New Evidence to Guide Ectopic Pregnancy Diagnosis and Management

A multicenter cohort study analysing the implementation of a new guideline for women with pregnancy of unknown location or ectopic pregnancy in the Netherlands

OBJECTIVE

Evaluation of the implementation of a new guideline for diagnosis and treatment of women with pregnancy of unknown location (PUL) or ectopic pregnancy (EP).

DESIGN

Multicenter retrospective cohort study.

SETTING

Six hospitals in the Northern part of the Netherlands.

POPULATION AND METHODS

Women above 18-years old with a final diagnosis of PUL or EP between January 2012 to April 2020.

MAIN OUTCOME MEASURES

Diagnostic findings, type of treatment and outcomes, before and after implementation of the guideline. User interpretation of the guidelines.

RESULTS

1306 women with PUL (N = 289) or EP (N = 1017) were included. The amount of women diagnosed with PUL has significantly (P < 0.001) increased between the previous guideline (16.6 %; 115/693) and the new guideline (28.4 %;174/693). A significantly lower percentage of women, after implementation of the new guideline, underwent surgical management (odds ratio [OR] = 0.516, 95 % confidence interval [CI] 0.399 - 0.668P < 0.001) versus treatment with MTX (odds ratio [OR]=2.529, 95% confidence interval [CI] 1.719-3.723, P<0.001). The overall success of treatment with MTX was 80.5 % (N = 103) compared to 95.2 % (N = 907) of surgery (P < 0.007). There was no observed difference in adverse events or guideline adherence between the guidelines.

CONCLUSION

The implementation of the new guideline contributes to an increase in women diagnosed with PUL and treated with MTX. Treatment with MTX caused more complications and a lower treatment success compared to women undergoing surgery. This did not lead to an increase in adverse events between the guidelines. The overall adherence to the guidelines was equal.

KEY MESSAGE

Implementation of the new guideline contributes to an increase in women diagnosed with PUL and conservative treatment with methotrexate (a drug with a higher risk of complications and a lower successful treatment compared to surgery), however this did not lead to an increase in adverse events between the old and new guideline.

Evaluating Medical and Surgical Treatments for Ectopic Pregnancy at a Tertiary Hospital in Dubai

INTRODUCTION

The current data about ectopic pregnancy in the UAE is limited, including the incidence, method of management, and its effectiveness. This study aimed to determine the frequency of medical and surgical management in the treatment of ectopic pregnancy and the efficacy of each modality used.

METHOD

Two hundred and nine patients were diagnosed with ectopic pregnancies in the years 2018 and 2019 in Latifa Hospital and were included in this study. The patients were treated with either intramuscular injection of methotrexate (single or two doses) or surgical management.

RESULTS

Methotrexate was administered to 101 patients (48%). In 77 patients (76%), a single dose of methotrexate was administered, and in 24 patients (24%), two doses of methotrexate were administered. In the single-dose group, 75.3% (58 out of 77 patients) were successfully treated and completely recovered. While in the two-dose group, the success rate was 58.3% (14 out of 24 patients). On the other hand, among patients who underwent surgical management, the success rate was 97.2% (105 out of 108 patients). The difference in the success rates was statistically significant.

CONCLUSION

The results of the study showed that medical and surgical management were used almost equally in managing patients with ectopic pregnancy (48% vs. 52%, respectively). Furthermore, it was shown that single-dose methotrexate treatment was more successful than two doses. However, surgical management had the highest success rate among the three modalities.

Successful Management of Cervical and Tubal Stump Double Pregnancy after Assisted Reproductive Technologies Using Multiple High Doses of Methotrexate: A Case Report

The incidence of ectopic pregnancy (EP) has increased in recent years, owing to causes such as pelvic inflammatory diseases and assisted reproductive technologies (ART). The present study reported a case of a 33-year-old nulliparous woman with a history of previous ectopic pregnancies, who underwent pelvic ultrasound in August 2022, which revealed a double EP including a cervical pregnancy and a tubal stump pregnancy. Despite known risk factors and elevated beta-human chorionic gonadotropin (β-hCG) levels, a conservative approach, utilizing multiple doses of systemic methotrexate (MTX) injections, was employed to preserve fertility at the Regional Perinatal Center in Aktobe, Kazakhstan. Treatment efficacy was monitored through β-hCG levels and ultrasound imaging, with successful resolution of both EPs and preservation of reproductive function. The present case highlighted the safety and efficacy of MTX therapy in managing complex EP presentations, emphasizing the necessity of individualized treatment approaches in reproductive medicine, particularly in terms of preserving fertility in patients undergoing ART. Multiple high doses of MTX injections were beneficial for pregnancy with two distinct regions, fetal cardiac activity, and elevated serum β-hCG level. Further research is required to explore optimal treatment strategies for EP, considering patient-specific factors and treatment goals.

