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Namavar Jahromi B, Fardid M, Esmaili E, Kavosi Z, Shiravani Z, Jafari A, Keshavarz K. Cost-Effectiveness Analysis of Different Methods of Treatment of Tubal Ectopic Pregnancy in the South of Iran. Value Health Reg Issues 2021; 28:90-97. [PMID: 34839112 DOI: 10.1016/j.vhri.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/03/2021] [Accepted: 06/16/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES The aim of the study was to evaluate the cost-effectiveness of different methods of treating tubal ectopic pregnancy in the south of Iran. METHODS This study was an economic evaluation that analyzed and compared the cost-effectiveness and cost utility of 3 treatment methods, including single-dose methotrexate, double-dose methotrexate, and surgery in patients with tubal ectopic pregnancy. In this study, a decision tree model was used. The outcomes included in the model were the percentage of successful treatment and the average utility score of each treatment method. The study was conducted from the social perspective, and a one-way and probabilistic sensitivity analysis was performed to measure the effects of uncertainty. RESULTS The incremental cost-effectiveness ratio of surgery compared with single-dose methotrexate was positive and equal to $5812 purchasing power parity; moreover, the results of one-way analysis showed the highest sensitivity toward the effectiveness of single-dose methotrexate. Scatter plots also revealed that surgery in 82% and 96% of simulations was at the acceptable region compared with a single-dose and double-dose methotrexate, respectively and was below the threshold. It was identified as a more cost-effective strategy. Furthermore, the acceptability curves showed that in 81.4% of simulations, surgery was the most cost-effective treatment for thresholds less than $20 950 purchasing power parity. CONCLUSIONS On the basis of the results of this study, surgery can be used as the first line of treatment for ectopic pregnancy. In addition, the best drug strategy was single-dose methotrexate because this strategy reduced costs and increased treatment success and quality-adjusted life-years compared with double-dose methotrexate.
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Affiliation(s)
- Bahia Namavar Jahromi
- Infertility Research Center and Shiraz Otolaryngology Research Center, Department of Otorhinolaryngology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mozhgan Fardid
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Elahe Esmaili
- Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Kavosi
- Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Shiravani
- Department of Obstetrics and Gynecology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdosaleh Jafari
- Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Khosro Keshavarz
- Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.
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Inal ZO, Inal HA. Comparison of Four Methods of Treating Ectopic Pregnancy: A Retrospective Cohort Study. Geburtshilfe Frauenheilkd 2018; 78:70-77. [PMID: 29375148 PMCID: PMC5778193 DOI: 10.1055/s-0043-122151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 10/29/2017] [Accepted: 11/01/2017] [Indexed: 12/27/2022] Open
Abstract
Objective
To compare the results of expectant management, single and multidose methotrexate (MTX) and surgical management of ectopic pregnancy (EP).
Materials and Methods
In this retrospective cohort study, the original files of 233 patients who were treated for EP between May 2009 and December 2016 were analyzed. The patients were assigned to the following groups based on the applied treatment methods: Group 1, expectant management (n = 24), Group 2, single-dose MTX (n = 144), Group 3, multiple-dose MTX (n = 25), and Group 4, surgical intervention (n = 40). The following parameters were recorded and assessed: sociodemographic characteristics, pelvic ultrasonography findings (gestational sac, ectopic mass appearance, positive fetal cardiac activity), serum beta-human chorionic gonadotropin (β-hCG) levels on Day 0, Day 4, and Day 7, and surgical procedures in women that underwent surgical interventions.
Results
The sociodemographic characteristics were similar in all four groups. The percentage of ectopic mass and positive fetal cardiac activity was greater and the diameter of the mass was larger in Group 4 than in the other groups. The β-hCG values on Day 0, Day 4, and Day 7 were statistically different between the groups (p < 0.001). The cutoff value for the β-hCG change for EP resolution was 18% between Day 0 and Day 4 (AUC = 0.726, p < 0.001) and 15% between Day 4 and Day 7 (AUC = 0.874, p < 0.001). The probability of the requirement for an additional dose of MTX was 0.78 (95% CI 0.71 – 0.87; p < 0.001) times lower in patients who had a > 18% decrease in β-hCG levels from Day 0 to Day 4 in comparison to those who had a decrease < 18% from Day 0 to Day 4. The probability of the requirement for an additional dose of MTX was 1.64 (95% CI 1.25 – 2.16; p < 0.001) times greater in patients whose reduction in β-hCG levels from Day 4 to Day 7 was < 15% in comparison to those who had > 15% reduction from Day 4 to Day 7.
Conclusions
Additional dose requirements for patients with EP may be predicted early in the changes in β-hCG levels between Day 0 and Day 4. Further prospective studies are required to elucidate this issue.
