Methotrexate or expectant management in women with an ectopic pregnancy or pregnancy of unknown location and low serum hCG concentrations? A randomized comparison

Comparison of the success rates of a single dose and an additional dose of methotrexate on the 4th day in patients whose β-hCG values do not fall after a single dose of methotrexate (Day 0-4)

INTRODUCTION

This study's aim is to investigate whether the rise in β-hCG levels between days 0 and 4 in patients with tubal ectopic pregnancy who have received a single dose of methotrexate has prognostic value in treatment success, and to investigate whether administering a second dose on day 4 enhances treatment success.

MATERIAL AND METHODS

Patients diagnosed with ectopic pregnancy and experiencing an increase in β- hCG levels on day 4 after initiation of methotrexate treatment were included in our study. Patients treated with a single dose Methotrexate (MTX) protocol until December 2019 were retrospectively screened from January 2018 to December 2019. Patients receiving a second dose on day 4 until September 2021 were prospectively enrolled from January 2020 to September 2021. A decrease of over 15 % in the β-hCG value after the 4th dose was considered as treatment success.

RESULTS

Treatment success rates were compared between these two groups. 115 patients with ectopic pregnancy were included in the study. A single dose methotrexate protocol was applied in 67 of the patients (Group 1), while an additional dose methotrexate was applied in 48 (Group 2). The treatment was successful in 40 patients (59.7 %) in Group 1 and in 39 patients (81.3 %) in Group 2. The success rate of the treatment was significantly higher in patients who received an additional dose methotrexate protocol (p = 0.014).

DISCUSSION

This study shows that; it is possible to increase success rates by applying an additional MTX dose on the 4th day in cases with an increase in β-hCG on the 4th day.

Can failure be predicted in methotrexate treatment with the modified parameter?

OBJECTIVE

The objective of the study was to increase the prediction of success of single-dose methotrexate therapy in ectopic pregnancy patients with modified parameters obtained from complete blood count and beta-human chorionic gonadotropin (β-hCG) parameters. In this way, it was aimed to predict patients whose methotrexate treatment may fail and rupture, to avoid unnecessary methotrexate treatment, to shorten the duration of hospital stay and to reduce patient mortality.

MATERIALS AND METHODS

233 patients diagnosed with ectopic pregnancy between January 1, 2017, and March 01, 2022, in the obstetrics and gynecology service of a tertiary center were included in the study.

RESULTS

The mean of β-hCG was 1976 in the methotrexate group and 2358 in the surgery group (p < 0.05). The ROC curve determined the effect of BW (β-hCGxWBC/1000) and BP (β-hCGx1000/PLT) markers in diagnosing patients who will need surgery in ectopic pregnancy. The areas under the ROC curve for β-hCG, BW and BP were 0.86, 0.99 and 0.94, respectively (p < 0.05). β-hCG > 2139.03, BW > 30.96 and BP > 10.17 values were significantly associated with the need for surgery in ectopic pregnancy patients (p < 0.05). Logistic regression analysis revealed that a 1-unit increase in BP caused a statistically significant 1.77-fold increase in surgical need in patients with ectopic pregnancy. In contrast, a 1-unit increase in BW caused a 2.34-fold increase in surgical need (p < 0.05).

CONCLUSION

The study results showed that BW and BP values together with β-hCG are effective in predicting ectopic pregnancy patients who may undergo surgery.

β-Human Chorionic Gonadotropin Dynamics in Early Gestational Events: A Practical and Updated Reappraisal

In the last decade, the widespread use of transvaginal ultrasound and the availability of highly specific serum assays of human chorionic gonadotropin (hCG) have become mainstays in the evaluation of early pregnancy. These tests have revolutionized the management of pregnancies of unknown location and markedly reduced the morbidity and mortality associated with the misdiagnosis of ectopic pregnancy. However, despite several advances, their misuse and misinterpretations are still common, leading to an increased use of healthcare resources, patient misinformation, and anxiety. This narrative review aims to succinctly summarize the β-hCG dynamics in early gestation and provide general gynecologists a practical approach to patients with first-trimester symptomatic pregnancy.

Expectant management versus systemic methotrexate in the management of persistent pregnancy of unknown location, a seven-year retrospective analysis

PURPOSE

To compare Expectant management to systemic methotrexate in the management of persistent pregnancy of unknown location with beta-hCG levels below the discrimination zone.

METHODS

A retrospective cohort study was conducted on 71 women with persistent pregnancy of unknown location. They were divided into two groups according to the applied management; Group 1, (n = 40) who were managed expectantly and Group 2 (n = 31) who were given a single dose of methotrexate. Data variables were collected and analyzed to evaluate whether expectant management was as effective as methotrexate.

RESULTS

There was no significant difference between the two groups regarding age, parity, gestational age, body mass index and day seven beta-hCG. Success rates were (32 patients (80%) and 28 patients (90.3%) in expectant management and methotrexate groups, respectively (P > 0.05). The mean values for day zero and day four beta-hCG were significantly higher and the mean duration for complete recovery was statistically shorter in the methotrexate group (P < 0.05). There were no significant differences between the two groups regarding prior ectopic, percentage of beta-hCG level drop on day four and day seven, success rate, occurrence of sequelae and patient satisfaction that area under the curve (AUC) for group 1 (expectant management) is 0.566 at 95% Confidence Interval of (0.388: 0.745).

CONCLUSION

Expectant management is an effective and safe alternative to single-dose methotrexate for persistent PUL with beta-hCG levels below the discrimination zone.

The impact of systemic methotrexate and surgical management on fertility preservation in tubal ectopic pregnancy among Saudi women

BACKGROUND

The impact of various management plans on subsequent fertility after tubal ectopic pregnancy (EP) is not well known. The objective of the present study was an evaluation of the subsequent fertility outcome among women with EP managed either surgical or medical with systemic methotrexate or medical management followed by surgical one.

PATIENTS AND METHODS

A retrospective cohort study was done by reviewing of medical records of all women diagnosed with EP at King Faisal Military Hospital, Southern Region, Saudi Arabia throughout the period from January 2015 to December 2016 provided that they were hemodynamic stable, with starting βhCG level less than 10000 IU/L, and adnexal mass less than 5 cm. These cases were followed for four years from January 2017 to December 2020.

RESULTS

The study included 85 women with EP. Their mean age was 31.3 ± 6.7 years. Medical management (systemic Methotrexate) was followed in 48.2% of cases whereas surgical management was applied for 43.5% of them while medical management followed by surgical one was seen in 8.2% of cases. Complete follow-up throughout 2017-2020 was available for 52 women. A history of recurrent EP was observed among 3 women (5.8%). Most of them (75%) had a viable pregnancy. There was no statistically significant association between the method of management of EP and subsequent fertility, although the rate of normal pregnancy (intrauterine viable pregnancy ≥ 24 weeks which is the age of viability at our hospital) was higher among those managed surgically or by medical followed by surgical management than those managed medical only (84.6% and 100% vs. 62.5%).

CONCLUSION

Although the normal pregnancy rate was higher among those managed surgically or by medical followed by surgical management than those managed medically only, this was not statistically significant.

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.

Methotrexate vs expectant management for treatment of tubal ectopic pregnancy: An individual participant data meta-analysis

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.

Early (Days 1-4) post-treatment serum hCG level changes predict single-dose methotrexate treatment success in tubal ectopic pregnancy

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).

Have we overlooked the role of mifepristone for the medical management of tubal ectopic pregnancy?

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.

