Risk factors for recurrent ectopic pregnancy: a case-control study

Do the change in β-hCG values between the 0th and 4th days in tubal ectopic pregnancy treatment with a single-dose methotrexate (MTX) protocol predict the need for a second dose of MTX?

AIM

The single-dose methotrexate (MTX) regimen is effective and minimizes side effects but an additional second dose is needed in case of failure in an ectopic pregnancy (EP). We aimed to predict the additional MTX dose by evaluating the change in β-hCG values between day 0 and day 4 in EPs with administered single-dose MTX regimen.

METHOD

A total of 454 tubal EPs between 2013 and 2019 were evaluated retrospectively. Cases cured with a single dose of MTX without an additional dose were accepted as the control group, and cases under a single-dose regimen were cured by applying a second dose of MTX on the 7th day were accepted as the study group. Obstetric and demographic characteristics and the change in β-hCG values compared in both groups.

RESULTS

Age, body mass index (BMI), gravida, smoking, abdominal surgery, presence of IUDs, initial β-hCG levels (0th day), and EP size were similar in both groups, but the presence of previous EP history was significantly higher in the study group. The change of β-hCG from days 0 and 4 determined that a 20% increase predicts the need for a second dose of MTX with 72.4% sensitivity, and 87.8% negative predictive value (NPV).

CONCLUSION

The single-dose MTX protocol is successful in 83.3% of convenient cases (as the control group), but an increase of 20% in β-hCG between days 0 and 4 predicts the patients who need to be administered second-dose MTX, and thus, a double-dose MTX protocol will be achieved early.

Global burden of pelvic inflammatory disease and ectopic pregnancy from 1990 to 2019

BACKGROUND

Pelvic inflammatory disease (PID) is a widespread female public problem worldwide. And it could lead to infertility, preterm labor, chronic pelvic pain, and ectopic pregnancy (EP) among reproductive-aged women. This study aimed to assess the global burden and trends as well as the chaning correlation between PID and EP in reproductive-aged women from 1990 to 2019.

METHODS

The data of PID and EP among reproductive-aged women (15 to 49 years old) were extracted from the Global Burden of Disease study 2019. The disease burden was assessed by calculating the case numbers and age-standardized rates (ASR). The changing trends and correlation were evaluated by calculating the estimated annual percentage changes (EAPC) and Pearson's correlation coefficient.

RESULTS

In 2019, the ASR of PID prevalence was 53.19 per 100,000 population with a decreasing trend from 1990 (EAPC: - 0.50), while the ASR of EP incidence was 342.44 per 100,000 population with a decreasing trend from 1990 (EAPC: - 1.15). Globally, PID and EP burdens changed with a strong positive correlation (Cor = 0.89) globally from 1990 to 2019. In 2019, Western Sub-Saharan Africa, Australasia, and Central Sub-Saharan Africa had the highest ASR of PID prevalence, and Oceania, Eastern Europe, and Southern Latin America had the highest ASR of EP incidence. Only Western Europe saw significant increasing PID trends, while Eastern Europe and Western Europe saw increasing EP trends. The highest correlations between PID and EP burden were observed in Burkina Faso, Laos, and Bhutan. General negative correlations between the socio-demographic index and the ASR of PID prevalence and the ASR of EP incidence were observed at the national levels.

CONCLUSION

PID and EP continue to be public health burdens with a strong correlation despite slightly decreasing trends detected in ASRs globally. Effective interventions and strategies should be established according to the local situation by policymakers.

Association of Neighborhood Economic Status and Race With Developing Pelvic Inflammatory Disease After Sexually Transmitted Infections

OBJECTIVE

To explore the association of neighborhood-level socioeconomic status (SES) and race with developing pelvic inflammatory disease (PID) after sexually transmitted infection (STI) among female adolescents and young adults in Maryland.

METHODS

We used Maryland statewide hospital claims data (outpatient and inpatient visits) for this retrospective cohort study. Female adolescents and young adults aged 15-24 years who had at least one STI from July 1, 2013, to March 31, 2015, were included. A participant entered the cohort on the date of the first STI diagnosis and was followed up until PID occurrence or 3 years after the first STI. Median household income of the participant's residential ZIP code tabulation area was used as the neighborhood-level SES. Discrete-time hazard models were used to estimate the hazard of PID.

