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Al Wattar BH, Solangon SA, de Braud LV, Rogozińska E, Jurkovic D. Effectiveness of treatment options for tubal ectopic pregnancy: A systematic review and network meta-analysis. BJOG 2024; 131:5-14. [PMID: 37443463 DOI: 10.1111/1471-0528.17594] [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: 04/04/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Tubal ectopic pregnancy (TEP) is a common gynaecological emergency. Several medical and surgical treatment options exist, but it is not clear which is the safest and most effective treatment. OBJECTIVES To compare the effectiveness of expectant, medical and surgical treatment options for TEP using a systematic review and network meta-analysis. SEARCH STRATEGY MEDLINE, EMBASE, and CENTRAL from inception till September 2022. SELECTION CRITERIA Randomised trials that evaluated any treatment option for woman with a TEP. DATA COLLECTION AND ANALYSIS We performed pairwise and network meta-analyses using a random effect model. We assessed the studies' risk of bias, heterogeneity and network inconsistency. We reported primarily on TEP resolution and treatment failure using relative risk (RR) and 95% confidence-intervals (CI). MAIN RESULTS We included 31 randomised trials evaluating ten treatments (n = 2938 women). Direct meta-analysis showed no significant benefit for using methotrexate compared to expectant management for TEP resolution. Network meta-analysis showed similar effect-size for most conservative treatment options compared to expectant management for TEP resolution (glucose intra-sac instillation vs. expectant RR 0.84, 95% CI 0.63-1.12; methotrexate intra-sac instillation vs. expectant RR 0.91, 95% CI 0.75-1.10; multi-dose methotrexate vs. expectant RR 1.00, 95% CI 0.88-1.15; prostaglandin intra-sac instillation vs. expectant RR 0.75, 95% CI 0.53-1.07; salpingotomy vs. expectant RR 0.99, 95% CI 0.84-1.16; single dose methotrexate vs. expectant RR 0.97, 95% CI 0.85-1.10; single dose methotrexate + mifepristone vs. expectant RR 1.09, 95% CI 0.89-1.33). All treatment options showed a higher risk of failure compared to salpingectomy. CONCLUSIONS There is insufficient evidence to support the use of any medical treatment option for TEP over expectant management.
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Affiliation(s)
- Bassel H Al Wattar
- Beginning Assisted Conception Unit, Epsom and St Helier University Hospitals, London, UK
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Sarah A Solangon
- Women's Health Department, University College London Hospitals, London, UK
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - Lucrezia V de Braud
- Women's Health Department, University College London Hospitals, London, UK
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - Ewelina Rogozińska
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Davor Jurkovic
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials & Methodology, University College London, London, UK
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
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Sonalkar S, Gilmore E. A fresh look at treatment for ectopic pregnancy. Lancet 2023; 401:619-620. [PMID: 36738758 DOI: 10.1016/s0140-6736(23)00181-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 01/19/2023] [Indexed: 02/04/2023]
Affiliation(s)
- Sarita Sonalkar
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Emma Gilmore
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
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Horne AW, Tong S, Moakes CA, Middleton LJ, Duncan WC, Mol BW, Whitaker LHR, Jurkovic D, Coomarasamy A, Nunes N, Holland T, Clarke F, Doust AM, Daniels JP. Combination of gefitinib and methotrexate to treat tubal ectopic pregnancy (GEM3): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet 2023; 401:655-663. [PMID: 36738759 DOI: 10.1016/s0140-6736(22)02478-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 10/26/2022] [Accepted: 11/21/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Tubal ectopic pregnancies can cause substantial morbidity or even death. Current treatment is with methotrexate or surgery. Methotrexate treatment fails in approximately 30% of women who subsequently require rescue surgery. Gefitinib, an epidermal growth factor receptor inhibitor, might improve the effects of methotrexate. We assessed the efficacy of oral gefitinib with methotrexate, versus methotrexate alone, to treat tubal ectopic pregnancy. METHODS We performed a multicentre, randomised, double-blind, placebo-controlled trial across 50 UK hospitals. Participants diagnosed with tubal ectopic pregnancy were administered a single dose of intramuscular methotrexate (50 mg/m2) and randomised (1:1 ratio) to 7 days of additional oral gefitinib (250 mg daily) or placebo. The primary outcome, analysed by intention to treat, was surgical intervention to resolve the ectopic pregnancy. Secondary outcomes included time to resolution of ectopic pregnancy and serious adverse events. This trial is registered at the ISRCTN registry, ISCRTN 67795930. FINDINGS Between Nov 2, 2016, and Oct 6, 2021, 328 participants were allocated to methotrexate and gefitinib (n=165) or methotrexate and placebo (n=163). Three participants in the placebo group withdrew. Surgical intervention occurred in 50 (30%) of 165 participants in the gefitinib group and in 47 (29%) of 160 participants in the placebo group (adjusted risk ratio 1·15, 95% CI 0·85 to 1·58; adjusted risk difference -0·01, 95% CI -0·10 to 0·09; p=0·37). Without surgical intervention, median time to resolution was 28·0 days in the gefitinib group and 28·0 days in the placebo group (subdistribution hazard ratio 1·03, 95% CI 0·75 to 1·40). Serious adverse events occurred in five (3%) of 165 participants in the gefitinib group and in six (4%) of 162 participants in the placebo group. Diarrhoea and rash were more common in the gefitinib group. INTERPRETATION In women with a tubal ectopic pregnancy, adding oral gefitinib to parenteral methotrexate does not offer clinical benefit over methotrexate and increases minor adverse reactions. FUNDING National Institute of Health Research.
