Overview and guidelines of off-label use of methotrexate in ectopic pregnancy: report by CNGOF

Systemic methotrexate (MTX) in early pregnancy: a retrospective study of a tertiary maternity hospital

BACKGROUND

Methotrexate (MTX) is used in clinical practice as a medical treatment option in patients with early pregnancy complications like ectopic pregnancy.

AIMS

To review systemic MTX therapy use in the first trimester of pregnancy in our hospital and to examine subsequent clinical outcomes.

METHODS

Retrospective review of all women treated with systemic MTX in early pregnancy identified from electronic prescription records from 1 January 2018 to 31 December 2020 at Cork University Maternity Hospital, Ireland. Relevant data was transcribed from electronic health records.

RESULTS

Indications for treatment were tubal ectopic pregnancy (70%, n = 51), persistent pregnancy of unknown location (22%, n = 16) and caesarean scar pregnancy (7%, n = 5). Treatment was successful in 88% (n = 44) of tubal ectopic pregnancies with 73% (n = 37) and 14% (n = 7) of women receiving a single dose and repeated doses, respectively. Only 8% (n = 4) of tubal ectopic pregnancies required emergency surgery for subsequent tubal rupture. In 93% (n = 15) of cases of persistent pregnancy of unknown location, treatment was successful with one patient requiring uterine evacuation. Women with caesarean scar pregnancy were treated with combined MTX and uterine evacuation without complication.

CONCLUSIONS

The efficacy of medical treatment with systemic MTX for confirmed tubal ectopic pregnancy in our hospital is in line with national and international standards. Careful consideration should be given to treating caesarean scar pregnancy and persistent pregnancy of unknown location with systemic MTX. Systemic MTX use guided by clinicians specialised in early pregnancy complications and safe medication practices may improve treatment success and reduce adverse events.

Do the change in β-hCG values between the 0th and 4th days in tubal ectopic pregnancy treatment with a single-dose methotrexate (MTX) protocol predict the need for a second dose of MTX?

AIM

The single-dose methotrexate (MTX) regimen is effective and minimizes side effects but an additional second dose is needed in case of failure in an ectopic pregnancy (EP). We aimed to predict the additional MTX dose by evaluating the change in β-hCG values between day 0 and day 4 in EPs with administered single-dose MTX regimen.

METHOD

A total of 454 tubal EPs between 2013 and 2019 were evaluated retrospectively. Cases cured with a single dose of MTX without an additional dose were accepted as the control group, and cases under a single-dose regimen were cured by applying a second dose of MTX on the 7th day were accepted as the study group. Obstetric and demographic characteristics and the change in β-hCG values compared in both groups.

RESULTS

Age, body mass index (BMI), gravida, smoking, abdominal surgery, presence of IUDs, initial β-hCG levels (0th day), and EP size were similar in both groups, but the presence of previous EP history was significantly higher in the study group. The change of β-hCG from days 0 and 4 determined that a 20% increase predicts the need for a second dose of MTX with 72.4% sensitivity, and 87.8% negative predictive value (NPV).

CONCLUSION

The single-dose MTX protocol is successful in 83.3% of convenient cases (as the control group), but an increase of 20% in β-hCG between days 0 and 4 predicts the patients who need to be administered second-dose MTX, and thus, a double-dose MTX protocol will be achieved early.

Pregnancies at the Uterotubal Junction: A Review of Terminology (Interstitial, Cornual, and Angular) and Recommendations for Management

Ectopic pregnancies are one of the most common causes of obstetric mortality worldwide. Interstitial ectopic pregnancies, defined as an extracavitary pregnancy within the portion of the Fallopian tube that transverses the myometrium, have reported mortality rates approximately seven times higher than all types of ectopic pregnancy combined. In contrast, intracavitary eccentric gestations, often labeled as "cornual" or "angular" pregnancies, have reportedly high rates of live birth. Unfortunately, the terms "interstitial," "cornual," and "angular" have long been used with varying diagnostic criteria and often interchangeably to describe a pregnancy near the uterotubal junction. The inconsistency in nomenclature and lack of clear diagnostic criteria to distinguish among these pregnancies has resulted in a paucity of data to provide accurate prognostic information and guide appropriate management. This review article aims to provide historical context for the terms "interstitial," "cornual," and "angular;" discuss previous and more recent innovations of diagnostic methods; and provide recommendations for concise terminology and inform management.

Safety profile of methotrexate used off-label in ectopic pregnancy: an active monitoring study based on a Chinese hospital pharmacovigilance system

OBJECTIVE

Methotrexate (MTX) is characterized as first-line therapy although its indication of ectopic pregnancy is off-label use. We aimed to conduct a retrospective cohort study to investigate the incidence, characteristics of adverse drug reactions (ADRs) of MTX, provide valuable insights for medical workers.

METHODS

Basing on China Hospital Pharmacovigilance System (CHPS), a retrospective analysis was performed to evaluate the safety of MTX (n = 672). An active monitoring model was set to detect ADR signals from the hospital information system. Frequency, Common Terminology Criteria for Adverse Events (CTCAE) grade proportion and association of dose exposure with ADRs were presented as outcomes.