Ectopic pregnancy in uterosacral ligament following in vitro fertilisation (IVF) in a patient with Allen-Masters syndrome

We describe the case of a woman with mild endometriosis and Allen-Masters syndrome after in vitro fertilisation (IVF), presenting at 7 weeks 2 days gestation with abdominal pain. A transvaginal ultrasound revealed a gestational sac with a non-viable fetus near the right ovary. Laparoscopy was performed due to escalating abdominal pain which revealed a ruptured ectopic pregnancy at the right uterosacral ligament (USL) and blood in the pouch of Douglas. A peritoneal incision along the USL facilitated drainage and removal of the ectopic pregnancy. A pathological investigation described the presence of endometrial tissue directly adjacent to products of conception, which suggested a retroperitoneal implantation that may have been facilitated by the presence of an endometriotic lesion. This case underscores the distinctive clinical trajectory of unconventional ectopic pregnancies, provides novel insights into the pathophysiological mechanism of ectopic implantation and underscores the crucial role of comprehensive patient assessment during IVF and subsequent pregnancy in ensuring effective management.

Interstitial ectopic pregnancy: A rare case report

INTRODUCTION

Interstitial pregnancies are a rare form of ectopic pregnancy with life threatening consequences. Thus, the aim of this report is to shed light on the importance of early diagnosis for optimal outcomes.

CASE PRESENTATION

Herein, we present a case of an interstitial ectopic pregnancy in a 31-year-old Syrian female who presented only with mild non-specific abdominal pain. The ultrasound showed a gestational sac in the right horn of the uterus non-communicating with the endometrial cavity suggesting an interstitial ectopic pregnancy. Cornual excision and salpingectomy were performed with laparotomy instead of laparoscopy due to resource-limited facilities. Follow-up with serum human chorionic gonadotropin β-HCG continued until the hormone levels became undetectable.

DISCUSSION

Interstitial ectopic pregnancies can present with non-classic symptoms. Ultrasonographic evaluation for lower abdominal pain in women at the first trimester is essential to detect interstitial ectopic pregnancies.

CONCLUSION

Early diagnosis is key to prevent the life threatening progression of interstitial pregnancy, so this diagnosis should be kept in mind in women presenting with first trimester abdominal pain and/or vaginal bleeding.

Successful management of prolonged abdominal pregnancy in low-resource setting: a case report

Ectopic pregnancy is a life-threatening complication of pregnancy and represents the leading cause of maternal mortality in the first trimester. In developing countries early diagnosis, necessary for favorable outcomes, is often unavailable and women are often not aware of possible conditions and associated complications. Moreover, access to sexual and reproductive health services and antenatal care are limited in such settings. Finally, management options are restricted and often performed in emergency with higher risk of complications and mortality. We report here a 33-year-old woman presenting a 41 weeks abdominal pregnancy successfully managed in a low-resource setting.

Imaging of Acute Abdominopelvic Pain in Pregnancy and Puerperium-Part I: Obstetric (Non-Fetal) Complications

Acute abdominopelvic pain in pregnant and postpartum patients presents clinical and therapeutic challenges, often requiring quick and accurate imaging diagnosis. Ultrasound remains the primary imaging investigation. Magnetic resonance imaging (MRI) has been shown to be a powerful diagnostic tool in the setting of acute abdominal pain during pregnancy and puerperium. MRI overcomes some drawbacks of US, avoiding the ionizing radiation exposure of a computed tomography (CT) scan. Although CT is not usually appropriate in pregnant patients, it is crucial in the emergency evaluation of postpartum complications. The aim of this article is to provide radiologists with a thorough familiarity with the common and uncommon pregnancy and puerperium abdominal emergencies by illustrating their imaging appearances. The present first section will review and discuss the imaging findings for acute abdominopelvic pain of obstetric (non-fetal) etiology.

Suitable endometrial thickness on embryo transfer day may reduce ectopic pregnancy rate and improve clinical pregnancy rate

BACKGROUND

This retrospective study aimed to investigate the most suitable endometrial thickness (EMT) on the day of embryo transfer that could reduce ectopic pregnancy rate (EPR) and improve clinical pregnancy rate (CPR) in fresh embryo transfer patients with early follicular phase long-acting regimen.

