Atkinson Monique, Gupta Sarika, Mcgee Therese
Department of Obstetrics and Gynaecology, Westmead Hospital, Westmead, New South Wales, Australia.
Aust N Z J Obstet Gynaecol. 2014 Oct;54(5):475-9. doi: 10.1111/ajo.12257.
In ectopic pregnancy (EP) management, failure of βhCG to fall more than 15% between Days 4 and 7 after methotrexate administration indicates the need for a second dose. Regimens preferring a 25% fall in βhCG between methotrexate administration and Day 7 have been proposed.
Our study analysed these and other regimens' performance in predicting treatment success. Secondarily, we investigated how each regimen guided the prescription of additional methotrexate doses.
Medical files of 88 women with ultrasound confirmed tubal EP and pretreatment βhCG <6000 IU/L, unsuitable for expectant management, were retrospectively analysed. The βhCG monitoring regimens studied were (i) 15% fall Day 4-7, (ii) 25% fall Day 0/1-7, (iii) any fall Day 0/1-7, (iv) any fall Day 0/1-4 and (v) 20% fall Day 0/1-4. Treatment success was defined if the EP resolved without surgical intervention. Statistical analysis was performed using McNemar's test.
Overall, treatment success with methotrexate was 92% (n = 81/88). Predicting success of methotrexate (PPV 98-100%) and detecting those needing surgery (specificity 86-100%) were equivalent across all monitoring regimens. However, the 25% Day 0/1-7 fall (and the Day 0/1-4 regimens) over-selected women for a second dose of methotrexate (P < 0.05).
The performance of each regimen is equivalent to the traditional 15% fall Day 4-7 regimen in predicting treatment success. However, a regimen aiming for a 25% fall in βhCG Day 0/1-7 over-selects patients for a second methotrexate dose. In comparison, any drop in βhCG Day 0/1-7 does not over-select women and eliminates Day 4 testing.
在异位妊娠（EP）的治疗中，甲氨蝶呤给药后第4天至第7天β人绒毛膜促性腺激素（βhCG）下降幅度未超过15%表明需要给予第二剂药物。有人提出了更倾向于甲氨蝶呤给药至第7天βhCG下降25%的治疗方案。
我们的研究分析了这些及其他方案在预测治疗成功方面的表现。其次，我们调查了每种方案如何指导额外甲氨蝶呤剂量的处方。
回顾性分析了88例经超声确诊为输卵管异位妊娠且治疗前βhCG<6000 IU/L、不适合期待治疗的女性的病历。所研究的βhCG监测方案为：（i）第4天至第7天下降15%；（ii）第0/1天至第7天下降25%；（iii）第0/1天至第7天有任何下降；（iv）第0/1天至第4天有任何下降；（v）第0/1天至第4天下降20%。如果异位妊娠在无手术干预的情况下得以解决，则定义为治疗成功。使用McNemar检验进行统计分析。
总体而言，甲氨蝶呤治疗成功率为92%（n = 81/88）。在所有监测方案中，预测甲氨蝶呤治疗成功（阳性预测值98 - 100%）和检测出需要手术的患者（特异性86 - 100%）的效果相当。然而，第0/1天至第7天下降25%（以及第0/1天至第4天的方案）让更多女性被选择接受第二剂甲氨蝶呤（P < 0.05）。
在预测治疗成功方面，每种方案的表现与传统的第4天至第7天下降15%的方案相当。然而，旨在使第0/1天至第7天βhCG下降25%的方案会让更多患者被选择接受第二剂甲氨蝶呤。相比之下，第0/1天至第7天βhCG有任何下降不会让更多女性被选择接受治疗，并且无需在第4天进行检测。
