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Rev Bras Ginecol Obstet. 2024;46:e-rbgo64
, , , , 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.
Summary
Rev Bras Ginecol Obstet. 2024;46:e-rbgo64
, , , , 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.
Summary
Rev Bras Ginecol Obstet. 1998;20(3):127-135
DOI 10.1590/S0100-72031998000300002
A prospective study was performed with 42 patients with unruptured ectopic pregnancy, which intended to elaborate an index to orient the systemic treatment with the administration of a single intramuscular dose of methotrexate (50 mg/m²). Patients were monitored with beta-hCG titers on days 1, 4 and 7 after the methotrexate. When the titers of beta-hCG declined more than 15%, between days 4 and 7 after methotrexate, the patients were discharged and had an outpatient follow-up monitored with beta-hCG titers weekly until the titers were less than 5 mIU/ml, which represents success of the treatment. We prepared an index for the systemic treatment with methotrexate, with five parameters: (1) initial titers of beta-hCG; (2) aspects of the image at ultrasound (hematosalpinx, gestational sac, live embryo); (3) size of the mass; (4) free fluid in cul-de-sac; (5) collor doppler. Each parameter received a grade from 0 to 2. Grade 0 represented bad prognosis, favorable parameters received grade 2 and borderline parameters received grade one. The success rate with a single dose of methotrexate was 69.0% (29/42). The color doppler was performed in 20 of the 42 patients; in this group of 20 patients the success rate was 75.0% (15/20). In the 22 patients who were not submitted to the color doppler, the average grade of the score in the successful cases was 6.6, and in the unsuccessful it was 3.1. In the group who underwent the doppler (20 patients) the average was 7.9 in the successful cases and 4.2 in the cases that failed. In the present study the cut-off grade was 5, for most of the patients with grades above 5 had a successful treatment (15/16 - 93.75%), while grades equal or below 5 failed. The score will help to indicate the best cases for the medical treatment. We do not advise the treatment when the grade is equal or below 5. Therefore, we can predict a good evolution of the treatment when the grade is above five.
Summary
Rev Bras Ginecol Obstet. 1998;20(3):127-135
DOI 10.1590/S0100-72031998000300002
A prospective study was performed with 42 patients with unruptured ectopic pregnancy, which intended to elaborate an index to orient the systemic treatment with the administration of a single intramuscular dose of methotrexate (50 mg/m²). Patients were monitored with beta-hCG titers on days 1, 4 and 7 after the methotrexate. When the titers of beta-hCG declined more than 15%, between days 4 and 7 after methotrexate, the patients were discharged and had an outpatient follow-up monitored with beta-hCG titers weekly until the titers were less than 5 mIU/ml, which represents success of the treatment. We prepared an index for the systemic treatment with methotrexate, with five parameters: (1) initial titers of beta-hCG; (2) aspects of the image at ultrasound (hematosalpinx, gestational sac, live embryo); (3) size of the mass; (4) free fluid in cul-de-sac; (5) collor doppler. Each parameter received a grade from 0 to 2. Grade 0 represented bad prognosis, favorable parameters received grade 2 and borderline parameters received grade one. The success rate with a single dose of methotrexate was 69.0% (29/42). The color doppler was performed in 20 of the 42 patients; in this group of 20 patients the success rate was 75.0% (15/20). In the 22 patients who were not submitted to the color doppler, the average grade of the score in the successful cases was 6.6, and in the unsuccessful it was 3.1. In the group who underwent the doppler (20 patients) the average was 7.9 in the successful cases and 4.2 in the cases that failed. In the present study the cut-off grade was 5, for most of the patients with grades above 5 had a successful treatment (15/16 - 93.75%), while grades equal or below 5 failed. The score will help to indicate the best cases for the medical treatment. We do not advise the treatment when the grade is equal or below 5. Therefore, we can predict a good evolution of the treatment when the grade is above five.
