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American Family Physician May 2020Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. In the United States, the estimated prevalence of ectopic pregnancy is 1% to 2%,... (Review)
Review
Ectopic pregnancy occurs when a fertilized ovum implants outside of the uterine cavity. In the United States, the estimated prevalence of ectopic pregnancy is 1% to 2%, and ruptured ectopic pregnancy accounts for 2.7% of pregnancy-related deaths. Risk factors include a history of pelvic inflammatory disease, cigarette smoking, fallopian tube surgery, previous ectopic pregnancy, and infertility. Ectopic pregnancy should be considered in any patient presenting early in pregnancy with vaginal bleeding or lower abdominal pain in whom intrauterine pregnancy has not yet been established. The definitive diagnosis of ectopic pregnancy can be made with ultrasound visualization of a yolk sac and/or embryo in the adnexa. However, most ectopic pregnancies do not reach this stage. More often, patient symptoms combined with serial ultrasonography and trends in beta human chorionic gonadotropin levels are used to make the diagnosis. Pregnancy of unknown location refers to a transient state in which a pregnancy test is positive but ultrasonography shows neither intrauterine nor ectopic pregnancy. Serial beta human chorionic gonadotropin levels, serial ultrasonography, and, at times, uterine aspiration can be used to arrive at a definitive diagnosis. Treatment of diagnosed ectopic pregnancy includes medical management with intramuscular methotrexate, surgical management via salpingostomy or salpingectomy, and, in rare cases, expectant management. A patient with diagnosed ectopic pregnancy should be immediately transferred for surgery if she has peritoneal signs or hemodynamic instability, if the initial beta human chorionic gonadotropin level is high, if fetal cardiac activity is detected outside of the uterus on ultrasonography, or if there is a contraindication to medical management.
Topics: Chorionic Gonadotropin, beta Subunit, Human; Diagnosis, Differential; Female; Humans; Methotrexate; Pregnancy; Pregnancy, Ectopic; Risk Factors; Salpingostomy; Ultrasonography, Prenatal
PubMed: 32412215
DOI: No ID Found -
Women's Health (London, England) 2023Ectopic pregnancies are the leading cause of maternal mortality in the first trimester, with an incidence of 5%-10% of all pregnancy-related deaths. Diagnosis of ectopic... (Review)
Review
Ectopic pregnancies are the leading cause of maternal mortality in the first trimester, with an incidence of 5%-10% of all pregnancy-related deaths. Diagnosis of ectopic pregnancies is difficult due to clinical mimics and non-specific symptoms of abdominal pain and vaginal bleeding. The current standard for ectopic pregnancy diagnosis includes ultrasound imaging and β-human chorionic gonadotropin (β-hCG) monitoring. In addition to β-hCG, serum markers are being explored as a potential for diagnosis, with activin-AB and pregnancy-associated plasma protein A specifically showing promise. Other diagnostic methods include endometrial sampling, with dilation and curettage showing the highest specificity; however, frozen section reduces the diagnostic timeline which may improve outcomes. Treatment options for confirmed ectopic pregnancies include medical, surgical, and expectant management. Chosen treatment methodology is based on β-hCG levels, hematologic stability, and risk of ectopic pregnancy rupture. Current innovations in ectopic pregnancy management aim to preserve fertility and include laparoscopic partial tubal resection with end-to-end anastomosis and uterine artery embolization with intrauterine infusion of methotrexate. Psychological interventions to improve patient mental health surrounding ectopic pregnancy diagnosis and treatment are also valuable innovations. This literature review aims to bring light to current ectopic pregnancy diagnostics, treatments, and future directions.
Topics: Pregnancy; Female; Humans; Pregnancy, Ectopic; Chorionic Gonadotropin, beta Subunit, Human; Methotrexate; Ultrasonography; Laparoscopy
PubMed: 36999281
DOI: 10.1177/17455057231160349 -
Ugeskrift For Laeger Apr 2020This review summarises the knowledge of abdominal ectopic pregnancy (AEP), which is a rare condition with higher morbidity and mortalilty than other types of ectopic... (Review)
Review
This review summarises the knowledge of abdominal ectopic pregnancy (AEP), which is a rare condition with higher morbidity and mortalilty than other types of ectopic pregnancies. The condition can be primary, if the pregnancy implants directly on to an abdominal site, or it can be secondary after a tubar abortion. AEP differs from tubal pregnancies by a normal level of human chorionic gonadotropin and rare vaginal bleeding, which causes a diagnostic delay. In an early pregnancy the treatment is laparoscopic removal, but in second and third trimester pregnancies laparotomy is preferred, if possible preceded by MRI for mapping of vascular involvement and location of placenta.
