A Systematic Review and Meta-analysis of Surgical Treatment of Ectopic Pregnancy with Salpingectomy versus Salpingostomy

The relationship between serum levels of epidermal growth factor and β-human chorionic gonadotropin and the type and prognosis of ectopic pregnancy

PURPOSE

This work aimed to explore the relationship between epidermal growth factor (EGF) and β-human chorionic gonadotropin (β-HCG) and ectopic pregnancy types and impact on prognosis.

METHODS

Twenty women with normal pregnancies (NPs) were recruited as control group, and twenty women each with tubal pregnancy (TP) and cervical pregnancy (CP) were recruited. Blood samples were collected to detect EGF and β-HCG. Data on length of hospital stay and incidence of complications were collected. The differences in serum EGF and β-HCG levels were compared among groups and within various types of ectopic pregnancy using analysis of variance and Pearson correlation analysis.

RESULTS

Serum EGF and β-HCG were notably lower in TP and CP group vs. controls (P < 0.05). In subgroup analysis within the types of ectopic pregnancy, serum EGF levels were drastically higher in TP group vs. CP group (P < 0.05). Serum EGF levels were negatively correlated with pregnancy outcomes and incidence of complications (P < 0.05). In patients with TP and CP, serum EGF and β-HCG recovery time and hospital stay differed drastically (P < 0.05). Serum EGF and β-HCG levels showed optimal cutoff values identified at 2.65 μg/L and 11,745.35 IU/L, respectively. The corresponding area under the curve (AUC) values were 0.885 and 0.841.

CONCLUSION

Elevated levels of EGF may be associated with the occurrence of ectopic pregnancy and may impact the type of ectopic pregnancy, pregnancy outcomes, and the incidence of complications. Further clinical research is warranted to investigate these findings.

A Spontaneous Tubal Heterotopic Triplet Pregnancy Resulting in Viable Twin Deliveries

There are limited U.S. reports of spontaneous triplet heterotopic pregnancies discussing both maternal and fetal outcomes. A 34-year-old patient at 7 weeks of gestation presented to the emergency department with abdominal pain. She was diagnosed with a spontaneous heterotopic triplet pregnancy, consisting of a twin monochorionic-diamniotic intrauterine gestation and a ruptured left ectopic pregnancy. She underwent a laparoscopic unilateral salpingectomy. Her antepartum course was complicated by gestational diabetes mellitus and fetal growth restriction. Delivery of liveborn twins was via a cesarean delivery at 32 weeks. Timely intervention and management of a ruptured spontaneous triplet heterotopic pregnancy can result in a viable twin delivery with overall favorable maternal and newborn outcomes, although long-term implications due to prematurity and other twin sequelae exist.

Ectopic Pregnancy in the Round Ligament Following Bilateral Salpingectomy: A Case Report

Ectopic pregnancies, characterized by the implantation of a fertilized ovum outside the uterine cavity, typically occur in the fallopian tubes. However, rare cases have been reported where implantation occurs in atypical locations. Round ligament pregnancy, a rare form of ectopic pregnancy, poses significant risks and can lead to life-threatening complications. This case report describes the presentation and management of a 31-year-old gravida four, para two (G4P2012) female who presented with acute left lower quadrant and pelvic pain. The patient's medical history included a prior bilateral salpingectomy. Physical examination revealed severe left lower quadrant tenderness with guarding. A positive urine pregnancy test and elevated serum quantitative beta-human chorionic gonadotrophin level of 1,735 mIU/mL (normal range: <5 mIU/mL) confirmed pregnancy. Transvaginal ultrasound revealed an empty intrauterine cavity with no gestational sac or fetal pole. A 2 cm cystic structure was identified attached to the left ovary. Ectopic pregnancy was diagnosed, methotrexate was administered, and the patient was discharged with a scheduled outpatient follow-up. However, she returned to the emergency room within 48 hours reporting persistent pelvic pain. At this moment, it was decided that emergent surgical intervention was required. The surgical exploration confirmed the presence of a ruptured ectopic pregnancy in the round ligament, requiring excision and hemostasis. This case report highlights the importance of considering abnormal localization of ectopic pregnancy as a differential diagnosis in women presenting with pelvic pain, even after bilateral salpingectomies. It emphasizes the challenges in diagnosis and management when ectopic pregnancy occurs in atypical sites and highlights the necessity for vigilant follow-up and prompt surgical intervention when medical management fails.

