Future Perspectives of Ectopic Pregnancy Treatment-Review of Possible Pharmacological Methods

Evaluating single-dose methotrexate alone versus methotrexate with letrozole for treating ectopic pregnancy: a comparative study

PURPOSE

Ectopic pregnancy (EP) constitutes 1-2% of all pregnancies. Methotrexate (MTX) is commonly used in treating EP, but it has some limitations and potential side effects. Clinical studies have shown that letrozole, an aromatase inhibitor, may potentially be used in conjunction with MTX therapy. In our study, we explored the efficacy of adding letrozole to MTX in managing EP.

METHODS

Between June 2021 and September 2022, a total of 60 patients diagnosed with EP at the Faculty of Medicine, Yüzüncü Yıl University, were randomly divided into two groups. Group 1 received MTX alone, while Group 2 received a combination of MTX and letrozole. The primary outcome measure was the change in serum β-hCG levels. Secondary outcomes included the need for surgical intervention and the occurrence of side effects.

RESULTS

Both groups demonstrated similar success rates in treatment, and there was no significant difference between the MTX and MTX + letrozole groups regarding the need for surgical intervention. Although β-hCG levels declined more rapidly in the MTX + letrozole group, these decreases were not statistically significant. The combination of MTX and letrozole in the treatment of ectopic pregnancy has shown similar efficacy to single-dose MTX.

CONCLUSION

Letrozole may offer a potential contribution to MTX therapy by providing a more pronounced reduction in β-hCG levels, but further research with larger sample sizes and longer follow-up periods is needed to confirm these findings.

Increasing trends of laparoscopic procedures in non-obstetric surgery during pregnancy over 17 years at a single center: Retrospective case-control study

OBJECTIVE

This study aimed to examine the diseases requiring surgery during pregnancy, the changes in surgical methods over time, and the characteristics of surgeries performed in different trimesters.

METHODS AND MATERIALS

A retrospective study conducted at Bundang CHA Hospital between 2006 and 2023 analyzed surgeries performed during pregnancy and compared laparoscopic and open approaches across the three trimesters of pregnancy. Additionally, general (appendicitis, cholecystitis) and gynecologic (heterotopic pregnancy, adnexal torsion) cases were compared.

RESULTS

Among 36 181 delivery patients, 101 (0.28%) underwent surgery. The most common conditions were appendicitis (44.6%), cholecystitis (1.9%), heterotopic pregnancy (23.8%), adnexal torsion (27.7%), and cancer (1.9%). The laparoscopic group had a shorter operative time (41.5 ± 19.3 vs. 57.9 ± 33.9 min, p = 0.009) and hospital stay (4.9 ± 2.7 vs. 9.0 ± 9.8 days, p = 0.016) than open surgery group. Heterotopic pregnancy (47.1%) and adnexal torsion (39.2%) were common in the first trimester, whereas appendicitis peaked in the second (80%) and third trimesters (66.7%). The increasing use of assisted reproductive technology (ART) has led to a rise in gynecological patients requiring surgery in the first trimester, resulting in more laparoscopic surgeries during this period. Interestingly, an increase in laparoscopic surgery was also observed in general surgery during the second and third trimesters. Perioperative tocolysis was more frequent (51.1% vs. 3.8%, p < 0.001) and of longer duration (4.6 ± 8.8 vs. 0.1 ± 0.6 days, p = 0.001) after general surgical procedures.

CONCLUSION

Laparoscopic surgery during pregnancy offers several advantages such as shorter operative time and hospital stay. Since 2011, laparoscopic surgery for the entire gestational period has been on the rise.

Broad ligament ectopic pregnancy with full-term live birth: a rare case report from Syria

Ectopic pregnancy, the implantation of a fertilized zygote outside the uterine cavity, presents with abdominal pain and vaginal bleeding. Diagnosis relies on clinical signs, and treatment involves surgery or methotrexate in selected cases. A 24-year-old woman at 37 weeks of gestation underwent elective cesarean delivery under general anesthesia, revealing an unexpected broad ligament ectopic pregnancy. The live fetus and placenta were successfully delivered without complications. The study reports a rare asymptomatic broad ligament ectopic pregnancy until 37 weeks, diagnosed by laparotomy-treatment involved removing the ovary and placenta and preserving the uterus. A healthy male baby and mother recovered well. This rare ectopic pregnancy, with placental implantation in the broad ligament, resulted in a successful cesarean delivery of a healthy infant and complication-free recovery, highlighting the importance of timely diagnosis and skilled surgical intervention.