Summary
Rev Bras Ginecol Obstet. 2008;30(3):149-159
DOI 10.1590/S0100-72032008000300008
It is advisable to do the non-invasive diagnosis of ectopic pregnancy precociously, before there is the tube rupture, combining for that the transvaginal ultrasonography with the dosage of the b-fraction of the chorionic gonadotrophin. A range of treatment options may be used. Either a surgical intervention or a clinical treatment may be taken into consideration. Laparotomy is indicated in cases of hemodynamic instability. Laparoscopy is the preferential route for the treatment of tube pregnancy. Salpingectomy should be performed in patients having the desired number of children, while salpingostomy should be indicated in patients willing to have more children, when the b-hCG titers are under 5,000 mUI/mL and the surgical conditions are favorable. The use of methotrexate (MTX) is a consecrated clinical procedure and should be indicated as the first option of treatment. The main criteria for MTX indication are hemodynamic stability, b-hCG <5,000 mUI/mL, anexial mass <3,5 cm, and no alive embryo. It is preferable a single intramuscular dose of 50 mg/m², because it is easier, more practical and with less side effects. Protocol with multiple doses should be restricted for the cases with atypical localization (interstitial, cervical, caesarean section scar and ovarian) with values of b-hCG >5,000 mUI/mL and no alive embryo. Indication for local treatment with an injection of MTX (1 mg/kg) guided by transvaginal ultrasonography should occur in cases of alive embryos, but with an atypical localization. An expectant conduct should be indicated in cases of decrease in the b-hCG titers within 48 hous before the treatment, and when the initial titers are under 1,500 mUI/mL. There are controversies between salpingectomy and salpingostomy, concerning the reproductive future. Till we reach an agreement in the literature, the advice to patients who are looking forward to a future gestation, is to choose either surgical or clinical conservative conducts.
Summary
Rev Bras Ginecol Obstet. 2008;30(3):149-159
DOI 10.1590/S0100-72032008000300008
It is advisable to do the non-invasive diagnosis of ectopic pregnancy precociously, before there is the tube rupture, combining for that the transvaginal ultrasonography with the dosage of the b-fraction of the chorionic gonadotrophin. A range of treatment options may be used. Either a surgical intervention or a clinical treatment may be taken into consideration. Laparotomy is indicated in cases of hemodynamic instability. Laparoscopy is the preferential route for the treatment of tube pregnancy. Salpingectomy should be performed in patients having the desired number of children, while salpingostomy should be indicated in patients willing to have more children, when the b-hCG titers are under 5,000 mUI/mL and the surgical conditions are favorable. The use of methotrexate (MTX) is a consecrated clinical procedure and should be indicated as the first option of treatment. The main criteria for MTX indication are hemodynamic stability, b-hCG <5,000 mUI/mL, anexial mass <3,5 cm, and no alive embryo. It is preferable a single intramuscular dose of 50 mg/m², because it is easier, more practical and with less side effects. Protocol with multiple doses should be restricted for the cases with atypical localization (interstitial, cervical, caesarean section scar and ovarian) with values of b-hCG >5,000 mUI/mL and no alive embryo. Indication for local treatment with an injection of MTX (1 mg/kg) guided by transvaginal ultrasonography should occur in cases of alive embryos, but with an atypical localization. An expectant conduct should be indicated in cases of decrease in the b-hCG titers within 48 hous before the treatment, and when the initial titers are under 1,500 mUI/mL. There are controversies between salpingectomy and salpingostomy, concerning the reproductive future. Till we reach an agreement in the literature, the advice to patients who are looking forward to a future gestation, is to choose either surgical or clinical conservative conducts.
Summary
Rev Bras Ginecol Obstet. 1999;21(3):153-157
DOI 10.1590/S0100-72031999000300006
Purpose: to evaluate the efficacy of color Doppler in the prediction of results of the systemic treatment of unruptured ectopic pregnancy with a single dose of methotrexate. Methodology: twenty patients with a diagnosis of ectopic pregnancy were included in the study. The inclusion criteria were: hemodynamic stability, adnexal mass < 5.0 cm and decline of the titers of beta-hCG less than 15% in an interval of 24 h. The exclusion criteria were hepatic or renal disease and blood dyscrasias. Follow-up was by serial determinations of beta-hCG on days 4 and 7 after the beginning of the treatment, and weekly until the titers were negative. The patients were classified into 3 groups according to color Doppler: high risk (trophoblastic flow covering more than 2/3 of the mass), medium risk (when trophoblastic flow compromised 1/3 to 2/3 of tubal mass) and low risk (when trophoblastic flow covered less than 1/3 of the mass). Results: the success of the treatment with a single dose was 75% (15/20); when a second dose of MTX was used, the success rate was 85%. When comparing color Doppler with the results of the medical treatment, we had high risk in 4 patients and in all the treatment failed; medium and low risk in 16 patients, and in 15 the treatment was successful. Conclusion: color Doppler showing high risk indicated an unfavorable situation for the medical treatment with MTX, while medium and low risk in color doppler were favorable situations for the clinical treatment. However, these results should always be analyzed in association with the evolution curve of the beta-hCG titers.