RESULTS

The total incidence of ADRs was 54.0%. Anaemia (37.6%) was the most frequent ADR, followed by hepatic function abnormal (11.3%), hyperuricemia (6.1%), neutropenia (4.6%), leukopenia (4.0%), and dyslipidaemia (2.5%). For the composition of all ADRs, CTCAE grade one, two and three dominated for 86.3%, 12.1% and 1.6%, respectively. The severity of hepatic function abnormal was more serious in the two-dose exposed group (p = .021), while other types of ADRs had no statistical or clinical differences. Logistic regression analysis showed the incidence of any ADRs (OR 1.87 [1.31-2.64]; p = .001), hepatic function abnormal (OR 2.75 [1.69-4.48]; p < .001), dyslipidaemia (OR 5.15 [1.87-14.13]; p = .001) were significantly higher in the two-dose exposed group. After adjusted, the positive associations were still maintained.

CONCLUSIONS

MTX is quite safe in ectopic pregnancy, despite its mild to moderate hematotoxicity, hepatotoxicity and nephrotoxicity. Taking CHPS can present the accurate denominator of the incidence of adverse drug reactions into account, our study advocates that it may have great potential to be used as an active monitoring tool for off-label drug use risk management.

Methotrexate for CSPs

Expectant management of a cesarean scar pregnancy (CSP) is associated with a high risk of severe maternal morbidity. Therefore, most experts recommend immediate termination after the diagnosis of a CSP. However, there is no consensus about the optimal management of a CSP in terms of efficacy, safety, and preservation of future fertility. Methotrexate (MTX) is a folic acid antagonist that has been largely used to treat tubal ectopic pregnancies. This review summarizes the current knowledge and uncertainties about the administration of MTX as a medical or non-invasive option to terminate a CSP; the preferred injection route (systemic or local/intragestational), the comparison with other treatment modalities, and the prognostic factors for MTX success will be discussed, as well as the recommendations from scientific societies.

Clinical Presentation as a Predictor of the Response to Methotrexate Therapy in Patients with Ectopic Pregnancy

Purpose

Ectopic pregnancy can be fatal if not diagnosed and timely treated. There is an increase in ectopic pregnancy rate which attributes in part to fertility medications and procedures and early diagnosis. Methotrexate, a folic acid antagonist, is widely used in the medical treatment of ectopic pregnancy. Many studies examined the safety and success rate of methotrexate looking into factors affecting the success rate, if the patient may present with symptoms such as abdominal pain, and some consider this as impeding rupture and it might affect the success of medical treatment. This study evaluates the success rate of methotrexate treatment outcomes in regard to presentation and looks into other factors that can help choosing a single or multiple dose modality.

Methods

This is a retrospective review of 154 cases of ectopic pregnancy treated with methotrexate from January 2011 to December 2020 at King Khalid University Hospital (KKUH). Demographic data, clinical presentation, treatment progress, and outcome and failure rate were collected and analyzed. Student's t-test was used for statistical analysis of associations in SPSS.

Results

154 patients were treated with MTX; of those patients, 25 received more than one dose. The difference between the responses to MTX treatment in symptomatic and asymptomatic individuals was not significant (p = 0.267). 131 (85%) had successful treatment. There were no associations between patient BMI, ectopic mass size, or ectopic mass site, the presence or absence of pelvic fluid on ultrasound at diagnosis, and the treatment success rate. There was a significant decline in the treatment success rate with increasing β-hCG levels on the presentation day (p = 0.035) and on day 4 (p value <0.001) of treatment.

Conclusion

MTX treatment can be used to manage symptomatic patients with ectopic pregnancy. The success rate in symptomatic patients is not different from that in asymptomatic patients. β - hCG levels > 5000 IU/L. Pretreatment and on day 4 posttreatment is associated with higher failure rate.

A 10-Year Review of Methotrexate Treatment for Ectopic Pregnancy in a Malaysian Tertiary Referral Hospital

Background Ectopic pregnancy was recorded as the fourth principal cause of maternal death in Malaysia in 2019. Early diagnosis and use of methotrexate treatment proved to be safe and effective alternatives to surgical treatment. This study investigates the success rate of methotrexate treatment for ectopic pregnancy in a tertiary hospital in Malaysia. Methods This was a retrospective review of 73 patients with ectopic pregnancies treated with methotrexate according to a single-dose protocol from January 2009 until November 2019. The diagnosis of ectopic pregnancy was made using a combination of transvaginal scan and serial serum β-hCG levels. Their clinical and demographic data were reviewed. Serum β-hCG levels were measured at pre- and post-treatment to determine the rate of successful resolution. Results The overall success rate was 87.7% (64/73 patients) with methotrexate treatment. Fifty-six patients (76.7%) were successfully treated with a single dose of methotrexate, and eight patients (11.0%) required a second dose of methotrexate. There was no relation between socio-demographic, pre-treatment β-hCG levels, ectopic mass size, and treatment efficacy. Smaller size of ectopic pregnancy (adjusted OR=29.23; 95% CI: 2.69, 317.90; P=0.006) and absence of free fluid at the pouch of Douglas (POD) (adjusted OR=27.31; 95% CI: 2.84, 262.32; P=0.004) was found to increase the likelihood of overall treatment success. Absence of fetal cardiac activities was found to increase the likelihood of first-dose methotrexate treatment success (OR=10.20; 95% CI: 1.93, 53.79; P=0.006). Conclusions Early diagnosis of ectopic pregnancy may reduce morbidity and mortality. In carefully selected cases, methotrexate treatment has been proven to be cost-effective and avoided risks associated with surgery and anaesthesia.

