CLINICAL EPIDEMIOLOGY 2021 ACTIVITY U1A8 Clinical Case A 26-year-old woman comes to the emergency department because of a sudden onset of right-sided lower abdominal pain that began 3 hours ago and has been increasing in intensity. She noticed vaginal spotting 2 hours ago. Her last menstrual period was 6 weeks ago. She has been sexually active since age 17 with multiple partners. She uses foam for contraception. She had an appendectomy in the past. She is afebrile, and vital signs are stable. On examination she has flat abdomen with lower quadrant tenderness and rebound, right more than the left. Speculum examination reveals only minimal dark vaginal blood without cervical purulence. Bimanual examination reveals a closed, thick cervix moderately tender to motion. Her uterus is slightly enlarged and softened. Right adnexal tenderness is present, but there is no palpable mass. Serum quantitative β-hCG: 3,500 mIU/mL CBC: Hemoglobin 13.0 Transvaginal U/S: normal uterus without an intrauterine gestational sac PATIENT INTERVENTION • Young woman • Ectopic regnancy Laparoscopic salpingostomy COMPARISON Laparoscopic methotrexate injection vs laparoscopic salpingostomy OUTCOMES • Lower treatment failure rate? • Reduce risk for future ectopic pregnancies? • Preserves future fertility? • Lower post treatment complications? • Lower rate of persistent EP? Is salpingostomy related to bene cial e ect on future fertility in ectopic pregnancies than laparoscopic methotrexate injection? Laparoscopy, methotrexate injection, fertility, ectopic pregnancies, salpingostomy Laparoscopic surgery is the most effective treatment in women with tubal EP. There’s no difference in fertility between intratubal MTX or salpingostomy. Both have not showed beneficial effect on posterior IUP rates, whereas the risk of repeat EP was increased although not significantly. Long-term reproductive outcomes are slightly more favorable in patients with laparoscopic local methotrexate injection, in a retrospective study where women who went under local MTX injection had higher IUP rate than those with salpingostomy. Although must be considered that the MTX injection is only effective on those women who’s initial hCG is <2,000miU/ml and size at laparoscopy less than <2.0. ff fi Martha Sarahí Barrón Onofre 217017 1 CLINICAL EPIDEMIOLOGY 2021 ACTIVITY U1A8 1. On PubMed, start an advanced search 2. Select MeSH Terms 3. Introduce the key words from the break down of your PICO query 4. Obtained only 2 results 5. Click on one of the results and discover similar articles 6. Collect 7 articles from this database Martha Sarahí Barrón Onofre 217017 2 CLINICAL EPIDEMIOLOGY 2021 ACTIVITY U1A8 1. 2. 3. 4. Sing in with CREATIVA account Select Tripdatabase resource Select PICO search Introduce the data from your previous breakdown 5. Select Evidence type and/or Clinical Area (i.e. Evidence type: All secondary evidence, Clinical area: OB-Gyn 6. Select the results 7. I obtained only 2 results related with my clinical question and type of clinical evidence Martha Sarahí Barrón Onofre 217017 3 CLINICAL EPIDEMIOLOGY 2021 ACTIVITY U1A8 1. Enter to Scopus database 2. Start an advanced search 3. Introduce keywords and add to the search with the boolean operators 4. Initiate search 5. Obtained only 1 result Martha Sarahí Barrón Onofre 217017 4 CLINICAL EPIDEMIOLOGY 2021 ACTIVITY U1A8 SELECTED ARTICLES: • Hajenius, P., Mol, B., Bossuyt, P., Ankum, W., & Van der Veen, F. (2000). Interventions for tubal ectopic pregnancy. The Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd000324 • Kooi, S. (1993). Critical Comparisons of Alternative Therapies for Ectopic Pregnancy! Fertility and Sterility, 59(1), 244–245. doi:10.1016/s0015-0282(16)55651-9 • Mol, F., Mol, B., Ankum, W., Van der Veen, F., & Hajenius, P. (2008). Current evidence on surgery, systemic methotrexate and expectant management in the treatment of tubal ectopic pregnancy: a systematic review and meta-analysis. Hum. Reprod, 14(4), 309-319. doi:10.1093/humupd/dmn012 • Porpora, M. G., Oliva, M. M., Cristofaro, A. D., Montanino, G., & Cosmi, E. V. (1996). Comparison of local injection of methotrexate and linear salpingostomy in the conservative laparoscopic treatment of ectopic pregnancy. The Journal of the American Association of Gynecologic Laparoscopists, 3(2), 271–276. doi:10.1016/ s1074-3804(96)80012-0 • Practice Committee of American Society for Reproductive Medicine. (2013). Medical treatment of ectopic pregnancy: a committee opinion. Fertil Steril. 100(3):638-44. doi: 10.1016/j.fertnstert.2013.06.013. • Shalev, E., Peleg, D., Bustan, M., Romano, S., & Tsabari, A. (1995). Limited role for intratubal methotrexate treatment of ectopic pregnancy. Fertility and Sterility, 63(1), 20–24. doi:10.1016/s0015-0282(16)57290-2 • Zilber, Pansky, Bukovsky, & Golan. (1996). Laparoscopic salpingostomy versus laparoscopic local methotrexate injection in the management of unruptured ectopic gestation. American Journal of Obstetrics and Gynecology, 175(3), 600–602. doi:10.1053/ob.1996.v175.a74249 Martha Sarahí Barrón Onofre 217017 5