Tubal Pathologies and Fertility Outcomes: A Review

Anomalies of the fallopian tubes represent one of the most significant elements that might contribute to reproductive issues. They can be inherited or acquired; they are among the most important problems of the profession. Although there is much discussion regarding which therapies for each tubal disease are the most effective and result in the best long-term reproductive outcomes. During the evaluation of an infertile couple, certain anomalies of the fallopian tubes are frequently discovered. These abnormalities were thought, for a long time, to not have an influence on fertility; however, in recent years, researchers have discovered that they seem to play a crucial role in fertility problems. Couples in industrialized countries are postponing childbearing, which raises the risk of women developing tubal diseases before they are ready to become pregnant. These disorders may have a negative impact on a woman's ability to get pregnant. The goals of this study are to conduct research to gain a deeper understanding of the recent advancements that have been made in the field of tubal diseases and to carry out an evaluation of the medical conducts that have the best fertility outcomes. We searched both Medline and PubMed, paying special attention to the most relevant articles that have been added to either database over the course of the last six years.

Reproductive outcomes of ectopic pregnancy with conservative and surgical treatment: A systematic review and meta-analysis

BACKGROUND

Ectopic pregnancy (EP), one of the most common gynecological emergencies, is the major cause of maternal death in the first trimester and increases the incidence of infertility and repeat ectopic pregnancy (REP). The aim of this study was to compare the effects of different treatment methods for tubal EP on natural pregnancy outcomes.

METHODS

We systematically searched PubMed, Embase, Cochrane Library, Web of Science, and Clinical Trials for observational studies on EP (published until October 30,2022 in English) comparing methotrexate (MTX) versus surgery, MTX versus salpingostomy, MTX versus salpingectomy, salpingostomy versus salpingectomy, and MTX versus expectant treatment. Our main endpoints included subsequent natural intrauterine pregnancy (IUP) and REP. We assessed the pooled data using Review Manager software (version 5.3) with a random effects model.

RESULTS

Of 1274 identified articles, 20 were eligible and 3530 participants were included in our analysis. There was a significant difference in the odds of subsequent IUP in tubal EP patients who underwent MTX compared with those who were treated with surgery [odds ratios (OR) = 1.52, 95% confidence interval (CI):1.20-1.92]. No significant difference was found in the odds of REP between the 2 groups (OR = 1.12, 95% confidence interval [CI]: 0.84-1.51). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared to those after salpingostomy (OR = 1.04,95% CI: 0.79-1.38; OR = 1.10, 95% CI: 0.64-1.90). There was a significant difference in the odds of subsequent IUP in patients after MTX compared with those after salpingectomy (OR = 2.11, 95% CI: 1.52-2.93). No significant difference was found in the odds of REP between the 2 groups (OR = 0.98, 95% CI: 0.57-1.71). There was a significant difference in the odds of subsequent IUP between patients who underwent salpingostomy and those who underwent salpingectomy (OR = 1.61, 95% CI: 1.29-2.01). No significant difference was found in the odds of REP between the 2 groups (OR = 1.21, 95% CI: 0.62-2.37). There was no significant difference in the odds of subsequent IUP and REP in patients after MTX compared with those after expectant treatment (OR = 1.25, 95% CI: 0.64-2.45; OR = 0.69, 95% CI: 0.09-5.55).

CONCLUSION

For hemodynamically stable tubal EP patients, MTX has advantages over surgery, particularly salpingectomy, in improving natural pregnancy outcomes. However, MTX is not inferior to salpingostomy and expectant treatment.

Disseminated ectopic pregnancy after salpingotomy in a 30-year-old patient

We present a case of a 30-year old patient who devoloped a disseminated abdominal pregnancy after receiving a salpingotomy due to a prior tubal pregnancy.

Reproductive outcomes after expectant and surgical management for tubal pregnancy: a retrospective study

Background: The management of ectopic pregnancy is widely debated. Salpingectomy, salpingostomy, and expectant management are widely performed, but the best approach in terms of keeping good future spontaneous fertility chances is yet to be determined. Material and methods: We performed a retrospective analysis (Clinical Trial ID: NCT05479786) of the medical records of patients with an ultrasonographic or surgical diagnosis of tubal ectopic pregnancy that were admitted to the University of Debrecen Clinical Centre between 2012 and 2020. Results: A total of 312 patients were included in the analysis. Patients managed expectantly and patients treated with salpingostomy had significantly higher rates of clinical pregnancy than patients treated with salpingectomy. Pregnancy outcomes and recurrence rates were comparable between the study groups. Salpingectomy was found to decrease the likelihood of conceiving spontaneously by 65%. A stratified analysis based on serum β-HCG levels demonstrated that all treatment modalities carry the same reproductive opportunities for patients presenting with β-HCG levels ≤ 1745 IU/L. Conclusion: Salpingectomy was found to decrease the patient's chance of achieving a natural conception. Conservative approaches should be considered with caution only when the patient's clinical condition permits, and the patient is appropriately counseled.