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Affiliation(s)
- Zeynep Ozturk Inal
- Konya Education and Research Hospital, Department of Gynecology, Konya, Turkey
| | - Hasan Ali Inal
- Konya Education and Research Hospital, Department of Gynecology, Konya, Turkey
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A Case of Ruptured Interstitial Ectopic Pregnancy: Ultrasonographic Appearance With Gross Pathology Correlate. Ultrasound Q 2017; 33:181-183. [PMID: 28481765 DOI: 10.1097/ruq.0000000000000294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Song T, Kim MK, Kim ML, Jung YW, Yun BS, Seong SJ. Single-dose versus two-dose administration of methotrexate for the treatment of ectopic pregnancy: a randomized controlled trial. Hum Reprod 2015; 31:332-8. [PMID: 26701971 DOI: 10.1093/humrep/dev312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/20/2015] [Indexed: 12/27/2022] Open
Abstract
STUDY QUESTION Can a two-dose methotrexate treatment protocol improve the treatment success rate compared with a single-dose protocol in women with an ectopic pregnancy? SUMMARY ANSWER The two-dose protocol was not superior to the single-dose protocol for the treatment of ectopic pregnancy. WHAT IS KNOWN ALREADY Although the two-dose methotrexate protocol for ectopic pregnancy was recently introduced to combine the efficacy and convenience of the fixed multi-dose and single-dose protocols, studies comparing the success rates, treatment satisfaction and acceptability of the single-dose and two-dose treatment protocols for ectopic pregnancy are currently lacking. STUDY DESIGN, SIZE, DURATION A randomized trial was conducted on 92 participants with tubal ectopic pregnancy, between May 2013 and April 2015. PARTICIPANT/MATERIALS, SETTING, METHODS Patients who were diagnosed with tubal ectopic pregnancy and who elected to undergo systemic methotrexate treatment were randomly assigned to follow either the single-dose (n = 46) or two-dose protocol (n = 46). The primary outcome measure was treatment success without surgical intervention. The secondary outcome measures were the incidence of methotrexate-associated side effects, β-human chorionic gonadotrophin (β-hCG) resolution time, cost of care received and treatment satisfaction. MAIN RESULTS AND THE ROLE OF CHANCE There were no differences in baseline characteristics between the groups. The success rates between the single-dose and two-dose groups did not show a significant difference [82.6 versus 87.0%; relative risk (RR) 0.95; 95% confidence interval (CI) 0.80-1.13]. However, the success rate in a subgroup of participants with a pretreatment β-hCG level of >5000 mIU/ml appeared to be higher in the two-dose group than in the single-dose group (80.0 versus 58.8%), although the difference was not statistically significant. No significant differences in methotrexate-associated side effects, cost or treatment satisfaction were observed between the groups. The two-dose group required a lower number of days for the β-hCG level to decrease to <5 mIU/ml than the single-dose group (25.7 ± 13.6 versus 31.9 ± 14.1 days; P = 0.025). LIMITATIONS, REASONS FOR CAUTION Some caution is warranted in interpreting the results due to an overoptimistic sample size calculation on the basis of the biggest difference as reported in literature between the success rates of two protocols. WIDER IMPLICATIONS OF THE FINDINGS The single-dose protocol with the option to elaborate to a second dose in the case of treatment failure could stand as the treatment for most cases of ectopic pregnancy. STUDY FUNDING/COMPLETING OF INTERESTS None. TRIAL REGISTRATION NUMBER www.clinicaltrials.gov, no. NCT01855568. TRIAL REGISTRATION DATE 10 May 2013. DATE OF FIRST PATIENT'S ENROLMENT 26 May 2013.
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Affiliation(s)
- Taejong Song
- Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Mi-La Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Yong Wook Jung
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Bo Seong Yun
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
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Malhotra R, Bramante RM, Radomski M, Nelson M. Mirror image artifact mimicking heterotopic pregnancy on transvaginal ultrasound: case series. West J Emerg Med 2015; 15:712-4. [PMID: 25247050 PMCID: PMC4162736 DOI: 10.5811/westjem.2014.5.22508] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 05/21/2014] [Accepted: 05/31/2014] [Indexed: 12/27/2022] Open
Abstract
Vaginal bleeding in early pregnancy is a common emergency department complaint. Point-of-care ultrasound is a useful tool to evaluate for intrauterine ectopic pregnancy. Emergency physicians performing these studies need to be cognizant of artifacts produced by ultrasound technology, as they can lead to misdiagnosis. We present two cases where mirror-image artifacts initially led to a concern for heterotopic pregnancies but were excluded on further imaging.
