Changing Paradigms in the Initial Treatment of Ectopic Pregnancy at a University Hospital in Brazil

Tavares, Bárbara Virginia Gonçalves; Delfino, Letícia Sathler; Ignarro, Isabella Silvestre; Baccaro, Luiz Francisco

doi:10.1055/s-0043-1768999

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Revista Brasileira de Ginecologia e Obstetrícia

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Sumário

Original Article, High Risk Pregnancy • Rev Bras Ginecol Obstet. 45 (4) • 2023 • https://doi.org/10.1055/s-0043-1768999 copy

Changing Paradigms in the Initial Treatment of Ectopic Pregnancy at a University Hospital in Brazil

Mudança de paradigmas do tratamento inicial de gravidez ectópica em um hospital universitário no Brasil

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To evaluate the use of different treatment options for ectopic pregnancy and the frequency of severe complications in a university hospital.

Methods

Observational study with women with ectopic pregnancy admitted at UNICAMP Womeńs Hospital, Brazil, between 01/01/2000 and 12/31/2017. The outcome variables were the type of treatment (first choice) and the presence of severe complications. Independent variables were clinical and sociodemographic data. Statistical analysis was carried out by the Cochran–Armitage test, chi-square test, Mann–Whitney test and multiple Cox regression.

Results

In total 673 women were included in the study. The mean age was 29.0 years (± 6.1) and the mean gestational age was 7.7 (± 2.5). The frequency of surgical treatment decreased significantly over time (z = -4.69; p < 0.001). Conversely, there was a significant increase in the frequency of methotrexate treatment (z = 4.73; p < 0.001). Seventy-one women (10.5%) developed some type of severe complication. In the final statistical model, the prevalence of severe complications was higher in women who were diagnosed with a ruptured ectopic pregnancy at admission (PR = 2.97; 95%CI: 1.61–5.46), did not present with vaginal bleeding (PR = 2.45; 95%CI: 1.41–4.25), had never undergone laparotomy/laparoscopy (PR = 6.69; 95%CI: 1.62–27.53), had a non-tubal ectopic pregnancy (PR = 4.61; 95%CI: 1.98–10.74), and do not smoke (PR = 2.41; 95%CI: 1.08–5.36).

Conclusion

there was a change in the first treatment option for cases of ectopic pregnancy in the hospital during the period of analysis. Factors inherent to a disease that is more difficult to treat are related to a higher frequency of severe complications.

Keywords
Pregnancy complications; Pregnancy; Tubal; Pregnancy trimester first; Uterine hemorrhage

Variables	n	Prevalence	Power of the sample	Sample Size for 80% power
Surgical treatment	n = 673	64,34%	0.754	n = 747
Methotrexate treatment	n = 673	25,85%	0.864	n = 543
Expectant management	n = 673	9,81%	0.998	n = 180
Presence of severe complications	n = 673	10.55%	0.998	n = 201

Characteristics	n	%
Age (y)
< 20	39	5.79
20–29	308	45.77
30–39	303	45.02
40–49	23	3.42
Years of schooling*
≤ 9	110	44.5
≤ 12	111	44.5
> 12 (college)	26	11.0
Marital status*
With partner	382	73.5
Without partner	138	26.5
Skin color*
White	420	70.1
Brown	129	21.6
Black	47	7.8
Yellow	2	0.3
Indigenous	1	0.2
Previous pregnancies*
0	161	23.96
1	187	27.83
2	141	20.98
≥ 3	183	27.23
Previous cesarean sections*
0	471	70.19
1	136	20.27
≥ 2	64	9.54
Previous abortions*
0	400	59.52
1	187	27.83
≥ 2	85	12.65

Treatments	Frequency (%)
Type of treatment (first choice)
Surgical	64.64
Methotrexate	25.85
Expectant	9.81
Methotrexate protocol
Short	98.32
Long	1.68
Surgery access route
Pfannenstiel	64.24
Laparoscopy	21.22
Median incision	13.56
Laparoscopy followed by Pfannenstiel	0.98
Type of surgery
Salpingectomy	77.57
Salpingophorectomy	4.30
Salpingostomy	8.01
Other	10.16

Variables	Severe complication		n	p-value
	Yes (%)	No (%)
Location				0.004^b b Fisher's exact test.
Tubal	85.92	95.35	635
Nontubal	14.08	4.65	38
Abdominal pain				< 0.001^a a Chi-square test.
Yes	83.10	62.17	432
No	16.90	37.83	239
Vaginal bleeding				< 0.001^a a Chi-square test.
Yes	43.66	64.17	416
No	56.34	35.83	255
Previous ectopic				0.002^a a Chi-square test.
Yes	2.82	17.11	105
No	97.18	82.89	568
Previous laparotomy				0.011^a a Chi-square test.
Yes	11.27	24.75	157
No	88.73	75.25	516
Smoking				0.029^a a Chi-square test.
Yes	15.63	28.52	156
No	84.38	71.48	420
Skin color				0.015^a a Chi-square test.
White	83.61	68.59	420
Non-white	16.39	31.41	179
Ectopic pregnancy integrity				< 0.001^a a Chi-square test.
Non-ruptured	27.94	63.23	399
Ruptured	72.06	36.77	270
Type of treatment (first choice)				< 0.001^a a Chi-square test.
Surgical	90.14	61.30	433
Methotrexate	8.45	27.91	174
Expectant	1.41	10.80	66
Surgical access route				< 0.001^b b Fisher's exact test.
Laparoscopy	2.94	24.04	108
Laparoscopy followed by Pfannenstiel	1.47	0.91	5
Median laparotomy	29.41	11.11	69
Pfannenstiel	66.18	63.95	327
Median laparotomy	29.41	11.11	69
Pfannenstiel	66.18	63.95	327

Variables	Severe complication		p-value*
	Yes	No
	Mean ± SD	Mean ± SD
Serum β-hCG at diagnosis (mIU/mL)	16,325 ± 24,529	5,300.9 ± 10,459	0.005
Gestational sac diameter (mm)	43.20 ± 21.40	36.73 ± 19.96	0.016
Methotrexate dose (mg)	93.50 ± 32.89	86.7 ± 21.76	0.921
Height (cm)	159.46 ± 7.50	161.11 ± 6.52	0.049
Body surface area (m²)	1.69 ± 0.19	1.69 ± 0.16	0.833
Gestational age at diagnosis (ultrasound-weeks)	9.91 ± 4.33	7.46 ± 2.06	0.019
Number of previous pregnancies	1.61 ± 1.52	1.72 ± 1.51	0.452
Number of previous cesarean sections	0.40 ± 0.75	0.43 ± 0.77	0.660
Length of hospital stay (days)	3.85 ± 2.23	3.14 ± 1.94	< 0.001

Variables	p-value	P.R.*	95% CI PR*
Ectopic pregnancy integrity at diagnosis
Non-ruptured (ref)	−	1,00	−
Ruptured	<0,001	2,97	1,61–5,46
Vaginal bleeding
Yes (ref)	−	1,00	−
No	0,002	2,45	1,41–4,25
Surgical history such as laparotomy or laparoscopy
Yes (ref)	−	1,00	−
No	0,009	6,69	1,62–27,53
Smoking
Yes	−	1.00	−
No	0.031	2.41	1.08–5.36
Ectopic pregnancýs location
Tubal (ref)	−	1,00	−
Non-tubal	<0,001	4,61	1,98–10,74

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[1] Address for correspondence Bárbara Virginia Gonçalves Tavares, Address: Alexander Fleming, 101, 13083-881, Cidade Universitária, Campinas, SP, Brazil (barbaravgtavares@gmail.com)