Topics: Abortion, Induced; Chorionic Gonadotropin; Delayed Diagnosis; Female; Humans; Pregnancy; Pregnancy, Ectopic; Pregnancy, Tubal
PubMed: 32286219
DOI: No ID Found -
Australian Family Physician May 2016Twenty to forty per cent of pregnant women will experience bleeding during the first trimester. Initial presentation is usually to the general practitioner.... (Review)
Review
BACKGROUND
Twenty to forty per cent of pregnant women will experience bleeding during the first trimester. Initial presentation is usually to the general practitioner. Complications of miscarriage, including threatened miscarriage and ectopic pregnancy, are the most common diagnoses. The failure to diagnose an ectopic pregnancy may have life-threatening consequences for a woman.
OBJECTIVE
The aim of this article is to review the history, examination findings, investigations and management options for miscarriage and ectopic pregnancy.
DISCUSSION
Early pregnancy bleeding is a very distressing symptom for which a woman seeks reassurance that she has an ongoing pregnancy. It is not always possible to make a diagnosis at the first presentation. In some cases, the need for follow-up investigations or referral to a gynaecologist is required. As healthcare providers, we should continue to review and update our knowledge in the management of this common presentation in order to optimise our care of these patients.
Topics: Abortion, Spontaneous; Female; Humans; Pregnancy; Pregnancy Complications; Pregnancy Trimester, First; Pregnancy, Ectopic; Ultrasonography, Prenatal; Uterine Hemorrhage
PubMed: 27166462
DOI: No ID Found -
Fertility and Sterility Jul 2019To provide information on the birth outcomes of future intrauterine pregnancies in women whose first pregnancy was ectopic.
OBJECTIVE
To provide information on the birth outcomes of future intrauterine pregnancies in women whose first pregnancy was ectopic.
DESIGN
Population-based longitudinal cohort study.
SETTING
All hospitals in Quebec, Canada, 1989-2013.
PATIENT(S)
Group surgically treated for an ectopic first pregnancy: 15,823 women; comparison group with an intrauterine first pregnancy: 1,101,748 women.
INTERVENTION(S)
Not applicable.
MAIN OUTCOME MEASURE(S)
Repeat ectopic pregnancy, future delivery of a live infant, stillbirth, cesarean delivery, preterm birth, low birth weight, preeclampsia, gestational diabetes, and postpartum hemorrhage as well as other outcomes of pregnancy.
RESULT(S)
The overall prevalence of ectopic first pregnancy was 14.2 per 1,000 women, of whom 10% of women with an ectopic first pregnancy had a future ectopic. Regardless of age, women with ectopic first pregnancies had an increased risk of adverse birth outcomes at future intrauterine pregnancies, including 1.27 times the risk of preterm birth (95% confidence interval [CI], 1.18-1.37), 1.20 times the risk of low birth weight (95% CI, 1.10-1.31), 1.21 times the risk of placental abruption (95% CI, 1.04-1.41), and 1.45 times the risk of placenta previa (95% CI, 1.10-1.91). Older women with a prior ectopic pregnancy had particularly elevated risks of placental abruption (risk ratio 1.42; 95% CI, 1.16-1.69).
CONCLUSION(S)
Women with ectopic first pregnancies have an increased risk of adverse birth outcomes during subsequent intrauterine pregnancies. These women may benefit from closer clinical management in pregnancy to prevent adverse birth outcomes.
Topics: Adult; Cesarean Section; Female; Fertility; Humans; Live Birth; Longitudinal Studies; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Pregnancy, Ectopic; Prevalence; Quebec; Registries; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Young Adult
PubMed: 31056305
DOI: 10.1016/j.fertnstert.2019.03.019 -
International Journal of Environmental... Oct 2022Ectopic pregnancy, that is, a blastocyst occurring outside the endometrial cavity of the uterus, affects nearly 2% of pregnancies. The treatment of ectopic pregnancy is... (Review)
Review
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.