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Affiliation(s)
- Radhika Malhotra
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Robert M Bramante
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | | | - Mathew Nelson
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
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Fylstra DL. Avoiding misdiagnosing an early intrauterine pregnancy as an ectopic pregnancy. World J Obstet Gynecol 2015; 4:58-63. [DOI: 10.5317/wjog.v4.i3.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 05/16/2015] [Accepted: 07/17/2015] [Indexed: 02/05/2023] Open
Abstract
In women at risk for an ectopic pregnancy, every effort should be made to exclude the presence of an intrauterine pregnancy before embarking on an irreversible treatment for ectopic pregnancy. The diagnosis of ectopic pregnancy, unless directly visualized with transvaginal ultrasound, is made with the exclusion of an intrauterine pregnancy. Measurement of human chorionic gonadotrophin and progesterone levels, and transvaginal ultrasound are the tools used to evaluate early pregnancy. In women at risk for an ectopic pregnancy, every effort should be made to exclude the presence of an intrauterine pregnancy before embarking on an irreversible treatment course. Methotrexate is an antimetabolite that inhibits DNA synthesis and repair and cell replication. It is administered to ostensible destroy a pregnancy, especially ectopic pregnancies. When administered to an intrauterine pregnancy, embryonic death and missed abortion is the most common result, but early embryos that survive this exposure are likely to have multiple anomalies. The mistaken administration of methotrexate to an intrauterine pregnancy is made because of misinterpretation of the discriminatory zone of human chorionic gonadotropin (hCG), misinterpretation of early hCG serum levels, misinterpretation of early transvaginal ultrasound images, and failure to clinically correlate hCG levels and ultrasound findings.
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Erol O, Suren D, Unal B, Ozel D, Kumru S, Sezer C. Significance of trophoblastic infiltration into the tubal wall in ampullary pregnancy. Int J Surg Pathol 2015; 23:271-6. [PMID: 25710937 DOI: 10.1177/1066896915572682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A total of 81 patients with an ampullary ectopic pregnancy undergoing salpingectomy were enrolled in the study. The ampullary pregnancies were classified according to the depth of trophoblastic infiltration into tubal wall as follows: Stage I, limited to mucosa; Stage II, extension to the tubal muscularis; Stage III, complete tubal wall infiltration up to the serosa. An association was observed between serum β-human chorionic gonadotropin (β-hCG) levels and the depth of trophoblastic infiltration. Significantly higher severe ischemic changes and rupture of tubal wall were observed in patients with stage III infiltration compared with the other groups. A significant association was found between the absolute depth of trophoblastic invasion and severe ischemic changes, and also rupture of serosa. In conclusion, serum β-hCG levels are associated with depth of trophoblastic invasion into the tubal wall, severe ischemic changes, and rupture of the tubal wall.
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Affiliation(s)
- Onur Erol
- Antalya Training and Research Hospital, Antalya, Turkey
| | - Dinc Suren
- Antalya Training and Research Hospital, Antalya, Turkey
| | | | | | | | - Cem Sezer
- Antalya Training and Research Hospital, Antalya, Turkey
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Dominguez F, Moreno-Moya JM, Lozoya T, Romero A, Martínez S, Monterde M, Gurrea M, Ferri B, Núñez MJ, Simón C, Pellicer A. Embryonic miRNA profiles of normal and ectopic pregnancies. PLoS One 2014; 9:e102185. [PMID: 25013942 PMCID: PMC4094496 DOI: 10.1371/journal.pone.0102185] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 06/16/2014] [Indexed: 12/27/2022] Open
Abstract
Our objective was to investigate the miRNA profile of embryonic tissues in ectopic pregnancies (EPs) and controlled abortions (voluntary termination of pregnancy; VTOP). Twenty-three patients suffering from tubal EP and twenty-nine patients with a normal ongoing pregnancy scheduled for a VTOP were recruited. Embryonic tissue samples were analyzed by miRNA microarray and further validated by real time PCR. Microarray studies showed that four miRNAs were differentially downregulated (hsa-mir-196b, hsa-mir-30a, hsa-mir-873, and hsa-mir-337-3p) and three upregulated (hsa-mir-1288, hsa-mir-451, and hsa-mir-223) in EP compared to control tissue samples. Hsa-miR-196, hsa-miR-223, and hsa-miR-451 were further validated by real time PCR in a wider population of EP and control samples. We also performed a computational analysis to identify the gene targets and pathways which might be modulated by these three differentially expressed miRNAs. The most significant pathways found were the mucin type O-glycan biosynthesis and the ECM-receptor-interaction pathways. We also checked that the dysregulation of these three miRNAs was able to alter the expression of the gene targets in the embryonic tissues included in these pathways such as GALNT13 and ITGA2 genes. In conclusion, analysis of miRNAs in ectopic and eutopic embryonic tissues shows different expression patterns that could modify pathways which are critical for correct implantation, providing new insights into the understanding of ectopic implantation in humans.
