Initial beta-hCG Level Research Articles

Tubal ectopic pregnancy: comparative management between pre and Covid-19 pandemic periods.

To evaluate whether there were differences in the presentation of patients with tubal ectopic pregnancy (EP) during the first year of the COVID-19 pandemic. We performed a retrospective cohort study of all cases of tubal EP between March 2019 and March 2020 (pre-pandemic) and between March 2020 and March 2021 (pandemic). We compared between these two groups the risk factors, clinical characteristics, laboratory data, sonographic aspects, treatment applied and complications. We had 150 EP diagnoses during the two years studied, of which 135 were tubal EP. Of these, 65 were included in the pre-pandemic and 70 in the pandemic period. The prevalence of lower abdominal pain was significantly higher in the pandemic compared to the pre-pandemic period (91.4% vs. 78.1%, p=0.031). There was no significant difference in shock index, initial beta-hCG level, hemoglobin level at diagnosis, days of menstrual delay, aspect of the adnexal mass, amount of free fluid on ultrasound, and intact or ruptured presentation between the groups. Expectant management was significantly higher during the pandemic period (40.0% vs. 18.5%, p=0.008), surgical management was lower during the pandemic period (47.1% vs. 67.7%, p=0.023), and number of days hospitalized was lower in the pandemic period (1.3 vs. 2.0 days, p=0.003). We did not observe a significant difference in patient history, laboratory and ultrasound characteristics. Abdominal pain was more common during the pandemic period. Regarding treatment, we observed a significant increase in expectant and a decrease in surgical cases during the pandemic period.

Management of uterine ectopic pregnancy - local vs. systemic methotrexate.

The aim of this study was to compare ultrasound-guided local methotrexate (MTX) vs. systemic methotrexate in uterine ectopic pregnancy regarding the beta human chorionic gonadotropin (hCG) clearance duration. Patients with interstitial pregnancy, cervical pregnancy or cesarean scar pregnancy were included. Methotrexate was administered locally ultrasound-guided (25mg methotrexate fixed dose) or systemically (intramuscular; 50mg/m2 body weight). Beta hCG clearance duration in days formed the main outcome measure. Forty-six patients with uterine ectopic pregnancy were included. The mean estimated beta hCG clearance duration was 29.2days longer in patients with local methotrexate compared with systemic methotrexate (64.7 vs. 31.5days, respectively; p=0.026). There was no significant difference between local vs. systemic methotrexate regarding adverse events such as bleeding (p=0.376), pain (p=0.146) or secondary surgery (p=0.631). There was no association of initial beta hCG levels (p=0.746), initial progesterone levels (p=0.870) or patients' age (p=0.604) and the beta hCG clearance duration. No significant difference in beta hCG clearance duration comparing local methotrexate injection with aspiration vs. local methotrexate injection without aspiration could be found (mean 49.4 and 71.6days, respectively, p=0.225). In patients with uterine ectopic pregnancies, the mean estimated beta hCG clearance duration was 29.2days longer when applying local methotrexate compared with systemic methotrexate.

Ectopic pregnancy: when is expectant management safe?

This study was conducted to evaluate expectant management in asymptomatic patients with an initial serum beta-hCG titer of <2,500 IU/l and to determine the independent ability of initial serum beta-hCG titers and trend of serum beta-hCG to predict successful expectant management. A cohort of patients (N = 418) with suspected ectopic pregnancy (EP) between January 1991 and July 2008 is described. Three groups were defined: group I (n = 182), immediate surgical intervention (<24 h); group IIa (n = 130), unsuccessful expectant management (surgical intervention during follow-up), and group IIb (n = 99), successful expectant management (spontaneous regression of trophoblast). Hospital protocol was not complied in 35 cases (Table 1). Beta-hCG levels >3,000 IU/l occur in our expectant management group; however, none of these cases were successful. Unnecessary surgery was prevented in 14% (n = 7) of asymptomatic patients with initial beta-hCG of >2,000 IU/l. The success rate of expectant management was 49%, without a rise in complication rate or number of acute cases. In conclusion, the initial serum beta-hCG cutoff level of 2,000 IU/l is not a rigid upper limit for accepting expectant management in suspected EP and best practice is case specific. In asymptomatic patients, the serum beta-hCG cutoff level of at least 2,500 IU/l can be used for expectant management. This cutoff could be higher, but interpretation is limited due to censure in follow-up inherent to the predefined clinical protocol. There is no gain in including patients for expectant management with initial serum beta-hCG level >3,000 IU/l.

