Serum β-human chorionic gonadotropin profile and its correlations with ultrasound parameters in low-lying-implantation ectopic pregnancy in the first trimester

What assessment, intervention and diagnostics should women with early pregnancy bleeding receive in the emergency department and when? A scoping review and synthesis of evidence

BACKGROUND

Vaginal bleeding is a frequent complication in early pregnancy, care that women receive, or lack thereof, can have immediate and long-term consequences. There is a lack of cogent, synthesised evidence on the assessment, interventions, and diagnostics for the management of early pregnancy bleeding in the emergency department (ED). This paper reports the results of a scoping review that identified that examined the literature to clarify concepts and generate a synthesis of the evidence for the assessment, interventions, diagnostics and management of early pregnancy bleeding in the ED.

METHODS

Five databases were searched. Practice guidelines and statements were sourced from professional organisations, and online repositories. Three types of data were included: practice guidelines, reviews, and primary research. Data were extracted and collated, and findings were synthesised into a clinical guideline.

RESULTS

A total 122 (of 3602) papers from database searching, and six (of 46) practice guidelines were included. Seventy-seven publications reported on assessment including performing vital observations. Thirty-six reported on interventions including administration of analgesia, and 114 reported on diagnostics, which most (n = 93) recommended use of ultrasound. Few (12 %) of practice statements and guidelines recommended care not based in current evidence. The study yielded an evidence-based practice guideline to be used for initial management of early pregnancy bleeding.

CONCLUSIONS

The practice guideline generated by this examination and synthesis of the evidence offers comprehensive, evidence informed recommendations for the initial management of early pregnancy bleeding. Continued research and knowledge translation for initial management of early pregnancy bleeding is needed to reduce variation in emergency care and improve outcomes for women.

Risk factors associated with the failure of local methotrexate combined with minimally invasive surgery for late cesarean scar pregnancy

BACKGROUND

This study aimed to investigate the risk factors related to the failure of initial combined local methotrexate (MTX) treatment and minimally invasive surgery for late cesarean scar pregnancy (CSP).

METHODS

This retrospective case-control study was conducted between January 2016 and December 2023, involving patients with late CSP (≥ 8 weeks) who received local MTX injection combined with either hysteroscopic or laparoscopic surgery. Cesarean scar pregnancy was classified as type I, II, or III based on the direction of growth of the gestational sac and the residual myometrial thickness as assessed by ultrasound. Binary logistic regression analysis was utilized to identify the risk factors associated with the failure of the initial combined treatment.

RESULTS

Overall, 574 patients with late CSP were included in our study. Among them, 29 patients (5.1%) experienced treatment failure with the initial local MTX combined with minimally invasive surgery, while 545 patients (94.9%) achieved successful treatment outcomes. In the univariate analysis, several potential risk factors associated with the initial combined treatment failure were identified, including baseline serum β-human chorionic gonadotropin (β-hCG) levels, type of CSP, time interval between MTX and surgery, and positive fetal heart activity before surgery. Subsequent binary logistic regression analysis revealed the following independent risk factors linked to the failure of the initial combined treatment: baseline serum β-hCG levels exceeding 94,000 IU/L [odds ratio (OR) 3.060, 95% confidence interval (CI) 1.387-6.749, P = 0.006], type III CSP (OR 3.574, 95% CI 1.147-11.135, P = 0.028), a time interval greater than seven days between MTX and surgery (OR 3.847, 95% CI 1.725-8.581, P = 0.001), and the presence of a fetal heartbeat before surgery (OR 4.405, 95% CI 1.014-19.128, P = 0.048).

CONCLUSION

The findings indicate that higher baseline serum β-hCG levels, an extended time interval between MTX and surgery, type III CSP and a positive preoperative fetal heartbeat are significant risk factors for the failure of initial local MTX combined with minimally invasive surgery in patients with late CSP. Individualized treatment strategies are recommended for these high-risk patients with late CSP.

Ag nanoparticle in situ decorated on Ti3C2Tx with excellent SERS and EIS immunoassay performance for beta-human chorionic gonadotropin

