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Mikhitarian M, Goodnight III W, Keefe N. Local Methotrexate Plus Uterine Artery Embolization for High-Risk Interstitial Ectopic Pregnancy. Semin Intervent Radiol 2023; 40:357-361. [PMID: 37575342 PMCID: PMC10415050 DOI: 10.1055/s-0043-1770712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Interstitial ectopic pregnancy involves the interstitial portion of the fallopian tube and is among the most hazardous of all ectopic pregnancies, with the highest risk of uterine rupture and maternal mortality. Unlike tubal ectopic pregnancy, management of interstitial pregnancy is not well standardized. Systemic methotrexate (MTX) and surgical resection are the primary treatment options; however, failure rates and risk of bleeding remain high. Alternative minimally invasive techniques have been described-including uterine artery embolization (UAE) and local injection of MTX or potassium chloride-and may confer improved success rates. We report a case of a high-risk 28-year-old female with an interstitial ectopic pregnancy successfully treated with combined local injection of MTX plus UAE. We describe our technique and the unique medical management in the setting of a known bleeding disorder.
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Affiliation(s)
- Mark Mikhitarian
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - William Goodnight III
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Nicole Keefe
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Naredi N, Tripathy S, Sharma R. Transvaginal ultrasound-guided methotrexate instillation for failed medical management of ectopic pregnancies in subfertile women. J Hum Reprod Sci 2022; 15:90-95. [PMID: 35494196 PMCID: PMC9053346 DOI: 10.4103/jhrs.jhrs_1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Ectopic pregnancy (EP) defined as extrauterine implantation of the embryo can be managed medically or surgically. Medical management entails systemic administration of the antineoplastic drug methotrexate (MTX) which, if not successful, surgical management is resorted to. However, we carried out this study wherein the failed medical management cases were given intra-gestational sac MTX instead of surgery. Aim: The aim of this study was to assess the efficacy of intra-gestational MTX administration as a treatment modality for failed medical management of ectopic pregnancies. Study Setting and Design: It was a prospective interventional study carried out at the Reproductive Medicine Centre of a tertiary care hospital. Materials and Methods: It was a prospective interventional study wherein 12 patients of EP with failed medical management (as per established criteria) were administered intra-gestational MTX with follicle aspiration needle under transvaginal sonography guidance. Statistical Analysis Used: Data were collected in Microsoft Excel. Numerical continuous variables were expressed as mean ± standard deviation. Categorical variables were expressed as count/percentage. Results: All the patients responded to the local administration of MTX, with none requiring rescue surgery. In addition, no one had any complication of the local instillation. However, one patient required an additional dose of MTX. Conclusion: Intra-gestational MTX administration is a viable non-surgical modality for treatment of ectopic pregnancies even in cases of failed medical management with an added benefit of tubal preservation.
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Kang OJ, Koh JH, Yoo JE, Park SY, Park JI, Yang S, Lee SH, Lee SJ, Ahn JW, Roh HJ, Kim JS. Ruptured Hemorrhagic Ectopic Pregnancy Implanted in the Diaphragm: A Rare Case Report and Brief Literature Review. Diagnostics (Basel) 2021; 11:diagnostics11122342. [PMID: 34943579 PMCID: PMC8699918 DOI: 10.3390/diagnostics11122342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 11/16/2022] Open
Abstract
The mortality and morbidity rates of non-tubal ectopic pregnancies with abdominal hemorrhaging are 7-8 times higher than those of tubal pregnancies. Diaphragmatic pregnancy is a rare non-tubal ectopic form, causing acute abdominal hemoperitoneum. Here, we present a case of a primary diaphragmatic ectopic pregnancy with hemorrhage that was immediately diagnosed and successfully managed with laparoscopic surgery. Rapid and accurate diagnosis using appropriate imaging modalities is critical for improving the prognosis of a child-bearing woman with an abdominal pregnancy.
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Affiliation(s)
- Ok Ju Kang
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea;
| | - Ji Hye Koh
- Department of Obstetrics and Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Korea; (J.H.K.); (J.E.Y.); (S.Y.P.); (S.-H.L.); (S.-J.L.); (J.-W.A.); (H.-J.R.)
| | - Ji Eun Yoo
- Department of Obstetrics and Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Korea; (J.H.K.); (J.E.Y.); (S.Y.P.); (S.-H.L.); (S.-J.L.); (J.-W.A.); (H.-J.R.)
| | - So Yeon Park
- Department of Obstetrics and Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Korea; (J.H.K.); (J.E.Y.); (S.Y.P.); (S.-H.L.); (S.-J.L.); (J.-W.A.); (H.-J.R.)
| | - Jeong-Ik Park
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Korea; (J.-I.P.); (S.Y.)
| | - Songsoo Yang
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Korea; (J.-I.P.); (S.Y.)
| | - Sang-Hun Lee
- Department of Obstetrics and Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Korea; (J.H.K.); (J.E.Y.); (S.Y.P.); (S.-H.L.); (S.-J.L.); (J.-W.A.); (H.-J.R.)
