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Yu J, Peng Y, Yu L, Shi S. Laparoscopic surgery for ectopic pregnancy: A comparative study on the clinical benefits and impact on tubal patency and reproductive outcomes. Technol Health Care 2024:THC230920. [PMID: 38517813 DOI: 10.3233/thc-230920] [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: 03/24/2024]
Abstract
BACKGROUND Ectopic pregnancy is a major contributor to maternal morbidity and mortality across the globe. OBJECTIVE This study aims to investigate the clinical benefits of laparoscopic surgery in treating ectopic pregnancy, and its impact on tubal patency and reproductive outcomes. METHODS A clinical study was conducted to compare laparoscopic and medical conservative treatment for ectopic pregnancy. A total of 206 patients were treated for ectopic pregnancy at our hospital from January 2018 to June 2020. Among them, 46 underwent laparoscopic ipsilateral salpingectomy, 54 underwent laparoscopic ipsilateral salpingostomy with lesion removal, and 106 were treated conservatively with medication. RESULTS The age range and average age of each group are provided, with no significant differences in these general demographic characteristics (p> 0.05). Both the salpingostomy and medication groups had higher rates of ectopic pregnancy compared to the salpingectomy group, with statistically significant differences (p< 0.05). The comparison of ectopic pregnancy rates between the salpingostomy and medication groups showed no significant difference. Within three years, the salpingostomy group had 10 cases of recurrent ectopic pregnancy, with 2 cases on the same side, while the medication group had 18 cases, with 8 cases on the same side. At 3 months after the normalization of blood β-HCG, the salpingostomy group showed 43 cases of tubal patency (patency rate: 79.63%), while the medication group showed 57 cases (patency rate: 53.77%), with a statistically significant difference between the two groups (p= 0.01). CONCLUSION Laparoscopic surgery for ectopic pregnancy offers significant clinical benefits over conservative medical treatment, including higher rates of tubal patency and improved reproductive outcomes. These findings support laparoscopic surgery as an effective approach for the management of ectopic pregnancy.
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Affiliation(s)
- Juan Yu
- Department of Gynaecology and Obstetrics, Aviation General Hospital of China Medical University and Beijing Institute of Translational Medicine, Chinese Academy of Sciences, Beijing, China
| | - Yan Peng
- Department of Gynaecology and Obstetrics, Aviation General Hospital of China Medical University and Beijing Institute of Translational Medicine, Chinese Academy of Sciences, Beijing, China
| | - Liqun Yu
- Department of Gynaecology and Obstetrics, Aviation General Hospital of China Medical University and Beijing Institute of Translational Medicine, Chinese Academy of Sciences, Beijing, China
| | - Shutian Shi
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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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.
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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
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Grainger TC, McDougall A, Magama Z, Ranawakagedon J, Mallick R, Odejinmi F. Women's experiences of birth and birth options counselling after laparoscopic or open myomectomy. J OBSTET GYNAECOL 2023; 43:2205516. [PMID: 37200382 DOI: 10.1080/01443615.2023.2205516] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 04/16/2023] [Indexed: 05/20/2023]
Abstract
There is emerging evidence that vaginal birth after open and laparoscopic myomectomy may be safe in many pregnancies, however, there are no studies examining the perspectives of women who have given birth post myomectomy and their preferences regarding mode of birth. We performed a retrospective questionnaire survey of women who had an open or laparoscopic myomectomy followed by a pregnancy within 3 maternity units in a single NHS trust in the UK over a 5-year period. Our results revealed only 53% felt actively involved in the decision making for their birth plan and 90% had not been offered a specific birth options counselling clinic. Of those who had either a successful trial of labour after myomectomy (TOLAM) or elective caesarean section (ELCS) in the index pregnancy, 95% indicated satisfaction with their mode of birth however, 80% would prefer vaginal birth in a future pregnancy. Whilst long term prospective data is required to fully establish the safety of vaginal birth after laparoscopic and open myomectomy, this study is the first to explore the subjective experiences of women who had given birth post laparoscopic or open myomectomy and has highlighted the inadequate involvement of these women in the decision-making process.IMPACT STATEMENTWhat is already known on this subject? Fibroids are the commonest female solid tumours in women of childbearing age with surgical management including open and laparoscopic excision techniques. However, the management of a subsequent pregnancy and birth remains controversial with no robust guidance on which women may be suitable for vaginal birth.What do the results of this study add? We present the first study to our knowledge which explores women's experiences of birth and birth options counselling after open and laparoscopic myomectomy.What are the implications of these findings for clinical practice and/or further research? We provide a rationale for using birth options clinics to facilitate an informed decision-making process and highlight the current inadequate guidance for clinicians on how to advise women having a pregnancy following a myomectomy. Whilst long term prospective data is required to fully establish the safety of vaginal birth after laparoscopic and open myomectomy, this needs to be carried out in a way which promotes the preferences of the women affected by this research.
