Unruptured Tubal Pregnancy Research Articles

The efficacy of multiple-dose methotrexate treatment for unruptured tubal ectopic pregnancy and conversion rate to surgery: a study on 294 cases

In this prospective study 294 patients diagnosed with ectopic pregnancy (EP) were treated with multiple-dose methotrexate (MTX) to determine the conversion rate to surgery. We concluded that multiple-dose MTX treatment had a low success rate, and the success rate was not related to initial b-hCG value; it was more related to the size of gestational mass before treatment.

P427 Trophoblastic invasion of the unruptured tubal pregnancy evaluated by histopathology, serum marker and immunohistochemistry

International Journal of Gynecology & ObstetricsVolume 107, Issue S2 p. S535-S535 Poster presentations P427 Trophoblastic invasion of the unruptured tubal pregnancy evaluated by histopathology, serum marker and immunohistochemistry J. Elito Jr, J. Elito JrSearch for more papers by this authorL. Camano, L. CamanoSearch for more papers by this authorT. Fernandes, T. FernandesSearch for more papers by this authorJ. Stavale, J. StavaleSearch for more papers by this authorL. Oliveira, L. OliveiraSearch for more papers by this authorE. Souza, E. SouzaSearch for more papers by this author J. Elito Jr, J. Elito JrSearch for more papers by this authorL. Camano, L. CamanoSearch for more papers by this authorT. Fernandes, T. FernandesSearch for more papers by this authorJ. Stavale, J. StavaleSearch for more papers by this authorL. Oliveira, L. OliveiraSearch for more papers by this authorE. Souza, E. SouzaSearch for more papers by this author First published: 20 November 2009 https://doi.org/10.1016/S0020-7292(09)61919-6AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume107, IssueS2Abstracts of XIX FIGO World Congress of Gynecology and ObstetricsOctober 2009Pages S535-S535 RelatedInformation

Examination of the effects of methotrexate on histological and steroid receptor changes in the endosalpinx of the rat

Objectives Methotrexate (MTX) has been a prevalent drug in conservative treatment of unruptured tubal pregnancy for many years. However, few researchers have performed morphological and protein analysis simultaneously to evaluate the specific toxic effects of MTX on the fallopian tubes. The aim of this study was to investigate acute and long-term toxic effects of increasing doses of MTX on the fallopian tubes and a possible dose–effect relationship. We also discuss the potential implications for subsequent pregnancies. Study design At the 10th day and the 2nd and 3rd months after MTX treatment, a total of 108 females SD rats in estrus stage (27 rats in each group) were collected according to the dose of MTX i.p.: 1, 2, 5 mg/kg body weight in groups I, II and III respectively and physiological saline i.p. in group IV for control. Nine rats in each group were killed at each time point and tissues close to the ampulla of the fallopian tubes were dissected for HE staining and routine histological observation. Estrogen receptor (ER) and progesterone receptor (PR) expression was detected by immunohistochemistry and Western blot. Results Morphological observation showed acute endosalpingitis in group I, becoming more intense with increasing doses of MTX in groups II and III in a reversible mode. Expression of ER in the endosalpinx significantly decreased in parallel with increasing doses of MTX in a dose–effect manner, which was reversible in groups I and II and irreversible in group III. Furthermore, ER and PR could recover close to normal levels in groups I and II after the 3rd month, while they could not restore to normal in group III. Conclusions These results provide the first evidence that MTX (≥5 mg/kg) can induce long-term, irreversible damage to steroid hormone receptors in the fallopian tubes in a dose-dependent manner. We tentatively suggest that MTX should be used in a relatively small and safe range of dosage in order to avoid impairment and potential risk of subsequent tubal pregnancy or infertility.

Conservative management of tubal ectopic pregnancy

In this chapter an overview is given of the best available evidence on the conservative treatment for tubal ectopic pregnancy, i.e., expectant management and medical treatment with systemic methotrexate. From the two randomized controlled trials on expectant management, no conclusions can be drawn yet. It may be that women with low serum hCG levels need not be treated at all, but more research needs to be done in this subgroup of women to reach firm conclusions. Systemic methotrexate in a fixed multiple-dose i/m regimen can be recommended for hemodynamically stable women with an unruptured tubal ectopic pregnancy and no signs of active bleeding presenting with serum hCG concentrations<3,000 IU/l. In women with serum hCG concentrations<1,500 IU/l, a single-dose methotrexate regimen can be considered.