Daily variations and levels of human chorionic gonadotropin before methotrexate treatment as predictors of treatment success

AIM

The aim of this study is to investigate the role of human chorionic gonadotropin (hCG) daily variations and levels prior to methotrexate treatment as predictors for treatment outcome.

METHODS

This retrospective study included patients who had a sonographically confirmed ectopic pregnancy at the International Peace Maternity and Child Health Hospital between November 2015 and June 2020. The associations of hCG levels and daily variations with the treatment success were evaluated by multivariable logistic regression and receiver operator characteristic (ROC) curve. Establish a nomogram that predicts how methotrexate (MTX) therapy will turn out. The performance of the model was assessed utilizing concordance index, receiver operating characteristic curves, and calibration plots.

RESULTS

The median serum hCG levels before treatment and hCG daily variation in the failure group were higher than those in the success group (487.8 vs. 270.7 IU/L, -1.86% vs. 7.29%, both p < 0.01). According to the ROC curve analysis, the cutoff values of serum hCG level before treatment and daily variations were 617.35 IU/L and 1.76%/day. By multivariable logistic regression analysis, serum hCG levels before treatment (odds ratio [OR]: 1.001, 95% confidence interval [CI]: 1.000 ~ 1.001) and hCG daily variations were independently associated with the treatment success (OR: 1.033, 95% CI: 1.015 ~ 1.052). The nomogram was effective at predicting the outcome of MTX treatment with a receiver operating characteristic area under the curve of 0.717 (p < 0.001). The nomogram's calibration curve was almost parallel to the ideal diagonal line.

CONCLUSION

We successfully created a nomogram based on serum hCG levels before treatment and hCG daily changes to anticipate the result of MTX therapy, which could assist medical professionals in selecting therapeutic schedule for patients with tubal pregnancies.

Medication-Wide Association Study Using Electronic Health Record Data of Prescription Medication Exposure and Multifetal Pregnancies: Retrospective Study

Background

Medication-wide association studies (MWAS) have been applied to assess the risk of individual prescription use and a wide range of health outcomes, including cancer, acute myocardial infarction, acute liver failure, acute renal failure, and upper gastrointestinal ulcers. Current literature on the use of preconception and periconception medication and its association with the risk of multiple gestation pregnancies (eg, monozygotic and dizygotic) is largely based on assisted reproductive technology (ART) cohorts. However, among non-ART pregnancies, it is unknown whether other medications increase the risk of multifetal pregnancies.

Objective

This study aimed to investigate the risk of multiple gestational births (eg, twins and triplets) following preconception and periconception exposure to prescription medications in patients who delivered at Penn Medicine.

Methods

We used electronic health record data between 2010 and 2017 on patients who delivered babies at Penn Medicine, a health care system in the Greater Philadelphia area. We explored 3 logistic regression models: model 1 (no adjustment); model 2 (adjustment for maternal age); and model 3—our final logistic regression model (adjustment for maternal age, ART use, and infertility diagnosis). In all models, multiple births (MBs) were our outcome of interest (binary outcome), and each medication was assessed separately as a binary variable. To assess our MWAS model performance, we defined ART medications as our gold standard, given that these medications are known to increase the risk of MB.

Results

Of the 63,334 distinct deliveries in our cohort, only 1877 pregnancies (2.96%) were prescribed any medication during the preconception and first trimester period. Of the 123 medications prescribed, we found 26 (21.1%) medications associated with MB (using nominal P values) and 10 (8.1%) medications associated with MB (using Bonferroni adjustment) in fully adjusted model 3. We found that our model 3 algorithm had an accuracy of 85% (using nominal P values) and 89% (using Bonferroni-adjusted P values).

Conclusions

Our work demonstrates the opportunities in applying the MWAS approach with electronic health record data to explore associations between preconception and periconception medication exposure and the risk of MB while identifying novel candidate medications for further study. Overall, we found 3 novel medications linked with MB that could be explored in further work; this demonstrates the potential of our method to be used for hypothesis generation.

Early Ectopic Pregnancy Refractory to Methotrexate Treatment: A Case Report

Methotrexate (MTX) is known as a systemic treatment for early ectopic pregnancy with low serum beta-human chorionic gonadotropin (βhCG) levels. Here we present our experience of an unsatisfactory outcome following MTX treatment for early tubal pregnancy.

The case is a 39-year-old female with left tubal ectopic pregnancy and a history of one right tubal ectopic pregnancy and an uneventful episode of delivery. In the absence of any contraindications, the patient underwent initial MTX treatment. At first, her serum βhCG level was 1,258 mIU/mL but remained elevated. Then she underwent a second and third dose of MTX. After a month, the serum βhCG level had not declined to within an acceptable range. The ectopic mass was enlarged as determined by transvaginal ultrasonography and hemoperitoneum. A laparoscopic salpingectomy was performed.

Early ectopic tubal pregnancy can be managed medically with a high success rate. However, repeat ectopic pregnancy indicates an increased risk of treatment failure to medical treatment, and should be mentioned to the patient when discussing their treatment options.

