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Restaino S, D’Indinosante M, Perelli F, Arcieri M, Cherchi V, Petrillo M, Cavaliere AF, Cianci S, Pellecchia G, Meniconi RL, Coppola A, Chiantera V, Scambia G, Driul L, Vizzielli G. Ergonomics in the operating room and surgical training: a survey on the Italian scenario. Front Public Health 2024; 12:1417250. [PMID: 39171296 PMCID: PMC11337608 DOI: 10.3389/fpubh.2024.1417250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/08/2024] [Indexed: 08/23/2024] Open
Abstract
Introduction Surgical-related injuries are frequent, in fact the reported percentage of musculoskeletal disorders in surgeons is between 47% and 87%. These conditions are caused by long periods of standing, incorrect postures, repeated movements, little rest between operations, the lack of integrated operator rooms, the correct number and arrangement of monitors and the use of non-ergonomic instruments. This survey aims to assess the Italian overview both highlighting how prevalent surgical-related injury is in our surgeons and whether there is an operating room ergonomics education program in Italian surgical specialty schools. Methods An anonymous questionnaire was designed through SurveyMonkey© web application. This survey was composed of 3 different sections concerning the general characteristics of the participants, their surgical background and any training performed, and any injuries or ailments related to the surgical activity. The survey was carried out in the period 1th of December 2022 and the 6th of February 2023. Results At the close of our survey, 300 responses were collected. Among the participants, the two most represented specialties were Gynecology and Obstetrics (42.3%) and General Surgery (39.7%) and surgeons were mainly employed in the Northern regions of Italy (54.8%). Analyzing the participants' background, 61.7% of the respondents had laparoscopic training during their training and only 53.1% had a pelvic trainer during their residency. In accordance with 98.7% of the respondents, during surgery we have the feeling of being in an uncomfortable position that causes discomfort or muscle pain, and regarding the frequency of these discomforts, the majority of our study population experiences these problems monthly (46.2%), while in 29.6% it is experienced weekly, 12.1% annually and finally 12.1% daily. The surgical approach that is most correlated with these disorders is laparoscopy (62.7%) while the one that causes the least discomfort is robotic surgery (1.4%). These discomforts cause 43.9% of our population to take a break or do short exercises to reduce pain during surgery, and the body areas most affected are the back (61.6%), neck (40.6%) and shoulders (37.8%). Conclusion Despite this, our survey allows us to highlight some now-known gaps present in the surgical training program of our schools and the lack of protection toward our surgeons during their long career.
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Affiliation(s)
- Stefano Restaino
- Clinic of Obstetrics and Gynecology, “S. Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Marco D’Indinosante
- Dipartimento per le Scienze Della Salute Della Donna, del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Federica Perelli
- Division of Gynaecology and Obstetrics, Santa Maria Annunziata Hospital, USL Toscana Centro, Florence, Italy
| | - Martina Arcieri
- Clinic of Obstetrics and Gynecology, “S. Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Vittorio Cherchi
- General Surgery Clinic and Liver Transplant Center, University Hospital of Udine, Udine, Italy
| | - Marco Petrillo
- Gynecologic and Obstetric Clinic, Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Anna Franca Cavaliere
- Department of Gynecology and Obstetrics of "San Giovanni Calibita" Fatebenefratelli Hospital-Gemelli Hospital, Rome, Italy
| | - Stefano Cianci
- Dipartimento di Ginecologia Oncologica e Chirurgia Ginecologica Miniinvasiva, Università degli studi di Messina, Policlinico G. Martino, Messina, Italy
| | | | - Roberto Luca Meniconi
- Department of General Surgery and Liver Transplantation, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Vito Chiantera
- Unit of Gynecologic Oncology, National Cancer Institute, IRCCS, Fondazione "G. Pascale", Naples, Italy
| | - Giovanni Scambia
- Dipartimento per le Scienze Della Salute Della Donna, del Bambino e di Sanità Pubblica, UOC Ginecologia Oncologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Lorenza Driul
- Clinic of Obstetrics and Gynecology, “S. Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
| | - Giuseppe Vizzielli
- Clinic of Obstetrics and Gynecology, “S. Maria della Misericordia” University Hospital, Azienda Sanitaria Universitaria Friuli Centrale (ASUFC), Udine, Italy
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Yeniocak AS, Tercan C, Dagdeviren E, Arabacı O, Genc EE. Evaluation of a scoring system to predict treatment success with single-dose methotrexate in ectopic pregnancy. Arch Gynecol Obstet 2024; 309:2047-2055. [PMID: 38488896 DOI: 10.1007/s00404-024-07458-6] [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: 01/09/2024] [Accepted: 03/04/2024] [Indexed: 03/17/2024]
Abstract
PURPOSE This study sought to assess the efficacy of a newly developed scoring system in predicting treatment outcomes for ectopic pregnancy among patients undergoing single-dose methotrexate therapy. The primary research question centered on the reliability and predictive accuracy of objective parameters in determining methotrexate therapy success. METHODS Conducted as a retrospective single-center cohort study, data from 172 ectopic pregnancy patients treated with methotrexate between January 2021 and January 2023 were analyzed. Parameters including adnexal mass size, peritoneal fluid presence, yolk sac identification, endometrial thickness, ectopic pregnancy location, and initial B-hCG levels were meticulously evaluated for their association with treatment outcomes. RESULTS Following the exclusion of 21 emergency surgery cases, the final analysis comprised 151 patients. Notable associations were observed between specific parameters (fetal cardiac activity, adnexal mass size > 3.5 cm, peritoneal fluid presence, yolk sac identification, endometrial thickness > 10 mm, and initial B-hCG levels) and treatment outcomes (p < 0.001). Additionally, the novel scoring system demonstrated promising predictive performance. At a cutoff of 2.50, it achieved a sensitivity of 91.7% and a specificity of 59.7%. Increasing the cutoff to 3.50 resulted in a sensitivity of 94.0%, with a specificity of 46.3%. CONCLUSION Objective parameters, particularly those integrated into the developed scoring system, exhibited substantial associations with methotrexate therapy outcomes in ectopic pregnancy. These findings underscore the potential of an objective scoring model to significantly influence clinical decision-making in therapy, offering avenues for enhanced prognostication and patient care in treatment outcomes.
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Affiliation(s)
- Ali Selcuk Yeniocak
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey.
| | - Can Tercan
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Emrah Dagdeviren
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Onur Arabacı
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Emine Elif Genc
- Department of Obstetrics and Gynecology, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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Capmas P, Panjo H, Artignan J, Babelhadj A, Benoist I, Decouzon J, Jarrige C, Leglise M, Renoncet V, Pelletier-Fleury N. Women's preferences for less active ectopic pregnancy treatment: A discrete choice experiment. Eur J Obstet Gynecol Reprod Biol 2024; 292:175-181. [PMID: 38035866 DOI: 10.1016/j.ejogrb.2023.11.032] [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: 09/06/2023] [Revised: 11/14/2023] [Accepted: 11/23/2023] [Indexed: 12/02/2023]
Abstract
RESEARCH QUESTION Shared decision-making has become a hallmark of quality care and is increasingly spotlighted in practice guidelines. Little is known about women's views for treatment of less active ectopic pregnancy. What are the preferences of women for less active ectopic pregnancy treatment-related attributes? DESIGN A discrete choice model with 8 attributes depicting ectopic pregnancy treatment including varying levels of first-line treatment effectiveness, length of hospitalization, cost, length of sick leave, of convalescence, need for surgical management, for emergency care during convalescence and for tube removal was used. Childbearing aged women, i.e. those who might experience an ectopic pregnancy in the future, were recruited. They were asked to choose between hypothetical treatments in 18 choice tasks with different levels of all treatment attributes. A conditional logit McFadden's choice model was performed. The main outcome measure was preference weights for less active ectopic pregnancy treatment-related attributes. RESULTS A total of 5770 observations from 178 women were analysed. The attributes displaying the highest marginal impacts on women's decisions included: higher rate of first-line treatment effectiveness, lower rate of tube removal, lower rate of surgical management, shorter length of hospitalization and, to a lesser extent, but still significant, shorter length of convalescence, absence of risk of emergency care during convalescence and lower cost. CONCLUSIONS Trade-offs made by women between the attributes of less active ectopic pregnancy treatment suggest that no treatment option, either medical or surgical, is an obvious preferred option. These results encourage the promotion of shared decision-making.
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Affiliation(s)
- Perrine Capmas
- Centre of Research in Epidemiology and Population Health (CESP), UMR1018, Inserm, Paris Saclay University, Hôpital Paul Brousse, 16 Avenue Paul Vaillant Couturier F-94816 Villejuif, France; Gynecology and Obstetrics Department, Bicetre Hospital, GHU Sud, AP-HP, 78 avenue du Général Leclerc, F-94276 Le Kremlin Bicetre, France; GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France.
| | - Henri Panjo
- Centre of Research in Epidemiology and Population Health (CESP), UMR1018, Inserm, Paris Saclay University, Hôpital Paul Brousse, 16 Avenue Paul Vaillant Couturier F-94816 Villejuif, France
| | - Juliette Artignan
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Aicha Babelhadj
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Inès Benoist
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Julie Decouzon
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Claire Jarrige
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Mylène Leglise
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Valérie Renoncet
- GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
| | - Nathalie Pelletier-Fleury
- Centre of Research in Epidemiology and Population Health (CESP), UMR1018, Inserm, Paris Saclay University, Hôpital Paul Brousse, 16 Avenue Paul Vaillant Couturier F-94816 Villejuif, France; GyneSpri Participatory Research Group, Association GyneSpri, 28 rue Anatole France, 94300 Vincennes, France
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Solangon SA, Van Wely M, Van Mello N, Mol BW, Ross JA, Jurkovic D. Methotrexate vs expectant management for treatment of tubal ectopic pregnancy: An individual participant data meta-analysis. Acta Obstet Gynecol Scand 2023; 102:1159-1175. [PMID: 37345445 PMCID: PMC10407021 DOI: 10.1111/aogs.14617] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/31/2023] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION Ectopic pregnancy is an important health condition which affects up to 1 in 100 women. Women who present with mild symptoms and low serum human chorionic gonadotrophin (hCG) are often treated with methotrexate (MTX), but expectant management with close monitoring is a feasible alternative. Studies comparing the two treatments have not shown a statistically significant difference in uneventful resolution of ectopic pregnancy, but these studies were too small to define whether certain subgroups could benefit more from either treatment. MATERIAL AND METHODS We performed a systematic review and individual participant data meta-analysis (IPD-MA) of randomized controlled trials comparing systemic MTX and expectant management in women with tubal ectopic pregnancy and low hCG (<2000 IU/L). A one-stage IPD-MA was performed to assess overall treatment effects of MTX and expectant management to generate a pooled intervention effect. Subgroup analyses and exploratory multivariable analyses were undertaken according to baseline serum hCG and progesterone levels. Primary outcome was treatment success, defined as resolution of clinical symptoms and decline in level of serum hCG to <20 IU/L, or a negative urine pregnancy test by the initial intervention strategy, without any additional treatment. Secondary outcomes were need for blood transfusion, surgical intervention, additional MTX side-effects and hCG resolution times. TRIAL REGISTRATION NUMBER PROSPERO: CRD42021214093. RESULTS 1547 studies reviewed and 821 remained after duplicates removed. Five studies screened for eligibility and three IPD requested. Two randomized controlled trials supplied IPD, leading to 153 participants for analysis. Treatment success rate was 65/82 (79.3%) after MTX and 48/70 (68.6%) after expectant management (IPD risk ratio [RR] 1.16, 95% confidence interval [CI] 0.95-1.40). Surgical intervention rates were not significantly different: 8/82 (9.8%) vs 13/70 (18.6%) (RR 0.65, 95% CI 0.23-1.14). Mean time to success was 19.7 days (95% CI 17.4-22.3) after MTX and 21.2 days (95% CI 17.8-25.2) after expectant management (P = 0.25). MTX specific side-effects were reported in 33 MTX compared to four in the expectant group. CONCLUSIONS Our IPD-MA showed no statistically significant difference in treatment efficacy between MTX and expectant management in women with tubal ectopic pregnancy with low hCG. Initial expectant management could be the preferred strategy due to fewer side-effects.
