Conservative treatment in non-tubal ectopic pregnancy and predictors of treatment failure

Cesarean Scar Ectopic Pregnancy: A Retrospective Study of Ultrasound-Guided Suction Evacuation From Saudi Arabia

Objectives Globally, as rates of cesarean section increase, so do the rates of cesarean scar ectopic pregnancies. The objective of this study is to describe our experiences in managing cesarean scar ectopic pregnancy (CSEP) in King Abdullah Bin Abdulaziz University Hospital. Method This retrospective cohort study was conducted at King Abdullah Bin Abdulaziz University Hospital, Riyadh, Saudi Arabia. The study included women of reproductive age who presented with a cesarean scar ectopic pregnancy (CSEP) and a diagnosis confirmed by the transvaginal ultrasound. The suction evacuation was performed by ultrasound-guided suction evacuation. All the relevant data was retrieved from medical records. Results We reported ten CSEPs managed by ultrasound-guided suction evacuation. All ten patients successfully underwent ultrasound-guided suction evacuation for CSEP without complications. Most of the patients experienced minimal blood loss, except one case developed excessive blood loss, which was controlled by balloon tamponade. All the patients were dischargeable on the same day of the procedure or the following day, and they experienced a significant decrease in beta-human chorionic gonadotropin (HCG) levels, ultimately reaching undetectable levels, apart from one case in which the histopathology confirmed partial molar pregnancy and is still undergoing follow-up by beta-HCG till the date of study publication. All patients were discharged with advice for an early scan in subsequent pregnancies. The study revealed ultrasound-guided suction evacuation's effectiveness, safety, and advantages as a minimally invasive and reasonable approach to managing early CSEP.  Conclusion Ultrasound-guided suction evacuation can be safely and effectively applied to CSEP management, and it remains one of the most cost-effective methods.

A 20 year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital - a retrospective review

BACKGROUND

Non-tubal ectopic pregnancies account for < 10% of all ectopic pregnancies. Due to its rarity and wide variation in clinical practice, there is no guideline or consensus for its management. We reported our 20-year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital.

METHODS

This is a retrospective review of all women admitted for non-tubal ectopic pregnancies from January 2003 to December 2022 in a tertiary hospital. Women with non-tubal ectopic pregnancies diagnosed by ultrasound or operation were included for analysis.

RESULTS

Within the study period, 180 women were diagnosed to have non-tubal ectopic pregnancies at a mean gestation of 6.8 weeks. 16.7% (30/180) were conceived via assisted reproduction. Medical treatment was the first-line management option for 81 women, of which 75 (92.1%) women received intralesional methotrexate administered under transvaginal ultrasound guidance. The success rate of intralesional methotrexate ranges from 76.5% to 92.3%. Intralesional methotrexate was successful even in cases with a positive fetal pulsation or with high human chorionic gonadotrophin levels up to 252605U/L. Twenty seven women were managed expectantly and 40 underwent surgery. Nine (11.1%), two (6.1%), and one (2.3%) women required surgery due to massive or recurrent bleeding following medical, expectant, or surgical treatment. Hysterotomy and uterine artery embolization were necessary to control bleeding in one Caesarean scar and one cervical pregnancy.

CONCLUSIONS

Intralesional methotrexate is more effective than systemic methotrexate and should be considered as first line medical treatment for non-tubal ectopic pregnancies. It has a high success rate in the management of unruptured non-tubal ectopic pregnancies even in the presence of fetal pulsations or high human chorionic gonadotrophin levels, but patients may require a prolonged period of monitoring. Close surveillance and readily available surgery were required due to the risk of heavy post-procedural intra-abdominal bleeding.

Transvaginal natural orifice endoscopic surgery for tubal ectopic pregnancy: A more suitable surgical approach for enhanced recovery after surgery

Objective

We aimed to determine the safety of Vaginal natural orifice transluminal endoscopic surgery (vNOTES) in terms of the Enhanced Recovery after Surgery (ERAS) concept for tubal pregnancy surgery and provide a detailed process of vNOTES for tubal pregnancy surgery, including experience and key points for surgeons performing this procedure.

