured at pre- and post-treatment to determine the rate of successful resolution. Results The overall success rate was 87.7% (64/73 patients) with methotrexate treatment. Fifty-six patients (76.7%) were successfully treated with a single dose of methotrexate, and eight patients (11.0%) required a second dose of methotrexate. There was no relation between socio-demographic, pre-treatment β-hCG levels, ectopic mass size, and treatment efficacy. Smaller size of ectopic pregnancy (adjusted OR=29.23; 95% CI: 2.69, 317.90; P=0.006) and absence of free fluid at the pouch of Douglas (POD) (adjusted OR=27.31; 95% CI: 2.84, 262.32; P=0.004) was found to increase the likelihood of overall treatment success. Absence of fetal cardiac activities was found to increase the likelihood of first-dose methotrexate treatment success (OR=10.20; 95% CI: 1.93, 53.79; P=0.006). Conclusions Early diagnosis of ectopic pregnancy may reduce morbidity and mortality. In carefully selected cases, methotrexate treatment has been proven to be cost-effective and avoided risks associated with surgery and anaesthesia.
Collapse
|
39
|
Yu Y, Li Y, Yang X, Fan Q, Cao D, Wang Y. Daily variations and levels of human chorionic gonadotropin before methotrexate treatment as predictors of treatment success. J Obstet Gynaecol Res 2022; 48:3128-3136. [PMID: 36056536 DOI: 10.1111/jog.15413] [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: 04/20/2022] [Revised: 08/11/2022] [Accepted: 08/20/2022] [Indexed: 12/01/2022]
Abstract
AIM The aim of this study is to investigate the role of human chorionic gonadotropin (hCG) daily variations and levels prior to methotrexate treatment as predictors for treatment outcome. METHODS This retrospective study included patients who had a sonographically confirmed ectopic pregnancy at the International Peace Maternity and Child Health Hospital between November 2015 and June 2020. The associations of hCG levels and daily variations with the treatment success were evaluated by multivariable logistic regression and receiver operator characteristic (ROC) curve. Establish a nomogram that predicts how methotrexate (MTX) therapy will turn out. The performance of the model was assessed utilizing concordance index, receiver operating characteristic curves, and calibration plots. RESULTS The median serum hCG levels before treatment and hCG daily variation in the failure group were higher than those in the success group (487.8 vs. 270.7 IU/L, -1.86% vs. 7.29%, both p < 0.01). According to the ROC curve analysis, the cutoff values of serum hCG level before treatment and daily variations were 617.35 IU/L and 1.76%/day. By multivariable logistic regression analysis, serum hCG levels before treatment (odds ratio [OR]: 1.001, 95% confidence interval [CI]: 1.000 ~ 1.001) and hCG daily variations were independently associated with the treatment success (OR: 1.033, 95% CI: 1.015 ~ 1.052). The nomogram was effective at predicting the outcome of MTX treatment with a receiver operating characteristic area under the curve of 0.717 (p < 0.001). The nomogram's calibration curve was almost parallel to the ideal diagonal line. CONCLUSION We successfully created a nomogram based on serum hCG levels before treatment and hCG daily changes to anticipate the result of MTX therapy, which could assist medical professionals in selecting therapeutic schedule for patients with tubal pregnancies.
Collapse
Affiliation(s)
- Yuchong Yu
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuhong Li
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoming Yang
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiong Fan
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dan Cao
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yudong Wang
- Department of Gynecologic Oncology, the International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty of Gynecologic Oncology, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases Affifiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
40
|
ÇETİN F, BAYRAMOĞLU TEPE N, SUCU S, BADEMKIRAN MH, KUTLAR İ. Analysis of multiple-dose methotrexate therapy in tubal ectopic pregnancies. CUKUROVA MEDICAL JOURNAL 2022. [DOI: 10.17826/cumj.1037172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
|
41
|
Quinto L, Ross ME, VanArendonk SH. Overview and Management of Tubal Ectopic Pregnancy. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lauren Quinto
- Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, Texas, USA
| | - Megan E. Ross
- Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, Texas, USA
| | - Sarah H. VanArendonk
- Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, Texas, USA
| |
Collapse
|
42
|
Ruptured ectopic pregnancies following methotrexate treatment: clinical course and predictors for improving patient counseling. Reprod Sci 2022; 29:1209-1214. [DOI: 10.1007/s43032-022-00881-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 02/07/2022] [Indexed: 10/19/2022]
|
43
|
Ku CW, Ong I, Chan JKY, Ee TX. Abdominal heterotopic pregnancy post-IVF double embryo transfer. BMJ Case Rep 2022; 15:15/2/e246649. [PMID: 35131787 PMCID: PMC8823037 DOI: 10.1136/bcr-2021-246649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Uterosacral ligament (USL) is an uncommon site of implantation for abdominal ectopic pregnancies. This is the first case of USL heterotopic pregnancy post invitro fertilisation (IVF). The patient presented 6 weeks after a double embryo transfer with acute onset abdominal pain and was diagnosed with a suspected live tubal ectopic pregnancy with a viable intrauterine pregnancy on ultrasound. A diagnostic laparoscopy revealed an ectopic pregnancy implanted on the left USL which was resected and confirmed on histology. The patient was discharged well on postoperative day 2 with a viable intrauterine pregnancy. This case highlights the importance of considering non-tubal heterotopic pregnancies in the context of risk factors including IVF with double embryo transfer presenting with abdominal pain.