| | - Soo-Jeong Lee
- Department of Obstetrics and Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Korea; (J.H.K.); (J.E.Y.); (S.Y.P.); (S.-H.L.); (S.-J.L.); (J.-W.A.); (H.-J.R.)
| | - Jun-Woo Ahn
- Department of Obstetrics and Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Korea; (J.H.K.); (J.E.Y.); (S.Y.P.); (S.-H.L.); (S.-J.L.); (J.-W.A.); (H.-J.R.)
| | - Hyun-Jin Roh
- Department of Obstetrics and Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Korea; (J.H.K.); (J.E.Y.); (S.Y.P.); (S.-H.L.); (S.-J.L.); (J.-W.A.); (H.-J.R.)
| | - Jeong Sook Kim
- Department of Obstetrics and Gynecology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan 44033, Korea; (J.H.K.); (J.E.Y.); (S.Y.P.); (S.-H.L.); (S.-J.L.); (J.-W.A.); (H.-J.R.)
- Correspondence:
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Tuncay G, Karaer A, Coskun EI, Melekoglu R. Treatment of unruptured cornual pregnancies by local injections of methotrexate or potassium chloride under transvaginal ultrasonographic guidance. Pak J Med Sci 2018; 34:1010-1013. [PMID: 30190771 PMCID: PMC6115548 DOI: 10.12669/pjms.344.14600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To demonstrate the outcome of intralesional management and show the safety of local treatment of cornual pregnancy. Methods Eight patients were treated with local methotrexate or potassium chloride injection. All patients underwent transvaginal ultrasound examination and were diagnosed by the criteria defined by Timor-Tritsch. In the case of fetal heart beat observation, potassium chloride was injected; and in the case of no heart beat detection, methotrexate was used. A follicle aspiration needle was inserted directly into the gestational sac under transvaginal guidance. Results Although it has been considered to be a risk factor, none of the patients in our study had previous ectopic pregnancy, history of infertility / in vitro fertilization, or cornual pregnancy. One of the patients had a medical history of abortion. In four cases, methotrexate was injected, and three patients received potassium chloride as a local treatment. None of the patients had any complication in the peri- or postoperative period. Conclusion Using a local approach, the treatment agent can reach the area of the cornual pregnancy in high concentrations. Based on this case series, a local approach seems to be an effective and fertility-sparing method for treating unruptured cornual pregnancies.
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Affiliation(s)
- Gorkem Tuncay
- Dr. Gorkem Tuncay MD. Assistant Professor, Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Abdullah Karaer
- Dr. Abdullah Karaer MD. Associate Professor, Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Ebru Inci Coskun
- Dr. Ebru Inci Coskun MD. Assistant Professor, Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Rauf Melekoglu
- Dr. Rauf Melekoglu MD. Assistant Professor, Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, Malatya, Turkey
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Panelli DM, Phillips CH, Brady PC. Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. FERTILITY RESEARCH AND PRACTICE 2015; 1:15. [PMID: 28620520 PMCID: PMC5424401 DOI: 10.1186/s40738-015-0008-z] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 09/29/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar. FINDINGS Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality. CONCLUSION This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.
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Affiliation(s)
- Danielle M. Panelli
- Department of Obstcpetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115 USA
| | - Catherine H. Phillips
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Paula C. Brady
- Department of Obstcpetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115 USA
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Iwase A, Nakamura T, Nakahara T, Goto M, Kikkawa F. Assessment of ovarian reserve using anti-Müllerian hormone levels in benign gynecologic conditions and surgical interventions: a systematic narrative review. Reprod Biol Endocrinol 2014; 12:125. [PMID: 25510324 PMCID: PMC4274680 DOI: 10.1186/1477-7827-12-125] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 12/14/2014] [Indexed: 11/10/2022] Open
Abstract
The usefulness of anti-Müllerian hormone (AMH) for the quantitative evaluation of ovarian reserve has been established. Therefore, serum AMH has been recently applied to the assessment of ovarian reserve outside infertility treatment. We conducted a computer-based search, using keywords, through the PubMed database from inception until May 2014 and summarized available studies evaluating ovarian damage caused by gynecologic diseases, such as endometriosis and ovarian tumor, as well as surgical interventions, such as cystectomy and uterine artery embolization (UAE), to discuss the usefulness of serum AMH. Most of the studies demonstrated a decline of serum AMH levels after cystectomy for endometriomas. It is not conclusive whether electrocoagulation or suturing is preferable. The effects of other gynecologic diseases and interventions, such as hysterectomy and UAE, on ovarian reserve are controversial. Serum AMH levels should be considered in determining the indication and selection of operative methods for benign gynecologic conditions.
