Women's Health Institute, Cleveland Clinic Foundation (Drs. Gingold and Falcone, and Ms. Mei).
School of Medicine, Case Western Reserve University School of Medicine (Drs. Janmey and Gemmell), Cleveland, Ohio; UPMC Magee-Womans Hospital, Pittsburgh, Pennsylvania (Dr. Janmey).
J Minim Invasive Gynecol. 2021 Jul;28(7):1334-1342.e3. doi: 10.1016/j.jmig.2020.09.003. Epub 2020 Sep 7.
To determine whether completion rates of salpingostomy for tubal ectopic pregnancy are compromised by initial medical management with methotrexate (MTX).
Retrospective cohort study.
Single academic hospital system.
Patients requiring surgery for ectopic pregnancy between 2006 and 2017.
A subset of patients who went directly to surgery, and all patients who failed MTX before requiring surgery underwent detailed chart review. Salpingostomy plan and success rate and salpingostomy failure reasons were compared between patients pretreated with MTX and those who were MTX-untreated.
Among 94 ectopic pregnancies requiring surgery after failed MTX treatment, 55 (59%) underwent planned salpingostomy. From 693 ectopic pregnancies managed without MTX, 166 were analyzed in detail, of which 80 (48%) underwent planned salpingostomy. The patients who underwent planned salpingostomy were thinner (body mass index 27.3 ± 7.2 kg/m vs 29.3 ± 8.3 kg/m; p = .048), less frequently African American (33% vs 47%; p = .017), and more likely to have a visualized adnexal lesion (70% vs 52%; p = .004) than those undergoing planned salpingectomy. Preoperative ultrasound identified fetal cardiac activity and hemoperitoneum at comparable rates. MTX exposure was not associated with age, body mass index, race, ectopic risk factors, human chorionic gonadotropin levels, or gestational age at diagnosis, but the patients treated with MTX underwent surgery later than those who were untreated (gestational age 53.4 ± 11.2 days vs 43.5 ± 11 days; p <.001). The differences between the adnexal lesion size and rates of fetal cardiac activity and hemoperitoneum on ultrasound related to MTX exposure did not meet significance. Planned salpingostomy was completed in 22 (40%) of the patients treated with MTX vs 34 (42%) of those who were untreated. The reasons for failure, surgery time, and rates of hemoperitoneum or ectopic rupture were not associated with MTX exposure. Body mass index, race, tubal anastomosis history, visualization of the adnexal lesion, and MTX exposure were not significantly associated with the salpingostomy rate in a multivariate logistic regression model, but having a subspecialist surgeon (odds ratio 2.70; 95% confidence interval, 1.08-6.76; p = .033) and tubal rupture at surgery (odds ratio 0.23; 95% confidence interval, 0.09-0.54; p = .001) were.
The initial medical management of an ectopic pregnancy with MTX is not associated with a decreased salpingostomy success rate.
确定在异位妊娠初始使用甲氨蝶呤（MTX）进行医学治疗是否会影响输卵管吻合术的完成率。
回顾性队列研究。
单家学术医院系统。
2006 年至 2017 年间需要手术治疗的异位妊娠患者。
直接进行手术的患者为一组，所有 MTX 治疗失败后需要手术的患者均进行详细的图表审查。比较 MTX 预处理患者和未接受 MTX 治疗患者的输卵管吻合术计划和成功率以及输卵管吻合术失败的原因。
在 94 例 MTX 治疗失败后需要手术的异位妊娠患者中，55 例（59%）进行了计划的输卵管吻合术。在 693 例未接受 MTX 治疗的异位妊娠患者中，详细分析了 166 例，其中 80 例（48%）进行了计划的输卵管吻合术。进行计划输卵管吻合术的患者更瘦（体重指数 27.3±7.2kg/m 与 29.3±8.3kg/m；p=0.048），非裔美国人的比例较低（33%与 47%；p=0.017），且更可能在术前超声检查中发现附件病变（70%与 52%；p=0.004）。术前超声检查发现胎儿心脏活动和血腹的比例相似。MTX 暴露与年龄、体重指数、种族、异位妊娠危险因素、人绒毛膜促性腺激素水平或诊断时的孕龄无关，但接受 MTX 治疗的患者比未接受治疗的患者接受手术的时间更晚（孕龄 53.4±11.2 天与 43.5±11 天；p<0.001）。与 MTX 暴露相关的附件病变大小以及胎儿心脏活动和血腹的超声检查率之间的差异没有达到显著性。在接受 MTX 治疗的 22 例（40%）患者中完成了计划的输卵管吻合术，而在未接受 MTX 治疗的 34 例（42%）患者中完成了计划的输卵管吻合术。失败的原因、手术时间以及血腹或异位妊娠破裂的发生率与 MTX 暴露无关。体重指数、种族、输卵管吻合术史、附件病变的可视化以及 MTX 暴露在多变量逻辑回归模型中与输卵管吻合术率均无显著相关性，但具有亚专科医师（比值比 2.70；95%置信区间，1.08-6.76；p=0.033）和手术时输卵管破裂（比值比 0.23；95%置信区间，0.09-0.54；p=0.001）是。
异位妊娠初始使用 MTX 进行医学治疗不会降低输卵管吻合术的成功率。
