Ectopic pregnancy

Predictors of Successful Medical Management With Methotrexate in Unruptured Tubal Ectopic Pregnancy

Introduction Medical treatment with methotrexate (MTX) is a safe and effective alternative to surgery in carefully selected cases of ectopic pregnancies diagnosed early prior to rupture. Aim To determine the optimal pre-treatment levels of beta human chorionic gonadotropin (𝛽-hCG) and its changing trends most likely to have a successful outcome with medical management. Material and methods A prospective observational study was conducted in a tertiary teaching hospital from December 2018 to May 2021. "Single-dose" MTX regime was used for medical management of ectopic pregnancy in patients fulfilling the selection criteria. The 𝛽-hCG levels were recorded at baseline and on day 4 and day 7 of MTX injection. Thereafter, at weekly intervals till complete resolution or surgical intervention due to failure of medical management. In addition, receiver operating characteristic (ROC) curve analysis for a pre-treatment 𝛽-hCG cut-off value and changing trends in post-treatment 𝛽- hCG levels most likely to have a successful outcome with MTX treatment were determined. Results Fifty patients fulfilling the inclusion criteria were included in the study, with successful medical management in 33 (66%). The mean pre-treatment 𝛽-hCG levels in women with successful medical management were 3270.97 (+/- 901) compared to 5249.17 (+/-808.02) for those with treatment failure (p=0.00001). The mean 𝛽-hCG level in the failed treatment group was significantly higher on day 4 than the pre-treatment levels (6742.56 +/- 572 vs. 5249.17+/- 808.02; p<0.05). Inadequate reduction of 𝛽-hCG level on day 7 (<15% of day 4 levels) requiring repeat dosage of MTX was more likely to have an unsuccessful outcome (p=0.00001). The area under curve (AUC) value of 0.905 (95% CI: 0.814-0.996) depicted that pre-treatment 𝛽-hCG level of 4000 mIU/ml taken as the cut-off value was able to predict levels ≤4000 mIU/ml had a greater likelihood of successful outcome with MTX, having a sensitivity of 84.5%, specificity of 83.3%, positive predictive value (PPV) of 90.3%, and negative predictive value (NPV) of 75% (p< 0.05). Demographic variables or previous clinical history, considered risk factors for ectopic pregnancy, did not affect the outcome of medical management in this study. Conclusion Medical management of ectopic pregnancy is a viable first-line treatment option in carefully selected patients. In this study, the most important predictors for the successful outcome of medical management were the pre-treatment β-hCG levels and their fall on day 4 and day 7 after MTX therapy.

Future Perspectives of Ectopic Pregnancy Treatment-Review of Possible Pharmacological Methods

Ectopic pregnancy, that is, a blastocyst occurring outside the endometrial cavity of the uterus, affects nearly 2% of pregnancies. The treatment of ectopic pregnancy is surgical or pharmacological. Since surgical management is associated with numerous serious side effects, conservative treatment is sought. The treatment of choice in the majority of cases is based on pharmacotherapy with methotrexate (MTX) in a single- or multi-dose regimen. Although the efficacy of methotrexate reaches between 70 and 90%, its use requires specific conditions regarding both the general condition of the patient and the characteristic features of the ectopic pregnancy. Moreover, MTX can cause severe adverse effects, including stomatitis, hepatotoxicity and myelosuppression. Therefore, clinicians and researchers are still looking for a less toxic, more effective treatment, which could prevent surgeries as a second-choice treatment. Some studies indicate that other substances might constitute a good alternative to methotrexate in the management of ectopic pregnancies. These substances include aromatase inhibitors, especially letrozole. Another promising substance in EP treatment is gefitinib, an inhibitor of EGFR tyrosine domain which, combined with MTX, seems to constitute a more effective alternative in the management of tubal ectopic pregnancies. Other substances for local administration include KCl and absolute ethanol. KCl injections used in combination with MTX may be used when foetal heart function is detected in cervical ectopic pregnancies, as well as in heterotopic pregnancy treatment. Absolute ethanol injections proved successful and safe in caesarean scar pregnancies management. Thus far, little is known about the use of those substances in the treatment of ectopic pregnancies, but already conducted studies seem to be promising.

