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Cheng M, Tao X, Wang F, Shen N, Xu Z, Hu Y, Huang P, Luo P, He Q, Zhang Y, Yan F. Underlying mechanisms and management strategies for regorafenib-induced toxicity in hepatocellular carcinoma. Expert Opin Drug Metab Toxicol 2024:1-16. [PMID: 39225462 DOI: 10.1080/17425255.2024.2398628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Hepatocellular carcinoma (HCC) accounts for 85% of liver cancer cases and is the third leading cause of cancer death. Regorafenib is a multi-target inhibitor that dramatically prolongs progression-free survival in HCC patients who have failed sorafenib therapy. However, one of the primary factors limiting regorafenib's clinical utilization is toxicity. Using Clinical Trials.gov and PubMed, we gathered clinical data on regorafenib and conducted a extensive analysis of the medication's adverse reactions and mechanisms. Next, we suggested suitable management techniques to improve regorafenib's effectiveness. AREAS COVERED We have reviewed the mechanisms by which regorafenib-induced toxicity occurs and general management strategies through clinical trials of regorafenib. Furthermore, by examining the literature on regorafenib and other tyrosine kinase inhibition, we summarized the mechanics of the onset of regorafenib toxicity and mechanism-based intervention strategies by reviewing the literature related to regorafenib and other tyrosine kinase inhibition. EXPERT OPINION One of the primary factors restricting regorafenib's clinical utilization and combination therapy is its toxicity reactions. To optimize regorafenib treatment regimens, it is especially important to further understand the specific toxicity mechanisms of regorafenib as a multi-kinase inhibitor.
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Affiliation(s)
- Mengting Cheng
- College of Pharmaceutical Sciences, Center for Drug Safety Evaluation and Research of Zhejiang University, Hangzhou, China
- Clinical Pharmacy Center, Department of Pharmacy, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Xinyu Tao
- Clinical Pharmacy Center, Department of Pharmacy, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Fei Wang
- Outpatient Pharmacy, Department of Pharmacy, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Nonger Shen
- Clinical Pharmacy Center, Department of Pharmacy, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
| | - Zhifei Xu
- College of Pharmaceutical Sciences, Center for Drug Safety Evaluation and Research of Zhejiang University, Hangzhou, China
| | - Yuhuai Hu
- Department of Pharmacology and Toxicology, Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou, China
| | - Ping Huang
- Clinical Pharmacy Center, Department of Pharmacy, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for malignant tumor, Hangzhou, Zhejiang, People's Republic of China
| | - Peihua Luo
- College of Pharmaceutical Sciences, Center for Drug Safety Evaluation and Research of Zhejiang University, Hangzhou, China
- Department of Pharmacology and Toxicology, Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou, China
| | - Qiaojun He
- College of Pharmaceutical Sciences, Center for Drug Safety Evaluation and Research of Zhejiang University, Hangzhou, China
- Department of Pharmacology and Toxicology, Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou, China
| | - Yiwen Zhang
- Clinical Pharmacy Center, Department of Pharmacy, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, China
- Zhejiang Provincial Clinical Research Center for malignant tumor, Hangzhou, Zhejiang, People's Republic of China
- Key Laboratory of Endocrine Gland Diseases of Zhejiang Province, Hangzhou, China
| | - Fangjie Yan
- Department of Pharmacology and Toxicology, Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou, China
- Institute of Pharmacology & Toxicology, Zhejiang Province Key Laboratory of Anti-Cancer Drug Research, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
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Forbes LA, Nuthivana N, Morales R. Successful Management of Spontaneous Unilateral Twin Ectopic Pregnancy With Two-Step Dose of Methotrexate. Case Rep Obstet Gynecol 2024; 2024:5543780. [PMID: 39188358 PMCID: PMC11347029 DOI: 10.1155/2024/5543780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/17/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024] Open
Abstract
