Medical management of tubal pregnancy: Number 3, December 1998 clinical management guidelines for obstetriciandashgynecologists

Multiple-dose and double-dose versus single-dose administration of methotrexate for the treatment of ectopic pregnancy: a systematic review and meta-analysis

In this systematic review and meta-analysis, the effectiveness and safety among different dosage of methotrexate protocols for the treatment of unruptured tubal ectopic pregnancy was evaluated. Six studies of randomized contorlled trials were identified through searches conducted on PubMed, Embase and Cochrane Library between January 1974 and March 2016. The overall success rate of multiple-dose protocol was similar to the single-dose protocol (RR 1.07, 95% CI 0.99 to 1.17, I² = 0%). The difference between double-dose and single-dose groups was not significant (RR 1.09, 95% CI 0.98 and 1.20, I² = 0%). The incidence of side-effects of double-dose regimen was similar with single-dose regimen. Side-effects, however, are more common in multiple-dose regimen (RR 1.64, 95% CI 1.15 to 2.34, P = 0.006, I² = 0%). This meta-analysis indicated that the incidence of side-effects of multiple-dose protocol was significantly higher than single-dose protocol, and the success rates between them were similar. The double-dose regimen was an efficient and safe alternative to the single-dose protocol. Further high-quality researches are needed to confirm our findings and to develop the optimal protocol.

Methotrexate treatment for ectopic pregnancy after assisted reproductive technology: A case-control study

OBJECTIVES

Ectopic pregnancy (EP) occurs in 2% to 5.6% of pregnancies achieved by assisted reproductive technology (ART). EP treatment options include medical treatment by uses of methotrexate (MTX) systemic injection. The objective of this study was to compare MTX treatment effectiveness for EP occurring spontaneously or following ART.

METHODS

A case-control study performed in the department of obstetrics and gynecology at a tertiary health care center in France. Twenty EP achieved by ART (ART group) and 60 spontaneous EP (SEP group) received MTX treatment between January 2002 and May 2012. The main outcome measures were MTX treatment failure rates, number of MTX injections administered and recovery time.

RESULTS

MTX treatment failure rates observed in ART and SEP groups were similar (3/20 [15%] versus 10/60 [17%]: OR=0.88 [0.22-3.58]). Mean duration of recovery time in patients with successful MTX treatment did not differ between ART and SEP groups (33±14 days versus 28±13 days, P=0.39). A second MTX injection was required more frequently in ART group than in SEP group (10/20 [50%] versus 10/60 [17%]: OR=5 [1.65-15.15]).

CONCLUSIONS

It is concluded that MTX treatment is equally effective for spontaneous EP and EP achieved by ART, two injections of MTX being more frequently required in case of ART.

Predictors of Success of a Single-Dose Methotrexate in the Treatment of Ectopic Pregnancy

BACKGROUND

Ectopic pregnancy (EP) is the commonest cause of maternal mortality-related death in the first trimester. Methotrexate (MTX) remains the first-line treatment in optimally selected patients.

OBJECTIVE

To evaluate the success rate and predictors of success of a single-dose MTX treatment in EP.

SUBJECTS AND METHOD

We studied retrospectively 109 patients with unruptured EP who were treated with Intramuscular MTX administered in a dose of 50 mg/m(2) on days 0 and in additional doses on day 7 if β-hCG levels did not decrease by 15 % during the follow-up period. The study was conducted at the Maternity and Children Hospital Buraidah, Saudi Arabia from June 2013 to December 2013. Pretreatment β-β-hCG, EP mass diameter, peritoneal fluid, and fetal cardiac activity were evaluated. The main outcome measures were success rate, the predictors of success without surgical treatment.

RESULT

Under this regime, the overall success rate was 60.6 % of patients. Of the failure group, only 4.7 % of patients experienced rupture of EP. No side effects were reported. The main predictors of failure were initial β-hCG value ≥ 3.500 mIU/mL OR 4.11 (1.646-12.248, 0.043) and EP diameter 3.73 (1.646-12.10, p = 0.003).