RESULTS

Of the 2,873 participants, 88.5% were of Black race, and 67.2% were aged 20-24 years. The hazard of PID after an STI among Black women was 1.40 times that of White women (95% CI 1.06-1.85). After adjustment for age, insurance type, and number of STI events, the hazard ratio (HR) did not change. However, adding neighborhood-level SES to the model attenuated the disparity in PID after STI between Black and White women (HR 1.25, 95% CI 0.94-1.67).

CONCLUSION

Racial disparities in PID diagnosis are mitigated by neighborhood-level SES.

Modeling human ectopic pregnancies with trophoblast and vascular organoids

Ruptured ectopic pregnancy (REP), a pregnancy complication caused by aberrant implantation, deep invasion, and overgrowth of embryos in fallopian tubes, could lead to rupture of fallopian tubes and accounts for 4%-10% of pregnancy-related deaths. The lack of ectopic pregnancy phenotypes in rodents hampers our understanding of its pathological mechanisms. Here, we employed cell culture and organoid models to investigate the crosstalk between human trophoblast development and intravillous vascularization in the REP condition. Compared with abortive ectopic pregnancy (AEP), the size of REP placental villi and the depth of trophoblast invasion are correlated with the extent of intravillous vascularization. We identified a key pro-angiogenic factor secreted by trophoblasts, WNT2B, that promotes villous vasculogenesis, angiogenesis, and vascular network expansion in the REP condition. Our results reveal the important role of WNT-mediated angiogenesis and an organoid co-culture model for investigating intricate communications between trophoblasts and endothelial/endothelial progenitor cells.

Trophoblastic infiltration of tubal pregnancy may have an association with chronic inflammation of the fallopian tube

OBJECTIVE

To explore the factors associated with trophoblastic infiltration in ampullary pregnancy from the perspective of clinical and pathologic characteristics.

METHODS

A single-center, retrospective, clinicopathologic cohort study was conducted in women who were diagnosed with tubal pregnancy and underwent salpingectomy in the International Peace Maternal and Child Health Care Hospital from January 2018 to June 2021.

RESULTS

A total of 333 eligible women diagnosed with ampullary pregnancy were included in the analysis. Multivariate logistic analysis showed that preoperative β-human chorionic gonadotropin greater than 3000 IU/L (adjusted odds ratio [aOR] 3.77, 95% confidence interval [CI] 2.02-7.03), and vascular remodeling phenomenon (aOR 4.34, 95% CI 2.41-7.83) were positively correlated with the infiltration of extravillous trophoblasts into serosa, while presence of chronic inflammation of the fallopian tube was a negatively corellated factor (aOR 0.49, 95% CI 0.29-0.85).

CONCLUSION

The depth of trophoblastic infiltration in tubal pregnancy may be related to the presence of chronic inflammation in the fallopian tube. A tubal pregnancy in a tube with chronic salpingitis is more likely to develop into an abortive ectopic pregnancy; whereas in a fallopian tube without chronic inflammation, the risk of it developing into a ruptured ectopic pregnancy increases. Hence, early identification is needed to properly address this dangerous pregnancy situation.

[Embryo stage impact on the risk of ectopic pregnancy after In Vitro Fecondation]

OBJECTIVES

Ectopic pregnancies are still the first mortality cause of the first semestre of pregnancy. They are much more frequent in IVF (2-5%) than in the standard population (1-2%). The aim of this study was to compare the rate of ectopic pregnancies following a fresh embryo transfer done whether at an clived embryo stage (day 2 or 3 of the embryo development) or at a blastocyst stage (day 5 or 6 of the embryo development).

METHODS

This is a monocentric retrospective study including all 18 to 43 year-old patients getting pregnant (ßHCG>100 UI/L) after a fresh embryo transfer from In Vitro Fecondation with or without Intra-Cytoplasmic Sperm Injection, between January 1st 2014 and December 30th 2020 in the Hospital of Besançon (France). This population has been divided into 2 groups according to the embryo stage on the day of transfer.