Summary
Rev Bras Ginecol Obstet. 1999;21(3):153-157
DOI 10.1590/S0100-72031999000300006
Purpose: to evaluate the efficacy of color Doppler in the prediction of results of the systemic treatment of unruptured ectopic pregnancy with a single dose of methotrexate. Methodology: twenty patients with a diagnosis of ectopic pregnancy were included in the study. The inclusion criteria were: hemodynamic stability, adnexal mass < 5.0 cm and decline of the titers of beta-hCG less than 15% in an interval of 24 h. The exclusion criteria were hepatic or renal disease and blood dyscrasias. Follow-up was by serial determinations of beta-hCG on days 4 and 7 after the beginning of the treatment, and weekly until the titers were negative. The patients were classified into 3 groups according to color Doppler: high risk (trophoblastic flow covering more than 2/3 of the mass), medium risk (when trophoblastic flow compromised 1/3 to 2/3 of tubal mass) and low risk (when trophoblastic flow covered less than 1/3 of the mass). Results: the success of the treatment with a single dose was 75% (15/20); when a second dose of MTX was used, the success rate was 85%. When comparing color Doppler with the results of the medical treatment, we had high risk in 4 patients and in all the treatment failed; medium and low risk in 16 patients, and in 15 the treatment was successful. Conclusion: color Doppler showing high risk indicated an unfavorable situation for the medical treatment with MTX, while medium and low risk in color doppler were favorable situations for the clinical treatment. However, these results should always be analyzed in association with the evolution curve of the beta-hCG titers.
Summary
Rev Bras Ginecol Obstet. 2002;24(5):309-313
DOI 10.1590/S0100-72032002000500004
Purpose: to evaluate the importance of endometrial thickness measurement as an orienting factor for the clinical treatment of unruptured tubal pregnancy. Method: longitudinal observational study, in which the greatest measure of the endometrial thickness was evaluated in millimeters, in the uterine longitudinal axis, through transvaginal ultrasonography. Our study group included 181 patients, all of them respecting the utilization criteria for the clinical treatment (expectant or medicated with methotrexate). Through Student's t test we evaluated the difference between the average thickness of the cases who presented successful results with the treatment and the average of those who failed. Results: the average endometrial thickness of the patients who presented successful results with the medical treatment (31 cases) was 6.4 mm, while the average in the cases of failure was 11.5 mm. These results were significantly different. The average thickness of the successful group with expectant management (128 cases) was 9.0 mm, while the average of those who failed was 9.6 mm. These values were not statistically different. Conclusions: the greatest measure of the endometrial thickness of the uterine longitudinal axis through transvaginal ultrasonography proved to be valuable as a new orienting factor for the medical treatment of patients with a diagnosis of unruptured tubal pregnancy. It may become a useful and auxiliary tool for the recommendation of the use of methotrexate. On the other hand, thickness did not show to be useful as an orienting factor for establishing expectant management.
Summary
Rev Bras Ginecol Obstet. 2002;24(5):309-313
DOI 10.1590/S0100-72032002000500004
Purpose: to evaluate the importance of endometrial thickness measurement as an orienting factor for the clinical treatment of unruptured tubal pregnancy. Method: longitudinal observational study, in which the greatest measure of the endometrial thickness was evaluated in millimeters, in the uterine longitudinal axis, through transvaginal ultrasonography. Our study group included 181 patients, all of them respecting the utilization criteria for the clinical treatment (expectant or medicated with methotrexate). Through Student's t test we evaluated the difference between the average thickness of the cases who presented successful results with the treatment and the average of those who failed. Results: the average endometrial thickness of the patients who presented successful results with the medical treatment (31 cases) was 6.4 mm, while the average in the cases of failure was 11.5 mm. These results were significantly different. The average thickness of the successful group with expectant management (128 cases) was 9.0 mm, while the average of those who failed was 9.6 mm. These values were not statistically different. Conclusions: the greatest measure of the endometrial thickness of the uterine longitudinal axis through transvaginal ultrasonography proved to be valuable as a new orienting factor for the medical treatment of patients with a diagnosis of unruptured tubal pregnancy. It may become a useful and auxiliary tool for the recommendation of the use of methotrexate. On the other hand, thickness did not show to be useful as an orienting factor for establishing expectant management.