METHODS

A total of 11,738 IVF/ICSI cycles, comprising 4,489 non-clinical pregnancies, 7,121 intrauterine pregnancies, and 128 ectopic pregnancy cycles after fresh embryo transfer, recorded between September 2017 and December 2020. Clinical pregnancy (CP) and ectopic pregnancy (EP) were the primary outcomes. Multivariate logistic regression was used to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI) for EP and CP. Patients were divided into three groups based on the EMT (6-10 mm, 11-15 mm, and 16-20 mm). CPR and EPR per millimeter of EMT were drawn into a line chart, and three groups were analyzed by Chi-square test.

RESULTS

After controlling for potential confounders, EMT had a significant effect on CP (aOR = 1.07; 95% CI, 1.05-1.08; P = 0.00) and EP (aOR = 0.88; 95% CI, 0.82-0.94; P = 0.00). With the increase of EMT, CPR increased and EPR decreased. Pearson correlation coefficients were r = 0.708 (P = 0.00) and r =-0.558 (P = 0.03), respectively. Significant differenceswere detected in the CPRs and EPRs (all P = 0.00). The CPR in the 6-10 mm group (54.88%) was significantly lower than that in the 11-15 mm group (64.23%) and the 16-20 mm group (64.40%) (P = 0.00). The EPR in the 6-10 mm group (2.72%) was significantly higher than that in the other two groups (1.60% and 0.97%, P = 0.00). The difference in CPR and EPR between the 11-15 mm group and the 16-20 mm group was not statistically significant, which indicated that EMT ≥ 11 mm simultaneously reduced the EPR and increased the CPR.

CONCLUSIONS

EMT was inversely proportional to EPR and directly proportional to CPR in fresh embryo transfer cycles. The EMT ≥ 11 mm on the day of embryo transfer could simultaneously achieve lower EPR and higher CPR. Accordingly, more attention should be given to the EMT of women who underwent ART treatment.

Comparison of the application value of transvaginal ultrasound and transabdominal ultrasound in the diagnosis of ectopic pregnancy

BACKGROUND

Ectopic pregnancy (EP) is one of the most common acute abdominal diseases in gynecology. Once the condition of EP is delayed, it may lead to massive hemorrhage, shock, and even death in a short time, seriously threatening the patient’s life. Early diagnosis is the key to preventing and improving the prognosis of EP. Transabdominal ultrasound (TAS) and transvaginal ultrasound (TVS) are the main diagnostic methods for abdominal diseases. The purpose of this study is to explore the application value and effect of TAS and TVS in the diagnosis of EP, hoping to provide more valuable references for the diagnosis of EP.

AIM

To explore the application value of TAS and TVS in the diagnosis of EP and to improve the level of clinical diagnosis.

METHODS

A total of 140 patients with EP admitted to our hospital from July 2018 to July 2020 were selected for this study. All patients were divided into two groups according to the examination methods. 63 patients who underwent abdominal ultrasound examination were set as the TAS group, while 77 patients who underwent TVS examination were set as the TVS group. We compared the diagnostic accuracy and misdiagnosis rates between the two types of ultrasound examinations, as well as the postoperative pathological results of the two diagnostic methods for different types of ectopic pregnancies. We also analyzed the sonograms for the presence of mixed ectopic masses, adnexal masses, ectopic gestational sacs, the presence or absence of visible embryo and fetal heart in the ectopic sac shadow, and the detection of fluid in the rectal fossa of the uterus, such as the adnexal area, yolk sac, and embryo, etc. In addition, the diagnosis time, days of gestational sac appearance, operation time, endometrial thickness, and blood flow resistance index were compared as well.

RESULTS

After performing both types of ultrasound examinations in 140 patients with EP, we found that the diagnostic accuracy of TVS was significantly higher than that of TAS, and the misdiagnosis rate was significantly lower than that of TAS. The differences were statistically significant (P < 0.05). In addition, the detection rate of TVS was better than that of TAS for the presence of mixed masses, adnexal masses, ectopic gestational sacs, the presence or absence of visible embryo and fetal heart in the shadow of the ectopic sac, and sonograms such as the adnexal area, yolk sac, and embryo, etc. The coincidence rate of its postoperative pathological examination results was significantly higher than those of TAS. The diagnosis time and the days of gestational sac appearance by TVS were significantly shorter than that by TAS, and the operation time was earlier than that by TAS. What’s more, the detection rates of the endometrial thickness £ 1.5 mm and blood flow resistance £ 0.5 were significantly higher in TVS diagnosis of EP than in TAS. All differences were statistically significant (P < 0.05).

CONCLUSION

Compared with TAS, TVS has the advantages of high detection accuracy and good sonogram performance.