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Affiliation(s)
- Francisco Dominguez
- Fundación IVI, Instituto Universitario IVI, INCLIVA, Valencia, Spain
- INCLIVA Biomedical Research, Valencia, Spain
- * E-mail:
| | | | | | | | | | | | | | | | | | - Carlos Simón
- Fundación IVI, Instituto Universitario IVI, INCLIVA, Valencia, Spain
| | - Antonio Pellicer
- Fundación IVI, Instituto Universitario IVI, INCLIVA, Valencia, Spain
- Hospital Universitario LaFe, Valencia, Spain
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Krissi H, Peled Y, Eitan R, Bishara A, Goldchmit C, Ben-Haroush A. Single-dose methotrexate injection for treatment of ectopic pregnancy in women with relatively low levels of human chorionic gonadotropin. Int J Gynaecol Obstet 2013; 121:141-3. [DOI: 10.1016/j.ijgo.2012.11.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 11/10/2012] [Accepted: 01/23/2013] [Indexed: 12/27/2022]
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Abdulaziz Al-Turki H. Trends in ectopic pregnancies in eastern saudi arabia. ISRN OBSTETRICS AND GYNECOLOGY 2013; 2013:975251. [PMID: 23533797 PMCID: PMC3596907 DOI: 10.1155/2013/975251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Accepted: 01/22/2013] [Indexed: 12/27/2022]
Abstract
Background. The objective of this study was to estimate trends in ectopic pregnancies (EP) in a tertiary care center of Eastern Saudi Arabia. Method. Information about patients with ectopic pregnancies who had been admitted to King Fahd Hospital of the University, AlKhobar, between January 2000 and 31 December 2011 was collected from a computerized hospital registry. Age-specific ectopic pregnancy incidence was calculated. The data was analyzed using SPSS (Statistical Package for the Social Sciences), version 14.0 (Chicago, IL, USA). Results. There were 274 EPs during the study period; the yearly incidence in terms of 24,098 deliveries was 1.19%. The average age was 28.99 Å 5.62 years. During a three-year period (2000-2002), the incidence was 0.92%; from 2003 to 2005, the incidence was 1.01%; from 2006 to 2008, the incidence was 1.51%; and from 2009 to 2011, the incidence was 1.35%. Age-adjusted ectopic pregnancy incidence rates steadily increased from 92.23 per 10,000 women years during the period 2000-2002 to 149.408 during the 2006-2008 period; since then, it has declined to 110.313 per 10,000 women years. Conclusions. Our study reveals that the incidence of EP has decreased from what it had been during the mid-2000s but has remained significantly elevated when compared to the early 2000s.
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Affiliation(s)
- Haifa Abdulaziz Al-Turki
- College of Medicine, University of Dammam, Dammam 31442, Saudi Arabia
- King Fahd Hospital of the University, Al-Khobar 31952, Saudi Arabia
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Selim MF. Does Salpingotomy for Tubal Ectopic Pregnancy Always Require Methotrexate Prophylaxis? J Gynecol Surg 2012. [DOI: 10.1089/gyn.2011.0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Veena P. Use of Mifepristone along with methotrexate in medical management of unruptured ectopic pregnancy. J OBSTET GYNAECOL 2011; 31:667. [DOI: 10.3109/01443615.2011.593651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Foster AM, Dennis A, Smith F. Do Religious Restrictions Influence Ectopic Pregnancy Management? A National Qualitative Study. Womens Health Issues 2011; 21:104-9. [DOI: 10.1016/j.whi.2010.11.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 11/15/2010] [Accepted: 11/16/2010] [Indexed: 12/27/2022]
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Stein JC, Wang R, Adler N, Boscardin J, Jacoby VL, Won G, Goldstein R, Kohn MA. Emergency Physician Ultrasonography for Evaluating Patients at Risk for Ectopic Pregnancy: A Meta-Analysis. Ann Emerg Med 2010; 56:674-83. [DOI: 10.1016/j.annemergmed.2010.06.563] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2010] [Revised: 06/03/2010] [Accepted: 06/28/2010] [Indexed: 12/27/2022]
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Moon HS, Kim SG, Park GS, Choi JK, Koo JS, Joo BS. Efficacy of bleeding control using a large amount of highly diluted vasopressin in laparoscopic treatment for interstitial pregnancy. Am J Obstet Gynecol 2010; 203:30.e1-6. [PMID: 20451893 DOI: 10.1016/j.ajog.2010.02.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2009] [Revised: 11/25/2009] [Accepted: 02/10/2010] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We sought to report the safety and effectiveness of bleeding control using a large amount of highly diluted vasopressin in laparoscopic management of interstitial pregnancy. STUDY DESIGN This was an uncontrolled retrospective review of 20 patients who were laparoscopically treated for interstitial pregnancy using a large amount of highly diluted vasopressin. For hemostasis, 1 ampule of vasopressin was diluted in 1000 mL of normal saline (1000-fold) and 150-250 mL of diluted vasopressin was injected in the uterus below interstitial pregnancy. RESULTS Mean patient age and gestational age was 33.5 years and 6.7 weeks, respectively. Mean blood loss was 24 mL. The mean serum human chorionic gonadotropin level was 10,950, 4065, and 959 mIU/mL on the day of operation and postoperative days 1 and 4, respectively. CONCLUSION Laparoscopic management of interstitial pregnancy using a large amount of highly diluted vasopressin is safe and effective in hemostasis with minimal blood loss and no complications.