The Prevalence, Indications, Outcomes of the Most Common Major Gynecological Surgeries in Kazakhstan and Recommendations for Potential Improvements into Public Health and Clinical Practice: Analysis of the National Electronic Healthcare System (2014-2019)

OBJECTIVES

Major gynecological surgeries are indicated for the treatment of female genital pathologies. It is key to examine trends in gynecologic surgical procedures and updated recommendations by international gynecological societies to find opportunities for improvement of local guidelines. To date, a very limited number of reports have been published on the epidemiology of gynecological surgeries in Kazakhstan. Moreover, some local guidelines for gynecological conditions do not comply with the international recommendations. Thus, this study aims to investigate the prevalence, indications, and outcomes of the most common major gynecological surgeries by analyzing large-scale Kazakhstani healthcare data, and identifying possible opportunities for improvement of the local public health and clinical practice.

METHODS

A descriptive, population-based study among women who underwent a gynecological surgery in healthcare settings across the Republic of Kazakhstan during the period of 2014-2019 was performed. Data were collected from the Unified Nationwide Electronic Health System (UNEHS).

RESULTS

In total, 80,401 surgery cases were identified and analyzed in the UNEHS database for a period of 6 years (2014-2019). The median age of the participants was 40 years old, with 61.1% in reproductive age. The most prevalent intervention was a unilateral salpingectomy-29.4%, with 72.6% patients aged between 18-34 years. The proportion of different types of hysterectomies was 49.4%. In 20% of cases, subtotal abdominal hysterectomy was performed due to uterine leiomyoma. The proportion of laparoscopic procedures in Kazakhstani gynecological practice is as low-11.59%.

CONCLUSIONS

The Kazakhstani public health and gynecological care sector should reinforce implementation of contemporary treatment methods and up-to-date policies and guidelines. The overall trends in surgical procedures performed for gynecological pathologies, including uterine leiomyoma and ectopic pregnancy treatment, should be changed in favor of the minimally invasive methods in order to adopt a fertility-sparing approach.

The current and future state of surgery in reproductive endocrinology

PURPOSE OF REVIEW

The last decade has witnessed a radical change in the field of reproductive surgery. The increasing success of in-vitro fertilization (IVF) has caused a huge shift in emphasis with many downstream consequences. This review outlines the changes and provides insight into the future of reproductive surgery.

RECENT FINDINGS

With compelling evidence that IVF overcomes the detrimental effects of endometriosis on infertility and with two new oral medications available for management of endometriosis, momentum is shifting towards nonsurgical management of endometriosis. There is increasing recognition that except for submucous myomas, other myomas are unlikely to affect fertility and miscarriage. This, in addition to many emerging alternative modalities for management of myomas (oral GnRH antagonists, radiofrequency ablation), is likely to further decrease classic myomectomies but provide alternative, less invasive options. Caesarean scar defects have been recognized as having significant reproductive consequences and surgical management has become the standard of care. Fallopian tubes are now implicated in development of ovarian cancer, and as a result, salpingectomies are being performed in lieu of tubal ligations. Tubal anastomosis will soon become a historical surgery. Division of uterine septum remains controversial, and a clear answer will remain elusive. Uterine transplant is the single most significant advance in reproductive surgery in the past century.

SUMMARY

Reproductive surgery is evolving with the times. Although some surgical techniques will become historical, others will become mainstream.

Risk factors and clinical characteristics associated with a ruptured ectopic pregnancy: A 19-year retrospective observational study

Ectopic pregnancy is the most common cause of maternal mortality in the first trimester of pregnancy. The aim of this study was to find risk factors and clinical characteristics associated with ruptured ectopic pregnancies at a medical center in eastern Taiwan in a 19-year period. This was a retrospective observational study that included patients diagnosed with ectopic pregnancy between August 1999 and December 2018. Data about the demographic variables, initial presentation, pre-treatment beta-human chorionic gonadotropin levels, treatment routes (laparoscopy or laparotomy), surgical methods (salpingostomy or salpingectomy), operation time, blood loss amount, the status of ectopic pregnancy (ruptured or unruptured), the requirement for transfusion, and duration of hospital stay were collected. The categorical and continuous variables were analyzed using the correlation coefficients. This study included 225 women who were diagnosed as having an ectopic pregnancy. There were 49 and 176 women with unruptured and ruptured ectopic pregnancies, respectively. The beta-human chorionic gonadotropin levels, history of previous ectopic pregnancy, pelvic inflammatory disease, tubal surgery, abdominal history, and vaginal bleeding were not significantly different between the 2 groups. The ratio of women with abdominal pain was significantly higher in the ruptured ectopic pregnancy group than in the unruptured group (89.1% vs. 63.8%, respectively, P < .001). Preoperative hemoglobin was lower in the ruptured group compared with the unruptured group (P < .001). Blood loss, postoperative hemoglobin, and blood transfusion were significantly higher in the ruptured group than in the unruptured group (P = .000 and P = .001 for blood loss and blood transfusion, respectively). Multiple logistic regression analysis revealed that abdominal pain and blood loss were associated with ruptured tubal pregnancies (adjusted odds ratio [95% confidence intervals]: 3.42 {1.40, 8.40}; 1.01 {1.005, 1.014}, respectively). In conclusion, early pregnancy with abdominal pain, more parity, and lower preoperative hemoglobin should be aware of the possibility of ruptured ectopic pregnancy. More blood loss, transfusion and lower postoperative hemoglobin were also noted with ruptured ectopic pregnancy.

