Management Of Ectopic Pregnancy Research Articles

Posterior Colpotomy in Ectopic Pregnancy Management: A 12-Year Surgical Analysis

Posterior Colpotomy in Ectopic Pregnancy Management: A 12-Year Surgical Analysis

Management of nontubal ectopic pregnancies - single center experience

Aims: Ectopic pregnancies can be defined as pregnancies in which the growing blastocyst implants outside the endometrial cavity. However, it is assumed that 0.5-1% of all pregnancies are ectopic pregnancies. The most common extrauterine implantation site is the fallopian tube. Non-tubal pregnancies (NTG Non-tubal pregnancies) account for less than 5% of all ectopic pregnancies but cause 8 times higher maternal mortality than tubal pregnancies. The study aimed to determine the frequency of nontubal ectopic pregnancies in a tertiary care unit in Turkey and the differences that may differentiate patients from tubal ectopic pregnancies. Methods: The purpose of this retrospective study was to analyze and describe the treatments of patients who were hospitalized for ectopic pregnancy in the Gynecology and Obstetrics Clinic of Mengücekgazi Training and Research Hospital from May 2014 to May 2024. Obstetric/gynecologic history, risk factors for previous ectopic non-tubal pregnancy, serum-hCG levels at the moment of diagnosis, ultrasound findings, surgical or medical treatment and treatment outcomes were presented. Results: In our institutional records, 240 patients received an ectopic pregnancy diagnosis. and n=23 nontubal ectopic pregnancies were identified. Cervical pregnancy (CP) (n=2), interstitial pregnancy (IP) (n=2), cesarean scar pregnancy (ScP) (n=10), ovarian pregnancy (OvP) (n=9) were detected. Conclusion: It emerges from our sample that NT-EP needs to be diagnosed quickly. This can assist in the conservative use of a medical or minimally invasive method. The significant advance in imaging technologies allows for a faster diagnosis, allowing the patient to be transferred to a referred center from where the best procedures can be selected, reducing the potential impact of surgery on the patient’s fertility.

The Effectiveness of Letrozole Alone or in Combination with Methotrexate in the Management of Ectopic Pregnancy, A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to investigate the effect of letrozole alone or in combination with Methotrexate on the management of ectopic pregnancy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were applied for reporting. The EMBASE, PubMed, Scopus, and Web of Science databases were searched for relevant studies focused on women diagnosed with ectopic pregnancy and managed non-surgically with letrozole alone or in combination with methotrexate (MTX) until April 2024. The success rate, laboratory findings, and complications were analyzed and reported. Meta-analysis was done using RevMan 5.4.1 software. Out of 129 unique studies obtained, 7 of them were found eligible for final review; of which, 3 were nonrandomized prospective cohort studies, 2 were randomized clinical trials, and 2 study were case studies. In 5 studies letrozole was used as monotherapy. While in another study letrozole was used with MTX. The meta-analysis showed a significantly lower level of β-HCG in the letrozole group compared to MTX, 7days after initiation of treatment (Fixed effect model, MD = -92.22, 95%CI: [-159.39, -25.04], P = 0.007, I2 = 0%). There was no significant difference in the level of anti-mullerian hormone (AMH) between groups (Fixed effect model, MD = 0.18, 95%CI: [-0.09, 0.45], P = 0.20, I2 = 0%). Success rate, platelet count, and level of liver enzymes seemed to be better or similar among patients receiving Letrozole compared to patients receiving Methotrexate. Letrozole exhibits potential as a therapeutic option for ectopic pregnancies; however, further randomized clinical trials are necessary to establish strong evidence.

Clinical profile and management of non-tubal ectopic pregnancy: Experience from a tertiary care hospital in the United Arab Emirates (UAE).

