Factors Predicting Persistent Ectopic Pregnancy After Laparoscopic Salpingostomy or Salpingotomy for Tubal Pregnancy: A Retrospective Cohort Study

Study ObjectiveTo identify factors predictive of persistent ectopic pregnancy (PEP) in women who have undergone laparoscopic salpingostomy or salpingotomy for tubal pregnancy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingTertiary referral center.PatientsNinety-nine women who underwent laparoscopic tubal preservation surgery for ectopic pregnancy.InterventionsSeventy women underwent laparoscopic salpingostomy, and the remaining 29 women underwent laparoscopic salpingotomy.Measurements and Main ResultsFactors predicting PEP were evaluated. The change in serum beta human chorionic gonadotropin (β-hCG) levels from baseline observed between postoperative days 5 and 10 (ChCGD5-10) was a predictor of PEP (odds ratio [OR], 0.80; p = .01). Based on receiver operating characteristic (ROC) curve analysis, a cutoff value of 93.1% was determined, with an area under the ROC curve of 0.95 (sensitivity, 85.7%; specificity, 100%). Nonetheless, when considering perioperative variables only, body mass index (BMI) was identified as a predictor of PEP (OR, 0.71; p = .03). Based on the ROC analysis, a BMI cutoff value of ≤22 kg/m² was determined, with an ROC area of 0.73 (sensitivity, 43.2%; specificity, 100%). In addition, a higher baseline β-hCG level (hazard ratio [HR], 1.0002; p = .009) and left tubal pregnancy (HR, 6.46; p = .03) were predictive of recurrent ectopic pregnancy. There were no differences in the perioperative outcomes, PEP rates, or subsequent intrauterine pregnancy rates between the salpingostomy and salpingotomy groups. In addition, surgical method was not a predictor of recurrent ectopic pregnancy.ConclusionsChCGD5-10 was identified as a predictor for PEP, suggesting that it might be more clinically useful for the follow-up of PEP. When considering perioperative variables only, BMI was a predictor for PEP. In addition, there was no significant difference in clinical outcomes between the salpingostomy and salpingotomy groups.     

两种不同治疗方法对异位妊娠预后影响的临床分析

目的:分析评价药物保守治疗和手术治疗异位妊娠对患者预后的影响。方法:对有生育要求的171例异位妊娠患者,分别对其中65例实施肌内注射MTX(药物组),106例行输卵管切除术(手术组)。结果:药物组中,在经过1或2个疗程MTX化疗后,彻底治愈51例,治愈率为78.5%,平均治疗时间为21±7天。手术组,治愈率为100%。随访2年,两组再次宫内受孕的成功率药物组45.1%,手术组51.9%,差异无显著性(P>0.05)。结论:肌内注射MTX治疗未破裂异位妊娠是一种安全而较为有效的治疗措施,其治疗后再次宫内受孕的成功率与手术组相比无明显差异。     

甲氨蝶呤单剂量肌内注射治疗异位妊娠的临床研究

目的：探讨影响甲氨蝶呤（methotrexate,MTX）单剂量肌内注射（肌注）治疗异位妊娠（ectopic pregnancy,EP）疗效的相关因素。 方法：回顾性分析武汉大学人民医院2006年7月—2011年7月行MTX单剂量肌注治疗的EP患者临床资料。结果：纳入269例EP患者,根据最终结局分为失败组和成功组,失败组52例（19.3%）,成功组217例（80.7%）。失败组的初始血人绒毛膜促性腺激素β亚单位（β-hCG）浓度、EP史比例、妊娠周、包块直径高于成功组（P＜0.05）。多因素Logistic回归分析提示,初始β-hCG为2 000～5 000 IU/L及≥5 000 IU/L,妊娠周为6～8周及＞8周、超声包块直径≥4 cm是MTX单剂量肌注治疗失败的危险因素。患者年龄、妊娠次数、人工流产史、盆腔手术史、节育器使用史与治疗失败率无关（P＞0.05）。受试者工作特征（receiver operating characteristic,ROC）曲线选择1 871.5 IU/L为初始β-hCG预测治疗成功的阈值,敏感度为82.7%,特异度为70%,曲线下面积为 0.8（P＜0.05）。结论：初始β-hCG浓度高、妊娠时间长、包块直径大是MTX单剂量肌注治疗失败的危险因素,须谨慎行MTX单剂量肌注方案,治疗期间应密切观察。     