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Casanova BC, Sammel MD, Chittams J, Timbers K, Kulp JL, Barnhart KT. Prediction of outcome in women with symptomatic first-trimester pregnancy: focus on intrauterine rather than ectopic gestation. J Womens Health (Larchmt) 2009; 18:195-200. [PMID: 18991513 DOI: 10.1089/jwh.2008.0896] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Symptoms of vaginal bleeding and abdominal pain are common in cases of ectopic pregnancy (EP), spontaneous abortions (SAB), and complications of an intrauterine pregnancy (IUP). It is important to determine if efforts should focus on differentiating EP from an IUP (IUP + SAB) or a viable IUP from a nonviable gestation (EP + SAB) in women at risk for EP. METHODS This is a retrospective cohort study of women who presented with bleeding or pain or both during the first trimester of pregnancy. The cohort was divided into subjects diagnosed with IUP vs. (EP + SAB). The same cohort was then divided into subjects diagnosed with EP vs. (IUP + SAB). Logistic regression models based on risk factors for both outcomes (EP vs. [IUP + SAB] and IUP vs. [EP + SAB]) were obtained. ROC curves as well as Hosmer-Lemeshow goodness of fit and Akaike's information criterion (AIC) were used. RESULTS Overall, 18.1% (n = 367) of the women were diagnosed with EP, 58.8% (n = 1192) were diagnosed with an SAB, and 23.1% (n = 467) had an ongoing IUP. The area under the ROC curve for the model IUP vs. (EP + SAB) was statistically greater than the model EP vs. (IUP + SAB), p < 0.001. AIC and Hosmer-Lemeshow goodness of fit confirmed the better accuracy of the model comparing IUP vs. (EP + SAB). CONCLUSIONS Information collected at initial presentation from women at risk for EP to be used for building prediction rules should focus on differentiating a viable from a nonviable pregnancy rather than attempting to distinguish an extrauterine from an intrauterine pregnancy. However, this distinction should not affect current clinical care.
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Affiliation(s)
- Bruno C Casanova
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, University of Pennsylvania, Philadelphia, PA 19104, USA
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The expression of receptivity markers in the fallopian tube epithelium. Histochem Cell Biol 2009; 132:159-67. [DOI: 10.1007/s00418-009-0593-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2009] [Indexed: 12/27/2022]
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Aggarwal A, Thomas M, Spitzer RF, Kives S, Allen L. Methotrexate in the Management of Adolescents With Ectopic Pregnancies: A Physician Survey. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2009; 31:254-262. [DOI: 10.1016/s1701-2163(16)34124-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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20
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Tubal ectopic pregnancy: diagnosis and management. Arch Gynecol Obstet 2008; 279:443-53. [DOI: 10.1007/s00404-008-0731-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2008] [Accepted: 07/08/2008] [Indexed: 12/27/2022]
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Silva C, Sammel MD, Zhou L, Gracia C, Hummel AC, Barnhart K. Human chorionic gonadotropin profile for women with ectopic pregnancy. Obstet Gynecol 2007; 107:605-10. [PMID: 16507931 DOI: 10.1097/01.aog.0000198635.25135.e7] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To analyze serial human chorionic gonadotropin (hCG) levels in women presenting to the emergency department who were ultimately confirmed to have ectopic pregnancies. METHODS Human chorionic gonadotropin levels were obtained over time until definitive diagnosis. To be included, women had to have at least 2 hCG measurements. Human chorionic gonadotropin curves were characterized and their slopes calculated. RESULTS Two hundred women received diagnoses of ectopic pregnancy with the help of serial hCG values and were included in the study. No curve adequately characterized the pattern of hCG values so attention was focused on the initial 2 values. The median slope of log hCG among all subjects was 0.11 (25% increase in 2 days). However, 60% of subjects had an initial rise in hCG, and 40% had an initial fall. The rise in hCG for women with ectopic pregnancies (0.28; 75% increase in 2 days) was slower than the mean increase reported for a viable intrauterine pregnancy. The decline in hCG for women with ectopic pregnancies (-0.225; 27% decline in 2 days) was slower than the mean reported for completed spontaneous abortion. However, 20.8% of women presented with a rise in hCG values similar to the minimal rise for women with a viable gestation, and 8% of women presented with a fall in hCG values similar to women with a completed spontaneous abortion. CONCLUSION There is no single way to characterize the pattern of hCG for ectopic pregnancy. The number of women with ectopic pregnancy who experience an increase in hCG values is approximately equal to the number of those who experience a decrease. The hCG profile in women with ectopic pregnancy can mimic that of an intrauterine pregnancy or a completed spontaneous abortion in approximately 29% of cases. LEVEL OF EVIDENCE II-2.