Differences in Ectopic Pregnancy Rates between Fresh and Frozen Embryo Transfer after In Vitro Fertilization: A Large Retrospective Study

Ectopic pregnancy (EP) is increasingly found in women treated with in vitro fertilization and embryo transfer (IVF−ET). With the development of the freeze-all policy in reproductive medicine, it is controversial whether frozen embryo transfer (FET) could reduce the rate of EP. In this single-center, large-sample retrospective study, we analyzed 16,048 human chorionic gonadotrophin (hCG)-positive patients who underwent fresh embryo transfer (ET) or FET cycles between January 2013 and March 2022. Throughout the study, the total EP rate was 2.09% (336/16,048), 2.16% (82/3803) in the ET group, and 2.07% (254/12,245) in the FET group. After adjustment for age, infertility causes, and other confounding factors, logistic regression results showed no statistical difference in EP rates between FET and ET groups (odds ratio (OR) 0.93 (0.71−1.22), p > 0.05). However, among the 3808 patients who underwent fresh ET cycles, the OR for EP was significantly lower in the long agonist protocol group than in the gonadotropin-releasing hormone antagonist (GnRH-ant) protocol group (OR 0.45 (0.22−0.93), p < 0.05). Through a large retrospective study, we demonstrated a slightly lower EP rate in FET cycles than in fresh ET cycles, but there was no significant difference. The long agonist protocol in ET cycles had a significantly lower risk of EP than the GnRH-ant protocol.

Interstitial pregnancy is one of the most serious and uncommon ectopic pregnancies: Case report

Background

Ectopic pregnancies are a dreaded and common cause of first-trimester metrorrhagia. They refer to the implantation and development of the embryo outside the uterine cavity. Interstitial localization is uncommon and corresponds to implantation of the embryo in the intramural part of the uterine tube. It has an unforeseen evolution with a risk of cataclysmic hemorrhage by uterine rupture in the absence of early diagnosis and management.

Case presentation

We herein present the uncommon case of a 26-year-old female patient, second gestation, nulliparous, who underwent a pelvic ultrasonography in the emergency department for pelvic pain associated with a two-month amenorrhea. A past history of left salpingectomy for a ruptured tubal ectopic pregnancy 3 years ago was found. Pelvic ultrasound allowed us to detect a ruptured ectopic interstitial pregnancy at 7 weeks of amenorrhea. Significant hemoperitoneum and hemodynamic instability required emergency laparotomy. The condition was confirmed preoperatively and the patient underwent a corneal resection. The postoperative course was uneventful and the patient was discharged on day 4 postoperatively.

Conclusions

The interstitial ectopic pregnancy is an uncommon and life-threatening condition. The importance of early ultrasound detection is of paramount importance to allow conservative treatment with methotrexate injections. Delayed diagnosis requires cornual uterine resection with all the complications that it implies.

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Interstitial ectopic pregnancy is an uncommon and life-threatening condition.

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Conservative management with methotrexate injections can only be proposed after an early diagnosis.

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The importance of early ultrasound screening is emphasized, especially in cases of previous ectopic pregnancies.

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

Background:

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

Method:

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

Results:

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

Conclusion:

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

The incidence of ectopic/heterotopic pregnancies after blastocyst-stage frozen-thawed embryo transfers compared with that after cleavage-stage: a Society for Assisted Reproductive Technologies Clinical Outcomes Reporting System study

OBJECTIVE

To investigate whether there is a difference in the ectopic/heterotopic pregnancy rate of blastocyst-stage frozen-thawed embryo transfers (FETs) compared with that of cleavage-stage FETs.

DESIGN

A retrospective cohort study.

SETTING

Not applicable.

PATIENTS

Women undergoing autologous FETs at either the blastocyst stage (n = 118,572) or the cleavage stage (n = 117,619), as reported to the Society for Assisted Reproductive Technology from 2004 to 2013.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Pregnancy outcomes, specifically ectopic pregnancy rates and heterotopic pregnancy rates.

RESULTS

Among those who became pregnant, there was a significantly lower incidence of ectopic/heterotopic pregnancies in blastocyst-stage FETs versus that in cleavage-stage FETs (0.8% vs. 1.1%). The differences in ectopic/heterotopic pregnancy rates remained statistically significant after controlling for confounders such as tubal factor infertility and number of embryos transferred.

CONCLUSIONS

Blastocyst-stage FET was associated with a lower ectopic/heterotopic pregnancy rate compared with cleavage-stage FET.

Diagnostic Accuracy of Preoperative Conventional MRI for Patients With Ectopic Pregnancy

Objective

To assess the utility of preoperative magnetic resonance imaging (MRI) in the diagnosis of tubal pregnancy.

Summary of background data

Most cases of ectopic pregnancy are tubal pregnancies. Preoperative accurate diagnosis including the location of the tubal pregnancy is important.

Method

We performed a retrospective single-center cohort study evaluating patients who underwent surgery for ectopic pregnancy from April 2004 to March 2016 and who underwent preoperative MRI. Sixty patients were enrolled in the study. Chorion confirmed at the tubal pregnancy site detected by MRI was defined as a correct diagnosis.