To study the clinical profile and management outcomes of non-tubal ectopic pregnancy at a tertiary care hospital in the United Arab Emirates (UAE). Case files of non-tubal ectopic pregnancy (NTEP) patients from October 2017 to October 2020 presented to Alqasmi Women and Children's Hospital, Sharjah, were included in the study. The data was extracted from available medical records. A total of 30 confirmed cases of NTEP were identified with the following break-up: caesarean scar ectopic pregnancy (n=14; 46.7%), cornual pregnancy (n=11; 36.7%), cervical pregnancy (n=3; 10%) and ovarian pregnancy n=2; 6.7%). Abdominal pain was the most common presenting symptom, present in 23 (76.7% patients) followed by vaginal bleeding in 17 (56.7%) patients. Ten women were managed medically, ten required surgical treatment, and eight were managed with combined medical and surgical treatments; Two patients were managed expectantly. Patients in each treatment strategy did well and there were no deaths. One patient in the medical treatment group developed complications after one month and underwent subtotal hysterectomy. Patients with NTEP were presented with varying symptoms and signs depending upon the location of NTEP. The different currently available management options for NTEP seem to be effective and safe when carefully selected based on the clinical merits of each case.

Laparoscopic Management for Bilateral Tubal Ectopic Pregnancies Following Intrauterine Insemination

Laparoscopic Management for Bilateral Tubal Ectopic Pregnancies Following Intrauterine Insemination

Prevalence and management of ectopic and molar pregnancies in 17 countries in Africa and Latin America and the Caribbean: a secondary analysis of the WHO multi-country cross-sectional survey on abortion

IntroductionThere are limited global data on ectopic pregnancy (EP) and molar pregnancy (MP), making it important to understand their epidemiology and management across different regions. Our study aimed to describe...

Early diagnosis, effective treatment: modern approaches to the management of ectopic pregnancies

Purpose of research: The aim of this article is to provide an overview of the diagnosis and management of atypical ectopic pregnancy, with particular reference to pregnancy in the cesarean scar. The importance of early detection and medical intervention will be described, as well as the impact of advanced diagnostic techniques and modern treatments on the curability of patients.This article aims to provide valuable insights into the development of effective strategies for the diagnosis, treatment and prognosis of ectopic pregnancy. State of knowledge: Ectopic pregnancies account for 1-2% of all pregnancies, with the majority (90%) occurring in the fallopian tube. Less commonly, they present as ovarian, cervical or abdominal pregnancies. Advances in diagnosis and treatment have made it possible to identify rare forms such as cesarean scar pregnancy (0.15% of all pregnancies), interstitial pregnancy and recurrent ectopic pregnancy on tubal remnants. Techniques such as transvaginal ultrasound (TVS), MRI and laparoscopy have the potential to improve diagnostic accuracy and treatment outcomes. Modern interventions such as transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and methotrexate have shown promise in terms of safety and efficacy. Conclusions: Ectopic pregnancy and its complications have a significant impact on the psycho-physical health of patients, requiring ongoing research to improve diagnostic and therapeutic methods. Future studies should focus on long-term outcomes and the coordination of multidisciplinary medical care to further improve diagnosis and treatment.

A Case Control Study of vNOTES versus Conventional Laparoscopic Salpingectomy for Ectopic Pregnancy