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Affiliation(s)
- Andrew W Horne
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK.
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Catherine A Moakes
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - W Colin Duncan
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia; Aberdeen Centre for Women's Health Research, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, UK
| | - Lucy H R Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Davor Jurkovic
- Institute for Women's Health, University College Hospital, London, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, University of Birmingham, Birmingham, UK
| | - Natalie Nunes
- Department of Obstetrics and Gynaecology, West Middlesex University Hospital, Chelsea and Westminster Hospital Foundation Trust, London, UK
| | - Tom Holland
- Department of Obstetrics and Gynaecology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fiona Clarke
- Department of Obstetrics and Gynaecology, East Lancashire Hospitals NHS Trust, Burnley, UK
| | - Ann M Doust
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Jane P Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
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Leziak M, Żak K, Frankowska K, Ziółkiewicz A, Perczyńska W, Abramiuk M, Tarkowski R, Kułak K. Future Perspectives of Ectopic Pregnancy Treatment-Review of Possible Pharmacological Methods. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph192114230. [PMID: 36361110 PMCID: PMC9656791 DOI: 10.3390/ijerph192114230] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/22/2022] [Accepted: 10/26/2022] [Indexed: 06/03/2023]
Abstract
Ectopic pregnancy, that is, a blastocyst occurring outside the endometrial cavity of the uterus, affects nearly 2% of pregnancies. The treatment of ectopic pregnancy is surgical or pharmacological. Since surgical management is associated with numerous serious side effects, conservative treatment is sought. The treatment of choice in the majority of cases is based on pharmacotherapy with methotrexate (MTX) in a single- or multi-dose regimen. Although the efficacy of methotrexate reaches between 70 and 90%, its use requires specific conditions regarding both the general condition of the patient and the characteristic features of the ectopic pregnancy. Moreover, MTX can cause severe adverse effects, including stomatitis, hepatotoxicity and myelosuppression. Therefore, clinicians and researchers are still looking for a less toxic, more effective treatment, which could prevent surgeries as a second-choice treatment. Some studies indicate that other substances might constitute a good alternative to methotrexate in the management of ectopic pregnancies. These substances include aromatase inhibitors, especially letrozole. Another promising substance in EP treatment is gefitinib, an inhibitor of EGFR tyrosine domain which, combined with MTX, seems to constitute a more effective alternative in the management of tubal ectopic pregnancies. Other substances for local administration include KCl and absolute ethanol. KCl injections used in combination with MTX may be used when foetal heart function is detected in cervical ectopic pregnancies, as well as in heterotopic pregnancy treatment. Absolute ethanol injections proved successful and safe in caesarean scar pregnancies management. Thus far, little is known about the use of those substances in the treatment of ectopic pregnancies, but already conducted studies seem to be promising.
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Affiliation(s)
- Milena Leziak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Klaudia Żak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Karolina Frankowska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Aleksandra Ziółkiewicz
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Weronika Perczyńska
- I Chair and Department of Oncological Gynaecology and Gynaecology, Student Scientific Association, Medical University of Lublin, 20-081 Lublin, Poland
| | - Monika Abramiuk
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
| | - Rafał Tarkowski
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
| | - Krzysztof Kułak
- I Chair and Department of Oncological Gynaecology and Gynaecology, Medical University of Lublin, 20-081 Lublin, Poland
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Italiano S, Tong S, Readman E, Tassone M, Hastie R, Pritchard N. Combination methotrexate and gefitinib: A potential medical treatment for inoperable nontubal ectopic pregnancy. J Obstet Gynaecol Res 2019; 46:531-535. [PMID: 31814216 DOI: 10.1111/jog.14169] [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: 09/13/2019] [Accepted: 11/14/2019] [Indexed: 11/29/2022]
Abstract
Nontubal ectopic pregnancies present as a therapeutic challenge. A 35-year-old primigravida at 7 weeks gestation had a live interstitial ectopic pregnancy and contraindications to surgery. The patient was treated with a multidose methotrexate regimen combined with oral gefitinib (250 mg daily for 7 days). The peak human chorionic gonadotropin (hCG) of the patient was recorded at 19 510 IU/L and began declining from day 4 of combination therapy (day 6 of initial treatment). Successful resolution of the ectopic was demonstrated by cessation of the fetal heart by day 15 and hCG falling to 23 IU/L by day 42. A 10-year review of all nontubal ectopic pregnancies treated with methotrexate identified 46 cases, which had a comparable time to resolution to combination therapy. However, for cases where cardiac activity was present, the median time to resolution following methotrexate treatment was 64 days (47-87 days), 22 days longer than combination therapy. Combination therapy may provide a safe medical treatment for inoperable nontubal ectopic pregnancy.