Collapse
Affiliation(s)
- Chee Wai Ku
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| | - Isabella Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jerry Kok Yen Chan
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Tat Xin Ee
- Department of Reproductive Medicine, KK Women's and Children's Hospital, Singapore
- Duke-NUS Medical School, Singapore
| |
Collapse
|
44
|
Poordast T, Naghmehsanj Z, Vahdani R, Moradi Alamdarloo S, Ashraf MA, Samsami A, Najib FS. Evaluation of the recurrence and fertility rate following salpingostomy in patients with tubal ectopic pregnancy. BMC Pregnancy Childbirth 2022; 22:2. [PMID: 34979988 PMCID: PMC8721972 DOI: 10.1186/s12884-021-04299-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 11/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background Ectopic pregnancy is one of the leading causes of pregnancy-related mortality; the treatment strategies associated with this condition entail complications, such as recurrence of ectopic pregnancy or infertility. The objective of this study was to evaluate the recurrence and fertility rate after salpingostomy in patients with tubal ectopic pregnancy. Methods This cross-sectional retrospective study was conducted at four referral centers of Obstetrics and Gynecology, under the supervision of Shiraz University of Medical Sciences (Iran). The medical records of 125 patients with tubal pregnancy were reviewed. These patients underwent laparoscopic salpingostomy from April 2009 to March 2016.Data on maternal age, BMI, history of previous EP, genital tract infection, IUD insertion, history of previous surgery, and infertility were further obtained. The patients were followed up for approximately 1 to 7 years. The recurrence of EP and subsequent pregnancy rate were assessed during the follow-up period. Results There was no statistically significant relationship between post-salpingostomy recurrence and maternal age, previous abdominopelvic surgery, and history of infertility(P = .425); however, the post-salpingostomy recurrence of EP was correlated with BMI (P = 0.001), previous history of EP (P = 0.001), genital tract infection (P = 0.001), and IUD insertion (P = 003). Among 95 women who had no contraception, pregnancy occurred in 51 cases (53.6%) and recurrence of EP was observed in 16 patients (12.8%). Conclusions Our results suggest that salpingostomy is a safe method with a low risk of recurrence and good fertility outcomes for women who consider future pregnancy.
Collapse
Affiliation(s)
- Tahereh Poordast
- Infertility Research Center, Department of Obstetrics and Gynecology, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Naghmehsanj
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Razie Vahdani
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Mohammad Ali Ashraf
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Almtaj Samsami
- OB & GYN Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Fatemeh Sadat Najib
- Infertility Research Center, Department of Obstetrics and Gynecology, Shiraz Medical School, Shiraz University of Medical Sciences, Shiraz, Iran.
| |
Collapse
|
45
|
Fan YY, Liu YN, Mao XT, Fu Y. The Prevalence of Ectopic Gestation: A Five-Year Study of 1273 Cases. Int J Gen Med 2021; 14:9657-9661. [PMID: 34934342 PMCID: PMC8684394 DOI: 10.2147/ijgm.s344648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022] Open
Abstract
Objective This study aims to investigate the prevalence, related risk factors, manifestations, and management of ectopic pregnancy in the first hospital of the Jilin University over a five-year period. Methods A retrospective study of ectopic pregnancy was conducted in the First Hospital of the Jilin University between January 1, 2010 and December 31, 2014. The results were analyzed using simple descriptive statistics and reported as frequencies and percentages. Results The results revealed that out of 16,050 gynecological admissions to the hospital over the five-year period, there were 1273 ectopic pregnancies, with a prevalence rate of 7.93% of all gynecological admissions. The majority of these patients were aged 25-34 y and had a past history of abortion (61%) and uterine cavity surgery (38.6%), and a significant number were nulliparous (549, 43.1%). Bleeding accompanied by abdominal pain were the most common presenting complaints (65.2%). A unilateral salpingectomy was performed for most of these patients. Conclusion Ectopic pregnancy had notable morbidity over the five-year period under study, and a history of abortion and uterine cavity surgery were identified as associated risk factors that limited the future reproductive potential of nulliparous women. Therefore, targeted health education campaigns should be conducted in order to enlighten this group of women and the public at large.