Dispensing of Potentially Harmful Prescription Drugs in 1.8 Million Pregnant Women in France: A Nationwide Study Based on Two Risk Classification Systems

Introduction

Nationwide prevalence of potentially harmful drug prescribing during pregnancy is unknown in France, and several risk classification systems (RCS) exist to guide prescribers.

Objective

The aim of this study was to estimate the nationwide prevalence of potentially harmful drug prescribing during pregnancy in France and to describe maternal characteristics associated with this prescription.

Methods

This drug utilisation study, conducted on the French health databases (67 million beneficiaries), included all pregnancies beginning in 2016–2017, regardless of pregnancy outcome. Potentially harmful drug prescribing was defined as at least one reimbursement during pregnancy of Swedish RCS category D drugs, Australian RCS category D/X drugs, or contraindicated drugs in France for drugs not listed in these two RCSs. Maternal characteristics associated with potentially harmful drug prescribing were described using a univariate logistic regression analysis.

Results

Among the 1,844,447 pregnant women identified, the prevalence of potentially harmful drug prescribing was higher according to the Australian RCS (3.9%) than according to the Swedish RCS (2.2%), with good agreement between the two RCSs (Kappa = 0.81 [0.74–0.87]). This prevalence increased to 9.2% and 6.9%, respectively, when considering contraindications in France. Prescribing of teratogenic drugs, including retinoids and valproate, was highest during the first trimester, whereas prescribing of foetotoxic drugs decreased after the first trimester but remained high for nonsteroidal anti-inflammatory drugs (N = 10,021). In women with no chronic diseases, polymedication (five or more drugs) was the strongest maternal characteristic associated with potentially harmful drug prescribing in both RCSs.

Conclusions

Potentially harmful drug prescribing during pregnancy is not uncommon in France. This study supports the comparative analysis of RCS to assess potentially harmful drug prescribing in claims databases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-021-01117-4.

Women-specific routes of administration for drugs: A critical overview

The woman's body presents a number of unique anatomical features that can constitute valuable routes for the administration of drugs, either for local or systemic action. These are associated with genitalia (vaginal, endocervical, intrauterine, intrafallopian and intraovarian routes), changes occurring during pregnancy (extra-amniotic, intra-amniotic and intraplacental routes) and the female breast (breast intraductal route). While the vaginal administration of drug products is common, other routes have limited clinical application and are fairly unknown even for scientists involved in drug delivery science. Understanding the possibilities and limitations of women-specific routes is of key importance for the development of new preventative, diagnostic and therapeutic strategies that will ultimately contribute to the advancement of women's health. This article provides an overview on women-specific routes for the administration of drugs, focusing on aspects such as biological features pertaining to drug delivery, relevance in current clinical practice, available drug dosage forms/delivery systems and administration techniques, as well as recent trends in the field.

Efficacy of In Situ Methotrexate Injection in the Treatment of Nontubal Ectopic Pregnancies: A Retrospective Multicenter Study

STUDY OBJECTIVE

Evaluation of the efficacy of different injection sites of methotrexate in the treatment of nontubal ectopic pregnancies.

DESIGN

Retrospective multicenter study.

SETTING

Multicenter, including 3 teaching hospitals, an intercommunal hospital, and a clinic.

PATIENTS

A total of 106 patients with nontubal ectopic pregnancies, including 59 interstitial, 39 cesarean scar, and 8 cervical or isthmic.

INTERVENTIONS

Overall, 58 patients received methotrexate via intramuscular injection (IM group), 35 received methotrexate via in situ injection (IS group), and 13 received a combination of both in situ and intramuscular injections of methotrexate (IS + IM group).

MEASUREMENTS AND MAIN RESULTS

The main end point of this study was measured via the primary success rate (defined as a negative β-human chorionic gonadotropin level without recourse to any additional treatment) of treatment with methotrexate according to injection site. The primary success rate was 46.55% in the IM group, 60% in the IS group, and 61.54% in the IS + IM group, respectively. In the multivariate analysis, the primary success rate of treatment was significantly correlated to the in situ injection of methotrexate, either solely or in conjunction with an intramuscular injection of methotrexate administered the following day, (odds ratio = 2.7; 95% confidence interval, 1.03-7.14).

CONCLUSION

Solely an intramuscular injection of methotrexate is a less efficient first-line treatment strategy for the conservative management of nontubular ectopic pregnancy. The use of an in situ injection of methotrexate should therefore be preferred.

UTERINE RUPTURE IN THIRD TRIMESTER OF PREGNANCY FOLLOWING CORNUAL RESECTION DUE TO ECTOPIC PREGNANCY

Uterine rupture during pregnancy is a critical obstetric complication associated with maternal and fetal mortality and morbidity. The risk is increased in patients with a history of previous uterine surgery including cesarean section, myomectomy, salpingectomy, as well as uterine and placental anomalies and polyhydramnios. It can also occur spontaneously. We present a case of uterine rupture in the early third trimester in a woman who had undergone previous laparoscopic removal of the left fallopian tube due to sactosalpinx and laparotomic removal of left uterine horn due to ectopic pregnancy.

[Methotrexate: How long between administration and conception?]

In women of childbearing age, methotrexate is prescribed in many indications other than cancer, either chronically (psoriasis, rheumatoid arthritis, IBD, etc.) or occasionally (ectopic pregnancies). The time given to these patients to consider pregnancy is currently subject to great variability depending on the sources. Analysis of the available objective evidence suggests that it is not justified to unnecessarily lengthen this period, and that conceiving the menstrual cycle following stopping methotrexate is quite possible.