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Affiliation(s)
| | - Madelon Van Wely
- Center for Reproductive MedicineAmsterdam University Medical CenterAmsterdamthe Netherlands
- Amsterdam Reproduction and Development Research InstituteAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Norah Van Mello
- Amsterdam Reproduction and Development Research InstituteAmsterdam University Medical CenterAmsterdamthe Netherlands
- Obstetrics and GynecologyAmsterdam University Medical CenterAmsterdamthe Netherlands
| | - Ben W. Mol
- The Ritchie Centre, Department of Obstetrics and GynecologyMonash UniversityClaytonVictoriaAustralia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and NutritionUniversity of AberdeenAberdeenUK
| | - Jackie A. Ross
- Early Pregnancy and Gynaecology Assessment UnitKing's College London HospitalLondonUK
| | - Davor Jurkovic
- Institute for Women's HealthUniversity College LondonLondonUK
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Gupta A, Pajai S, Shrivastava D, Singh Thakur A, Shaikh M. A Rare Case of Adnexal Pregnancy After Bilateral Tubal Clamping. Cureus 2023; 15:e43284. [PMID: 37692569 PMCID: PMC10492606 DOI: 10.7759/cureus.43284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
An adnexal pregnancy after tubal clamping is a very rare entity. Very few such cases have been reported in the past. Here, we discuss a case of such an occurrence. A 35-year-old female with third gravida and a history of two abortions with secondary infertility conceived via in vitro fertilization was admitted to the ward for observation with a history of amenorrhea of one and a half months and a known case of hypothyroidism. The ultrasonography showed left ectopic adnexal pregnancy that was managed conservatively. With a previous history of left ectopic pregnancy, the patient was managed with exploratory laparotomy with left partial salpingectomy. This case is used to illustrate the need to gather a complete medical history and take ectopic pregnancy into account in women who are of reproductive age and have a history of ectopic pregnancies.
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Affiliation(s)
- Aishwarya Gupta
- Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sandhya Pajai
- Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Deepti Shrivastava
- Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Aditi Singh Thakur
- Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Muneeba Shaikh
- Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Levin G, Ohayon A, Weissbach T, Burke YZ, Meyer R. Ectopic first pregnancy treated by methotrexate versus salpingectomy-Maternal and perinatal outcomes in a subsequent pregnancy: A retrospective study. Int J Gynaecol Obstet 2023; 160:823-828. [PMID: 35871755 PMCID: PMC10087190 DOI: 10.1002/ijgo.14365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/30/2022] [Accepted: 07/17/2022] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Gabriel Levin
- Department of Gynecologic Oncology, Hadassah Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Aviran Ohayon
- Faculty of Medicine, St. George's University of London, London, UK
| | - Tal Weissbach
- Faculty of Medicine, Tel-Aviv-Hebrew University, Tel-Aviv, Israel.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Yechiel Z Burke
- Faculty of Medicine, Tel-Aviv-Hebrew University, Tel-Aviv, Israel.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Raanan Meyer
- Faculty of Medicine, Tel-Aviv-Hebrew University, Tel-Aviv, Israel.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat-Gan, Israel.,The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Ramat-Gan, Israel
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Conservative Management of Cervical Pregnancy with the Administration of Methotrexate and Potassium Chloride: A Case Report. Case Rep Obstet Gynecol 2022; 2022:1352868. [DOI: 10.1155/2022/1352868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/23/2022] [Accepted: 10/31/2022] [Indexed: 11/09/2022] Open
Abstract
Background. Cervical pregnancy is a rare form of ectopic pregnancy in which the fetus implants and grows inside the endocervical canal. This report aims at introducing a case of successful conservative management of cervical ectopic pregnancy. Case presentation. The patient was a 35-year-old woman, who had received treatment for primary infertility for 5 years. She complained of painless bleeding on day 37 of gestational age with a start point from 10 days before. The patient had stable vital signs and was referred to Shahid Akbar Abadi Hospital in Tehran affiliated with the Iran University of Medical Sciences. In the ultrasonography, the pregnancy sac and the yolk sac with the embryonic pole with a positive fetal heart rate were presented and located near the internal os, so the cervical pregnancy was diagnosed, and after treatment with intramuscular methotrexate and intra-amniotic administration of potassium chloride, a gradual decrease in β-HCG levels was observed without the need for additional interventional treatment. Conclusion. The primary takeaway of our report is that the conservative treatment, including intramuscular methotrexate and intrauterine potassium chloride administration, may be effective in treating cervical pregnancy that can be detected early without the use of curettage.
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Wenjing L, Haibo L. Therapeutic effect of laparoscopic salpingotomy vs. salpingectomy on patients with ectopic pregnancy: A systematic review and meta-analysis. Front Surg 2022; 9:997490. [PMID: 36303847 PMCID: PMC9592917 DOI: 10.3389/fsurg.2022.997490] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background and aim Laparoscopic treatment of ectopic pregnancy mainly includes laparoscopic salpingotomy and salpingectomy. We aimed to assess the therapeutic effect of laparoscopic salpingotomy and salpingectomy on patients with tubal pregnancy. Methods From January 2000 through June 2022, the Cochrane Library, Medline, PubMed, Web of Science, EMBASE, and the Chinese Biomedicine Database were searched for studies that compared the therapeutic effect of laparoscopic salpingotomy vs. salpingectomy in the treatment of tubal pregnancy. Results Twenty-four randomized clinical trials (RCTs) studies were incorporated into this analysis. No statistical differences were found between the two groups in terms of operation duration and postoperative hospitalize length, but the volume of intraoperative blood loss in patients with laparoscopic salpingotomy was less than that in salpingectomy. Importantly, the natural intrauterine pregnancy rate after laparoscopic salpingotomy was significantly higher than those who underwent salpingectomy. In addition, laparoscopic salpingotomy can better protect the ovarian reserve function and endocrine function and provide favorable conditions for the second pregnancy. Conclusion Patients with ectopic tubal pregnancy should give priority to laparoscopic salpingotomy for embryo extraction.
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Cardall AK, Jacobson JC, Prager S, Flynn AN, Russo J. Medical management of ectopic pregnancy in a family planning clinic: a case series. Contraception 2022; 109:68-72. [PMID: 35031302 DOI: 10.1016/j.contraception.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 11/01/2021] [Accepted: 11/06/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate safety of medical management of ectopic pregnancy in a free-standing family planning clinic setting. METHODS We retrospectively reviewed cases of ectopic pregnancy between January 2014 and December 2018 which were identified using a "Beta Board" tracking system. Planned Parenthood of Orange and San Bernardino Counties staff added patients the "Beta Board" if they had a positive urine pregnancy test without definitive ultrasound diagnosis of intrauterine pregnancy and/or symptoms suggestive of ectopic pregnancy, such as vaginal bleeding and cramping. Patients were included in the study if they had received a final diagnosis of ectopic pregnancy. RESULTS Of 5083 patients tracked via the Beta Board, 260 patients presented to a Planned Parenthood free-standing, family planning clinic with ectopic pregnancy. Ninety-five patients were treated with methotrexate entirely at the clinic. There were no deaths. Four ectopic pregnancies ruptured and eight required surgery. CONCLUSION Treatment of ectopic pregnancy with methotrexate in the family planning clinic setting can be safe and effective with reassuring outcomes that are similar to the hospital setting.
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Affiliation(s)
- Anna K Cardall
- School of Medicine, University of California, Irvine, Irvine, California, 1001 Health Sciences Rd, Irvine CA 92617.
| | - Janet C Jacobson
- Planned Parenthood of Orange and San Bernardino Counties, 700 S. Tustin St. Orange, CA 92866.
| | - Sarah Prager
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, 1959 NE Pacific St. Seattle WA, 98195.
| | - Anne N Flynn
- Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, 3400 Spruce St, Philadelphia, PA 19104.
| | - Jennefer Russo
- Department of Obstetrics and Gynecology, Harbor UCLA Medical Center, Torrance, CA, 1000 W Carson St, Torrance, CA 90502.
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Lin C, Hsieh H. Early Ectopic Pregnancy Refractory to Methotrexate Treatment: A Case Report. Cureus 2021; 13:e19686. [PMID: 34976471 PMCID: PMC8681904 DOI: 10.7759/cureus.19686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2021] [Indexed: 11/11/2022] Open
Abstract
Methotrexate (MTX) is known as a systemic treatment for early ectopic pregnancy with low serum beta-human chorionic gonadotropin (βhCG) levels. Here we present our experience of an unsatisfactory outcome following MTX treatment for early tubal pregnancy. The case is a 39-year-old female with left tubal ectopic pregnancy and a history of one right tubal ectopic pregnancy and an uneventful episode of delivery. In the absence of any contraindications, the patient underwent initial MTX treatment. At first, her serum βhCG level was 1,258 mIU/mL but remained elevated. Then she underwent a second and third dose of MTX. After a month, the serum βhCG level had not declined to within an acceptable range. The ectopic mass was enlarged as determined by transvaginal ultrasonography and hemoperitoneum. A laparoscopic salpingectomy was performed. Early ectopic tubal pregnancy can be managed medically with a high success rate. However, repeat ectopic pregnancy indicates an increased risk of treatment failure to medical treatment, and should be mentioned to the patient when discussing their treatment options.
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Cervical Twin Heterotopic Pregnancy: Overview of Ectopic Pregnancies and Scanning Detection Algorithm. MEDICINA-LITHUANIA 2021; 57:medicina57090969. [PMID: 34577892 PMCID: PMC8471448 DOI: 10.3390/medicina57090969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 11/17/2022]
Abstract
Background: Ectopic pregnancy is the leading cause of gestation-related deaths during the first trimester. Cervical twin heterotopic pregnancies, when ectopic, constitute a small and rare part of gynecological surgery. Case Presentation: A 30-year-old pregnant woman (gravida 3, para 2) presented with mild pain in the lower abdomen and traces of bleeding per vaginum for three days. Transvaginal ultrasonography revealed a balloon-shaped cervical canal with a visible gestational sac measuring 3.5 × 3.9 cm. A second gestational sac was seen in the uterine cavity. The measurements of the gestational sacs corresponded to 7 + 4 weeks' pregnancy. A decision for medical abortion with mifepristone and misoprostol was made. However, due to an incomplete abortion and continuous bleeding, a curettage was performed. Conclusions: Spontaneous heterotopic pregnancy with the ectopic pregnancy located in the cervix is an extremely rare clinical condition requiring urgent treatment in order to reduce maternal mortality and morbidity and preserve fertility.
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Shehab QJ, Dolloway L, Damra AM, Al Zoubi MS, Albeitawi SN. Negative histology in surgically managed tubal ectopic pregnancy. Int J Gynaecol Obstet 2021; 157:719-722. [PMID: 34478570 DOI: 10.1002/ijgo.13913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/23/2021] [Accepted: 09/02/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the rate of negative histology following salpingectomy for suspected ectopic pregnancy. METHODS A retrospective case series in a university hospital in the southwest of England was carried out. The records of all patients who had a salpingectomy for suspected ectopic pregnancy between January 2007 and December 2012 were reviewed. The primary outcome was the histology result. RESULTS In total, 359 salpingectomies were performed for suspected ectopic pregnancy over 6 years. On histologic examination, 4.7% of fallopian tubes did not have evidence of an implantation site or trophoblastic tissue. When the macroscopic appearance of the fallopian tube was correlated with the surgical findings (e.g., rupture with large hemoperitoneum) and follow-up notes were reviewed thoroughly, the histology of 0.84% of all salpingectomies was not consistent with a tubal ectopic pregnancy. CONCLUSIONS True negative histology for surgically managed ectopic pregnancy is less than 1%.
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Affiliation(s)
- Qasem J Shehab
- Clinical Sciences Department, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | | | - Amal M Damra
- Pediatrics Department, Faculty of Medicine, Al Balqaa' Applied University, Jordan
| | - Mazhar S Al Zoubi
- Department of Basic Medical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Soha N Albeitawi
- Clinical Sciences Department, Faculty of Medicine, Yarmouk University, Irbid, Jordan
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Díaz-Narváez MC, Enriquez-Enriquez EC. Embarazo heterotópico de ubicación tubárica. Reporte de caso. CASE REPORTS 2021. [DOI: 10.15446/cr.v7n2.86507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. El embarazo heterotópico se considera una patología de interés debido a que, aunque su incidencia es baja, su tasa de mortalidad es elevada; además, esta es una entidad que representa un reto diagnostico por sus diversas presentaciones clínicas.
Presentación del caso. Mujer de 32 años, mestiza, procedente de Pasto (Colombia) y en estado de embarazo, quien asistió al servicio de urgencias de una institución de tercer nivel de atención por un dolor abdominal difuso asociado a sangrado vaginal. Teniendo en cuenta los hallazgos imagenológicos (ecografía) y los niveles de gonadotropina encontrados, la paciente fue diagnosticada con embarazo heterotópico de ubicación tubárica derecha que requirió tratamiento quirúrgico por laparotomía. A los 8 días del procedimiento la paciente asistió a control y mediante ecografía se evidenció continuidad de embarazo intrauterino.