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Affiliation(s)
- Thomas C Grainger
- The Women's Centre, Division of Women's and Children's Health, Whipps Cross University Hospital, Barts Health NHS Trust London, London, UK
| | - Anna McDougall
- The Women's Centre, Division of Women's and Children's Health, Whipps Cross University Hospital, Barts Health NHS Trust London, London, UK
| | - Zwelihle Magama
- The Women's Centre, Division of Women's and Children's Health, Whipps Cross University Hospital, Barts Health NHS Trust London, London, UK
| | - Jeewantha Ranawakagedon
- The Women's Centre, Division of Women's and Children's Health, Whipps Cross University Hospital, Barts Health NHS Trust London, London, UK
| | - Rebecca Mallick
- The Women's Centre, Division of Women's and Children's Health, Whipps Cross University Hospital, Barts Health NHS Trust London, London, UK
| | - Funlayo Odejinmi
- The Women's Centre, Division of Women's and Children's Health, Whipps Cross University Hospital, Barts Health NHS Trust London, London, UK
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Mansouri Z, Tarafdari A, Azizi S, Mehdikhani B, Shababi A, Vaghef Davari F. A case report of heterochronic presentation of a bilateral tubal pregnancy. Clin Case Rep 2023; 11:e8072. [PMID: 37900710 PMCID: PMC10600360 DOI: 10.1002/ccr3.8072] [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: 07/07/2023] [Revised: 09/15/2023] [Accepted: 10/08/2023] [Indexed: 10/31/2023] Open
Abstract
Key Clinical Message This paper highlights that diagnosis and treatment of one ectopic pregnancy does not rule out the happening of a second ectopic pregnancy in the same patient concurrently, especially if the patient has rising β-hCG and persistent symptoms. Abstract Bilateral tubal pregnancy (BTP) is the most uncommon form of tubal ectopic pregnancy. Complications can lead to maternal morbidity and mortality. We reported a case of left tubal pregnancy and the patient underwent laparoscopic salpingostomy. During the follow-up, the contralateral ectopic pregnancy was discovered and treated with MTX.
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Affiliation(s)
- Zeinab Mansouri
- Department of Obstetrics & Gynecology, Imam Khomeini Hospital complexTehran University of Medical sciencesTehranIran
| | - Azam Tarafdari
- Department of Obstetrics & Gynecology, Imam Khomeini Hospital complexTehran University of Medical sciencesTehranIran
| | - Sepideh Azizi
- Shahid Akbarabadi Clinical Research Development Unit (ShACRDU)Iran University of Medical Sciences (IUMS)TehranIran
| | | | - Amirali Shababi
- School of MedicineIran University of Medical SciencesTehranIran
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Socioeconomic Analysis of the Surgical Management of Ectopic Pregnancies: An Analysis of the National Inpatient Sample. J Minim Invasive Gynecol 2022; 29:641-648. [PMID: 34995774 DOI: 10.1016/j.jmig.2021.12.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 11/24/2022]
Abstract
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.
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Ozcan MCH, Wilson JR, Frishman GN. A Systematic Review and Meta-analysis of Surgical Treatment of Ectopic Pregnancy with Salpingectomy versus Salpingostomy. J Minim Invasive Gynecol 2020; 28:656-667. [PMID: 33198948 DOI: 10.1016/j.jmig.2020.10.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/20/2020] [Accepted: 10/22/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the fertility outcomes of salpingectomy compared with those of salpingostomy among patients treated for tubal ectopic pregnancies, including a separate analysis of women with risk factors along with a review of the surgical technique. DATA SOURCES Systematic review and meta-analysis from 1990 to the present through PubMed, Embase, CINAHL, and Ovid MEDLINE. The search string included "tubal pregnancy" or "ectopic" as well as "salpingectomy" and various terms describing salpingotomy. METHODS OF STUDY SELECTION Articles studying women who underwent surgical management of an ectopic pregnancy and the contrasted outcomes of salpingectomy vs salpingostomy were reviewed. The primary outcomes included subsequent intrauterine pregnancy (IUP) and repeat ectopic pregnancy (REP). TABULATION, INTEGRATION, AND RESULTS Two randomized controlled trials (RCTs), which consisted mostly of patients classified as low risk, and patients from 16 cohort studies were included. In the RCTs, there was no significant difference in the odds of subsequent IUP in patients who underwent a salpingectomy compared with those who were treated with salpingotomy (odds ratio [OR] 0.97; 95% confidence interval [CI], 0.71-1.33). However, a significant and clinically meaningful difference was noted in the cohort studies, with the patients having a lower chance of IUP after salpingectomy (OR 0.45; 95% CI, 0.39-0.52). No significant difference was noted in the OR for a REP in the randomized trials (OR 0.77; 95% CI, 0.41-1.47), but the patients followed in the cohort studies had a cumulatively higher risk of REP after a salpingostomy (OR 0.73; 95% CI, 0.60-0.90). The subgroup analysis examining women within the studies with risk factors for tubal pathology found an even more impressive lowering in the odds of a subsequent IUP in patients classified as at-risk who were treated with salpingectomy (OR 0.30; 95% CI, 0.17-0.54), with a change in the direction of the odds for an REP rate favoring those who were treated with salpingostomy (OR 1.96; 95% CI, 0.88-4.35). CONCLUSION Salpingectomy has clear advantages over salpingostomy, and RCTs consisting mainly of patients classified as low risk show no difference in outcomes between salpingectomy and salpingostomy. However, in cohort studies inclusive of all patients, the likelihood of a subsequent spontaneous IUP is decreased in patients treated with salpingectomy, and salpingostomies may be especially underused in women with risk factors for tubal disease.