Cervical pregnancy management: An updated stepwise approach and algorithm

The aim of this short review was to present and categorizes most of updated successful interventions for cervical pregnancy (CP) management in a simple designed easily recognized diagram together with a proposed algorithm of these interventions beside author clinical experience. A comprehensive literature search was carried out in the following electronic databases, PubMed, Scopus, Embase, Google Scholar, Directory of Open Access Journals and Cochrane electronic databases. Keywords including cervical ectopic pregnancy, medical treatment, conservative management, successful interventions, uterine artery embolization and hysteroscopy were used to search these various databases. There are different successful CP management interventions reported in the literature varied from simple to complex regimens according to the patient situation, obstetrician experience and availability of health services. These approaches were categorized in a stepwise diagram and a proposed algorithm. Up till now, there is no consensus regarding the optimal CP management. To the best of knowledge, this review was unprecedented in organizing and categorizing the different successful CP management interventions. The proposed currently undertaken stepwise approach diagram and algorithm highlights the rapidly changing management of CP and open the door for further meta-analysis.

Conservative treatment in non-tubal ectopic pregnancy and predictors of treatment failure

OBJECTIVES

To find possible predictive factors to predict the failure of conservative treatment of non-tubal ectopic pregnancy. For that purpose, we assessed the rate of failure, complications and need for additional interventions of the different primary treatment regimens in non-tubal ectopic pregnancies that occurred in our center.

STUDY DESIGN

Retrospective single-center study conducted at Hospital Clínic of Barcelona (Spain). Conservative treatment regimens included medical (systemic single or multiple dose methotrexate; ultrasound-guided intrasaccular injection of methotrexate or chloride potassium; surgical (oophorectomy in case of ovarian ectopic pregnancy, surgical curettage). The main outcome measures were success of primary treatment and the need for additional interventions. The secondary outcomes were success rate of conservative treatment, incidence of complications, days to discharge from the hospital, days until negative β-hCG, days until complete resolution of the process. Possible predictor factors for primary treatment failure were assessed.

RESULTS

A total of 39 cases were included. Primary treatment was successful in 74 % (29/39). The rate of failure of primary treatment was higher in the group with presence of embryo heartbeat than in the group without, 46 % vs. 15 % respectively (p < 0.0001). Among the cases that required additional treatments, none of them required hysterectomy. Presence of embryo heartbeat significantly increased the likelihood of failure of the primary treatment (OR 4.71, 95 % CI 1.03-21.65, p < 0.05). Every doubling of the β-hCG levels increased the risk of treatment failure by 54 % (OR 1.54, 95 % CI 1.03-2.39, p < 0.05).

CONCLUSIONS

Conservative treatment is a safe option for treatment of non-tubal ectopic pregnancy. The presence of embryo heartbeat and β-hCG levels at diagnosis may be used as predictive factors of failure of conservative treatment.

Predictors and clinical features of methotrexate (MTX) therapy for ectopic pregnancy

BACKGROUND

Ectopic pregnancy is a major life- and fertility-threatening women's health concern. As a result of advances in examination technology, an increasing number of ectopic pregnancies can be diagnosed early and treated with medical methods instead of surgery. The aim of this study was to summarize the clinical features and identify the predictors of success of methotrexate (MTX) treatment of ectopic pregnancy.

METHODS

This was a retrospective study of 238 ectopic pregnancies treated with MTX in the Department of Gynecology of Shaanxi Provincial People's Hospital from January 2017 to December 2017.

RESULTS

Patients were divided into two groups: the successful treatment group (n = 166) and the failed treatment group (n = 72). The overall success rate of MTX therapy for ectopic pregnancy was 69.75%. The mean initial beta-human chorionic gonadotropin (β-hCG) level was significantly lower in the successful treatment group than in the failed treatment group (2538.08 IU/L versus 3533.17 IU/L, P = 0.000). The treatment success rate of the group with an initial β-hCG concentration less than 4000 IU/L was significantly higher than that of the group with an initial β-hCG concentration greater than 4000 IU/L. However, the success rate of the group with an initial β-hCG concentration greater than 4000 IU/L was still relatively high (54.55%). β-hCG levels were significantly increased on the 4th day in the failed treatment group (P = 0.000). Compared to the initial β-hCG level, the day-4 β-hCG level increased by more than 8.21%, indicating that the treatment was effective. The diagnostic sensitivity was 88.6%, the specificity was 74.5%, and the area under the receiver operating characteristic (ROC) curve was 0.863 (95% confidence interval (CI): 0.805-0.920).

CONCLUSIONS

MTX therapy as a treatment option is safe and effective for asymptomatic, hemodynamically stable patients with ectopic pregnancies who are interested in conservative treatment, regardless of the serum β-hCG level or adnexal mass size. The change in the β-hCG level between the initial day and the 4th day is an effective and early predictive tool for the success of MTX therapy for ectopic pregnancy.