RESULTS

Nine hundred and twenty two patients have been included. There were statistically more ectopic pregnancies after a blastocyst transfer (n=4; 5.4%) than after a clived embryo transfer (n=14; 1.7%). (P=0.049) CONCLUSION: In our population, there were more ectopic pregnancies from blastocyst(s) transfers than from clived embryo(es).

Pregnancy outcomes following in vitro fertilization treatment in women with previous recurrent ectopic pregnancy

Objectives

The aim of this study was to investigate the impact of a history of recurrent ectopic pregnancy (EP) on pregnancy outcomes of subsequent in vitro fertilization (IVF) treatment.

Methods

A retrospective cohort study involving 457 women with a history of recurrent EP (REP group), 912 women with a history of single EP (SEP group), and 1169 women with a history of intrauterine pregnancy (IUP group) as the control group, was conducted. IVF outcomes were compared for each cohort.

Results

The incidence of EP in the REP group after IVF treatment was significantly lower than those in the SEP group (2.4% vs. 6.8%, P = 0.011), and similar to those in the IUP group (2.4% vs. 2.1%, P = 0.830). No significant differences were observed in the clinical pregnancy rate, miscarriage rate, and live birth rate among the three groups. There was no statistically significant difference in the recurrent EP rate between the salpingectomy and salpingostomy treatments. Adjusting for maternal and treatment factors did not influence live birth rates for women with previous REP compared with women with previous SEP and those with IUP. The odds of EP were 82.2% lower (OR 0.178, 95% CI 0.042–0.762; P = 0.020) in women who had blastocyst transfer compared with cleavage embryo transfer in the SEP group. The odds of EP were over six times (OR 6.260, 95% CI 1.255–31.220; P = 0.025) in women who underwent double embryo transfer as opposed to single embryo transfer in the IUP group.

Conclusion

Our results indicate that women with previous recurrent EP have a lower risk of EP after IVF in comparison with women with previous single EP. Previous EP has no significant adverse effect on the main IVF outcomes. The salpingostomy and salpingectomy treatments of EP do not significantly affect the incidence of recurrent EP after IVF.

Fertility outcomes subsequent to medical and surgical treatment for ectopic pregnancy: A retrospective cohort study in Iran

Background

Ectopic pregnancy (EP) and its treatment methods may affect subsequent fertility outcomes.

Objective

To compare methotrexate (MTX), laparoscopic salpingostomy, and salpingectomy methods of EP treatment and their effects on fertility outcomes.

Materials and Methods

This retrospective cohort study was performed on women receiving a definitive diagnosis of tubular EP from 2014 to 2017 at Arash Medical Center, Tehran, Iran. In total, 194 women were studied, of which 64 were treated with MTX, 52 underwent salpingostomy, and 78 underwent salpingectomy, depending on their clinical status. Basic information, obstetrics history, and major outcomes of the treatment after an 18-month follow-up, including recurrence of EP, miscarriage, and successful intrauterine pregnancy (IUP), were recorded and variables were compared among the three groups.

Results

There was no significant difference in fertility outcomes among the three groups. Among the studied variables, predictors of successful IUP after EP treatment were multiparity (Hazard Ratio (HR): 1.37; 95%CI: 1.06-1.77), no history of miscarriage (HR: 2.37; 95%CI: 1.01-5.56), and a higher number of live births (HR: 1.54; 95%CI: 1.01-2.37). On the other hand, predictors of EP recurrence included nulliparity (HR: 1.61; 95%CI: 1.02-2.53) and a lower number of live births (HR: 3.84; 95%CI: 1.43-10.98). The effect of other factors, including the utilized therapeutic modalities, was not statistically significant.

Conclusion

The current study results demonstrated that after an 18-month follow-up, fertility outcomes, including recurrence of EP and successful IUP, were not significantly different among the subjects with EP treated with MTX, salpingostomy, or salpingectomy. Further studies with long-term follow-ups are recommended.