Nonsurgical Management of Live Tubal Ectopic Pregnancy by Ultrasound-Guided Local Injection and Systemic Methotrexate

Study ObjectiveTo evaluate outcomes relative to treatment using systemic methotrexate (MTX) alone or systemic MTX combined with ultrasound (US)–guided local injection of potassium chloride (KCl) or MTX in women with live tubal ectopic pregnancies.DesignCase-control study (Canadian Task Force classification II-2).SettingDepartments of Obstetrics and Gynecology in 2 hospitals in China.PatientsEighty-two women with live tubal ectopic pregnancies.InterventionParticipants in the study received treatment using either systemic MTX (n = 37; systemic treatment group) or systemic MTX and US-guided local injection of either MTX or KCl (n = 45; combined treatment group).Measurements and Main ResultsPatient clinical features and outcomes were compared. There were no significant differences between the patient groups insofar as baseline gestational age, β-human chorionic gonadotropin concentration, or size of conceptus. The success rate in patients who received combined therapy (93.3%) was much higher than in those who received only systemic treatment (73.0%) (p < .05). In the combined treatment group, the success rate was similar between women who received locally injected KCl (95.2%) and those who received locally injected MTX (91.7%).ConclusionThe significantly higher success rate in patients who received combined US-guided local injection and systemic MTX suggests that this is an efficient nonsurgical option in women with tubal pregnancy, high serum β-human chorionic gonadotropin concentration, and fetal cardiac activity.     

Retrospective Study on Laparoscopic Management of Ectopic Pregnancy

Purpose

To evaluate various laparoscopic methods for management of tubal ectopic pregnancy and study the incidence of ectopic pregnancy including the incidence of cornual ectopic pregnancy and conversion to laparotomy during laparoscopic procedure.

Methods

A retrospective study was conducted in North Point Hospital, Delhi, on all laparoscopies conducted in 4 years, i.e., from January 2008 to December 2011.

Results

Incidence of ectopic pregnancy was 4.62 % (out of all laparoscopic surgeries over 4 years) and that for cornual pregnancy was 4.65 % (out of all ectopic pregnancies); no laparotomy was done for the management of ectopic pregnancy. The site of ectopic pregnancy in the tubal pregnancy varied, with 76.75 % in the ampullary region, 16.27 % isthumic, 2.33 % fimbrial, and 4.65 % in the cornual region. Salpingectomy was done in 53.5 % cases and 46.5 % of patients underwent a conservative approach in the form of salpingostomy.

Conclusion

The laparoscopic management of ectopic pregnancy is a safe and effective option with greatly reduced morbidity.     

Laparoscopic Salpingostomy with Electrocautery in the Management of Tubal Pregnancy

From August, 1990 to May, 1991, all cases of tubal pregnancy presenting to King George V Hospital for Mothers and Infants were considered for laparoscopic salpingostomy. This procedure involved opening the affected Fallopian tube with diathermy, removal of ectopic tissue via the laparoscope, achieving haemostasis and leaving the tubal incision to heal by secondary intention. The procedure was undertaken in 35 patients and was successfully performed in 31 patients with an average operating time of 66.4 minutes (+/- 20.1 minutes). Average hospital stay was 2.1 days (+/- 1.3). This paper examines the technique and results of the initial learning curve for laparoscopic salpingostomy and finds that with knowledge of potential hazards and care in surgery, this operation can be safely carried out in a selected group of patients.     