Effectiveness of conservative medical treatment for non-tubal ectopic pregnancies: a multicenter study

OBJECTIVE

To assess the effectiveness of conservative treatment for the management of non-tubal ectopic pregnancies (NTEP) METHODS: Retrospective cohort study in three centers (two referral centers) of patients managed for NTEP diagnosed by 2D or 3D ultrasonograhy. Patients underwent one of the following: expectant management, systemic methotrexate (MTX) injection, local MTX injection, combined MTX injection (local and systemic), local injection of hyperosmolar glucose, or misoprostol administration. The primary endpoint was final success defined by resolution of hCG level without need for emergency surgical treatment. Sixty-four patients diagnosed with NTEP were included: 37 (57%) had an interstitial pregnancy, 23 (35.9%) a cesarean scar pregnancy, two (3.1%) a cervical pregnancy and two (3.1%) an ovarian pregnancy.

RESULTS

Six patients (9.4%) underwent expectant management, 24 (37.5%) a systemic MTX injection, 28 (43.8%) a local injection of MTX, three (4.7%) a combined MTX injection, one (1.6%) a local injection of hyperosmolar glucose (1.6%), and two (3.1%) were administered misoprostol. The median age was 32 years (22-45) and mean follow-up was 41 months. The final success rate overall was 92.2%: 100% for expectant management, 87.5% for systemic MTX, 96.4% for local MTX, 100% for combined injection of MTX, 100% for local injection of hyperosmolar glucose, and 50% for misoprostol. No patient required a hysterectomy. Nine (14.1%) patients required surgery, including five (7.8% (5/64)) following a rupture of the NTEP.

CONCLUSIONS

Our results suggest that conservative medical management of NTEP is effective and safe and should be the first-line treatment for pauci-symptomatic patients with an NTEP.

Luteal blood flow as a predictive factor for methotrexate treatment outcomes in women with unruptured tubal pregnancy

BACKGROUND

Blood flow in the corpus luteum is associated with luteal function. However, the impact of luteal blood flow on methotrexate (MTX) treatment in women with unruptured tubal pregnancy has not been reported. The aim of the present study was to observe the impact of luteal blood flow on the therapeutic effect of MTX in women with unruptured tubal pregnancy.

METHODS

A prospective observational study recruited 129 women with unruptured tubal pregnancy in the First Affiliated Hospital of Xi'an Jiaotong University from September 2016 to June 2018. One hundred and fifteen women were treated successfully with MTX, and women were divided into 2 groups according to luteal blood flow: the poor luteal blood flow group and the abundant luteal blood flow group. The therapeutic effects were compared between the two groups.

RESULTS

Women in the abundant luteal blood flow group had a significantly higher serum β-human chorionic gonadotropin (β-hCG) level 4 days, 1 week and 2 weeks after MTX treatment compared with women in the poor luteal blood flow group (P < 0.05). The average diameter of the ectopic mass 1 week, 2 weeks and 3 weeks after MTX treatment in women with abundant luteal blood flow was significantly larger (P < 0.05), and the time of serum β-hCG clearance and ectopic mass disappearance were significantly longer compared with those in women in the poor luteal blood flow group (P < 0.05).

CONCLUSIONS

Luteal blood flow might be a predictive factor for MTX treatment outcomes in women with unruptured tubal pregnancy, and those with abundant luteal blood flow need a longer recovery time.

Early prediction of the success of methotrexate treatment success by 24-hour pretreatment increment in HCG and day 1-4 change in HCG

RESEARCH QUESTION

Several studies have tried to identify early markers of treatment outcome after methotrexate (MTX) treatment for ectopic pregnancy, including pretreatment and day 4 human chorionic gonadotrophin (HCG) concentrations and their corresponding changes, and the increment in HCG during the initial 24 h after treatment. There have, however, been conflicting results. This study aimed to re-evaluate the role of these markers in the earlier identification of treatment success in a large cohort of women.

DESIGN

This was a retrospective cohort study including women diagnosed with an ectopic pregnancy and treated with a regimen of a single dose of MTX. A comparison of maternal and gestation characteristics was made between groups in whom treatment was successful or failed.

RESULTS

A total of 292 women treated with single-dose intramuscular MTX for ectopic pregnancy were included in this study. In the overall cohort, the treatment success rate with a single dose of MTX was 62.7% (183/292). Only two independent determinants were significantly associated with treatment success: the initial 24-h percentage increase in HCG (adjusted odds ratio [OR] 1.82, 95% confidence interval [CI] 1.26-2.63; P < 0.001) and the percentage change in HCG from day 1 to day 4 (adjusted OR 1.12, 95% CI 1.04-1.21; P < 0.001). The optimal cut-off points for prediction of treatment success were an increment of less than 17% in the 24 h before treatment and a decrease of more than 22% between the day 1 and day 4 HCG concentrations.

CONCLUSIONS

A small increase in HCG concentration 24 h before treatment with MTX, alongside a decline in HCG concentration from day 1 to day 4, may predict the success of medical treatment for an ectopic pregnancy.

Laparoscopic reversible occlusion of uterine arteries and cornuostomy for advanced interstitial pregnancy

During laparoscopic enucleation of an interstitial pregnancy, adequate hemostatic control is of paramount importance due to the high vascularization of the uterine cornus. However, no consensus or guidance exists regarding the optimal hemostatic technique. We report laparoscopic reversible uterine arteries occlusion as hemostatic technique during laparoscopic enucleation by cornuostomy of an interstitial pregnancy at advanced gestational age (46 × 40 mm gestational sac). Preliminary identification of the uterine arteries and bilateral reversible occlusion by Hem-o-Lok clips allowed bleeding control during surgery. The laparoscopic procedure was performed without complications and with limited blood loss. The reported case reinforces the feasibility of this minimally invasive technique in interstitial pregnancy.

