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Başkıran Y, Uçkan K, Çeleğen İ. Can failure be predicted in methotrexate treatment with the modified parameter? Arch Gynecol Obstet 2024; 310:477-483. [PMID: 38714561 DOI: 10.1007/s00404-024-07433-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 02/14/2024] [Indexed: 05/10/2024]
Abstract
OBJECTIVE The objective of the study was to increase the prediction of success of single-dose methotrexate therapy in ectopic pregnancy patients with modified parameters obtained from complete blood count and beta-human chorionic gonadotropin (β-hCG) parameters. In this way, it was aimed to predict patients whose methotrexate treatment may fail and rupture, to avoid unnecessary methotrexate treatment, to shorten the duration of hospital stay and to reduce patient mortality. MATERIALS AND METHODS 233 patients diagnosed with ectopic pregnancy between January 1, 2017, and March 01, 2022, in the obstetrics and gynecology service of a tertiary center were included in the study. RESULTS The mean of β-hCG was 1976 in the methotrexate group and 2358 in the surgery group (p < 0.05). The ROC curve determined the effect of BW (β-hCGxWBC/1000) and BP (β-hCGx1000/PLT) markers in diagnosing patients who will need surgery in ectopic pregnancy. The areas under the ROC curve for β-hCG, BW and BP were 0.86, 0.99 and 0.94, respectively (p < 0.05). β-hCG > 2139.03, BW > 30.96 and BP > 10.17 values were significantly associated with the need for surgery in ectopic pregnancy patients (p < 0.05). Logistic regression analysis revealed that a 1-unit increase in BP caused a statistically significant 1.77-fold increase in surgical need in patients with ectopic pregnancy. In contrast, a 1-unit increase in BW caused a 2.34-fold increase in surgical need (p < 0.05). CONCLUSION The study results showed that BW and BP values together with β-hCG are effective in predicting ectopic pregnancy patients who may undergo surgery.
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Affiliation(s)
- Yusuf Başkıran
- Istinye University Faculty of Medicine, Istanbul, Turkey.
| | - Kazım Uçkan
- Van Yuzuncu Yil University Faculty of Medicine, Van, Turkey
| | - İzzet Çeleğen
- Van Yuzuncu Yil University Faculty of Medicine, Van, Turkey
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Grigoriu C, Bohiltea R, Mihai B, Zugravu C, Furtunescu F, Georgescu T, Munteanu D. Success rate of methotrexate in the conservative treatment of tubal ectopic pregnancies. Exp Ther Med 2021; 23:150. [DOI: 10.3892/etm.2021.11073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 07/23/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Corina Grigoriu
- Department of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Roxana Bohiltea
- Department of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Bianca Mihai
- Department of Obstetrics and Gynecology, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Corina Zugravu
- Department of Food Hygiene and Nutrition, ‘Carol Davila’ University of Medicine and Pharmacy, 050463 Bucharest, Romania
| | - Florentina Furtunescu
- Department of Public Health and Management, Faculty of Medicine, ‘Carol Davila’ University of Medicine and Pharmacy, 050463 Bucharest, Romania
| | - Tiberiu Georgescu
- Department of Pathology, ‘Carol Davila’ University of Medicine and Pharmacy, 050463 Bucharest, Romania
| | - Diana Munteanu
- Department of Medical Expertise and Work Capacity Recovery, National Institute of Medical Expertise and Work Capacity Recovery, 050653 Bucharest, Romania
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Revzin MV, Pellerito JS, Moshiri M, Katz DS, Nezami N, Kennedy A. Use of Methotrexate in Gynecologic and Obstetric Practice: What the Radiologist Needs to Know. Radiographics 2021; 41:1819-1838. [PMID: 34597234 DOI: 10.1148/rg.2021210038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Methotrexate (MTX) is the primary pharmaceutical agent that is used for management of disorders arising from trophoblastic tissue. Its widespread international use is mostly attributable to its noninvasive, safe, and effective characteristics as a treatment option for ectopic pregnancy (EP) and gestational trophoblastic disease (GTD), with the large added benefit of fertility preservation. Although the effects of MTX usage are well documented in the gynecologic and obstetric literature, there is a scarcity of radiologic literature on the subject. Depending on the type of EP, the route of MTX