Laparoscopic salpingocentesis using methotrexate in combination with oral mifepristone for successful treatment of interstitial pregnancy: a case report

To report two cases of women who presented with amenorrhea, lower abdominal pain, and vaginal bleeding and who were diagnosed with advanced interstitial pregnancy after initial negative laparoscopies. Case report. Early pregnancy unit of district general hospital. A 39-year-old woman with a history of right salpingectomy for ectopic pregnancy and a 28-year-old woman with a history of miscarriage. Laparoscopic salpingocentesis with methotrexate (50 mg/m(2)) after aspiration of an equivalent amount of amniotic fluid. The remainder, based on the calculated dose, was given intramuscularly. Oral mifepristone (200 mg) was given postoperatively. Complete resolution of interstitial pregnancy in both instances with two subsequent, successful intrauterine pregnancies delivered at term in the second patient. There were no intraoperative or postoperative complications. Expected decline in beta human chorionic gonadotropin (beta-hCG) levels without the need for any further intervention(s). Interstitial pregnancy may be successfully and safely managed by the use of laparoscopic salpingocentesis with methotrexate and mifepristone despite high initial beta-hCG levels.

Laparoscopic cornuotomy in the management of an advanced interstitial ectopic pregnancy: a case report

To report the successful treatment of an advanced interstitial ectopic pregnancy via laparoscopic cornuotomy following treatment failure with methotrexate (MTX). A 28-year-old, gravida 3, para 0 woman with a history of successfully treated tubal pregnancy with medical therapy 2 years ago, presented with spotting bleeding and lower abdominal pain. Her initial beta-hCG level was 11706 mIU/ml and the transvaginal ultrasound examination showed an empty uterine cavity with a gestational sac 8 x 10 x 9 mm in diameter having no fetal pole or yolk sac, located just adjacent to the left uterine cornual region. She was introduced 50 mg of systemic MTX with the presumed diagnosis of interstitial pregnancy. Because the serum beta-hCG level raised to 18654 mIU/ml and a fetal pole with cardiac activity emerged on the ultrasound on the fourth day after MTX injection, laparoscopy was planned. The interstitial pregnancy was successfully treated via laparoscopic cornuotomy with the preservation of the uterus. In advanced interstitial pregnancies with high hCG levels, systemic MTX therapy is expected to be ineffective. Laparoscopic cornuotomy is a minimally invasive and effective method of treatment with the advantage of preserving future fertility.

Transvaginal Ultrasound-Guided Treatment of Cervical Pregnancy

To describe our experience with sonographically guided injection of methotrexate and potassium chloride (KCl) to treat early cervical pregnancy. We prospectively reviewed all cases of cervical pregnancies treated conservatively through transvaginal ultrasound-guided therapy at our institutions. Thirty-eight cases were identified, from 1993 through 2004. All cases were managed with transvaginal intra-amniotic and intrachorionic injection of 50 mg of methotrexate under ultrasound guidance. An additional intracardiac fetal injection of 2 mL KCl was given for those cervical pregnancies with documented cardiac activity. Follow-up sonographic examinations and serum beta-hCG measurements were performed twice weekly for 2 weeks after the procedure, then weekly. The mean initial beta-hCG level was 38,948 milli-International Units/mL and ranged from 5,608 to 103,256 milli-International Units/mL for 22 cases with fetal heart activity and from 2,765 to 18,648 milli-International Units/mL for 16 cases without. Gestational age ranged from 5.4 to 14 weeks (mean 8.8 weeks). All cervical pregnancies were successfully aborted, with an average resolution of the cervical mass in 49 days. Postoperative beta-hCG declined to less than 5 milli-International Units/mL within a mean of 38 days. A mean 4.5-year follow-up showed that, of 21 patients who desired pregnancy, 18 had achieved subsequent successful pregnancies. Cervical pregnancies can be successfully managed without surgical intervention through local injection of methotrexate and KCl. This treatment not only ablates the ectopic pregnancy but also preserves the uterus for subsequent pregnancies.