The incidence of unilateral tubal twin pregnancy is 1/20,000-1/250,000 with about 100 reported cases. Four of the six cases that were medically managed were successful. A 24-year-old female presented to the emergency department (ED) with vaginal bleeding and abdominal cramping. She was hemodynamically stable without signs of an acute abdomen. Laboratory evaluation revealed she was pregnant with a serum beta-human chorionic gonadotropin (b-hCG) of 798 mIU/mL. Transvaginal ultrasound (TVUS) revealed a single left tubal pregnancy with a yolk sac. The patient elected medical management with body surface area (BSA)-based intramuscular (IM) methotrexate (MTX). On Day 4, the patient returned to the ED; her b-hCG was 727 mIU/mL. TVUS revealed twin left tubal pregnancies with yolk sacs and fetal poles without cardiac activity. The patient elected to continue medical management with a second dose of BSA-based IM MTX. On Day 6, the patient returned to the ED with abdominal and rectal pain. She was hemodynamically stable without signs of an acute abdomen. Her b-hCG was 533 mIU/mL. TVUS showed persistent twin left tubal pregnancies-one at 5 weeks gestational age and the other at 6 weeks gestational age-without evidence of rupture. The patient continued serial b-hCGs. Thirty-one days after the first dose of MTX, her b-hCG was < 1 mIU/mL. TVUS showed resolution of tubal pregnancies. The patient consented to the publication of this case report. This case documents the successful treatment of spontaneous, unilateral tubal twin pregnancies with two-step dosing of IM MTX.
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Affiliation(s)
- Lauren A. Forbes
- Department of Obstetrics and GynecologyEastern Virginia Medical School at Old Dominion University, Norfolk, Virginia, USA
| | - Navya Nuthivana
- Department of Obstetrics and GynecologyEastern Virginia Medical School at Old Dominion University, Norfolk, Virginia, USA
| | - Renee Morales
- Department of Obstetrics and GynecologyEastern Virginia Medical School at Old Dominion University, Norfolk, Virginia, USA
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Geng D, Liu M, Wu D, Yue B. The relationship between serum levels of epidermal growth factor and β-human chorionic gonadotropin and the type and prognosis of ectopic pregnancy. Arch Gynecol Obstet 2024; 310:1179-1187. [PMID: 38683393 DOI: 10.1007/s00404-024-07523-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024]
Abstract
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.
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Affiliation(s)
- Dandan Geng
- Department of Gynecology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, No 39, 12 Qiao Road, Jinniu District, Chengdu, 610075, Sichuan, China.
- Department of Traditional Chinese Medicine, The Forth Hospital of Shijiazhuang, Shijiazhuang, 050000, China.
| | - Manfang Liu
- Department of Traditional Chinese Medicine, The Forth Hospital of Shijiazhuang, Shijiazhuang, 050000, China
| | - Dongyan Wu
- Department of Gynecology, The Forth Hospital of Shijiazhuang, Shijiazhuang, 050000, China
| | - Benming Yue
- Department of Gynecology, The Forth Hospital of Shijiazhuang, Shijiazhuang, 050000, China
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Wu J, Cai Y, Jiang N, Qian Y, Lyu R, You Q, Zhang F, Tao H, Zhu H, Nawaz W, Chen D, Wu Z. Pralatrexate inhibited the replication of varicella zoster virus and vesicular stomatitis virus: An old dog with new tricks. Antiviral Res 2024; 221:105787. [PMID: 38145756 DOI: 10.1016/j.antiviral.2023.105787] [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: 10/09/2023] [Revised: 12/18/2023] [Accepted: 12/19/2023] [Indexed: 12/27/2023]
Abstract
Varicella zoster virus (VZV) is associated with herpes zoster (HZ) or herpes zoster ophthalmicus (HZO). All antiviral agents currently licensed for the management of VZV replication via modulating different mechanisms, and the resistance is on the rise. There is a need to develop new antiviral agents with distinct mechanisms of action and adequate safety profiles. Pralatrexate (PDX) is a fourth-generation anti-folate agent with an inhibitory activity on folate (FA) metabolism and has been used as an anti-tumor drug. We observed that PDX possessed potent inhibitory activity against VZV infection. In this study, we reported the antiviral effects and the underlying mechanism of PDX against VZV infection. The results showed that PDX not only inhibited VZV replication in vitro and in mice corneal tissues but also reduced the inflammatory response and apoptosis induced by viral infection. Furthermore, PDX treatment showed a similar anti-VSV inhibitory effect in both in vitro and in vivo models. Mechanistically, PDX inhibited viral replication by interrupting the substrate supply for de novo purine and thymidine synthesis. In conclusion, this study discovered the potent antiviral activity of PDX with a novel mechanism and presented a new strategy for VZV treatment that targets a cellular metabolic mechanism essential for viral replication. The present study provided a new insight into the development of broad-spectrum antiviral agents.