administration and dosage may vary. US plays an essential role in the diagnosis and differentiation of various types of EPs, pregnancy-related complications, and complications related to MTX therapy, as well as the assessment of eligibility criteria for MTX usage. A knowledge of expected imaging findings following MTX treatment, including variability in echogenicity and shape of the EP, size fluctuations, changes in vascularity and gestational sac content, and the extent of hemoperitoneum, is essential for appropriate patient management and avoidance of unnecessary invasive procedures. A recognition of sonographic findings associated with pregnancy progression and complications such as tubal or uterine rupture, severe hemorrhage, septic abortion, and development of arteriovenous communications ensures prompt patient surgical management. The authors discuss the use of MTX in the treatment of disorders arising from trophoblastic tissue (namely EP and GTD), its mechanism of action, its route of administration, and various treatment regimens. The authors also provide a focused discussion of the role of US in the detection and diagnosis of EP and GTD, the assessment of the eligibility criteria for MTX use, and the identification of the sonographic findings seen following MTX treatment, with specific emphasis on imaging findings associated with MTX treatment success and failure. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Margarita V Revzin
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - John S Pellerito
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Mariam Moshiri
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Douglas S Katz
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Nariman Nezami
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
| | - Anne Kennedy
- From the Department of Radiology and Biomedical Imaging, Yale University School of Medicine, 333 Cedar St, PO Box 208042, Room TE-2, New Haven, CT 06520 (M.V.R.); Department of Radiology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Manhasset, NY (J.S.P.); Department of Radiology, University of Washington Medical Center, Seattle, Wash (M.M.); Department of Radiology, NYU Winthrop University Hospital, Mineola, NY (D.S.K.); Interventional Radiology and Image-Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Ga (N.N.); and Department of Radiology, University of Utah Health, Salt Lake City, Utah (A.K.)
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The Largest Tubal Pregnancy: 14th Week. Case Rep Obstet Gynecol 2020; 2020:4728730. [PMID: 32518701 PMCID: PMC7260646 DOI: 10.1155/2020/4728730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/02/2020] [Accepted: 05/12/2020] [Indexed: 01/07/2023] Open
Abstract
Subsequent development and implantation of embryo outside the uterine lining are defined as an ectopic pregnancy. Ectopic pregnancies have a wide range of presentations, for example, acute hemoperitoneum to chronic ectopic pregnancy. The case presented is an unusual case of ectopic pregnancy with large hematosalpinx with classic symptoms. To the best of the authors' knowledge, this case is the largest intact tubal ectopic pregnancy reported ever in the 14th week of gestation. A 40-year-old patient presented to the emergency department with lower abdominal pain, mild dysuria, and loose motion. The patient's previous menstrual cycles were regular till four months ago, then started to be irregular, and she had no history of chronic diseases except repeated pelvic inflammatory diseases (PID). Clinically, the patient was hemodynamically stable. On palpation, the abdomen was tender, and cervical movements were not tender. BHCG in the blood came very high. The bedside point-of-care ultrasound (POCUS) showed free fluid in the abdomen and a sac in the left adnexa with a living fetus (visible heartbeats). The conventional ultrasound showed 14 weeks of an extrauterine gestational sac with visible early pregnancy. Differential diagnosis was either an abdominal pregnancy versus a complicated tubal pregnancy. The surgical pathology report confirmed the diagnosis of ectopic tubal pregnancy as the tube was dilated in the middle portion containing chorionic villi, decidual reaction, and the whole gestational sac consistent with the ectopic tubal pregnancy. The patient had a successful laparotomy with salpingectomy and hemostasis and did well after the operation. So, an intact ectopic tubal pregnancy may last until the 14th week of gestation.