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Affiliation(s)
- Meghan C H Ozcan
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island (Drs. Ozcan and Frishman).
| | - Jeffrey R Wilson
- W.P. Carey School of Business, Arizona State University, Tempe, Arizona (Dr. Wilson)
| | - Gary N Frishman
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women & Infants Hospital, Providence, Rhode Island (Drs. Ozcan and Frishman)
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7
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Effect of Methotrexate on Salpingostomy Completion Rate for Tubal Ectopic Pregnancy: A Retrospective Cohort Study. J Minim Invasive Gynecol 2020; 28:1334-1342.e3. [PMID: 32911090 DOI: 10.1016/j.jmig.2020.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/01/2020] [Accepted: 09/04/2020] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To determine whether completion rates of salpingostomy for tubal ectopic pregnancy are compromised by initial medical management with methotrexate (MTX). DESIGN Retrospective cohort study. SETTING Single academic hospital system. PATIENTS Patients requiring surgery for ectopic pregnancy between 2006 and 2017. INTERVENTIONS A subset of patients who went directly to surgery, and all patients who failed MTX before requiring surgery underwent detailed chart review. Salpingostomy plan and success rate and salpingostomy failure reasons were compared between patients pretreated with MTX and those who were MTX-untreated. MEASUREMENTS AND MAIN RESULTS Among 94 ectopic pregnancies requiring surgery after failed MTX treatment, 55 (59%) underwent planned salpingostomy. From 693 ectopic pregnancies managed without MTX, 166 were analyzed in detail, of which 80 (48%) underwent planned salpingostomy. The patients who underwent planned salpingostomy were thinner (body mass index 27.3 ± 7.2 kg/m2 vs 29.3 ± 8.3 kg/m2; p = .048), less frequently African American (33% vs 47%; p = .017), and more likely to have a visualized adnexal lesion (70% vs 52%; p = .004) than those undergoing planned salpingectomy. Preoperative ultrasound identified fetal cardiac activity and hemoperitoneum at comparable rates. MTX exposure was not associated with age, body mass index, race, ectopic risk factors, human chorionic gonadotropin levels, or gestational age at diagnosis, but the patients treated with MTX underwent surgery later than those who were untreated (gestational age 53.4 ± 11.2 days vs 43.5 ± 11 days; p <.001). The differences between the adnexal lesion size and rates of fetal cardiac activity and hemoperitoneum on ultrasound related to MTX exposure did not meet significance. Planned salpingostomy was completed in 22 (40%) of the patients treated with MTX vs 34 (42%) of those who were untreated. The reasons for failure, surgery time, and rates of hemoperitoneum or ectopic rupture were not associated with MTX exposure. Body mass index, race, tubal anastomosis history, visualization of the adnexal lesion, and MTX exposure were not significantly associated with the salpingostomy rate in a multivariate logistic regression model, but having a subspecialist surgeon (odds ratio 2.70; 95% confidence interval, 1.08-6.76; p = .033) and tubal rupture at surgery (odds ratio 0.23; 95% confidence interval, 0.09-0.54; p = .001) were. CONCLUSION The initial medical management of an ectopic pregnancy with MTX is not associated with a decreased salpingostomy success rate.