Predictive value of PAPP-A for ectopic pregnancy and analysis of related factors

The present study was designed to analyze the expression of pregnancy-associated plasma protein-A (PAPP-A) in the serum of patients with ectopic pregnancy (EP) and related factors inducing this condition. Seventy-five patients with EP admitted to the Affiliated Hospital of Jining Medical University from January 2018 to February 2019 were selected as the research group, and another 59 healthy pregnant women of the corresponding age, gravidity and gestational week were enrolled in the control group. ELISA was employed to detect the serum expression levels of PAPP-A and inflammatory factors such as interleukin-8 (IL-8) and tumor necrosis factor-α (TNF-α). ROC was adopted to evaluate the diagnostic value of serum PAPP-A in patients with EP, and Pearson correlation coefficient was applied to analyze the correlation of PAPP-A with inflammatory factors IL-8 and TNF-α. Serum PAPP-A expression was significantly lower in EP patients than those in the control group. The area under the curve (AUC) of serum PAPP-A in diagnosing EP patients was 0.812, and the PAPP-A value in the control group was significantly higher than that of the research group at 7-8 weeks and ≥9 weeks. With regard to the expression of inflammatory factors, the research group presented markedly higher IL-8 and TNF-α levels than the control group. PAPP-A was negatively related to inflammatory factors IL-8 and TNF-α in the research group. In addition, it was revealed that patients with a history of genital surgery, salpingotomy, pelvic infection, EP or low PAPP-A expression were at high risk of EP. In conclusion, PAPP-A was revealed to be lowly expressed in the serum of EP patients, and to negatively be correlated with inflammatory factors IL-8 and TNF-α, which may serve as a useful marker for the diagnosis and prognosis of EP.

Recurrent Ectopic Pregnancy: Current Perspectives

Ectopic pregnancy represents a potentially life-threatening diagnosis. The risk factors for recurrent ectopic pregnancy have been enumerated but are not yet clearly defined. Understanding which risk factors are perhaps more common may allow providers to counsel and manage patients with a higher level of scrutiny.

The association between mitochondrial DNA copy number, telomere length, and tubal pregnancy

Growing evidence has demonstrated association between the occurrence of tubal ectopic pregnancy (TP) and oxidative stress (OS) status, in which mitochondria and telomeres play important roles. However, little is known about the underlying correlation between TP and the mitochondrial DNA copy number (mtDNAcn) or telomere length (TL) abnormalities. In this study, we found OS level was elevated in TP patients. We hierarchically detected the relative mtDNAcn and TL of villi from normal pregnancy (NP) and TP samples according to different gestational age, fetal sex, maternal age, and BMI. The results revealed that the relative mtDNAcn was significantly lower in the villi in the TP group compared with the NP cohort, which was negatively correlated with OS status. In the NP group, the mtDNAcn in the female subgroup was apparently lower than that in the male subgroup, while no statistical difference was found in the mtDNAcn in the TP group between the female and male subgroups. Moreover, the relative TL in the TP group was at a similar level to the NP group, and no statistical correlation was observed between relative TL and OS level. In summary, our findings indicate that the abnormal level of mtDNAcn rather than TL is correlated with TP, which provides new insights into the mechanism of TP.

Risk factors and clinical characteristics of recurrent ectopic pregnancy: A case-control study

OBJECTIVE

To compare signs and symptoms between patients with recurrent ectopic pregnancies (REP) and primary ectopic pregnancies (PEP) and to identify potential risk factors of REP.

MATERIALS AND METHODS

Data from 2014 to 2016 were analyzed. The study included 81 women each diagnosed with REP and PEP with no recurrence of ectopic pregnancy (EP) before January 2019. Information, including historical factors and findings at presentation of both group were collected. Data were compared between the two groups. Associations between REP and the risk factors were analyzed by logistic regression.