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Affiliation(s)
- Celso Silva
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104, USA
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Huang SC, Hsu TY. Term tubal pregnancy with a liveborn and healthy baby. Pediatr Dev Pathol 2007; 10:69-71. [PMID: 17378620 DOI: 10.2350/06-01-0009.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2006] [Accepted: 03/22/2006] [Indexed: 12/27/2022]
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Elito Junior J, Camano L. Unruptured tubal pregnancy: different treatments for early and late diagnosis. SAO PAULO MED J 2006; 124:321-4. [PMID: 17322952 PMCID: PMC11068276 DOI: 10.1590/s1516-31802006000600004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2006] [Accepted: 10/06/2006] [Indexed: 12/27/2022] Open
Abstract
CONTEXT AND OBJECTIVE There is evidence that ectopic pregnancies present different behavioral patterns. These distinct evolutions of ectopic pregnancies represent two different natural histories. To evaluate these evolution patterns, we compared patients undergoing medical treatment and expectant management according to their gestational age and initial beta-hCG levels. DESIGN AND SETTING Prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center. METHODS Among 119 cases of unruptured ectopic pregnancies diagnosed from April 1999 to February 2004, 57 received systemic treatment with methotrexate 50 mg/m(2) (body surface area) intramuscularly and 62 were managed expectantly. In this study we evaluated the beta-hCG levels at presentation and amenorrhea duration. RESULTS There was a significant difference between the two groups regarding amenorrhea duration and initial beta-hCG levels (p < 0.001). The group with decreasing beta-hCG levels (managed expectantly) had longer amenorrhea (mean: 8.87 +/- 1.71 weeks) and lower initial beta-hCG levels (mean: 648.8 +/- 754.7 mIU/ml). On the other hand, the group treated with methotrexate had shorter amenorrhea (mean: 6.81 +/- 1.88 weeks) and higher beta-hCG levels at presentation (2642.7 +/- 2315.1 mIU/ml). CONCLUSIONS The data suggest that ectopic pregnancies can be categorized into two groups: those with early diagnosis and shorter amenorrhea, increasing or maintained beta-hCG levels over 24 and 48-hour intervals and higher beta-hCG levels requiring medical treatment; and those with late diagnosis and longer amenorrhea, decreased beta-hCG levels over 24 and 48-hour intervals and lower beta-hCG levels requiring expectant management.
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Affiliation(s)
- Julio Elito Junior
- Department of Obstetrics, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.
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Abstract
Women who present with pain and bleeding in the first trimester are at risk for ectopic pregnancy, a life-threatening condition. Conditions that predispose a woman to ectopic pregnancy are damaged fallopian tubes from prior tubal surgery or previous pelvic infection, smoking, and conception using assisted reproduction. Many women without risk factors can develop an ectopic pregnancy. A diagnostic algorithm that includes the use of transvaginal ultrasonography, human chorionic gonadotropin (hCG) concentrations, and, sometimes, uterine curettage can definitively diagnose women at risk in a timely manner. The absence of an intrauterine pregnancy above an established cut point of hCG is consistent with an abnormal pregnancy but does not distinguish a miscarriage from an ectopic pregnancy. When the initial hCG value is low, serial hCG values can be used to determine whether a gestation is potentially viable or spontaneously resolving. The minimal rise in hCG for a viable pregnancy is 53% in 2 days. The minimal decline of a spontaneous abortion is 21-35% in 2 days, depending on the initial level. A rise or fall in serial hCG values that is slower than this is suggestive of an ectopic pregnancy. Women diagnosed with an unruptured ectopic pregnancy are potential candidates for medical management with methotrexate. Intramuscular injection with methotrexate can be used to safely treat an ectopic pregnancy with success rates, tubal patency rates, and future fertility that are similar to those obtained with conservative surgery. Success rates using methotrexate are inversely rated to baseline hCG values and are higher using "multidose" compared with "single-dose" regimens. Surgical treatment may be conservative or definitive and should be attempted in most cases via laparoscopy.