Apoptosis versus necrosis in tubal ectopic pregnancies following Methotrexate

Methotrexate administration for the treatment of tubal ectopic pregnancies has been shown to cause tubal mass enlargement. Our hypothesis was that, by administrating Methotrexate, a local necrotic reaction occurs, leading to hematoma formation and eventually fallopian tube rupture. Salpingectomy specimens were collected, analysed and divided into three equal groups: patients who received Methotrexate but who ultimately failed medical treatment, patients who had a viable ectopic pregnancy and patients with a self-resolving ectopic pregnancy that were operated due to other medical indications. The specimens were dyed using the Cleaved Caspase-3 (Asp175) Rabbit mA. Specimens were divided into three equal groups and analysed. The patients in self-resolving ectopic pregnancy group were older and had more pregnancies. Rates of apoptosis were found to be less than 1% per slide. Necrosis was not evident in any of the pathological specimens. It seems Methotrexate administration does not lead to a significant tubal necrotic reaction. Further studies are required.

Gestörte Frühgravidität

Eine Schwangerschaft kann intrauterin, ektop oder an einem unklaren Ort liegen und entwicklungsphysiologisch vital oder gestört sein. Die transvaginale Sonographie ermöglicht die Darstellung einer intrauterinen Schwangerschaft ab einem Schwellenwert des humanen Choriongonadotropins (hCG) von 1000 IU/l in der etwa sechsten Schwangerschaftswoche (SSW). Ektope Schwangerschaften sind abhängig von der SSW gegebenenfalls erschwert sonographisch erkennbar. Der Verlauf des hCG-Werts kann hilfreich dabei sein, eine physiologische von einer gestörten Frühschwangerschaft zu unterscheiden, muss aber immer in Zusammenschau mit der Klinik und dem Ultraschallbefund interpretiert werden. Bei einem frühen Abort kann abhängig von der Klinik exspektativ oder medikamentös vorgegangen werden. Die Indikation zur Kürettage sollte insgesamt zurückhaltend gestellt werden. Bei einer ektopen Schwangerschaft sollte abhängig von SSW und Klinik eine operative Therapie oder eine Methotrexattherapie durchgeführt werden.

Non-surgical management of tubal ectopic pregnancy: A systematic review and meta-analysis

BACKGROUND

Ectopic pregnancy (EP) is a common cause of acute abdominal pain in the field of gynecology. Because the majority of women with EP are hemodynamically stable, non-surgical therapy is a viable option. The goal of this study was to determine the most effective non-surgical therapy for hemodynamically stable EP.

METHODS

We performed a systematic review and meta-analysis. We searched PubMed, LILACS, SciELO, CINAHL, Embase, and the Cochrane library in May 2020, with no starting date restrictions.Studies were restricted to randomized controlled trials, which were included if the target population contained women with tubal EP and the intervention was non-surgical management. The primary outcome measure was treatment success defined by a decrease in serum hCG to a level ranging from five mIU/mL to 50 mIU/mL. Secondary outcome measures were side effects, time needed to treat, number of injections and operative rate.

RESULTS

We conducted a meta-analysis of 15 studies that included 1573 women who were diagnosed with EP and managed non-surgically. There was no significant difference in treatment success in the matched groups; however, single-dose MTX was associated with fewer side effects than multiple-dose (relative risk 0.48, 95% confidence interval 0.28-0.80, P = .006) and two-dose therapies (relative risk 0.74, 95% confidence interval 0.55-1.00, P = .05).

CONCLUSIONS

We highly recommend that single-dose MTX without mifepristone be used first-line in patients who require conservative therapy due to the inherent negative effects of mifepristone. An EP woman with a low -hCG level that is falling or plateauing should receive expectant treatment to reduce adverse effects.

Management of early gestations with low beta-human chorionic gonadotropin conceived by assisted reproductive technologies: performance of M4 predictive model

OBJECTIVES

To assess the safety and performance of the M4 model for classifying as high risk or low risk for ectopic pregnancy (EP) pregnancies conceived by assisted reproductive technologies (ART) that present with low beta-human chorionic gonadotropin (β-hCG) concentration in early gestation.

METHODS

This was a prospective cohort study of 243 pregnancies conceived by ART with low β-hCG levels (5-50 IU/L) at 4 + 0 to 4 + 2 weeks' gestation. After subsequent β-hCG testing at 48 h, pregnancies were classified according to the M4 model into the following categories: (i) high risk, probable EP/persistent pregnancy of unknown location (PPUL), when the risk for EP was ≥ 5%; (ii) low risk, probable intrauterine pregnancy (IUP), when the risk of EP was < 5% and the likelihood of IUP was greater than that of a failed pregnancy of unknown location (FPUL); and (iii) low risk, probable FPUL, when the risk of EP was < 5% and the likelihood of a FPUL was greater than that of an IUP. The predictive performance of the M4 model for EP and its ability to discriminate between high- and low-risk pregnancies was assessed using the final pregnancy outcome at 11 to 13 weeks of gestation as reference, which was classified as EP/PPUL, FPUL or IUP.

RESULTS

The sensitivity and specificity of the M4 model in detecting a high-risk pregnancy (EP/PPUL) were 60.0% (95% CI, 43.6-74.4%) and 79.8% (95% CI, 73.8-84.7%), respectively. The area under the receiver-operating-characteristics curve of the M4 model for discriminating between high-risk and low-risk (FPUL/IUI) pregnancies was 0.72 (95% CI, 0.62-0.81). The model had a positive likelihood ratio of 2.97 (95% CI, 2.03-4.36) and a negative likelihood ratio of 0.50 (95% CI, 0.33-0.76). The kappa index was 0.30 (95% CI, 0.16-0.43), indicating a low degree of agreement between the model classification and the final diagnosis. No serious adverse events related directly to the application of the M4 model were observed, although 14 pregnancies classified ultimately as high risk had been categorized initially as low risk by the M4 model. Of these, seven resolved with expectant management, five with methotrexate (MTX) and two required laparoscopic surgery (one after failure of medical treatment with MTX and one after deviation from the follow-up protocol). There were no cases of EP/PPUL with additional complications or need for blood or other blood product transfusion. Of the 243 ART pregnancies with low β-hCG concentration in early gestation, only 47 (19.3%) had an IUP, half (24/47) of which had an early miscarriage, resulting in only 9.5% (23/243) cases having an ongoing pregnancy.

CONCLUSIONS

Application of the M4 model in pregnancies conceived by ART with low β-hCG concentration in early gestation showed limited capacity in classifying them as being at low or high risk for EP, therefore, its use in pregnancies of this type is not recommended. No serious adverse events or complications related to the use of the model were observed. These pregnancies have a low probability of ending in an IUP as well as a high rate of early miscarriage. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Management of tubal ectopic pregnancy with methotrexate in the setting of symptomatic Coronavirus disease 2019 (COVID-19): A case report

Background

Coronavirus Disease 2019 (COVID-19) represents a complex therapeutic challenge. As the pandemic progresses, patients are presenting with ectopic pregnancies (EPs) and symptomatic COVID-19.

Objective

We present the management of a patient with multiple medical comorbidities and tubal EP in the setting of severe symptomatic COVID-19 infection where all management options were precluded.

Methods

Case report with literature review of management of tubal EP in the setting of severe symptomatic COVID-19 infection.

Result

After careful consideration of options, the patient underwent successful medical management with methotrexate while receiving supportive care for COVID-19.

Conclusions

Methotrexate proved to be the safest therapeutic option in this patient. Management of patients with severe COVID-19 and gynaecologic emergencies should be individualised and carefully reviewed with evolving knowledge of COVID-19.

Methotrexate versus expectant management in ectopic pregnancy: a meta-analysis

BACKGROUND

Ectopic pregnancy (EP) affects 1-2% of all pregnant females'(Barnhart et al., Expert Opin Pharmacother 2(3):409-417, 2001) that can require emergent surgical intervention. Noninvasive diagnostic tests like transvaginal ultrasound (TVUS), and serial β-hCG levels have enabled early diagnosis and allowed medical therapy to be tried. Methotrexate (MTX) versus expectant management, both have been considered safe but superiority of one over the other is lacking.