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Barnhart KT, Sammel MD, Stephenson M, Robins J, Hansen KR, Youssef WA, Santoro N, Eisenberg E, Zhang H. Optimal treatment for women with a persisting pregnancy of unknown location, a randomized controlled trial: The ACT-or-NOT trial. Contemp Clin Trials 2018; 73:145-151. [PMID: 30243810 PMCID: PMC6231403 DOI: 10.1016/j.cct.2018.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Pregnancy of unknown location (PUL) is not a diagnosis but a transient state used to classify a woman when she has a positive pregnancy test without definitive evidence of an intra-uterine or extra-uterine pregnancy on transvaginal ultrasonography. Management of a persisting PUL varies substantially, including expectant or active management. Active management can include uterine cavity evacuation or systemic administration of methotrexate. To date, no consensus has been reached on whether either management strategy is superior or non-inferior to the other. DESIGN Randomized controlled trial. SETTING Academic medical centers. PATIENTS We plan to randomize 276 persisting PUL-diagnosed women who are 18 years or older from Reproductive Medicine Network clinics and additional interested sites, all patients will be followed for 2 years for fertility and patient satisfaction outcomes. INTERVENTIONS Randomization will be 1:1:1 ratio between expectant management, uterine evacuation and empiric use of methotrexate. After randomization to initial management plan, all patients will be followed by their clinicians until resolution of the PUL. The clinician will determine whether there is a change in management, based on clinical symptoms, and/or serial human chorionic gonadotropin (hCG) concentrations and/or additional ultrasonography. MAIN OUTCOME The primary outcome measure in each of the 3 treatment arms is the uneventful clinical resolution of a persistent PUL without change from the initial management strategy. Secondary outcome measures include: number of ruptured ectopic pregnancies, number and type of re-interventions (additional methotrexate injections or surgical procedures), treatment complications, adverse events, number of visits, time to resolution, patient satisfaction, and future fertility. CONCLUSION This multicenter randomized controlled trial will provide guidance for evidence-based management for women who have persisting pregnancy of unknown location.
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MESH Headings
- Female
- Humans
- Pregnancy
- Abortifacient Agents, Nonsteroidal/therapeutic use
- Abortion, Spontaneous/blood
- Abortion, Spontaneous/diagnosis
- Abortion, Spontaneous/diagnostic imaging
- Abortion, Spontaneous/therapy
- Chorionic Gonadotropin/blood
- Diagnosis, Differential
- Dilatation and Curettage
- Methotrexate/therapeutic use
- Pregnancy, Ectopic/blood
- Pregnancy, Ectopic/diagnosis
- Pregnancy, Ectopic/diagnostic imaging
- Pregnancy, Ectopic/therapy
- Ultrasonography
- Watchful Waiting
- Randomized Controlled Trials as Topic
- Multicenter Studies as Topic
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Affiliation(s)
- Kurt T Barnhart
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States; Department of Biostatistics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States.
| | - Mary D Sammel
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Mary Stephenson
- Department of Obstetrics and Gynecology, University of Illinois at Chicago, Chicago, IL, United States
| | - Jared Robins
- Division of Reproductive Endocrinology and Infertility, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Karl R Hansen
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences, Oklahoma City, OK, United States
| | - Wahid A Youssef
- Department of Obstetrics and Gynecology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, United States
| | - Nanette Santoro
- Department of Obstetrics and Gynecology, University of Colorado, Denver, United States
| | - Esther Eisenberg
- Reproductive Sciences Branch, Eunice Kennedy Shriver NICHD, Rockville, MD, United States
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, CT, United States
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6
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Lesavre M, Curinier S, Capmas P, Rabischong B, Fernandez H. [Treatment of tubal ectopic pregnancy by methotrexate]. ACTA ACUST UNITED AC 2015; 44:212-9. [PMID: 25661494 DOI: 10.1016/j.jgyn.2014.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/02/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To make a literature analyse about methotrexate as a treatment of tubal ectopic pregnancy. MATERIALS AND METHODS We made a PubMed research and found articles, randomized control studies, systematic revues and meta-analyses of the Cochrane Database about ectopic pregnancies treated by methotrexate. We made a summary of these articles. RESULTS Methotrexate can be used as a treatment of tubal ectopic pregnancy with hCG<5000 UI/L and expectative is an option if hCG level is lower than 1500 UI/L. Medical treatment by methotrexate seems to be less effective than surgical salpingotomy but the rate of recurrence and the rate of intra-uterine pregnancy are similar regardless of the treatment chosen. Fertility seems to be the same after treatment by methotrexate. Economically, methotrexate is less expensive than the surgical management (laparoscopy). CONCLUSION Methotrexate can be used as a treatment of tubal ectopic pregnancies if every criterions of safety are gathered.
