A 5-year experience of the changing management of ectopic pregnancy

The diagnosis and management of ectopic pregnancy presenting to Mater Dei Hospital between June 2019 and June 2020

The incidence of ectopic pregnancies has steadily increased over recent years and despite advances in treatment it still remains a major cause of maternal morbidity and mortality. The objective of this audit was to assess whether diagnosis and management is occurring as per international suggested guidance and practice. This study is a retrospective one using data collected from June 2019 to June 2020. All data were password protected and kept anonymous. No patient contact occurred. The standard cross referenced was the 'April 2019 NICE Guideline on the Management of Ectopic Pregnancy'. Thirty-one ectopic pregnancies occurred between June 2019 and June 2020. Twenty-nine underwent surgical management and two medical. Six out of the 29 surgically managed patients were managed incorrectly. Twenty-four of the surgical cases were managed laparoscopically. Presence of a foetal heart rate remained undocumented in 21 out of 31 of cases. The results highlight the ease of access to emergency gynaecological services at Malta's national hospital. However, this audit did highlight the discrepancy that can occur in examination in association with ectopic pregnancy. An inconsistency was noted in documentation. Additionally, a number of cases could have been offered and benefitted from different modes of management.Impact StatementWhat is already known on this subject? Ectopic pregnancy (EP) is an important cause of morbidity and mortality in mothers of childbearing age. The diagnostic method and appropriate management for EP has been extensively studied. Concrete- and evidence-based guidelines guide clinical management and improve morbidity and mortality. Local guidelines improve clinical outcome.What do the results of this study add? This study shows the impact of clinical outcome without a national guideline to guide management on a national level. Malta has one national hospital in which the local obstetrics and gynaecology department is run. The results of this study thus comprise of nationwide statistics on EP and its management. Ectopic pregnancies are managed without a local guideline in place. It also reflects the ease of access to health care in smaller countries.What are the implications of these findings for clinical practice and/or further research? The findings of this study have resulted in the production of a local guideline for the management of EP, as well as the introduction of a protocol for obtaining methotrexate for medical management. It has introduced new ultrasound machines and staff training to aid diagnostics. Further re-auditing will be carried out to analyse the impact a local guideline has on clinical practice at a national level.

Effect of Methotrexate on Salpingostomy Completion Rate for Tubal Ectopic Pregnancy: A Retrospective Cohort Study

STUDY OBJECTIVE

To determine whether completion rates of salpingostomy for tubal ectopic pregnancy are compromised by initial medical management with methotrexate (MTX).

DESIGN

Retrospective cohort study.

SETTING

Single academic hospital system.

PATIENTS

Patients requiring surgery for ectopic pregnancy between 2006 and 2017.

INTERVENTIONS

A subset of patients who went directly to surgery, and all patients who failed MTX before requiring surgery underwent detailed chart review. Salpingostomy plan and success rate and salpingostomy failure reasons were compared between patients pretreated with MTX and those who were MTX-untreated.

MEASUREMENTS AND MAIN RESULTS

Among 94 ectopic pregnancies requiring surgery after failed MTX treatment, 55 (59%) underwent planned salpingostomy. From 693 ectopic pregnancies managed without MTX, 166 were analyzed in detail, of which 80 (48%) underwent planned salpingostomy. The patients who underwent planned salpingostomy were thinner (body mass index 27.3 ± 7.2 kg/m² vs 29.3 ± 8.3 kg/m²; p = .048), less frequently African American (33% vs 47%; p = .017), and more likely to have a visualized adnexal lesion (70% vs 52%; p = .004) than those undergoing planned salpingectomy. Preoperative ultrasound identified fetal cardiac activity and hemoperitoneum at comparable rates. MTX exposure was not associated with age, body mass index, race, ectopic risk factors, human chorionic gonadotropin levels, or gestational age at diagnosis, but the patients treated with MTX underwent surgery later than those who were untreated (gestational age 53.4 ± 11.2 days vs 43.5 ± 11 days; p <.001). The differences between the adnexal lesion size and rates of fetal cardiac activity and hemoperitoneum on ultrasound related to MTX exposure did not meet significance. Planned salpingostomy was completed in 22 (40%) of the patients treated with MTX vs 34 (42%) of those who were untreated. The reasons for failure, surgery time, and rates of hemoperitoneum or ectopic rupture were not associated with MTX exposure. Body mass index, race, tubal anastomosis history, visualization of the adnexal lesion, and MTX exposure were not significantly associated with the salpingostomy rate in a multivariate logistic regression model, but having a subspecialist surgeon (odds ratio 2.70; 95% confidence interval, 1.08-6.76; p = .033) and tubal rupture at surgery (odds ratio 0.23; 95% confidence interval, 0.09-0.54; p = .001) were.

CONCLUSION

The initial medical management of an ectopic pregnancy with MTX is not associated with a decreased salpingostomy success rate.