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Affiliation(s)
- Beata E Seeber
- Department of Obstetrics and Gynecology, Penn Fertility Care, Philadelphia, PA 19003, USA
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Duggal BS, Tarneja P, Sharma RK, Rath SK, Wadhwa RD. Laparoscopic Management of Ectopic Pregnancies. Med J Armed Forces India 2004; 60:220-3. [PMID: 27407636 DOI: 10.1016/s0377-1237(04)80049-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
To compare the laparoscopic approach with laparotomy in the treatment of ectopic pregnancy, a retrospective analysis involving 52 patients with ectopic pregnancies was done. The aim of this study was to evaluate the safety and efficacy of laparoscopic surgery for ectopic pregnancies. 30 patients underwent laparoscopic management while 22 patients were managed by conventional laparotomy. In the laparoscopic group, the postoperative morbidity and post-hospital stay were significantly less. Although laparoscopic surgery for ectopic pregnancies is a new approach and it is not widely practised in service hospitals, it has more advantages than open surgery and it has been well accepted by the surgeons and patients. It is a safe and feasible approach.
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Affiliation(s)
- B S Duggal
- Classified Specialist (Obstetrics and Gynaecology), Military Hospital, Shillong
| | - P Tarneja
- Ex-Professor and Head, Department of Obstetrics and Gynaecology, Armed Forces Medical College, Pune
| | - R K Sharma
- Classified Specialist (Obstetrics and Gynaecology), Army Hospital (R & R), Delhi Cantt
| | - S K Rath
- Classified Specialist (Obstetrics and Gynaecology), 151 Base Hospital, C/o 99 APO
| | - R D Wadhwa
- Classified Specialist (Obstetrics and Gynaecology), Military Hospital, Dehradun
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Affiliation(s)
- Anthony R Pivarunas
- Department of Obstetrics and Gynecology, Sisters of Charity Hospital, Buffalo, NY
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Barnhart KT, Rinaudo P, Hummel A, Pena J, Sammel MD, Chittams J. Acute and chronic presentation of ectopic pregnancy may be two clinical entities. Fertil Steril 2003; 80:1345-51. [PMID: 14667867 DOI: 10.1016/j.fertnstert.2003.04.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The diagnosis of ectopic pregnancy (EP) is often confirmed at presentation (acute), but often requires serial beta-hCG levels to confirm the diagnosis (chronic). The purpose of this study is to analyze whether these clinical presentations represent a spectrum of disease. DESIGN The retrospective cohort study of 452 patients diagnosed with EP at the University of Pennsylvania in the years 1990-1999. SETTING University of Pennsylvania, Philadelphia, Pennsylvania. PATIENT(S) Four hundred fifty-two patients diagnosed with EP. Patients diagnosed with EP were divided into two groups according to the time of diagnosis. MAIN OUTCOME MEASURE(S) A total of 37 parameters were examined including historic and demographic factors, findings at presentation, and treatment and outcome variables. RESULT(S) The two groups were similar in terms of historic EP risk factors. Multivariable analysis demonstrates that women with a chronic presentation were less likely to have received fertility medications (odds ratio [OR] 0.23; 95% confidence interval [CI] 0.06-0.84), less likely to present with pain (OR 0.29; 95% CI 0.12-0.71), have a lower beta-hCG level at presentation (9,849 mIU/mL +/- 16,726 vs. 1,787 mIU/mL +/- 4,717), lower chance of rupture (OR 0.19; 95% CI 0.05-0.73), and less frequently have blood type 0. CONCLUSION(S) Women diagnosed with ectopic pregnancy can be categorized into two groups, those with an acute presentation and those with a chronic presentation. Differences in risk factors, presentation, and outcome may reflect differences in trophoblast viability or invasive potential.
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Affiliation(s)
- Kurt T Barnhart
- Center for Reproductive Medicine and Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19104, USA.