Conclusiones. El pilar fundamental para el diagnóstico del embarazo heterotópico es la sospecha clínica, pero es necesario confirmarlo mediante ayudas diagnosticas como la ecografía y a través de la medición de los niveles de gonadotropina coriónica humana. Este evento se debe sospechar en pacientes con cuadro de dolor abdominal a pesar de que no tengan factores de riesgo para presentarlo. La elección de tratamiento (médico o quirúrgico) depende de la condición clínica y hemodinámica de cada paciente y de la ubicación y el tamaño del embarazo ectópico.
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Balalau OD, Conea IM, Bacalbasa N, Dumitriu AS, Paunica S, Vasilache A, Olaru OG. Management of hemoperitoneum due to rupture of the ovarian cyst. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2021. [DOI: 10.25083/2559.5555/6.1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Ovarian cyst is the most common female gynecological pathology and it is characteristic of reproductive age. Its rupture causes the sudden onset of pelvic-abdominal pain, often associated with physical exertion or sexual contact. The differential diagnosis is made with other causes of lower abdominal pain: ectopic pregnancy, adnexal torsion, pelvic inflammatory disease or acute appendicitis. The clinical picture may vary depending on the type of ruptured cyst. Dermoid cyst causes severe symptoms due to chemical peritonitis that occurs in response to extravasation of sebaceous contents in the peritoneal cavity.Surgical treatment is indicated for complicated forms of cystic rupture. Most cases have self-limiting, quantitatively reduced bleeding and spontaneous resorption within a few days.Patients diagnosed with ovarian cyst are recommended for regular ultrasound monitoring to prevent complications such as cystic rupture or adnexal torsion.The identification of any ovarian tumor mass in the woman at menopause requires further investigation to rule out the causes of malignancy.
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Obst KL, Oxlad M, Due C, Middleton P. Factors contributing to men's grief following pregnancy loss and neonatal death: further development of an emerging model in an Australian sample. BMC Pregnancy Childbirth 2021; 21:29. [PMID: 33413199 PMCID: PMC7792062 DOI: 10.1186/s12884-020-03514-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background Historically, men’s experiences of grief following pregnancy loss and neonatal death have been under-explored in comparison to women. However, investigating men’s perspectives is important, given potential gendered differences concerning grief styles, help-seeking and service access. Few studies have comprehensively examined the various individual, interpersonal, community and system/policy-level factors which may contribute to the intensity of grief in bereaved parents, particularly for men. Methods Men (N = 228) aged at least 18 years whose partner had experienced an ectopic pregnancy, miscarriage, stillbirth, termination of pregnancy for foetal anomaly, or neonatal death within the last 20 years responded to an online survey exploring their experiences of grief. Multiple linear regression analyses were used to examine the factors associated with men’s grief intensity and style. Results Men experienced significant grief across all loss types, with the average score sitting above the minimum cut-off considered to be a high degree of grief. Men’s total grief scores were associated with loss history, marital satisfaction, availability of social support, acknowledgement of their grief from family/friends, time spent bonding with the baby during pregnancy, and feeling as though their role of ‘supporter’ conflicted with their ability to process grief. Factors contributing to grief also differed depending on grief style. Intuitive (emotion-focused) grief was associated with support received from healthcare professionals. Instrumental (activity-focused) grief was associated with time and quality of attachment to the baby during pregnancy, availability of social support, acknowledgement of men’s grief from their female partner, supporter role interfering with their grief, and tendencies toward self-reliance. Conclusions Following pregnancy loss and neonatal death, men can experience high levels of grief, requiring acknowledgement and validation from all healthcare professionals, family/friends, community networks and workplaces. Addressing male-specific needs, such as balancing a desire to both support and be supported, requires tailored information and support. Strategies to support men should consider grief styles and draw upon father-inclusive practice recommendations. Further research is required to explore the underlying causal mechanisms of associations found. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-020-03514-6.
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Affiliation(s)
- Kate Louise Obst
- School of Psychology, University of Adelaide, Adelaide, South Australia.
| | - Melissa Oxlad
- School of Psychology, University of Adelaide, Adelaide, South Australia
| | - Clemence Due
- School of Psychology, University of Adelaide, Adelaide, South Australia
| | - Philippa Middleton
- South Australian Health and Medical Research Institute, Adelaide, South Australia
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Kingsbury B, Sam D, Jeyasudha R, Thomas E, Rebekah G, Lionel J. Ectopic pregnancies: Catch them early, treat them wisely! J Family Med Prim Care 2020; 9:4911-4918. [PMID: 33209821 PMCID: PMC7652111 DOI: 10.4103/jfmpc.jfmpc_684_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/10/2020] [Accepted: 07/04/2020] [Indexed: 11/15/2022] Open
Abstract
Introduction: Ectopic pregnancy (EP) is a common condition encountered in Obstetrics and Gynecology. Different management protocols are currently available for haemodymanically stable patients but definitive recommendations is yet to be established, especially in developing countries with limited resources. Aim: To determine the outcome of EP in patients who are haemodynamically stable and to evaluate the factors that would predict success of specific management protocols in them. Methodology: Haemodynamically stable patients with HCG levels <1500 mIU/ml were recruited for expectant management, 1500–5000 mIU/ml were given MTX and those with >5000 mIU/ml were managed surgically. Results: The overall success rate for expectant management was 92.7% and that with MTX was 80%. Baseline HCG values was found to be the only significant factor for predictor of success of treatment in the expectant group (P 0.05). The size of mass seen on USG did not have a significant correlation with beta HCG values (P 0.257). Conclusion: Of all the predictors for success of treatment that have been studied, the initial HCG value alone remains of paramount importance. Women with initial values of HCG <1500 mIU/ml can be offered expectant management, with a much better assurance of success for those with values <1000 mIU/ml. Those with values <5000 mIU/ml can be given MTX, with single dose being sufficient most often for <3000 mIU/ml. The presence of fluid restricted to the pelvis on USG can be managed non-surgically. One should not opt for surgical management only on the basis of size of the adnexal mass on USG.
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Affiliation(s)
- Beena Kingsbury
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Dibu Sam
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamil Nadu, India
| | - R Jeyasudha
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Elsy Thomas
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Grace Rebekah
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Jessie Lionel
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, Tamil Nadu, India
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Salari N, Kazeminia M, Shohaimi S, Nankali AAD, Mohammadi M. Evaluation of treatment of previous cesarean scar pregnancy with methotrexate: a systematic review and meta-analysis. Reprod Biol Endocrinol 2020; 18:108. [PMID: 33168010 PMCID: PMC7650162 DOI: 10.1186/s12958-020-00666-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/30/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Previous caesarean scar pregnancy is one type of ectopic pregnancy in myometrium and fibrous tissue of previous caesarean scar. One of the therapeutic methods of this type of ectopic pregnancy is treatment with methotrexate. Given various findings on the treatment of caesarean scar pregnancy with methotrexate and lack of global report in this regard, we aimed to achieve a global report on the treatment of CSP with methotrexate through related literature review and analysis of the results of the studies, to enable more precise planning to reduce complications of CSP. METHOD This review study extracted information through searching national and international databases of SID،, Embase, ScienceDirect, ، Scopus, ، PubMed, Web of Science (ISI) between 2003 and January 2020. To perform the meta-analysis, random-effects model and heterogeneity of the studies with I2 index were investigated. Data were sanalysed using Comprehensive Meta-Analysis version 2. RESULTS In total, 26 articles with a sample size of 600 individuals were enrolled in the meta-analysis. According to the results of the study, the mean level of β-hCG was 28,744.98 ± 4425.1 mIU/ml before the intervention and was 23,836.78 ± 4533.1 mIU/ml after the intervention. The mean intraoperative blood loss (ml) was 4.8 ± 3.76 ml, mean hospital stay (days) was 11.7 ± 1.2 days, mean time for serum-hCG normalization (days) was 41.6 ± 3.2 days, success was 90.7% (95% CI: 86.7-93.5%), and complication was 9% (95% CI: 6.3-12.8%). CONCLUSION The results of the current study show methotrexate significantly reduces β-hCG levels and can be effective in treating caesarean scar pregnancy and its complications.
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Affiliation(s)
- Nader Salari
- grid.412112.50000 0001 2012 5829Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
- grid.412112.50000 0001 2012 5829Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohsen Kazeminia
- grid.412112.50000 0001 2012 5829Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shamarina Shohaimi
- grid.11142.370000 0001 2231 800XDepartment of Biology, Faculty of Science, Universiti Putra Malaysia, Serdang, Selangor Malaysia
| | - Anis al-Dawlah Nankali
- grid.412112.50000 0001 2012 5829Department of Obstetrics and Gynecology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Masoud Mohammadi
- grid.412112.50000 0001 2012 5829Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Baggio S, Garzon S, Russo A, Ianniciello CQ, Santi L, Laganà AS, Raffaelli R, Franchi M. Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant management. Arch Gynecol Obstet 2020; 303:259-268. [PMID: 32852572 PMCID: PMC7854461 DOI: 10.1007/s00404-020-05749-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 08/13/2020] [Indexed: 12/18/2022]
Abstract
Purpose To compare fertility and reproductive outcome after surgical, medical, and expectant management for tubal ectopic pregnancy (EP). Methods 133 of 228 patients, who were managed between January 2012 and December 2017 for a tubal EP, tried to conceive immediately after treatment: 86 out of 173 (49.7%) underwent surgical treatment; 38 (21.9%) were treated with methotrexate (MTX), and 49 (28.3%) had expectant management. Clinical data were retrieved by medical records, fertility outcomes were obtained by phone follow-up. The cumulative incidence (CI) of intrauterine clinical pregnancy (CP), miscarriage, live birth (LB), and recurrent EP, and the time between treatment and first intrauterine CP were compared between women treated with MTX, surgery and expectant management. Results The CI of intrauterine CP starting from 12 months after the EP was 65.3% for the expectant management, 55.3% for the MTX group, and 39.5% for surgery (p = 0.012). Post-hoc analysis showed expectant management having higher intrauterine CP and LB, and shorter time between treatment and first intrauterine CP compared to surgery (p < 0.05). The CI of recurrent EP was comparable between the 3 groups. The analysis stratified per βhCG cut-off of 1745 mUI/mL and EP mass cut-off of 25 mm reported consistent results. Conclusions Women successfully managed by expectation appear to have better reproductive outcomes compared to women who underwent surgery, with the shortest time to achieve a subsequent intrauterine CP. Therefore, if safely applicable the expectant management should be considered in the case of tubal EP. The fact that the chosen treatment was primarily guided by the βhCG value and EP mass diameter based on the protocol, which is intrinsically related to the characteristics of the EP, represents the main limitation of the present study. Indeed, we cannot completely exclude that the observed differences between treatments are related to the EP itself instead of the treatment.
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Affiliation(s)
- Silvia Baggio
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy. .,Department of Obstetrics and Gynecology, "Sacro Cuore" Hospital, Negrar Di Valpolicella, Verona, Italy.
| | - Simone Garzon
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Anna Russo
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | | | - Lorenza Santi
- Department of Endocrinology, Diabetes and Metabolism, AOUI Verona, University of Verona, Verona, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Ricciarda Raffaelli
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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Odejinmi F, Clark TJ, Mallick R. Getting back to business: considerations for restarting non-cancer gynaecological surgery following the COVID-19 peak. Facts Views Vis Obgyn 2020; 12:119-127. [PMID: 32832926 PMCID: PMC7431199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
As we begin to pass the first peak of the coronavirus pandemic, the backlog of routine gynaecological surgical work is becoming more apparent and continues to build day by day. The potential for further pandemic surges remain; however it is imperative that elective gynaecological surgery is restored safely, ethically and in a timely manner. The risks of COVID-19 transmission and potential increased surgical morbidity must be weighed up against the patient's ongoing symptoms and quality of life. Universal screening and testing of patients attending for routine surgery, as well as staff testing and retesting, will be fundamental to reducing the risks to both patients and staff, and avoiding the higher morbidity encountered when operating on asymptomatic infected patients. The aim of this paper is to explore pathways to safely reintroduce elective benign gynaecological surgery and the challenges that will be encountered including patient counselling and informed consent, surgical prioritisation and the screening and testing of patients and staff, as well as the logistical and ethical challenges of reintroducing benign surgery during COVID-19 times.
