Undisturbed tubal pregnancies with positive fetal heart treated medically: Case study.

The incidence of ectopic pregnancy (EP) is 1.3-2.4%. Suspicion of EP starts after a positive serum pregnancy test and failure to visualize the intrauterine gestational sac (GS) by transvaginal sonography (TVS). About 88% of tubal EPs are diagnosed by absent intrauterine GS and the presence of an adnexal mass during TVS. Medical treatment of EP using methotrexate (MTX) is cost-effective with a similar success rate to surgical treatment. The presence of fetal heart beats, ß-human chorionic gonadotropin >5000 mIU/mL, and EP size >4 cm are relative contraindications for using MTX in the treatment of EP.

Non-surgical management of tubal ectopic pregnancy: A systematic review and meta-analysis.

BACKGROUND: Ectopic pregnancy (EP) is a common cause of acute abdominal pain in the field of gynecology. Because the majority of women with EP are hemodynamically stable, non-surgical therapy is a viable option. The goal of this study was to determine the most effective non-surgical therapy for hemodynamically stable EP. METHODS: We performed a systematic review and meta-analysis. We searched PubMed, LILACS, SciELO, CINAHL, Embase, and the Cochrane library in May 2020, with no starting date restrictions.Studies were restricted to randomized controlled trials, which were included if the target population contained women with tubal EP and the intervention was non-surgical management. The primary outcome measure was treatment success defined by a decrease in serum hCG to a level ranging from five mIU/mL to 50 mIU/mL. Secondary outcome measures were side effects, time needed to treat, number of injections and operative rate. RESULTS: We conducted a meta-analysis of 15 studies that included 1573 women who were diagnosed with EP and managed non-surgically. There was no significant difference in treatment success in the matched groups; however, single-dose MTX was associated with fewer side effects than multiple-dose (relative risk 0.48, 95% confidence interval 0.28-0.80, P = .006) and two-dose therapies (relative risk 0.74, 95% confidence interval 0.55-1.00, P = .05). CONCLUSIONS: We highly recommend that single-dose MTX without mifepristone be used first-line in patients who require conservative therapy due to the inherent negative effects of mifepristone. An EP woman with a low -hCG level that is falling or plateauing should receive expectant treatment to reduce adverse effects.

Ectopic pregnancy: a single-center experience over ten years.

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, ß-human chorionic gonadotropin (ß-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- 5) that was diagnosed in the 7th gestational week. The only association found was between the ß-HCG level and LOS, with a linear regression ß coefficient of 0.01 and a P-value of 0.04. CONCLUSION: EP is a relatively common condition affecting approximately 1% of all pregnancies. ß-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.

Increase rate of ruptured tubal ectopic pregnancy during the COVID-19 pandemic.

OBJECTIVE: During the 2020 COVID-19 pandemic there was a decrease in emergency room arrivals. There is limited evidence about the effect of this change in behavior on women's health. We aimed to evaluate the impact of the COVID-19 pandemic on the diagnosis, treatment and complications of women presenting with a tubal Ectopic Pregnancy (EP). STUDY DESIGN: This is a single centre retrospective cohort study. We compared the clinical presentation, treatment modalities and complications of all women presenting in our institution with a tubal EP during the COVID-19 pandemic between 15 March and 15 June 2020, with women who were treated in our institution with the same diagnosis in the corresponding period for the years 2018-2019. RESULTS: The study group included 19 cases of EP (N = 19) that were treated between the 15 March 2020 and 15 June 2020. The control group included 30 cases of EP (N = 30) that were admitted to in the corresponding period during 2018 and 2019. Maternal age, parity, gravity and mode of conception (natural vs. assisted) were similar between the two groups. There was no difference in the mean gestational age (GA) according to the last menstrual period. In the study group more women presented with sonographic evaluation of high fluid volume in the abdomen than in the control group (53 % vs 17 %, P value 0.01). This finding is correlated with a more advanced disease status. In the study group there was a highly statistically significant 3-fold increase in rupture among cases (P < 0.005) and a 4-fold larger volume of blood in the entrance to the abdomen (P < 0.002). We found that there were no cases of ruptured EP in the group of women who were pregnant after assisted reproduction. CONCLUSION: We found a higher rate of ruptured ectopic pregnancies in our institution during the COVID-19 pandemic. Health care providers should be alerted to this collateral damage in the non-infected population during the COVID-19 pandemic.