Topics: Pregnancy; Female; Humans; Abortifacient Agents, Nonsteroidal; Methotrexate; Pregnancy, Ectopic; Treatment Outcome; Ethanol; Retrospective Studies
PubMed: 36361110
DOI: 10.3390/ijerph192114230 -
Obstetrics and Gynecology May 2023To establish a new cesarean scar ectopic pregnancy clinical classification system with recommended individual surgical strategy and to evaluate its clinical efficacy in...
OBJECTIVE
To establish a new cesarean scar ectopic pregnancy clinical classification system with recommended individual surgical strategy and to evaluate its clinical efficacy in treatment of cesarean scar ectopic pregnancy.
METHODS
This retrospective cohort study included patients with cesarean scar ectopic pregnancy in Qilu Hospital in Shandong, China. From 2008 to 2015, patients with cesarean scar ectopic pregnancy were included to determine risk factors for intraoperative hemorrhage during cesarean scar ectopic pregnancy treatment. Univariable analysis and multivariable logistic regression analyses were used to explore the independent risk factors for hemorrhage (300 mL or greater) during a cesarean scar ectopic pregnancy surgical procedure. The model was internally validated with a separate cohort. Receiver operating characteristic curve methodology was used to identify optimal thresholds for the identified risk factors to further classify cesarean scar ectopic pregnancy risk, and the recommended operative treatment was established for each classification group by expert consensus. A final cohort of patients from 2014 to 2022 were classified according to the new classification system, and the recommended surgical procedure and clinical outcomes were abstracted from the medical record.
RESULTS
Overall, 955 patients with first-trimester cesarean scar ectopic pregnancy were included; 273 were used to develop a model to predict intraoperative hemorrhage with cesarean scar ectopic pregnancy, and 118 served as an internal validation group for the model. Anterior myometrium thickness at the scar (adjusted odds ratio [aOR] 0.51, 95% CI 0.36-0.73) and average diameter of the gestational sac or mass (aOR 1.10, 95% CI 1.07-1.14) were independent risk factors for intraoperative hemorrhage of cesarean scar ectopic pregnancy. Five clinical classifications of cesarean scar ectopic pregnancy were established on the basis of the thickness and gestational sac diameter, and the optimal surgical option for each type was recommended by clinical experts. When the classification system was applied to a separate cohort of 564 patients with cesarean scar ectopic pregnancy, the overall success rate of recommended first-line treatment with the new classification grouping was 97.5% (550/564). No patients needed to undergo hysterectomy. Eighty-five percent of patients had a negative serum β-hCG level within 3 weeks after the surgical procedure; 95.2% of patients resumed their menstrual cycles within 8 weeks.
CONCLUSION
Anterior myometrium thickness at the scar and the diameter of the gestational sac were confirmed to be independent risk factors for intraoperative hemorrhage during cesarean scar ectopic pregnancy treatment. A new clinical classification system based on these factors with recommended surgical strategy resulted in high treatment success rates with minimal complications.
Topics: Pregnancy; Female; Humans; Retrospective Studies; Cicatrix; Cesarean Section; Pregnancy, Ectopic; Pregnancy Trimester, First; Blood Loss, Surgical
PubMed: 37023450
DOI: 10.1097/AOG.0000000000005113 -
Reproductive Biology and Endocrinology... Jun 2021The aim of this study was to investigate characteristics associated with ectopic pregnancy (EP) that could be utilized for predicting morbidity or mortality.
PURPOSE
The aim of this study was to investigate characteristics associated with ectopic pregnancy (EP) that could be utilized for predicting morbidity or mortality.
METHODS
This was a retrospective analysis of pregnancy-related records from a tertiary center over a period of ten years. Data on age, gravidity, parity, EP risk, amenorrhea duration, abdominal pain presence and location, β-human chorionic gonadotropin (β-HCG) level, ultrasound findings, therapeutic intervention, exact EP implantation site and length of hospital stay (LOS) were obtained from the database. The LOS was used as a proxy for morbidity and was tested for an association with all variables. All statistical analyses were conducted with Stata® (ver. 16.1, Texas, USA).