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Affiliation(s)
- F Odejinmi
- Whipps Cross Hospital, Barts Health NHS Trust, Whipps Cross Road, Leytonstone, London, United Kingdom
| | - T J Clark
- Department of Obstetrics and Gynaecology, Birmingham Women's and Children's Hospital, Birmingham, United Kingdom
| | - R Mallick
- Princess Royal Hospital, Brighton and Sussex University Hospitals NHS Trust, Lewes Road, Haywards Heath, United Kingdom
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Wang X, Huang L, Yu Y, Xu S, Lai Y, Zeng W. Risk factors and clinical characteristics of recurrent ectopic pregnancy: A case-control study. J Obstet Gynaecol Res 2020; 46:1098-1103. [PMID: 32281241 PMCID: PMC7384140 DOI: 10.1111/jog.14253] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 03/10/2020] [Accepted: 03/16/2020] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Xinyan Wang
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Lu Huang
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Yan Yu
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Sheng Xu
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Yucheng Lai
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
| | - Wenjie Zeng
- Department of Gynecology, Zhejiang Provincial People's Hospital, Hangzhou Medical College, People's Hospital, Hangzhou, China
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Egbe TO, Nana-Njamen T, Elong F, Tchounzou R, Simo AG, Nzeuga GP, Njamen Nana C, Manka’a E, Tchente Nguefack C, Halle-Ekane GE. Risk factors of tubal infertility in a tertiary hospital in a low-resource setting: a case-control study. FERTILITY RESEARCH AND PRACTICE 2020; 6:3. [PMID: 32161654 PMCID: PMC7059396 DOI: 10.1186/s40738-020-00073-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 02/21/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Infertility is the inability to sustain a pregnancy in a woman with regular (2-3 times per week) unprotected sexual intercourse for a period of 1 year. This is a major public health problem that remains under-recognised in Cameroon and most countries in sub-Saharan Africa. This study aimed at identifying the risk factors associated with tubal infertility in a tertiary hospital in Douala, Cameroon. METHODS We conducted a case-control study at the Obstetrics, Gynaecology and Radiology Departments of the Douala Referral Hospital from October 1, 2016, to July 30, 2017. We recruited 77 women with tubal infertility diagnosed using hysterosalpingography and 154 unmatched pregnant women served as controls. Data on socio-demographic, reproductive and sexual health, and radiologic assessments were collected using a pretested questionnaire. The data were analysed using the Statistical Package for the Social Sciences (SPSS) software version 24.0. Logistic regression models were fitted to identify demographic, reproductive health factors, surgical, medical and toxicological factors associated with tubal infertility. The adjusted odds ratios (AOR) and their 95% confidence interval were interpreted. Statistical significance set at p < 0.05. RESULTS Sixty-one per cent of respondents had secondary infertility. Following multivariate logistic regression analysis, respondents who were housewives (AOR 10.7; 95% CI: 1.68-8.41, p = 0.012), self-employed (AOR 17.1; 95% CI: 2.52-115.8, p = 0.004), with a history of Chlamydia trachomatis infection (AOR 17.1; 95% CI: 3.4-85.5, p = 0.001), with Mycoplasma infection (AOR 5.1; 95% CI: 1.19-22.02, p = 0.03), with ovarian cyst (AOR 20.5; 95% CI: 2.5-168.7, p = 0.005), with uterine fibroid (AOR 62.4; 95% CI: 4.8-803.2, p = 0.002), have undergone pelvic surgery (AOR 2.3; 95% CI: 1.0-5.5, p = 0.05), have undergone other surgeries (AOR 49.8; 95% CI: 6.2-400, p = 0.000), diabetic patients (AOR 10.5; 95% CI 1.0-113.4, p = 0.05) and those with chronic pelvic pain (AOR 7.3; 95% CI: 3.2-17.1, p = 0.000) were significantly associated with tubal infertility while the young aged from 15 to 25 (AOR 0.07; 95% CI: 0.01-0.67, 0.021), those in monogamous marriages (AOR 0.05; 95% CI: 0.003-1.02, p = 0.05), as well as those with a history of barrier contraceptive methods (condom) (AOR 0.17; 95% CI: 0.03-1.1, p = 0.06) were less likely to have tubal infertility. CONCLUSION The following factors were independently associated with tubal infertility: being a housewife, self-employed, history of Chlamydia trachomatis, Mycoplasma infection, and uterine fibroid. Furthermore, a history of pelvic surgery and other surgeries, diabetes mellitus, and chronic pelvic pain were also associated with tubal infertility. Young age, persons in monogamous marriages and users of barrier methods of contraception (condom) were less likely to have tubal infertility. Identification of these factors will be a target of intervention to avoid tubal infertility.
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Affiliation(s)
- Thomas Obinchemti Egbe
- Department of Obstetrics and Gynecology, Douala Referral Hospital, Douala, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Theophile Nana-Njamen
- Department of Obstetrics and Gynecology, Douala Referral Hospital, Douala, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | - Felix Elong
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
| | | | | | | | - Cedric Njamen Nana
- Department of Obstetrics and Gynecology, Douala Referral Hospital, Douala, Cameroon
| | | | - Charlotte Tchente Nguefack
- Department of Obstetrics and Gynecology, Douala Referral Hospital, Douala, Cameroon
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Gregory Edie Halle-Ekane
- Department of Obstetrics and Gynecology, Douala Referral Hospital, Douala, Cameroon
- Faculty of Health Sciences, University of Buea, Buea, Cameroon
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Guideline-based quality indicators for early pregnancy assessment units. Reprod Biomed Online 2020; 40:453-459. [PMID: 32044275 DOI: 10.1016/j.rbmo.2019.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 11/22/2019] [Accepted: 12/03/2019] [Indexed: 11/22/2022]
Abstract
RESEARCH QUESTION What valid guideline-based quality indicators can measure quality of care in early pregnancy assessment units (EPAU)? DESIGN The systematic RAND-modified Delphi method was used to develop an indicator set from four evidence-based guidelines. An international expert panel was assembled to extract recommendations from these guidelines to establish quality indicators. RESULTS A total of 119 recommendations were extracted. Eleven recommendations received a high median score and top five score above the 75th percentile and were selected as key recommendations. The expert panel reassessed 15 high score recommendations and top five score between the 50th and 75th percentile as well as one high score recommendation without consensus. Eight of these 16 recommendations were selected in the second round as key recommendations. The key recommendations were formulated into a set of 19 quality indicators, summarized as follows: women referred to an EPAU could be seen within 24 h and receive a clear explanation on treatment options; designated senior staff members could be responsible for the unit and staff could have had ultrasound training; protocols could be available for daily practice covering all treatment options for miscarriage and ectopic pregnancy; and an EPAU could have access to urine pregnancy testing and serum HCG assays. CONCLUSIONS Nineteen quality indicators to measure early pregnancy care provided by EPAU were identified.
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Alur-Gupta S, Cooney LG, Senapati S, Sammel MD, Barnhart KT. Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis. Am J Obstet Gynecol 2019; 221:95-108.e2. [PMID: 30629908 DOI: 10.1016/j.ajog.2019.01.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/18/2018] [Accepted: 01/02/2019] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the treatment success and failure rates, as well as side effects and surgery rates, between methotrexate protocols. DATA SOURCES PubMed, Embase, and the Cochrane library searched up to July 2018. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared women with ectopic pregnancies receiving the single-dose, two-dose, or multi-dose methotrexate protocols. STUDY APPRAISAL AND SYNTHESIS METHODS Odds of treatment success, treatment failure, side effects, and surgery for tubal rupture, as well as length of follow-up until treatment success, were compared using random and fixed effects meta-analysis. Sensitivity analyses compared treatment success in the groups with high human chorionic gonadatropin (hCG) values and a large adnexal mass, as defined by individual studies. The Cochrane Collaboration tool was used to assess risk of bias. RESULTS The 2-dose protocol was associated with higher treatment success compared to the single-dose protocol (odds ratio [OR], 1.84; 95% CI, 1.13, 3.00). The 2-dose protocol was more successful in women with high hCG (OR, 3.23; 95% CI, 1.53, 6.84) and in women with a large adnexal mass (OR, 2.93; 95% CI, 1.23, 6.9). The odds of surgery for tubal rupture were lower in the 2-dose protocol (OR, 0.65; 95% CI, 0.26, 1.63), but this was not statistically significant. The length of follow-up was 7.9 days shorter for the 2-dose protocol (95% CI, -12.2, -3.5). The odds of side effects were higher in the 2-dose protocol (OR, 1.53; 95% CI, 1.01, 2.30). Compared to the single-dose protocol, the multi-dose protocol was associated with a nonsignificant reduction in treatment failure (OR, 0.56; 95% CI, 0.28, 1.13) and a higher chance of side effects (OR, 2.10; 95% CI, 1.24, 3.54). The odds of surgery for tubal rupture (OR, 1.62; 95% CI, 0.41, 6.49) and time to follow-up (OR, -1.3; 95% CI, -5.4, 2.7) were similar. CONCLUSION The 2-dose methotrexate protocol is superior to the single-dose protocol for the treatment of ectopic pregnancy in terms of treatment success and time to success. Importantly, these findings hold true in patients thought to be at a lower likelihood of responding to medical management, such as those with higher hCGs and a large adnexal mass.
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Affiliation(s)
- Snigdha Alur-Gupta
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA.
| | - Laura G Cooney
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA
| | - Suneeta Senapati
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA
| | - Mary D Sammel
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA
| | - Kurt T Barnhart
- Division of Reproductive Endocrinology and Infertility, University of Pennsylvania, Philadelphia, PA
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Bi Y, She Y, Tian Z, Wei Z, Huang Q, Liao S, Ye Y, Qin A, Yang Y. Efficacy and safety of laparoscopy versus local injection with absolute ethanol in the management of tubal ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol X 2019; 3:100032. [PMID: 31403121 PMCID: PMC6687442 DOI: 10.1016/j.eurox.2019.100032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 04/22/2019] [Accepted: 04/28/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To compare the efficacy and safety between laparoscopy and local injection with absolute ethanol (AE) for treating tubal ectopic pregnancy (EP). STUDY DESIGN Retrospective cohort study of ectopic pregnancies in the fallopian tube from two tertiary hospitals between January 2015 and December 2017. Clinical information such as presenting symptoms, reproductive history, possible risk factors, initial diagnosis, serum beta-human chor-ionic gonadotropin (β-HCG) level, transvaginal ultrasonography findings, methods of treatment and outcomes were reviewed and analyzed. RESULTS A total of 119 patients were identified for this study. The diagnosis was based on clinical manifestations, ultrasonography scan and dynamic serum β-HCG. 71.4% of women (85/119) had at least one risk factor for ectopic pregnancy, with the most common risk factors being a history of induced labor, uterine curettage, spontaneous abortion or tubal pregnancy. 64 patients were managed by laparoscopic surgery (Group A) and 2 subjects were failure and followed by a systemic methotrexate (MTX) prescription. The other 55 patients had local injection with absolute ethanol, of which 9 cases failed, followed by a second local injection and intramuscular MTX. The HCG decrease rate post absolute ethanol injection was a value predictive factor for prognosis. Moreover, the pregnancy rate one-year post treatment in local injection subjects (10/55, 18.2%) was higher than that of surgical subjects (5/64, 7.8%). CONCLUSION Local injection of absolute ethanol and laparoscopic surgery for tubal ectopic pregnancy are both effective and relatively safe, but laparoscopic surgery has better efficacy and shorten hospitalization day. Local injection may be less invasiveness and thus beneficial to fertility preservation.