From ß-hCG values to counseling in tubal pregnancy: what do women want?

Tubal pregnancy represents an entity that every gynecologist will encounter during professional life. Because of the high prevalence among the pregnant population, standardized protocols are needed in order to choose the optimal strategy for each case. Accurate ultrasound pictures are supporting a more precise diagnosis of ectopic tubal pregnancy, the evolution of which should be closely monitored in follow-up with serial ß-hCG values. Laparoscopy, intramuscular methotrexate, and active expectant management are all involved, however, tailoring the best treatment to the patient's needs is the challenge to focus on. This manuscript describes how in routinary practice an evidence-based diagnostic process should be the key factor to go for the best possible management. When possible, a longsighted less invasive approach should be preferred, aiming to preserve the patient's fertility for years to come. An optimal choice of the management should involve the patient or the couple in the decision-making process to reach the ultimate goal of compliance.

The Effect of Preoperative Neutrophil-To-Lymphocyte Ratio and Platelet-To-Lymphocyte Ratio on Predicting Rupture Risk in Tubal Ectopic Pregnancies.

BACKGROUND: Consecutive measurements of ß-hCG levels and sonographic evaluation of adnexae are critical for choosing the optimal management in ampullar tubal ectopic pregnancies (EP). To select suitable patients for conservative approach, there is a need for an affordable and reliable marker for determining rupture risk. Evaluation of systemic inflammatory markers in combination with serum ß-hCG levels and ultrasound might help to decide the appropriate treatment option. OBJECTIVE: The purpose of the present study was to evaluate the diagnostic value of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in determining the rupture risk in ampullar tubal EPs and to compare with intraoperative findings. METHODS: A total of 142 patients who underwent surgery for tubal EP were included. Seventy-two patients were in the intraoperatively diagnosed tubal rupture group and 70 patients without rupture findings were included in the control group. Both groups were compared for inflammation markers, ß-hCG levels, and sonographic findings. RESULTS: Both NLR and PLR levels were found to be significantly higher in the tubal rupture group (4.62 ± 3.13 vs. 2.67 ± 1.43, 162.94 ± 63.61 vs. 115.84 ± 41.15, p < 0.01, respectively). According to the receiver operating characteristic analysis performed for the diagnostic performance of tubal diameter measurement, ß-hCG, NLR, and PLR levels were significantly associated with histopathologically confirmed tubal rupture (p < 0.01). CONCLUSION: Systemic inflammatory markers are feasible and affordable tools for predicting tubal rupture risk in ampullar EPs and might be useful for determining surgery decision especially in low resource settings.

Cost-effectiveness analysis of medical management versus conservative surgery for early tubal pregnancy.

STUDY QUESTION: Is conservative surgery (laparoscopic salpingotomy) cost-effective, using fertility as the endpoint compared with medical management (Methotrexate) in women with an early tubal pregnancy? SUMMARY ANSWER: Conservative surgery appeared slightly, but not statistically significantly, more effective than medical management but also more costly. WHAT IS KNOWN ALREADY: Women with an early tubal pregnancy treated with medical therapy (Methotrexate) or conservative surgery (laparoscopic salpingotomy) have comparable future intrauterine pregnancy rates by natural conception. Also, cost-minimisation studies have shown that medical therapy was less expensive than conservative surgery, but there is no cost-effectiveness study comparing these two treatments with fertility as the endpoint. STUDY DESIGN, SIZE, DURATION: A multicentre randomised controlled trial-based (DEMETER study) cost-effectiveness analysis of conservative surgery compared with medical therapy in women with an early tubal pregnancy was performed. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Included women had an ultrasound that confirmed an early tubal pregnancy. They were randomly allocated to conservative surgery or to medical therapy. The study clinical outcome was the intrauterine pregnancy rate. The payer's perspective was considered. Costs of conservative surgery and medical therapy were compared. The analysis was performed according to the intention-to-treat principle. Missing variables were imputed using the fully conditional method. To characterise uncertainty and to provide a summary of it, a non-parametric bootstrap resampling was executed and cost-effectiveness accessibility curves were constructed. MAIN RESULTS AND THE ROLE OF CHANCE: At baseline, costs per woman in the conservative surgery group and in the medical therapy group were 2627€ and 2463€, respectively, with a statistically significant difference of +164€. Conservative surgery resulted in a marginally, but non-significant (P = 0.46), higher future intrauterine pregnancy rate compared to medical therapy (0.700 vs. 0.649); leading, after bootstrap, to an incremental cost-effectiveness ratio of 1299€ (95% CI = -29 252; +29 919). Acceptability curves showed that conservative surgery could be considered a cost-effective treatment at a threshold of 3201€ for one additional future intrauterine pregnancy. LIMITATIONS, REASONS FOR CAUTION: A limitation was that monetary valuation was carried out using 2016 euros while the DEMETER study took place from 2005 to 2009. Anyway, the results would not have been very different given the marginal changes in the health insurance reimbursement tariffs during this period. WIDER IMPLICATIONS OF THE FINDINGS: Conservative surgery can be considered a cost-effective treatment, if the additional cost of 3201€ per additional future intrauterine pregnancy is an acceptable financial effort for the payer. STUDY FUNDING/COMPETING INTEREST(S): None. TRIAL REGISTRATION NUMBER: NCT 00137982.