Ectopic first pregnancy treated by methotrexate versus salpingectomy-Maternal and perinatal outcomes in a subsequent pregnancy: A retrospective study

OBJECTIVE

To study obstetric outcomes of a second pregnancy among women with a first ectopic pregnancy (EP) treated with methotrexate compared with laparoscopic salpingectomy.

METHODS

A retrospective cohort study including all women with a first EP and a following pregnancy that concluded by delivery at ≥24 weeks of gestation between March 2011 and April 2021. Second pregnancy outcomes were compared between women treated with methotrexate and those treated with salpingectomy in their first pregnancy.

RESULTS

Overall, 125 women were included, of which 64 (51.2%) were treated with methotrexate and 61 (48.8%) were treated with salpingectomy. In women treated with salpingectomy, the proportion of women conceiving by in vitro fertilization and those with measured gestational sac diameter or β-subunit human chorionic gonadotropin was higher. The proportion of women conceiving by in vitro fertilization in their second pregnancy was higher in the salpingectomy group (55.2% versus 18.0%, P < 0.001). All maternal and neonatal outcomes were similar in both groups. The rate of low birth weight < 2500 g was 7.8% in the methotrexate group versus 18% in the salpingectomy group (P = 0.111).

CONCLUSION

Maternal and neonatal outcomes of a second pregnancy among women treated for EP in their first pregnancy are similar in women treated by methotrexate and those treated by salpingectomy.

Clinical Presentation as a Predictor of the Response to Methotrexate Therapy in Patients with Ectopic Pregnancy

Purpose

Ectopic pregnancy can be fatal if not diagnosed and timely treated. There is an increase in ectopic pregnancy rate which attributes in part to fertility medications and procedures and early diagnosis. Methotrexate, a folic acid antagonist, is widely used in the medical treatment of ectopic pregnancy. Many studies examined the safety and success rate of methotrexate looking into factors affecting the success rate, if the patient may present with symptoms such as abdominal pain, and some consider this as impeding rupture and it might affect the success of medical treatment. This study evaluates the success rate of methotrexate treatment outcomes in regard to presentation and looks into other factors that can help choosing a single or multiple dose modality.

Methods

This is a retrospective review of 154 cases of ectopic pregnancy treated with methotrexate from January 2011 to December 2020 at King Khalid University Hospital (KKUH). Demographic data, clinical presentation, treatment progress, and outcome and failure rate were collected and analyzed. Student's t-test was used for statistical analysis of associations in SPSS.

Results

154 patients were treated with MTX; of those patients, 25 received more than one dose. The difference between the responses to MTX treatment in symptomatic and asymptomatic individuals was not significant (p = 0.267). 131 (85%) had successful treatment. There were no associations between patient BMI, ectopic mass size, or ectopic mass site, the presence or absence of pelvic fluid on ultrasound at diagnosis, and the treatment success rate. There was a significant decline in the treatment success rate with increasing β-hCG levels on the presentation day (p = 0.035) and on day 4 (p value <0.001) of treatment.

Conclusion

MTX treatment can be used to manage symptomatic patients with ectopic pregnancy. The success rate in symptomatic patients is not different from that in asymptomatic patients. β - hCG levels > 5000 IU/L. Pretreatment and on day 4 posttreatment is associated with higher failure rate.

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

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

Shikonin Could Be Used to Treat Tubal Pregnancy via Enhancing Ferroptosis Sensitivity

Background

Albeit oxidative stress has been implied in the pathogenesis of tubal pregnancy (TP), there are scant data to suggest that ferroptosis occurs in TP. Shikonin plays a pivotal role in redox status, but whether it can regulate ferroptosis to treat TP remains unknown.

Methods

We collected and analyzed ferroptosis-related indices from the villous tissue (VT) of women suffering from TP and from women with a normal pregnancy. In vitro, we used shikonin and/or RAS-selective lethal 3 (RSL3) to intervene HTR-8/SVneo cells and further detected ferroptosis indices and cell functions. Finally, the expression of the nuclear factor erythroid 2-related factor 2 (Nrf2) is pharmacologically activated to explore the effect of Nrf2 on shikonin regulating ferroptosis.

Results

Increased malondialdehyde content, reduced levels of glutathione and glutathione peroxidase (GPx), and upregulated protein expression which promoted ferroptosis were observed in the VT of TP patients, suggesting that ferroptosis occurred during TP. In vitro, shikonin enhanced ferroptosis sensitivity in HTR-8/SVneo cells induced by RSL3 via amplifying lipid peroxidation, which mainly included increasing cellular reactive oxygen species (ROS), lipid ROS and Fe²⁺ level. RSL3 and/or shikonin inhibited Nrf2 and downregulated protein expression of SLC7A11 and GPx4 caused by RSL3 + shikonin co-treatment, which could be reversed under activation of Nrf2. Hence, shikonin facilitated lipid peroxidation by inhibiting Nrf2 signaling. Additionally, shikonin and/or RSL3 potently inhibited the invasion and migration of HTR-8/SVneo cells.