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Abstract
BACKGROUND To determine the incidence and reasons for misdiagnosis in interstitial ectopic pregnancy. METHODS We conducted a retrospective study from 1990 to 2001. Women with interstitial pregnancy were identified and their case records retrieved and reviewed. Reasons for delay in diagnosis and associated morbidity were recorded. RESULTS Thirty-six women were diagnosed as having interstitial pregnancy during the study period. Initial diagnosis was incorrect in 15 cases (41.7%). In 14 cases, the interstitial pregnancies were mistaken as intrauterine pregnancy. These misdiagnoses resulted in six inappropriate surgical procedures (evacuation of uterus) being performed and led to rupture of interstitial pregnancy in eight women. In two women, the interstitial pregnancy was mistaken as normal intrauterine pregnancy while the uterus itself was thought to be a cervical fibroid. In both cases, the interstitial pregnancies ruptured at 18-20 weeks of gestation. CONCLUSION Despite advances in sonographic skills and equipment and the availability of beta-human chorionic gonadotropin (hCG) monitoring, misdiagnosis of interstitial pregnancy still occurs frequently. Clinicians should be aware of the limitations of various investigations and maintain a high index of suspicion.
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Affiliation(s)
- Louis Yik-Si Chan
- Department of Obstetrics and Gynecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
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Abstract
Ectopic pregnancy (EP) is a major cause of maternal morbidity and mortality. The treatment of this condition is primarily surgical, but medical management in selected cases is safe, effective, cost-effective and eliminates the morbidity of surgery. Methotrexate (MTX) is a folate antagonist that can be used for non-oncologic purposes including the treatment of EP. The dose and duration of MTX therapy for EP is much lower than that used in oncology cases, thus reducing side effects and increasing safety. MTX selectively acts on rapidly dividing cells, such as trophoblast cells which comprise the implantation site of the early gestation. The two most common methods of administering MTX to patients with EP are im. administration of a single-dose, based on body surface area and calculated by the equation 50 mg/m(2) (without the need for leucovorin rescue), or the multiple-dose regimen of 1 mg/kg of MTX, alternating with 0.1 mg/kg of leucovorin rescue. Both methods have a similar side effect profile, resulting in the rare occurrence of nausea, vomiting, stomatitis, elevated liver function tests, anorexia and diarrhoea. The two methods yield success rates similar to those of conservative surgical therapy with similar future fertility. The potential single- and multi-dose methods have never been directly compared, but it appears that the success of multiple dosing is more effective. As the efficacy of MTX therapy is not 100%, women must be followed clinically until there is compete resolution of human Chorionic Gonadotropin (hCG) titres from their serum.
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Affiliation(s)
- K Barnhart
- Division of Human Reproduction, Department of Obstetrics and Gynecology, 106 Dulles, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
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Sowter MC, Farquhar CM, Petrie KJ, Gudex G. A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy. BJOG 2001; 108:192-203. [PMID: 11236120 DOI: 10.1111/j.1471-0528.2001.00038.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
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.
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Affiliation(s)
- M C Sowter
- University Department of Obstetrics and Gynaecology, National Women's Hospital, Auckland, New Zealand
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Sowter MC, Farquhar CM, Petrie KJ, Gudex G. A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy. ACTA ACUST UNITED AC 2001. [DOI: 10.1016/s0306-5456(00)00038-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Barnhart K, Esposito M, Coutifaris C. An update on the medical treatment of ectopic pregnancy. Obstet Gynecol Clin North Am 2000; 27:653-67, viii. [PMID: 10958010 DOI: 10.1016/s0889-8545(05)70162-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Medical treatment of ectopic pregnancy with methotrexate has been shown to be effective and safe in appropriate patients. When considering medical management, the definitive diagnosis of an ectopic pregnancy and the assurance that the patient is a candidate are of paramount concern. An understanding of the mechanism of action and pharmacokinetics of methotrexate allows the clinician to better inform patients, recognize and treat side effects, and be cognizant when treatment is unsuccessful. Two common protocols, the "multi-dose" and the "single-dose" protocols, have excellent success rates; however, neither one of these is completely effective. The "multi-dose" protocol appears to have a higher success rate than the "single-dose" protocol.
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Affiliation(s)
- K Barnhart
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Medical Center, Philadelphia, USA
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Abstract
Ectopic pregnancy occurs in approximately 2% of all pregnancies in the United States, and is the nation's leading cause of first trimester maternal death. Its incidence has increased sixfold in the past 25 years, despite significant improvements in techniques for early diagnosis and management. This article reviews the epidemiology, risk factors, and common clinical presentations of ectopic pregnancy. Both traditional and newly developed strategies for diagnosis and management are described. The primary care physician is in an excellent position to screen for and diagnose ectopic pregnancy, and to counsel patients regarding treatment options and future risks. With the increasing trend toward outpatient nonsurgical management of ectopics, it is expected that the roll of the primary care physician in managing patients with ectopic pregnancy will continue to increase.
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Affiliation(s)
- R J Carr
- Department of Family Medicine, Georgetown University/Providence Hospital Family Practice Residency Program, Washington, DC, USA.
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