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Carroll FE, Gooberman-Hill R, Strange S, Blom AW, Moore AJ. What are patients' preferences for revision surgery after periprosthetic joint infection? A discrete choice experiment. BMJ Open 2020; 10:e031645. [PMID: 31969360 PMCID: PMC7044986 DOI: 10.1136/bmjopen-2019-031645] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Understanding patients' preferences for treatment is crucial to provision of good care and shared decisions, especially when more than one treatment option exists for a given condition. One such condition is infection of the area around the prosthesis after hip replacement, which affects between 0.4% and 3% of patients. There is more than one treatment option for this major complication, and our study aimed to assess the value that patients place on aspects of revision surgery for periprosthetic hip infection. DESIGN We identified four attributes of revision surgery for periprosthetic hip infection. Using a discrete choice experiment (DCE), we measured the value placed on each attribute by 57 people who had undergone either one-stage or two-stage revision surgery for infection. SETTING The DCE was conducted with participants from nine National Health Service hospitals in the UK. PARTICIPANTS Adults who had undergone revision surgery for periprosthetic hip infection (N=57). RESULTS Overall, the strongest preference was for a surgical option that resulted in no restrictions on engaging in valued activities after a new hip is fitted (β=0.7). Less valued but still important attributes included a shorter time taken from the start of treatment to return to normal activities (6 months; β=0.3), few or no side effects from antibiotics (β=0.2), and having only one operation (β=0.2). CONCLUSIONS The results highlight that people who have had revision surgery for periprosthetic hip infection most value aspects of care that affect their ability to engage in normal everyday activities. These were the most important characteristics in decisions about revision surgery.
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Affiliation(s)
- Fran E Carroll
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Rachael Gooberman-Hill
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Simon Strange
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ashley W Blom
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Andrew J Moore
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Abstract
RATIONALE Ectopic pregnancy (EP) is a condition in which a fertilized oocyte implants outside the uterine. Spontaneous bilateral tubal pregnancies are the rarest form of ectopic and are considered spontaneous when no fertility treatments are involved. There are few prior cases. Here I report a case of spontaneous bilateral tubal pregnancy. PATIENT CONCERNS A 24-year-old female with long lasting vaginal bleeding of 29 days duration. DIAGNOSES Transvaginal ultrasound observed small complex masses on both adnexal sides without intrauterine gestational sac, and the hCG level was 21438 IU/L. But diagnosing based only on imaging findings and blood test result was difficult. INTERVENTIONS Operative laparoscopy with salpingectomy bilaterally. OUTCOMES Villi were clearly shown in both resected tubes. A spontaneous bilateral tubal pregnancy was confirmed finally and the patient recovered uneventfully. LESSONS Women of reproductive age with irregular menstruation should get access to diagnosis and appropriate treatment without delay. Salpingotomy should also be considered if the patient had a strong wish for future pregnancy. Developments of diagnosis and management of such condition are strongly called for.
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Nicolaus K, Jimenez-Cruz J, Bräuer DM, Lehmann T, Mothes AR, Runnebaum IB. Endometriosis and Beta-hCG > 775 IU/l Increase the Risk of Non-tube-preserving Surgery for Tubal Pregnancy. Geburtshilfe Frauenheilkd 2018; 78:690-696. [PMID: 30057425 PMCID: PMC6059851 DOI: 10.1055/a-0635-8453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 04/23/2018] [Accepted: 05/28/2018] [Indexed: 11/28/2022] Open
Abstract
Introduction
Tubal pregnancy is the most clinically relevant form of ectopic pregnancy. Surgery consisting of laparoscopic salpingotomy is the therapeutic gold standard. This study looked at risk factors for non-tube-preserving surgery. The aim was to determine a cut-off value for beta-hCG levels, which could be used to predict the extent of tubal surgery.
Materials and Method
97 patients with tubal pregnancy who underwent primary salpingotomy in the Department of Gynecology and Obstetrics of Jena University Hospital between 2010 and 2016 were retrospectively analyzed. A prior medical history of risk factors such as adnexitis, ectopic pregnancy, tubal surgery, treatment for infertility and intrauterine pessary was included in the analysis. The study population was divided into two subgroups: (1) a group which underwent laparoscopic linear salpingotomy, and (2) a group which had laparoscopic partial tubal resection or salpingectomy. Risk factors for salpingectomy were determined using binary logistic regression analysis. Statistical analysis was done using SPSS, version 24.0, to identify risk factors for non-tube-preserving surgery.
Results
68 patients (70.1%) underwent laparoscopic salpingotomy and 29 patients (29.9%) had laparoscopic salpingectomy. The two groups differed with regard to age (p = 0.01) but not with regard to the parameters ‘gestational age’, ‘viability and rupture status of the ectopic pregnancy’ or ‘symptoms at presentation’. Patients who were known to have endometriosis prior to surgery or who were diagnosed with endometriosis intraoperatively were more likely to undergo salpingectomy (OR: 3.28; 95% CI: 0.9 – 10.8; p = 0.05). Calculated mean beta-hCG levels were higher in the salpingectomy group compared to the group who had tube-preserving salpingotomy (3277.8 IU/l vs. 9338.3 IU/l, p = 0.01). A cut-off beta-hCG value of 775 IU/l prior to surgery was predictive for salpingectomy with a true positive rate of 86.2% and increased the probability that salpingectomy would be necessary (OR: 5.23; 95% CI: 0.229 – 0.471; p = 0.005).