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Affiliation(s)
- M Lesavre
- Service de gynécologie-obstétrique, CHU Bicêtre, 78, avenue du général-Leclerc, 94276 Le Kremlin-Bicêtre, France.
| | - S Curinier
- Service de gynécologie-obstétrique, CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont Ferrand, France
| | - P Capmas
- Service de gynécologie-obstétrique, CHU Bicêtre, 78, avenue du général-Leclerc, 94276 Le Kremlin-Bicêtre, France
| | - B Rabischong
- Service de gynécologie-obstétrique, CHU Estaing, 1, place Lucie-Aubrac, 63003 Clermont Ferrand, France
| | - H Fernandez
- Service de gynécologie-obstétrique, CHU Bicêtre, 78, avenue du général-Leclerc, 94276 Le Kremlin-Bicêtre, France
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Cecchino GN, Araujo Júnior E, Elito Júnior J. Methotrexate for ectopic pregnancy: when and how. Arch Gynecol Obstet 2014; 290:417-23. [DOI: 10.1007/s00404-014-3266-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 04/17/2014] [Indexed: 11/24/2022]
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Fernandez H, Capmas P, Lucot JP, Resch B, Panel P, Bouyer J. Fertility after ectopic pregnancy: the DEMETER randomized trial. Hum Reprod 2013; 28:1247-53. [DOI: 10.1093/humrep/det037] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Sánchez-Hidalgo L, López de la Manzanara C, Alpuente A, Garrido R, Sánchez-Hipólito L, González-López A. Evaluación del tratamiento médico del embarazo ectópico con metotrexato. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2012. [DOI: 10.1016/j.gine.2011.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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de Bennetot M, Rabischong B, Aublet-Cuvelier B, Belard F, Fernandez H, Bouyer J, Canis M, Pouly JL. Fertility after tubal ectopic pregnancy: results of a population-based study. Fertil Steril 2012; 98:1271-6.e1-3. [PMID: 22818285 DOI: 10.1016/j.fertnstert.2012.06.041] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 06/12/2012] [Accepted: 06/14/2012] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the reproductive outcome after an ectopic pregnancy (EP) based on the type of treatment used, and to identify predictive factors of spontaneous fertility. DESIGN Observational population based-study. SETTING Regional sistry. PATIENT(S) One thousand sixty-four women registered from 1992 to 2008. INTERVENTION(S) Laparoscopic (radical or conservative), or medical treatment. MAIN OUTCOME MEASURE(S) Epidemiologic characteristics, clinical presentation, treatments performed, reproductive outcome, recurrence. RESULT(S) The 24-month cumulative rate of intrauterine pregnancy (IUP) was 67% after salpingectomy, 76% after salpingostomy, and 76% after medical treatment. IUP rate was lower after radical treatment compared with conservative treatments in univariable analysis. In multivariate analysis, IUP rate was significantly lower for patients >35 years old or with history of infertility or tubal disease. For them, IUP rate was significantly higher after conservative treatment compared with salpingectomy. The 2-year cumulative rate of recurrences was 18.5% after salpingostomy or salpingectomy and 25.5% after medical treatment. History of infertility or of previous live birth would be protective, in contrast to history of voluntary termination of pregnancy. CONCLUSION(S) Conservative strategy seems to be preferred, whenever possible, to preserve patients' fertility without increasing the risk of recurrence. The choice between conservative treatments does not rely on subsequent fertility, but more likely on their own indications and therapeutic effectiveness. Risk factors of recurrence could be considered for secondary prevention.