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Affiliation(s)
- Yin Bi
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yuanping She
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Guilin Medical University, Guilin, People’s Republic of China
| | - Zhengping Tian
- Center of Reproductive Medicine, The Affiliated Hospital of Guilin Medical University, Guilin, People’s Republic of China
| | - Zhiyao Wei
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Qiuyan Huang
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Shengbin Liao
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yuan Ye
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Guilin Medical University, Guilin, People’s Republic of China
| | - Aiping Qin
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
| | - Yihua Yang
- Center of Reproductive Medicine, The First Affiliated Hospital of Guangxi Medical University, Nanning, People’s Republic of China
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Kanmaz AG, Inan AH, Beyan E, Budak A. Role of various complete blood count parameters in predicting the success of single-dose Methotrexate in treating ectopic pregnancy. Pak J Med Sci 2018; 34:1132-1136. [PMID: 30344563 PMCID: PMC6191789 DOI: 10.12669/pjms.345.15356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective The protocol of 15% BhCG decrease between Days four and seven is frequently used for evaluating the success of methotrexate administration in treating ectopic pregnancy. Our objective was to study the usage of hematologic parameters for evaluating the success of methotrexate administration in treating ectopic pregnancy. Method This study was conducted between February 2014 and December 2016. Data of 434 patients were retrospectively scanned for the study. One hundred sixty-one patients whose Day one, four and seven results were recorded in the hospital information system and who were followed up until their BhCG levels decreased <10 IU/L were enrolled in the study. Three types of complete blood cell count parameters of the patients were used: 1) Neutrophil-to-lymphocyte ratio (NLR). 2) Platelet distribution width (PDW), 3) Platelet count (PLT). Results Patients were separated into two groups as those who were treated with single-dose methotrexate and those who required surgical treatment. A significant difference was detected between the groups in terms of NLR levels on Days 1, 4, and 7 (p=0.012, p=0.035, and p=0.001, respectively). There was no significant difference detected between the groups for PDW and PLT counts on Days one, four and seven. Conclusions NLR can also be used as an alternative to BhCG for evaluating the success of single-dose methotrexate administration in treating ectopic pregnancy. However, there is need for further studies on this topic.
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Affiliation(s)
- Ahkam Goksel Kanmaz
- Dr. Ahkam Goksel Kanmaz, Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Abdurrahman Hamdi Inan
- Dr. Abdurrahman Hamdi Inan, Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Emrah Beyan
- Dr. Emrah Beyan, Department of Obstetrics and Gynecology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Adnan Budak
- Dr. Adnan Budak, Izmir Provincial Health Directorate, Izmir, Turkey
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Abstract
OBJECTIVE The objective of this study was to determine the outcomes of women who presented to the emergency department (ED) with suspected ectopic pregnancy and received methotrexate as first-line treatment. METHODS This was a retrospective chart review of pregnant (< 12 week' gestational age) women from an academic tertiary care ED with a diagnosis of ectopic pregnancy, rule-out ectopic pregnancy, or pregnancy of unknown location over a 7-year period. RESULTS Of 612 patients with a suspected ectopic pregnancy at initial ED presentation, 326 (53.3%) had non-ectopic pregnancy outcomes, 30 (4.9%) were diagnosed with a ruptured ectopic pregnancy at the index ED visit, and 18 (2.9%) were diagnosed and managed as non-tubal ectopic pregnancies and excluded from further analyses; 238 patients were diagnosed with a tubal ectopic pregnancy, and 152 (63.9%) were treated with methotrexate at the index ED visit or in follow-up. Of patients treated with methotrexate, 27 (17.8%) went on to require surgical management, with 17 (11.2%) documented as having ruptured on surgical evaluation. CONCLUSION The proportion of patients failing methotrexate as first-line treatment was higher than previously reported. Further investigation is needed to determine whether methotrexate failure was due to non-adherence to recommended guidelines.
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27
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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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Czuczwar P. The role of ultrasonography in methotrexate therapy for ectopic pregnancy. J Ultrason 2018; 18:158-161. [PMID: 30451410 PMCID: PMC6440515 DOI: 10.15557/jou.2018.0023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2018] [Indexed: 11/23/2022] Open
Abstract
Medical management of ectopic pregnancy with methotrexate, an antimetabolite of folic acid, is an important alternative to surgical treatment, as it ensures a similar outcome whilst being far less invasive. Ultrasound evaluation does not only facilitate an accurate diagnosis, but also helps to select patients most likely to benefit from methotrexate treatment, as opposed to those with a high likelihood of failure of medical management, who are thus eligible for primary surgical treatment. Ultrasound also allows to monitor the outcome of methotrexate therapy. This study is a review of literature regarding the management of ectopic pregnancy with methotrexate. Such ultrasound findings as the size of the ectopic mass, presence of fetal heart rate and free fluid have been confirmed as effective eligibility criteria for therapy with methotrexate. In the future, possibly also endometrial stripe thickness and the vascularity of the ectopic mass may be considered predictive of successful methotrexate therapy. The initial increase in size of the ectopic mass following methotrexate therapy confirms its effectiveness, and should not prompt concern.
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Affiliation(s)
- Piotr Czuczwar
- 3rd Department of Gynecology, Medical University of Lublin, Lublin, Poland
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29
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Conti V, Luciano G, Pecoraro G, Iovieno R, Filippelli A, Guida M. Multidosing Intramuscular Administration of Methotrexate in Interstitial Pregnancy With Very High Levels of β-hCG: A Case Report and Review of the Literature. Front Endocrinol (Lausanne) 2018; 9:363. [PMID: 30042729 PMCID: PMC6048239 DOI: 10.3389/fendo.2018.00363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 06/18/2018] [Indexed: 01/17/2023] Open
Abstract
Ectopic pregnancy (EP) is the implantation of an embryo outside the endometrial cavity of the uterus. Signs and symptoms of EP may arise between the 6th and the 8th week of gestation and include vaginal bleeding, lower abdominal and pelvic pain. Frequently EPs implant in the fallopian tubes. A rare EP is the interstitial pregnancy, a life-threatening condition being responsible for nearly 20% of all deaths caused by EPs. Because of its unique location, the diagnosis is difficult and based on signs and specific criteria together with measuring of serum β-hCG. Usually, EP is treated by surgical approach, which is associated with increased morbidity, decreased fertility and increased likelihood of hysterectomy and uterine rupture in a subsequent pregnancy. Early diagnosis is crucial to life saving and allowing alternative therapeutic interventions such as pharmacological treatments. Methotrexate (MTX) represents the mainstay therapy. There is no standard care for the interstitial pregnancy for what concerns either surgical or pharmacological approaches. We reported a case of a 36-year-old woman admitted to the Hospital of Salerno-Italy with a value of serum β-hCG of 35,993 IU/L. Transvaginal ultrasonography revealed an empty uterine cavity and a mass of 35.7 mm in diameter characterized by a hypoechoic central area. The patient was in stable haemodynamic condition and no haematologic, renal and hepatic impairments were recorded. Despite the high serum β-hCG levels, a pharmacological approach was preferred to a surgical one. The patient was treated with intramuscular administration of MTX in daily dose of 1 mg/Kg alternated with 0.1 mg/kg folinic acid for 5 days. The patient remained hospitalized for 20 days and no side effects were reported. The decrease of the serum β-hCG was monitored and more than 15% reduction was detected between the 4th and the 7th day after the beginning of the treatment. The serum β-hCG became undetectable 35 days after. A multidosing intramuscular administration of MTX was effective and safe even in the presence of very high serum β-hCG levels. Together with similar cases reported in literature, the present results can contribute to improve the decision making in the treatment of the interstitial pregnancy.
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Affiliation(s)
- Valeria Conti
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
| | - Giovanni Luciano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
| | - Giovanni Pecoraro
- Unit of Gynecology and Obstetrics of “San Giovanni di Dio e Ruggi d'Aragona”, University Hospital, Salerno, Italy
| | - Roberto Iovieno
- Unit of Gynecology and Obstetrics of “San Giovanni di Dio e Ruggi d'Aragona”, University Hospital, Salerno, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
| | - Maurizio Guida
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, Fisciano, Italy
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Abdelazim IA, Nussair B, Zhurabekova G, Svetlana S, Abu-Faza M, Naser W. Comment on An Intrauterine Gestational Sac Surrounded by Thin Myometrium at Fundus. J Med Ultrasound 2018; 26:168-169. [PMID: 30283207 PMCID: PMC6159320 DOI: 10.4103/jmu.jmu_58_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Ibrahim A. Abdelazim
- Department of Obstetrics and Gynecology, Ahmadi Hospital, Kuwait Oil Company, Ahmadi, Kuwait, Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
| | - Bassam Nussair
- Department of Obstetrics and Gynecology, Royal Medical Services, Amman, Jordan
| | - Gulmira Zhurabekova
- Department of Normal and Topographical Anatomy, West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
| | - Shikanova Svetlana
- Department of Obstetrics and Gynecology, West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
| | - Mohannad Abu-Faza
- Department of Obstetrics and Gynecology, Ahmadi Hospital, Kuwait Oil Company, Ahmadi, Kuwait
| | - Waheeb Naser
- Department of Obstetrics and Gynecology, Ahmadi Hospital, Kuwait Oil Company, Ahmadi, Kuwait
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Ozyurek ES, Akmut E, Kaya E, Akca A, Akbayır O. Predictors of failure of the commonly used single-dose methotrexate protocol for treating tubal ectopic pregnancies. Taiwan J Obstet Gynecol 2017; 56:755-760. [PMID: 29241915 DOI: 10.1016/j.tjog.2017.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES This study identified patients who would benefit from an earlier additional medical intervention and/or continuing close surveillance even if commonly used parameters indicated sufficient medical treatment to determine markers of treatment failure. MATERIALS AND METHODS A retrospective analysis of patients with a preliminary diagnosis of ectopic pregnancy treated with the single-dose methotrexate protocol. Group 1: cases cured with a single dose of methotrexate; Group 2: cases who required more than one dose of methotrexate or surgery following the first dose. Demographics, clinical/sonographic findings, observation period, and β-human chorionic gonadotropin (hCG) levels were compared among the two groups. Thresholds were defined and a regression analysis was performed to define independent predictors of failure. RESULTS Data from 120 patients were analyzed: Group 1 (n = 92); Group 2 (n = 28). β-hCG levels measured at all time points, and day (0-4) and day (4-7) changes, presence of adnexial masses, and infertility were significantly different among the two groups. Only the day (0-4) and day (4-7) changes in β-hCG levels were independent predictors of failure. CONCLUSION Day (0-4) thresholds or newly defined day (4-7) thresholds were not more sensitive than the conventional day (4-7) criteria. Day (0-4) β-hCG levels increased by more than 9.7% in half the patients who required additional methotrexate doses or surgery despite fulfillment of the conventional day (4-7) criteria. In contrast, no cases of treatment failure were observed if the day (0-4) decrease was >26.6%.
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Affiliation(s)
- Eser Sefik Ozyurek
- Bagcilar Research and Training Hospital, Gynecology and Obstetrics Department, Istanbul, Turkey.
| | - Evren Akmut
- Bagcilar Research and Training Hospital, Gynecology and Obstetrics Department, Istanbul, Turkey
| | - Erdal Kaya
- Bagcilar Research and Training Hospital, Gynecology and Obstetrics Department, Istanbul, Turkey
| | - Aysu Akca
- Kanuni Sultan Suleyman Research and Training Hospital, Gynecological and Obstetrics Department, Istanbul, Turkey
| | - Ozgur Akbayır
- Kanuni Sultan Suleyman Research and Training Hospital, Gynecological and Obstetrics Department, Istanbul, Turkey
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Brüggmann D, Kollascheck J, Quarcoo D, Bendels MH, Klingelhöfer D, Louwen F, Jaque JM, Groneberg DA. Ectopic pregnancy: exploration of its global research architecture using density-equalising mapping and socioeconomic benchmarks. BMJ Open 2017; 7:e018394. [PMID: 29025848 PMCID: PMC5652463 DOI: 10.1136/bmjopen-2017-018394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE About 2% of all pregnancies are complicated by the implantation of the zygote outside the uterine cavity and termed ectopic pregnancy. Whereas a multitude of guidelines exists and related research is constantly growing, no thorough assessment of the global research architecture has been performed yet. Hence, we aim to assess the associated scientific activities in relation to geographical and chronological developments, existing research networks and socioeconomic parameters. DESIGN Retrospective, descriptive study. SETTING On the basis of the NewQIS platform, scientometric methods were combined with novel visualising techniques such as density-equalising mapping to assess the scientific output on ectopic pregnancy. Using the Web of Science, we identified all related entries from 1900 to 2012. RESULTS 8040 publications were analysed. The USA and the UK were dominating the field in regard to overall research activity (2612 and 723 publications), overall citation numbers and country-specific H-Indices (US: 80, UK: 42). Comparison to economic power of the most productive countries demonstrated that Israel invested more resources in ectopic pregnancy-related research than other nations (853.41 ectopic pregnancy-specific publications per 1000 billlion US$ gross domestic product (GDP)), followed by the UK (269.97). Relation to the GDP per capita index revealed 49.3 ectopic pregnancy-specific publications per US$1000 GDP per capita for the USA in contrast to 17.31 for the UK. Semiqualitative indices such as country-specific citation rates ranked Switzerland first (24.7 citations per ectopic pregnancy-specific publication), followed by the Scandinavian countries Finland and Sweden. Low-income countries did not exhibit significant research activities. CONCLUSIONS This is the first in-depth analysis of global ectopic pregnancy research since 1900. It offers unique insights into the global scientific landscape. Besides the USA and the UK, Scandinavian countries and Switzerland can also be regarded as leading nations with regard to their relative socioeconomic input.