RESULTS

The findings revealed that compared to the patients in the PEP group, REP patients had significantly lower education (P = 0.001), higher proportion of previous infertility (P < 0.001) and different methods of PEP treatment (P = 0.001). Clinical data of the last operation revealed significantly higher occurrences of pelvic and peritubal adhesions (P < 0.05). Further multiple regression analysis showed that lower educational background (odds ratio [OR] = 4.183 95% confidence interval [CI] 1.311-13.344 P = 0.016), nulliparity (OR = 12.312 95% CI 3.382-44.824 P < 0.001), history of salpingotomy (OR = 7.129 95% CI 1.022-49.748 P < 0.05) and abortion (OR for one abortion = 21.576, P = 0.001; OR for two abortions =36.794, P < 0.001; OR for three abortions or more = 119.013, P < 0.001) were significant risk factors for REP.

CONCLUSION

Active education on contraception is required for patients with lower educational level and history of abortion. Different plans should be formulated for patients with EP. For EP patients wanting fertility, the risk between fertility preservation and REP needs to be evaluated as reproductive function cannot be pursued blindly while ignoring the risk of recurrence.

Serum soluble FMS-like tyrosine kinase-1 in ectopic pregnancy

CONTEXT

The diagnosis of an ectopic pregnancy (EP) requires the usage of serial beta-human chorionic gonadotropin (hCG) measurements and ultrasonography to locate the gestational sac. With the rising trends in its incidence, a rapid, noninvasive biomarker to detect this condition at the earliest can aid in decreasing the morbidity and mortality linked with EP.

AIMS

This study was performed to determine the serum level of soluble FMS-like tyrosine kinase-1 (sFLT-1) at 4-10-week gestation in EP and normal pregnancy and to identify whether it can be used as a biomarker to distinguish an EP from a normal intrauterine pregnancy.

SETTINGS AND DESIGN

This was a prospective case-control study conducted over 2 years from 2015 to 2017 in 280 women between the age groups of 19 and 38 years at a tertiary level hospital.

SUBJECTS AND METHODS

Levels of sFLT-1 in sera of 140 women with EP and 140 women with normal pregnancy were assayed by a sandwich enzyme-linked immunosorbent assay at Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India.

STATISTICAL ANALYSIS USED

Statistical analyses were performed with SPSS software version 16.0, and P ≤ 0.05 was considered statistically significant.

RESULTS

The median sFLT-1 level in EP was 419 pg/ml. This was significantly lower than the value of 898 pg/ml in normal pregnancy. Receiver operating characteristic curve analysis showed that at a cutoff of 623 pg/ml, sFLT-1 was able to distinguish an EP from a normal intrauterine pregnancy with a sensitivity of 98.6% and a specificity of 90.7%.

CONCLUSIONS

The present study showed the significant early lowering of sFLT-1 in EP and may be considered as an effective biomarker compared to beta-hCG.

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.

Risk factors for recurrent ectopic pregnancy following single-dose methotrexate treatment

Objective: Our study aimed to investigate the predisposing factors for recurrence of an ectopic pregnancy (EP) following single-dose methotrexate (MTX) treatment for a primary EP. Methods: This was a retrospective cohort study performed in a tertiary care medical centre including all patients diagnosed with primary EP and treated with a single-dose regimen of intramuscular MTX. EPs with future recurrence were compared with first time only EPs, to identify risk factors for recurrent EP. Forward stepwise multivariate logistic regression analyses were subsequently carried out. Results: The study included 272 women. Of those, 22 (8.1%) had a recurrent EP. Women in the recurrent EP group had a higher rate of abortions (45.5% vs 32.7%; p = 0.02), previous pelvic surgery (45.5% vs 6.5%; p < 0.001) and both pelvic and uterine surgery (4.5% vs 1.6%; p < 0.001). Conception by assisted reproductive technology (ART) was more common among the non-recurrent EP group (23.0% vs 4.5%; p = 0.04). Success of single-dose MTX treatment was lower in the recurrent EP group compared with the non-recurrent EP group (36.4% vs 65.7%; p = 0.006). A history of pelvic surgery was independently associated with recurrent EP (adjusted odds ratio [OR] 17.6; 95% confidence interval [CI] 4.9, 63.2; p = 0.001). Treatment success of single-dose MTX was independently protective for recurrent EP (adjusted OR 0.25; 95% CI 0.08, 0.76; p = 0.02). Conclusions: Among women with an EP, attention should be paid to those with previous pelvic surgery. Efforts should be made to achieve medical treatment success to prevent recurrent EP.