Conclusion

This study firstly showed that ferroptosis may be involved in TP pathogenesis and shikonin potentially targeted ferroptosis to treat TP.

Predicting the Outcome of a Pregnancy of Unknown Location: What Can the Endometrial Stripe Thickness Reveal?

Objectives:

To investigate the role of the uterine endometrial thickness and sonographic pattern as potential predictors for a pregnancy with an unknown location (PUL) and its possible outcomes.

Materials and Methods:

A convenient sample of 330 symptomatic extra preposition female patients were enrolled in this study with a diagnosis of PUL. The clinical variables of endometrial stripe thickness and endometrial sonographic pattern were determined with transvaginal sonography. These sonographic examinations (it seems that examination in this context is a countable noun) were conducted during the first 24 hours of referral, and their predictive values for PUL outcomes (normal intrauterine pregnancy (IUP), ectopic pregnancy (EP), and pregnancy loss) were assessed after clinical follow-up sessions provided a definite outcome. The statistical significance was set a priori at a P value < .05.

Results:

The mean initial endometrial stripe thickness among participants, with a normal IUP, was more than those patients with an abnormal pregnancy outcome ( P < .05). The optimum cut-off value for predicting a an EP, compared to a normal IUP was 11 mm and had a sensitivity of 73.3% and specificity of 39% ( P < .001). These results also demonstrated no statistically significant relationship between the PUL outcome and the categories of endometrial sonographic pattern ( P = .15).

Conclusion:

In this large cohort of patients, the endometrial stripe thickness of more than 11 mm, among those who were symptomatic and deemed as PUL, had the potential to predict ectopic pregnancy as an unlikely diagnosis.

Term Abdominal Pregnancy with Live Baby: Case Report from Hiwot Fana Specialized University Hospital, Eastern Ethiopia

Purpose

To present a rare case of term abdominal pregnancy with live baby.

Observation

A 30-year-old gravida VI para V, all alive, woman who did not remember her last menstrual period but was stated amenorrheic for 9 months visited Hiwot Fana Specialized University Hospital (HFSUH) with abdominal pain of two weeks duration. The woman was diagnosed with a term abdominal pregnancy and underwent a laparotomy. The outcome of treatment was a 3200 gm healthy male baby and a total abdominal hysterectomy was done.

Conclusion and Importance

Term abdominal pregnancy is an extremely rare type of ectopic pregnancy that can cause diagnostic challenges and leads to life threatening conditions both before and after diagnosis because of the rupture of major blood vessels.

Retrospective Evaluation of Patients Treated for Ectopic Pregnancy: Experience of a Tertiary Center

OBJECTIVE

 In recent years, there has been an increase in the incidence of ectopic pregnancies; therefore, it is important for tertiary centers to report their approaches and outcomes to expand and improve treatment modalities. The aim of the present study was to evaluate the general characteristics, treatment and outcomes of cases diagnosed with ectopic pregnancy.

METHODS

 In total, 432 patients treated for ectopic pregnancy between February 2016 and June 2019 were retrospectively evaluated.

RESULTS

 Overall, 370 patients had tubal pregnancy, 32 had cesarean scar pregnancy, 18 had pregnancy of unknown location, 6 had cervical pregnancy, and 6 had interstitial pregnancy. The most important risk factors were advanced age (> 35 years; prevalence: 31.2%) and smoking (prevalence: 27.1%). Thirty patients who did not have any symptoms of rupture and whose human chorionic gonadotropin (β-hCG) levels were ≤ 200 mIU/ml were followed-up with expectant management, while 316 patients whose β-hCG levels were between 1,500 mIU/ml and 5,000 mIU/ml did not have an intrauterine gestational sac on the transvaginal or abdominal ultrasound, did not demonstrate findings of rupture, and were treated with a systemic multi-dose methotrexate treatment protocol. In total, 24 patients who did not respond to the medical treatment, 20 patients whose β-hCG levels were > 5,000 mIU/ml, 16 patients who had shown symptoms of rupture at the initial presentation, and 6 patients diagnosed with interstitial pregnancy underwent surgery. Patients with cervical and scar pregnancies underwent ultrasound-guided curettage, and no additional treatment was needed.

CONCLUSION

 The fertility status of the patients, the clinical and laboratory findings, and the levels of β-hCG are the factors that must be considered in planning the appropriate treatment.