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Affiliation(s)
- Jing Wu
- Medical School of Nanjing University, Nanjing, China
| | - Yurong Cai
- School of Life Science, Ningxia University, Yinchuan, China
| | - Na Jiang
- Medical School of Nanjing University, Nanjing, China
| | - Yajie Qian
- Nanjing Stomatological Hospital, Medical School of Nanjing University, Nanjing, China
| | - Ruining Lyu
- Medical School of Nanjing University, Nanjing, China
| | - Qiao You
- Medical School of Nanjing University, Nanjing, China
| | - Fang Zhang
- Department of Burn and Plastic Surgery, Affiliated Hospital of Zunyi Medical University, Zunyi, China
| | - Hongji Tao
- Medical School of Nanjing University, Nanjing, China
| | - Haotian Zhu
- Medical School of Nanjing University, Nanjing, China
| | - Waqas Nawaz
- Hȏpital Maisonneuve-Rosemont, School of Medicine, University of Montreal, Canada
| | - Deyan Chen
- Medical School of Nanjing University, Nanjing, China.
| | - Zhiwei Wu
- Medical School of Nanjing University, Nanjing, China; Northern Jiangsu People's Hospital, Affiliated Teaching Hospital of Medical School, Nanjing University, Yangzhou, China; State Key Laboratory of Analytical Chemistry for Life Science, Nanjing University, Nanjing, China; School of Life Science, Ningxia University, Yinchuan, China.
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Al Wattar BH, Solangon SA, de Braud LV, Rogozińska E, Jurkovic D. Effectiveness of treatment options for tubal ectopic pregnancy: A systematic review and network meta-analysis. BJOG 2024; 131:5-14. [PMID: 37443463 DOI: 10.1111/1471-0528.17594] [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: 04/04/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Tubal ectopic pregnancy (TEP) is a common gynaecological emergency. Several medical and surgical treatment options exist, but it is not clear which is the safest and most effective treatment. OBJECTIVES To compare the effectiveness of expectant, medical and surgical treatment options for TEP using a systematic review and network meta-analysis. SEARCH STRATEGY MEDLINE, EMBASE, and CENTRAL from inception till September 2022. SELECTION CRITERIA Randomised trials that evaluated any treatment option for woman with a TEP. DATA COLLECTION AND ANALYSIS We performed pairwise and network meta-analyses using a random effect model. We assessed the studies' risk of bias, heterogeneity and network inconsistency. We reported primarily on TEP resolution and treatment failure using relative risk (RR) and 95% confidence-intervals (CI). MAIN RESULTS We included 31 randomised trials evaluating ten treatments (n = 2938 women). Direct meta-analysis showed no significant benefit for using methotrexate compared to expectant management for TEP resolution. Network meta-analysis showed similar effect-size for most conservative treatment options compared to expectant management for TEP resolution (glucose intra-sac instillation vs. expectant RR 0.84, 95% CI 0.63-1.12; methotrexate intra-sac instillation vs. expectant RR 0.91, 95% CI 0.75-1.10; multi-dose methotrexate vs. expectant RR 1.00, 95% CI 0.88-1.15; prostaglandin intra-sac instillation vs. expectant RR 0.75, 95% CI 0.53-1.07; salpingotomy vs. expectant RR 0.99, 95% CI 0.84-1.16; single dose methotrexate vs. expectant RR 0.97, 95% CI 0.85-1.10; single dose methotrexate + mifepristone vs. expectant RR 1.09, 95% CI 0.89-1.33). All treatment options showed a higher risk of failure compared to salpingectomy. CONCLUSIONS There is insufficient evidence to support the use of any medical treatment option for TEP over expectant management.