[Intrauterine contraception: CNGOF Contraception Guidelines]

OBJECTIVE

To provide national clinical guidelines focusing on intrauterine contraception.

METHODS

A systematic review of available literature was performed using Pubmed and Cochrane libraries. American, British and Canadian guidelines were considered as well.

RESULTS

Intrauterine contraception (IUC) displays a wide panel of indications, including adolescents, nulliparous, patients living with HIV before AIDS (Grade B) and women with history of ectopic pregnancy (Grade C). Cervical cancer screening should not be modified in women with IUC (Grade B). Bimanual examination and cervix inspection are mandatory before device insertion (Grade B). Patients should not systematically undergo screening for sexually transmitted infections (STI) before device insertion (Grade B). Screening for STI should be preferably done before insertion but it can be performed at the time of device insertion in asymptomatic women (Grade B). Routine antibiotic prophylaxis and premedication are not recommended before insertion (Grade A). A follow-up visit may be offered several weeks after insertion (Professional consensus). Routine pelvic ultrasound examination in not recommended after device insertion (Grade B). In patients with IUC, unscheduled bleeding, when persistent or associated with pelvic pain, requires further investigation to rule out complication (Professional agreement). Suspected uterine perforation warrants radiological workup to locate the device (Professional consensus). Laparoscopic approach should be preferred for elective removal of intrauterine device from abdominal cavity (Professional consensus). In case of accidental pregnancy with intrauterine device in situ, ectopic pregnancy should be excluded (Grade B). In case of viable and desired intrauterine pregnancy, intrauterine device removal is recommended if the strings are reachable (Grade C). Detection of Actinomyces-like organisms on pap smear in asymptomatic patients with intrauterine contraception does not require further intervention (Grade B). Immediate removal of intrauterine device is not recommended in case of STI or pelvic inflammatory disease (Grade B). Device removal should be considered in the absence of clinical improvement after 48 to 72 hours of appropriate treatment (Grade B).

CONCLUSION

Intrauterine contraception is a long-acting and reversible contraception method displaying great efficacy and high continuation rate. In contrast, complication rate is low. It should thus be offered to both nulliparous and multiparous women.

Left-Right Asymmetry of Tubal Pregnancy: A 12-Year Retrospective Hospital-Based Study

STUDY OBJECTIVE

To investigate whether there are left-right asymmetries, factors affecting lateral dominance, and clinical feature differences in the left and right sides of tubal pregnancy (TP).

DESIGN

Retrospective study (Canadian Task Force classification II-2).

SETTING

International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University.

PATIENTS

Patients (n = 6186) with TP treated surgically.

INTERVENTIONS

We used data from the digital medical records system of the hospital. Women diagnosed with ectopic pregnancy(EP) between January 2005 and December 2016 in the inpatient department of gynecology were included. All data from the medical files were obtained retrospectively, including demographic characteristics; reproductive, gynecologic, and surgical history; clinical features; and treatment. Patients who were previously treated by salpingectomy or nonsurgical management and those with unknown-site EP or non-TPs were excluded.

MEASUREMENTS AND MAIN RESULTS

The overall frequency of right-sided TP was 54.48% (3370/6186), which is significantly higher than 50% (p < .001, binominal test). The proportion of right-sided TPs decreased with age (p for trend = .007) and from the proximal (interstitial) end to the distal (fimbrial) end of the tube (p for trend = .017). Of the TP patients with a corpus luteum, we found the corpus luteum was more frequently located in the right ovary (p < .001) and in the contralateral ovary to the TP side in 41.38% of cases. However, tubal rupture was more frequent in left TP than the in right TP (p = .005).

CONCLUSION

The left-right asymmetries of TP include right-side dominance and the clinical feature differences between the 2sides of TP.

Prediction of recurrent ectopic pregnancy: A five-year follow-up cohort study

OBJECTIVE

To evaluate the value of different clinical risk factors in the prediction of recurrent ectopic pregnancies (REP).