CONCLUSION

The success rate of MTX in this study was 60.6 %, and the initial β-hCG concentration and EP diameter were the best predictors of successful treatment with MTX. Furthermore, MTX should be offered only to those patients with β-hCG <2,000 mIU/mL and EP mass size <3.5 cm.

Diagnosis and Management of Ectopic Pregnancy

Ectopic pregnancy remains to be an important cause of maternal morbidity and mortality worldwide, although the incidence has remained unchanged especially in developed countries over the last decade. Several factors are responsible for this, including misdiagnosis and failure to institute timely appropriate treatment aimed at preserving fertility and minimizing the associated morbidity. Recent advances in imaging and biomonitoring have reduced the number of women presenting with ruptured ectopic pregnancy. Any attempt to reduce the consequences of ectopic pregnancies must, therefore, focus on improving the diagnosis of the unruptured type and evidenced-based treatment, which is cost effective. In this review, the authors discuss the diagnosis and treatment of this complication in the light of the recent evidence highlighting how improvements can be made to reduce the consequences.

A pragmatic and evidence-based management of ectopic pregnancy

The incidence of ectopic pregnancy is approximately 2% of all pregnancies, and it remains the leading cause of death in early pregnancy. Over 95% of ectopic pregnancies are tubal pregnancies, and the remainders are nontubal pregnancies. The highest risk factor for ectopic pregnancy is a previous tubal pregnancy followed by previous tubal surgery, tubal sterilization, tubal pathology, and current intrauterine device use. The apparent increase in the incidence of nontubal ectopic pregnancy including heterotopic pregnancy may be attributed to the increasing number of pregnancies because of in vitro fertilization treatment. In most cases, an ectopic pregnancy can be treated medically with a single dose of methotrexate. Surgical treatment is still needed in women who are hemodynamically unstable and in those who do not fulfill the criteria for methotrexate treatment. Usually surgical treatment can be performed by laparoscopy and in some cases by hysteroscopy. Laparotomy is rarely needed even in women with intraperitoneal bleeding.

Ectopic pregnancy after infertility treatment

Early pregnancy complications are more common in women who conceive after infertility treatment. Most of these occur before 12 weeks of gestation and include miscarriage, vaginal bleeding, intrauterine hematoma, vanishing twin, and ectopic pregnancy (EP). The incidence of EPs following infertility treatment is much higher compared with that in spontaneous pregnancies. The occurrence of an EP is very distressing to an infertile couple, who has lots of hopes pinned on the treatment outcome, especially because of the cost incurred and the physical and mental trauma both have gone through during the treatment process. The association between infertility and EP is complex, as it can be a consequence of infertility as well as a cause. The two principal risk factors for an EP are genital tract infections and tubal surgeries. Though several etiologies are proposed, but patients with tubal factor infertility are at an increased risk of an EP. Earlier diagnosis of EP helps to improve prognosis and optimize subsequent fertility. It is pivotal to evaluate the likelihood of subsequent occurrence of an EP and be too vigilant when treating. The correct choice of the treatment modality should be made to prevent the recurrence. The early prediction of the pregnancy outcome therefore has great importance for both the couple and clinician. Today with the help of sensitive beta human chorionic gonadotropin (β-hCG) assays and transvaginal sonography, one can diagnose an EP prior to symptoms, and conservative treatment for the preservation of the fallopian tube is possible. Conservative management in the form of expectant and medical management should be considered as a first-line treatment modality, provided that the overall clinical picture suggests that it is safe to do so. If not, laparoscopic management of EPs appears to be the favored approach of management as compared to laparotomy.

Establishing a human chorionic gonadotropin cutoff to guide methotrexate treatment of ectopic pregnancy: a systematic review

OBJECTIVE

Successful medical management of an ectopic pregnancy is inversely associated with initial hCG level. The purpose of this publication is to assess whether there is a level of hCG above which failure rate substantially increases.

DESIGN

A systematic review and summary analysis was performed, including studies reporting methotrexate treatment outcomes as stratified by various hCG ranges.

SETTING

Academic medical center.

PATIENT(S)

Review of published information regarding patients treated with methotrexate.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Success and failure rate of medical management.