Pristimerin Suppresses Trophoblast Cell Epithelial-Mesenchymal Transition via miR-542-5p/EGFR Axis

Background

Ectopic pregnancy (EP) is an ectopic embryo implantation occurred outside the uterine cavity. Nowadays, more attention have garnered in fast and effective treatment with less side effects. Pristimerin is known as the clinical application for anti-cancer, and the effect on EP therapy is still unclear.

Materials and Methods

Trophoblast cell line HTR-8/SVneo was used; then, we performed cell counting kit-8 assay, wound healing assay, flow cytometry and real-time polymerase chain reaction analysis (RT-PCR) to detect the cell viability, migration ability, apoptosis and epithelial–mesenchymal transition (EMT) under pristimerin treatment. In addition, public bioinformatic database was used to discover the connection between molecular and genes. Finally, we used miRNA transfection and RT-PCR techniques to determine the underlying molecular mechanism.

Results

We revealed that pristimerin inhibited trophoblast cells proliferation, migration and EMT, while induced trophoblast cell apoptosis. Furthermore, expression of miR-542-5p, AGO2 and EGFR was suppressed in HTR-8/SVneo cells post pristimerin treatment, and miR-542-5p silence showed the same effect. Combing pristimerin treatment and miR-542-5p silence showed a synergistic action.

Conclusion

Pristimerin could be an effective treatment to block embryo implantation by miR-542-5p and EGFR down-regulation.

Predictors and clinical features of methotrexate (MTX) therapy for ectopic pregnancy

BACKGROUND

Ectopic pregnancy is a major life- and fertility-threatening women's health concern. As a result of advances in examination technology, an increasing number of ectopic pregnancies can be diagnosed early and treated with medical methods instead of surgery. The aim of this study was to summarize the clinical features and identify the predictors of success of methotrexate (MTX) treatment of ectopic pregnancy.

METHODS

This was a retrospective study of 238 ectopic pregnancies treated with MTX in the Department of Gynecology of Shaanxi Provincial People's Hospital from January 2017 to December 2017.

RESULTS

Patients were divided into two groups: the successful treatment group (n = 166) and the failed treatment group (n = 72). The overall success rate of MTX therapy for ectopic pregnancy was 69.75%. The mean initial beta-human chorionic gonadotropin (β-hCG) level was significantly lower in the successful treatment group than in the failed treatment group (2538.08 IU/L versus 3533.17 IU/L, P = 0.000). The treatment success rate of the group with an initial β-hCG concentration less than 4000 IU/L was significantly higher than that of the group with an initial β-hCG concentration greater than 4000 IU/L. However, the success rate of the group with an initial β-hCG concentration greater than 4000 IU/L was still relatively high (54.55%). β-hCG levels were significantly increased on the 4th day in the failed treatment group (P = 0.000). Compared to the initial β-hCG level, the day-4 β-hCG level increased by more than 8.21%, indicating that the treatment was effective. The diagnostic sensitivity was 88.6%, the specificity was 74.5%, and the area under the receiver operating characteristic (ROC) curve was 0.863 (95% confidence interval (CI): 0.805-0.920).

CONCLUSIONS

MTX therapy as a treatment option is safe and effective for asymptomatic, hemodynamically stable patients with ectopic pregnancies who are interested in conservative treatment, regardless of the serum β-hCG level or adnexal mass size. The change in the β-hCG level between the initial day and the 4th day is an effective and early predictive tool for the success of MTX therapy for ectopic pregnancy.

Comparison of novel two-port and conventional multiport laparoscopic surgery approaches for benign adnexal masses: The Bagli method

AIM

This study primarily aims to describe the safety and efficacy of a novel two-port (5 and 10-mm) laparoscopic surgery (TPLS) approach for benign adnexal masses compared with conventional multiport laparoscopic surgery (CMLS) in excisional procedures such as salpingectomy and oophorectomy.

METHODS

This is a retrospective case-control study. Forty-four patients were divided into two groups: two-port (5 mm and 10 mm) laparoscopic surgery group (n: 22) and conventional multiport (three/four port) laparoscopic surgery group (n: 22), with similar indications. All procedures, except ovarian detorsions, included salpingectomy, oophorectomy or salpingo-ophorectomy. The groups were evaluated using their demographic, clinical, intraoperative and postoperative data, and survey questions that were asked were used for analyzing cosmetic satisfaction, surgical satisfaction and preference rates of the TPLS.