The relationship between serum levels of epidermal growth factor and β-human chorionic gonadotropin and the type and prognosis of ectopic pregnancy

PURPOSE

This work aimed to explore the relationship between epidermal growth factor (EGF) and β-human chorionic gonadotropin (β-HCG) and ectopic pregnancy types and impact on prognosis.

METHODS

Twenty women with normal pregnancies (NPs) were recruited as control group, and twenty women each with tubal pregnancy (TP) and cervical pregnancy (CP) were recruited. Blood samples were collected to detect EGF and β-HCG. Data on length of hospital stay and incidence of complications were collected. The differences in serum EGF and β-HCG levels were compared among groups and within various types of ectopic pregnancy using analysis of variance and Pearson correlation analysis.

RESULTS

Serum EGF and β-HCG were notably lower in TP and CP group vs. controls (P < 0.05). In subgroup analysis within the types of ectopic pregnancy, serum EGF levels were drastically higher in TP group vs. CP group (P < 0.05). Serum EGF levels were negatively correlated with pregnancy outcomes and incidence of complications (P < 0.05). In patients with TP and CP, serum EGF and β-HCG recovery time and hospital stay differed drastically (P < 0.05). Serum EGF and β-HCG levels showed optimal cutoff values identified at 2.65 μg/L and 11,745.35 IU/L, respectively. The corresponding area under the curve (AUC) values were 0.885 and 0.841.

CONCLUSION

Elevated levels of EGF may be associated with the occurrence of ectopic pregnancy and may impact the type of ectopic pregnancy, pregnancy outcomes, and the incidence of complications. Further clinical research is warranted to investigate these findings.

Efficacy of letrozole for the treatment of tubal ectopic pregnancy: A meta-analysis

BACKGROUND

Tubal ectopic pregnancy (EP) is a life-threatening condition, especially if undiagnosed or misdiagnosed, tipically in low income countries and/or where women have limited access to health care. The current management protocol of tubal EP consists of either surgical management, or medical management with methotrexate. Recent studies, while few, have suggested that letrozole, an aromatase inhibitor, may play a role in the medical treatment of tubal EP.

OBJECTIVES

To evaluate the effectiveness of letrozole alone in the medical treatment of tubal EP.

SEARCH STRATEGY

Electronic databases were searched until 31 December 2023.

SELECTION CRITERIA

Retrospective or prospective studies reporting the treatment of tubal EP with letrozole alone were considered eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Pooled results were expressed as OR with 95 %CI. Heterogeneity was assessed using Higgins I2. Subgroup analysis was performed to compare outcomes according to time after intervention. Subgroup differences were checked through χ2 test.

RESULTS

A total of 152 patients were included. Seventy-nine patients (51.97 %) were treated with letrozole, 39 patients (16.54 %) with methotrexate, and 34 patients (31.49 %) underwent surgical treatment. Pooled data analysis supports the consistency of the effect of letrozole in reducing β-hCG over time at a comparable rate among studies, and that treatment with letrozole is superior to surgery and has the same efficacy as methotrexate. However, all the included studies were judged at high risk of bias in terms of study design, sample representativeness, and sampling technique. Furthermore, short and long term side effects were not reported in any of the included studies.

CONCLUSIONS

Letrozole is a promising alternative to methotrexate and surgical therapy in the treatment of tubal EP. Although this meta-analysis suggests efficacy and low hazard of the drug and encourages its application, the data available today remain extremely sparse, which weakens any claims that can be made, and is not sufficient to assert that letrozole is safe and effective in the treatment of EPs. There is an absolute need for randomized studies with accurate patient selection, fixed doses, large sample sizes, and reporting of short- and long-term side effects to refute or confirm this assumption.