Collapse
Affiliation(s)
- Yan-Yan Fan
- Department of Obstetrics and Gynecology, The First Hospital of Jilin University, Changchun, 130021, People's Republic of China
| | - Yi-Nan Liu
- Department of Otorhinolaryngology, Jilin Province Faw General Hospital, Changchun, 130011, People's Republic of China
| | - Xin-Tong Mao
- Department of Obstetrics and Gynecology, Beijing Hospital of Traditional Chinese Medicine, Beijing, 10010, People's Republic of China
| | - Yan Fu
- Department of Obstetrics and Gynecology, The First Hospital of Jilin University, Changchun, 130021, People's Republic of China
| |
Collapse
|
46
|
Grigoriu C, Bohiltea R, Mihai B, Zugravu C, Furtunescu F, Georgescu T, Munteanu D. Success rate of methotrexate in the conservative treatment of tubal ectopic pregnancies. Exp Ther Med 2021; 23:150. [DOI: 10.3892/etm.2021.11073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/23/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Corina Grigoriu
- Department of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Roxana Bohiltea
- Department of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Bianca Mihai
- Department of Obstetrics and Gynecology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Corina Zugravu
- Department of Food Hygiene and Nutrition, ‘Carol Davila’ University of Medicine and Pharmacy, 050463 Bucharest, Romania
| | - Florentina Furtunescu
- Department of Public Health and Management, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050463 Bucharest, Romania
| | - Tiberiu Georgescu
- Department of Pathology, ‘Carol Davila’ University of Medicine and Pharmacy, 050463 Bucharest, Romania
| | - Diana Munteanu
- Department of Medical Expertise and Work Capacity Recovery, National Institute of Medical Expertise and Work Capacity Recovery, 050653 Bucharest, Romania
| |
Collapse
|
47
|
Refeno V, Rasamimanana NG, Abasse BA, Ramarokoto MPM, Fanomezantsoa MJE, Randaoharison PG. Methotrexate-induced toxidermia and pancytopenia in a patient with ectopic pregnancy: a case report. J Med Case Rep 2021; 15:579. [PMID: 34872594 PMCID: PMC8650356 DOI: 10.1186/s13256-021-03111-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 09/13/2021] [Indexed: 12/27/2022] Open
Abstract
Background Methotrexate is an anticancer drug from the antimetabolite class. It is also used in gynecology and obstetrics and is the molecule of choice for the medical treatment of ectopic pregnancies. We report a case of toxidermia associated with severe pancytopenia induced by methotrexate for ectopic pregnancy. Case presentation A 30-year-old Malagasy (African) woman was admitted to the Emergency and Intensive Care Department for probable toxidermia following injection of 75 mg of methotrexate for an ectopic pregnancy. She had developed generalized erythema, which started 48 hours after the injection. The secondary onset of phlyctenular maculopapular skin lesions, generalized purpura, and erosions of the oral mucosa in a context of febrile jaundice prompted her hospitalization. On admission, the patient presented with febrile neutropenia, pancytopenia, renal failure, and hepatic cytolysis. She received transfusions of fresh whole blood, erythromycin, and amphotericin B. The course was fatal within 2 days of hospitalization. The patient died of multiple organ failure. Conclusions Our case is mainly distinguished by the lack of use of granulocyte growth factors and folinic acid. In the event of severe reactions to methotrexate, the management should be multidisciplinary and as much as possible within an intensive care unit.