Methods

The Longitudinal Vaginal Natural Orifice Transluminal Endoscopic Surgery Study (LovNOTESS), which was conducted in Chengdu, China. A total of 219 patients who underwent tubal ectopic pregnancy surgery between September 2021 and March 2022. The patients underwent salpingectomy or salpingostomy using transumbilical laparoendoscopic single-site surgery (LESS) or vNOTES, according to their preferences. This study prospectively collected perioperative and one-year follow-up data on tubal pregnancy outcomes after vNOTES and compared them with those after LESS.

Results

The vNOTES group showed a shorter surgical duration, hospitalization duration, and postoperative exhaust time and a lower analgesic medication usage rate, but it showed a higher surgical conversion rate. The vNOTES approach reduced the postoperative exhaust time by approximately 9 h (95% confidence interval [CI]: -11.93, -5.57 h, p < .001) and the risk of postoperative analgesic drug use by 77% (odds ratio, 0.23; 95% CI: 0.10, 0.61, p = .023).

Conclusion

vNOTES can shorten the exhaust time and duration of hospitalization, reduce postoperative pain, and avoid surface surgical scars in tubal pregnancy surgeries, consistent with the ERAS concept. However, more comprehensive preoperative evaluation of patients who choose vNOTES is required to reduce the occurrence of intraoperative conversion.Trial registration: ChiCTR2100053483.

Predictive value of serum βHCG level in ectopic pregnancy: A cross sectional study

Background and Aims

Ectopic pregnancy (EP) is a potentially life-threatening emergency. We investigate the predictive value of serum βHCG level and it's changes from the baseline to the 4th and 7th days after single dose (SD) methotrexate (MTX) treatment in successful treatment of tubal EP. It is important for early diagnosis of EP.

Methods

In this cross-sectional study, 690 women with tubal EP and under treatment with SD MTX were evaluated. Successful and failed groups were analyzed on the baseline, 4th and 7th days of MTX treatment. Data were analyzed using SPSS22 software. All p values of less than 0/05 were considered satistically significant.

Results

SD MTX treatment was successful in 584 (84.7%) patients. The mean baseline ßHCG value was 882.35 ± 430.76 in the successful group and 1083.99 ± 1080.25 in the failed group. There was a 19.53% decrease in ßHCG values between the baseline and 4th days in the successful group and a 12.94% increase in the failed group (p < 0.001). On days baseline, 4 and 7; receiver operating characteristic curve analysis's value was 504.5, 429, 279 for cut off; 58%, 73%, 81% for sensitivity and 51%, 52%, 55% for specificity, respectively.

Conclusion

A decrease in the ßHCG value and/or a cut-off decrease of 59.9% on the baseline, 4th day and 81.6% between the baseline and 7th days, can predict the successful treatment of tubal EP with SD MTX.

A 10‐year retrospective cohort study of non‐tubal ectopic pregnancy management outcomes in an Australian tertiary centre

Introduction

Non-tubal ectopic pregnancy (NTEP) is a rare but significant early pregnancy complication which can result in maternal morbidity and mortality. There is however a lack of evidence-based guidelines for the management of NTEP.

Purpose

To evaluate the success rates of expectant, medical and surgical management in the treatment of NTEP at our tertiary centre.

Methods

Retrospective cohort study from 2010 to 2020. All NTEP were classified by ectopic sites. Primary management was classified by expectant, medical [systemic methotrexate (Sys-MTX) and/or local ultrasound-guided injection of MTX and/or KCl intra-sac (L-MTX, L-MTX/KCl)] or surgical. Primary management was considered successful if no change in intervention was required. Treatment complications were compared.

Results

Twenty-four NTEP were identified, which included 14 interstitial pregnancies (IP), 9 caesarean scar pregnancies (CSP) and 1 ovarian pregnancy (OP), which gave NTEP an incidence of 7.12% among all EP (4.15% for IP, 2.67% for CSP and 0.30% for OP). The success of primary surgical management was 100% (7/7), primary medical management was 76.9% (10/13) and primary expectant management was 33.3% (1/3). Primary medical management had a non-statistically significant greater mean time to serum ß-human Chorionic Gonadotrophin <5 IU/L, mean length of hospitalisation, mean number of follow-up visits and hospital re-presentation/readmissions compared to primary surgical management. There was no other difference in complication rates between the treatment management groups.

Conclusion

Surgery remains the most effective way to manage NTEP. However, medical management can be a safe and effective alternative option in carefully selected cases.