Comparing the effectiveness of letrozole versus methotrexate for treatment of ectopic pregnancy: A randomized controlled trial

OBJECTIVE

To evaluate the efficacy of two different regimens of Letrozole, an aromatase inhibitor, in the management of ectopic pregnancy compared to methotrexate.

STUDY DESIGN

This randomized controlled trial was conducted on 88 women diagnosed with ectopic pregnancy with a baseline level of serum beta-human chorionic gonadotropin under 3000 mIU/mL between June 30, 2023, and December 30, 2023, at the Department of Obstetrics and Gynecology of the Vali-e-Asr Hospital affiliated with Tehran University of Medical Sciences. Participants were allocated into either methotrexate (n = 43), 5-day course Letrozole (n = 24), or 10-day course Letrozole (n = 21) treatments. The methotrexate group received a single dose of 50 mg/m2 dosage intramuscular methotrexate. The 5-day Letrozole group received a 2.5 mg Letrozole tablet three times daily for 5 days, whereas the 10-day Letrozole group received a 2.5 mg Letrozole tablet twice daily for 10 days. The primary outcome was the treatment response, defined as the achievement of a negative serum beta-human chorionic level without the need for additional methotrexate treatment or surgery. The secondary outcomes were the need for additional methotrexate dose or laparoscopic surgery intervention. The trial protocol was prospectively registered in ClinicalTrials.gov with code NCT05918718.

RESULTS

The treatment response rates in methotrexate, 5-day Letrozole, and 10-day Letrozole groups were 76.7 %, 75.0 %, and 90.5 %, respectively, with no significant differences between the groups (P-value = 0.358). A total of 10 (23.3 %) patients from the methotrexate group, 3 (12.5 %) from the 5-day Letrozole group, and 2 (9.5 %) from the 10-day Letrozole group required an additional methotrexate dose, with no significant differences between the groups (P-value = 0.307). Furthermore, only 3 (12.5 %) patients, all from the 5-day Letrozole group, were suspected of tubal rupture and underwent surgery (P-value = 0.016).

CONCLUSION

Our findings suggest Letrozole as a safe alternative to methotrexate in treating stable ectopic pregnancies, with a favorable treatment response rate. However, there is still a need for future larger studies to determine the applicability of Letrozole in the EP management. Also, the non-significant higher effectiveness of the 10-day Letrozole regimen than the 5-day Letrozole group underscores the need for future research to determine the optimal Letrozole regimen for the management of ectopic pregnancy.

Bilateral tubal ectopic pregnancy following induction ovulation can be missed in emergent ultrasonography: Case report

INTRODUCTION

Bilateral tubal ectopic pregnancy (BTP) is a rare and potentially life-threatening condition that is, often challenging to diagnose preoperatively.

PRESENTATION OF CASE

We present a case of BTP in a 25-year-old primigravid woman with a history of infertility due to polycystic ovarian syndrome. She was receiving letrozole when she presented with severe abdominal pain and vaginal bleeding. Initial evaluation revealed a ruptured ectopic pregnancy in the right fallopian tube, prompting an emergency laparotomy. During surgery, a second intact ectopic mass was discovered in the left fallopian tube, highlighting the diagnostic complexity of BTP. Management involved a salpingectomy on the right side and salpingostomy on the left to preserve fertility.

DISCUSSION

This case underscores the importance of considering BTP in the differential diagnosis of ectopic pregnancies and the necessity for thorough preoperative imaging studies, namely ultrasonography and surgical exploration, to prevent missed diagnoses.

CONCLUSION

BTP is a rare and challenging clinical entity that requires a comprehensive approach to diagnosis and management. Early recognition, prompt intervention, and close surveillance are essential to mitigate the risk of maternal morbidity and mortality associated with this condition.

A Systematic Review about Cervical Pregnancy and our Experience

Background

Cervical ectopic pregnancy is a relatively rare type of ectopic pregnancy and has no standardized guidelines for management.

Methods

This systematic review is based on the collection of case reports, published in PubMed/MEDLINE about the resolution of ectopic cervical pregnancies over the last decade and the presentation of a case managed in our healthcare unit. Studies involving cervical pregnancy in the first trimester with the presence of a viable embryo and β-hCG in the serum below 100.000 mIU/mL were included, while heterotopic pregnancies were excluded.

