Sten Grove Thomsen

Methotrexate treatment of ectopic pregnancy

The last decade has witnessed an increasing number of reports indicating that ectopic pregnancy (EP) can be successfully and safely treated with methotrexate (MTX). This review summarizes the results. In large series, as many as 45% of a population of women with EP has been treated with MTX. Success rates of 82–95% have been achieved. Tubal patency on the affected side was preserved in 79–91% of the cases. Preliminary assessment of subsequent fertility suggests that 47–69% will obtain an intrauterine pregnancy. Complications have been only few and of minor importance. However, the majority of reports do not include controls. Randomized studies are needed to optimize patient selection, treatment regimens, long‐term toxicity, future fertility, and cost‐benefits.

Success and spontaneous pregnancy rates following systemic methotrexate versus laparoscopic surgery for tubal pregnancies: A randomized trial

Objective. To determine which treatment should be offered to women with a non‐ruptured tubal pregnancy: a single dose of methotrexate (MTX) or laparoscopic surgery. Design. Prospective, randomized, open multicenter study. Setting. Seven Danish departments of obstetrics and gynecology. Sample. A total of 106 women diagnosed with ectopic pregnancy (EP). Methods. Between March 1997 and September 2000, 1,265 women were diagnosed with EP, 395 (31%) were eligible, 109 (9%) were randomized of whom 106 had an EP. The study was originally powered to a sample size of 422 patients. The women were randomized to either medical (MTX; 53) or surgical (laparoscopic salpingotomy; 53) treatment. Follow‐up by questionnaire and through national patient databases for a maximum of 10 years. Main outcome measures. Uneventful decline of plasma‐human chorionic gonadotropin to less than 5 IU/L, rates of spontaneous, subsequent intrauterine, and recurrent ectopic pregnancies. Results. The success rates were 74% following MTX treatment and 87% after surgery (n.s.); the subsequent spontaneous intrauterine pregnancy rate was 73% after MTX and 62% after surgery; and the EP rate was 9.6% after MTX and 17.3% following surgery (n.s.). Conclusions. In women with an EP, who are hemodynamically stable and wishing to preserve their fertility, medical treatment with single dose MTX tends to be equal to treatment with laparoscopic surgery regarding success rate, complications, and subsequent fertility. Although the two treatment modalities seemed to be similar in outcome, it is crucial that the diagnosis is based on a high‐quality ultrasonographic evaluation, as two patients had intrauterine pregnancies despite fulfilling the diagnostic algorithm for EP.

Correlation between self-reported gestational age and ultrasound measurements.

Background.  We studied the agreement between different measurements of gestational age, i.e. self‐reported gestational age in the Danish National Birth Cohort Study, ultrasound‐estimated gestational age from the medical records in one Danish county and gestational age from the Danish National Hospital Discharge Register.

Cesarean section: Is pretransfusion testing for red cell alloantibodies necessary?

Background.  Routine pretransfusion testing for red cell alloantibodies (RBCab) in cesarean patients is standard practice in many obstetric centers. The objective of the present study was to evaluate the usefulness of this test.

Ectopic pregnancy: histopathology and assessment of cell proliferation with and without methotrexate treatment.

OBJECTIVE To evaluate tubal morphology, trophoblast proliferation, and inflammatory reaction in response to methotrexate (MTX) treatment of ectopic pregnancy (EP). DESIGN Nonrandomized controlled study. SETTING Academic hospital. PATIENTS Archival specimens from 10 EP unsuccessfully treated with MTX and 10 cases primarily treated by surgery. INTERVENTIONS Ki67/hCG and Ki67/human placental lactogen double immunohistochemical methods were used to examine trophoblastic spread, placentation, hormone production, decidualization, vascular invasion, hemorrhage, rupture, and proliferative index of the cytotrophoblast. B and T-lymphocyte responses were evaluated by CD3 and CD20. RESULTS Trophoblastic spread and placentation were confined to the tubal mucosa after MTX treatment, whereas invasion of the muscularis and subserosa was common in the controls. The proliferative index was reduced (19 percent versus 93 percent), although a high proliferative index was found in two of three cases complicated by rupture. Polar proliferation of Ki67-positive cytotrophoblast toward the implantation site was abolished in MTX-treated cases. Decidual reaction was not observed. No correlation was observed between the above-mentioned findings and gestational age, level of beta-hCG, dose of MTX, or interval to surgery. CONCLUSION Trophoblastic spread, differentiation, and invasion were compromised by MTX treatment. Methotrexate seems to decrease cytotrophoblast proliferation. Whether a missing decrease in proliferation index reflects treatment failure awaits a larger population-based study.