Two-dimensional transition metal carbides, nitrides, and carbonitrides (MXene), with excellent optical and electrical properties, are promising substrates for surface-enhanced Raman scattering (SERS) and electrochemical sensors. Therefore, a unique 3D-decorated structure containing silver (Ag) nanoparticles and Ti₃C₂T_x was designed as the substrates of SERS and electrochemical impedance spectroscopy (EIS) immunosensors. The Ag/Ti₃C₂T_x composite significantly increases Raman intensity, which is attributed to the synergistic effect of Ti₃C₂T_x and Ag nanoparticles. Based on the SERS performance of the Ag/Ti₃C₂T_x composite, the magnetic properties of Fe₃O₄ and the specificity of antigen-antibody, a sandwich-structured SERS immunosensor is constructed, which can effectively detect trace amounts of beta-human chorionic gonadotropin (β-hCG). The SERS immunosensor exhibits a wide linear range of 5.0 × 10^-6-1.0 mIU mL^-1, and a low detection limit of 9.0 × 10^-7 mIU mL^-1. Meanwhile, the Ag/Ti₃C₂T_x-based EIS immunosensor is constructed for the portable detection of β-hCG, which exhibits a wide linear range of 5.0 × 10^-2-1.0 × 10² mIU mL^-1, a low detection limit of 9.5 × 10^-3 mIU mL^-1. Moreover, two immunosensors can be used to detect actual serum samples with satisfactory recovery (98.5-102.2%). This work could guide the design of low-cost, sensitive, flexible, and portable biosensors. The SERS and EIS substrates composited with Ti₃C₂T_x and Ag nanoparticles enable excellent performance for detecting β-hCG.

Analysis of pregnancy outcomes following surgical treatment of cesarean scar pregnancy

Purpose

To investigate the surgical treatment approaches for patients with Cesarean scar pregnancy (CSP) and the effects on subsequent pregnancy.

Methods

CSP patients admitted to Shengjing Hospital of China Medical University from January 2013 to December 2018 were retrospectively analyzed to collect their clinical characteristics, and follow-up of postoperative pregnancies.

Results

A total of 1126 CSP patients were enrolled in this study, including 595 (52.84%) CSP type I, 415 (36.86%) CSP type II, and 116 (10.30%) CSP type III cases. There were significant differences between the three types of patients in terms of β-HCG levels, gestational sac diameter, clinical symptoms and presence of fetal heartbeat at diagnosis (P < 0.01). Among these, 89.90% of CSP type I, 88.90% of CSP type II and 50% of CSP type III patients were treated with hysteroscopic lesion excision, 7.9% of CSP type I and 2.2% of CSP type II patients underwent ultrasound-monitored curettage, and the remaining patients underwent lesion excision and and simultaneous repair of excised lesions by different routes (trans-laparoscopic, transabdominal or transvaginal methods). And 5.55% of CSP type I, 22.65% of CSP type II and 43.10% of CSP type III patients were treated with adjunctive uterine artery embolization (UAE). The patients were followed up for more than 2 years after surgery. Among the 166 re-pregnancies, 58 (34.94%) were normal pregnancies, 17 patients reoccurred with CSP, the recurrent rate of CSP was 10.24%. All 58 normal pregnancies were terminated by cesarean section, with a mean gestational week of delivery of (38.36 ± 2.25) weeks, a mean birth weight of (3228.45 ± 301.96)g, and the postnatal Apgar score was (9.86 ± 0.23) points at 1 min and all 5 min were 10 points. Logistic regression analysis suggested that the number of previous cesarean deliveries was a risk factor for recurrent CSP (RCSP) (OR = 10.82, 95% CI: 2.52–46.50, P = 0.001).

Conclusions

The type of CSP is related to β-HCG values, presence of fetal heartbeat, gestational sac diameter and clinical symptoms. Hysteroscopic therapy is a commonly used surgical procedure and UAE is often used as an adjuvant treatment. For subsequent pregnancies, the number of previous cesarean deliveries is a risk factor for recurrent CSP.

A novel approach with concomitant laparoscopic uterine artery ligation and D&C as initial treatment for complicated gestational trophoblast disease in cesarean scar and cervical ectopic pregnancies

OBJECTIVE

Gestational trophoblast disease (GTD) in low-lying implantation ectopic pregnancy (LLIEP) is extremely rare. Surgical removal of GTD lesions which is the initial treatment of choice carries a high risk of intraoperative massive bleeding. Adequate management is challenging and inconclusive.

CASE REPORT

We present two unusual cases with a diagnosis of GTD in advanced LLIEP. The first case had choriocarcinoma in cesarean scar and the second case had mole pregnancy in cervix. Both cases were managed with laparoscopy uterine artery ligations followed by transvaginal intrauterine curettage and vacuum aspiration with a small amount of surgical blood loss and then resumed regular menstruation. To understand the different surgical approaches and their potential advantages in managing such rare diseases, relevant cases in the literature were reviewed.

CONCLUSION

Much attention should be paid to avoid massive bleeding at initial surgical intervention in patients with GTD in advanced LLIEP. This novel approach with combination of laparoscopic uterine artery ligations and evacuating curettage in selected patients is highly recommended to minimize surgical blood loss. The obvious advantages include technical feasibility, less surgery-related bleeding and potential fertility preservation.