Conclusion
Endometriosis and a beta-hCG value of more than 775 IU/l significantly increased the risk for non-tube-preserving surgery in women with tubal pregnancy.
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Affiliation(s)
- Kristin Nicolaus
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Jorge Jimenez-Cruz
- Abteilung für Geburtshilfe und Pränatalmedizin, Universitatsklinikum Bonn, Bonn, Germany
| | - Dominik Michael Bräuer
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Thomas Lehmann
- Institut für Medizinische Statistik, Informatik und Dokumentation, Universitätsklinikum Jena, Jena, Germany
| | - Anke Regina Mothes
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Ingo B Runnebaum
- Klinik und Poliklinik für Frauenheilkunde und Fortpflanzungsmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Germany
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Mikhail E, Salemi JL, Schickler R, Salihu HM, Plosker S, Imudia AN. National rates, trends and determinants of inpatient surgical management of tubal ectopic pregnancy in the United States, 1998-2011. J Obstet Gynaecol Res 2018; 44:730-738. [PMID: 29359520 DOI: 10.1111/jog.13588] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/18/2017] [Indexed: 11/30/2022]
Abstract
AIM To describe the frequency and temporal trends of inpatient hospitalization for tubal ectopic pregnancy as well as patients' characteristics, determinants and the current national trends in surgical management of ectopic pregnancy. METHODS We conducted a retrospective, cross-sectional analysis of patients who were treated for tubal ectopic pregnancy in an inpatient hospital setting in the United States from 1998 to 2011 using data from the Nationwide Inpatient Sample databases. National frequency and significant changes in the rate of surgical management of tubal ectopic pregnancy in the inpatient setting are described. RESULTS The study included 334 639 tubal ectopic pregnancies for women aged 18-50 in the United States from 1998 to 2011. The rate of tubal ectopic pregnancy (per 10 000 maternal admissions) decreased from 77.2 in 1998 to 40.5 in 2011. The proportion of tubal ectopic pregnancies for which salpingostomy was performed decreased from 17.0% in 1998 to 7.0% in 2011, while the rate of salpingectomy increased from 69.3% in 1998 to 80.9% in 2011. The temporal change in surgical choice was not different in states with comprehensive in vitro fertilization insurance mandates. CONCLUSION The rate of tubal ectopic pregnancy managed in the inpatient setting in the United States decreased 5% annually between 1998 and 2011. The rate of salpingectomies performed annually increased whereas that of salpingostomy decreased over time. The surgical approach selected for the management of tubal ectopic pregnancies was not influenced by a state's in vitro fertilization mandate status.
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Affiliation(s)
- Emad Mikhail
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Jason L Salemi
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Robyn Schickler
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Hamisu M Salihu
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Shayne Plosker
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
| | - Anthony N Imudia
- Department of Obstetrics and Gynecology, University of South Florida, Morsani College of Medicine, Tampa, Florida, USA
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Zhang D, Chen A, Gu Y. Ruptured secondary abdominal pregnancy after primary laparoscopic treatment for tubal pregnancy: A case report. Medicine (Baltimore) 2017; 96:e9254. [PMID: 29390363 PMCID: PMC5815775 DOI: 10.1097/md.0000000000009254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Most secondary abdominal pregnancies happen after spontaneous abortion of tubal pregnancy or ruptured intrauterine pregnancy. However, we presented a case of ruptured secondary abdominal pregnancy after primary laparoscopic treatment of tubal pregnancy. CASE REPORT The ectopic pregnant lesion in the affected tube was thoroughly removed in the primary laparoscopy, and nothing abnormal was detected in abdomen or pelvis. Beta human chorionic gonadotropin levels dropped significantly after surgery, but the patient came back again for severe abdominal pain with beta human chorionic gonadotropin increasing, and free peritoneal fluid in the pouch of Douglas was detected at ultrasonography. The secondary laparoscopy was done according to the intraperitoneal hemorrhage and unstable vital signs. The secondary pregnancy was found ruptured in the splenic flexure of the colon. Although several cases of secondary abdominal pregnancies were reported in the literature, herein we describe a case secondary to the salpingotomy of the primary tubal pregnancy. CONCLUSION After surgery for ectopic pregnancy, the patient's serum beta human chorionic gonadotropin levels should be closely followed until negative. When persistent ectopic pregnancy was suspected after surgery, physicians should keep in mind a rare possibility of secondary abdominal pregnancy.