Prediction of delivery date by sonography in the first and second trimesters

To compare the dates of delivery predicted by last menstrual period (LMP), crown–rump length (CRL) and biparietal diameter (BPD) with the actual date of delivery in a population of pregnant women divided into those with certain and those with uncertain LMP.

Open Randomized Comparison of Prostaglandin E2 Given by Intracervical Gel or Vagitory for Preinduction Cervical Ripening and Induction of Labor

Intracervical application of prostaglandin E2 (PGE2) in a viscous gel was compared with conventional wax‐based PGE2 vagitories (pessaries) for ripening of the cervix prior to induction of labor. A total of 226 healthy pregnant women at term were randomly allocated to receive intracervical gel with an effective dose of 0.5 mg (n = 116) or vagitories containing 2.5 mg PGE2 (n = 110). All women had a modified cervical score of ≤ 4. The numbers of cases contributed by each of the three centers were similar. There was no significant difference in parity, gestational length, maternal characteristics, indications for induction or preinduction cervical scores between the treatment groups. The rate of spontaneous birth was 71% in the gel group, compared with 69% in the vagitory group. Successful treatment was defined as active labor within 24 h or a change in cervical dilatation allowing artificial rupture of the membranes with subsequent progressive labor. The success rate was not significantly different in the gel group (82%) compared with the vagitory group (80%). There were no differences in the frequency of fetal distress, outcome of labor, assisted delivery rates or maternal side effects. The cervical scores were not different at 12 and 24 h after application. Intracervical gel and intravaginal application of PGE2 were similar in their efficacy and safety for ripening of the cervix and inducing labor at term.

Alternative treatment for symptomatic fibroids.

The present review discusses treatment options for symptomatic fibroids. Although the standard treatment of fibroids has been surgical hysterectomy, an increasing number of reports indicate that uterine artery embolization with preservation of the uterus is a promising alternative. Other surgical and medical approaches reported during the past year are also addressed. The review summarizes patient selection, contraindications, results, complications and future considerations. Complications following uterine artery embolization treatment for symptomatic fibroids have been minor in comparison with those following hysterectomy. Although patient satisfaction is good, none of the studies included control individuals and further studies are needed to optimize patient selection and to evaluate long-term results of treatment.

Smoking habits and maternal serum a‐fetoprotein levels during the second trimester of pregnancy

Summary. In a prospective study the influence of cigarette smoking on maternal serum a‐fetoprotein levels at 16 weeks gestation was examined. Significantly higher levels were found in 120 smokers compared with 138 non‐smokers (median 54.0 and 44.3 μg/1 respectively, P<0.001). No difference in maternal body weight between the two groups could account for the results. The possibility of smoking‐induced increased permeability of the placental barrier is discussed.

Fibroids treated by uterine artery embolization

An increasing number of reports indicate that uterine fibroids can be successfully treated with uterine artery embolization (UAE). UAE seems to be a promising treatment for women who want to retain their uterus. This review summarizes the technical considerations and the results. UAE is a radiological procedure using angiography for visualization of the blood circulation. Subsequently, the flow through the uterine arteries is blocked resulting in infarction of fibroids. Success rates of 87% have been achieved with an average 57% reduction of fibroid volume. Complications have been few compared to hysterectomy and patient satisfaction is high. However, none of the reports include controls. Further studies are needed to optimize patient selection and to evaluate long‐term results.