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Affiliation(s)
- Bassel H Al Wattar
- Beginning Assisted Conception Unit, Epsom and St Helier University Hospitals, London, UK
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Sarah A Solangon
- Women's Health Department, University College London Hospitals, London, UK
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - Lucrezia V de Braud
- Women's Health Department, University College London Hospitals, London, UK
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - Ewelina Rogozińska
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Davor Jurkovic
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
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Laschi S, Sfragano PS, Ranaldi F, Palchetti I. Progesterone and β-hCG Determination Using an Electrochemical Combo-Strip for Pregnancy Monitoring. Int J Mol Sci 2023; 24:15381. [PMID: 37895061 PMCID: PMC10607536 DOI: 10.3390/ijms242015381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/06/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
The development of analytical devices that can allow an easy, rapid and cost-effective measurement of multiple markers, such as progesterone and β-hCG, could have a role in decreasing the burden associated with pregnancy-related complications, such as ectopic pregnancies. Indeed, ectopic pregnancies are a significant contributor to maternal morbidity and mortality in both high-income and low-income countries. In this work, an effective and highly performing electrochemical strip for a combo determination of progesterone and β-hCG was developed. Two immunosensing approaches were optimized for the determination of these two hormones on the same strip. The immunosensors were realized using cost-effective disposable electrode arrays and reagent-saving procedures. Each working electrode of the array was modified with both the IgG anti-β-hCG and anti-progesterone, respectively. By adding the specific reagents, progesterone or β-hCG can then be determined. Fast quantitative detection was achieved, with the analysis duration being around 1 h. Sensitivity and selectivity were assessed with a limit of detection of 1.5 × 10-2 ng/mL and 2.45 IU/L for progesterone and β-hCG, respectively. The proposed electrochemical combo-strip offers great promise for rapid, simple, cost-effective, and on-site analysis of these hormones and, thus, for the development of a point-of-care diagnostic tool for early detection of pregnancy-related complications.
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Affiliation(s)
- Serena Laschi
- Department of Chemistry “Ugo Schiff”, University of Florence, 50019 Florence, Italy; (S.L.); (P.S.S.)
| | - Patrick Severin Sfragano
- Department of Chemistry “Ugo Schiff”, University of Florence, 50019 Florence, Italy; (S.L.); (P.S.S.)
| | - Francesco Ranaldi
- Department of Experimental and Clinical Biomedical Sciences “Mario Serio”, University of Florence, 50139 Florence, Italy;
- “Nanobiosens” Joint Lab, University of Florence, 50139 Florence, Italy
| | - Ilaria Palchetti
- Department of Chemistry “Ugo Schiff”, University of Florence, 50019 Florence, Italy; (S.L.); (P.S.S.)