输卵管妊娠发病机制的最新研究进展

输卵管妊娠是最常见的异位妊娠,约占异位妊娠的98%,其病因及发病机制至今尚不明确。长期以来,输卵管手术和生殖道感染等各种高危因素导致输卵管内膜形态异常、炎性粘连、管腔狭窄甚至闭塞的解剖形态学异常改变被认为是输卵管妊娠的主要病因。最近研究发现,输卵管受精卵转运异常（包括各种因素导致的输卵管平滑肌收缩或输卵管纤毛摆动改变,以及输卵管微环境改变等功能性异常）可能是导致输卵管妊娠发生的重要机制。此外,免疫因素及细胞因子也可能在输卵管妊娠形成过程中起到一定作用。     

Methotrexate for Nonsurgical Treatment of Ectopic Pregnancy: Nursing Implications

Early diagnosis of ectopic pregnancy can provide women an alternative to surgical therapy. Nonsurgical treatment using methotrexate is cost-effective, restores subsequent fertility, and decreases the morbidity and mortality intrinsic to traditional surgical procedures. This article reviews the risk factors, signs and symptoms, diagnostic techniques, and nursing care for medically treated ectopic pregnancy.     

Recurrent Tubal Ectopic Pregnancy Management and the Risk of a Third Ectopic Pregnancy

Study ObjectiveTo evaluate the rate of a third ectopic pregnancy according to the modality of treatment of the second ectopic pregnancy.DesignRetrospective cohort study.SettingUniversity-affiliated tertiary medical center.PatientsOne hundred eleven women who had 2 ectopic pregnancies and a third consecutive pregnancy between 2003 and 2018.InterventionsSurgery or medical treatment as required.Measurements and Main ResultsWith regard to the modality of treatment of the second ectopic pregnancy, the patients were divided into 3 groups: expectant management, medical treatment with methotrexate, and laparoscopic salpingectomy. Univariate and multivariate analyses were conducted to assess the association of various parameters of the second ectopic pregnancy with the occurrence of a third ectopic pregnancy in the consecutive pregnancy. Twenty women (18.0%) were managed expectantly, 55 (49.6%) were treated with methotrexate, and 36 (32.4%) underwent surgery. Expectant management resulted in significantly higher rates of a third ectopic pregnancy compared with treatment with methotrexate or surgical intervention (50.0% vs 18.2% and 13.8%, respectively; p = .005). In the cases of 2 ipsilateral ectopic pregnancies, the interventional approach (medical or surgical treatment) resulted in lower recurrence rates compared with expectant management (25.7% vs 60.0%, respectively; p = .043).ConclusionThe risk of a third episode of an ectopic pregnancy after expectant management of a second ectopic pregnancy is extremely high. An interventional approach by treatment with methotrexate or salpingectomy is therefore preferred for recurrent ectopic pregnancy management, especially in ipsilateral recurrences.     

Left–Right Asymmetry of Tubal Pregnancy: A 12-Year Retrospective Hospital-Based Study

Study Objective

To investigate whether there are left–right asymmetries, factors affecting lateral dominance, and clinical feature differences in the left and right sides of tubal pregnancy (TP).

A Hepatic Ectopic Pregnancy Treated with Direct Methotrexate Injection

EDITORIAL COMMENT: We accepted this paper for publication not only because of its rare anecdotal interest but also because it seems to us that if ever an ectopic pregnancy warrants management with direct injection of methotrexate it is when it is attached to areas such as described in this paper where horrendous haemorrhage or damage to the biliary tract could occur as mentioned in the cases reviewed from the literature.
Summary: An ectopic pregnancy of the liver posterior to the porta hepatis and therefore in a surgically hazardous area was successfully treated with injection of methotrexate at laparotomy.     

Safety of Laparoscopic Surgery for Benign Diseases during Pregnancy: A Nationwide Retrospective Cohort Study

Study Objective

To compare fetal, maternal, and operative outcomes of laparoscopic surgery versus laparotomy for major benign diseases including appendicitis, cholecystitis, adnexal masses, and uterine myoma during pregnancy.