METHODS

We searched for RCT that have shown efficacy of MTX versus expectant management in hemodynamically stable patients. Our primary outcome was whether one modality is superior to the other.

RESULTS

Four RCT were included in the meta-analysis after review. Our pooled analysis when comparing MTX and expectant management showed us that the difference between the uneventful decline in β-hCG levels (treatment success) was statistically insignificant (RR = 1.06, 95% CI 0.93-1.21) with no significant heterogeneity between trials (I² = 0.0%, P = 0.578). The difference between need for surgical intervention between methotrexate and expectant management was also statistically insignificant (RR = 0.77, 95% CI 0.43-1.40) with no significant heterogeneity between trials (I² = 0.0%, P = 0.552).

CONCLUSION

We conclude that expectant management is not inferior to MTX in hemodynamically stable patients with ectopic pregnancy that have declining or low β-hCG levels.

Effect of an Active vs Expectant Management Strategy on Successful Resolution of Pregnancy Among Patients With a Persisting Pregnancy of Unknown Location: The ACT or NOT Randomized Clinical Trial

IMPORTANCE

Women with an early nonviable pregnancy of unknown location are at high risk of ectopic pregnancy and its inherent morbidity and mortality. Successful and timely resolution of the gestation, while minimizing unscheduled interventions, are important priorities.

OBJECTIVE

To determine if active management is more effective in achieving pregnancy resolution than expectant management and whether the use of empirical methotrexate is noninferior to uterine evacuation followed by methotrexate if needed.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter randomized clinical trial recruited 255 hemodynamically stable women with a diagnosed persisting pregnancy of unknown location between July 25, 2014, and June 4, 2019, in 12 medical centers in the United States (final follow up, August 19, 2019).

INTERVENTIONS

Eligible patients were randomized in a 1:1:1 ratio to expectant management (n = 86), active management with uterine evacuation followed by methotrexate if needed (n = 87), or active management with empirical methotrexate using a 2-dose protocol (n = 82).

MAIN OUTCOMES AND MEASURES

The primary outcome was successful resolution of the pregnancy without change from initial strategy. The primary hypothesis tested for superiority of the active groups combined vs expectant management, and a secondary hypothesis tested for noninferiority of empirical methotrexate compared with uterine evacuation with methotrexate as needed using a noninferiority margin of -12%.

RESULTS

Among 255 patients who were randomized (median age, 31 years; interquartile range, 27-36 years), 253 (99.2%) completed the trial. Ninety-nine patients (39%) declined their randomized allocation (26.7% declined expectant management, 48.3% declined uterine evacuation, and 41.5% declined empirical methotrexate) and crossed over to a different group. Compared with patients randomized to receive expectant management (n = 86), women randomized to receive active management (n = 169) were significantly more likely to experience successful pregnancy resolution without change in their initial management strategy (51.5% vs 36.0%; difference, 15.4% [95% CI, 2.8% to 28.1%]; rate ratio, 1.43 [95% CI, 1.04 to 1.96]). Among active management strategies, empirical methotrexate was noninferior to uterine evacuation followed by methotrexate if needed with regard to successful pregnancy resolution without change in management strategy (54.9% vs 48.3%; difference, 6.6% [1-sided 97.5% CI, -8.4% to ∞]). The most common adverse event was vaginal bleeding for all of the 3 management groups (44.2%-52.9%).

CONCLUSIONS AND RELEVANCE

Among patients with a persisting pregnancy of unknown location, patients randomized to receive active management, compared with those randomized to receive expectant management, more frequently achieved successful pregnancy resolution without change from the initial management strategy. The substantial crossover between groups should be considered when interpreting the results.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02152696.

Diagnosis and Management of Ectopic Pregnancy: A Comparative Review of Major National Guidelines

Importance

Ectopic pregnancies (EPs) represent a severe early pregnancy complication that is associated with increased risks of maternal morbidity and mortality. Over the years, there has been a significant reduction in the mortality from this complication by improving the diagnostic tools and the treatment options.

Objective

The aim of this study was to review and compare the recommendations from published guidelines on this potentially fatal condition.

Evidence Acquisition

A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence on EP was carried out.

Results

All the guidelines point out the crucial role of sonography in the prompt diagnosis of EP and describe similar sonographic findings. There is a consensus on the indications and contraindications to the use of methotrexate, the post-treatment surveillance, and the criteria of expectant management. The indications for a surgical approach are not well established, although the Royal College of Obstetricians and Gynaecologists, the Royal College of Physicians of Ireland, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence agree that a laparoscopy is preferred to laparotomy for hemodynamically stable patients. The latter is considered a better option only in emergency conditions. However, there is controversy in the recommended methotrexate protocols and the evaluation of β-human chorionic gonadotrophin and progesterone levels.

Conclusion

It is of paramount importance to build consistent international protocols, so as to help clinicians all over the world diagnose EPs in the most timely and accurate way and subsequently treat them effectively as a nonurgent medical condition, with the intention to lower the mortality and morbidity rate.

Evaluating the agreement of ultrasound imaging and beta-human chorionic gonadotropin (β-hCG) measurement in confirming completed medical abortion: cross-sectional study

Objective: Clinical methods that are generally used to evaluate the completeness of medical abortion are not reliable. Ultrasound imaging and beta-human chorionic gonadotropin (β-hCG) measurements are used to diagnose completed medical abortion, but a precise evaluation of these two methods has shown contradictory results. The purpose of this study is to evaluate the agreement of serum β-hCG measurement and ultrasound imaging to confirm complete medical abortion.

Materials and Methods: This study was conducted on pregnant women who had been referred to our center for medical abortion from 2015 to 2017. All cases occurred in the first trimester of pregnancy. They obtained one or two doses of vaginal misoprostol for medical abortion. Success rate of medical abortion was measured by both transvaginal ultrasound imaging and consecutive serum β-hCG measurements two to four weeks after initial treatment.

Results: Among the 275 women who completed the study, complete medical abortion was confirmed by serum β-hCG in 231 women (84.3%) and transvaginal ultrasound imaging in 195 women (70.8%) after two weeks. All remaining cases completed the medical abortion after an additional two weeks, confirmed by both transvaginal ultrasound imaging and serum β-hCG. The sensitivity, specificity, positive, and negative predictive values of β-hCG were 95.2%, 86.7%, 84%, and 70%, respectively; and these values for transvaginal ultrasound imaging were 68.5% 64.5%,77%, and 30.%, respectively, for the diagnosis of completed medical abortion.

Conclusion: Serum β-hCG measurement is as effective as transvaginal ultrasound imaging to confirm successful medical abortion in early pregnancy.

An Audit of Management of Ectopic Pregnancy in a Major Tertiary Healthcare Service

Background: Ectopic pregnancy remains the most common cause of early pregnancy mortality, with management options differing according to clinical presentation and investigations. This audit aims to investigate the indications for medical and surgical management of ectopic pregnancy at a tertiary hospital network, in order to assess variances in practice and adherence to local hospital protocols.

Methods: A retrospective audit of the management of women with a diagnosis of ectopic pregnancy was performed over 12 months from July 2018 to June 2019, at three hospitals in the largest healthcare network in Victoria, Australia. Information collected included patient demographics, risk factors for ectopic pregnancy, pathology and radiology results, documented indication for surgery, and any complications of treatment. A subgroup analysis of data was done to investigate changes and deficiency in management of ectopic pregnancy compared to local hospital protocol.