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Affiliation(s)
- Dörthe Brüggmann
- Department of Obstetrics and Gynecology, Keck School of Medicine of USC, Los Angeles, California, USA
- Division of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Frankfurt
- Department of Gynecology and Obstetrics, Goethe-University, Frankfurt, Germany
| | - Jana Kollascheck
- Division of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Frankfurt
| | - David Quarcoo
- Division of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Frankfurt
| | - Michael H Bendels
- Division of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Frankfurt
| | - Doris Klingelhöfer
- Division of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Frankfurt
| | - Frank Louwen
- Department of Gynecology and Obstetrics, Goethe-University, Frankfurt, Germany
| | - Jenny M Jaque
- Department of Obstetrics and Gynecology, Keck School of Medicine of USC, Los Angeles, California, USA
| | - David A Groneberg
- Division of Female Health and Preventive Medicine, Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University, Frankfurt
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Comparison of alternative βhCG follow-up protocols after single-dose methotrexate therapy for tubal ectopic pregnancy. Arch Gynecol Obstet 2017; 296:1161-1165. [PMID: 28932897 DOI: 10.1007/s00404-017-4527-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 09/08/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the performances of five different βhCG follow-up protocols after single-dose methotrexate therapy for tubal ectopic pregnancy (EP). METHODS Data of patients who received single-dose methotrexate therapy for tubal EP at a university hospital between January 2011 and July 2016 were reviewed. A 'successful methotrexate treatment' was defined if the EP treated with no need for surgery. The performances of different protocols were tested by comparing with the currently used '15% βhCG decrease between days 4 and 7' protocol. The tested follow-up protocols were '20, 25%, and any βhCG decrease between days 0/1 and 7' and '20% and any βhCG decrease between days 0/1 and 4'. RESULTS Among the 96 patients evaluated, 12 (12.5%) required second dose. Totally, 91 (94.8%) patients treated successfully with no need for surgery. Four patients were operated within 4 days following the second dose. One patient who did not need second dose according to the standard follow-up protocol was operated on the 10th day due to rupture (specificity = 80%). Two protocols, namely '20% βhCG decrease between days 0/1 and 7' and 'any βhCG decrease between days 0/1 and 7' did not show statistically significant differences from the index protocol regarding the number of patients who should be assigned to 2nd dose. CONCLUSIONS 'Any βhCG decrease between days 0/1 and 7' protocol may substitute the currently used one to decide second dose methotrexate in tubal EP management. Omitting 4th day measurement seems to be more convenient and cost effective.
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Hsu JY, Chen L, Gumer AR, Tergas AI, Hou JY, Burke WM, Ananth CV, Hershman DL, Wright JD. Disparities in the management of ectopic pregnancy. Am J Obstet Gynecol 2017; 217:49.e1-49.e10. [PMID: 28288792 PMCID: PMC5484775 DOI: 10.1016/j.ajog.2017.03.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/26/2017] [Accepted: 03/02/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Ectopic pregnancy is common among young women. Treatment can consist of either surgery with salpingectomy or salpingostomy or medical management with methotrexate. In addition to acute complications, treatment of ectopic pregnancy can result in long-term sequelae that include decreased fertility. Little is known about the patterns of care and predictors of treatment in women with ectopic pregnancy. Similarly, data on outcomes for various treatments are limited. OBJECTIVE We examined the patterns of care and outcomes for women with ectopic pregnancy. Specifically, we examined predictors of medical (vs surgical) management of ectopic pregnancy and tubal conservation (salpingostomy vs salpingectomy) among women who underwent surgery. STUDY DESIGN The Perspective database was used to identify women with a diagnosis of tubal ectopic pregnancy treated from 2006-2015. Perspective is an all-payer database that collects data on patients at hospitals from throughout the United States. Women were classified as having undergone medical treatment, if they received methotrexate, and surgical treatment, if treatment consisted of salpingostomy or salpingectomy. Multivariable models were developed to examine predictors of medical treatment and of tubal conserving salpingostomy among women who were treated surgically. RESULTS Among the 62,588 women, 49,090 women (78.4%) were treated surgically, and 13,498 women (21.6%) received methotrexate. Use of methotrexate increased from 14.5% in 2006 to 27.3% by 2015 (P<.001). Among women who underwent surgery, salpingostomy decreased over time from 13.0% in 2006 to 6.0% in 2015 (P<.001). Treatment in more recent years, at a teaching hospital and at higher volume centers, were associated with the increased use of methotrexate (P<.05 for all). In contrast, Medicaid recipients (adjusted risk ratio, 0.92; 95% confidence interval, 0.87-0.98) and uninsured women (adjusted risk ratio, 0.87; 95% confidence interval, 0.82-0.93) were less likely to receive methotrexate than commercially insured patients. Among those who underwent surgery, black (adjusted risk ratio, 0.76; 95% confidence interval, 0.69-0.85) and Hispanic (adjusted risk ratio, 0.80; 95% confidence interval, 0.66-0.96) patients were less likely to undergo tubal conserving surgery than white women and Medicaid recipients (adjusted risk ratio, 0.69; 95% confidence interval, 0.64-0.75); uninsured women (adjusted risk ratio, 0.60; 95% confidence interval, 0.55-0.66) less frequently underwent salpingostomy than commercially insured patients. CONCLUSION There is substantial variation in the management of ectopic pregnancy. There are significant race- and insurance-related disparities associated with treatment.
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Affiliation(s)
- Jennifer Y Hsu
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Ling Chen
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Arielle R Gumer
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Ana I Tergas
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; New York Presbyterian Hospital, New York, NY
| | - June Y Hou
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Hospital, New York, NY
| | - William M Burke
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Hospital, New York, NY
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Dawn L Hershman
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY; New York Presbyterian Hospital, New York, NY
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, New York, NY; New York Presbyterian Hospital, New York, NY.
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Canelas CM, Shih RD, Clayton LM, Giroski LJ, Alter SM, Feinstein S, Learman LA. Repeat acute abdomen and hemoperitoneum during the same pregnancy due to a ruptured ectopic treated by salpingostomy. Am J Emerg Med 2017; 35:942.e1-942.e3. [DOI: 10.1016/j.ajem.2017.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 01/12/2017] [Indexed: 11/25/2022] Open
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Hamid AAA, Yousry A, El Radi SA, Shabaan OM, Mazen E, Nabil H. Clinical audit of ectopic pregnancy. Electron Physician 2017; 9:4009-4013. [PMID: 28461878 PMCID: PMC5407236 DOI: 10.19082/4009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 10/27/2016] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
| | - Almraghy Yousry
- Assistant Professor of Obstetrics and Gynecology, Faculty of Medicine, Assuit Al-Azhar University, Egypt
| | - Safwat Abd El Radi
- Professor of Obstetrics & Gynecology Faculty of Medicine, Assuit University, Egypt
| | - Omar Mamdouh Shabaan
- Professor of Obstetrics & Gynecology Faculty of Medicine, Assuit University, Egypt
| | - Elzahry Mazen
- Assistant Professor of Obstetrics and Gynecology, Faculty of Medicine, Assuit Al-Azhar University, Egypt
| | - Halal Nabil
- Lecturer of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Egypt
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De Blasis I, Vinci V, Sergi ME, Capozza F, Saldari M, Moro F, Moruzzi MC, Testa AC, Manganaro L. Early and late onset complications of gynaecologic surgery: a multimodality imaging approach. Facts Views Vis Obgyn 2017; 9:5-14. [PMID: 28721179 PMCID: PMC5506770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The role of imaging after surgery is pivotal to drive clinical management of early and/or late onset complications. Most frequently used imaging technique after pelvic surgery is Ultrasound (US), Magnetic Resonance Imaging (MRI) and Computed Tomography (CT). While Ultrasound is a standard procedure, using grey scale and/or colour Doppler evaluation, MRI and CT scan protocols should be derived on the basis of the specific indication of the exam. Correct evaluation of female pelvis after gynaecologic surgery, having in mind the most frequent complications, is based on the correct use of the instruments and on the experience of the examiner, who should be aware of the history of the patient, type of surgery and clinical symptoms for which the exam is required; the clinician should be aware of the possibilities and limits of the different techniques, in order to choose the most appropriate imaging modality and promptly make a correct diagnosis.
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Affiliation(s)
- I De Blasis
- Catholic University of the Sacred Heart, Obstetrics and Gynaecology, Rome
| | - V Vinci
- University of Rome Sapienza, Department of Radiological Sciences
| | - ME Sergi
- University of Rome Sapienza, Department of Radiological Sciences
| | - F Capozza
- University of Rome Sapienza, Department of Radiological Sciences
| | - M Saldari
- University of Rome Sapienza, Department of Radiological Sciences
| | - F Moro
- Catholic University of the Sacred Heart, Obstetrics and Gynaecology, Rome
| | - MC Moruzzi
- Catholic University of the Sacred Heart, Obstetrics and Gynaecology, Rome
| | - AC Testa
- Catholic University of the Sacred Heart, Obstetrics and Gynaecology, Rome
| | - L Manganaro
- University of Rome Sapienza, Department of Radiological Sciences
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Pretreatment serum human chorionic gonadotropin cutoff value for medical treatment success with single-dose and multi-dose regimen of methotrexate in tubal ectopic pregnancy. Obstet Gynecol Sci 2017; 60:79-86. [PMID: 28217676 PMCID: PMC5313368 DOI: 10.5468/ogs.2017.60.1.79] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 08/11/2016] [Accepted: 08/14/2016] [Indexed: 11/23/2022] Open
Abstract
Objective To investigate individual pretreatment serum human chorionic gonadotropin (hCG) cutoff value for medical treatment success with single-dose and multi-dose regimen of methotrexate in tubal ectopic pregnancy. Methods Eighty-five women who received methotrexate for the treatment of tubal ectopic pregnancy during 2003 to 2015 were selected. Fifty-three women received a single-dose regimen and 32 women received a multi-dose regimen. Medical treatment failure was defined as necessity of surgical treatment. The medical treatment success rate was estimated in both regimens and the pretreatment serum hCG titer to predict the success was assessed by receiver operating characteristics curve analysis. Results Pretreatment clinical and laboratory parameters were similar between group of single-dose regimen and multi-dose regimen. Treatment success rate was 64.2% in the single-dose regimen group and 71.9% in the multi-dose regimen group (P>0.05). Pretreatment serum hCG titer was an independent prognostic factor for treatment success in each regimen. Serum hCG cutoff value to predict the treatment success was 3,026 IU/L in single-dose regimen group and 3,711 IU/L in multi-dose regimen group. Conclusion We recommend use of single-dose regimen when pretreatment serum hCG <3,026 IU/L but multi-dose regimen may be favored when initial serum hCG level between 3,026 and 3,711 IU/L.