Unruptured tubal pregnancy: different treatments for early and late diagnosis

There is evidence that ectopic pregnancies present different behavioral patterns. These distinct evolutions of ectopic pregnancies represent two different natural histories. To evaluate these evolution patterns, we compared patients undergoing medical treatment and expectant management according to their gestational age and initial beta-hCG levels. Prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center. Among 119 cases of unruptured ectopic pregnancies diagnosed from April 1999 to February 2004, 57 received systemic treatment with methotrexate 50 mg/m(2) (body surface area) intramuscularly and 62 were managed expectantly. In this study we evaluated the beta-hCG levels at presentation and amenorrhea duration. There was a significant difference between the two groups regarding amenorrhea duration and initial beta-hCG levels (p < 0.001). The group with decreasing beta-hCG levels (managed expectantly) had longer amenorrhea (mean: 8.87 +/- 1.71 weeks) and lower initial beta-hCG levels (mean: 648.8 +/- 754.7 mIU/ml). On the other hand, the group treated with methotrexate had shorter amenorrhea (mean: 6.81 +/- 1.88 weeks) and higher beta-hCG levels at presentation (2642.7 +/- 2315.1 mIU/ml). The data suggest that ectopic pregnancies can be categorized into two groups: those with early diagnosis and shorter amenorrhea, increasing or maintained beta-hCG levels over 24 and 48-hour intervals and higher beta-hCG levels requiring medical treatment; and those with late diagnosis and longer amenorrhea, decreased beta-hCG levels over 24 and 48-hour intervals and lower beta-hCG levels requiring expectant management.

A medical management of interstitial ectopic pregnancy: A 5‐year clinical study

Medical treatment of the rare interstitial ectopic pregnancy with methotrexate has been considered an alternative to surgical resection. To determine the treatment success rate with a single-dose intravenous methotrexate/folinic acid regimen and to identify predictors of treatment outcome. A 5-year audit (April 2000-August 2005) was carried out, collecting clinical imaging data and serum beta-human chorionic gonadotrophin (beta-hCG). Time taken for complete beta-hCG resolution was recorded, and a negative beta-hCG result was used as an endpoint of successful outcome. Of the 13 cases, two required urgent surgery for rupture on presentation. In the remaining 11 cases, intravenous methotrexate (300 mg) was used, with oral folinic acid rescue (15 mg x 4 doses). There were no side-effects. Complete beta-hCG resolution was achieved in 10 of the 11 medically treated cases (91% success rate), requiring 21-129 days. Successful outcome was seen with initial beta-hCG level as high as 106 634 IU/L and gestation sac as large as 6 cm and a live fetus. The methotrexate/folinic acid regimen used as a one-dose treatment is safe and effective for unruptured interstitial pregnancy, with no side-effects and the advantage of avoiding invasive surgery. Subsequent tubal patency and reproductive function are yet to be ascertained.

Predictors of Success of Repeated Injections of Single-dose Methotrexate Regimen for Tubal Ectopic Pregnancy

The purpose of this study is to evaluate predictors of success of repeated injections of methotrexate in the single-dose regimen for the treatment of tubal ectopic pregnancy. All patients who had ectopic tubal pregnancy and were treated with a single dose regimen were retrospectively identified. 126 patients were treated with methotrexate. Among them, 39 patients were adequate for this study. 33 were treated with the 2nd dose and 27 were successfully cured. Additionally, 6 who were injected with the 3rd dose were all cured as well. Therefore, in our study, the success rate for the repeated injections of methotrexate was found to be 84.6% (33/39). The mean initial β-hCG level was significantly lower in patients who were successfully treated than in patients who failed (3915.3±3281.3 vs. 8379.7±2604.4 IU/mL, p<0.05). The success rate is 96% when the β-hCG level is less than 6,000 IU/mL and is 58% when β-hCG is greater than 6,000 IU/mL (OR=18.57, 95% CI 1.86-185.89). The initial β-hCG level is the only factor that has significant meaning as predictor of success of repeated injections of methotrexate in the single-dose regimen. Repeated injections of methotrexate may be particularly effective when the initial β-hCG level is below 6,000 IU/mL.