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Zhang Y, Chen J, Lu W, Li B, Du G, Wan X. Clinical characteristics of persistent ectopic pregnancy after salpingostomy and influence on ongoing pregnancy. J Obstet Gynaecol Res 2017; 43:564-570. [PMID: 28127836 PMCID: PMC5347973 DOI: 10.1111/jog.13251] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 10/17/2016] [Accepted: 11/08/2016] [Indexed: 12/01/2022]
Abstract
AIM The aim of this study was to assay the clinical characteristics of persistent ectopic pregnancy (PEP) and its influence on ongoing pregnancy. METHODS We retrospectively reviewed 2498 patients who received salpingostomies as primary management for ectopic pregnancies from January 2004 to December 2009, using medical records and telephone inquiries. Clinical characteristics of the 52 patients (2.08%) who were diagnosed with PEP after salpingostomy were compared with those who received satisfactory treatment. The odds ratios and 95% confidential intervals were calculated for each variable by univariate and (for significantly different factors) multivariate analysis. RESULTS Preoperatively, patients with PEP after salpingostomy significantly differed from the non-PEP patients in gestational age, mass size and pelvic adhesiolysis. Serum β-human chorionic gonadotropin levels in PEP patients were monitored after surgery, which had declined by 28.31% on postoperative day (POD) 4, 40.22% on POD 7, 51.46% on POD 10 and 53.43% on POD 21. Repeat ectopic pregnancy (REP) tended to occur more frequently in PEP patients (PEP: 5 cases, 10.20%; non-PEP: 4 cases, 2.80%; P = 0.034). Multivariate analysis showed that pelvic adhesions and PEP were the strongest independent predictors of REP. CONCLUSION Gestational age, mass size and pelvic adhesions were significantly correlated with PEP. PEP was an independent prognostic factor for REP. However, a multicenter study is needed to support and extend our findings.
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Affiliation(s)
- Yongli Zhang
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jinhong Chen
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen Lu
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bilan Li
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guiqiang Du
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoping Wan
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
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14
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Laparoscopic tube-preserving surgical procedures for ectopic tubal pregnancy. Obstet Gynecol Sci 2016; 59:512-518. [PMID: 27896254 PMCID: PMC5120071 DOI: 10.5468/ogs.2016.59.6.512] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/16/2016] [Accepted: 06/20/2016] [Indexed: 11/08/2022] Open
Abstract
Objective To present our experience with laparoscopic tube-preserving surgery for ectopic tubal pregnancy and evaluate its feasibility and efficacy. Methods This was a prospective study of 57 consecutive patients with ectopic tubal pregnancies undergoing laparoscopic tube-preserving procedures including salpingotomy, salpingostomy, segmental resection and reanastomosis, and fimbrial milking. The outcome measures were treatment success rates and homolateral patency rates. Results Of the 57 surgical procedures, 55 (96.4%) were performed successfully without any additional intervention. The number of patients receiving salpingotomy, salpingostomy, segmental resection and reanastomosis, and fimbrial milking were 24 (42.1%), 25 (43.9%), 4 (7.0%), and 2 (3.5%), respectively. Two case was switched to salpingectomy because excessive bipolar coagulation was required to obtain hemostasis at the tubal bleeding bed. Over a mean β-human chorionic gonadotropin resolution time of 18.3±5.9 days, no persistent trophoblast or postoperative complications occurred. A tubal patency test using hysterosalpingography was performed in 15 cases at 3 months postoperatively. Among these, the homolateral tubal patency rate was 75% (11 of 15) and the contralateral patency rate was 80% (12 of 15). Conclusion Tube-preserving surgery is a feasible and safe treatment option for ectopic tubal pregnancy. However, considering that the optimal goal of tube-preserving surgical procedures is not the treatment success, some caution is warranted in interpreting results of this study.
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Odejinmi F, Huff KO, Oliver R. Individualisation of intervention for tubal ectopic pregnancy: historical perspectives and the modern evidence based management of ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2016; 210:69-75. [PMID: 27940397 DOI: 10.1016/j.ejogrb.2016.10.037] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/21/2016] [Indexed: 11/30/2022]
Abstract
Historically, ectopic pregnancy was a life-threatening condition where diagnosis was possible only at post mortem or laparotomy and maternal mortality was up to 90%. The evolution in the management of ectopic pregnancy has meant that diagnosis can be made using non-invasive techniques with an aim to identify the ectopic gestation before tubal rupture. This enables health care professionals to offer management options that consider not only maternal mortality, but morbidity and fertility outcomes as well. In spite of this, diagnostic techniques and management options are not without limitations. Research is currently focused on new tests with a single diagnostic capability, diagnostic and treatment algorithms and safe methods of triaging patients. This article aims to review the current literature on the diagnosis and management of ectopic pregnancy and to formulate a pathway to help individualise care and achieve the best possible outcome.