Results

Nineteen articles reporting twenty-three case reports are demonstrated explicitly emphasizing on the management techniques. There is no established approach for the management of this type of ectopic pregnancy.

Conclusion

It is important to consider the conservative approaches as first-line treatment in all cases of cervical pregnancy preserving fertility. Minimally invasive methods are also described and preferred as second-line treatment, as reported in our literature review.

Heterotopic pregnancy after a single embryo transfer with successful perinatal outcome: case report and literature review

A heterotopic pregnancy is a rare and serious pathological pregnancy. In this paper, we report a rare case of heterotopic pregnancy and perform a literature review. A 30-year-old patient with a history of left adnexectomy presented with persistent lower abdominal pain and hemorrhagic shock after single embryo transfer. Emergency laparoscopic exploration revealed a ruptured mass in the right isthmus of the fallopian tube, for which right salpingectomy was performed. After anti-inflammatory treatment and fetal preservation, the intrauterine pregnancy progressed smoothly, and a healthy baby was delivered at 39 weeks gestation. In this case, the patient's heterotopic pregnancy was possibly due to a natural pregnancy caused by sexual intercourse during treatment, so we recommend that sexual intercourse be avoided during transfer cycles.

Navigating Interstitial Heterotopic Pregnancy: A Case Report

Interstitial heterotopic pregnancy (IHP), an exceedingly rare and clinically intricate phenomenon, presents a diagnosis that challenges healthcare providers in obstetric care. This case report provides valuable insights into the complexities of diagnosing and managing IHPs, shedding light on the pivotal role of early and precise identification. Through a meticulous examination of a 28-year-old patient's clinical history and diagnostic journey, this report underscores the significance of advanced imaging techniques and swift decision making, ultimately leading to the accurate diagnosis of an IHP. Furthermore, it highlights the life-saving importance of cornuostomy as a safe and effective intervention, preserving the intrauterine pregnancy while successfully resolving the ectopic gestation. This case report serves as a compelling reminder of the critical need for timely diagnosis and individualized treatment in cases of IHPs, ultimately enhancing the understanding and management of this rare obstetric condition.

Prediction of Tubal Rupture in Ectopic Pregnancy Using Methotrexate Treatment Protocols and Hematological Markers

Ectopic pregnancy is a pregnancy complication in which the embryo implants outside the uterine cavity. Although medical treatment is chosen first, sometimes a rupture may occur, and surgical treatment may be required. The parameters to predict rupture have been the subject of many studies. This study aimed to compare the efficacy of different methotrexate protocols in the treatment of ectopic pregnancy and determine the parameters and methotrexate treatment protocols that can predict the risk of rupture. A total of 128 patients diagnosed with ectopic pregnancy were included in this study. Patients were separated into three categories based on their treatment protocols. Regarding the occurrence of rupture, all three groups were compared. The hematological parameters and methotrexate treatment protocols were analyzed and compared between groups. The mean age was 31.9 years. Parity was significantly higher in patients who received multiple doses of methotrexate compared to the other groups. There were significant variations observed among the groups regarding parity, initial β-hCG values, hematocrit (HTC), and mean corpuscular volume (MCV) (p = 0.048, p < 0.001, p = 0.019, and p = 0.047, respectively). According to receiver operating characteristic analysis, neutrophil-to-lymphocyte ratio (NLR) levels were significantly associated with histopathologically confirmed tubal rupture (p < 0.05). NLR levels should be examined in ectopic pregnancy, and the possibility of rupture should be considered in cases with high NLR levels. The potential of NLR to predict ectopic pregnancy rupture should be explored in multicenter prospective studies.

A unilateral twin ectopic pregnancy in the fallopian tube: A rare case report

INTRODUCTION

The implantation of a fertilized ovum outside of the normal uterine cavity is referred to as ectopic pregnancy, most frequently in the fallopian tube. Unilateral tubal twins are a rare diagnosis since they occur in around 1 in 125,000 spontaneous pregnancies.