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Affiliation(s)
- Marianne de Bennetot
- Department of Obstetrics and Gynecology, Pôle de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Estaing, Clermont-Ferrand, France
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12
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Varma R, Gupta J. Tubal ectopic pregnancy. BMJ CLINICAL EVIDENCE 2012; 2012:1406. [PMID: 22321966 PMCID: PMC3285146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
INTRODUCTION Approximately 1/100 pregnancies are ectopic, with the conceptus usually implanting in the fallopian tube. Some ectopic pregnancies resolve spontaneously, but others continue to grow and lead to rupture of the tube. Risks are higher in women with damage to the fallopian tubes due to pelvic infections, surgery, or previous ectopic pregnancy. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical question: What treatments improve outcomes in women with unruptured tubal ectopic pregnancy? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2011 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations, such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). The authors also separately searched Medline and Pubmed up to July 2011 in addition to the Clinical Evidence systematic search to support the comments and clinical guide sections. RESULTS We found 19 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: salpingotomy, salpingectomy, methotrexate, methotrexate following salpingotomy, methotrexate plus mifepristone, and expectant management.
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Affiliation(s)
- Rajesh Varma
- Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
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Cong Q, Li G, Jiang W, Li B, Wang Y, Yao L, Wang S, Xu C. Ectopic choriocarcinoma masquerading as a persisting pregnancy of unknown location: case report and review of the literature. J Clin Oncol 2011; 29:e845-8. [PMID: 22042964 DOI: 10.1200/jco.2011.37.1096] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Qing Cong
- Obstetrics and Gynecology Hospital, Shanghai Medical School, China
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Dhar H, Hamdi I, Rathi B. Methotrexate treatment of ectopic pregnancy: experience at nizwa hospital with literature review. Oman Med J 2011; 26:94-8. [PMID: 22043392 DOI: 10.5001/omj.2011.24] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2010] [Accepted: 01/09/2011] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES Ectopic pregnancy occurs when the embryo fails to implant within the uterine cavity. Methotrexate, a folic acid antagonist has been widely used to treat ectopic pregnancy. The aim of this study is to determine the efficacy of methotrexate treatment for ectopic pregnancies in our settings which will in-turn help us reduce maternal mortality and morbidity. METHODS This was a retrospective review of 60 cases of ectopic pregnancy treated with single dose methotrexate in Nizwa hospital, Oman. Demographic data, clinical presentation, treatment progress, outcome, side effects and future fertility follow up were analysed using a computer database. Selection criteria included hemodynamically stable women with ß-hcg level of ≤5000 mIU/ml, adnexal mass ≤4 cm, absent cardiac activity and hemoperitoneum less than 100 ml. Human chorionic gonadotrophin (hcg) assay and clinical presentation were used to determine cases which warranted surgical intervention. RESULTS The success rate of single dose methotrexate therapy in our study was 65% (n=39) and 35% (n=21) required surgical intervention compared to reported success rate of 67-100% published in various studies. Careful selection of cases and confining strictly to the criteria improved the success rate from 40% to 60% in five and half years of the study. The mean average time of resolution of ectopic pregnancy was 32 days for a single dose and 58 days for repeat second or third doses. Eight cases of pregnancy of unknown location were treated successfully with Methotrexate. No major side effects were noted. A successful fertility outcome of 30% in the first year followed by 13.3% in the subsequent second year with a secondary infertility rate of 11.6% was observed in this study. CONCLUSION Methotrexate treatment of ectopic pregnancies is safe and effective with no major side effects. Intramuscular methotrexate has the advantage of tubal conservation and saves patients from requiring surgery. It is easier to administer than intraoperative route, which is by laparoscopy and needs expertise. Our study showed single dose methotrexate to be an effective treatment option for selected patients with unruptured tubal ectopic pregnancy.