RESULTS
The incidence of EP in a cohort of 30,247 pregnancies over a ten-year period was 1.05%. Patients presented with lower abdominal pain in 87.9% of cases, and the likelihood of experiencing pain was tenfold higher if fluid was detectable in the pouch of Douglas. Only 5.1% of patients had a detectable embryonic heartbeat, and 18.15% had one or more risk factors for EP. While most EPs were tubal, 2% were ovarian. The LOS was 1.9 days, and laparoscopic intervention was the main management procedure. The cohort included one genetically proven dizygotic heterotopic pregnancy (incidence, 3.3 × 10) that was diagnosed in the 7th gestational week. The only association found was between the β-HCG level and LOS, with a linear regression β coefficient of 0.01 and a P-value of 0.04.
CONCLUSION
EP is a relatively common condition affecting approximately 1% of all pregnancies. β-HCG correlates with EP-related morbidity, but the overall morbidity rate of EP is low regardless of the implantation site. Laparoscopic surgery is an effective therapeutic procedure that is safe for managing EP, even in cases of heterotopic pregnancy.
Topics: Abdominal Pain; Abortifacient Agents, Nonsteroidal; Adult; Cesarean Section; Chorionic Gonadotropin, beta Subunit, Human; Douglas' Pouch; Female; Humans; Incidence; Intrauterine Devices; Laparoscopy; Length of Stay; Methotrexate; Middle Aged; Pregnancy; Pregnancy, Ectopic; Pregnancy, Heterotopic; Pregnancy, Ovarian; Pregnancy, Tubal; Reproductive Techniques, Assisted; Retrospective Studies; Risk Factors; Salpingectomy; Salpingostomy; Smoking; Young Adult
PubMed: 34059064
DOI: 10.1186/s12958-021-00761-w -
Lancet (London, England) Feb 2023Tubal ectopic pregnancies can cause substantial morbidity or even death. Current treatment is with methotrexate or surgery. Methotrexate treatment fails in approximately... (Randomized Controlled Trial)
Randomized Controlled Trial
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/m) 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.
Topics: Pregnancy; Female; Humans; Methotrexate; Gefitinib; Pregnancy, Ectopic; Proportional Hazards Models; Double-Blind Method
PubMed: 36738759
DOI: 10.1016/S0140-6736(22)02478-3 -
BJOG : An International Journal of... Jan 2019There is no international consensus on how to manage women with a pregnancy of unknown location (PUL). (Meta-Analysis)
Meta-Analysis
BACKGROUND
There is no international consensus on how to manage women with a pregnancy of unknown location (PUL).
OBJECTIVES
To present a systematic quantitative review summarising the evidence related to management protocols for PUL.
SEARCH STRATEGY
MEDLINE, COCHRANE and DARE databases were searched from 1 January 1984 to 31 January 2017. The primary outcome was accurate risk prediction of women initially diagnosed with a PUL having an ectopic pregnancy (high risk) as opposed to either a failed PUL or intrauterine pregnancy (low risk).
SELECTION CRITERIA
All studies written in the English language, which were not case reports or series that assessed women classified as having a PUL at initial ultrasound.
DATA COLLECTION AND ANALYSIS
Forty-three studies were included. QUADAS-2 criteria were used to assess the risk of bias. We used a novel, linear mixed-effects model and constructed summary receiver operating characteristic curves for the thresholds of interest.
MAIN RESULTS
There was a high risk of differential verification bias in most studies. Meta-analyses of accuracy were performed on (i) single human chorionic gonadotrophin (hCG) cut-off levels, (ii) hCG ratio (hCG at 48 hours/initial hCG), (iii) single progesterone cut-off levels and (iv) the 'M4 model' (a logistic regression model based on the initial hCG and hCG ratio). For predicting an ectopic pregnancy, the areas under the curves (95% CI) for these four management protocols were as follows: (i) 0.42 (0.00-0.99), (ii) 0.69 (0.57-0.78), (iii) 0.69 (0.54-0.81) and (iv) 0.87 (0.83-0.91), respectively.
CONCLUSIONS
The M4 model was the best available method for predicting a final outcome of ectopic pregnancy. Developing and validating risk prediction models may optimise the management of PUL.
TWEETABLE ABSTRACT
Pregnancy of unknown location meta-analysis: M4 model has best test performance to predict ectopic pregnancy.
Topics: Chorionic Gonadotropin; Decision Support Techniques; Female; Humans; Logistic Models; Pregnancy; Pregnancy, Ectopic; Progesterone; ROC Curve; Risk Assessment; Sensitivity and Specificity
PubMed: 30129999
DOI: 10.1111/1471-0528.15442