Treatment, failures and complications of ectopic pregnancy: changes over a 20 year period

Prognostic factors for spontaneous resolution of an ectopic pregnancy

OBJECTIVE

To identify factors that can accurately predict the spontaneous resolution of an ectopic pregnancy.

STUDY DESIGN

This retrospective cohort analysis was conducted in the Department of Gynecology of a tertiary, university-affiliated medical center. Patients admitted to the center from January 2015 to July 2022 with a tubal ectopic pregnancy who met the criteria for expectant management were included. Beta-human chorionic gonadotropin (ß-hCG) levels were assessed at admission and at subsequent 24-hour intervals. Patients with declining levels were discharged for routine ambulatory ß-hCG follow-up until levels became undetectable. Patients who achieved a successful outcome were designated as the "spontaneous resolution group," while patients who underwent further hospitalization for methotrexate or surgery constituted the" failure group". Demographic, clinical, laboratory, and ultrasound parameters collected at first admission were compared between groups.

RESULTS

Among the initial group of 210 eligible patients, 7 were lost to follow-up, 161 achieved spontaneous resolution, and 42 were readmitted for active intervention. Multivariate logistic regression analysis revealed that the last ß-hCG level before discharge (last ß-hCG) and the ratio between ß-hCG at discharge to ß-hCG at admission were the only independent parameters to predict outcomes. Patients with ß-hCG < 650 IU/L at discharge and a decline of 50% or more in ß-hCG level during hospitalization, had a 97% success rate with expectant management. Patients with ß-hCG discharge levels ≥ 1,000 IU/L had a 50% chance of success, regardless of whether their ß-hCG levels had declined. For all other patients, a 76% success rate was found.

CONCLUSION

Short-term, serial ß-hCG follow-up at the initial presentation can help predict the spontaneous resolution of an ectopic pregnancy.

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

Background:

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

Method:

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

Results:

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

Conclusion:

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

Beyond Guidelines: Effectiveness of a Programme in Achieving Operative Laparoscopy for all Women Requiring Surgical Management of Ectopic Pregnancy

BACKGROUND/AIMS

Operative laparoscopy (OL) is considered the gold standard surgical treatment of ectopic pregnancy (EP). We questioned whether a training programme to foster OL treatment is able to ensure that all women needing surgical management are treated by OL irrespective of the site of EP, haemodynamic status and clinical complexity.

METHODS

A 13-year cohort study of 963 women who underwent surgical management was conducted. We instituted a 'universal OL' programme in 2003 for the management of all the types of EP irrespective of the haemodynamic status.

RESULTS

There were 802 women in the prospective (2003-2013) and 161 in the retrospective arm (2000-2002). The rate of OL before 2003 was 34%. During the year of programme implementation, the OL rate rose from 89% in 2003 to 96% in 2004. It took 4 years to achieve a 100% OL rate in haemodynamically stable patients. In 2013, we were able to achieve OL treatment for all patients irrespective of haemodynamic status, the complexity of surgery or the location of EP.

CONCLUSION

Our study demonstrates that a dedicated team with special training in minimal invasive surgery can improve surgical management of all categories of EPs, and this goal should be achievable across most units.

A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy

OBJECTIVE

To compare single dose systemic methotrexate (50 mg/m2) with laparoscopic surgery for the treatment of unruptured tubal pregnancy.

DESIGN

An open, pragmatic, prospective randomised trial.

SETTING

Departments of obstetrics and gynaecology at three hospitals in Auckland, New Zealand.

PARTICIPANTS

Clinically stable women with an unruptured tubal pregnancy diagnosed by transvaginal ultrasound and quantitative serum beta-hCG measurement. Inclusion criteria included a serum beta-hCG concentration < 5,000 IU/L, and a tubal pregnancy of < 3.5 cm diameter.

MAIN OUTCOME MEASURES

Treatment success, physical and psychological functioning, side effects, and subsequent ipsilateral tubal patency.

RESULTS

Two hundred and eighteen women with ectopic pregnancies were seen at the three hospitals. 79 women (36% eligibility rate) were eligible for trial entry and 62 women (78% recruitment rate) were recruited. Twenty-six of the 28 women (93%) randomised to laparoscopic surgery required no further treatment, compared with 22 of the 34 women (65%) randomised to methotrexate (95% CI of difference in success rate 10 - 47%; P < 0.01). Two women (7%) in the laparoscopic surgery group had persistent trophoblast. Nine women (26%) in the methotrexate group required more than one dose of methotrexate and five women (15%) underwent laparoscopy during follow up. In the laparoscopy group three women (11%) had negative laparoscopies and two women (7%) had were found to have a ruptured fallopian tube at the time of surgery. Women treated with methotrexate had significantly better objective physical functioning scores but there were no differences in any other psychological outcomes. Women treated with methotrexate experienced greater and more prolonged vaginal bleeding. The likelihood of methotrexate treatment failure was greater at higher serum beta-hCG concentrations. Ipsilateral tubal patency rates were similar in each group.

CONCLUSION

This trial shows that in the treatment of tubal pregnancy single dose systemic methotrexate is a less effective treatment than laparoscopic salpingotomy. It is well tolerated, but should only be offered as an alternative to surgery to women who have mild symptoms and present at low serum beta-hCG concentrations. In our population this likely to be no more than a quarter of women presenting with a tubal pregnancy.

Surgical and medical management of tubal and non-tubal ectopic pregnancies

This article highlights recent findings in the diagnosis and management of ectopic pregnancy. While the search for the ideal biochemical marker for ectopic pregnancy continues, new protocols have been described for the management of persistent ectopic pregnancy. The role of nuclear marker Ki-67 in trophoblastic proliferation and the only randomized trial to date involving systemic methotrexate and laparoscopic surgery are discussed. The management of cervical, interstitial and heterotopic pregnancies are reviewed.