RESULT(S)

Five observational studies, including 503 women, were found that reported successes in using single-dose methotrexate stratified by initial hCG concentration. Failure rates increase with increasing hCG levels. A substantial and statistically significant increase in failure rates is seen when comparing patients who have initial hCG levels of >5,000 mIU/mL with those who have initial levels of <5,000 mIU/mL (odds ratio: 5.45; 95% confidence interval: 3.04, 9.78). The failure rate for women who had an initial concentration between 5,000 and 9,999 mIU/mL was significantly higher than that for those who had initial levels between 2,000 and 4,999 mIU/mL (odds ratio: 3.76; 95% confidence interval: 1.16, 12.33).

CONCLUSION(S)

Results support a substantial increase in failure of medical management with single-dose methotrexate when the initial hCG is above 5,000 mIU/mL. Methotrexate should be used with caution in patients with ectopic pregnancy who present with hCG levels above this level.

[Medical treatment of ectopic pregnancy: a randomized clinical trial comparing metotrexate-mifepristone and methotrexate-placebo]

BACKGROUND

Medical treatment of ectopic pregnancy is widespread. To increase the efficacy of methotrexate, combination with mifepristone has been proposed.

METHODS

We performed a large prospective multicentre double-blind sequential randomized trial in order to compare the efficacy of methotrexate and mifepristone (600 mg given orally) versus methotrexate and placebo.

RESULTS

Two hundred twelve ectopic pregnancies were randomized. There was no significant difference in the initial characteristics between the 2 groups. There was no significant difference in the success rate of medical treatment between the methotrexate-mifepristone (n=113) and the methotrexate-placebo group (n=99): 79.6% (90/113) vs 74.2% (72/97) respectively, RR [95% CI]: 1.07 [0.92-1.25], p=0.41. However, there was a quantitative interaction between progesterone level and effect of treatment: when progesterone level was 10 ng/l, the efficacy of the combination of mifepristone and methotrexate was significantly higher than the combination of methotrexate and placebo, with a 83.3% success rate (15/18) vs 38.5% (5/13) respectively.

CONCLUSION

Our study failed to demonstrate any benefit of the addition of mifepristone to methotrexate. By contrast, the quantitative interaction between treatment effect and base line serum progesterone suggested that this combination could be reserved to ectopic pregnancies associated with high serum progesterone concentrations.

Primary omental ectopic pregnancy

Omental ectopic pregnancy is a rare form of ectopic pregnancy. Presented here is a case primary omental ectopic pregnancy according to Studdiford's criteria. This patient presented with epigastric pain and anemia without vaginal bleeding, lower abdominal or pelvic pain. Pregnancy status was confirmed after admission. Transvaginal ultrasound examination revealed intrauterine contraceptive device in situ and a large amount of free peritoneal fluid, but no intrauterine sac or adnexal mass. Laparoscopy was performed but pelvic pathology did not account for the 2500 mL of haemoperitoneum. Laparotomy was carried out and partial omentectomy was performed.

Ectopic pregnancy: an update

This review addresses recent publications that investigate etiology, epidemiology and different modalities in diagnosis and therapy for ectopic pregnancy. A significant proportion of recent work has focused in the development of new diagnostic tools to aid in the early detection of ectopic pregnancy. Diagnostic modalities have included systemic and local markers, vascular endothelial growth factor, vascular cell adhesion molecule-1, urokinase plasminogen activator receptor, cervical fetal fibronectin, and hormonal level determinations. In addition, magnetic resonance imaging, ultrasonography, color flow mapping and endometrial thickness have been evaluated. New studies have investigated controversial issues related to the cost of the medical versus surgical treatment and the use of different medications and techniques for the management of ectopic pregnancy. Most important of all, several lines of investigation have addressed the use of human chorionic gonadotropin, algorithms, and scoring systems as prognostic indicators of successful therapy and to determine the risk of complications. The management of cervical, interstitial and heterotopic pregnancy is evaluated in this review and a summary of recent proposed diagnostic tools and concepts in management is also presented.