Surgical treatment of ectopic pregnancy

Ectopic pregnancy remains the leading cause of death in the first trimester of pregnancy. Today, serial serum hCG measurements and transvaginal ultrasound examination can provide early detection of most ectopic pregnancies allowing medical treatment with methotrexate. In those who require surgery, the type of procedure depends on the clinical situation and the location of the pregnancy. Most of the cases can and should be performed by laparoscopy. Compared with laparotomy, the laparoscopic approach is associated with many advantages including short hospital stay, low cost and less adhesion formation. In addition, hemoperitoneum is not a contraindication for performing laparoscopy. Linear salpingostomy is the procedure of choice when unruptured tubal pregnancy is found in women who want to preserve their fertility; otherwise, salpingectomy is performed. Fertility performance after salpingostomy and salpingectomy is comparable. Similar to the case with tubal ectopic pregnancy in general, women with non-tubal ectopic pregnancy such as cervical, interstitial, or Caesarean scar pregnancy should be first treated medically with methotrexate. These types of ectopic pregnancies may be associated with massive bleeding during surgery. Precautionary procedures should be considered and these include the placement of an angiographic catheter for possible uterine artery embolization. These pregnancies can also be treated laparoscopically.

Study on tubal patency after treatment of unruptured tubal pregnancy

Objective To evaluate tubal pateney by hysterosalpingography after treatment of tubal pregnancy.Methods 80 patients with tubal pregnancy underwent hysteresalpingography after clinical treatment.Of them,30 were treated with methotrexate of 50mg/m2 intramuscularly( study group,n=30) and 50 were followed up expeetandy (control group,n=50).Results Ipsilateral and contralateral tubal pateneies in the study group were 84% and 97% ,respectively,whereas in the control group were 78% and 92% ,respeetively.There were no statistically significant differences between the two groups.Conclusion Appropriate options for unruptured tubal pregnancy includes either expectant management or methotrexate treatment,both of which result in similar tubal patency rate. Key words: Pregnancy,tubal; Expectant treatment; Methotrexate; Hysteregalpingography

Predictive power of serum CA-125 and LDH in the outcome of first trimester pregnancies with human chorionic gonadotropin levels below discriminatory zone

The present study aims to investigate the predictive power of serum CA-125 and lactate dehydrogenase (LDH) for evaluating the outcome of first trimester pregnancies with beta human chorionic gonadotropin levels below discriminatory zone (<or=1,000 mIU/mL). A total of 107 women with tubal ectopic pregnancies (30 ruptured and 77 unruptured), 105 women with normal intrauterine pregnancies and 100 women with intrauterine abortions were eligible for the study. Women with intrauterine abortion were found to have significantly higher CA-125 and LDH levels compared to women with ectopic and normal intrauterine pregnancies. Ruptured tubal pregnancies resulted in significantly higher CA-125 and statistically similar LDH levels compared with unruptured tubal pregnancies. Although CA-125 levels were found to be unrelated to gestational age in normal intrauterine normal and abortive as well as ruptured and unruptured ectopic pregnancies; LDH levels were directly correlated with gestational age in ruptured tubal ectopic pregnancies. Consequently, the ability to determine the disintegration of ectopic trophoblastic or fetal tissues would be of great value in the management of hemodynamically stable patients with beta hCG levels below discriminatory zone. Intrauterine abortive pregnancies seem to yield high serum CA-125 concentrations combined with high LDH levels which indicate more extensive trophoblastic tissue damage than caused by intrauterine and ectopic pregnancies.

Successful Intrauterine Pregnancy following salpingostomy; Case Report

Ectopic pregnancy occurs more in young women who still desire children. Because of tubal rupture, salpingectomy which leads to tubal loss and reduced reproductive potentials is the commonest management option. This is a case report of a primipara who had ruptured left tubal ectopic pregnancy managed by salpingectomy and later had unruptured heterotopic pregnancy involving the contralateral tube and managed by salpingostomy, after which she had spontaneous abortion of the associated intrauterine pregnancy. Initial marital disharmony, followed by an uneventful intrauterine pregnancy carried to term with caesarean delivery of a live female baby. In well-selected cases, conservative tubal surgeries should be encouraged in preference to radical surgeries in the management of unruptured tubal pregnancies.