While the laparoscopic approach is the surgical treatment of choice for ectopic pregnancy, vNOTES is emerging as an alternative route with its good optical visibility and avoidance of abdominal incisions. The authors compare demographics and outcome data of vNOTES vs conventional laparoscopic salpingectomy for the surgical management of ectopic pregnancy. Case control study SETTING: A London University hospital PATIENTS: Women with ectopic pregnancy unsuitable for medical management who underwent surgical management INTERVENTION: 25 cases of vNOTES vs 25 conventional laparoscopic salpingectomy MEASUREMENTS AND MAIN RESULTS: The mean patient age (29.7±53 vs 31.4±6.7 days), parity (1.2±1.1 vs 1.6±2.1), BMI (26.7±5.3 vs 27.2±5.4 kg/m3), gestation age (8.44±2.1 vs 7.3±1.7 weeks) and βhCG levels (3725.4±3674.8 vs 4376.5±6493.4 IU/litre) were comparable (p>0.05, t test) between patients having vNOTES vs conventional laparoscopic salpingectomy. While estimated blood loss was similar (218.2±491.7 vs 173.5±138.7 mls)(p>0.001), vNOTES patients had statistically shorter duration of surgery (35.8±14.4 vs 75.8±19.7 mins)(p<0.001, t test) and length of stay (median: 11.5 vs 19.7 hours)(U=72, p<0.05, Mann-Whitney U test). Less patients in the vNOTES group required postoperative opioids (9% vs 25%) and median Visual Analogue Score (/10) for pain at 24 hours was significantly lower (2.0 vs 4.0)(U=75, p<0.05, Mann-Whitney U test). Patients from the vNOTES group were able to return to normal daily activity 11.3 days quicker (5.8±4.3 vs 17.1±8.2 days)(p<0.05, t test). vNOTES cases cost approximately USD150 more due to the price of the commercial kits but this is offset by reduced intraoperative time, length of stay and need for postprocedure analgesia. Patients undergoing vNOTES have shorter intraoperative times and length of stays, less postoperative pain and more rapid recovery, which help mitigate higher cost incurred by commercial kits. While the vNOTES approach for ectopic pregnancy appears safe and efficacious, more robust data from larger randomised studies are needed.

A 20 year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital – a retrospective review

BackgroundNon-tubal ectopic pregnancies account for < 10% of all ectopic pregnancies. Due to its rarity and wide variation in clinical practice, there is no guideline or consensus for its management. We reported our 20-year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital.MethodsThis is a retrospective review of all women admitted for non-tubal ectopic pregnancies from January 2003 to December 2022 in a tertiary hospital. Women with non-tubal ectopic pregnancies diagnosed by ultrasound or operation were included for analysis.ResultsWithin the study period, 180 women were diagnosed to have non-tubal ectopic pregnancies at a mean gestation of 6.8 weeks. 16.7% (30/180) were conceived via assisted reproduction. Medical treatment was the first-line management option for 81 women, of which 75 (92.1%) women received intralesional methotrexate administered under transvaginal ultrasound guidance. The success rate of intralesional methotrexate ranges from 76.5% to 92.3%. Intralesional methotrexate was successful even in cases with a positive fetal pulsation or with high human chorionic gonadotrophin levels up to 252605U/L. Twenty seven women were managed expectantly and 40 underwent surgery. Nine (11.1%), two (6.1%), and one (2.3%) women required surgery due to massive or recurrent bleeding following medical, expectant, or surgical treatment. Hysterotomy and uterine artery embolization were necessary to control bleeding in one Caesarean scar and one cervical pregnancy.ConclusionsIntralesional methotrexate is more effective than systemic methotrexate and should be considered as first line medical treatment for non-tubal ectopic pregnancies. It has a high success rate in the management of unruptured non-tubal ectopic pregnancies even in the presence of fetal pulsations or high human chorionic gonadotrophin levels, but patients may require a prolonged period of monitoring. Close surveillance and readily available surgery were required due to the risk of heavy post-procedural intra-abdominal bleeding.

Surgical management of an ectopic pregnancy in the setting of an unexpected Müllerian anomaly: intraoperative and postoperative implications

