BJOG Exchange
DOI: 10.1111/1471-0528.12489 www.bjog.org
Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy
Sir, We read with interest the article by Ahn et al.1 on a novel and interesting approach to a very relevant aspect of early pregnancy complications. The management of unruptured interstitial pregnancy is complex and the preferred management options vary from centre to centre. We were impressed by the potential benefits of ultrasound-guided transcervical forceps extraction (UTCE) to the patient in the short term, with regard to reducing patient morbidity, and also in the long term, with regard to future pregnancy options for mode of delivery. We agree with the authors’ conclusion of the limitations of the study being that it was a small retrospective, single-centre non-randomised controlled study; but accept that the nature of the condition would make a randomised study difficult to design. Furthermore, the rarity of interstitial pregnancies means that studies involving larger numbers would be difficult to organise. However, with respect to the methodology and patient recruitment, it is not clear whether members of the study team counselled women about their options. If so, this may have produced an element of bias. We would be interested to hear from the authors about the type of anaesthetic, if any, used during the procedure in the event that this would be reproduced in other units. Unfortunately, the results did not reflect the promise of the study objec-
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tives. Our interpretation of the results was that the overall success rate was better for surgical (100%) and medical management (100%) than for UTCE (83.3%). In addition, the serious complications were equivalent to current accepted practice options and the duration of stay was similar. It would be interesting to know what statistical analyses were undertaken to support the statement of a high success rate of the procedure. We are also less positive about the training opportunities to develop this technique given the low incidence of interstitial pregnancy. The impact on mode of delivery in future pregnancies does not appear to have been addressed in this study given that 66% of women undergoing UTCE went on to deliver by caesarean section, albeit for other indications. Given the above, we do not think that UTCE could be applied to current UK practice at this time and would require detailed ethical approval and appraisal by a recognised organisation, e.g. the National Institute of Clinical Health and Excellence, before implementation. &
References 1 Ahn JW, Lee SJ, Lee S, Kang S, Won HS. Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy. BJOG 2013;120:1285–8.
S Malalasekera, M Esmyot, S-J Herrington, O Greer, B Erinle, A Pathan, MA Mahran & D Patil Department of Obstetrics and Gynaecology, Bedford Hospital NHS Trust, Bedford, UK Accepted 28 August 2013. DOI: 10.1111/1471-0528.12489
Author’s reply Sir, We appreciate the interest shown by Malalasekera and colleagues in our work.1,2 We would like to note that our work is a retrospective case series investigated in a non-randomised, small-numbered and single-centre study. We also would like to highlight the rarity of interstitial pregnancies as the discussants have commented. Our study was not a non-randomised controlled study. It was an assembly of retrospective case series (uncontrolled longitudinal study) for each treatment method used for unruptured interstitial pregnancy, similar to a previous study.3 Because of the rarity of interstitial pregnancies, the homogeneity required for statistical analysis could not be achieved among the different treatment groups. Further, we could not control the probable biases, including biases created by counselling of women about their treatment options by the members of the study team. Therefore, we designed our study as a retrospective case series. Hence, it would be incorrect to interpret our result as ‘the overall success rate was better for surgical (100%) and medical management (100%) than for UTCE [ultrasound-guided transcervical forceps extraction] (83.3%)’.1 However, in a broad sense, the result can be interpreted as ‘high success rate of UTCE’.2 The interpretation depends on the reader’s personal perspective. Additionally, except for the first procedure, the other five consecutive procedures in the UTCE series were all successful, and the success rates of medical or surgical
ª 2014 Royal College of Obstetricians and Gynaecologists
BJOG Exchange
methods of other previous studies were not 100%, which differs from our study.3–5 We administered intravenous nonsteroidal anti-inflammatory drugs for pain control before patient positioning. For sedation, we administered 2.5 mg/kg of 1% propofol in slow intravenous bolus (2 minutes) after uterine sounding. If the sedation obtained was not satisfactory, additional boluses of 20–30 mg propofol were administered up to a total dose of 200 mg. In the original article,2 we recommended practicing UTCE during common elective dilatation and curettage for missed abortion, not during rare interstitial pregnancy. If a recogni-
sed organisation, e.g. NICE, could evaluate the effectiveness of UTCE for interstitial pregnancies, including impact on mode of delivery in future pregnancies, we would be pleased. &
References 1 Malalasekera S, Esmyot M, Herrington S-J, Greer O, Erinle B, Pathan A, et al. Ultrasoundguided transcervical forceps extraction of unruptured interstitial pregnancy. BJOG 2013; 120. 2 Ahn JW, Lee SJ, Lee S, Kang S, Won HS. Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy. BJOG 2013;120:1285–8. 3 Verma U, English D, Brookfield K. Conservative management of nontubal
ª 2014 Royal College of Obstetricians and Gynaecologists
ectopic pregnancies. Fertil Steril 2011;96 (1391–5):e1391. 4 Sagiv R, Debby A, Keidar R, Kerner R, Golan A. Interstitial pregnancy management and subsequent pregnancy outcome. Acta Obstet Gynecol Scand 2013;92:1327–30. 5 Larrain D, Marengo F, Bourdel N, Jaffeux PB, Aublet-Cuvelier B, Puly JL, et al. Proximal ectopic pregnancy: a descriptive general population-based study and results of different management options in 86 cases. Fertil Steril 2011;95:867–71.
