Diagnosing ectopic pregnancy in the emergency setting

Lee, Robert; Dupuis, C; Chen, Byron Y.; Smith, Andrew P.; Kim, Young H.

doi:10.14366/usg.17044

Cited by 54 publications

(42 citation statements)

References 16 publications

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“…Tubal ectopic pregnancies (EPs) comprise 98% of all EPs ( Lee et al , 2018 ). It is a prevalent condition, occurring in 1–2% of all reported pregnancies in the developed world ( Elson et al , 2016 ).…”

Section: Introductionmentioning

confidence: 99%

Efficacy and safety of expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis

Colombo

Leonardi

Armour

et al. 2020

Human Reproduction Open

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STUDY QUESTION Is expectant management (EM) of tubal ectopic pregnancy (EP) an effective and safe treatment strategy when compared to alternative interventions? SUMMARY ANSWER There is insufficient evidence to conclude EM yields a difference in the resolution of tubal EP, the avoidance of surgery or time to resolution of tubal EP when compared to intramuscular methotrexate in stable patients with β-hCG <1500 IU/l. WHAT IS ALREADY KNOWN The utilisation of medical and surgical management for EP is well established. EM aims to allow spontaneous resolution of the EP without intervention. STUDY DESIGN, SIZE, AND DURATION We performed a systematic review and meta-analysis, searching Ovid MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, OpenGrey.eu, Google Scholar, cross-referencing citations and trial registries to 15 December 2019. There were no limitations placed on language or publication date. Search terms included tubal EP and EM as well as variations of these terms. PARTICIPANTS/MATERIALS, SETTING AND METHOD We considered studies that included patients with tubal EP, EM as a comparator, and that were randomised controlled trials (RCTs). The primary outcome was resolution of tubal EP. Secondary outcomes included avoidance of surgery and the time to resolution of EP. Two reviewers independently selected the studies, assessed bias and extracted data. Relative risk (RR) and mean difference with 95% CI were assessed using a random effects model. The certainty of evidence was scored according to Grading of Recommendations Assessment, Development and Evaluation guidelines. MAIN RESULTS AND THE ROLE OF CHANCE In total, 920 studies were screened. Five studies were eligible for inclusion in the systematic review. Two RCTs comparing methotrexate to EM were identified as being eligible for inclusion in meta-analysis. No RCTs comparing surgery to EM were identified. Compared with EM, there was insufficient evidence that methotrexate yields a difference on resolution of tubal EP (RR 1.04, 95% CI 0.88–1.23, P = 0.67; two RCTs, moderate-certainty evidence), avoiding surgery (RR 1.10, 95% CI 0.94–1.29, P = 0.25; two RCTs, low-certainty evidence) or the time to resolution of tubal EP (−2.56 days (favouring EM), 95% CI −7.93–2.80, P = 0.35; two RCTs, low-certainty evidence). LIMITATIONS, REASONS FOR CAUTION Only two RCTs with a total of 103 patients were eligible for inclusion in this meta-analysis. Further RCTs comparing EM to medical and surgical management are needed and these should also report adverse events. Patient preference should also be evaluated. WIDER IMPLICATIONS OF THE FINDINGS We found insufficient evidence of differences in terms of resolution, avoidance of surgery and time to resolution between expectant and medical management. Given the imprecision in the effect estimates as demonstrated by the wide CIs, resulting in the downgrading of certainty of evidence for all outcomes in this meta-analysis, larger RCTs comparing interventions for tubal EP are needed. Caution should be exercised when trying to decide between EM and methotrexate to treat tubal EP. STUDY FUNDING/COMPETING INTEREST(S) There was no funding for this study. NICM receives funding from various sources; none specifically supported this research. M.L. reports grants from Australian Women and Children's Research Foundation, outside the submitted work. M.A.: As a medical research institute, NICM Health Research Institute receives research grants and donations from foundations, universities, government agencies and industry. Sponsors and donors provide untied and tied funding for work to advance the vision and mission of the Institute. This systematic review was not specifically supported by donor or sponsor funding to NICM. M.A. reports a partnership grant with Metagenetics outside the submitted work. G.C. reports grants from Australian Women and Children's Research Foundation, personal fees from Roche and GE Healthcare, outside the submitted work. The remaining authors report no conflicts of interest. PROSPERO REGISTRATION NUMBER CRD42020142736

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Section: Introductionmentioning

confidence: 99%

Efficacy and safety of expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis

Colombo

Leonardi

Armour

et al. 2020

Human Reproduction Open

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“…Studies have highlighted its case fatality rates of 1-3% in developing countries, which is 10 times higher than developed countries (7). To prevent its mortality, early diagnosis and treatment of ectopic pregnancy is fundamental (8). Additionally, early diagnosis and treatment of ectopic pregnancy is associated with minimized morbidity (9).…”