Results

Mean estimated gestational age at the time of MRI according to the last menstrual period was 7 weeks (median: 5 weeks; range: 3–10 weeks). Ectopic pregnancy was diagnosed by MRI in 57 cases, and all cases were either left or right tubal pregnancy. In 52 cases, the actual position matched the MRI findings. In 5 cases, the location of tubal ectopic pregnancy was different from that diagnosed by MRI, or no tubal pregnancy was observed intraoperatively. In 2 cases, no ectopic pregnancy site was observed on MRI, but tubal pregnancy was confirmed by surgery. In one case, an ectopic pregnancy site was not found, and the tube showed normal findings on MRI. The sensitivity of MRI diagnosis was 96.2%, specificity was 16.7%, positive predictive value was 91.1%, and negative predictive value was 33.3%.

Conclusion

In cases of ectopic pregnancy treated surgically, the sensitivity of MRI diagnosis, including identification of the location of ectopic pregnancy, is high.

Use of Methotrexate in Gynecologic and Obstetric Practice: What the Radiologist Needs to Know

Methotrexate (MTX) is the primary pharmaceutical agent that is used for management of disorders arising from trophoblastic tissue. Its widespread international use is mostly attributable to its noninvasive, safe, and effective characteristics as a treatment option for ectopic pregnancy (EP) and gestational trophoblastic disease (GTD), with the large added benefit of fertility preservation. Although the effects of MTX usage are well documented in the gynecologic and obstetric literature, there is a scarcity of radiologic literature on the subject. Depending on the type of EP, the route of MTX administration and dosage may vary. US plays an essential role in the diagnosis and differentiation of various types of EPs, pregnancy-related complications, and complications related to MTX therapy, as well as the assessment of eligibility criteria for MTX usage. A knowledge of expected imaging findings following MTX treatment, including variability in echogenicity and shape of the EP, size fluctuations, changes in vascularity and gestational sac content, and the extent of hemoperitoneum, is essential for appropriate patient management and avoidance of unnecessary invasive procedures. A recognition of sonographic findings associated with pregnancy progression and complications such as tubal or uterine rupture, severe hemorrhage, septic abortion, and development of arteriovenous communications ensures prompt patient surgical management. The authors discuss the use of MTX in the treatment of disorders arising from trophoblastic tissue (namely EP and GTD), its mechanism of action, its route of administration, and various treatment regimens. The authors also provide a focused discussion of the role of US in the detection and diagnosis of EP and GTD, the assessment of the eligibility criteria for MTX use, and the identification of the sonographic findings seen following MTX treatment, with specific emphasis on imaging findings associated with MTX treatment success and failure. Online supplemental material is available for this article. ^©RSNA, 2021.

Association Between White Blood Cells at Baseline and Treatment Failure of MTX for Ectopic Pregnancy

Purpose: The aim of this study was to evaluate white blood cell (WBC) count as a risk factor related to methotrexate (MTX) treatment failure in patients with ectopic pregnancy (EP).

Methods: A total of 236 women diagnosed with EP and treated with a single dose of MTX were included. The exposure variable was WBC count at baseline, and the outcome was MTX treatment outcome. Both a multivariate binary logistics regression model and subgroup analysis were performed to evaluate the association between WBC and MTX non-response.

Results: WBC count was associated with the risk of treatment failure, and the odds ratio (OR) in different multivariate models was stable [minimally adjusted model: OR 1.2, 95% confidence interval (CI): 1.0–1.3, p = 0.008; fully adjusted model: OR 1.2, 95% CI: 1.0–1.4, p = 0.026]. For WBCs in group T3 (>8.9 × 109/L), the association between WBC count and treatment failure was significant (minimally adjusted model: OR: 2.0, 95% CI: 1.0–3.8, p = 0.050; fully adjusted model: OR: 2.2, 95% CI: 1.1–5.6, p = 0.034). Subgroup analysis showed that in participants with regular menstruation (OR 1.1, 95% CI: 1.0–1.3), WBC count was significantly different from irregular menstruation (OR 1.8, 95% CI: 1.2–2.8); p for interaction was 0.031.

Conclusions: We found a reliable and non-linear relationship between WBC count and MTX treatment failure for EP.

Case of rupture ectopic pregnancy with emergency contraception levonorgestrel 0.075 mg in a lactating woman

Levonorgestrel emergency contraception (LNG-EC) tends to make uterus unfavorable for implantation but does not prevent embryo implantation. Emergency contraceptives pills should be used with caution among lactating women who at the same time should be monitored closely for ectopic pregnancy.