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Affiliation(s)
- Funlayo Odejinmi
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK.
| | - Keren O Huff
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK
| | - Reeba Oliver
- Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK
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16
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Fertilité et risque de récidive après traitement chirurgical d’une grossesse extra-utérine : salpingotomie versus salpingectomie. ACTA ACUST UNITED AC 2016; 45:129-38. [DOI: 10.1016/j.jgyn.2015.08.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 07/18/2015] [Accepted: 08/25/2015] [Indexed: 11/24/2022]
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Mol F, van Mello N, Strandell A, Jurkovic D, Ross J, Yalcinkaya T, Barnhart K, Verhoeve H, Graziosi G, Koks C, Mol B, Ankum W, van der Veen F, Hajenius P, van Wely M. Cost-effectiveness of salpingotomy and salpingectomy in women with tubal pregnancy (a randomized controlled trial). Hum Reprod 2015; 30:2038-47. [DOI: 10.1093/humrep/dev162] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2014] [Accepted: 06/01/2015] [Indexed: 11/12/2022] Open
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Refaat B, Dalton E, Ledger WL. Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies. Reprod Biol Endocrinol 2015; 13:30. [PMID: 25884617 PMCID: PMC4403912 DOI: 10.1186/s12958-015-0025-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/03/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Ectopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment. METHODS The scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected. RESULTS A history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence. CONCLUSIONS EP/HP are tragic events in a couple's reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.
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Affiliation(s)
- Bassem Refaat
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-Abdiyah Campus, PO Box 7607, Makkah, KSA.
| | - Elizabeth Dalton
- School of Women's & Children's Health, University of New South Wales, Sydney, NSW, 2031, Australia.
| | - William L Ledger
- School of Women's & Children's Health, University of New South Wales, Sydney, NSW, 2031, Australia.
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Fallopian tube stripping forceps: a novel instrumental design for distal tubal pregnancy laparoscopy. Eur J Obstet Gynecol Reprod Biol 2014; 183:109-13. [PMID: 25461362 DOI: 10.1016/j.ejogrb.2014.10.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 10/09/2014] [Accepted: 10/22/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare a new method using fallopian tube stripping forceps (FTSF) for salpingostomy in laparoscopic tubal pregnancy management. STUDY DESIGN Comparative observational study. A total of 102 patients with ampullary tubal pregnancy were treated as follows: 56 patients (Group 1) underwent stripping by FTSF, and 46 patients (Group 2) underwent salpingostomy. The bleeding, operation time, persistent ectopic pregnancy (EP) rate, and the first reproductive performance were investigated. RESULTS We found less intraoperative bleeding, shorter operation times, and lower rates of EP recurrence in Group 1 compared with Group 2. In contrast, we observed no significant differences in the persistent EP rate, the occurrences of spontaneous intrauterine pregnancy and miscarriage, and the rates of successful IVF between the two groups. CONCLUSION For distal tubal pregnancy with an ectopic mass ≤30mm, laparoscopic fallopian tube stripping assisted by FTSF may be an easy, less-damaging, conservative operational modality with lower recurrent EP compared with salpingostomy for patients who desire future pregnancy.
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van den Wijngaard L, Rodijk ICM, van der Veen F, Gooskens-van Erven MHW, Koks CAM, Verhoeve HR, Mol BWJ, van Wely M, Mochtar MH. Patient preference for a long-acting recombinant FSH product in ovarian hyperstimulation in IVF: a discrete choice experiment. Hum Reprod 2014; 30:331-7. [DOI: 10.1093/humrep/deu307] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Song T, Kim MK, Kim ML, Jung YW, Yoon BS, Seong SJ. Laparoscopic Salpingotomy Using the Floseal Hemostatic Sealant in Patients with Tubal Pregnancy. J Laparoendosc Adv Surg Tech A 2014; 24:651-5. [DOI: 10.1089/lap.2014.0179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Taejong Song
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Mi-La Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Yong Wook Jung
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Bo Sung Yoon
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, Republic of Korea
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Affiliation(s)
- Thomas D'Hooghe
- Leuven University Fertility Centre, Department Obstetrics and Gynecology, University Hospital Gasthuisberg, KU Leuven, 3000 Leuven, Belgium; Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven, 3000 Leuven, Belgium.