Collapse
Affiliation(s)
- Valéry Refeno
- Medicine Faculty of Mahajanga, Oncology Department of Professor ZAFISAONA Gabriel Teaching Hospital, Mahajanga, Madagascar.
| | - Naharisoa Giannie Rasamimanana
- Medicine Faculty of Mahajanga, Emergency and Intensive Care Department of Professor ZAFISAONA Gabriel Teaching Hospital, Mahajanga, Madagascar
| | - Baco Abdallah Abasse
- Medicine Faculty of Antananarivo, Mother and Child Complex of Professor ZAFISAONA Gabriel Teaching Hospital, Mahajanga, Madagascar
| | | | | | - Pierana Gabriel Randaoharison
- Medicine Faculty of Mahajanga, Mother and Child Complex of Professor ZAFISAONA Gabriel Teaching Hospital, Mahajanga, Madagascar
| |
Collapse
|
48
|
Bobdiwala S, Kyriacou C, Christodoulou E, Farren J, Mitchell-Jones N, Al-Memar M, Ayim F, Chohan B, Kirk E, Abughazza O, Guruwadahyarhalli B, Guha S, Vathanan V, Gould D, Stalder C, Timmerman D, Van Calster B, Bourne T. Evaluating cut-off levels for progesterone, β human chorionic gonadotropin and β human chorionic gonadotropin ratio to exclude pregnancy viability in women with a pregnancy of unknown location: A prospective multicenter cohort study. Acta Obstet Gynecol Scand 2021; 101:46-55. [PMID: 34817062 DOI: 10.1111/aogs.14295] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/13/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There is no global agreement on how to best determine pregnancy of unknown location viability and location using biomarkers. Measurements of progesterone and β human chorionic gonadotropin (βhCG) are still used in clinical practice to exclude the possibility of a viable intrauterine pregnancy (VIUP). We evaluate the predictive value of progesterone, βhCG, and βhCG ratio cut-off levels to exclude a VIUP in women with a pregnancy of unknown location. MATERIAL AND METHODS This was a secondary analysis of prospective multicenter study data of consecutive women with a pregnancy of unknown location between January 2015 and 2017 collected from dedicated early pregnancy assessment units of eight hospitals. Single progesterone and serial βhCG measurements were taken. Women were followed up until final pregnancy outcome between 11 and 14 weeks of gestation was confirmed using transvaginal ultrasonography: (1) VIUP, (2) non-viable intrauterine pregnancy or failed pregnancy of unknown location, and (3) ectopic pregnancy or persisting pregnancy of unknown location. The predictive value of cut-off levels for ruling out VIUP were evaluated across a range of values likely to be encountered clinically for progesterone, βhCG, and βhCG ratio. RESULTS Data from 2507 of 3272 (76.6%) women were suitable for analysis. All had data for βhCG levels, 2248 (89.7%) had progesterone levels, and 1809 (72.2%) had βhCG ratio. The likelihood of viability falls with the progesterone level. Although the median progesterone level associated with viability was 59 nmol/L, VIUP were identified with levels as low as 5 nmol/L. No single βhCG cut-off reliably ruled out the presence of viability with certainty, even when the level was more than 3000 IU/L, there were 39/358 (11%) women who had a VIUP. The probability of viability decreases with the βhCG ratio. Although the median βhCG ratio associated with viability was 2.26, VIUP were identified with ratios as low as 1.02. A progesterone level below 2 nmol/L and βhCG ratio below 0.87 were unlikely to be associated with viability but were not definitive when considering multiple imputation. CONCLUSIONS Cut-off levels for βhCG, βhCG ratio, and progesterone are not safe to be used clinically to exclude viability in early pregnancy. Although βhCG ratio and progesterone have slightly better performance in comparison, single βhCG used in this manner is highly unreliable.