Rectal ectopic pregnancy: A case report

RATIONALE

Abdominal ectopic pregnancy is a very rare form of ectopic pregnancy, yet is associated with higher morbidity due to atypical clinical presentation and misdiagnosis. In this report, we present a case of abdominal ectopic pregnancy with placenta invading to the rectal wall.

PATIENT CONCERNS

A 32-year-old woman was admitted to our hospital with an increasing serum ß-hCG level after diagnostic laparoscopy for ectopic pregnancy in the provincial hospital. During the laparoscopy, no gestational sac was found. She was discharged and scheduled for a follow-up visit to assess the level of ß-hCG. One week later, her serum ß-hCG level increased from 7000 IU/l to 12000 IU/l. Transvaginal Doppler ultrasound and abdominal computed tomography (CT) angiography demonstrated a right adnexal mass adherent to the rectal wall.

DIAGNOSIS

A rectal ectopic pregnancy is suspected.

INTERVENTIONS

Laparoscopic surgery was successfully performed in our hospital to remove the products of conception.

OUTCOMES

Histologic examination confirmed the diagnosis of a rectal ectopic pregnancy. The patient had an uneventful recovery and was discharged the next few days.

LESSONS

This case report reveals that an abdominal pregnancy is remarkably difficult to diagnose and manage. The gynecologists need to be aware of the possibility of gestational sac between the uterus and the rectum. To make early diagnosis of abdominal pregnancy, they need to combine clinical findings, imaging techniques (ultrasound, CT, MRI) and serial human chorionic gonadotropin measurements. Laparoscopic management should be considered in early abdominal pregnancy. A multidisciplinary team of gynecologists and gastrointestinal surgeons is required to deal with rectal ectopic pregnancy.

Effect of Methotrexate on Salpingostomy Completion Rate for Tubal Ectopic Pregnancy: A Retrospective Cohort Study

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.

Adrenomedullin insufficiency alters macrophage activities in fallopian tube: a pathophysiologic explanation of tubal ectopic pregnancy

Ectopic pregnancy is the major cause of maternal morbidity and mortality in the first trimester of pregnancy. Tubal ectopic pregnancy (TEP) accounts for nearly 98% of all ectopic pregnancies. TEP is usually associated with salpingitis but the underlying mechanism in salpingitis leading to TEP remains unclear. Adrenomedullin (ADM) is a peptide hormone abundantly expressed in the fallopian tube with potent anti-inflammatory activities. Its expression peaks at the early luteal phase when the developing embryo is being transported through the fallopian tube. In the present study, we demonstrated reduced expression of ADM in fallopian tubes of patients with salpingitis and TEP. Using macrophages isolated from the fallopian tubes of these women, our data revealed that the salpingistis-associated ADM reduction contributed to aggravated pro-inflammatory responses of the tubal macrophages resulting in production of pro-inflammatory and pro-implantation cytokines IL-6 and IL-8. These cytokines activated the expression of implantation-associated molecules and Wnt signaling pathway predisposing the tubal epithelium to an adhesive and receptive state for embryo implantation. In conclusion, this study provided evidence for the role of ADM in the pathogenesis of TEP through regulating the functions of tubal macrophages.

The effect of laparoscopic salpingectomy for ectopic pregnancy on ovarian reserve

BACKGROUND

Salpingectomy may damage ovarian reserve by direct vascular interruption to the ovary or thermal vascular injury from electrosurgery. It is plausible that this risk may increase in the context of salpingectomy conducted for ectopic pregnancy due to the distension of the fallopian tube and vascular changes associated with pregnancy.

AIM

To report anti-Müllerian hormone (AMH) concentrations before and after laparoscopic salpingectomy for ectopic pregnancy as an indicator of change in ovarian reserve.

MATERIALS AND METHODS

Women aged 18-44 years scheduled for salpingectomy for tubal ectopic pregnancy were prospectively recruited. Serum AMH concentrations were measured immediately prior to surgery, then repeated four months post-operatively. In all cases, salpingectomy was conducted laparoscopically using bipolar electrosurgery and mechanical scissors. A group of women scheduled for uterine curettage for first trimester miscarriage was recruited to ensure any observed change in AMH concentration in the women undergoing salpingectomy was secondary to surgery, rather than an effect of pregnancy.

RESULTS

Paired pre- and post-operative serum AMH concentrations were obtained from 32 women with tubal ectopic pregnancy. The mean age of the women was 33.6 ± 4.6 years. There was no significant difference in the median pre- and post-operative AMH concentrations (13.00 pmol/L (range 5-67 pmol/L) vs 15.25 pmol/L (range 3-96 pmol/L), P = 0.575). Median AMH concentrations also remained stable in women experiencing a first trimester miscarriage (10.40 pmol/L (range 3.9-37.8 pmol/L) vs 13.67 pmol/L (range 2.8-30.5 pmol/L), P = 0.185).