Results: Over a 12-month period, 138 women were diagnosed with an ectopic pregnancy, of which 99 (72%) received surgical management and 39 (28%) received medical management. Four women within the medical group were excluded from analysis, one due to loss of follow-up and three patients who were diagnosed with nontubal ectopic pregnancies. About 94% (33/35) of women who received methotrexate were within hospital guidelines for medical management and 91% (32/35) were successfully managed without surgery. All women who received surgical management underwent a salpingectomy and 97% (96/99) had clear indications documented for surgery within local protocol.

Conclusion: Overall, the majority of women with ectopic pregnancy were treated according to local guidelines. Expectant management and the option of salpingostomy as a surgical alternative could be considered in the local guidelines. The dissemination of this clinical audit data is aimed at continuing clinical governance and improvements in outcomes.

Recurrent Tubal Ectopic Pregnancy Management and the Risk of a Third Ectopic Pregnancy

STUDY OBJECTIVE

To evaluate the rate of a third ectopic pregnancy according to the modality of treatment of the second ectopic pregnancy.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated tertiary medical center.

PATIENTS

One hundred eleven women who had 2 ectopic pregnancies and a third consecutive pregnancy between 2003 and 2018.

INTERVENTIONS

Surgery or medical treatment as required.

MEASUREMENTS AND MAIN RESULTS

With regard to the modality of treatment of the second ectopic pregnancy, the patients were divided into 3 groups: expectant management, medical treatment with methotrexate, and laparoscopic salpingectomy. Univariate and multivariate analyses were conducted to assess the association of various parameters of the second ectopic pregnancy with the occurrence of a third ectopic pregnancy in the consecutive pregnancy. Twenty women (18.0%) were managed expectantly, 55 (49.6%) were treated with methotrexate, and 36 (32.4%) underwent surgery. Expectant management resulted in significantly higher rates of a third ectopic pregnancy compared with treatment with methotrexate or surgical intervention (50.0% vs 18.2% and 13.8%, respectively; p = .005). In the cases of 2 ipsilateral ectopic pregnancies, the interventional approach (medical or surgical treatment) resulted in lower recurrence rates compared with expectant management (25.7% vs 60.0%, respectively; p = .043).

CONCLUSION

The risk of a third episode of an ectopic pregnancy after expectant management of a second ectopic pregnancy is extremely high. An interventional approach by treatment with methotrexate or salpingectomy is therefore preferred for recurrent ectopic pregnancy management, especially in ipsilateral recurrences.

Efficacy and safety of expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis

STUDY QUESTION

Is expectant management (EM) of tubal ectopic pregnancy (EP) an effective and safe treatment strategy when compared to alternative interventions?

SUMMARY ANSWER

There is insufficient evidence to conclude EM yields a difference in the resolution of tubal EP, the avoidance of surgery or time to resolution of tubal EP when compared to intramuscular methotrexate in stable patients with β-hCG <1500 IU/l.

WHAT IS ALREADY KNOWN

The utilisation of medical and surgical management for EP is well established. EM aims to allow spontaneous resolution of the EP without intervention.

STUDY DESIGN SIZE AND DURATION

We performed a systematic review and meta-analysis, searching Ovid MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, OpenGrey.eu, Google Scholar, cross-referencing citations and trial registries to 15 December 2019. There were no limitations placed on language or publication date. Search terms included tubal EP and EM as well as variations of these terms.

PARTICIPANTS/MATERIALS SETTING AND METHOD

We considered studies that included patients with tubal EP, EM as a comparator, and that were randomised controlled trials (RCTs). The primary outcome was resolution of tubal EP. Secondary outcomes included avoidance of surgery and the time to resolution of EP. Two reviewers independently selected the studies, assessed bias and extracted data. Relative risk (RR) and mean difference with 95% CI were assessed using a random effects model. The certainty of evidence was scored according to Grading of Recommendations Assessment, Development and Evaluation guidelines.

MAIN RESULTS AND THE ROLE OF CHANCE

In total, 920 studies were screened. Five studies were eligible for inclusion in the systematic review. Two RCTs comparing methotrexate to EM were identified as being eligible for inclusion in meta-analysis. No RCTs comparing surgery to EM were identified. Compared with EM, there was insufficient evidence that methotrexate yields a difference on resolution of tubal EP (RR 1.04, 95% CI 0.88-1.23, P = 0.67; two RCTs, moderate-certainty evidence), avoiding surgery (RR 1.10, 95% CI 0.94-1.29, P = 0.25; two RCTs, low-certainty evidence) or the time to resolution of tubal EP (-2.56 days (favouring EM), 95% CI -7.93-2.80, P = 0.35; two RCTs, low-certainty evidence).

LIMITATIONS REASONS FOR CAUTION

Only two RCTs with a total of 103 patients were eligible for inclusion in this meta-analysis. Further RCTs comparing EM to medical and surgical management are needed and these should also report adverse events. Patient preference should also be evaluated.

WIDER IMPLICATIONS OF THE FINDINGS

We found insufficient evidence of differences in terms of resolution, avoidance of surgery and time to resolution between expectant and medical management. Given the imprecision in the effect estimates as demonstrated by the wide CIs, resulting in the downgrading of certainty of evidence for all outcomes in this meta-analysis, larger RCTs comparing interventions for tubal EP are needed. Caution should be exercised when trying to decide between EM and methotrexate to treat tubal EP.

STUDY FUNDING/COMPETING INTERESTS

There was no funding for this study. NICM receives funding from various sources; none specifically supported this research. M.L. reports grants from Australian Women and Children's Research Foundation, outside the submitted work. M.A.: As a medical research institute, NICM Health Research Institute receives research grants and donations from foundations, universities, government agencies and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of the Institute. This systematic review was not specifically supported by donor or sponsor funding to NICM. M.A. reports a partnership grant with Metagenetics outside the submitted work. G.C. reports grants from Australian Women and Children's Research Foundation, personal fees from Roche and GE Healthcare, outside the submitted work. The remaining authors report no conflicts of interest.

PROSPERO REGISTRATION NUMBER

CRD42020142736.

Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant management

Purpose

To compare fertility and reproductive outcome after surgical, medical, and expectant management for tubal ectopic pregnancy (EP).

Methods

133 of 228 patients, who were managed between January 2012 and December 2017 for a tubal EP, tried to conceive immediately after treatment: 86 out of 173 (49.7%) underwent surgical treatment; 38 (21.9%) were treated with methotrexate (MTX), and 49 (28.3%) had expectant management. Clinical data were retrieved by medical records, fertility outcomes were obtained by phone follow-up. The cumulative incidence (CI) of intrauterine clinical pregnancy (CP), miscarriage, live birth (LB), and recurrent EP, and the time between treatment and first intrauterine CP were compared between women treated with MTX, surgery and expectant management.

Results

The CI of intrauterine CP starting from 12 months after the EP was 65.3% for the expectant management, 55.3% for the MTX group, and 39.5% for surgery (p = 0.012). Post-hoc analysis showed expectant management having higher intrauterine CP and LB, and shorter time between treatment and first intrauterine CP compared to surgery (p < 0.05). The CI of recurrent EP was comparable between the 3 groups. The analysis stratified per βhCG cut-off of 1745 mUI/mL and EP mass cut-off of 25 mm reported consistent results.

Conclusions

Women successfully managed by expectation appear to have better reproductive outcomes compared to women who underwent surgery, with the shortest time to achieve a subsequent intrauterine CP. Therefore, if safely applicable the expectant management should be considered in the case of tubal EP. The fact that the chosen treatment was primarily guided by the βhCG value and EP mass diameter based on the protocol, which is intrinsically related to the characteristics of the EP, represents the main limitation of the present study. Indeed, we cannot completely exclude that the observed differences between treatments are related to the EP itself instead of the treatment.