Non‐surgical management of live ectopic pregnancy with ultrasound‐guided local injection: a case series

To describe a series of consecutive cases of live ectopic pregnancies managed with ultrasound-guided local injection of methotrexate (MTX) or potassium chloride (KCl). Eighteen consecutive women with live and unruptured, tubal, cornual or cervical ectopic pregnancies referred to our unit for evaluation and management underwent risk-benefit counseling. Under transvaginal ultrasound guidance, puncture and injection of the ectopic pregnancy was performed using an automated puncture device. Either MTX or KCl was injected, producing immediate cessation of fetal cardiac activity. Of the 18 ectopic pregnancies, 10 were cervical, four were tubal and four were cornual. The mean initial beta-hCG level was 33 412 IU and the mean gestational age was 6 + 6 weeks. Ten ectopic gestational sacs were injected with KCl and eight were injected with MTX. There was no difference in time to resolution of the ectopic pregnancies between those injected with KCl and those with MTX. Unruptured live ectopic pregnancies of many types can be successfully managed without surgical intervention through local injection of KCl or MTX.

The predictive value of an initial serum beta human chorionic gonadotropin level for pregnancy outcome following in vitro fertilization.

Our purpose was to assess the predictive value for pregnancy outcome of an initial serum quantitative beta-hCG measurement obtained 11 or 12 days after embryo transfer in an in vitro fertilization program. A prospective, descriptive study of 153 pregnancies achieved via in vitro fertilization-embryo transfer was performed. Initial beta-hCG levels and subsequent pregnancy outcomes were compared. The overall mean initial beta-hCG level was 91 +/- 85.8 mIU/ml for normal (singleton, multiple-gestation) pregnancies and 29 +/- 24.9 mIU/ml for abnormal (miscarriage, ectopic) pregnancies (P < 0.01; power, > 80%). While 93.9% of patients with initial beta-hCG levels > or = 42 mIU/ml had normal pregnancies, 56.4% of those with initial levels < 42 mIU/ml experienced abnormal outcomes. With 42 mIU/ml as the cutoff level for predicting a normal pregnancy, this screening test yielded a sensitivity of 79.3% and a specificity of 83.8%. Initial serum beta-hCG levels obtained 11 or 12 days after embryo transfer may be predictive of pregnancy outcome in an in vitro fertilization program.

Combined chemotherapy in the medical management of tubal pregnancy.

The medical management of early unruptured tubal ectopic pregnancies is gaining acceptance internationally as an alternative to surgical procedures. This method has been shown to be effective and safe in properly selected cases and with adequate supervision. Most of the work however has been done using either methotrexate or prostaglandins. The present study aimed to evaluate the efficacy of a combined therapeutic regimen. The efficacy was noted to be at least as good but with fewer side-effects. The treatment was effective in 18 out of 19 cases of tubal pregnancies (94.7%). One patient complained of a gastritis which resolved with antacids. One patient experienced abdominal cramps and transient hypotension probably as a profound vagal response during tubal abortion. The median time to resolution varied directly with the initial serum beta HCG level at diagnosis. All patients who responded to the therapy described the experience as painless and viewed the treatment positively as it spared them the need for surgery and its attendant anaesthetic risks. However, we strongly recommend caution and close supervision and to keep the patient in the hospital at least for the first week of therapy.

Behandlung der Eileiterschwangerschaft mit Prostaglandinen: Eine Multizenterstudie

In this prospective multi-centre-study, the new treatment of tubal pregnancies by means of local prostaglandin (PG) F2 alpha and systemic PG E2 application was compared to the usual surgical technique of eliminating the conceptus. In 71 patients treated with PG, the method proved to be successful in 81%; 21 patients (19%) required surgical intervention later. With an initial beta-hCG level of 2500 mIE/ml, the success rate increased to 88%. The duration of hospitalisation was significantly reduced in the PG group compared to the patients treated by primary operation (3 +/- 1 versus 6 +/- 2 days). In the PG-group, only 2 of 24 hysterosalpingograms showed tubal occlusions after treatment, whereas occlusion was present in 3 of 8 patients of the surgically treated group. Four subsequent intrauterine pregnancies in the PG-group occurred compared to none in the surgical group. PG treatment of tubal pregnancy in patients with a low initial beta-hCG value (less than 2500 mIE/ml) revealed promising results with regard to reduced postoperative morbidity and future fertility.