CONCLUSION

Laparoscopic salpingectomy using electrosurgery and mechanical scissors does not damage ovarian reserve. AMH concentrations do not fluctuate from baseline in the first trimester of pregnancy.

Extracellular Vesicles Mediated Early Embryo-Maternal Interactions

Embryo-maternal crosstalk is an important event that involves many biological processes, which must occur perfectly for pregnancy success. This complex communication starts from the zygote stage within the oviduct and continues in the uterus up to the end of pregnancy. Small extracellular vesicles (EVs) are part of this communication and carry bioactive molecules such as proteins, lipids, mRNA, and miRNA. Small EVs are present in the oviductal and uterine fluid and have important functions during fertilization and early embryonic development. Embryonic cells are able to uptake oviductal and endometrium-derived small EVs. Conversely, embryo-derived EVs might modulate oviductal and uterine function. In this review, our aim is to demonstrate the role of extracellular vesicles modulating embryo-maternal interactions during early pregnancy.

ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy

Ectopic pregnancy is defined as a pregnancy that occurs outside of the uterine cavity. The most common site of ectopic pregnancy is the fallopian tube. Most cases of tubal ectopic pregnancy that are detected early can be treated successfully either with minimally invasive surgery or with medical management using methotrexate. However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention. The purpose of this document is to review information on the current understanding of tubal ectopic pregnancy and to provide guidelines for timely diagnosis and management that are consistent with the best available scientific evidence.

A spontaneous bilateral tubal pregnancy: A case report

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.

Endometriosis and Beta-hCG > 775 IU/l Increase the Risk of Non-tube-preserving Surgery for Tubal Pregnancy

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.

Chemotherapy in the Emergency Department? There Is a Role for That: Methotrexate for Ectopic Pregnancy

Approximately 1.6% of all emergency department (ED) visits in the United States are for vaginal bleeding in early pregnancy, translating to around 500,000 ED visits per year. A potentially life-threatening condition, ectopic pregnancy occurs in 1.5%-2% of pregnancies. Many patients will require either surgical or pharmacological intervention following a positive diagnosis. With regard to pharmacological options, methotrexate, largely known for its use in the oncology arena, has emerged as the most effective nonsurgical option and the pharmacological agent of choice. However, this therapy is not without its own unique adverse event profile and patients should be adequately educated on the monitoring parameters of this pharmacotherapy.

Reduced Ectopic Pregnancy Rate on Day 5 Embryo Transfer Compared with Day 3: A Meta-Analysis

OBJECTIVE

To compare the risk of ectopic pregnancy (EP) after embryo transfer on day 3(D3-ET) and day 5(D5-ET).

DESIGN

Meta-analysis.

PATIENTS

Women with pregnancy resulting from in vitro undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

RESULT(S)

Twenty-two studies were identified through research conducted using the PubMed, Embase, and Cochrane databases and ClinicalTrials.gov. All studies were conducted prior to October 2016. Adding the reproductive data from our center, a total of 143 643 pregnancies were reviewed(D3-ET: n = 62027,D5-ET:n = 81616). A lower EP rate was found in women undergoing D5-ET than in those undergoing D3-ET [relative risk (RR), 0.67;95% confidence interval (CI), 0.54-0.85;143643 pregnancies in 23 studies; I2 = 67%]. These results were validated in subgroups of fresh embryo-transfer (Fre-ET) cycles [RR, 0.78; 95%CI, 0.69-0.88; 91 871 pregnancies in 21 studies; I2 = 29%] and frozen-thawed embryo-transfer (Fro-ET) cycles [RR, 0.43; 95%CI, 0.36-0.51; 51 772 pregnancies in 10 studies; I2 = 33%]. After separating out the randomized controlled trials (RCTs), a significant difference was found in the retrospective studies in both subgroups [both Fre-ET (RR,0.78;95% CI 0.69-0.88);91182 pregnancies in 14 studies; I2 = 45%] and Fro-ET(RR,0.43;95% CI 0.36-0.51; 51751pregnancies in 9 studies;I2 = 33%)], while the RCTs showed no statistical significance for Fre-ET cycles[RR,0.86;95% CI 0.32-2.26); 689 pregnancies in 7 studies; I2 = 0%].

CONCLUSION(S)

The present study indicates that D5-ET reduces the risk for EP in cycles that use IVF or ICSI, compared with D3-ET. It suggests that D5-ET may be a better choice for decreasing the EP rate in assisted reproductive technology. Further high-quality randomized controlled trials are anticipated.