Unilateral twin tubal pregnancy successfully treated with methotrexate

Spontaneous twin ectopic pregnancy is extremely rare. Among more than 100 reported cases of twin tubal pregnancies, successful treatment with methotrexate has yet to be reported. A 26-year-old nulliparouswomanwas admittedwith vaginal bleeding and abdominal pain. She had previously undergone infertility treatment using ovulation induction with gonadotropins and intrauterine insemination. On admission, the patient's serum level of beta-human chorionic gonadotropin (β-hCG) was 763 IU/mL. Two gestational sacs were observed in the left tube on transvaginal ultrasound. An increase in serum β-hCG level was observed on the third day of hospitalization. A multiple-dose regimen of methotrexate (1 mg/kg of methotrexate on days 1, 3, 5, and 7, and 0.1 mg/kg of folinic acid on days 2, 4, 6, and 8) was begun when the patient's β-hCG serum level reached987 IU/mL.On day1 ofmethotrexate treatment, dilatation and curettage was performed and endometrium without chorionic villi was reported by the pathologist. Serum levels of β-hCG reached 1091 IU/mL on day 2, 1219 IU/mL on day 4, and 750 IU/mL on day 6. A single dose of methotrexate (1 mg/kg) was repeated on the 14th day as the serum level of β-hCG reached 1200 IU/mL. Serum β-hCG levels declined to within the normal range 32 days after initiation of the treatment. The main risk factors in this case are infertility treatment and smoking. Marcovici et al. [1] showed that conventional methotrexate treatment was unsuccessful for spontaneous bilateral tubal ectopic pregnancies, while hemodynamically stable unruptured tubal ectopic pregnancies and heterotopic pregnancies could be successfully treated with systemic methotrexate [2]. The present case reports a unilateral twin tubal ectopic pregnancy treated successfully using systemic multiple doses of methotrexate.

Concurrent Tubal Ectopic Pregnancy and Acute Appendicitis

A 25-year-old woman had signs of an acute surgical abdomen. Differential diagnoses were ectopic pregnancy and acute appendicitis. Diagnostic laparoscopy revealed an apparent inflamed appendix and left-sided unruptured tubal ectopic pregnancy. This case illustrates the importance of considering multiple pathologic disorders in a patient with an acute surgical abdomen, especially in pregnancy. Furthermore, it shows that laparoscopy constitutes the optimal treatment modality in patients with multiple diagnoses, because it combines multifocal diagnosis and treatment without additional postoperative morbidity.

Injection MTX Oral Mifepristone in Treatment of Unruptured Tubal Pregnancy

目的 探讨经阴道超声穿刺注射MTX(甲氨蝶呤)加口服米非司酮治疗未破裂型输卵管妊娠的疗效.方法 观察组:采用经阴道超声穿刺注射MTX加口服米非司酮治疗,先用甲氨蝶呤(MTX)20 mg经阴道超声引导下注入异位妊娠病灶,治疗后当天口服米非司酮5 0mg,每日2次,连用4天.对照组:采用口服米非司酮5 0mg,每日2次,连用4天.结果 经阴道超声穿刺注射MTX加口服米非司酮治疗,成功率为90%,明显高于对照组.观察治疗期间病情变化,发现疗效与血β-HCG高低及盆腔包块大小、有无心管搏动有关.结论 经阴道超声穿刺注射MTX加口服米非司酮治疗未破裂型输卵管妊娠安全有效,适用于生命体征平稳、无剧烈腹痛、无心管搏动及血β-HCG＜3000mIU/ml的未破裂型输卵管妊娠,成功率明显高于对照组。

Ultrasonographic Endometrial Features in Tubal Pregnancy: Are They Predictive Factors of Successful Medical Treatment?