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Affiliation(s)
- Akira Iwase
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
- Department of Maternal and Perinatal Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | - Tomoko Nakamura
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | - Tatsuo Nakahara
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | - Maki Goto
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
| | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550 Japan
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Yasutake N, Tsunematsu R, Oishi H, Yahata H, Uchida S, Kobayashi H, Kato K. Successfully treated abdominal pregnancy causing hemoperitoneum using combined surgical and systemic methotrexate therapy: a case report and review of cases treated at Kyushu University Hospital. Gynecol Obstet Invest 2013; 76:188-92. [PMID: 23969319 DOI: 10.1159/000353980] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 06/19/2013] [Indexed: 11/19/2022]
Abstract
Abdominal pregnancy is a rare condition that accounts for only 1% of all ectopic pregnancies but results in high maternal morbidity and mortality. We present a case of abdominal pregnancy with massive peritoneal bleeding successfully treated using systemic methotrexate (MTX). A 34-year-old woman with amenorrhea for 8 weeks and a positive pregnancy test was referred for evaluation of ectopic pregnancy. Transvaginal ultrasonographic scan showed a gestational sac measuring 25 mm in diameter containing a viable embryo in the cul-de-sac and a considerable amount of free fluid in the patient's lower abdomen and pelvis. Laboratory parameters showed that her hemoglobin concentration was 5.8 g/dl and serum human chorionic gonadotropin concentration was 13,195 mIU/ml. Emergency surgery revealed an abdominal pregnancy in the cul-de-sac and a massive intra-abdominal hemorrhage. After a hemostasis procedure, the patient was successfully treated using systemic MTX. We also present the review of abdominal pregnancy cases treated using systemic MTX at our institution over 10 years. Systemic MTX treatment for abdominal pregnancy is safe and effective and makes it possible to avoid the risk of excessive bleeding by surgical resection of the implantation site.
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Affiliation(s)
- Nobuko Yasutake
- Department of Obstetrics and Gynecology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Szylit NA, Podgaec S, Traina E, Oliveira RDCS. Video laparoscopic intervention for an interstitial pregnancy after failure of clinical treatment. SAO PAULO MED J 2012; 130:202-7. [PMID: 22790554 PMCID: PMC10876192 DOI: 10.1590/s1516-31802012000300011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 01/05/2011] [Accepted: 07/11/2011] [Indexed: 11/22/2022] Open
Abstract
CONTEXT Interstitial pregnancy is a rare form of ectopic pregnancy for which the best therapeutic course of action has yet to be determined. Surgical intervention entails a high risk of hemorrhage due to the great vascularization of the cornual region of the uterus. Case descriptions facilitate the analysis of results and aid clinicians in determining the most appropriate course of action in these situations. CASE REPORT In a patient with an ultrasound diagnosis of interstitial pregnancy, clinical treatment using methotrexate was chosen. However, after one week, there was a marked decline in the serum level of the β subunit of chorionic gonadotropin hormone, although an ultrasound examination revealed embryonic cardiac activity. A second dose of the chemotherapy was administered. Embryonic cardiac activity persisted 48 hours later. Video laparoscopy was performed to achieve right-side cornual resection, which resulted in satisfactory resolution of the case.
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Affiliation(s)
- Nilson Abrão Szylit
- Birth Control Outpatient Clinic, Instituto Israelita de Responsabilidade Social Albert Einstein, São Paulo, Brazil.
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Thabet A, Kalva SP, Liu B, Mueller PR, Lee SI. Interventional Radiology in Pregnancy Complications: Indications, Technique, and Methods for Minimizing Radiation Exposure. Radiographics 2012; 32:255-74. [DOI: 10.1148/rg.321115064] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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The value of laparoscopy alone or combined with hysteroscopy in the treatment of interstitial pregnancy: analysis of 22 cases. Arch Gynecol Obstet 2011; 285:727-32. [DOI: 10.1007/s00404-011-2060-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Accepted: 08/02/2011] [Indexed: 11/26/2022]
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Management of ectopic pregnancies with poor prognosis through ultrasound guided intrasacular injection of methotrexate, series of 14 cases. Arch Gynecol Obstet 2011; 285:529-33. [DOI: 10.1007/s00404-011-2044-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 08/01/2011] [Indexed: 11/26/2022]
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Successful Laparoscopic Management of Early Splenic Pregnancy: Case Report and Review of Literature. J Minim Invasive Gynecol 2010; 17:794-7. [DOI: 10.1016/j.jmig.2010.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 06/17/2010] [Accepted: 07/03/2010] [Indexed: 11/23/2022]
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Glass T, Smith P, Hodges R, Holmes HJ. Intramural pregnancy presenting in a patient with tuberous sclerosis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2010; 38:393-396. [PMID: 20607850 DOI: 10.1002/jcu.20721] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Intramural pregnancies are a rare form of ectopic pregnancy located within the myometrium separate from the endometrial cavity. In an effort to prevent potential complications, diagnosis should be made early when more conservative approaches can be performed to preserve reproductive potential. The diagnosis of ectopic pregnancies can be successfully accomplished through sonography; however, intramural pregnancies may be difficult to diagnose as they can appear similar to other etiologies. We present a unique case of a ruptured intramural pregnancy diagnosed with sonography and pelvic MRI in a patient with tuberous sclerosis. Surgical enucleation of the intramural pregnancy was successfully performed with postoperative resolution of beta hCG levels.
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Affiliation(s)
- Tracy Glass
- Department of Obstetrics and Gynecology, Texas Tech University Health Sciences Center at Amarillo, Amarillo, TX 79106, USA
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