The Diagnosis and Treatment of Ectopic Pregnancy

BACKGROUND

Extrauterine pregnancy is a complication of the first trimester of pregnancy that arises in 1.3-2.4% of all pregnancies.

METHODS

This review is based on articles and guidelines retrieved by a selective PubMed search.

RESULTS

The presentation of extrauterine pregnancy is highly variable, ranging from an asymptomatic state, to pelvic pain that is worse on one side, to tubal rupture with hemorrhagic shock. 75% of tubal pre gnancies can be detected by transvaginal ultrasonography. In patients with a vital extrauterine pregnancy, the human chorionic gonadotropin concentration generally doubles within 48 hours. Laparoscopy is the gold standard of treatment. Two randomized, controlled trials comparing organ-preserving treatment with ablative surgery revealed no significant difference in pregnancy rates after the intervention, but precise details of the surgical procedures were not provided, and long-term fertility data are lacking. Metho - trexate therapy should be used only for strict indications.

CONCLUSION

Further randomized, controlled trials with longer follow-up will be needed to answer currently open questions about the potential for individualized surgical treatment and the proper role of pharmacotherapy.

[Cornual pregnancy: Management and subsequent fertility]

OBJECTIVE

Cornual pregnancy is a rare entity, representing 2% of ectopic pregnancies. Its management is poorly codified and often guided by the clinical situation. The aim of our study was to describe the management of cornual pregnancies, subsequent fertility, and obstetric outcomes according to the management.

METHODS

Observational retrospective unicentric study. Nineteen patients hospitalized for cornual pregnancy between 2006 and 2015 were included. The data was collected with medical records and a phone standardized questionnaire. Patients were managed according to hemodynamic status by either systemic or local methotrexate injection or surgical corneal resection.

RESULTS

Among the 19 patients, 32% (6) were treated by systemic injection (one failure treated by surgical treatment) and 68% (13) underwent surgical treatment by cornual resection. The median HCG rate decrease was 33 days (16-62). Among the twelve patients with a desire for a new pregnancy, 7 (58%) became pregnant without assisted reproductive technology (2 following medical treatment and 5 following surgical resection). Histological analysis of uterine horn showed proximal fallopian tube lesions in 76.9% of case (chronic salpingitis, endosalpingiosis and adenomyosis).

CONCLUSION

Cornual pregnancies are at high risk of hemorrhagic rupture. Ectopic recidive may occur. Fertility and obstetrical outcomes following cornual pregnancy are not affected whatever the initial treatment. Other studies are needed to aid clinical management according to HCG level and ultrasound features.

Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review

BACKGROUND

Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar.

FINDINGS

Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality.

CONCLUSION

This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.

Elevated serum interleukin-1β levels and interleukin-1β-to-interleukin-1 receptor antagonist ratio 1 week after embryo transfer are associated with ectopic pregnancy

OBJECTIVE

To investigate whether interleukin-1β (IL-1β) and interleukin-1 receptor antagonist (IL-1RA) serum levels in the early luteal phase differ in IVF cycles that result in an ectopic pregnancy (EP) when compared with other outcomes.

DESIGN

Retrospective cohort.

SETTING

Not applicable.

PATIENT(S)

A total of 307 women whose serum samples were available, with the following IVF outcomes: 103 live births, 80 negative pregnancy tests, 52 biochemical pregnancies, 47 EPs, and 25 miscarriages.

INTERVENTION(S)

Serum samples were obtained on cycle days 24 and 28 (cycle day 14 = day of egg retrieval). Levels of IL-1β and IL-1RA were determined by quantitative ELISA performed by blinded personnel.

MAIN OUTCOME MEASURE(S)

IL-1β and IL-1RA levels, IL-1β-to-IL-1RA ratio versus cycle outcome.

RESULT(S)

The IL-1β levels were predictive of an EP. At cycle days 24 and 28 the mean IL-1β levels were higher in patients with an EP (127.1 pg/mL and 166.9 pg/mL, respectively) than in women with any other IVF outcome (15.8-55.3 pg/mL and 14.8-75.5 pg/mL, respectively). At cycle day 24 the IL-1β-to-IL-1RA ratio was 0.18 in the ectopic group versus 0.01-0.09 in the other groups.

CONCLUSION(S)

Elevated IL-1β levels and IL-1β-to-IL-1RA ratio as early as 4 days before the first pregnancy test are associated with an EP. If confirmed by prospective studies, clinical application of these findings could potentially improve EP detection.