Peritoneal reimplantation of trophoblastic tissue following laparoscopic treatment of ectopic pregnancy: A case report and review of literature

Reimplantation of trophoblastic tissue in the abdomen after treatment of an ectopic pregnancy is rarely reported but is very likely an underestimated complication to laparoscopy. We present a case report and review of the literature. A total of 25 cases of reimplantation of trophoblastic tissue following laparoscopic removal of ectopic pregnancy (EP) have been reported in the period January 1989 to January 2018 including our case. No cases have been reported before 1989. The use of salpingostomy vs. salpingectomy as the primary treatment of EP prior to the complication is comparable. In approximately half of the cases the reimplanted trophoblastic tissue was placed in the peritoneum and the rest in the omentum, on the bowel, in the uterosacral ligament and on the uterine body. During surgery it is important to remove all pathologic tissue and the Trendelenburg position should be considered avoided. Treatment using a single-dose Methotrexate should be performed when there is a potential risk of retaining tissue or if the serum human chorionic gonadotropin (S-hCG) is insufficiently decreasing after surgery. All patients treated for an ectopic pregnancy should be considered monitored until S-hCG is undetectable.

The role of ultrasonography in methotrexate therapy for ectopic pregnancy

Medical management of ectopic pregnancy with methotrexate, an antimetabolite of folic acid, is an important alternative to surgical treatment, as it ensures a similar outcome whilst being far less invasive. Ultrasound evaluation does not only facilitate an accurate diagnosis, but also helps to select patients most likely to benefit from methotrexate treatment, as opposed to those with a high likelihood of failure of medical management, who are thus eligible for primary surgical treatment. Ultrasound also allows to monitor the outcome of methotrexate therapy. This study is a review of literature regarding the management of ectopic pregnancy with methotrexate. Such ultrasound findings as the size of the ectopic mass, presence of fetal heart rate and free fluid have been confirmed as effective eligibility criteria for therapy with methotrexate. In the future, possibly also endometrial stripe thickness and the vascularity of the ectopic mass may be considered predictive of successful methotrexate therapy. The initial increase in size of the ectopic mass following methotrexate therapy confirms its effectiveness, and should not prompt concern.

Multidosing Intramuscular Administration of Methotrexate in Interstitial Pregnancy With Very High Levels of β-hCG: A Case Report and Review of the Literature

Ectopic pregnancy (EP) is the implantation of an embryo outside the endometrial cavity of the uterus. Signs and symptoms of EP may arise between the 6th and the 8th week of gestation and include vaginal bleeding, lower abdominal and pelvic pain. Frequently EPs implant in the fallopian tubes. A rare EP is the interstitial pregnancy, a life-threatening condition being responsible for nearly 20% of all deaths caused by EPs. Because of its unique location, the diagnosis is difficult and based on signs and specific criteria together with measuring of serum β-hCG. Usually, EP is treated by surgical approach, which is associated with increased morbidity, decreased fertility and increased likelihood of hysterectomy and uterine rupture in a subsequent pregnancy. Early diagnosis is crucial to life saving and allowing alternative therapeutic interventions such as pharmacological treatments. Methotrexate (MTX) represents the mainstay therapy. There is no standard care for the interstitial pregnancy for what concerns either surgical or pharmacological approaches. We reported a case of a 36-year-old woman admitted to the Hospital of Salerno-Italy with a value of serum β-hCG of 35,993 IU/L. Transvaginal ultrasonography revealed an empty uterine cavity and a mass of 35.7 mm in diameter characterized by a hypoechoic central area. The patient was in stable haemodynamic condition and no haematologic, renal and hepatic impairments were recorded. Despite the high serum β-hCG levels, a pharmacological approach was preferred to a surgical one. The patient was treated with intramuscular administration of MTX in daily dose of 1 mg/Kg alternated with 0.1 mg/kg folinic acid for 5 days. The patient remained hospitalized for 20 days and no side effects were reported. The decrease of the serum β-hCG was monitored and more than 15% reduction was detected between the 4th and the 7th day after the beginning of the treatment. The serum β-hCG became undetectable 35 days after. A multidosing intramuscular administration of MTX was effective and safe even in the presence of very high serum β-hCG levels. Together with similar cases reported in literature, the present results can contribute to improve the decision making in the treatment of the interstitial pregnancy.

Embarazo ectópico cervical: diagnóstico preciso y enfoque de manejo médico. Reporte de caso

<p>El embarazo ectópico cervical es una condición exótica. Su diagnóstico y manejo plantean un desafío importante, dada su asociación con desenlaces maternos graves. La sospecha clínica y la juiciosa aplicación de los criterios diagnósticos permiten establecer modalidades de terapia conservativa. Este artículo reporta un caso de embarazo ectópico cervical con diagnóstico de imágenes de ultrasonido y resonancia nuclear magnética en el que se administró tratamiento con metotrexato. El seguimiento clínico, de los exámenes paraclínicos y de ultrasonido mostraron la resolución completa de la condición. Se revisan aspectos relacionados con el diagnóstico y tratamiento.</p>

Evaluation of Tubal Pregnancy After Treatment With Methotrexate by Ultrasound Elastography

OBJECTIVES

The purpose of this study was to evaluate the application of ultrasound elastography in the assessment of methotrexate (MTX) treatment for tubal pregnancy and the association with the elasticity score and human chorionic gonadotropin (hCG) concentration.