Effect and clinical value of coagulation test on adverse reactions of blood transfusion in patients with major bleeding in ectopic pregnancy

Influence and clinical value of coagulation test on adverse reactions of blood transfusion in patients with major bleeding of ectopic pregnancy were analyzed. Six hundred and twenty-seven cases of ectopic pregnancy admitted to Zibo First Hospital from July 2014 to March 2017 were retrospectively analyzed. The 369 patients who had adverse reactions after blood transfusion were selected as the experimental group. Another 258 patients without adverse reaction after blood transfusion were selected as the control group. Blood samples were collected 8 h before and after blood transfusion in both groups, and blood test was performed including blood count (RBC), white blood cell count (WBC), platelet count (PLT), HB, hematocrit (HCT), as well as indicators of coagulation, including thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen (FIB). There was no significant difference between the two groups in blood routine and blood coagulation test (P>0.05). After transfusion, the RBC, WBC, PLT, HB and HCT in the experimental group were significantly lower than those in the control group (P<0.05). TT, PT and APTT were higher than those in the control group (P<0.05), while FIB was significantly lower than that in the control group (P<0.001). The coagulation in the experimental group after blood transfusion was significantly worse than that in the control group. Coagulation test can be used as a marker of adverse reactions after transfusion in patients with massive bleeding in pregnancy, providing reference and guidance for clinical diagnosis and treatment.

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

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

Clinical audit of ectopic pregnancy

Objective

The aim of this study was to determine the risk factors of ectopic pregnancy in cases presented to the Woman’s Health Hospital (WHH) in Assuit University, and to perform clinical audit on strategies for management of ectopic pregnancy in the WHH.

Methods

This descriptive hospital based study was conducted at the Woman’s Health Hospital (WHH) of Assuit University (Egypt). There were 210 patients who were admitted to the WHH with the diagnosis of ectopic pregnancy in the period between February 1, 2015 through the end of October 2015. Data were analyzed by SPSS version 21, using descriptive statistics, Mann-Whitney U test, and Chi square.

Results

Ectopic pregnancy affects woman in the reproductive age. There are many risk factors that increase the chance of its occurrence; however, it may also occur in the absence of any risk factors (14.0%). Internal VD (72.5%) is the most frequent risk factor; other risk factors include history of abortion, previous CS, ovulation induction, history of infertility, or previous history of EP.

Conclusion

Clinical audit is an important item of any adequate health care. As regards to the clinical audit of EP management, we are not adhering to the guidelines.

Single-dose methotrexate for the treatment of ectopic pregnancy: Our experience from 2010 to 2015

Objective:

To evaluate the success of systemic single-dose methotrexate (MTX) treatment in patients with ectopic pregnancy (EP) and to investigate factors related to treatment success.

Methods:

This retrospective study had been performed in Yildirim Beyazit University between January 2010 and December 2015. Demographic and clinical characteristics, ultrasonografic findings, pretreatment serum β–human chorionic gonadotropin (β-hCG) and progesterone levels of 58 patients with EP were retrieved from hospital records retrospectively. The patients were grouped according to MTX treatment success (response vs. failure).

Results:

Single-dose MTX-treatment was successful in 72.4% (42/58) of patients. The mean pretreatment β-hCG level was significantly lower in responders than in failures (2080 ± 2322 vs. 5707 ± 3885 IU/L, p = 0.001), and 2678 IU/L was the most suitable cutoff to predict success (75% sensitivity, 73.8% specificity). Moreover, failure rate was 8.45 times more in group of patients whose β-hCG values were determined above the cutoff. The presence of fetal cardiac activity adversely affected treatment success (odds ratio = 12, p = 0.004). Treatment success was not affected by past history of ectopic pregnancy, thickness of endometrium, progesterone value or presences of pseudosac and free pelvic fluid.

Conclusion:

The success rate of single dose MTX in this study was 72.8 %, and we found that failure rate of MTX treatment was 8.45 times more in group of patients whose initial serum β-hCG values were above 2678 IU/L and 12 times more in patients with fetal cardiac activity

Challenges in the surgical management of ectopic pregnancy in a low-resource setting: Mpilo Central Hospital, Bulawayo, Zimbabwe

Background Ectopic pregnancy contributes to maternal morbidity and mortality, especially in low-resourced countries with limited facilities for early diagnosis and treatment. It is a very challenging condition to diagnose. Patients may collapse and die while undergoing investigation. Aims To assess surgical treatment given to patients presenting at Mpilo Central Hospital, the challenges that are faced and the outcomes; and also to document how women survive this dangerous condition in a setting challenged by low resources. Results All the patients had prompt life-saving surgery within 48 h of admission despite the challenges faced. The survival rate was 100% during the period of the study. Conclusion It is possible to prevent maternal mortality in low-resource countries by maintaining basic clinical and surgical skills.