Routine Monitoring of Liver, Renal, and Hematologic Tests After Single- or Double-Dose Methotrexate Treatment for Ectopic Pregnancies After In Vitro Fertilization

STUDY OBJECTIVE

To investigate the trends in liver function tests (LFTs), renal function tests (RFTs), and complete blood count (CBC) between day 1 and day 7 after single- or double-dose methotrexate (MTX) treatment for sonographically confirmed ectopic pregnancies.

DESIGN

Single center, retrospective chart review (Canadian Task Force classification II-3).

SETTING

University-affiliated center.

PATIENTS

All patients with a sonographically confirmed ectopic pregnancy after fresh in vitro fertilization-embryo transfer cycles between January 2004 and June 2013 treated with MTX were included.

INTERVENTIONS

Single- or double-dose MTX treatment.

MEASUREMENTS AND MAIN RESULTS

LFTs, specifically alanine aminotransferase (ALT), aspartate aminotransferase (AST), albumin, and total bilirubin levels, were measured on day of MTX administration (baseline) and 7 days later (day 7). Similar measurements of RFTs (blood urea nitrogen [BUN] and creatinine) and CBC (white blood cell [WBC] and platelets) were also performed. The change in LFTs, RFTs, and CBC (Δ) between baseline and day 7 was calculated for both single- and double-dose MTX protocols. Furthermore, the change in LFTs, RFTs, and CBC (Δ baseline vs day 7) for single- and double-dose MTX protocols were compared. Complete data was available for 107 patients: 89 (83.2%) and 18 (16.8%) patients received single- and double-dose MTX treatment, respectively. For either single- or double-dose treatment, no significant difference was found between baseline and day 7 ALT, AST, albumin, total bilirubin, BUN, creatinine, WBC, or platelet levels after MTX treatment. A comparison of post-treatment changes in LFTs, RFTs, and CBC (Δ baseline vs day 7) also showed no difference between single- and double-dose protocols.

CONCLUSION

Our study suggests that repeating LFTs, RFTs, or CBC on day 7 after single- or double-dose MTX treatment for sonographically confirmed ectopic pregnancies may not be necessary in patients with normal baseline testing on day 1.

Failure rate of single dose methotrexate in managment of ectopic pregnancy

Background. One of the treatment modalities for ectopic pregnancy is methotrexate. The purpose of this study is to identify the failure rate of methotrexate in treating patients with ectopic pregnancy as well as the risk factors leading to treatment failure. Methods. A retrospective chart review of 225 patients who received methotrexate as a primary management option for ectopic pregnancy. Failure of single dose of methotrexate was defined as drop of BHCG level less than or equal to 14% in the seventh day after administration of methotrexate. Results. 225 patients had methotrexate. Most of the patients (151 (67%)) received methotrexate based on the following formula: f 50 mg X body surface area. Single dose of methotrexate was successful in 72% (162/225) of the patients. 28% (63/225) were labeled as failure of single dose of methotrexate because of suboptimal drop in BhCG. 63% (40/63) of failure received a second dose of methotrexate, and 37% (23/63) underwent surgical treatment. Among patient who received initial dose of methotrexate, 71% had moderate or severe pain, and 58% had ectopic mass size of more than 4 cm on ultrasound. Conclusion. Liberal use of medical treatment of ectopic pregnancy results in 71% success rate.

Methotrexate success rates in progressing ectopic pregnancies: a reappraisal

OBJECTIVE

The purpose of this study was to determine the success rates of methotrexate in progressing ectopic pregnancies and to correlate them with beta-human chorionic gonadotropin (β-hCG) levels.

STUDY DESIGN

This retrospective cohort study that was carried out in a tertiary university-affiliated medical center included women who had been diagnosed with ectopic pregnancies between January 2001 and June 2013. Daily β-hCG follow-up examinations were performed to determine the progression of the ectopic pregnancy. Women with hemodynamically stable progressing ectopic pregnancies received methotrexate (50 mg/m(2) of body surface). We measured the success and failure rates for methotrexate treatment in correlation to β-hCG level.

RESULTS

One thousand eighty-three women were candidates for "watchful waiting" (β-hCG follow up). Spontaneous resolution and decline of β-hCG levels occurred in 674 patients (39.5%); 409 women (24.0%) had stable or increasing β-hCG levels and were treated with methotrexate. In 356 women (87.0%), the treatment was successful; 53 women (13.0%) required laparoscopic salpingectomy. Compared with prompt administration of methotrexate, our protocol resulted in lower overall success rates for all levels of β-hCG in women with progressing ectopic pregnancies: 75% in women with β-hCG levels of 2500-3500 mIU/mL, and 65% in women with β-hCG levels >4500 mIU/mL. A mathematic model was found describing the failure rates for methotrexate in correlation with β-hCG levels.