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Solangon SA, Van Wely M, Van Mello N, Mol BW, Ross JA, Jurkovic D. Methotrexate vs expectant management for treatment of tubal ectopic pregnancy: An individual participant data meta-analysis. Acta Obstet Gynecol Scand 2023; 102:1159-1175. [PMID: 37345445 PMCID: PMC10407021 DOI: 10.1111/aogs.14617] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Ectopic pregnancy is an important health condition which affects up to 1 in 100 women. Women who present with mild symptoms and low serum human chorionic gonadotrophin (hCG) are often treated with methotrexate (MTX), but expectant management with close monitoring is a feasible alternative. Studies comparing the two treatments have not shown a statistically significant difference in uneventful resolution of ectopic pregnancy, but these studies were too small to define whether certain subgroups could benefit more from either treatment. MATERIAL AND METHODS We performed a systematic review and individual participant data meta-analysis (IPD-MA) of randomized controlled trials comparing systemic MTX and expectant management in women with tubal ectopic pregnancy and low hCG (<2000 IU/L). A one-stage IPD-MA was performed to assess overall treatment effects of MTX and expectant management to generate a pooled intervention effect. Subgroup analyses and exploratory multivariable analyses were undertaken according to baseline serum hCG and progesterone levels. Primary outcome was treatment success, defined as resolution of clinical symptoms and decline in level of serum hCG to <20 IU/L, or a negative urine pregnancy test by the initial intervention strategy, without any additional treatment. Secondary outcomes were need for blood transfusion, surgical intervention, additional MTX side-effects and hCG resolution times. TRIAL REGISTRATION NUMBER PROSPERO: CRD42021214093. RESULTS 1547 studies reviewed and 821 remained after duplicates removed. Five studies screened for eligibility and three IPD requested. Two randomized controlled trials supplied IPD, leading to 153 participants for analysis. Treatment success rate was 65/82 (79.3%) after MTX and 48/70 (68.6%) after expectant management (IPD risk ratio [RR] 1.16, 95% confidence interval [CI] 0.95-1.40). Surgical intervention rates were not significantly different: 8/82 (9.8%) vs 13/70 (18.6%) (RR 0.65, 95% CI 0.23-1.14). Mean time to success was 19.7 days (95% CI 17.4-22.3) after MTX and 21.2 days (95% CI 17.8-25.2) after expectant management (P = 0.25). MTX specific side-effects were reported in 33 MTX compared to four in the expectant group. CONCLUSIONS Our IPD-MA showed no statistically significant difference in treatment efficacy between MTX and expectant management in women with tubal ectopic pregnancy with low hCG. Initial expectant management could be the preferred strategy due to fewer side-effects.
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Affiliation(s)
| | - Madelon Van Wely
- Center for Reproductive MedicineAmsterdam University Medical CenterAmsterdamthe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Norah Van Mello
- Amsterdam Reproduction and Development Research InstituteAmsterdam University Medical CenterAmsterdamthe Netherlands
- Obstetrics and GynecologyAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Ben W. Mol
- The Ritchie Centre, Department of Obstetrics and GynecologyMonash UniversityClaytonVictoriaAustralia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and NutritionUniversity of AberdeenAberdeenUK
| | - Jackie A. Ross
- Early Pregnancy and Gynaecology Assessment UnitKing's College London HospitalLondonUK
| | - Davor Jurkovic
- Institute for Women's HealthUniversity College LondonLondonUK
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Mackenzie SC, Moakes CA, Doust AM, Mol BW, Duncan WC, Tong S, Horne AW, Whitaker LHR. Early (Days 1-4) post-treatment serum hCG level changes predict single-dose methotrexate treatment success in tubal ectopic pregnancy. Hum Reprod 2023; 38:1261-1267. [PMID: 37178269 PMCID: PMC10320483 DOI: 10.1093/humrep/dead089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/12/2023] [Indexed: 05/15/2023] Open
Abstract