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Jurkovic D, Memtsa M, Sawyer E, Donaldson ANA, Jamil A, Schramm K, Sana Y, Otify M, Farahani L, Nunes N, Ambler G, Ross JA. Single-dose systemic methotrexate vs expectant management for treatment of tubal ectopic pregnancy: a placebo-controlled randomized trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:171-176. [PMID: 27731538 DOI: 10.1002/uog.17329] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2016] [Revised: 10/04/2016] [Accepted: 10/05/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Methotrexate is used routinely worldwide for the medical treatment of clinically stable women with a tubal ectopic pregnancy. This is despite the lack of robust evidence to show its superior effectiveness over expectant management. The aim of our multicenter randomized controlled trial was to compare success rates of methotrexate against placebo for the conservative treatment of tubal ectopic pregnancy. METHODS This study took place in two early-pregnancy units in the UK between August 2005 and June 2014. Inclusion criteria were clinically stable women with a conclusive ultrasound diagnosis of a tubal ectopic pregnancy, presenting with a low serum beta human chorionic gonadotropin (β-hCG) level of < 1500 IU/L. Women were assigned randomly to a single systemic injection of either 50 mg/m2 methotrexate or placebo. The primary outcome was a binary indicator for success of conservative management, defined as resolution of clinical symptoms and decline of serum β-hCG to < 20 IU/L or a negative urine pregnancy test without the need for any additional medical intervention. An intention-to-treat analysis was followed. RESULTS We recruited a total of 80 women, 42 of whom were assigned to methotrexate and 38 to placebo. The arms of the study were matched in terms of age, ethnicity, obstetric history, pregnancy characteristics and serum levels of β-hCG and progesterone. The rates of success were similar for the two study arms: 83% with methotrexate and 76% with placebo. On univariate analysis, this difference was not statistically significant (χ2 (1 degree of freedom) = 0.53; P = 0.47). On multivariate logistic regression, the serum level of β-hCG was the only covariate found to be significantly associated with outcome. The odds of failure increased by 0.15% for each unit increase in β-hCG (odds ratio, 1.0015 (95% CI, 1.0002-1.003); P = 0.02). In 14 women presenting with serum β-hCG of 1000-1500 IU/L, the success rate was 33% in those managed expectantly compared with 62% in those receiving methotrexate. This difference was not statistically significant and a larger sample size would be needed to give sufficient power to detect a difference in the subgroup of women with higher β-hCG. In women with successful conservative treatment, there was no significant difference in median β-hCG resolution times between study arms (17.5 (interquartile range (IQR), 14-28.0) days (n = 30) in the methotrexate group vs 14 (IQR, 7-29.5) days (n = 25) in the placebo group; P = 0.73). CONCLUSIONS The results of our study do not support the routine use of methotrexate for the treatment of clinically stable women diagnosed with tubal ectopic pregnancy presenting with low serum β-hCG (< 1500 IU/L). Further work is required to identify a subgroup of women with tubal ectopic pregnancy and β-hCG ≥ 1500 IU/L in whom methotrexate may offer a safe and cost-effective alternative to surgery. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. Comparación entre una sola dosis de metotrexate sistémico y la conducta expectante en el tratamiento de casos de embarazo ectópico tubárico: un ensayo aleatorio controlado con placebo RESUMEN OBJETIVO: El metotrexate se utiliza de modo rutinario en todo el mundo para el tratamiento de las mujeres clínicamente estables con un embarazo ectópico tubárico. Esto sucede a pesar de la falta de evidencia rigurosa que demuestre que su eficacia es superior a la conducta expectante. El objetivo de este ensayo controlado aleatorio multicéntrico fue comparar las tasas de éxito del metotrexate con las de un placebo para el tratamiento cauteloso del embarazo ectópico tubárico. MÉTODOS: Este estudio se llevó a cabo en dos clínicas de control de gestación temprana en el Reino Unido entre agosto de 2005 y junio de 2014. Los criterios de inclusión fueron mujeres clínicamente estables con un diagnóstico ecográfico concluyente de embarazo ectópico tubárico, las cuáles presentaban una concentración sérica baja de la β hormona coriónica gonadotrópica (β-hCG) inferior a 1500 UI/L. Las mujeres fueron asignadas aleatoriamente a una sola inyección sistémica de 50 mg/m2 de metotrexate o a placebo. El resultado primario fue un indicador binario del éxito del tratamiento conservador, definido como la resolución de los síntomas clínicos y la disminución en el suero de la β-hCG a <20 UI/L o una prueba de embarazo negativa en orina sin la necesidad de ninguna intervención médica adicional. Se hizo un análisis por intención de tratar. RESULTADOS Se reclutó un total de 80 mujeres; a 42 de ellas se les asignó el metotrexate y a 38 el placebo. Los grupos del estudio se realizaron en función de la edad, el origen étnico, los antecedentes obstétricos, las características del embarazo y los niveles séricos de la β-hCG y la progesterona. Las tasas de éxito fueron similares para los dos grupos de estudio: 83% con metotrexate y 76% con placebo. En el análisis univariante, esta diferencia no fue estadísticamente significativa (χ2 (1 grado de libertad) = 0,53; P = 0,47). En la regresión logística multivariante, el nivel sérico de la β-hCG fue la única covariable que se encontró significativamente asociada con el resultado. Las probabilidades de fracaso aumentaron en un 0,15% por cada unidad de aumento de la β-hCG (cociente de probabilidad 1,0015 (IC 95%, 1,0002-1,003); P = 0,02). La tasa de éxito en las 14 mujeres con un nivel sérico de la β-hCG de 1000-1500 UI/L fue del 33% en las tratadas con conducta expectante frente al 62% en las que recibieron metotrexate. Esta diferencia no fue estadísticamente significativa, por lo que se necesitaría un tamaño de muestra mayor, lo suficiente como para poder detectar diferencias en el subgrupo de mujeres con una β-hCG más elevada. En las mujeres en las que el tratamiento conservador tuvo éxito, no hubo una diferencia significativa en la mediana de los tiempos de resolución de la ß-hCG entre los grupos del estudio (17,5 (amplitud intercuartílica (IQR), 14-28,0) días (n = 30) en el grupo de metotrexate frente a 14 (IQR, 7-29.5) días (n = 25) en el grupo de placebo; P = 0,73). CONCLUSIONES Los resultados de este estudio no apoyan el uso rutinario de metotrexate para el tratamiento de las mujeres clínicamente estables diagnosticadas con un embarazo ectópico tubárico que presenta un nivel sérico bajo la β-hCG (<1500 UI/L). Serán necesarios estudios adicionales para identificar un subgrupo de mujeres con embarazo ectópico tubárico y β-hCG ≥1500 UI/L para quienes el metotrexate puede ofrecer una alternativa segura y rentable en comparación con la cirugía. : : ,,。。 : 2005820146,2。,,β(beta human chorionic gonadotropin,β-hCG)<1500 IU/L。,(50 mg/m2 )。,β-hCG<20 IU/L,。。 : 80,42,38。2、、、β-hCG。2:83%,76%。,[χ2 (1)=0.53;P=0.47]。logistic,β-hCG。β-hCG,0.15%[,1.0015(95% CI,1.0002~1.003);P=0.02]。14β-hCG1000~1500 IU/L,33%,62%。,β-hCG。,2β-hCG(P=0.73),17.5[(interquartile range,IQR),14~28.0](n=30),14 (IQR,7~29.5)(n=25)。 : 、、β-hCG(<1500 IU/L)。,β-hCG>1500 IU/L、。.
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Affiliation(s)
- D Jurkovic
- Institute for Women's Health, University College Hospital, London, UK
| | - M Memtsa
- Institute for Women's Health, University College Hospital, London, UK
| | - E Sawyer
- Early Pregnancy Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
| | - A N A Donaldson
- Applied Mathematics & Statistics Department, State University of New York, Stony Brook, NY, USA
| | - A Jamil
- Institute for Women's Health, University College Hospital, London, UK
| | - K Schramm
- Early Pregnancy Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
| | - Y Sana
- Early Pregnancy Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
| | - M Otify
- Early Pregnancy Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
| | - L Farahani
- Institute for Women's Health, University College Hospital, London, UK
| | - N Nunes
- Institute for Women's Health, University College Hospital, London, UK
| | - G Ambler
- Department of Statistical Science, University College London, London, UK
| | - J A Ross
- Early Pregnancy Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK
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Zhang Y, Chen J, Lu W, Li B, Du G, Wan X. Clinical characteristics of persistent ectopic pregnancy after salpingostomy and influence on ongoing pregnancy. J Obstet Gynaecol Res 2017; 43:564-570. [PMID: 28127836 PMCID: PMC5347973 DOI: 10.1111/jog.13251] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 10/17/2016] [Accepted: 11/08/2016] [Indexed: 12/01/2022]
Abstract
AIM The aim of this study was to assay the clinical characteristics of persistent ectopic pregnancy (PEP) and its influence on ongoing pregnancy. METHODS We retrospectively reviewed 2498 patients who received salpingostomies as primary management for ectopic pregnancies from January 2004 to December 2009, using medical records and telephone inquiries. Clinical characteristics of the 52 patients (2.08%) who were diagnosed with PEP after salpingostomy were compared with those who received satisfactory treatment. The odds ratios and 95% confidential intervals were calculated for each variable by univariate and (for significantly different factors) multivariate analysis. RESULTS Preoperatively, patients with PEP after salpingostomy significantly differed from the non-PEP patients in gestational age, mass size and pelvic adhesiolysis. Serum β-human chorionic gonadotropin levels in PEP patients were monitored after surgery, which had declined by 28.31% on postoperative day (POD) 4, 40.22% on POD 7, 51.46% on POD 10 and 53.43% on POD 21. Repeat ectopic pregnancy (REP) tended to occur more frequently in PEP patients (PEP: 5 cases, 10.20%; non-PEP: 4 cases, 2.80%; P = 0.034). Multivariate analysis showed that pelvic adhesions and PEP were the strongest independent predictors of REP. CONCLUSION Gestational age, mass size and pelvic adhesions were significantly correlated with PEP. PEP was an independent prognostic factor for REP. However, a multicenter study is needed to support and extend our findings.
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Affiliation(s)
- Yongli Zhang
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Jinhong Chen
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen Lu
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bilan Li
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Guiqiang Du
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaoping Wan
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
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Yang C, Cai J, Geng Y, Gao Y. Multiple-dose and double-dose versus single-dose administration of methotrexate for the treatment of ectopic pregnancy: a systematic review and meta-analysis. Reprod Biomed Online 2017; 34:383-391. [PMID: 28131495 DOI: 10.1016/j.rbmo.2017.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Revised: 01/01/2017] [Accepted: 01/04/2017] [Indexed: 01/01/2023]
Abstract
In this systematic review and meta-analysis, the effectiveness and safety among different dosage of methotrexate protocols for the treatment of unruptured tubal ectopic pregnancy was evaluated. Six studies of randomized contorlled trials were identified through searches conducted on PubMed, Embase and Cochrane Library between January 1974 and March 2016. The overall success rate of multiple-dose protocol was similar to the single-dose protocol (RR 1.07, 95% CI 0.99 to 1.17, I2 = 0%). The difference between double-dose and single-dose groups was not significant (RR 1.09, 95% CI 0.98 and 1.20, I2 = 0%). The incidence of side-effects of double-dose regimen was similar with single-dose regimen. Side-effects, however, are more common in multiple-dose regimen (RR 1.64, 95% CI 1.15 to 2.34, P = 0.006, I2 = 0%). This meta-analysis indicated that the incidence of side-effects of multiple-dose protocol was significantly higher than single-dose protocol, and the success rates between them were similar. The double-dose regimen was an efficient and safe alternative to the single-dose protocol. Further high-quality researches are needed to confirm our findings and to develop the optimal protocol.
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Affiliation(s)
- Chun Yang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jing Cai
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yuhong Geng
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ying Gao
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Ektopik Gebelikte 0. ve 4. gün β-HCG Değerleri ile Metotreksat Tedavisinin Başarısı Öngörülebilir mi? ANADOLU KLINIĞI TIP BILIMLERI DERGISI 2017. [DOI: 10.21673/anadoluklin.284474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Taran FA, Kagan KO, Hübner M, Hoopmann M, Wallwiener D, Brucker S. The Diagnosis and Treatment of Ectopic Pregnancy. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 112:693-703; quiz 704-5. [PMID: 26554319 DOI: 10.3238/arztebl.2015.0693] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 08/26/2015] [Accepted: 08/26/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND Extrauterine pregnancy is a complication of the first trimester of pregnancy that arises in 1.3-2.4% of all pregnancies. METHODS This review is based on articles and guidelines retrieved by a selective PubMed search. RESULTS The presentation of extrauterine pregnancy is highly variable, ranging from an asymptomatic state, to pelvic pain that is worse on one side, to tubal rupture with hemorrhagic shock. 75% of tubal pre gnancies can be detected by transvaginal ultrasonography. In patients with a vital extrauterine pregnancy, the human chorionic gonadotropin concentration generally doubles within 48 hours. Laparoscopy is the gold standard of treatment. Two randomized, controlled trials comparing organ-preserving treatment with ablative surgery revealed no significant difference in pregnancy rates after the intervention, but precise details of the surgical procedures were not provided, and long-term fertility data are lacking. Metho - trexate therapy should be used only for strict indications. CONCLUSION Further randomized, controlled trials with longer follow-up will be needed to answer currently open questions about the potential for individualized surgical treatment and the proper role of pharmacotherapy.