S-J Lee Department of Obstetrics and Gynaecology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea Accepted 17 September 2013. DOI: 10.1111/1471-0528.12490
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DOI: 10.1111/1471-0528.12489 www.bjog.org
Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy
Sir, We read with interest the article by Ahn et al.1 on a novel and interesting approach to a very relevant aspect of early pregnancy complications. The management of unruptured interstitial pregnancy is complex and the preferred management options vary from centre to centre. We were impressed by the potential benefits of ultrasound-guided transcervical forceps extraction (UTCE) to the patient in the short term, with regard to reducing patient morbidity, and also in the long term, with regard to future pregnancy options for mode of delivery. We agree with the authors’ conclusion of the limitations of the study being that it was a small retrospective, single-centre non-randomised controlled study; but accept that the nature of the condition would make a randomised study difficult to design. Furthermore, the rarity of interstitial pregnancies means that studies involving larger numbers would be difficult to organise. However, with respect to the methodology and patient recruitment, it is not clear whether members of the study team counselled women about their options. If so, this may have produced an element of bias. We would be interested to hear from the authors about the type of anaesthetic, if any, used during the procedure in the event that this would be reproduced in other units. Unfortunately, the results did not reflect the promise of the study objec-
130
tives. Our interpretation of the results was that the overall success rate was better for surgical (100%) and medical management (100%) than for UTCE (83.3%). In addition, the serious complications were equivalent to current accepted practice options and the duration of stay was similar. It would be interesting to know what statistical analyses were undertaken to support the statement of a high success rate of the procedure. We are also less positive about the training opportunities to develop this technique given the low incidence of interstitial pregnancy. The impact on mode of delivery in future pregnancies does not appear to have been addressed in this study given that 66% of women undergoing UTCE went on to deliver by caesarean section, albeit for other indications. Given the above, we do not think that UTCE could be applied to current UK practice at this time and would require detailed ethical approval and appraisal by a recognised organisation, e.g. the National Institute of Clinical Health and Excellence, before implementation. &
References 1 Ahn JW, Lee SJ, Lee S, Kang S, Won HS. Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy. BJOG 2013;120:1285–8.
S Malalasekera, M Esmyot, S-J Herrington, O Greer, B Erinle, A Pathan, MA Mahran & D Patil Department of Obstetrics and Gynaecology, Bedford Hospital NHS Trust, Bedford, UK Accepted 28 August 2013. DOI: 10.1111/1471-0528.12489
Author’s reply Sir, We appreciate the interest shown by Malalasekera and colleagues in our work.1,2 We would like to note that our work is a retrospective case series investigated in a non-randomised, small-numbered and single-centre study. We also would like to highlight the rarity of interstitial pregnancies as the discussants have commented. Our study was not a non-randomised controlled study. It was an assembly of retrospective case series (uncontrolled longitudinal study) for each treatment method used for unruptured interstitial pregnancy, similar to a previous study.3 Because of the rarity of interstitial pregnancies, the homogeneity required for statistical analysis could not be achieved among the different treatment groups. Further, we could not control the probable biases, including biases created by counselling of women about their treatment options by the members of the study team. Therefore, we designed our study as a retrospective case series. Hence, it would be incorrect to interpret our result as ‘the overall success rate was better for surgical (100%) and medical management (100%) than for UTCE [ultrasound-guided transcervical forceps extraction] (83.3%)’.1 However, in a broad sense, the result can be interpreted as ‘high success rate of UTCE’.2 The interpretation depends on the reader’s personal perspective. Additionally, except for the first procedure, the other five consecutive procedures in the UTCE series were all successful, and the success rates of medical or surgical
ª 2014 Royal College of Obstetricians and Gynaecologists
BJOG Exchange
methods of other previous studies were not 100%, which differs from our study.3–5 We administered intravenous nonsteroidal anti-inflammatory drugs for pain control before patient positioning. For sedation, we administered 2.5 mg/kg of 1% propofol in slow intravenous bolus (2 minutes) after uterine sounding. If the sedation obtained was not satisfactory, additional boluses of 20–30 mg propofol were administered up to a total dose of 200 mg. In the original article,2 we recommended practicing UTCE during common elective dilatation and curettage for missed abortion, not during rare interstitial pregnancy. If a recogni-
sed organisation, e.g. NICE, could evaluate the effectiveness of UTCE for interstitial pregnancies, including impact on mode of delivery in future pregnancies, we would be pleased. &
References 1 Malalasekera S, Esmyot M, Herrington S-J, Greer O, Erinle B, Pathan A, et al. Ultrasoundguided transcervical forceps extraction of unruptured interstitial pregnancy. BJOG 2013; 120. 2 Ahn JW, Lee SJ, Lee S, Kang S, Won HS. Ultrasound-guided transcervical forceps extraction of unruptured interstitial pregnancy. BJOG 2013;120:1285–8. 3 Verma U, English D, Brookfield K. Conservative management of nontubal
ª 2014 Royal College of Obstetricians and Gynaecologists
ectopic pregnancies. Fertil Steril 2011;96 (1391–5):e1391. 4 Sagiv R, Debby A, Keidar R, Kerner R, Golan A. Interstitial pregnancy management and subsequent pregnancy outcome. Acta Obstet Gynecol Scand 2013;92:1327–30. 5 Larrain D, Marengo F, Bourdel N, Jaffeux PB, Aublet-Cuvelier B, Puly JL, et al. Proximal ectopic pregnancy: a descriptive general population-based study and results of different management options in 86 cases. Fertil Steril 2011;95:867–71.
S-J Lee Department of Obstetrics and Gynaecology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, South Korea Accepted 17 September 2013. DOI: 10.1111/1471-0528.12490
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