ObjectiveTo describe the intraoperative and postoperative implications arising from the unexpected diagnosis of a Müllerian anomaly during the surgical management of an ectopic pregnancy. DesignVideo article. SettingAcademic Center. Subject(s)A 39-year-old nulligravid woman with anovulation and irregular menstrual cycles presented to the office. Her urine pregnancy test was incidentally positive; serum β-human chorionic gonadotropin (β-hCG) level was 5,644 mIU/mL. Outpatient transvaginal ultrasonography (TVUS) demonstrated a 2.1 x 1.7 x 2.2-cm thick-walled structure in the left adnexa without an intrauterine pregnancy. These findings were highly suspicious for a left tubal ectopic pregnancy. The patient was consented for laparoscopy with planned left salpingectomy. The patient included in this video gave consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites. InterventionDiagnostic laparoscopy did not show an obvious left tubal ectopic pregnancy. Instead, a right unicornuate uterus with a dilated rudimentary left uterine horn was seen. Both fallopian tubes and ovaries appeared normal. These laparoscopic findings were consistent with an ectopic pregnancy in the rudimentary horn. However, in the absence of informed consent for a hemi-hysterectomy and no evidence of ectopic rupture or bleeding within the pelvis, we decided to proceed with excision of the ectopic pregnancy from the uterine horn. An incision was made over the anterior surface of the uterine horn, and the pregnancy sac was dissected from the underlying myometrium and excised in its entirety. Left salpingectomy was also performed. The patient was discharged home the same day, and her β-hCG levels decreased to <5 mIU/mL within 28 days of surgery. Main Outcome MeasuresComplete resolution of a left rudimentary uterine horn ectopic pregnancy through surgical excision of the pregnancy sac without hemi-hysterectomy. ResultsPostoperative hysterosalpingography (HSG) demonstrated a right unicornuate uterus with normal fill and spill of the right fallopian tube. Magnetic resonance imaging (MRI) of the pelvis confirmed the findings of a right unicornuate uterus with a non-communicating left rudimentary uterine horn that did not contain any endometrial tissue. Thus, the patient did not require an interval hemihysterectomy. She underwent letrozole and intrauterine insemination treatment 5 months after the initial surgery, which resulted in a clinical intrauterine pregnancy. However, this pregnancy was terminated in the early second trimester due to findings of trisomy 18. She conceived naturally one year later, and this pregnancy resulted in a full-term vaginal birth at 39 weeks gestation. ConclusionUndiagnosed or unexpected Müllerian anomalies can impact the standard intraoperative and postoperative management of ectopic pregnancies.

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

ObjectiveTo evaluate the efficacy of two different regimens of Letrozole, an aromatase inhibitor, in the management of ectopic pregnancy compared to methotrexate. Study DesignThis 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. ResultsThe 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). ConclusionOur 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.

COMPARATIVE ANALYSIS OF MEDICAL AND SURGICAL MANAGEMENT OF ECTOPIC PREGNANCY

A pregnancy that occurs in any place other than the endometrial cavity is called ectopic pregnancy. Objectives: The main aim of the study is to find a comparative analysis of medical and surgical management of ectopic pregnancy. Methods: This retrospective study was conducted at Hospital Civil/SPH Quetta. from January 2023 to December 2023. Data was collected from 220 patients. Comprehensive clinical and demographic data were extracted from electronic medical records. These included patient age, gravidity, parity, gestational age at diagnosis, presenting symptoms, imaging results, serum β-hCG levels, treatment modalities utilised, procedural specifics, and post-intervention outcomes. Results: Data were collected from 220 patients suffering from ectopic pregnancies. The mean age of patients in the medical management group was 29.2±4.3 years, and 29.8±4.1 years in the surgical management group. Nulligravid patients were more prevalent in the medical management group (58%) compared to the surgical management group (45%), while multigravida patients were more evenly distributed between the two groups (42% vs. 55%). In comparing medical and surgical management of ectopic pregnancy, surgical management demonstrated a higher success rate (95%) compared to medical management (85%). Medical management with methotrexate typically resolved ectopic pregnancies within an average of 17 days, whereas surgical interventions varied in time to resolution. However, surgical management had a slightly higher complication rate (12%) than medical management (10%). Conclusion: It is concluded that both medical and surgical management options demonstrate high efficacy in resolving ectopic pregnancy, with considerations for individual patient characteristics and clinical presentations.

Diagnostic and management dilemmas of pregnancies at the utero-tubal junction: A case series and management algorithm.