RESULTS

There were no significant differences between the groups on demographic features. All patients were discharged within 24 h after both the procedures without any major (organ injury) or minor complication. Surgical satisfaction range was 8.82 (±1.01) in TPLS group and 7.27 (±1.6) in the CMLS group, and differences were significant (P = 0.002). Satisfaction with cosmesis was 95% in the TPLS group and 77% in the CMLS group, and this difference was not significant (P = 0.11). The preferences rate of TPLS was 68% among the 44 women.

CONCLUSION

Novel TPLS is feasible and safe in expert hands. In addition, it provides more surgical satisfaction to patients. However, there were not significant differences in long-term cosmesis results between the TPLS and CMLS groups.

Case report of persistent elevation of βhCG in a nonpregnant woman: A diagnostic puzzle

Detectable serum levels of beta subunit of human chorionic gonadotropin (βhCG) in nonpregnant, perimenopausal women bring confusion in both clinician and patient and could lead to unnecessary diagnostic and therapeutic procedures. A 45-year-old woman with the continuous elevation of βhCG underwent hysteroscopy, two laparoscopic surgeries, two explorative uterine cavity curettages and three cycles of cytostatic therapy. No ultrasonographic, macroscopic or histological signs of pregnancy, both uterine and ectopic or gestational trophoblastic disease were found. Both radiographic and computed tomography reports ruled out the presence of a nongynecological neoplasm. All recommended steps were taken for confirmation or ruling out the possibility of heterophile antibodies interference, but the results were not absolute. Finally, the referent laboratory confirmed the presence of the antibodies, but their exact type remains unknown. This case underlines the importance of the universally accepted protocol in the cases of persistent βhCG elevation in nonpregnant, perimenopausal women.

Shikonin suppresses trophoblast cell growth via regulation of GLI1, and p62 mediated caspase 8 activation

Unruptured ectopic pregnancy (UEP) is a common cause of morbidity and, occasionally, of mortality in women of reproductive age. Pharmacological intervention is a common therapeutic approach for early-stage UEP. Herein, we investigated the cytotoxic effect and novel mechanism of shikonin, a natural naphthoquinone pigment purified from Lithospermum erythrorhizon, in human trophoblast cells. These data demonstrated that shikonin suppressed proliferation and induced apoptosis in a time-dependent manner in HTR-8/SVneo cells. Shikonin blocked autophagic flux and promoted p62 interaction with caspase 8, resulting in caspase 8 activation. Moreover, shikonin suppressed GLI1 expression, and GLI1 overexpression attenuated shikonin-induced cell apoptosis. Although silencing GLI1 slightly promoted cell apoptosis, p62 overexpression enhanced GLI1 silencing-induced cell apoptosis by activating caspase 8. Furthermore, rapamycin increased shikonin-induced cell apoptosis in HTR-8/SVneo cells, whereas 3-MA attenuated the cytotoxic effect of shikonin. In conclusion, shikonin suppressed trophoblast cell growth by silencing GLI1 and increasing p62 co-mediated activation of caspase 8, which suggested a potential novel therapeutic target for UEP.

Anesthetic efficacy of propofol combined butorphanol in laparoscopic surgery for ectopic pregnancy: A protocol of systematic review and meta-analysis

BACKGROUND

Recent studies have suggested that propofol combined butorphanol (PB) has anesthetic effect in laparoscopic surgery (LS) for ectopic pregnancy (EP). But investigations of its potential effects are inconsistent. We will explore the current literature examining PB in LS for EP.

METHODS

We will perform a comprehensive search from MEDLINE, Embase, Cochrane Library, PsycINFO, Global Health, Web of Science, Allied and Complementary Medicine Database, and China National Knowledge Infrastructure from inception to the present. Other literatures, such as conference abstracts, references to the relevant reviews will also be checked. Two authors will check the titles, abstracts, and full texts independently. They will also independently carry out data collection and study quality assessment. We will conduct statistical analysis using RevMan 5.3 software.

RESULTS

This study will provide accurate results on the anesthetic effect and safety of PB in LS for EP.

CONCLUSION

This study will establish high-quality evidence of the anesthetic effect and safety of PB in LS for EP to facilitate the clinical practice and guideline development.

STUDY REGISTRATION NUMBER

INPLASY202040044.