Unilateral twin tubal pregnancy: a case report and review of the literature.

BACKGROUND: Unilateral twin tubal pregnancy is an extremely rare condition, occurring in 1/20.000-250.000 pregnancies and represents a major health risk for reproductive-aged women, leading to even life-threatening complications. AIM: We present a case of a 31-year-old woman with unilateral twin tubal pregnancy, treated with methotrexate and then surgically because of failure, followed by review of the literature. METHODS: Researches for relevant data were conducted utilizing multiple databases, including PubMed and Ovid. RESULTS: The most common type of twin ectopic pregnancy is the heterotopic (1/7000 pregnancies) in which in which both ectopic and intrauterine pregnancy occur simultaneously. Expectant, medical and surgical therapy have similar success rates in correctly selected patients. Two prospective randomized trials did not identify any statistically significant differences between groups receiving MTX as a single dose or in multiple doses. Among the 106 cases reported in literature, methotrexate was tried just in 4 patients (3 unilateral and 1 bilateral) before ours. Details are reported in the table 1. CONCLUSION: The recent shift in the treatment of singleton ectopic pregnancies to the less invasive medical therapy might apply even in the case of twin implants.

ACOG Practice Bulletin No. 193 Summary: Tubal Ectopic Pregnancy.

Ectopic pregnancy is defined as a pregnancy that occurs outside of the uterine cavity. The most common site of ectopic pregnancy is the fallopian tube. Most cases of tubal ectopic pregnancy that are detected early can be treated successfully either with minimally invasive surgery or with medical management using methotrexate. However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention. The purpose of this document is to review information on the current understanding of tubal ectopic pregnancy and to provide guidelines for timely diagnosis and management that are consistent with the best available scientific evidence.

ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy.

Ectopic pregnancy is defined as a pregnancy that occurs outside of the uterine cavity. The most common site of ectopic pregnancy is the fallopian tube. Most cases of tubal ectopic pregnancy that are detected early can be treated successfully either with minimally invasive surgery or with medical management using methotrexate. However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention. The purpose of this document is to review information on the current understanding of tubal ectopic pregnancy and to provide guidelines for timely diagnosis and management that are consistent with the best available scientific evidence.

ACOG Practice Bulletin No. 191 Summary: Tubal Ectopic Pregnancy.

Ectopic pregnancy is defined as a pregnancy that occurs outside of the uterine cavity. The most common site of ectopic pregnancy is the fallopian tube. Most cases of tubal ectopic pregnancy that are detected early can be treated successfully either with minimally invasive surgery or with medical management using methotrexate. However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention. The purpose of this document is to review information on the current understanding of tubal ectopic pregnancy and to provide guidelines for timely diagnosis and management that are consistent with the best available scientific evidence.

ACOG Practice Bulletin No. 191: Tubal Ectopic Pregnancy.

Ectopic pregnancy is defined as a pregnancy that occurs outside of the uterine cavity. The most common site of ectopic pregnancy is the fallopian tube. Most cases of tubal ectopic pregnancy that are detected early can be treated successfully either with minimally invasive surgery or with medical management using methotrexate. However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention. The purpose of this document is to review information on the current understanding of tubal ectopic pregnancy and to provide guidelines for timely diagnosis and management that are consistent with the best available scientific evidence.