Use of Cytomegalovirus-Specific Hyperimmunoglobulins in Pregnancy: A Retrospective Cohort

Objective

There is no consensus on the use of cytomegalovirus (CMV)–specific hyperimmunoglobulins (CSHIGs) for suspected congenital CMV infections during pregnancy, but this therapy is currently used in some countries. The objectives of this study were to describe tolerability and pregnancy outcome following treatment with monthly intravenous CSHIG and compare rates of positive PCR and postnatal symptoms according to whether CSHIGs were given or not.

持续性异位妊娠的影响因素分析

目的：回顾性分析异位妊娠保守性手术后持续性异位妊娠发生的原因。方法：随机选取我科2008年至2010年因异位妊娠行腹腔镜下输卵管开窗取胚术患者98例,并分成AB两组,A组患者74例术中给予稀释后甲氨喋呤管残腔内注射．B组患者24例未给于药物管腔注射,两组患者于术后第3天及第5天复查血清13一HCG,同时进行相应处理,根据妊娠部位及术中是否用药与发生持续性异位妊娠的概率进行比较。结果：A组74例患者无1例发生持续性异位妊娠,B组24例患者发生持续性异位妊娠3例,其中2例妊娠部位为输卵管伞端妊娠,结论：输卵管伞端妊娠组织开窗清除术与输卵管其他部位开窗取胚术比较发生持续性异位妊娠率高（P〈O．05）。术中输卵管中未给药（甲氨喋呤）比术中给药发生持续性异位妊娠率高（P〈0．05）。     

A Systematic Review of Single-Dose Intramuscular Methotrexate for the Treatment of Ectopic Pregnancy

EDITORIAL COMMENT: The authors state that their review of the literature of single-dose intramuscular methotrexate for the treatment of ectopic pregnancy-revealed cases where the woman represented with shock secondary to ruptured ectopic pregnancy, requiring emergency laparotomy, but no report of a maternal death. The Annual Report for the year 1996 of the Consultative Council on Obstetric and Paediatric Mortality and Morbidity of Victoria, Australia, released in April 1998, provided details of such a case: (page 74 of report) 'A 38-year-old woman had an ectopic pregnancy diagnosed and was treated conservatively with methotrexate. She developed anaemia and a haemoperitoneum and laparotomy was performed. The woman then developed a massive pulmonary thromboembolism and died 1 day later despite embolectomy'.
Summary: The use of single-dose intramuscular methotrexate for the primary treatment of ectopic pregnancy is increasing in frequency in many countries. We performed a systematic review of all available studies and case reports of intramuscular methotrexate to examine the therapeutic efficacy, side-effects and complication rates of this new treatment approach. The pooled data show a successful resolution rate of 71% (95% confidence interval 58% to 81%) after a single dose of intramuscular methotrexate and 84% (95% confidence interval 77% to 90%) after 1 or 2 doses. Side-effects were experienced by 24% (95% confidence interval 9% to 47%) of patients and 10% (95% confidence interval 7% to 14%) had a ruptured ectopic pregnancy. The pooled data show that single-dose intramuscular methotrexate is associated with a high failure rate. Follow-up is prolonged and there is a significant incidence of minor side-effects. Serious complications and side-effects have occurred. The use of intramuscular methotrexate should be confined to clinical trials until more evidence is obtained to support its more widespread use.     

Pelvic Infection and the Pathogenesis of Tubal Ectopic Pregnancy

All ectopic pregnancies occurring in a defined New Zealand urban area from the years 1970 and 1984 were studied (232 cases in total). The medical records and histological preparations were reviewed. A 38% increase in the incidence of ectopic pregnancy over this 15-year period is documented. The percentage of patients with histological evidence of past tubal infection increased from 40.6% in 1970 to 61.2% in 1984. Significant increases in the number of patients with histories of infertility or past pelvic infection and of patients with operative evidence of past infection were also noted. These results support the postulate that the increase in incidence of ectopic pregnancies over recent decades is strongly associated with the increase in prevalence of pelvic infection. Tubal damage secondary to previous pelvic infection is probably the major, although certainly not the only, aetiological factor in the development of tubal pregnancies.