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Affiliation(s)
- Hansa Dhar
- Department of Obstetrics and Gynecology, Nizwa Hospital, Nizwa, Oman
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15
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De Bennetot M, Rabischong B, Aublet-Cuvelier B, Belard F, Fernandez H, Bouyer J, Mage G, Pouly JL. [Risk factors for recurrence of ectopic pregnancy]. ACTA ACUST UNITED AC 2011; 41:55-61. [PMID: 22018441 DOI: 10.1016/j.jgyn.2011.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 09/10/2011] [Accepted: 09/15/2011] [Indexed: 10/16/2022]
Abstract
OBJECTIVES Investigate and identify the risk factors influencing the recurrence of ectopic pregnancies. PATIENTS AND METHODS The Auvergne ectopic pregnancy registry data were analyzed from 1992 to 2008. The appearance of a recurrence was studied among 1108 women from 18 to 44 years old, who attempted to conceive again. RESULTS One hundred and sixteen repeated ectopic pregnancies occurred (10.5 %) during the period under study. The rate of recurrence was significantly higher among women who had a history of voluntary termination of pregnancy (P=0.01). Conversely, fewer recurrences (P=0.01 and 0.0478) occurred among women having a history of infertility or previous live birth. The treatment for ectopic pregnancy, whether it is conservative or radical laparoscopic, or medical with methotrexate did not significantly influence the recurrence rate (P=0.86). CONCLUSION Reproductive history appears to involve the risk of repeated ectopic pregnancy and must be taken into account in their secondary prevention. As for the choice of treatment, the risk of recurrence does not seem to constitute a decisive argument.
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Affiliation(s)
- M De Bennetot
- Service de gynécologie-obstétrique et reproduction humaine, CHU de Clermont-Ferrand, CHU Estaing, 1, place Lucie-Aubrac, 63100 Clermont-Ferrand, France
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Sagili H, Mohamed K. Pregnancy of unknown location: an evidence-based approach to management. ACTA ACUST UNITED AC 2011. [DOI: 10.1576/toag.10.4.224.27438] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Einenkel J, Handzel R, Horn LC. Persisting pregnancy of unknown location—Keep your eyes peeled for choriocarcinoma. Eur J Obstet Gynecol Reprod Biol 2010; 153:229-31. [DOI: 10.1016/j.ejogrb.2010.07.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Revised: 07/12/2010] [Accepted: 07/23/2010] [Indexed: 10/19/2022]
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Barnhart K, van Mello NM, Bourne T, Kirk E, Van Calster B, Bottomley C, Chung K, Condous G, Goldstein S, Hajenius PJ, Mol BW, Molinaro T, O'Flynn O'Brien KL, Husicka R, Sammel M, Timmerman D. Pregnancy of unknown location: a consensus statement of nomenclature, definitions, and outcome. Fertil Steril 2010; 95:857-66. [PMID: 20947073 DOI: 10.1016/j.fertnstert.2010.09.006] [Citation(s) in RCA: 191] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 06/30/2010] [Accepted: 09/03/2010] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To improve the interpretation of future studies in women who are initially diagnosed with a pregnancy of unknown location (PUL), we propose a consensus statement with definitions of population, target disease, and final outcome. DESIGN A review of literature and a series of collaborative international meetings were used to develop a consensus for definitions and final outcomes of women initially diagnosed with a PUL. RESULT(S) Global differences were noted in populations studied and in the definitions of outcomes. We propose to define initial ultrasound classification of findings into five categories: definite ectopic pregnancy (EP), probable EP, PUL, probable intrauterine pregnancy (IUP), and definite IUP. Patients with a PUL should be followed and final outcomes should be categorized as visualized EP, visualized IUP, spontaneously resolved PUL, and persisting PUL. Those with the transient condition of a persisting PUL should ultimately be classified as nonvisualized EP, treated persistent PUL, resolved persistent PUL, or histologic IUP. These specific categories can be used to characterize the natural history or location (intrauterine vs. extrauterine) of any early gestation where the initial location is unknown. CONCLUSION(S) Careful definition of populations and classification of outcomes should optimize objective interpretation of research, allow objective assessment of future reproductive prognosis, and hopefully lead to improved clinical care of women initially identified to have a PUL.