METHODS

A total of 73 cases of unruptured tubal pregnancy were diagnosed and treated systemically with MTX. The sonographic characters of conventional transvaginal sonography and elastography and serum hCG concentrations before and after MTX therapy were retrospectively reviewed and analyzed.

RESULTS

The mean elasticity score was statistically significantly lower for the ectopic tubal masses of the success group (mean ± SD, 2.58 ± 0.68) than for the failure group (3.33 ± 0.47) on day 7 (P < .001) and similar on day 0. The median elasticity score for the success group on day 7 was 3, and for the failure group, it was 4. When elasticity scores of 3 and 2 were used for the criterion of successful MTX treatment, the elastography had 94.5% sensitivity, 61.1% specificity, 88.1% positive predictive value, and 78.6% negative predictive value. Elastography of the ectopic masses and subsequent hCG concentration at 1 week after the MTX injection in the success group had a strong relationship.

CONCLUSIONS

Our results suggest that transvaginal elastography was a useful tool in the evaluation of tubal pregnancy after pharmacologic management.

Predicting success of methotrexate treatment by pretreatment HCG level and 24-hour HCG increment

OBJECTIVE

To evaluate β-human chorionic gonadotropin (β-HCG) level and its 24-hour increment as predictors of successful methotrexate treatment for ectopic pregnancy.

METHODS

Data were retrospectively reviewed from women with ectopic pregnancy who were treated by single-dose methotrexate (50 mg/m² ) at a university hospital in Jerusalem, Israel, between January 1, 2000, and June 30, 2015. Serum β-HCG before treatment and its percentage increment in the 24 hours before treatment were compared between treatment success and failure groups.

RESULTS

Sixty-nine women were included in the study. Single-dose methotrexate treatment was successful for 44 (63.8%) women. Both mean β-HCG level and its 24-hour increment were lower for women with successful treatment than for those with failed treatment (respectively, 1224 IU\L vs 2362 IU\L, P=0.018; and 13.5% vs 29.6%, P=0.009). Receiver operator characteristic curve analysis yielded cutoff values of 1600 IU\L and 14% increment with a positive predictive value of 75% and 82%, respectively, for treatment success. β-HCG level and its 24-hour increment were independent predictors of treatment outcome by logistic regression (both P<0.01).

CONCLUSIONS

A β-HCG increment of less than 14% in the 24 hours before single-dose methotrexate and serum β-HCG of less than 1600 IU\L were found to be good predictors of treatment success.

Safety and Efficacy of Uterine Artery Embolization in Ectopic Pregnancies Refractory to Systemic Methotrexate Treatment: A Single-Center Study

BACKGROUND

To investigate the use of uterine artery embolization (UAE) to manage ectopic pregnancies that are refractory to systemic methotrexate (MTX) therapy and plagued by persistently high serum β-human chorionic gonadotrophin (hCG) levels and vaginal bleeding. The safety and efficacy of UAE were addressed.

MATERIALS AND METHODS

A retrospective review was conducted for thirteen patients (mean age 35.2 years; range 28-41 years), who were treated between December 2006 and June 2016. Each was subjected to UAE due to persistently high serum β-hCG levels and vaginal bleeding after systemic MTX therapy for ectopic pregnancy. Embolic agents used were non-spherical polyvinyl alcohol or gelatin sponge particles. Post-treatment follow-up was performed by monitoring for clinical signs of vaginal bleeding, serum β-hCG testing, and transvaginal US. Outcomes were technical success, clinical success, and complications.

RESULTS

Median follow-up period was 172.5 days (range 30-600 days). Technical success was achieved in all 13 patients (100%). In 10 patients, vaginal bleeding resolved after one UAE attempt (clinical success 76.0%). Rebleeding in other three (23.1%) was controlled through repeat UAE. Seven patients (53.8%) had additional dilatation and curettage to remove gestational sac remnants. All ectopic pregnancies were successfully treated by UAE, with normalization of serum β-hCG levels during follow-up monitoring (P = 0.01). Uterine preservation was achieved in all 13 patients, without major procedural complications.

CONCLUSION

UAE appears safe and effective as treatment of ectopic pregnancies marked by persistently high serum β-hCG levels and vaginal bleeding after systemic MTX treatment.

Chemotherapy in the Emergency Department? There Is a Role for That: Methotrexate for Ectopic Pregnancy

Approximately 1.6% of all emergency department (ED) visits in the United States are for vaginal bleeding in early pregnancy, translating to around 500,000 ED visits per year. A potentially life-threatening condition, ectopic pregnancy occurs in 1.5%-2% of pregnancies. Many patients will require either surgical or pharmacological intervention following a positive diagnosis. With regard to pharmacological options, methotrexate, largely known for its use in the oncology arena, has emerged as the most effective nonsurgical option and the pharmacological agent of choice. However, this therapy is not without its own unique adverse event profile and patients should be adequately educated on the monitoring parameters of this pharmacotherapy.