Section: Introductionmentioning

confidence: 99%

“…Additionally, early diagnosis and treatment of ectopic pregnancy is associated with minimized morbidity (9). Evidences show that in the majority of cases (98%) implementation occurs in uterine tubes and its most common complication is rupture of the ectopic pregnancy and life threatening hemorrhage (8).…”

Section: Introductionmentioning

confidence: 99%

Risk Factors for Ectopic Pregnancy: A Multi-center Case Control Study

Atta

Aram

Naseri

et al. 2021

Preprint

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Background: Ectopic pregnancy (EP) is defined as a pregnancy in which fertilized oocyte implants outside the endometrial cavity. Although there is no known etiology for ectopic pregnancy, some risk factors of EP have been determined. It has been evident that ectopic pregnancy can be of multifactorial origin. This multicenter research aims to study risk factors associated with increased risk of ectopic pregnancy in women living in Kabul. Methods: A multicenter case control study was conducted in five tertiary maternity hospitals located in Kabul, Afghanistan. A total of 457 pregnant women were included in this study. In the case group, women with diagnosed ectopic pregnancy, while in control group women with intrauterine pregnancy were included. For each case in this study, two controls were enrolled. Results: The mean (SD) age of women in case group was 27.9 (6) years while in control group it was 26.4 (5.5) years. This difference was not statistically significant. We found a significant association between history of abortion and EP (Adj. OR=1.57; 95%CI: 1.02, 2.42). Having history of abdominal/pelvic surgery was a risk factor for EP with adjusted OR 1.94 (95%CI: 1.15, 3.30). In this study we found an increasing risk of EP in women of 35 years or older compared to younger women (Crude OR=2.26; p= 0.024). In women reporting prior EP, the chance of its recurrence was increased (Crude OR= 9.64; 95%CI: 1.1, 83.2). No association of gravidity and parity was found with EP incidence. Conclusions: In this study we found a statistically significant association between history of abdominal/pelvic surgery and EP. In addition, history of abortion was suggested as a risk factor for ectopic pregnancy. In case of having a previous EP probability of its recurrence will be increased. Women with advanced age having other potential risk factors will be facing higher risk of EP.

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“…Patients with EP tend to be younger and have more birth demand . Mostly, patients with EP are identified by hCG levels monitoring and ultrasound scans before they have developed clinical symptoms . Therefore, conservative medication becomes the predominant treatment in EP, which is reasonable and economical practice.…”

Section: Introductionmentioning

confidence: 99%

Contribution of genetic polymorphism of methylene tetrahydrofolate reductase on the effect of methotrexate in ectopic pregnancy patients

Deng

Chen

Xue

et al. 2019

Clinical Laboratory Analysis

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Background: Methotrexate (MTX) is the prior drug in ectopic pregnancy (EP).However, approximately 10% of patients suffer from failure by MTX therapy.Reduced folate carrier 1 (RFC1), methylene tetrahydrofolate reductase (MTHFR), and dihydrofolate reductase (DHFR) are involved in the transport and effects of MTX in vivo. In the present study, we aim to investigate the relationship between the genetic polymorphisms of RFC1, MTHFR, and DHFR and the clinical efficacy of MTX in tubal pregnancies.Methods: 100 patients of EP were enrolled in this study. Polymorphisms of RFC1 G80A, MTHFR C677T, and DHFR A-317G were genotyped. β-hCG level was detected in day 0, 4, and 7 after MTX injection. Association of MTX efficacy and genetic polymorphisms was analyzed.Results: Methylene tetrahydrofolate reductase C677T was associated with MTX treatment (P = .017). The success rate of first MTX injection was superior in patients with harboring mutation allele of MTHFR gene than that in patients with wild-type gene (P = .001). However, there was no significant association between the polymorphisms of RFC1 G80A, DHFR A-317G, and surgical treatment (P = .709 and .476, respectively). In addition, β-hCG level decrement was not significantly changed by MTX injection with different polymorphisms of RFC1, MTHFR, and DHFR on either day 4 (P = .214, 0.197 and 0.270, respectively) or day 7 (P = .172, .554, and .726, respectively). Conclusion:Our results suggested that the reliable indicator was polymorphism of MTHFR C677T in failure by MTX injection. K E Y W O R D Sclinical efficacy, dihydrofolate reductase, ectopic pregnancy, genetic polymorphisms, methotrexate, methylene tetrahydrofolate reductase, reduced folate carrier 1

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Diagnosing ectopic pregnancy in the emergency setting

Cited by 54 publications

References 16 publications

Efficacy and safety of expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis

Efficacy and safety of expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis

Risk Factors for Ectopic Pregnancy: A Multi-center Case Control Study

Contribution of genetic polymorphism of methylene tetrahydrofolate reductase on the effect of methotrexate in ectopic pregnancy patients

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