A pregnancy at the utero-tubal junction is a rare type of ectopic pregnancy and is associated with high maternal morbidity if it remains undetected. In the present study we discuss four cases of ectopic pregnancies at the utero-tubal junction which caused diagnostic and management dilemmas. Four cases of early pregnancies with the gestational sac (G-sac) implanted near the utero-tubal junction are described. In case 1 this was suspected after a failed attempt at dilatation and curettage at our hospital, cases 2 and 3 presented with amenorrhea and pain abdomen and case 4 was diagnosed on first pregnancy documentation scan after frozen embryo transfer. As initial two-dimensional (2D) transvaginal scan (TVS) failed to diagnose the exact location of the G-sac, three-dimensional (3D) TVS helped to localize the exact location of pregnancy and subsequent individualized management. Case 1 had a partial intramural ectopic pregnancy managed by laparotomy and removal of the ectopic sac. The second and third cases were eccentric uterine pregnancies. The fourth was an interstitial ectopic pregnancy managed by a laparoscopic loop and stitch technique. This case series describes the role of 3D TVS for the evaluation of pregnancies implanted at the utero-tubal junction and individual management of eccentric intrauterine, interstitial ectopic and intramural ectopic pregnancies. A diagnostic algorithm for such types of cases and management options is discussed.

The effects of conservative and surgical approaches in tubal ectopic pregnancy on fertility.

Medical treatment, expectant approaches, and surgical treatment options are available in the treatment of ectopic pregnancy. Regardless of the treatment, in addition to its effectiveness, the main concern is to limit the risk of relapse and preserve fertility. Determine the impact of medical or surgical treatment for ectopic pregnancy on future fertility. Retrospective. Department of obstrtrics and gynecolgy at Ankara Etlik Zübeyde Hanım Women's Health Training and Research Hospital, Ankara, Turkey. Patients who were treated for ectopic pregnancy between June 2016 and November 2019 were allocated into two groups. Expectant approach or medical treatment by methotrexate constituted the conservative treatment group while salpingectomy by laparoscopy indicated the surgical treatment group. Fertility rates within two years following treatment were evaluated according to treatment options. 202 patients. Of the 202 patients, 128 had medical treatment and 74 patients had surgical treatment for ectopic pregnancy. Of 272 diagnosed with ectopic pregnancy, 70 were excluded for various reasons. Parity and unemployment rate was significantly higher in the surgical treatment (P=.006 and P=.12, respectively). Moreover, ectopic mass size and serum β-hCG levels were significantly higher in the surgical treatment group (P<.001 and P<.001, respectively). There were no significant differences between the conservative and surgical treatment groups in time to pregnancy (17.0 months vs 19.0 months, P=.255). Similarly, there was no significant difference between the conservative and surgical treatment groups with respect to history of infertility (P=.12). There were no significant differences between the conservative and surgical treatment groups in terms of live birth (51.6% vs 44.6%) and ectopic pregnancy (2.3% vs 1.4%) (P=.72 for both). There was no significant difference between the conservative and surgical treatment groups with respect to infertility rate (35.9% vs 41.9%, P=.72) and admittance to the IVF program (3.9% vs 6.8%, P=.39) following ectopic pregnancy treatment. Reproductive outcomes did not differ significantly in women undergoing expectant management, medical treatment, and surgery for ectopic pregnancy. This finding suggests that clinicians should not hesitate to act in favor of surgical treatment for ectopic pregnancy even if there were concerns for future fertility. Retrospective study.

Hysteroscopic subchorionic injection of methotrexate followed by laparoscopic excision of the gestational sac for the management of cesarean scar ectopic pregnancy: an innovative dual approach of a challenging pathology