CONCLUSION

The success rates for methotrexate treatment in progressing ectopic pregnancies after daily follow-up evaluation of β-hCG levels are lower than previously reported. This reflects redundant administration of methotrexate in cases in which the ectopic pregnancy eventually will resolve spontaneously.

MicroRNA and implantation

We provide a review of microRNA (miRNA) related to human implantation which shows the potential diagnostic role of miRNAs in impaired endometrial receptivity, altered embryo development, implantation failure after assisted reproduction technology, and in ectopic pregnancy and pregnancies of unknown location. MicroRNAs may be emerging diagnostic markers and potential therapeutic tools for understanding implantation disorders. However, further research is needed before miRNAs can be used in clinical practice for identifying and treating implantation failure.

Synthetic cannabinoids and potential reproductive consequences

Increases in emergency room visits due to abuse of designer drugs, popularly known by the street names "K2" and "Spice," are a cause for social, judicial, and clinical concerns. The psychoactive components in these herbal drugs mainly consist of different synthetic cannabinoids, and users of these street drugs are primarily within the age group of 12 to 20years old. The abusive use of synthetic cannabinoids results in anxiety, nausea, vomiting, tachycardia, elevated blood pressure, tremors, seizures, hallucinations, and paranoid behavior, but the effects of maternal use of synthetic cannabinoids during pregnancy are ambiguous due to limited studies in humans and a relative short history of the drugs. In this review, we discuss the known and potential adverse effects of synthetic cannabinoids on human pregnancy using knowledge gathered from studies in mice and limited studies in humans. In mice, multiple sites and stages of pregnancy are potential targets of synthetic cannabinoids, including preimplantation embryo development, oviductal embryo transport, implantation, placentation, and parturition. It is anticipated that maternal use of synthetic cannabinoids would result in severely compromised female fertility and pregnancy outcome.

Effect of methotrexate on neuroepithelium in the rat fetal brain

Pregnant rats were treated with 30 mg/kg of methotrexate (MTX) on gestation day 13, and fetal brains were examined histopathologically from 6 to 48 hr after the treatment. In the telencephalon of the control group, there were few pyknotic neuroepithelial cells throughout the experimental period. Six hr after MTX treatment, several pyknotic neuroepithelial cells scattered throughout the telencephalic wall. At 12–36 hr, pyknotic neuroepithelial cells increased significantly and were diffusely distributed throughout the telencephalic wall. Neuroepithelial cells were eliminated and showed sparse cell density at 36 hr in the telencephalon. Almost all fetuses died at 48 hr. Most of the pyknotic neuroepithelial cells were positively stained by the TUNEL method and positive for cleaved caspase-3. While mitotic and phospho-histone H3-positive neuroepithelial cells were located along the ventricular layer of telencephalon in the control group, they were rarely observed in the same region at 6–36 hr in the MTX-treated group. MTX induced few pyknotic changes to neuroepithelial cells in the metencephalon, compared to other parts of brain. The distribution of apoptotic neuroepithelial cells and the time-course changes of the indices of apoptotic and mitotic neuroepithelial cells were different from those of other DNA-damaging chemicals reported previously. The difference may reflect the disparity in mechanisms of apoptosis and the inhibition of cell proliferation in neuroepithelial cells induced by MTX. To our knowledge, this is the first report demonstrating histopathological findings of fetal brain damage induced by MTX.

Risk of ectopic pregnancy following day-5 embryo transfer compared with day-3 transfer

The incidence of ectopic pregnancy after IVF is increased approximately 2.5-5-fold compared with natural conceptions; however, the aetiology for this increased risk remains unclear. One proposed practice change to decrease the incidence of ectopic pregnancy is blastocyst embryo transfer on day 5 rather than cleavage-stage embryo transfer on day 3. A retrospective cohort study was conducted to compare the risk of ectopic pregnancy following fresh day-5 embryo transfer with day-3 embryo transfer among women who underwent IVF and achieved pregnancy from 1998 to 2011. There were 13,654 eligible pregnancies; 277 were ectopic. The incidence of ectopic pregnancy was 2.1% among day-3 pregnancies and 1.6% among day-5 pregnancies. The adjusted risk ratio for ectopic pregnancy from day-5 compared with day-3 transfer was 0.71 (95% confidence interval 0.46-1.10). Although this analysis included 13,654 cycles, with a two-sided significance level of 0.05, it had only 21.9% power to detect a difference between the low incidence of ectopic pregnancy among both day-3 and day-5 transfers. In conclusion, this study was not able to demonstrate a difference in the risk of ectopic pregnancy among day-3 compared with day-5 transfers.

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.

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.