Complete Tubal Abortion: A Rare Form of Ectopic Pregnancy.

Tubal abortion is characterized by the extrusion of an ectopic product of conception implanted in the fallopian tube through the abdominal ostium into the peritoneal cavity. It can be either complete or incomplete and may lead to severe bleeding. Recognition of a complete tubal abortion may be challenging but is essential because it allows conservative management which make possible preservation of tubal function and fertility without the need for further cytostatic therapy. A case of a 30 years-old woman admitted for lower abdominal pain is reported.The level of hCG was 659.2 mU/mL and transvaginal ultrasound reveled a fluid collection in the pouch of Douglas. Laparoscopy was subsequently performed for the suspicion of ectopic pregnancy with hemoperitoneum. Corroborating the hCG dynamics with the laparoscopic findings, the diagnosis of complete tubal abortion was established. The histopathological examination confirmed the presence of intermediate trophoblastic cells in the tissue collected during laparoscopy. Ultrasound examination helps recognition of hemoperitoneum but adds little value to the diagnosis of tubal abortion. Laparoscopic findings alone are only suggestive for complete tubal abortion but in combination with hCG dynamics, the diagnosis can be established. Conservative management might be sufficient in complete tubal abortion and ensures preservation of tubal function and fertility.

Individualisation of intervention for tubal ectopic pregnancy: historical perspectives and the modern evidence based management of ectopic pregnancy.

Historically, ectopic pregnancy was a life-threatening condition where diagnosis was possible only at post mortem or laparotomy and maternal mortality was up to 90%. The evolution in the management of ectopic pregnancy has meant that diagnosis can be made using non-invasive techniques with an aim to identify the ectopic gestation before tubal rupture. This enables health care professionals to offer management options that consider not only maternal mortality, but morbidity and fertility outcomes as well. In spite of this, diagnostic techniques and management options are not without limitations. Research is currently focused on new tests with a single diagnostic capability, diagnostic and treatment algorithms and safe methods of triaging patients. This article aims to review the current literature on the diagnosis and management of ectopic pregnancy and to formulate a pathway to help individualise care and achieve the best possible outcome.

Non-operative treatment of ruptured ectopic pregnancy.

Ruptured ectopic pregnancy often causes abdominal pain, vaginal bleeding and internal haemorrhage; it is a very serious condition and can be life-threatening. Patients with a ruptured ectopic pregnancy are normally treated by surgical intervention. We describe a case of a 20-year-old woman who presented with abdominal pain and vaginal bleeding. Urine human chorionic gonadotropin was positive and on examination she had localised tenderness of the abdomen. Transvaginal ultrasonography revealed a ruptured tubal pregnancy along with blood in the abdomen. The patient was closely monitored and treated conservatively, with a successful outcome. She recovered uneventfully. Our case shows that non-operative treatment of a ruptured ectopic pregnancy may be a possible non-invasive treatment option in highly selected patients.

Tubal ectopic pregnancy: our experience from 2000 to 2013.

In this paper we summarize our experience in diagnosis and treatment of 402 retrospectively collected tubal EP and review the most recent topics from the literature. Systemic Methotrexate (MTX) was effective in 56 out of 65 patients (failure rate 13.8%), in whom hCG level was significantly lower when compared to the failure group (p<0,05); we performed 299 salpingectomies, 297 of whom through laparoscopic approach. MTX single-dose is safe and effective in eligible patients; surgery represents the treatment of most of the EPs, mainly through laparoscopic approach.

Tubal rupture in ectopic pregnancy: is it predictable?

AIM: Ectopic pregnancies account for 10-15% of all maternal deaths. Rupture of an ectopic pregnancy is an urgent medical situation, therefore prediction of any tubal rupture before its occurrence is extremely important. The aim of this study was to evaluate the tubal rupture rate in different treatment modalities in EP cases and to find a hCG level on admission and/or size of ectopic mass predictive for tubal rupture. METHODS: Demographic data and medical data were extracted from patient charts for 211 cases who had diagnosis of tubal ectopic pregnancy. Women with tubal rupture were compared to those without rupture. RESULTS: Expectant management, single dose methotrexate and primary surgical treatment were applied to 83 cases (39%), 93 cases (44%) and 35 cases (17%), respectively. The tubal rupture occurred in 14.7% of the study population. If the EP mass diameter is <2 cm, no tubal rupture was found. hCG values at admission were found to be predictive for rupture. On admission, hCG level of 1855 IU/L had 93.5%, sensitivity and 29% positive predictive value for tubal rupture. CONCLUSION: In tubal ectopic pregnancy cases, hCG level on admission and size of ectopic pregnancy mass can predict tubal rupture.