STUDY DESIGN

This cohort study was carried out at a tertiary-care maternity hospital in Saudi Arabia, between January 2010 and June 2017. All women with a primary ectopic pregnancy (EP) were consecutively recruited, thoroughly assessed and followed up for a minimum duration of five-years (5.6 ± 0.61 years) to diagnose the nature and location of the subsequent pregnancies. The primary outcome measure was the occurrence of REP, while the secondary outcomes included intrauterine pregnancy, the pregnancy of unknown location and infertility rates.

RESULTS

A total of 272 women with a primary ectopic pregnancy (EP) were initially recruited, 217 women were included in the final analysis, among them 41 (18.9%) women had REP. Univariate analysis showed that women who subsequently developed REP had more prevalent prior miscarriages, evacuation of retained products of conception (ERPC), pelvic inflammatory disease (PID) and consanguinity, they also had lower hemoglobin levels at the time of primary EP, and lower prevalence of surgical treatment. Among the 143 surgically treated cases, salpingectomy, when compared to salpingostomy, and laparoscopy, when compared with laparotomy, were found to be associated with a lower risk of REP [RR = 0.32 (95% CI, 0.13-0.77) and 0.40 (95% CI, 0.18-0.86) respectively]. The occurrence of a subsequent delivery at any time after the primary EP was protective against REP [RR = 0.39 (95% CI, 0.22-0.68)], this protection is increased by almost nine folds if this delivery occurred at the descendant pregnancy [RR = 0.04 (95% CI, 0.01-0.17)]. Multivariable binary logistic regression revealed that prior PID, treatment modality and presenting hemoglobin level were independent predictors of REP. Receiver operating characteristic (ROC) curve was plotted using the predicted probability values derived from the multivariable binary logistic regression model, the area under the ROC curve was 0.792 (95% CI, 0.732-0.844).

CONCLUSION

Careful consideration of primary ectopic pregnancy data is a valuable tool to predict the potential risk of recurrence in the future.

Pregnancy Outcomes in Maternal Neuropsychiatric Illness and Substance Abuse

Introduction

Worldwide the prevalence of neuropsychiatric illness among women of reproductive age is higher than ever before. This study investigates the influences of maternal substance abuse/dependence and neuropsychiatric illness on pregnancy and neonatal outcomes.

Patients and Methods

Using a retrospective study design 185 pregnancies in women with neuropsychiatric illnesses or substance abuse were identified at a single centre over a period of 3.25 years and compared to 4907 pregnancies in healthy women without mental illness. Differences in pre-, peri- and postnatal pregnancy parameters were studied.

Results

Numbers of previous abortions on obstetric history were significantly higher in cases compared to controls, women with depression being especially affected. The number of antenatal visits was also higher among cases, especially in women with depression. The caesarean section rate was significantly higher in cases compared to controls. Children of women with neuropsychiatric illness were born at lower gestational ages than those of healthy control mothers, however there were no significant differences between case and control groups for birth weight, head circumference or Apgar scores. Some isolated differences were found for disease-specific case subgroups compared to controls.

Conclusion

The study shows a relationship between maternal neuropsychiatric illness and pregnancy outcomes independent of medication use. Rates of spontaneous abortion were higher. Children were born earlier, yet the neonatal outcomes birth weight, head circumference and Apgar score were not worse than children of mentally healthy women.

A Third Surgically Managed Ectopic Pregnancy after Two Salpingectomies Involving the Opposite Tube

Recurrent ectopic pregnancy in a remnant fallopian tube after ipsilateral salpingectomy is clinically rare. We report the extremely rare case of a third recurrent ectopic pregnancy after two previous salpingectomy procedures involving the opposite tube. A 26-year-old woman, gravida 3 para 0, experienced three ectopic pregnancies brought about by natural conception, all of which were treated surgically (right partial salpingectomy, right remnant tube resection, and left total salpingectomy). During the two salpingectomy procedures involving the right tube, the patency of the intact left tube was intraoperatively confirmed with indigo carmine. The most appropriate surgical intervention should be discussed when managing recurrent ectopic pregnancies. It might be necessary to perform total salpingectomy to reduce the risk of future recurrence on the remaining tube.