The aim of this study was to explain possible relationships in cases of ectopic pregnancy between sonographic endometrial features and treatment outcome following methotrexate (MTX) injection. A total of 157 cases of unruptured tubal pregnancy were diagnosed and treated systemically with MTX. The sonographic endometrial pattern, endometrial thickness and treatment outcome were retrospectively analyzed. There were four types of endometrial patterns: these were trilaminar, homogeneous, heterogeneous and pseudosac. Success rates following MTX treatment were different for each group: these were 64.7%, 78.4%, 50.0% and 46.2%, respectively ( p = 0.0129). And the risk of treatment failure was increased 3.64 times (95% CI 1.56 to 8.49) in heterogeneous thick pattern and 4.24 times (95% CI 1.18 to 15.23) in pseudosac pattern. In conclusion, when tubal pregnancy was seen in a pseudogestational sac pattern or a heterogeneous pattern, the failure rate of medical treatment was increased. This can serve as a reference for considering the decision about medical treatment in women with unruptured tubal pregnancy. (E-mail: haijkim@korea.ac.kr)

Transvaginal ultrasound-guided aspiration and instillation of hyperosmolar glucose for treatment of unruptured tubal heterotopic pregnancy

To report a case of tubal heterotopic pregnancy (HP) treated conservatively with transvaginal ultrasound-guided aspiration and instillation of hyperosmolar glucose. Aspiration of the tubal ectopic pregnancy and hyperosmolar glucose instillation was performed with a 16-gauge needle under transvaginal ultrasound guidance. Unruptured tubal HP with positive cardiac activity was treated successfully without any further interventions, and intrauterine pregnancy has reached full-term without any complications. Early diagnosis of this life-threatening condition is the key to its successful treatment. Transvaginal ultrasound-guided aspiration and hyperosmolar glucose injection can be safely performed for the treatment of unruptured tubal HP.

INTRAVENOUS METHOTREXATE FOR THE TREATMENT OF UN-RUPTURED ECTOPIC PREGNANCY

Objectives: To evaluate the efficiency and safety of intravenous mctholrcxntc as an alternative to surgery for (hetreatment of un-ruptured tubal pregnancy as well as cost effectiveness.Design: A cohort study.Setting: Madina Maternity and Children's Hospital (MMCH). Al Madinah Al Munawarah. KSA. Period from9/02/2005 to 26/06/2006 (01/01/I426H to 30/05/1427H)Methods: The authors studied thirty four patients with un-ruptured tubal cciopic pregnancies, clinically stable, whowere treated with intravenous methotrcxale according to a single-dose protocol. Prctrcalmcnl scrum concentrations ofhuman chorionic gonadotrophin (hCG) and progesterone, cndovaginal ultrasonography to asses si/.e of the mass, fetalcardiac activity and the presence of fluid in the peritoneal cavity (presumably blood) were done. All were correlatedwith the efficiency of therapy as defined by resolution of cciopic pregnancy (decline in hCG level to 15 mlU/ml or less)without the need for surgical intervention. The outcome measures also included the frequency of preservation of thelubes, subsequent ipsilaleral tubal patency and further pregnancy within one year.Results: The success rate was 88.2%. Thirty four patients of forty one (34 of 41) diagnosed as cciopic pregnancy weretreated with intravenous methotrcxate (82.9%). Twenty eight of thirty four (82.35%) were successfully treated with asingle-dose intravenous mcthotrexatc. Six patients (17.65%) needed a second dose of methotrcxate. The mean scrumchorionic gonadotrophin and progesterone concentrations were 3247.53 mlU/ml ± SD 348.1 and 8.54 ±13.1 ng/mlrespectivley. The mean time needed for serum hCG concentration to reach 15 mlU/ml or less (the resolution lime) was35.1±SD 12.8 days. Subsequent pregnancy rate within one year was 69.2% (9 women of 13). Side effects tomethotrcxate therapy were minimal.Conclusion: Single dose of intravenous methotrcxate therapy was well tolerated, cost-saving, non surgical, fallopian tube saving treatment for un-ruptured cciopic pregnancy

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.

Medical treatment of ectopic pregnancy

Methotrexate is an alternative to surgical treatment of unruptured tubal pregnancy. Among 39 women with the diagnosis of tubal pregnancy there were ten (10) cases without rupture of salpinx. Nine (9) out of these treated with Methotrexate. In one (1) case there was rupture immediately after the termination of the treatment. There were no experiences of major side effects from the treatment with Methotrexate. The passage through the tubes was examined laparoscopically 3 months after the treatment. There was passage through all affected tubes.