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Laparoscopic tube-preserving surgical procedures for ectopic tubal pregnancy. Obstet Gynecol Sci 2016; 59:512-518. [PMID: 27896254 PMCID: PMC5120071 DOI: 10.5468/ogs.2016.59.6.512] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 06/16/2016] [Accepted: 06/20/2016] [Indexed: 11/08/2022] Open
Abstract
Objective To present our experience with laparoscopic tube-preserving surgery for ectopic tubal pregnancy and evaluate its feasibility and efficacy. Methods This was a prospective study of 57 consecutive patients with ectopic tubal pregnancies undergoing laparoscopic tube-preserving procedures including salpingotomy, salpingostomy, segmental resection and reanastomosis, and fimbrial milking. The outcome measures were treatment success rates and homolateral patency rates. Results Of the 57 surgical procedures, 55 (96.4%) were performed successfully without any additional intervention. The number of patients receiving salpingotomy, salpingostomy, segmental resection and reanastomosis, and fimbrial milking were 24 (42.1%), 25 (43.9%), 4 (7.0%), and 2 (3.5%), respectively. Two case was switched to salpingectomy because excessive bipolar coagulation was required to obtain hemostasis at the tubal bleeding bed. Over a mean β-human chorionic gonadotropin resolution time of 18.3±5.9 days, no persistent trophoblast or postoperative complications occurred. A tubal patency test using hysterosalpingography was performed in 15 cases at 3 months postoperatively. Among these, the homolateral tubal patency rate was 75% (11 of 15) and the contralateral patency rate was 80% (12 of 15). Conclusion Tube-preserving surgery is a feasible and safe treatment option for ectopic tubal pregnancy. However, considering that the optimal goal of tube-preserving surgical procedures is not the treatment success, some caution is warranted in interpreting results of this study.
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Overview and guidelines of off-label use of methotrexate in ectopic pregnancy: report by CNGOF. Eur J Obstet Gynecol Reprod Biol 2016; 205:105-9. [DOI: 10.1016/j.ejogrb.2016.07.489] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 07/01/2016] [Accepted: 07/25/2016] [Indexed: 12/27/2022]
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Dalsgaard Jensen T, Penninga L. Non-operative treatment of ruptured ectopic pregnancy. BMJ Case Rep 2016; 2016:bcr-2016-215311. [PMID: 27298292 DOI: 10.1136/bcr-2016-215311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Ruptured ectopic pregnancy often causes abdominal pain, vaginal bleeding and internal haemorrhage; it is a very serious condition and can be life-threatening. Patients with a ruptured ectopic pregnancy are normally treated by surgical intervention. We describe a case of a 20-year-old woman who presented with abdominal pain and vaginal bleeding. Urine human chorionic gonadotropin was positive and on examination she had localised tenderness of the abdomen. Transvaginal ultrasonography revealed a ruptured tubal pregnancy along with blood in the abdomen. The patient was closely monitored and treated conservatively, with a successful outcome. She recovered uneventfully. Our case shows that non-operative treatment of a ruptured ectopic pregnancy may be a possible non-invasive treatment option in highly selected patients.
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Affiliation(s)
| | - Luit Penninga
- Region Avannaa, Ilulissat Hospital, Ilulissat, Greenland
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Comparison of the Fertility Outcome of Salpingotomy and Salpingectomy in Women with Tubal Pregnancy: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0152343. [PMID: 27015601 PMCID: PMC4807767 DOI: 10.1371/journal.pone.0152343] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 03/11/2016] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To compare the natural fertility outcomes of salpingotomy and salpingectomy among women treated for tubal pregnancy. METHODS An online database search including PubMed, Embase, CENTRAL and Web of Science was performed to identify studies comparing salpingotomy and salpingectomy to treat women with tubal pregnancy. The search included papers published after the databases were established until May 2015. Two reviewers independently screened literature according to the inclusion and exclusion criteria and then extracted data and assessed the methodological quality of all of the included studies. The meta-analysis was conducted using RevMan 5.3 software. The registration number is CRD42015017545 in PROSPERO. RESULTS Two randomized controlled trials (RCTs) and eight cohort studies, including a total of 1,229 patients, were znalyzed. The meta-analysis of the RCT subgroup indicated that there was no statistically significant difference in IUP rates (RR = 1.04, 95% CI = 0.89-1.21, P = 0.61) nor the repeat ectopic pregnancy (REP) rate (RR = 1.30, 95% CI = 0.72-2.38, P = 0.39) between the salpingotomy and salpingectomy group. In contrast, the cohort study subgroup analysis revealed that the IUP rate was higher in the salpingotomy group compared with the salpingectomy group (RR = 1.24, 95% CI = 1.08-1.42, P = 0.002); Salpingotomy also increased the risk of REP rate (RR = 2.27, 95% CI = 1.12-4.58, P = 0.02). The persistent ectopic pregnancy (PEP) occurred more frequently in the salpingotomy group than the salpingectomy group (RR = 11.61, 95% CI = 3.17-42.46, P = 0.0002). An IUP would be more likely to occur after salpingotomy than salpingectomy when the follow-up time was more than 36 months (RR = 1.16, 95% CI = 1.02-1.32, P = 0.03). The IUP rate (RR = 1.13, 95% CI = 1.01-1.26, P = 0.03), and the REP rate (RR = 1.62, 95% CI = 1.02-2.56, P = 0.04) was higher after salpingotomy than salpingectomy among patients from Europe compared with those from America. CONCLUSIONS Based on the available evidence, we believe that for patients with a healthy contralateral tube operated for tubal pregnancy, the subsequent fertility after salpingectomy and salpingotomy are similar in the long term. The fertility prospects will not be improved via salpingotomy compared with salpingectomy.
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Said TH. Laparoscopic Management of Interstitial Ectopic Using Simple and Safe Technique: Case Series and Review of Literature. J Obstet Gynaecol India 2016; 66:482-7. [PMID: 27651650 DOI: 10.1007/s13224-016-0862-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 02/09/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVE To determine the safety and sustainability of operative laparoscopy in surgical management of cornual and interstitial ectopic pregnancy using a simple and practical method. DESIGN Case series of five consecutive cases. SETTING Endoscopy unit in Alexandria University Hospital and Alexandria New Medical Center. PATIENTS Between July 2013 and May 2015, five women with interstitial and cornual ectopic pregnancies were admitted for laparoscopic surgical treatment. METHODS Full medical and surgical histories were taken. We explained all alternatives for both partners before informed. Patients underwent laparoscopy for management of the corneal ectopic. All surgeries were done by the same surgeon (T.S.) with different assistants. We gave different uterotonics drugs to devascularize the uterus. Two or more devascularization sutures were done on each end of the corneal ectopic. We used monopolar and bipolar electrocoagulation when indicated. We did linear cut of the interstitial ectopic with evacuation of the fetus and placental tissues. Extraction of the conceptus was performed through 10 mm port. Follow-up of the beta-hCG was done weekly till negative results were obtained. RESULTS The devascularization sutures together with uterotonics make the surgical treatment of interstitial ectopic easy and safe. This simple technique minimizes blood loss and decreases necrosis that follows excessive use of diathermy. This was demonstrated successfully in different types of interstitial ectopic. We did not remove any part of the uterus during surgery. Clinical criteria of the study cases were discussed. Type, size, blood loss and complications, and duration of the surgery were documented. CONCLUSION Operative laparoscopy using sutures and uterotonics is safe and sustainable approach in treatment of interstitial ectopic pregnancy.
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Affiliation(s)
- Tamer Hanafy Said
- Department of Obstetrics and Gynecology, Faculty of Medicine, El Shatby Maternity University Hospital, Alexandria University, 20 Saboungy Street, Saba Bacha, Alexandria, Egypt ; New Mexico University School of Medicine, Albuquerque, NM USA
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Demirdag E, Guler I, Abay S, Oguz Y, Erdem M, Erdem A. The impact of expectant management, systemic methotrexate and surgery on subsequent pregnancy outcomes in tubal ectopic pregnancy. Ir J Med Sci 2016; 186:387-392. [PMID: 26895299 DOI: 10.1007/s11845-016-1419-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/07/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The most common treatment modalities of ectopic pregnancy may influence long-term subsequent fertility outcomes in women who previously treated for ectopic pregnancy. AIMS Our objective was to compare long-term subsequent fertility outcomes after treatment with expectant management, systemic methotrexate (MTX) and surgery in tubal ectopic pregnancy. METHODS We searched our database for all women diagnosed with tubal ectopic pregnancy between January 2007 and January 2011 who were managed expectantly, with systemic MTX and with surgery. Treatment success and spontaneous pregnancy rates were compared in patients who desire to conceive following a tubal pregnancy. RESULTS One hundred twelve of 151 women desired to conceive following tubal ectopic pregnancy. Twenty-seven of 112 (24.1 %) patients were managed expectantly. Fifty-three (47.3 %) and 32 (28.5 %) patients were managed with systemic MTX or surgery, respectively. All patients in expectant and surgery groups were managed successfully. Two (3.7 %) patients had surgery after failed treatment with systemic MTX. Spontaneous intrauterine pregnancy rates were 62.9 % in expectantly managed women, 58.4 % in women with systemic MTX and 68.7 % in women with surgery (p > 0.05). CONCLUSIONS Treatment of ectopic pregnancy with either expectant management or systemic MTX is equally effective as compared to surgery. Spontaneous intrauterine pregnancy rates were comparable in expectant management, systemic methotrexate and surgery.
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Affiliation(s)
- E Demirdag
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - I Guler
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey.
| | - S Abay
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - Y Oguz
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - M Erdem
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
| | - A Erdem
- Department of Obstetrics and Gynecology, Gazi University School of Medicine, 06500, Besevler-Ankara, Turkey
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Song T, Kim MK, Kim ML, Jung YW, Yun BS, Seong SJ. Single-dose versus two-dose administration of methotrexate for the treatment of ectopic pregnancy: a randomized controlled trial. Hum Reprod 2015; 31:332-8. [PMID: 26701971 DOI: 10.1093/humrep/dev312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 11/20/2015] [Indexed: 12/27/2022] Open
Abstract
STUDY QUESTION Can a two-dose methotrexate treatment protocol improve the treatment success rate compared with a single-dose protocol in women with an ectopic pregnancy? SUMMARY ANSWER The two-dose protocol was not superior to the single-dose protocol for the treatment of ectopic pregnancy. WHAT IS KNOWN ALREADY Although the two-dose methotrexate protocol for ectopic pregnancy was recently introduced to combine the efficacy and convenience of the fixed multi-dose and single-dose protocols, studies comparing the success rates, treatment satisfaction and acceptability of the single-dose and two-dose treatment protocols for ectopic pregnancy are currently lacking. STUDY DESIGN, SIZE, DURATION A randomized trial was conducted on 92 participants with tubal ectopic pregnancy, between May 2013 and April 2015. PARTICIPANT/MATERIALS, SETTING, METHODS Patients who were diagnosed with tubal ectopic pregnancy and who elected to undergo systemic methotrexate treatment were randomly assigned to follow either the single-dose (n = 46) or two-dose protocol (n = 46). The primary outcome measure was treatment success without surgical intervention. The secondary outcome measures were the incidence of methotrexate-associated side effects, β-human chorionic gonadotrophin (β-hCG) resolution time, cost of care received and treatment satisfaction. MAIN RESULTS AND THE ROLE OF CHANCE There were no differences in baseline characteristics between the groups. The success rates between the single-dose and two-dose groups did not show a significant difference [82.6 versus 87.0%; relative risk (RR) 0.95; 95% confidence interval (CI) 0.80-1.13]. However, the success rate in a subgroup of participants with a pretreatment β-hCG level of >5000 mIU/ml appeared to be higher in the two-dose group than in the single-dose group (80.0 versus 58.8%), although the difference was not statistically significant. No significant differences in methotrexate-associated side effects, cost or treatment satisfaction were observed between the groups. The two-dose group required a lower number of days for the β-hCG level to decrease to <5 mIU/ml than the single-dose group (25.7 ± 13.6 versus 31.9 ± 14.1 days; P = 0.025). LIMITATIONS, REASONS FOR CAUTION Some caution is warranted in interpreting the results due to an overoptimistic sample size calculation on the basis of the biggest difference as reported in literature between the success rates of two protocols. WIDER IMPLICATIONS OF THE FINDINGS The single-dose protocol with the option to elaborate to a second dose in the case of treatment failure could stand as the treatment for most cases of ectopic pregnancy. STUDY FUNDING/COMPLETING OF INTERESTS None. TRIAL REGISTRATION NUMBER www.clinicaltrials.gov, no. NCT01855568. TRIAL REGISTRATION DATE 10 May 2013. DATE OF FIRST PATIENT'S ENROLMENT 26 May 2013.
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Affiliation(s)
- Taejong Song
- Department of Obstetrics and Gynecology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Mi Kyoung Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Mi-La Kim
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Yong Wook Jung
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Bo Seong Yun
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, 650-9 Yeoksam-1 Dong, Gangnam-gu, Seoul 135-081, Republic of Korea
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