To describe an effective two-step surgical approach for the management of cesarean scar ectopic pregnancies (CSEPs). CSEPs occur at an estimated frequency of 1 in 1,800 pregnancies, constituting approximately 6% of ectopic pregnancies in women with a history of prior cesarean delivery [1, 2]. Despite numerous recommended therapeutic approaches, the most effective treatment strategy remains uncertain [3]. We present an innovative double-step technique for the management of a patient with a CSEP involving hysteroscopic subchorionic injection of methotrexate (MTX), followed by laparoscopic resection of the residual gestational sac and simultaneous repair of the uterine defect. Academic tertiary hospital. A 34-year-old G2P1001 with a history of prior cesarean section presented at 10 weeks of gestation. Ultrasound revealed a gestational sac within the niche of the previous cesarean scar, confirming the diagnosis of a CSEP. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus, among others), and other applicable sites. The initial treatment involved hysteroscopic administration of MTX within the placental intervillous spaces, ensuring precise medication delivery. The administered dose of MTX was 1 mg/kg. Following the normalization of beta-human chorionic gonadotrophin (β-hCG) levels, laparoscopic resection of the remaining gestational sac and reconstruction of the uterine wall defect were performed. We have implemented a management strategy focusing on ectopic pregnancy removal and addressing defect revision. The hysteroscopic approach allows for a clear assessment of the ectopic pregnancy and facilitates precise MTX administration, enhancing its effectiveness by increasing drug concentration within the placental intervillous space. Delaying surgical repair until after the β-hCG levels have decreased reduces the risk of excessive bleeding during the procedure, as lower β-hCG levels are associated with reduced vascularity at the ectopic site. Subsequent laparoscopic resection allows for complete removal of the remaining products of conception and repair of the defect, preserving the uterus and restoring normal anatomy. Compared to other surgical approaches,our two-step approach enables a more precise evaluation of placental implantation, making it a highly effective surgical method. We successfully managed a CSEP using a double-step technique. This involved hysteroscopic injection of subchorionic MTX, followed by laparoscopic resection of the residual gestational sac. Concurrently, we repaired the uterine defect. Both procedures were performed in an outpatient setting without complications detected during or after treatment. At the follow-up visit, the patient reported good health, and subsequent ultrasound confirmed an empty isthmocele. This sequential hysteroscopic and laparoscopic approach represents a definitive and effective minimally invasive surgical option for the treatment of CSEP.

Steps to successful laparoscopic management of cesarean scar ectopic pregnancy

Steps to successful laparoscopic management of cesarean scar ectopic pregnancy

Cost-effectiveness analysis of expectant vs active management for treatment of persistent pregnancies of unknown location

BackgroundPersistent pregnancies of unknown location (PUL) are defined by abnormally trending serum human chorionic gonadotropin with nondiagnostic ultrasound. There is no consensus on optimal management. ObjectiveThis study was designed to assess the cost-effectiveness between three primary management strategies for persistent pregnancies of unknown location: (1) expectant management, (2) empirical two-dose methotrexate, (3) uterine evacuation followed by methotrexate, if indicated. Study DesignWe conducted a prospective economic evaluation performed concurrently with the Expectant versus Active Management for Treatment of Persistent Pregnancies of Unknown Location (ACT or NOT) multicenter randomized trial conducted from July 2014 to June 2019. Participants were randomized 1:1:1 to expectant management, two-dose methotrexate, or uterine evacuation. The analysis was from the healthcare sector perspective with a 6-week time horizon following randomization. Costs were expressed in 2018 U.S. dollars. Effectiveness was measured in quality-adjusted life-years (QALYs) and the rate of salpingectomy. Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves were generated. Sensitivity analyses were performed to assess the robustness of the analysis. ResultsMethotrexate had the lowest mean cost, $875, followed by expectant management $1085, and uterine evacuation $1902 (p=0.001). Expectant management had the highest mean QALY (0.1043) followed by methotrexate (0.1031) and uterine evacuation (0.0992) (p=0.0001). Salpingectomy rate was higher for expectant management compared to methotrexate (9.4% vs 1.2%; p=0.02) and expectant management compared to uterine evacuation (9.4% vs 8.1%; p=0.04). Uterine evacuation, with highest costs and lowest QALYs, was dominated by both expectant management and methotrexate. In the base case analysis, expectant management was not cost-effective compared to methotrexate at a willingness-to-pay of $150,000/QALY given an ICER of $175,083/QALY gained (95% CI, -$1,666,825-2,676,375). Threshold analysis demonstrated methotrexate administration would have to cost $214 (an increase of $16 or 8%) to favor expectant management. Expectant management would also be favorable in lower risk patient populations with rates of laparoscopic surgical management for ectopic pregnancy not exceeding 4% of pregnancies of unknown location. Based on the cost-effectiveness acceptability curves, the probability expectant management was cost-effective compared to methotrexate at a willingness-to-pay of $150,000/QALY gained was 50%. Results were dependent on the cost of surgical intervention, and the expected rate of methotrexate failure. ConclusionManagement of pregnancies of unknown location with a two-dose methotrexate protocol may be cost-effective compared to expectant management and uterine evacuation. While uterine evacuation was dominated, expectant management versus methotrexate results were sensitive to modest changes in treatment costs of both methotrexate and surgical management.