Ultrasound in Early Pregnancy: Viability, Unknown Locations, and Ectopic Pregnancies

Ultrasound is essential in the evaluation and management of pregnancies of unknown location. Differential diagnoses include early pregnancy loss, pregnancy of unknown location, and ectopic pregnancies. Both transabdominal and transvaginal routes should be available, in addition to physical examination, for complete evaluation. Diagnostic criteria for early pregnancy loss have expanded in recent years to ensure false positive results do not lead to inappropriate evacuation of desired pregnancies.

Unexpected rupture of an expectantly managed tubal ectopic pregnancy: a reminder for enhanced diligence

Expectant management of tubal ectopic pregnancies is a feasible and possibly preferable method of management in asymptomatic women with low serum β-human chorionic gonadotropin (hCG). This involves serial monitoring of β-hCG until negative, after which it is deemed as spontaneously resolved ectopic pregnancy. We describe a case of tubal ectopic pregnancy which was expectantly managed with an initial β-hCG of 585 mIU/mL until undetectable. This patient presented with ruptured ectopic pregnancy 8 weeks after the original diagnosis, at the level of 5 mIU/mL. This highlights the importance of close monitoring in the expectant management of tubal ectopic pregnancies, with the incorporation of imaging, even when serial β-hCG shows a persistently reducing trend.

The Management of Heterotopic Pregnancy with Transvaginal Ultrasound-Guided Local Injection of Absolute Ethanol

Aims:

The aim of the study is to present five cases of heterotopic pregnancy (HP) patients who received transvaginal ultrasound-guided local injection of absolute ethanol (AE).

Settings and Design:

This was a case series and literature review in Reproductive Medicine Center of the 105^th Hospital of the People's Liberation Army.

Materials and Methods:

Five primary infertile women who underwent assisted reproductive technology were diagnosed with HP and treated with local injection of AE (1.0–2.5 ml) under transvaginal ultrasound guidance. The size of intrauterine (IU) and ectopic sacs and the level of serum beta-human chorionic gonadotropin as well as pregnancy outcomes were monitored after treatment.

Statistical Analysis Used:

Not applicable.

Results:

Four of five cases presented with lack of Doppler flow in the injected area after AE injection. Meanwhile, IU pregnancy proceeded well after treatment and delivered a normal newborn. One case received emergency surgery 3 h after local injection of 2.5 ml AE because of the rupture of ectopic gestational sac (GS). An early abortion was identified 7 days after the surgery.

Conclusions:

Transvaginal ultrasound-guided local injection of AE is an alternative nonsurgical treatment for HP, yet overdose injection of AE will increase the risk of ectopic GS rupture.

Evaluation of serum biomarkers and efficacy of MTX in women with ectopic pregnancy

Ectopic pregnancy occurs when a fertilized ovum attaches outside the uterus. As a complication in approximately 1‑2% of all pregnancies, ectopic pregnancies may cause catastrophic hemorrhage as a result of invading maternal blood vessels. Therefore, early diagnosis and timely treatment are crucial for women with ectopic pregnancy. In this study, we aimed to identify and determine the efficacy of serum biomarkers for the prompt diagnosis of ectopic pregnancy. For this purpose, the serum concentrations of progesterone, β human chorionic gonadotropin (β‑hCG) and cancer antigen‑125 (CA125) were detected by solid‑phase, competitive binding chemiluminescent enzyme immunoassays. Flow cytometry was used to analyze the percentage of CD3+ T cells in women with ectopic pregnancy. Pathological analysis of tubal and villus tissues was performed by hematoxylin and eosin (H&E) staining. After receiving an injection of methotrexate (MTX), patients were examined by transvaginal ultrasound to detect the size of the echogenic mass. The results revealed that the serum levels of progesterone, β‑HCG and CA125 were significantly decreased in women with ectopic pregnancy, whereas the percentage of CD3+ T cells was increased in women with ectopic pregnancy. Histopathological examination revealed blood clots with small tissue fragments of a tubal‑type epithelium and incomplete pile structures. Five days after the MTX injection, an echogenic mass was found with a size of 1.7x1.2x1.6 cm that contained a gestational sac‑like structure and a yolk sac. On the whole, the findings of this study indicate the at the joint detection of progesterone, β‑HCG, CA125 serum levels and the CD3+ T cell percentage could be applied as a reliable indicator for the early diagnosis of ectopic pregnancy. MTX administration was determined to be an efficacious approach for the treatment of ectopic 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.

Pregnancy of unknown location: Evaluation and management

Early diagnosis of an extrauterine pregnancy is important for safe and effective management. However, a pregnancy's location often cannot be easily determined with abnormal implantations or prior to 5-6 weeks' gestation. Multiple testing strategies exist to diagnose an abnormal pregnancy when location is unknown, but caution needs to be used to avoid a false diagnosis. Medical treatment is optimal when an abnormal pregnancy is diagnosed early. Because most of these pregnancies are intrauterine, additional testing to localize the pregnancy will allow the correct choice of therapy and avoids unnecessary exposure to a toxic therapy. This testing strategy should be reserved for patients with significant concern for ectopic pregnancy, based on either risk factors or clinical findings. Overuse of this approach can lead to interruption of normal pregnancies.

Pregnancy of unknown location

Pregnancy of unknown location is a situation in which a positive pregnancy test occurs, but a transvaginal ultrasound does not show intrauterine or ectopic gestation. One great concern of pregnancy of unknown location is that they are cases of ectopic pregnancy whose diagnosis might be postponed. Transvaginal ultrasound is able to identify an ectopic pregnancy with a sensitivity ranging from 87% to 94% and a specificity ranging from 94% to 99%. A patient with pregnancy of unknown location should be followed up until an outcome is obtained. The only valid biomarkers with clinical application and validation are serum levels of the beta fraction of hCG and progesterone. A single serum dosage of hCG is used only to determine whether the value obtained is above or below the discriminatory zone, that means the value of serum hCG above which an intrauterine gestational sac should be visible on ultrasound. Serum progesterone levels are a satisfactory marker of pregnancy viability, but they are unable to predict the location of a pregnancy of unknown location: levels below 5 ng/mL are associated with nonviable gestations, whereas levels above 20 ng/mL are correlated with viable intrauterine pregnancies. Most cases are low risk and can be monitored by expectant management with transvaginal ultrasound and serial serum hCG levels, in addition to the serum progesterone levels. To minimize diagnostic error and intervene during progressive intrauterine gestation, protocol indicates active treatment only in situations when progressive intrauterine pregnancy is excluded and a high possibility of ectopic pregnancy exists.

Ectopic pregnancy incidence in the Republic of Korea in 2009-2015: A population-based cross-sectional study

We estimated the incidence of ectopic pregnancy (EP) and the success rate of expectant management of EP in South Korea. We analyzed data from 2009 to 2015 using the Health Insurance Review and Assessment Service National Inpatient Sample (HIRA-NIS) database. EP was identified by diagnostic codes, and strict EP was identified by both diagnostic codes and treatment codes. From 2009 to 2015, 369,701 cases of EP, abortion, or delivery were extracted from a total of 4,476,495 women. Of the total pregnancies, 8,556 cases were EPs. The incidence of EP was 34.1 ± 0.7 per 1,000 pregnancies and the incidence of strict EP was 17.3 ± 0.3 per 1,000 pregnancies. Among women aged 25-44 years, age was associated with a higher incidence of EP (odds ratio [OR]: 1.13; 95% confidence interval [CI]: 1.06, 1.19; P < 0.01). The incidence rates of EP (OR: 0.99; 95% CI: 0.97, 1.01; P = 0.51) did not significantly differ by year. The incidence of EP in Korea was 17.3 ± 0.3 per 1,000 pregnancies, and almost did not change over 7 years. About 50% of EPs were treated without surgery or methotrexate. This study provides an important reference for the treatment of EP.