PRESENTATION OF CASE

We report a case of A 39 -year- old female (Gravida 6, para 6) who presented to the emergency department with continuous abdominal pain and with vaginal bleeding, Transvaginal Ultrasound,and positive hCG levels suggested having an ectopic pregnancy that was managed by surgical laparotomy that revealed a twin ectopic pregnancy.

DISCUSSION

By using transvaginal ultrasound and urine/serum beta-human chorionic gonadotropin (bHCG) tests, early ectopic pregnancy identification has improved, reducing related morbidity and death. In our case, a gestational sac was detected during a vaginal ultrasound and the high level of bHCG (63,000) suggested an ectopic pregnancy. Surgical management was chosen because the pregnant sac was on the verge of bursting.

CONCLUSION

This case serves as a reminder of the importance of considering the potential for having twin ectopic pregnancies.

Establishment of the fetal-maternal interface: developmental events in human implantation and placentation

Early pregnancy is a complex and well-orchestrated differentiation process that involves all the cellular elements of the fetal-maternal interface. Aberrant trophoblast-decidual interactions can lead to miscarriage and disorders that occur later in pregnancy, including preeclampsia, intrauterine fetal growth restriction, and preterm labor. A great deal of research on the regulation of implantation and placentation has been performed in a wide range of species. However, there is significant species variation regarding trophoblast differentiation as well as decidual-specific gene expression and regulation. Most of the relevant information has been obtained from studies using mouse models. A comprehensive understanding of the physiology and pathology of human implantation and placentation has only recently been obtained because of emerging advanced technologies. With the derivation of human trophoblast stem cells, 3D-organoid cultures, and single-cell analyses of differentiated cells, cell type-specific transcript profiles and functions were generated, and each exhibited a unique signature. Additionally, through integrative transcriptomic information, researchers can uncover the cellular dysfunction of embryonic and placental cells in peri-implantation embryos and the early pathological placenta. In fact, the clinical utility of fetal-maternal cellular trafficking has been applied for the noninvasive prenatal diagnosis of aneuploidies and the prediction of pregnancy complications. Furthermore, recent studies have proposed a viable path toward the development of therapeutic strategies targeting placenta-enriched molecules for placental dysfunction and diseases.

Successful Ultrasound-Guided Methotrexate Intervention in the Treatment of Heterotopic Interstitial Pregnancy: A Case Report and Literature Review

PURPOSE

This study aims to share the experience of minimally invasive ultrasound-guided methotrexate intervention in the treatment of heterotopic interstitial pregnancy (HIP) with good pregnancy outcomes, and to review the treatment, pregnancy outcomes, and impact on the future fertility of HIP patients.

METHODS

The paper describes the medical history, clinical manifestations, treatment history, and clinical prognosis of a 31-year-old woman with HIP, and reviews cases of HIP from 1992 to 2021 published in the PubMed database.

RESULTS

The patient was diagnosed with HIP by transvaginal ultrasound (TVUS) at 8 weeks after assisted reproductive technology. The interstitial gestational sac was inactivated by ultrasound-guided methotrexate injection. The intrauterine pregnancy was successfully delivered at 38 weeks of gestation. Twenty-five HIP cases in 24 studies published on PubMed from 1992 to 2021 were reviewed. Combined with our case, there were 26 cases in total. According to these studies, 84.6% (22/26) of these cases were conceived by in vitro fertilization embryo transfer, 57.7% (15/26) had tubal disorders, and 23.1% (6/26) had a history of ectopic pregnancy; 53.8% (14/26) of the patients presented with abdominal pain and 19.2% (5/26) had vaginal bleeding. All cases were confirmed by TVUS. In total, 76.9% (20/26) of intrauterine pregnancies had a good prognosis (surgery vs. ultrasound interventional therapy 1:1). All fetuses were born without abnormalities.

CONCLUSIONS

The diagnosis and treatment of HIP remain challenging. Diagnosis mainly relies on TVUS. Interventional ultrasound therapy and surgery are equally safe and effective. Early treatment of concomitant heterotopic pregnancy is associated with high survival of the intrauterine pregnancy.