Successful management of an advanced interstitial ectopic pregnancy in a resource-limited setting: a case report

BackgroundInterstitial ectopic pregnancy is an ectopic gestation developing in the uterine part of the fallopian tube. The condition is rare and presents challenges for clinical as well as radiological diagnosis. This case report presents a rare case of interstitial ectopic pregnancy diagnosed intraoperatively.Case presentationA 36-year-old Black woman, referred from a peripheral health facility, presented at the emergency department with severe abdominal pains, vaginal spotting, nausea, and vomiting, with a 2-month history of irregular menstrual flow. Clinical and laboratory findings were suggestive of an acute abdomen likely due to a ruptured ectopic pregnancy (ultrasound was not available). An emergency exploratory laparotomy was done, which revealed a right adnexal ruptured interstitial pregnancy of a lifeless female fetus weighing 500 g (estimated mean gestational age of 22–23 weeks). The left fallopian tube looked normal. The site of rupture was repaired, followed by cleaning and closure of the abdomen. The post-operative period was uneventful, and the patient was discharged on postoperative day 7.ConclusionInterstitial pregnancies are uncommon and rarely attain advanced gestational ages, as in this case, compared with other tubal ectopic pregnancies. However, women presenting with signs of hypovolemic shock and acute abdomen, with a positive pregnancy test, warrant a high index of suspicion.

Minimally invasive management of ectopic pregnancy

Minimally invasive management of ectopic pregnancy

Laparoscopic surgery for ectopic pregnancy: A comparative study on the clinical benefits and impact on tubal patency and reproductive outcomes.

Ectopic pregnancy is a major contributor to maternal morbidity and mortality across the globe. This study aims to investigate the clinical benefits of laparoscopic surgery in treating ectopic pregnancy, and its impact on tubal patency and reproductive outcomes. A clinical study was conducted to compare laparoscopic and medical conservative treatment for ectopic pregnancy. A total of 206 patients were treated for ectopic pregnancy at our hospital from January 2018 to June 2020. Among them, 46 underwent laparoscopic ipsilateral salpingectomy, 54 underwent laparoscopic ipsilateral salpingostomy with lesion removal, and 106 were treated conservatively with medication. The age range and average age of each group are provided, with no significant differences in these general demographic characteristics (p> 0.05). Both the salpingostomy and medication groups had higher rates of ectopic pregnancy compared to the salpingectomy group, with statistically significant differences (p< 0.05). The comparison of ectopic pregnancy rates between the salpingostomy and medication groups showed no significant difference. Within three years, the salpingostomy group had 10 cases of recurrent ectopic pregnancy, with 2 cases on the same side, while the medication group had 18 cases, with 8 cases on the same side. At 3 months after the normalization of blood β-HCG, the salpingostomy group showed 43 cases of tubal patency (patency rate: 79.63%), while the medication group showed 57 cases (patency rate: 53.77%), with a statistically significant difference between the two groups (p= 0.01). Laparoscopic surgery for ectopic pregnancy offers significant clinical benefits over conservative medical treatment, including higher rates of tubal patency and improved reproductive outcomes. These findings support laparoscopic surgery as an effective approach for the management of ectopic pregnancy.