Collapse
Affiliation(s)
- Shabnam Bobdiwala
- Department of Obstetrics and Gynaecology, Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - Christopher Kyriacou
- Department of Obstetrics and Gynaecology, Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - Evangelia Christodoulou
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium.,Department of Cancer Epidemiology, DKFZ, Heidelberg, Germany
| | - Jessica Farren
- Department of Gynaecology, St Mary's Hospital, London, UK
| | | | - Maya Al-Memar
- Department of Obstetrics and Gynaecology, Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - Francis Ayim
- Department of Gynaecology, Hillingdon Hospital NHS Trust, London, UK
| | | | - Emma Kirk
- Department of Gynaecology, Royal Free NHS Foundation Trust, London, UK
| | - Osama Abughazza
- Department of Gynaecology, Royal Surrey County Hospital, Guildford, UK
| | | | - Sharmistha Guha
- Department of Gynaecology, Chelsea and Westminster NHS Trust, London, UK
| | | | - Debbie Gould
- Department of Gynaecology, St Mary's Hospital, London, UK
| | - Catriona Stalder
- Department of Obstetrics and Gynaecology, Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK
| | - Dirk Timmerman
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium.,Department of Gynecology, University Hospital Leuven, Leuven, Belgium
| | - Ben Van Calster
- Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| | - Tom Bourne
- Department of Obstetrics and Gynaecology, Tommy's National Centre for Miscarriage Research, Queen Charlotte's & Chelsea Hospital, Imperial College London, London, UK.,Department of Development & Regeneration, KU Leuven, Leuven, Belgium
| |
Collapse
|
49
|
Yu H, Wang W, Liang H, Wang K, Ling B. Severe Adverse Toxic Effects of Low-Dose Methotrexate Treatment on an Ectopic Pregnancy Patient With Methylenetetrahydrofolate Reductase Mutations: A Case Report. Front Med (Lausanne) 2021; 8:738315. [PMID: 34869432 PMCID: PMC8636773 DOI: 10.3389/fmed.2021.738315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 10/13/2021] [Indexed: 11/28/2022] Open
Abstract
Background: Low-dose methylenetetrahydrofolate (LD-MTX) has been widely used for the treatment of the ectopic pregnancy (EP) for many decades, and related severe adverse toxic effects are rare. Current studies have shown that the polymorphisms of methylenetetrahydrofolate reductase (MTHFR) gene can decrease the MTX clearance, leading to the metabolite accumulation. However, there is a lack of literature report on an MTHFR gene polymorphism associated with adverse toxic effects resulting from the use of LD-MTX in an EP. Case Presentation: We report a rare case of a 38-year-old female who developed persistent fever, grade IV myelosuppression, skin lesions, mucositis, and liver injury after single dose of LDMTX to treat EP. The personalized genetic testing showed that MTHFR TT (677C>T) and MTHFR AA (1298A>C) were detected. Gradually, the symptoms improved after calcium leucovorin (CF) rescue, continuous renal replacement therapy (CRRT), promoting blood system regeneration, and multiple supportive treatments. Conclusion: This is the first report on the serious adverse toxic effects of LD-MTX on an EP patient with MTHFR mutations. We aim to alert obstetricians and gynecologists to this rare condition. The unexpected life-threatening toxicity with LD-MTX should be highly considered and recognized early. In particular, some easily overlooked gastrointestinal, skin, and mucosal symptoms occur earlier than severe myelosuppression. When toxic effects are suspected, detecting the polymorphisms of an MTHFR gene and monitoring MTX concentration in blood could assist us to formulate individualized and active treatments.
Collapse
Affiliation(s)
- Huan Yu
- Department of Obstetrics and Gynaecology, China-Japan Friendship Hospital, Beijing, China
| | - Wenhui Wang
- Department of Obstetrics and Gynaecology, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Haiyan Liang
- Department of Obstetrics and Gynaecology, China-Japan Friendship Hospital, Beijing, China
| | - Kun Wang
- Department of Obstetrics and Gynaecology, China-Japan Friendship Hospital, Beijing, China
| | - Bin Ling
- Department of Obstetrics and Gynaecology, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| |
Collapse
|
50
|
Lin C, Hsieh H. Early Ectopic Pregnancy Refractory to Methotrexate Treatment: A Case Report. Cureus 2021; 13:e19686. [PMID: 34976471 PMCID: PMC8681904 DOI: 10.7759/cureus.19686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 11/11/2022] Open
Abstract
Methotrexate (MTX) is known as a systemic treatment for early ectopic pregnancy with low serum beta-human chorionic gonadotropin (βhCG) levels. Here we present our experience of an unsatisfactory outcome following MTX treatment for early tubal pregnancy. The case is a 39-year-old female with left tubal ectopic pregnancy and a history of one right tubal ectopic pregnancy and an uneventful episode of delivery. In the absence of any contraindications, the patient underwent initial MTX treatment. At first, her serum βhCG level was 1,258 mIU/mL but remained elevated. Then she underwent a second and third dose of MTX. After a month, the serum βhCG level had not declined to within an acceptable range. The ectopic mass was enlarged as determined by transvaginal ultrasonography and hemoperitoneum. A laparoscopic salpingectomy was performed. Early ectopic tubal pregnancy can be managed medically with a high success rate. However, repeat ectopic pregnancy indicates an increased risk of treatment failure to medical treatment, and should be mentioned to the patient when discussing their treatment options.
Collapse
|