Summary
Rev Bras Ginecol Obstet. 1999;21(6):347-350
DOI 10.1590/S0100-72031999000600008
Purpose: to evaluate safety and efficacy of intra-amniotic injection of methotrexate (MTX) for treatment of viable cervical pregnancy. Methods: four women with viable cervical pregnancy confirmed by ultrasound (US) were treated with transvaginal injection of MTX (1 mg/kg) under sonographic control. The follow-up was made with serial dosages of beta-hCG on days 1, 4 and 7 after injection and weekly until the titers were negative. Results: the patients were treated with success. The time for the titers of beta-hCG to become negative after the treatment was: 62 days (case 1), 84 days (case 2), 28 days (case 3) and 10 days (case 4). Conclusion: intra-amniotic injection of MTX can be used to avoid surgery in cases of viable cervical pregnancy.
Summary
Rev Bras Ginecol Obstet. 1999;21(6):347-350
DOI 10.1590/S0100-72031999000600008
Purpose: to evaluate safety and efficacy of intra-amniotic injection of methotrexate (MTX) for treatment of viable cervical pregnancy. Methods: four women with viable cervical pregnancy confirmed by ultrasound (US) were treated with transvaginal injection of MTX (1 mg/kg) under sonographic control. The follow-up was made with serial dosages of beta-hCG on days 1, 4 and 7 after injection and weekly until the titers were negative. Results: the patients were treated with success. The time for the titers of beta-hCG to become negative after the treatment was: 62 days (case 1), 84 days (case 2), 28 days (case 3) and 10 days (case 4). Conclusion: intra-amniotic injection of MTX can be used to avoid surgery in cases of viable cervical pregnancy.
Summary
Rev Bras Ginecol Obstet. 1999;21(8):465-470
DOI 10.1590/S0100-72031999000800007
SUMMARY Objective: to evaluate the inclusion parameters in the selection of cases of (tubal) ectopic pregnancy for expectant management and to assess the results. Methods: a prospective study was carried out in 70 patients with unruptured (tubal) ectopic pregnancy, with the objective to carry out an expectant management. The main inclusion criteria in this study were the diameter of the tubal mass, that should be equal or inferior to 5,0 cm, reduced titles of beta-hCG (beta fraction of the chorionic gonadotropic hormone) as compared to the initial value within an interval of 48 h, hemodynamic stability, wishes for future pregnancy and a written permission to participate in the study. All patients were observed in the hospital and when reduction in beta-hCG titles was observed, the patients were discharged from the hospital and followed in the outpatient department, with weekly determinations of beta-hCG until levels lower than 5 mIU/ml were reached, that were considered successful. Results: of the 70 patients who underwent expectant management, only one needed a surgical intervention, because of tubal rupture. The initial values of beta-hCG of the patients ranged from 27 mIU/ml to 41,000 mIU/ml. The average diameter of the tubal mass was 2.9 cm. The presence of free liquid in the peritoneal cavity was observed in 50 patients, small amount in 26 patients, moderate in 16 and large in 8 patients. The ultrasonographic resolution of hematosalpinx occurred in 58 patients and tubal ring was visualized in 12 patients. On color Doppler, 52 were at low risk and 18 at medium risk. Conclusions: the expectant management should be applied with safety in the cases that respect the inclusion criteria, the index of success of this study being 98.6%.
Summary
Rev Bras Ginecol Obstet. 1999;21(8):465-470
DOI 10.1590/S0100-72031999000800007
SUMMARY Objective: to evaluate the inclusion parameters in the selection of cases of (tubal) ectopic pregnancy for expectant management and to assess the results. Methods: a prospective study was carried out in 70 patients with unruptured (tubal) ectopic pregnancy, with the objective to carry out an expectant management. The main inclusion criteria in this study were the diameter of the tubal mass, that should be equal or inferior to 5,0 cm, reduced titles of beta-hCG (beta fraction of the chorionic gonadotropic hormone) as compared to the initial value within an interval of 48 h, hemodynamic stability, wishes for future pregnancy and a written permission to participate in the study. All patients were observed in the hospital and when reduction in beta-hCG titles was observed, the patients were discharged from the hospital and followed in the outpatient department, with weekly determinations of beta-hCG until levels lower than 5 mIU/ml were reached, that were considered successful. Results: of the 70 patients who underwent expectant management, only one needed a surgical intervention, because of tubal rupture. The initial values of beta-hCG of the patients ranged from 27 mIU/ml to 41,000 mIU/ml. The average diameter of the tubal mass was 2.9 cm. The presence of free liquid in the peritoneal cavity was observed in 50 patients, small amount in 26 patients, moderate in 16 and large in 8 patients. The ultrasonographic resolution of hematosalpinx occurred in 58 patients and tubal ring was visualized in 12 patients. On color Doppler, 52 were at low risk and 18 at medium risk. Conclusions: the expectant management should be applied with safety in the cases that respect the inclusion criteria, the index of success of this study being 98.6%.