A multi-centre, double-blind, placebo-controlled, randomised trial of combination methotrexate and gefitinib versus methotrexate alone to treat tubal ectopic pregnancies (GEM3): trial protocol

Background

Tubal ectopic pregnancy (tEP) is the most common life-threatening condition in gynaecology. Treatment options include surgery and medical management. Stable women with tEPs with pre-treatment serum human chorionic gonadotrophin (hCG) levels < 1000 IU/L respond well to outpatient medical treatment with intramuscular methotrexate. However, tEPs with hCG > 1000 IU/L can take significant time to resolve with methotrexate and require multiple outpatient monitoring visits. In pre-clinical studies, we found that tEP implantation sites express high levels of epidermal growth factor receptor. In early-phase trials, we found that combination therapy with gefitinib, an orally active epidermal growth factor receptor antagonist, and methotrexate resolved tEPs without the need for surgery in over 70% of cases, did not cause significant toxicities, and was well tolerated. We describe the protocol of a randomised trial to assess the efficacy of combination gefitinib and methotrexate, versus methotrexate alone, in reducing the need for surgical intervention for tEPs.

Methods and analysis

We propose to undertake a multi-centre, double-blind, placebo-controlled, randomised trial (around 70 sites across the UK) and recruit 328 women with tEPs (with pre-treatment serum hCG of 1000–5000 IU/L). Women will be randomised in a 1:1 ratio by a secure online system to receive a single dose of intramuscular methotrexate (50 mg/m²) and either oral gefitinib or matched placebo (250 mg) daily for 7 days. Participants and healthcare providers will remain blinded to treatment allocation throughout the trial. The primary outcome is the need for surgical intervention for tEP. Secondary outcomes are the need for further methotrexate treatment, time to resolution of the tEP (serum hCG ≤ 15 IU/L), number of hospital visits associated with treatment (until resolution or scheduled/emergency surgery), and the return of menses by 3 months after resolution. We will also assess adverse events and reactions until day of resolution or surgery, and participant-reported acceptability at 3 months.

Discussion

A medical intervention that reduces the need for surgery and resolves tEP faster would be a favourable treatment alternative. If effective, we believe that gefitinib and methotrexate could become standard care for stable tEPs.

Trial registration

ISRCTN Registry ISRCTN67795930. Registered 15 September 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3008-6) contains supplementary material, which is available to authorized users.

Optimal treatment for women with a persisting pregnancy of unknown location, a randomized controlled trial: The ACT-or-NOT trial

OBJECTIVE

Pregnancy of unknown location (PUL) is not a diagnosis but a transient state used to classify a woman when she has a positive pregnancy test without definitive evidence of an intra-uterine or extra-uterine pregnancy on transvaginal ultrasonography. Management of a persisting PUL varies substantially, including expectant or active management. Active management can include uterine cavity evacuation or systemic administration of methotrexate. To date, no consensus has been reached on whether either management strategy is superior or non-inferior to the other.

DESIGN

Randomized controlled trial.

SETTING

Academic medical centers.

PATIENTS

We plan to randomize 276 persisting PUL-diagnosed women who are 18 years or older from Reproductive Medicine Network clinics and additional interested sites, all patients will be followed for 2 years for fertility and patient satisfaction outcomes.

INTERVENTIONS

Randomization will be 1:1:1 ratio between expectant management, uterine evacuation and empiric use of methotrexate. After randomization to initial management plan, all patients will be followed by their clinicians until resolution of the PUL. The clinician will determine whether there is a change in management, based on clinical symptoms, and/or serial human chorionic gonadotropin (hCG) concentrations and/or additional ultrasonography.

MAIN OUTCOME

The primary outcome measure in each of the 3 treatment arms is the uneventful clinical resolution of a persistent PUL without change from the initial management strategy. Secondary outcome measures include: number of ruptured ectopic pregnancies, number and type of re-interventions (additional methotrexate injections or surgical procedures), treatment complications, adverse events, number of visits, time to resolution, patient satisfaction, and future fertility.

CONCLUSION

This multicenter randomized controlled trial will provide guidance for evidence-based management for women who have persisting pregnancy of unknown location.

Local privileges not universal rights: geographic variations in the science and clinical practice of reproductive medicine

Based on personal experience in the science and clinical practice of reproductive medicine in different settings, enormous variations are highlighted, demonstrating that freedom of research and clinical practice in reproductive medicine is a local privilege, not a universal right.

Diagnostic value of detection of serum β-HCG and CT-IgG combined with transvaginal ultrasonography in early tubal pregnancy

The diagnostic value of detection of serum β-human chorionic gonadotropin (β-HCG) and Chlamydia trachomatis immunoglobulin G (CT-IgG) combined with transvaginal ultrasonography in early tubal pregnancy was investigated. A total of 55 patients with early tubal pregnancy were selected as the tubal pregnancy group, while 55 subjects of normal intrauterine pregnancy were enrolled as the intrauterine pregnancy group. Transvaginal ultrasonography and quantitative detection of serum β-HCG and CT-IgG were performed for all patients, and the clinical examination results were analyzed and compared. The endometrial thickness and serum β-HCG level of patients with early tubal pregnancy were significantly lower than those of women with intrauterine pregnancy (6.7±1.5 vs. 11.6±1.2 mm; 776±109 vs. 5,598±187 U/l), and the differences were statistically significant (p<0.01); the serum CT-IgG antibody positive rate of patients in tubal pregnancy group (49.1%) was significantly higher than that in intrauterine pregnancy group (12.7%) (p<0.01); the serum CT-IgG antibody positive rates of patients with degree I, II and III of pelvic adhesion intubal pregnancy group were 28.6, 75.0 and 81.8%, respectively; the more severe the pelvic adhesion was, the higher the CT-IgG positive rate would be. The diagnostic coincidence rate of combined detection was significantly higher than that of single detection of serum β-HCG, progesterone and endometrial thickness. The detection of serum β-HCG and CT-IgG combined with transvaginal ultrasonography can diagnose the early tubal pregnancy soonest possible, and help choose the appropriate therapeutic methods depending on the situation to reduce the tubal damage of patients, so as to provide a reliable basis for the diagnosis, treatment and prognosis, and it has important clinical application value.

Morphological ultrasound types known as 'blob' and 'bagel' signs should be reclassified from suggesting probable to indicating definite tubal ectopic pregnancy

OBJECTIVE

In a recent consensus statement on early pregnancy nomenclature by Barnhart, a definite ectopic pregnancy (EP) was defined morphologically on transvaginal sonography (TVS) as an extrauterine gestational sac with yolk sac and/or embryo, with or without cardiac activity, whilst a probable EP was defined as an inhomogeneous adnexal mass ('blob' sign) or extrauterine sac-like structure ('bagel' sign). This study aims to determine whether these ultrasound markers used to define probable EP can be used to predict a definite tubal EP.

METHODS

This was a retrospective cohort study of women presenting to the Early Pregnancy Unit (EPU) at Nepean Hospital, Sydney, Australia between November 2006 and June 2016. Women classified with a probable EP or a pregnancy of unknown location (PUL), i.e. with no signs of extra- or intrauterine pregnancy (IUP), at their first TVS were included, whilst those with a definite tubal EP, IUP or non-tubal EP were excluded from the final analysis. The gold standard for tubal EP was histological confirmation of chorionic villi in Fallopian tube removed at laparoscopy. The performance of blob or bagel sign on TVS in the prediction of definite tubal EP was evaluated in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). This was compared with the performance of extrauterine gestational sac with yolk sac and/or embryo on TVS to predict definite tubal EP.