Management and outcome of 25 heterotopic pregnancies in Zhejiang, China.

OBJECTIVE: To characterize general attributes of women with heterotopic pregnancy (HP) in order to establish an optimal management regimen. STUDY DESIGN: A retrospective analysis was conducted on 25 HPs recorded at the Women's Hospital of Zhejiang University between 2007 and 2011. Data on patients' symptoms, risk factors, diagnostic features, treatment and outcome were collected and analysed. RESULTS: All patients had conceived via assisted reproductive technology (ART), 72% had a history of pelvic inflammatory disease and 68% of patients were symptomatic. Fifty-six percent of patients were diagnosed with HP via routine transvaginal ultrasound examination at approximately 6-7 weeks of gestation. Eighty percent of patients underwent surgical treatment (35% laparoscopic salpingectomy, 65% laparotomy), and 20% of patients underwent medical treatment with local injection of methotrexate (MTX) or MTX in combination with potassium chloride (KCl) into ectopic sites such as the cervix or interstitium. Eighty-eight percent of patients delivered live infants without congenital anomalies, and three patients (all of whom underwent surgical treatment) miscarried. CONCLUSIONS: Routine transvaginal ultrasound examination at approximately 6-7 weeks of gestation could facilitate the diagnosis of HP, although repeat ultrasound is necessary to avoid misdiagnosis. Prompt diagnosis and correct treatment, including local injection of MTX or MTX in combination with KCl into various ectopic sites, led to favourable prognoses.

Bilateral ectopic pregnancy following ICSI.

Bilateral tubal ectopic pregnancy is a rare clinical condition with an estimated prevalence of 1/200,000 spontaneous pregnancies. There is paucity of data on the prevalence of this rare condition following intracytoplasmic sperm injection and embryo transfer (ICSI-ET) cycles. We report two patients with bilateral tubal ectopic pregnancy following ICSI-ET. Both patients had normal, reassuring ß-human chorionic gonadotropin dynamics during follow-up; the diagnosis was performed when no gestational sac was noted at the first planned antenatal visit. Of the two patients, one was treated medically and the other surgically with laparoscopic salpingotomy and salpingectomy for the right and left sides, respectively. Both patients thereafter conceived and delivered healthy infants following subsequent ICSI-ET attempts.

Management of severe bleeding in a ruptured extrauterine pregnancy: a theragnostic approach.

Haemoperitoneum due to ruptured extrauterine pregnancy is a complication that may occur in the first trimester of pregnancy, but massive haemorrhage with severe shock is rare. When severe bleeding does occur, timely diagnosis and rapid haemostatic treatment are vital. We present the case of a 37-year-old woman with severe bleeding and shock due to ruptured extrauterine pregnancy.Management of the patient consisted of emergency laparotomy, red blood cell transfusion and targeted haemostatic therapy guided by rotational thromboelastometry using the fibrin-based clotting (FIBTEM) assay, (activation with tissue factor with addition of the platelet inhibitor cytochalasin D). As severe hypofibrinogenaemia was apparent, indicated by a FIBTEM maximum clot firmness (MCF) that was not measurable (i.e. < 2 mm) and a plasma fibrinogen level of 0.17 g/l, the patient was treated with 4 g fibrinogen concentrate. Tranexamic acid (1 g) was also administered.Rapid restoration of haemostasis was indicated by the improvement of thromboelastometric parameters (FIBTEM MCF 16 mm) and, later, laboratory coagulation tests (plasma fibrinogen 2.75 g/l), along with cessation of bleeding. No fresh frozen plasma (FFP) was administered. Surgery was successfully completed, and the patient was subsequently discharged 5 days after admission with no further complications. Haemorrhage in extrauterine pregnancy is commonly managed using autologous blood transfusion (via cell salvage) and homologous plasma transfusion. In this case of severe bleeding and shock due to ruptured extrauterine pregnancy, thromboelastometry-guided administration of fibrinogen concentrate enabled rapid restoration of haemostasis, complete avoidance of FFP transfusion and resulted in a successful outcome.