STUDY QUESTION What is the capacity of the change between Day 1 and Day 4 post-treatment serum human chorionic gonadotropin (hCG) levels for predicting single-dose methotrexate treatment success in tubal ectopic pregnancy? SUMMARY ANSWER Any fall in Days 1-4 serum hCG signified an 85% (95% CI 76.8-90.6) likelihood of treatment success for women with tubal ectopic pregnancy (initial hCG of ≥1000 and ≤5000 IU/l) managed with single-dose methotrexate. WHAT IS KNOWN ALREADY For those with tubal ectopic pregnancy managed by single-dose methotrexate, current guidelines advocate intervention if Days 4-7 hCG fails to fall by >15%. The trajectory of hCG over Days 1-4 has been proposed as an early indicator that predicts treatment success, allowing early reassurance for women. However, almost all prior studies of Days 1-4 hCG changes have been retrospective. STUDY DESIGN, SIZE, DURATION This was a prospective cohort study of women with tubal ectopic pregnancy (pre-treatment hCG of ≥1000 and ≤5000 IU/l) managed with single-dose methotrexate. The data were derived from a UK multicentre randomized controlled trial of methotrexate and gefitinib versus methotrexate and placebo for treatment of tubal ectopic pregnancy (GEM3). For this analysis, we include data from both treatment arms. PARTICIPANTS/MATERIALS, SETTING, METHODS Participants were categorized according to single-dose methotrexate treatment success or failure. Treatment success for this analysis was defined as complete and uneventful resolution of tubal ectopic pregnancy to serum hCG <30 IU/l following single-dose methotrexate treatment without additional treatment. Patient characteristics of the treatment success and failure groups were compared. Changes in Days 1-4, 1-7, and 4-7 serum hCG were evaluated as predictors of treatment success through receiver operating characteristic curve analysis. Test performance characteristics were calculated for percentage change ranges and thresholds including optimal classification thresholds. MAIN RESULTS AND THE ROLE OF CHANCE A total of 322 women with tubal ectopic pregnancy were treated with single-dose methotrexate. The overall single-dose methotrexate treatment success rate was 59% (n = 189/322). For any fall in serum hCG on Days 1-4, likelihood ratios were >3, while for any fall of serum hCG >20% on Days 1-7, likelihood ratios reached 5. Any rise of serum hCG on Days 1-7 and 4-7 strongly reduced the chance of success. Any fall in Days 1-4 hCG predicted single-dose methotrexate treatment success with a sensitivity of 58% and specificity 84%, resulting in positive and negative predictive values of 85% and 57%, respectively. Any rise in Days 1-4 serum hCG <18% was identified as an optimal test threshold that predicted treatment success with 79% sensitivity and 74% specificity, resulting in 82% positive predictive value and 69% negative predictive value. LIMITATIONS, REASONS FOR CAUTION Our findings may be limited by intervention bias resulting from existing guidelines which influences evaluation of hCG changes reliant on Day 7 serum hCG levels. WIDER IMPLICATIONS OF THE FINDINGS Examining a large prospective cohort, we show the value of Days 1-4 serum hCG changes in predicting single-dose methotrexate treatment success in tubal ectopic pregnancy. We recommend that clinicians provide early reassurance to women who have a fall or only a modest (<18%) rise in Days 1-4 serum hCG levels, that their treatment will likely be effective. STUDY FUNDING/COMPETING INTEREST(S) This project was supported by funding from the Efficacy and Mechanism Evaluation programme, a Medical Research Council and National Institute for Health Research partnership (grant reference number 14/150/03). A.W.H. has received honoraria for consultancy for Ferring, Roche, Nordic Pharma and AbbVie. W.C.D. has received honoraria from Merck and Guerbet and research funding from Galvani Biosciences. L.H.R.W. has received research funding from Roche Diagnostics. B.W.M. is supported by a NHMRC Investigator grant (GNT1176437). B.W.M. also reports consultancy for ObsEva and Merck and travel support from Merck. The other authors declare no competing interests. TRIAL REGISTRATION NUMBER This study is a secondary analysis of the GEM3 trial (ISRCTN Registry ISRCTN67795930).