CA‐125 levels in ruptured and unruptured tubal ectopic pregnancies

This prospective, single-blind and controlled clinical study aimed to research if CA-125 levels could be a useful test in the differential diagnosis of intact and ruptured tubal ectopic pregnancy. Sixty-five women with tubal ectopic pregnancy of 5-10 weeks' duration (27 women with ruptured tubal ectopic pregnancy [REP] and 38 women with unruptured tubal ectopic pregnancy [UREP]) and 65 women with normal intrauterine pregnancy (NIUP) of the same gestational age were studied prospectively. Serum CA-125 levels were measured in all women and these levels were compared among the REP, UREP, and NIUP groups. The mean CA-125 levels didn't show any significant difference between the REP and NIUP groups (P > 0.05). The mean CA-125 levels of these two groups were higher than that in the UREP group (P < 0.01, P < 0.001, respectively). The dispersion ratios of the CA-125 levels had a statistically significant difference between the REP and UREP groups (chi(2): 42.44, P < 0.0001). CA-125 levels weren't correlated with gestational weeks in the REP and UREP groups (r: 0.005, P > 0.05; r: 0.008, P > 0.05, respectively). In intact tubal ectopic pregnancies, expectant or managed with medical treatment, the increase of CA-125 levels in the serial measurements could be a supplementary test for an early diagnosis of tubal rupture.

Heterotopic pregnancy following ovulation induction by clomiphene citrate and timed intercourse: a case report

We report a combined intra-uterine and unruptured tubal pregnancy following ovulation induction by clomiphene citrate (CC) and timed intercourse. The diagnosis of heterotopic pregnancy (HP) is the major problem until occurrence of tubal rupture. Because HP is a life-threatening condition, the diagnosis should be made as soon as possible. In a spontaneous conception, HP is a rare event. The risk of HP significantly increases after ovulation induction. Clomiphene itself could be associated with a high HP rate. We present a case with normally developing intra-uterine singleton pregnancy successfully managed by salpingectomy of synchronous tubal pregnancy following ovulation induction by CC and a review of the literature.

A new predictive scoring system including shock index for unruptured tubal pregnancy patients

Objective Shock index (SI) and predictive score grading system including it for predicting medical treatment failure of tubal pregnancies have been studied. Study design Eighty-eight patients were diagnosed as nonruptured tubal pregnancies. Shock index was calculated as the ratio of heart rate to systolic arterial pressure. A predictive score was used based on four parameters including initial level of β-human chorionic gonadotropin (βhCG), aspect of the image on ultrasound, size of the ectopic mass and shock index value at admission. Results Forty patients have undergone to surgery because of tubal gestational sac size ≥4 cm and/or presence of fetal heart activity. Nineteen patients were managed expectantly. Twenty-four patients received single dose methotrexate (MTX) and five patients received second dose MTX. Success rate for single dose MTX therapy was 72% (21/29). The cut-off shock index value for tubal rupture was 0.77 with 89% sensitivity and 61% specifity. Conclusion In this study, we demonstrated that tubal pregnancy patients who were managed with nonsurgical measures at admission and who had SI values lower than 0.77 and predictive score grades greater and equal to 6.5 did not experience tubal rupture and did not need surgical intervention during nonsurgical management.

204: Laparoscopic Management of Atypical Presentation of Ectopic Pregnancy

To analysis twenty two hemodynamically stable patients of ectopic pregnancy clinically presented as an atypical form for accuracy of diagnosis, operative details and post operative morbidity. Three year, retrospective analysis. Victory Nursing & Infertility Management Centre, Khulna. Twenty-two. Laparoscopic Surgery. Twenty two patients with atypical presentation of ectopic pregnancy were successfully managed laparoscopically. All patients have dull ache pain in lower abdomen or any one iliac fossa. Regular and irregular menstrual pattern were 54.5% and 45.4% respectively, ultrasound findings were complex heterogeneous mass without any free fluid in 8 cases, definitive gestational sac 6, saclike structure 8 cases. Urinary β-hCG was positive 40.9% and negative 59%. Pre-operative diagnoses were chronic ectopic pregnancy 11, ruptured corpus luteum 6 and chocolate cyst 5. Operative diagnoses were chronic ectopic pregnancy 14, unruptured tubal pregnancy 5, ovarian ectopic 3. Surgical procedures were salpingostomy, salpingectomy, salpingoophrectomy, partial ovarian resection and only removal of sac with peritoneal toileting. Average operating time was 30–120 minutes. The average post-operative stay was 24–48 hours without any complications. Ectopic pregnancy does not present always typical form. In suspected cases these guidelines should help the gynecologist’s decision making for best obstetric outcome and able them to understand different possibilities.