RESULTS

During the study period, 7490 consecutive women attended the EPU, of whom 849 were analyzed. At primary TVS, 240/849 were diagnosed with probable EP, of which 174 (72.5%) were classified as blob sign and 66 (27.5%) as bagel sign. The remaining 609/849 were diagnosed with PUL, of which 47 had a final diagnosis of EP (including 24 blob sign, 19 bagel sign and four gestational sac with embryo/yolk sac). 101 of all 198 (51%) blob sign cases and 50 of all 85 (59%) bagel sign cases underwent laparoscopy and salpingectomy; histology proved a tubal EP in 98 (97%) of these blob-sign cases and 48 (96.0%) of the bagel-sign cases. The sensitivity for the blob and bagel signs in the prediction of definite tubal EP was 89.8% and 83.3%, respectively, the specificity was 99.5% and 99.6%, PPV was 96.7% and 95.2% and NPV was 98.3% and 98.6%. This was comparable to the sensitivity of extrauterine gestational sac with yolk sac and/or embryo on TVS in the prediction of definite tubal EP (sensitivity, 84.0%; specificity, 99.9%; PPV, 97.7%; NPV, 99.3% (P = 0.5)).

CONCLUSIONS

Blob and bagel signs seem to be the most common presentations of a tubal EP on TVS. Although they cannot be considered as a definitive sign of EP, their PPV is very high (> 95%); such women should therefore be considered at very high risk for having a tubal EP and should be treated as such. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Predictors of failure of the commonly used single-dose methotrexate protocol for treating tubal ectopic pregnancies

OBJECTIVES

This study identified patients who would benefit from an earlier additional medical intervention and/or continuing close surveillance even if commonly used parameters indicated sufficient medical treatment to determine markers of treatment failure.

MATERIALS AND METHODS

A retrospective analysis of patients with a preliminary diagnosis of ectopic pregnancy treated with the single-dose methotrexate protocol. Group 1: cases cured with a single dose of methotrexate; Group 2: cases who required more than one dose of methotrexate or surgery following the first dose. Demographics, clinical/sonographic findings, observation period, and β-human chorionic gonadotropin (hCG) levels were compared among the two groups. Thresholds were defined and a regression analysis was performed to define independent predictors of failure.

RESULTS

Data from 120 patients were analyzed: Group 1 (n = 92); Group 2 (n = 28). β-hCG levels measured at all time points, and day (0-4) and day (4-7) changes, presence of adnexial masses, and infertility were significantly different among the two groups. Only the day (0-4) and day (4-7) changes in β-hCG levels were independent predictors of failure.

CONCLUSION

Day (0-4) thresholds or newly defined day (4-7) thresholds were not more sensitive than the conventional day (4-7) criteria. Day (0-4) β-hCG levels increased by more than 9.7% in half the patients who required additional methotrexate doses or surgery despite fulfillment of the conventional day (4-7) criteria. In contrast, no cases of treatment failure were observed if the day (0-4) decrease was >26.6%.

Human placental growth hormone in ectopic pregnancy: Detection in maternal blood, immunohistochemistry and potential clinical implication

OBJECTIVE

To investigate human placental growth hormone (hGH-V) in ectopic pregnancy (EP): detection in maternal blood, correlation with immunohistochemistry and possible role as a marker for the course of EP.

DESIGN

Women presenting in the outpatient or emergency department of a tertiary care university hospital with a positive pregnancy test and strong suspicion of EP by ultrasound and/or symptoms were eligible for the study (n=70). Tissue specimens from the surgically treated patients (n=50) were examined by histopathology as well as by a hGH-V specific immohistochemistry set-up. A highly sensitive hGH-V specific immunoassay was used to analyse serum samples collected before treatment, day 1 post surgery samples and serial samples for medical treatment.

RESULT(S)

In EP patients' sera hGH-V was shown to be measurable for the first time (n=18). HGH-V however could not be detected in all patients' sera. HCG levels were significantly higher in the hGH-V serum positive group (p 0.001). HGH-V was localized to the syncytiotrophoblast in all specimens of EP examined by immunohistochemistry (n=10) regardless of the detection in the patient's blood.

CONCLUSION(S)

Placental growth hormone (hGH-V) was shown to be present both in ectopic pregnancy patients' sera and tissue. It may serve as a biomarker for monitoring the course and treatment of EP.

Single-dose systemic methotrexate vs expectant management for treatment of tubal ectopic pregnancy: a placebo-controlled randomized trial

OBJECTIVE

Methotrexate is used routinely worldwide for the medical treatment of clinically stable women with a tubal ectopic pregnancy. This is despite the lack of robust evidence to show its superior effectiveness over expectant management. The aim of our multicenter randomized controlled trial was to compare success rates of methotrexate against placebo for the conservative treatment of tubal ectopic pregnancy.

METHODS

This study took place in two early-pregnancy units in the UK between August 2005 and June 2014. Inclusion criteria were clinically stable women with a conclusive ultrasound diagnosis of a tubal ectopic pregnancy, presenting with a low serum beta human chorionic gonadotropin (β-hCG) level of < 1500 IU/L. Women were assigned randomly to a single systemic injection of either 50 mg/m² methotrexate or placebo. The primary outcome was a binary indicator for success of conservative management, defined as resolution of clinical symptoms and decline of serum β-hCG to < 20 IU/L or a negative urine pregnancy test without the need for any additional medical intervention. An intention-to-treat analysis was followed.

RESULTS

We recruited a total of 80 women, 42 of whom were assigned to methotrexate and 38 to placebo. The arms of the study were matched in terms of age, ethnicity, obstetric history, pregnancy characteristics and serum levels of β-hCG and progesterone. The rates of success were similar for the two study arms: 83% with methotrexate and 76% with placebo. On univariate analysis, this difference was not statistically significant (χ² (1 degree of freedom) = 0.53; P = 0.47). On multivariate logistic regression, the serum level of β-hCG was the only covariate found to be significantly associated with outcome. The odds of failure increased by 0.15% for each unit increase in β-hCG (odds ratio, 1.0015 (95% CI, 1.0002-1.003); P = 0.02). In 14 women presenting with serum β-hCG of 1000-1500 IU/L, the success rate was 33% in those managed expectantly compared with 62% in those receiving methotrexate. This difference was not statistically significant and a larger sample size would be needed to give sufficient power to detect a difference in the subgroup of women with higher β-hCG. In women with successful conservative treatment, there was no significant difference in median β-hCG resolution times between study arms (17.5 (interquartile range (IQR), 14-28.0) days (n = 30) in the methotrexate group vs 14 (IQR, 7-29.5) days (n = 25) in the placebo group; P = 0.73).