Socioeconomic Analysis of the Surgical Management of Ectopic Pregnancies: An Analysis of the National Inpatient Sample

STUDY OBJECTIVE

To identify racial and socioeconomic disparities in the surgical management of ectopic pregnancy DESIGN: The National Inpatient Sample (NIS) was sampled from 2015 to 2017 for inpatient hospitalizations for ectopic pregnancy. Cohorts were identified by surgical treatment type - open procedure versus laparoscopic procedure. Race/ethnicity, primary payer status, and median household income were primary variables of interest. Univariate and multivariable analysis was conducted.

DESIGN CLASSIFICATION

Retrospective SETTING: Nationwide inpatient analysis PATIENTS: Women presenting for ectopic pregnancy treatment INTERVENTIONS: Type of surgery MAIN OUTCOME MEASURES: Laparotomy versus laparoscopy for treatment MAIN RESULTS: A total of 18,725 cases were identified, 8,325 open and 10,400 laparoscopic. Hispanic women were more likely to receive open procedures as treatment for ectopic pregnancy compared to white women (OR 1.226, p<0.001). Women with private insurance were more likely to receive open procedures than women who were self-pay for treatment (OR 0.809, p<0.001). Women of lower median income status, <$60,000, were more likely to receive open procedures than women of fourth quartile income group. Black women predominantly made up the first quartile income group. When controlling for covariates, Black women were not more likely to receive one method of surgical procedure over another.

CONCLUSION

Income appears to be related to surgical management of ectopic pregnancy with women of lower median incomes receiving laparotomies over laparoscopic procedures. Equal access to healthcare remains a prudent need in communities of color. Further studies are needed to elucidate surgical decision-making in management of ectopic pregnancy.

Prevalence and determinants of ectopic pregnancy in Ethiopia: Systematic review and meta-analysis

Background:

Ectopic pregnancy is a life-threatening obstetric emergency, and is a major health problem for women of fertile age. Therefore, the aim of this systematic review and meta-analysis was to estimate the prevalence, determinant factors, and outcomes of ectopic pregnancy among fertile age women in Ethiopia.

Method:

International databases (MEDLINE/Pub Med, Hinari, Scopus, Google scholar, African journals, and literatures were searched and nine eligible cross sectional and two case control studies were included in this systematic review and meta-analysis. Eggers test and funnel plot were computed to check publication bias across the studies. Publication bias was computed using a funnel plot and eggers test. Heterogeneity of the studies was checked using Cochrane Q-test and I2 statistic.

Results:

The pooled prevalence of ectopic pregnancy in Ethiopia was 3.61% (95%CI: 2.24–4.98, I2 = 89.2.0%, p < 0.001). Having cesarean section scar (AOR = 7.44, 95%CI: 5.48–10.09), single marital status (AOR = 5.71, 95%CI: 4.76–6.85), history of sexually transmitted infection (AOR = 4.68, 95%CI: 3.04–7.19), history of abortion (AOR = 3.89, 95%CI: 3.35–4.52), history of ectopic pregnancy (AOR = 5.74, 95%CI: 3.81–8.65), and emergency contraceptive use (AOR = 8.72, 95%CI: 2.90–26.20) were the determinant factors for the occurrence of ectopic pregnancy.

Conclusion:

This systematic review and meta-analysis showed that the prevalence of ectopic pregnancy was high in Ethiopia. Thus, educating women to limit the number of sexual partners, smoking cessation, using a condom during sex helps prevent sexually transmitted infections and the risk of pelvic inflammatory disease is crucial.

The Prevalence of Ectopic Gestation: A Five-Year Study of 1273 Cases

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.