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Affiliation(s)
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Emma Readman
- Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | | | - Roxanne Hastie
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Natasha Pritchard
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Heidelberg, Victoria, Australia.,Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
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May J, Duncan C, Mol B, Bhattacharya S, Daniels J, Middleton L, Hewitt C, Coomarasamy A, Jurkovic D, Bourne T, Bottomley C, Peace-Gadsby A, Doust A, Tong S, Horne AW. A multi-centre, double-blind, placebo-controlled, randomised trial of combination methotrexate and gefitinib versus methotrexate alone to treat tubal ectopic pregnancies (GEM3): trial protocol. Trials 2018; 19:643. [PMID: 30458863 PMCID: PMC6247635 DOI: 10.1186/s13063-018-3008-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/20/2018] [Indexed: 11/12/2022] Open
Abstract
Background Tubal ectopic pregnancy (tEP) is the most common life-threatening condition in gynaecology. Treatment options include surgery and medical management. Stable women with tEPs with pre-treatment serum human chorionic gonadotrophin (hCG) levels < 1000 IU/L respond well to outpatient medical treatment with intramuscular methotrexate. However, tEPs with hCG > 1000 IU/L can take significant time to resolve with methotrexate and require multiple outpatient monitoring visits. In pre-clinical studies, we found that tEP implantation sites express high levels of epidermal growth factor receptor. In early-phase trials, we found that combination therapy with gefitinib, an orally active epidermal growth factor receptor antagonist, and methotrexate resolved tEPs without the need for surgery in over 70% of cases, did not cause significant toxicities, and was well tolerated. We describe the protocol of a randomised trial to assess the efficacy of combination gefitinib and methotrexate, versus methotrexate alone, in reducing the need for surgical intervention for tEPs. Methods and analysis We propose to undertake a multi-centre, double-blind, placebo-controlled, randomised trial (around 70 sites across the UK) and recruit 328 women with tEPs (with pre-treatment serum hCG of 1000–5000 IU/L). Women will be randomised in a 1:1 ratio by a secure online system to receive a single dose of intramuscular methotrexate (50 mg/m2) and either oral gefitinib or matched placebo (250 mg) daily for 7 days. Participants and healthcare providers will remain blinded to treatment allocation throughout the trial. The primary outcome is the need for surgical intervention for tEP. Secondary outcomes are the need for further methotrexate treatment, time to resolution of the tEP (serum hCG ≤ 15 IU/L), number of hospital visits associated with treatment (until resolution or scheduled/emergency surgery), and the return of menses by 3 months after resolution. We will also assess adverse events and reactions until day of resolution or surgery, and participant-reported acceptability at 3 months. Discussion A medical intervention that reduces the need for surgery and resolves tEP faster would be a favourable treatment alternative. If effective, we believe that gefitinib and methotrexate could become standard care for stable tEPs. Trial registration ISRCTN Registry ISRCTN67795930. Registered 15 September 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-3008-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- James May
- Simpsons Centre for Reproductive Health, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Colin Duncan
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Ben Mol
- Monash Health, Monash Medical Centre, Melbourne, Australia
| | - Siladitya Bhattacharya
- Obstetrics and Gynaecology, Division of Applied Clinical Sciences, University of Aberdeen, Aberdeen Maternity Hospital, Aberdeen, UK
| | - Jane Daniels
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, Queen's Medical Centre, Nottingham, UK
| | - Lee Middleton
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Catherine Hewitt
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Tommy's National Centre for Miscarriage Research, Birmingham Women's Hospital, Birmingham, UK
| | - Davor Jurkovic
- Gynaecology Diagnostic and Treatment Unit, University College Hospital, London, UK
| | - Tom Bourne
- Obstetrics and Gynaecology, Chelsea and Westminster NHS Hospital Foundation Trust, London, UK
| | | | | | - Ann Doust
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Stephen Tong
- University of Melbourne, Mercy Hospital for Women, Melbourne, Australia
| | - Andrew W Horne
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4SA, UK.
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