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Affiliation(s)
- Scott C Mackenzie
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Catherine A Moakes
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Ann M Doust
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - W Colin Duncan
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Lucy H R Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
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Hayashi T, Sano K, Konishi I. Histopathological Findings of Ectopic Pregnancy in Contraceptive-Wearing Woman. J Clin Med Res 2023; 15:384-389. [PMID: 37575351 PMCID: PMC10416193 DOI: 10.14740/jocmr4924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/22/2023] [Indexed: 08/15/2023] Open
Abstract
In normal pregnancy, the egg is fertilized in the fallopian tube. It later moves into the uterus, where it implants into the uterine endometrium. Therefore, implantation of the fertilized egg into the endometrium is not observed in many women using contraceptives. However, if the fallopian tubes are diseased or abnormal, the fertilized egg cannot travel to the endometrium. Thus, the fertilized egg is implanted in tissues other than the uterus, resulting in an ectopic pregnancy. In most cases of ectopic pregnancy, the fertilized egg is implanted into the left or right fallopian tube or in tissues other than the fallopian tubes such as the ovary. With laparoscopic surgery, the scars are small, and the pain and physical burden are also much lesser than those with open surgery; thus, the patient can be rehabilitated immediately. Laparoscopic surgery is preferred for the termination of ectopic pregnancies because the patients recovered quickly physically after surgery and can be discharged in a short period. This paper presents our experience in treating a 37-year-old woman who had a tubal pregnancy despite using a contraceptive. Contrast-enhanced magnetic resonance imaging showed a gestational sac within the right fallopian tube. Laparoscopic surgery was performed to resect the right fallopian tube. Pathological examination suggested that the ectopic pregnancy occurred at the organogenesis stage 9 weeks after fertilization. The pathological findings revealed subpopulations of cells from the ectoderm that were separated from other cells and more specifically formed spinal and ovarian structures. The implantation of the fertilized egg into the endometrium is not observed in many women using contraceptives. However, in rare cases, ectopic pregnancy occurs in women using contraceptives; thus, caution is necessary in diagnosis and treatment. This report presents valuable surgical pathological findings from such a rare case of ectopic pregnancy to understand the differentiation into each tissue during organogenesis.
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Affiliation(s)
- Takuma Hayashi
- Department of Cancer Medicine, National Hospital Organization Kyoto Medical Centre, Kyoto, Japan
- First-Track Medical R&D, The Japan Agency for Medical Research and Development (AMED), Tokyo, Japan
- Clinical Research, PRUM-iBio Study Group, National Hospital Organization Tokyo Headquarter, Tokyo, Japan
| | - Kenji Sano
- First-Track Medical R&D, The Japan Agency for Medical Research and Development (AMED), Tokyo, Japan
- Clinical Research, PRUM-iBio Study Group, National Hospital Organization Tokyo Headquarter, Tokyo, Japan
- Department of Clinical Laboratory, Shinshu University Hospital, Nagano, Japan
| | - Ikuo Konishi
- Department of Cancer Medicine, National Hospital Organization Kyoto Medical Centre, Kyoto, Japan
- First-Track Medical R&D, The Japan Agency for Medical Research and Development (AMED), Tokyo, Japan
- Clinical Research, PRUM-iBio Study Group, National Hospital Organization Tokyo Headquarter, Tokyo, Japan
- Department of Obstetrics and Gynecology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Oltman J, Balachander S, Mol BW, Woolner AMF. Have we overlooked the role of mifepristone for the medical management of tubal ectopic pregnancy? Hum Reprod 2023:7193344. [PMID: 37295950 PMCID: PMC10391312 DOI: 10.1093/humrep/dead116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/12/2023] [Indexed: 06/12/2023] Open
Abstract
Ectopic pregnancy is a risk of both spontaneous and assisted reproduction pregnancies. The majority of ectopic pregnancies abnormally implant within a fallopian tube (extrauterine pregnancies). In haemodynamically stable women, medical or expectant treatment can be offered. Currently accepted medical treatment is using a drug called methotrexate. However, methotrexate has potential adverse effects, and a significant proportion of women will still require emergency surgery (up to 30%) to remove the ectopic pregnancy. Mifepristone (RU-486) has anti-progesterone effects and has a role in managing intrauterine pregnancy loss and termination of pregnancy. On reviewing the literature and given progesterone's pivotal role in sustaining pregnancy, we propose that we may have overlooked the role of mifepristone in the medical management of tubal ectopic pregnancy in haemodynamically stable women.
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Affiliation(s)
- Julia Oltman
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Sanjana Balachander
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Ben W Mol
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
- Monash Medical Centre Clayton, Obstetrics and Gynaecology, Monash Medical Centre, Clayton, Victoria, Australia
- Monash University, Clayton, Victoria, Australia
| | - Andrea M F Woolner
- Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
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Sonalkar S, Gilmore E. A fresh look at treatment for ectopic pregnancy. Lancet 2023; 401:619-620. [PMID: 36738758 DOI: 10.1016/s0140-6736(23)00181-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Affiliation(s)
- Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Emma Gilmore
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
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