Summary
Rev Bras Ginecol Obstet. 2004;26(6):471-475
DOI 10.1590/S0100-72032004000600008
OBJECTIVE: to evaluate the correlation between the beta-human chorionic gonadotropin (beta-hCG) serum levels and the measurement of the endometrial thickness, in patients under treatment of ectopic pregnancy with methotrexate. METHODS: a prospective study in which the levels of beta-hCG as well as the largest measurement of the endometrial thickness on the uterine longitudinal axis through transvaginal ultrasound were evaluated at 24-48 h intervals in thirty-eight patients with hemodynamic stability, ectopic pregnancy, diameter <3.5 cm, and increased beta-hCG levels. All the patients got methotrexate in a single-dose therapy (50 mg/m² im). We compared the mean values of beta-hCG and endometrial thickness of cases that evolved successfully versus the poor responders using the Student t-test. Afterwards we analyzed the difference of the beta-hCG mean serum values related to the endometrial thickness(<10.0 mm and >10.0 mm) independently of the response to treatment employing the Student t-test. RESULTS: the mean values of beta-hCG and endometrial thickness in patients with successful treatment (28 cases) were 1936.2 mIU/ml and 6.4 mm, respectively, significanlty lower than the mean values for insuccessful cases: 6831.3 mIU/ml and 11.7 mm, respectively (p<0.05). The mean values of beta-hCG in women with endometrial thickness <10.0 mm were 2008.7 mIU/ml, significantly lower than the ones with endometrium >10.0 mm, whose mean values were 6925.9 mIU/ml (<0.05). CONCLUSIONS: the measurement of the endometrial thickness through ultrasound is under the beta-hCG serum values influence, and it showed to be a valuable additional factor to suggest medical treatment with methotrexate in the non-disrupted ectopic pregnancy.
Summary
Rev Bras Ginecol Obstet. 2004;26(6):471-475
DOI 10.1590/S0100-72032004000600008
OBJECTIVE: to evaluate the correlation between the beta-human chorionic gonadotropin (beta-hCG) serum levels and the measurement of the endometrial thickness, in patients under treatment of ectopic pregnancy with methotrexate. METHODS: a prospective study in which the levels of beta-hCG as well as the largest measurement of the endometrial thickness on the uterine longitudinal axis through transvaginal ultrasound were evaluated at 24-48 h intervals in thirty-eight patients with hemodynamic stability, ectopic pregnancy, diameter <3.5 cm, and increased beta-hCG levels. All the patients got methotrexate in a single-dose therapy (50 mg/m² im). We compared the mean values of beta-hCG and endometrial thickness of cases that evolved successfully versus the poor responders using the Student t-test. Afterwards we analyzed the difference of the beta-hCG mean serum values related to the endometrial thickness(<10.0 mm and >10.0 mm) independently of the response to treatment employing the Student t-test. RESULTS: the mean values of beta-hCG and endometrial thickness in patients with successful treatment (28 cases) were 1936.2 mIU/ml and 6.4 mm, respectively, significanlty lower than the mean values for insuccessful cases: 6831.3 mIU/ml and 11.7 mm, respectively (p<0.05). The mean values of beta-hCG in women with endometrial thickness <10.0 mm were 2008.7 mIU/ml, significantly lower than the ones with endometrium >10.0 mm, whose mean values were 6925.9 mIU/ml (<0.05). CONCLUSIONS: the measurement of the endometrial thickness through ultrasound is under the beta-hCG serum values influence, and it showed to be a valuable additional factor to suggest medical treatment with methotrexate in the non-disrupted ectopic pregnancy.