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Affiliation(s)
- Kurt Barnhart
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Jurkovic D. hCG as a patient. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2010; 36:395-399. [PMID: 20872934 DOI: 10.1002/uog.8820] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Desroque D, Capmas P, Legendre G, Bouyer J, Fernandez H. [Fertility after ectopic pregnancy]. ACTA ACUST UNITED AC 2010; 39:395-400. [PMID: 20478667 DOI: 10.1016/j.jgyn.2010.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 01/25/2010] [Accepted: 04/08/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND The subsequent fertility of women who had experienced ectopic pregnancy (EP) is the best criteria of the effectiveness of the treatment. In the absence of randomised trials comparing laparotomy, laparoscopy, medical treatment by methotrexate (MTX) and expectative, the only way to compare treatments is to make use of data from observational studies. METHODS The databases consulted were Medline, Cochrane Library, National Guideline Clearinghouse and Health Technology Assessment Database. Keywords used for research: fertility; ectopic pregnancy; expectative; methotrexate; salpingectomy; salpingotomy. RESULTS Twenty-four papers of randomised control trial (RCT) or observational studies were analysed. No difference between laparotomy and laparoscopy for fertility was found. Tubal suture does not modify the subsequent fertility. The risk of normal pregnancy or ectopic recurrence is similar between salpingotomy or salpingectomy when controlateral tube is normal. Conversely, in case of altered tube, the fertility appears higher after conservative treatment. Between conservative treatments, surgical or medical, no difference appears. CONCLUSIONS Conservative surgical treatment is the gold standard. However, the fertility seems similar with the other treatments. Three ongoing RCT could answer to the three main questions: Which is the best fertility between medical and conservative surgical treatment? Which is the best fertility between radical and conservative surgical treatment? Which is the best fertility between MTX and expectative?
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Affiliation(s)
- D Desroque
- Service de gynécologie obstétrique, hôpital Bicêtre, 78, rue du Général-Leclerc, 94275 le Kremlin-Bicêtre, France
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Varma R, Gupta J. Tubal ectopic pregnancy. BMJ CLINICAL EVIDENCE 2009; 2009:1406. [PMID: 19445747 PMCID: PMC2907783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Approximately 1/100 pregnancies are ectopic, with the conceptus usually implanting in the fallopian tube. Some ectopic pregnancies resolve spontaneously, but others continue to grow and lead to rupture of the tube. Risks are higher in women with damage to the fallopian tubes due to pelvic infections, surgery, or previous ectopic pregnancy. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical question: What treatments improve outcomes in women with unruptured tubal ectopic pregnancy? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). The authors also separately searched Medline and Pubmed up to May 2008 in addition to the Clinical Evidence systematic search to support the comments and clinical guide sections. RESULTS We found 47 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: salpingotomy, salpingectomy, systemic methotrexate, systemic methotrexate following salpingotomy, and expectant management.
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Affiliation(s)
- Rajesh Varma
- Guy's and St. Thomas' Hospital NHS Foundation Trust, London, UK
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Conservative management of tubal ectopic pregnancy. Best Pract Res Clin Obstet Gynaecol 2009; 23:509-18. [PMID: 19299204 DOI: 10.1016/j.bpobgyn.2008.12.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2008] [Accepted: 12/15/2008] [Indexed: 11/22/2022]
Abstract
In this chapter an overview is given of the best available evidence on the conservative treatment for tubal ectopic pregnancy, i.e., expectant management and medical treatment with systemic methotrexate. From the two randomized controlled trials on expectant management, no conclusions can be drawn yet. It may be that women with low serum hCG levels need not be treated at all, but more research needs to be done in this subgroup of women to reach firm conclusions. Systemic methotrexate in a fixed multiple-dose i/m regimen can be recommended for hemodynamically stable women with an unruptured tubal ectopic pregnancy and no signs of active bleeding presenting with serum hCG concentrations<3,000 IU/l. In women with serum hCG concentrations<1,500 IU/l, a single-dose methotrexate regimen can be considered.
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