CONCLUSIONS

The results of our study do not support the routine use of methotrexate for the treatment of clinically stable women diagnosed with tubal ectopic pregnancy presenting with low serum β-hCG (< 1500 IU/L). Further work is required to identify a subgroup of women with tubal ectopic pregnancy and β-hCG ≥ 1500 IU/L in whom methotrexate may offer a safe and cost-effective alternative to surgery. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Comparación entre una sola dosis de metotrexate sistémico y la conducta expectante en el tratamiento de casos de embarazo ectópico tubárico: un ensayo aleatorio controlado con placebo RESUMEN OBJETIVO: El metotrexate se utiliza de modo rutinario en todo el mundo para el tratamiento de las mujeres clínicamente estables con un embarazo ectópico tubárico. Esto sucede a pesar de la falta de evidencia rigurosa que demuestre que su eficacia es superior a la conducta expectante. El objetivo de este ensayo controlado aleatorio multicéntrico fue comparar las tasas de éxito del metotrexate con las de un placebo para el tratamiento cauteloso del embarazo ectópico tubárico. MÉTODOS: Este estudio se llevó a cabo en dos clínicas de control de gestación temprana en el Reino Unido entre agosto de 2005 y junio de 2014. Los criterios de inclusión fueron mujeres clínicamente estables con un diagnóstico ecográfico concluyente de embarazo ectópico tubárico, las cuáles presentaban una concentración sérica baja de la β hormona coriónica gonadotrópica (β-hCG) inferior a 1500 UI/L. Las mujeres fueron asignadas aleatoriamente a una sola inyección sistémica de 50 mg/m2 de metotrexate o a placebo. El resultado primario fue un indicador binario del éxito del tratamiento conservador, definido como la resolución de los síntomas clínicos y la disminución en el suero de la β-hCG a <20 UI/L o una prueba de embarazo negativa en orina sin la necesidad de ninguna intervención médica adicional. Se hizo un análisis por intención de tratar.

RESULTADOS

Se reclutó un total de 80 mujeres; a 42 de ellas se les asignó el metotrexate y a 38 el placebo. Los grupos del estudio se realizaron en función de la edad, el origen étnico, los antecedentes obstétricos, las características del embarazo y los niveles séricos de la β-hCG y la progesterona. Las tasas de éxito fueron similares para los dos grupos de estudio: 83% con metotrexate y 76% con placebo. En el análisis univariante, esta diferencia no fue estadísticamente significativa (χ2 (1 grado de libertad) = 0,53; P = 0,47). En la regresión logística multivariante, el nivel sérico de la β-hCG fue la única covariable que se encontró significativamente asociada con el resultado. Las probabilidades de fracaso aumentaron en un 0,15% por cada unidad de aumento de la β-hCG (cociente de probabilidad 1,0015 (IC 95%, 1,0002-1,003); P = 0,02). La tasa de éxito en las 14 mujeres con un nivel sérico de la β-hCG de 1000-1500 UI/L fue del 33% en las tratadas con conducta expectante frente al 62% en las que recibieron metotrexate. Esta diferencia no fue estadísticamente significativa, por lo que se necesitaría un tamaño de muestra mayor, lo suficiente como para poder detectar diferencias en el subgrupo de mujeres con una β-hCG más elevada. En las mujeres en las que el tratamiento conservador tuvo éxito, no hubo una diferencia significativa en la mediana de los tiempos de resolución de la ß-hCG entre los grupos del estudio (17,5 (amplitud intercuartílica (IQR), 14-28,0) días (n = 30) en el grupo de metotrexate frente a 14 (IQR, 7-29.5) días (n = 25) en el grupo de placebo; P = 0,73).

CONCLUSIONES

Los resultados de este estudio no apoyan el uso rutinario de metotrexate para el tratamiento de las mujeres clínicamente estables diagnosticadas con un embarazo ectópico tubárico que presenta un nivel sérico bajo la β-hCG (<1500 UI/L). Serán necesarios estudios adicionales para identificar un subgrupo de mujeres con embarazo ectópico tubárico y β-hCG ≥1500 UI/L para quienes el metotrexate puede ofrecer una alternativa segura y rentable en comparación con la cirugía. : : ,,。。 : 2005820146,2。,,β(beta human chorionic gonadotropin,β-hCG)<1500 IU/L。,(50 mg/m² )。,β-hCG<20 IU/L,。。 : 80,42,38。2、、、β-hCG。2:83%,76%。,[χ² (1)=0.53;P=0.47]。logistic,β-hCG。β-hCG,0.15%[,1.0015(95% CI,1.0002~1.003);P=0.02]。14β-hCG1000~1500 IU/L,33%,62%。,β-hCG。,2β-hCG(P=0.73),17.5[(interquartile range,IQR),14~28.0](n=30),14 (IQR,7~29.5)(n=25)。 : 、、β-hCG(<1500 IU/L)。,β-hCG>1500 IU/L、。.

Ectopic pregnancy treatment by combination therapy

Detectability of early stages of ectopic pregnancies has increased due to improvements in ultrasonographic and biochemical techniques. Since the patients’ future procreative plans must be taken into consideration when commencing treatment, the goal of this work was to compare the effects of treatment methods and their impact on fertility. The study included 91 patients treated surgically for ectopic pregnancy. The choice of treatment depended on patients’ general condition, ultrasonographic evaluation and serum level of beta-hCG. A combination of laparoscopic and conservative systemic treatment was applied in 70% of cases. More rapid beta-hCG reduction was noted when laparoscopy and intra-oviductal injection of hyperosmolar glucose or methotrexate (MTX) were combined with intramuscular administration of MTX at a dose of 50 mg/m2. Follow-up examination of 66 patients revealed that the greatest number of spontaneous pregnancies (48%) resulted after this combination therapy. We conclude that this combination treatment is safe and provides satisfactory results in terms of future fertility.

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.

Predictive factors for the methotrexate treatment outcome in ectopic pregnancy: A comparative study of 400 cases

OBJECTIVE

We sought to evaluate the global success rate of intramuscular methotrexate for the treatment of ectopic pregnancy, identify factors predictive of treatment success or failure, and study methotrexate tolerability in a large patient cohort.

STUDY DESIGN

For this single-center retrospective observational study, we retrieved the records of all women who had a clinically or echographically confirmed ectopic pregnancy with a Fernandez score <13 and who were treated according to a 1mg/kg intramuscular single-dose methotrexate protocol. Medical treatment failure was defined by an obligation to proceed to laparoscopy. Needing a second injection was not considered to be medical treatment failure.

RESULTS

Between February 2008 and November 2013 (69 months), 400 women received methotrexate for ectopic pregnancy. The medical treatment protocol was effective for 314 patients, i.e., an overall success rate of 78.5%. A single methotrexate dose was sufficient for 63.5% of the women and a second dose was successful for 73.2% of the remaining women. The medical treatment success rate fell as initial hCG levels climbed. The main factors associated with methotrexate failure included day (D) 0, D4 and D7 hCG levels, pretherapeutic blood progesterone, hematosalpinx at D0 and pain at D7. Early favorable kinetics of hCG levels was predictive of success. Methotrexate treatment was successful in 90% of women who had D0 hCG <1000IU/l. Methotrexate tolerability was good, with only 9% of the women reporting non-severe adverse effects. The fertility rate with delivery after medical treatment for ectopic pregnancy was 80.7%.

CONCLUSION

In this study, we showed that an initial hCG value <1000IU/l and favorable early HCG kinetics were predictive factors for the successful medical treatment of ectopic pregnancy by methotrexate, and hematosalpinx and pretherapeutic blood progesterone >5ng/ml at diagnosis were predictive of its failure. We also confirmed good tolerability for single-dose methotrexate protocols.

Individualisation of intervention for tubal ectopic pregnancy: historical perspectives and the modern evidence based management of ectopic pregnancy

Historically, ectopic pregnancy was a life-threatening condition where diagnosis was possible only at post mortem or laparotomy and maternal mortality was up to 90%. The evolution in the management of ectopic pregnancy has meant that diagnosis can be made using non-invasive techniques with an aim to identify the ectopic gestation before tubal rupture. This enables health care professionals to offer management options that consider not only maternal mortality, but morbidity and fertility outcomes as well. In spite of this, diagnostic techniques and management options are not without limitations. Research is currently focused on new tests with a single diagnostic capability, diagnostic and treatment algorithms and safe methods of triaging patients. This article aims to review the current literature on the diagnosis and management of ectopic pregnancy and to formulate a pathway to help individualise care and achieve the best possible outcome.