| | - Carla Tomassetti
- Leuven University Fertility Centre, Department Obstetrics and Gynecology, University Hospital Gasthuisberg, KU Leuven, 3000 Leuven, Belgium; Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven, 3000 Leuven, Belgium
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23
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Mol F, van Mello NM, Strandell A, Strandell K, Jurkovic D, Ross J, Barnhart KT, Yalcinkaya TM, Verhoeve HR, Graziosi GCM, Koks CAM, Klinte I, Hogström L, Janssen ICAH, Kragt H, Hoek A, Trimbos-Kemper TCM, Broekmans FJM, Willemsen WNP, Ankum WM, Mol BW, van Wely M, van der Veen F, Hajenius PJ. Salpingotomy versus salpingectomy in women with tubal pregnancy (ESEP study): an open-label, multicentre, randomised controlled trial. Lancet 2014; 383:1483-1489. [PMID: 24499812 DOI: 10.1016/s0140-6736(14)60123-9] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Tubal ectopic pregnancy can be surgically treated by salpingectomy, in which the affected Fallopian tube is removed, or salpingotomy, in which the tube is preserved. Despite potentially increased risks of persistent trophoblast and repeat ectopic pregnancy, salpingotomy is often preferred over salpingectomy because the preservation of both tubes is assumed to offer favourable fertility prospects, although little evidence exists to support this assumption. We aimed to assess whether salpingotomy would improve rates of ongoing pregnancy by natural conception compared with salpingectomy. METHODS In this open-label, multicentre, international, randomised controlled trial, women aged 18 years and older with a laparoscopically confirmed tubal pregnancy and a healthy contralateral tube were randomly assigned via a central internet-based randomisation program to receive salpingotomy or salpingectomy. The primary outcome was ongoing pregnancy by natural conception. Differences in cumulative ongoing pregnancy rates were expressed as a fecundity rate ratio with 95% CI, calculated by Cox proportional-hazards analysis with a time horizon of 36 months. Secondary outcomes were persistent trophoblast and repeat ectopic pregnancy (expressed as relative risks [RRs] with 95% CIs) and ongoing pregnancy after ovulation induction, intrauterine insemination, or IVF. The researchers who collected data for fertility outcomes were masked to the assigned intervention, but patients and the investigators who analysed the data were not. All endpoints were analysed by intention to treat. We also did a (non-prespecified) meta-analysis that included the findings from the present trial. This trial is registered, number ISRCTN37002267. FINDINGS 446 women were randomly assigned between Sept 24, 2004, and Nov 29, 2011, with 215 allocated to salpingotomy and 231 to salpingectomy. Follow-up was discontinued on Feb 1, 2013. The cumulative ongoing pregnancy rate was 60·7% after salpingotomy and 56·2% after salpingectomy (fecundity rate ratio 1·06, 95% CI 0·81-1·38; log-rank p=0·678). Persistent trophoblast occurred more frequently in the salpingotomy group than in the salpingectomy group (14 [7%] vs 1 [<1%]; RR 15·0, 2·0-113·4). Repeat ectopic pregnancy occurred in 18 women (8%) in the salpingotomy group and 12 (5%) women in the salpingectomy group (RR 1·6, 0·8-3·3). The number of ongoing pregnancies after ovulation induction, intrauterine insemination, or IVF did not differ significantly between the groups. 43 (20%) women in the salpingotomy group were converted to salpingectomy during the initial surgery because of persistent tubal bleeding. Our meta-analysis, which included our own results and those of one other study, substantiated the results of the trial. INTERPRETATION In women with a tubal pregnancy and a healthy contralateral tube, salpingotomy does not significantly improve fertility prospects compared with salpingectomy. FUNDING Netherlands Organisation for Health Research and Development (ZonMW), Region Västra Götaland Health & Medical Care Committee.
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Affiliation(s)
- Femke Mol
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands.
| | - Norah M van Mello
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | | | | | - Davor Jurkovic
- King's Early Pregnancy Unit, King's College Hospital, London, UK; Department of Obstetrics and Gynaecology, University College London Hospital, London, UK
| | - Jackie Ross
- King's Early Pregnancy Unit, King's College Hospital, London, UK
| | - Kurt T Barnhart
- Penn Fertility Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | | | | | - Harry Kragt
- Reinier de Graaf Hospital, Delft, Netherlands
| | - Annemieke Hoek
- University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | | | | | | | - Willem M Ankum
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands; School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, SA, Australia
| | - Madelon van Wely
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Fulco van der Veen
- Centre for Reproductive Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
| | - Petra J Hajenius
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, Netherlands
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Capmas P, Bouyer J, Fernandez H. Treatment of ectopic pregnancies in 2014: new answers to some old questions. Fertil Steril 2014; 101:615-20. [DOI: 10.1016/j.fertnstert.2014.01.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/16/2014] [Accepted: 01/16/2014] [Indexed: 10/25/2022]
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Murtaza UI, Ortmann MJ, Mando-Vandrick J, Lee ASD. Management of first-trimester complications in the emergency department. Am J Health Syst Pharm 2013; 70:99-111. [DOI: 10.2146/ajhp120069] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Umbreen I. Murtaza
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Melinda J. Ortmann
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | | | - Amy S. D. Lee
- Department of Gynecology-Obstetrics, The Johns Hopkins Hospital, Baltimore
- Emergency Medicine, Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
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Musters AM, de Bekker-Grob EW, Mochtar MH, van der Veen F, van Mello NM. Women's perspectives regarding subcutaneous injections, costs and live birth rates in IVF. Hum Reprod 2011; 26:2425-31. [DOI: 10.1093/humrep/der177] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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