Risk Factors of Recurrent Ectopic Pregnancy in Patients Treated With in vitro Fertilization Cycles: A Matched Case-Control Study

Objective: To study the risk factors for recurrent ectopic pregnancy (REP) in patients undergoing in vitro fertilization (IVF). Methods: This was a 1:4 matched case-control study that enrolled 227 REP patients and 908 matched intrauterine pregnancy (IUP) patients from the assisted reproductive technology (ART) center of the First Affiliated Hospital of Zhengzhou University from January 2012 to November 2019. Univariate analysis was carried out between the two groups for the occurrence of REP. Multivariate logistic regression analysis was used to explore the risk factors of REP after IVF. Results: The results of univariate analysis showed that there were significant differences in previous treatment of EP, stage of embryo and the number of embryos transferred between the two groups (all P < 0.05). The other factors did not have a significant effect on the probability of developing REP. Multivariate logistic regression analysis showed that after adjusting for confounders, previous treatment of EP, type of embryos transferred and stage of embryo were related to the occurrence of REP (all P < 0.05). Conclusion: Conservative treatment, frozen-thawed embryo transfer and cleavage embryo transfer were independent risk factors for REP after ART treatment.

Simulation-based Training in Ectopic Pregnancy and Salpingostomy

Objective Ectopic pregnancy leads to approximately 3% of deaths in pregnancy. Surgical management is indicated when patients are hemodynamically unstable or have signs of a ruptured ectopic pregnancy. Salpingectomy is more commonly performed, but salpingostomy is preferred in a patient with prior salpingectomy with a desire for future pregnancy. Due to the lack of exposure, salpingostomy is not frequently performed and most residents do not feel adequately trained. Our goal was to provide a hands-on simulation about ectopic pregnancy and salpingostomy in hopes that the simulation will improve the resident's confidence and knowledge in recognizing an ectopic pregnancy, identifying an appropriate candidate for surgical management, and performing a salpingostomy. Methods The educational initiative was aimed towards postgraduate year (PGY) 1-4 OB/GYN residents (n=11). Knowledge and confidence questionnaires were given to participants prior to and post-simulation. A gynecologic mannequin was modified by taking the existing pelvic organs and creating a tubal pregnancy. In the first part of the simulation, a hemodynamically unstable patient presented with lab and imaging findings consistent with an ectopic pregnancy. Once recognized and the decision made for surgical intervention, participants were transferred to a simulated operating room where they performed salpingostomy or salpingectomy on the mannequin. The simulation was followed by a debriefing session to discuss the actions and thought processes of participants, provide reflection, and incorporate improvement opportunities for future cases. Finally, participants engaged in a didactic lecture where they were educated about the incidence, presentation, and management of tubal ectopic pregnancy. Results Analysis of the knowledge questionnaires showed the median score pre- and post-intervention was 9 and 12, respectively, with a median change of 3 (p=0.001). The median confidence value pre- and post-intervention were 28 and 42, respectively, with a median value change of 12 (p<0.001). Conclusion Our intervention improved residents' confidence and knowledge in recognizing an ectopic pregnancy, identifying an appropriate candidate for surgical management, and performing a salpingostomy.

Analytical evaluation of the Radiometer AQT90 FLEX βhCG assay

Objectives

Many hospitals cannot afford an hCG assay on a central lab analyzer and turn to point of care testing (POCT) solutions. The Radiometer AQT90 FLEX is a small benchtop immunoareement between the AQT90 and comparator methods for samples with hCG ssay analyzer for use in the laboratory or at the patient bedside. This study evaluated the analytical performance of the AQT90's βhCG assay.

Methods

Precision was assessed using whole blood patient samples and two levels of quality control. Linearity was assessed by dilution of a high hCG plasma sample. Carryover and hook effect were assessed using high and low hCG samples. Method comparisons were done against Abbott i-STAT Total βhCG, Beckman Coulter Total βhCG (5th IS), and Roche hCG+β. Sample concentrations ranged from<2 IU/L to 4,973 IU/L.

Results

Repeatability and within-laboratory precision passed most manufacturer's claims and allowable error criteria. Linearity was validated from<2 IU/L to 4,741 IU/L. Hook effect was not observed up to 2,446,448 IU/L. Carryover was<4.0 ppm. A linear relationship was observed with i-STAT, Beckman and Roche methods. At>20 IU/L, biases were apparent against all three comparator assays (i-STAT: +20%, Roche: +30%, Beckman: +5 to 15%). At ≤20 IU/L, the acceptability of agreement varied according to TAE specifications. Concordance between AQT90 and comparator assays using 5 IU/L as the medical decision level ranged from 69% to 81%.

Conclusions

Overall, the AQT90 hCG assay performed well and would be suitable for smaller suburban or rural hospitals. Some limitations have been noted and should be kept in mind during clinical testing.

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Analytical evaluation of the Radiometer AQT90 FLEX βhCG assay.

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Most of Radiometer's claims and TAE criteria met by the AQT90.

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Clinically significant differences with comparators at high concentrations.

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Clinically insignificant differences with comparators at low concentrations.

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Suitable for use at smaller suburban or rural hospitals for hCG testing.