[Medical management of interstitiel pregnancy by in situ methotrexate]

Interstitial pregnancy management: A multicentric analysis of 98 patients from the FRANCOGENT group comparing surgery and medical treatment

OBJECTIVE

To evaluate the outcomes associated with each therapeutic option for patients diagnosed with interstitial pregnancy (IP).

METHODS

We conducted a multicentric retrospective cohort study within the departments of Gynecology and Obstetrics involved in the Francogent research group. Women treated for an interstitial pregnancy between January 2008 to December 2019 were included. Three therapeutic options were evaluated: surgical treatment (ST); in situ methotrexate combined with systemic methotrexate (IS-MTX); and systemic methotrexate (IM-MTX). Success of first-line treatment was defined by hCG negativation (<5I U/L). Secondary outcomes included the need for secondary surgical procedure, secondary medical treatment, emergency surgery, postoperative complications, duration of hospitalization, and delay before hCG negativation.

RESULTS

A total of 98 patients were managed for IP: 42 (42.9%) patients had IM-MTX; 34 (34.7%) had IS-MTX; and 22 (22.4%) had ST. First-line treatment was successful in all patients of the ST group (22/22, 100%), in 31% of patients within the IM-MTX group (13/42) and 70.6% (24/34) in the IS-MTX group. The sole parameter associated with the risk of treatment failure was the mode of methotrexate administration. The size of the gestational sac or the presence of fetal heartbeat was not associated with decreased medical treatment (IS or IM-MTX) efficiency.

CONCLUSION

Either ST or IS-MTX are good options for IP treatment associated with high success rates. A single-dose regimen of IM-MTX is less efficient than IS-MTX or ST. Symptomatic patients with severity criteria should always undergo emergency surgery. IP remains a high-risk condition that should be managed, whenever possible, in referral centers to potentialize the chances of favorable outcomes.

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.

Successful conservative medical management of an interstitial ectopic pregnancy at 10 weeks of gestation: A case report

Background

Interstitial pregnancy is a rare type of ectopic pregnancy, accounting for 2–6% of ectopic pregnancies, but it can be life threatening. There is no clear consensus on management, either surgical or medical, and it depends on hemodynamic stability and whether fertility-sparing treatment is requested.

Case Presentation

We present the case of a 35-year-old woman (G2, P1) who was diagnosed with an interstitial pregnancy at 10 weeks of gestation following in vitro fertilization. She was hemodynamically stable and requested fertility-sparing treatment. She was managed successfully with methotrexate and folinic acid with a hospital stay of 17 days.

Conclusion

Interstitial pregnancy can be managed medically. However, these patients require close monitoring.

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Iterstitial ectopic pregnancy accounts for 2-6% of ectopic pregnancies.

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Management may be either surgical or medical.

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Successful medical management with methotrexate regimen of a 10-week interstital pregnancy is described.

Methotrexate for Cornual Ectopic Pregnancy

A 27-year-old pregnant female presented to the emergency department with pelvic pain and vaginal bleeding. At the time of diagnosis, she had an ectopic pregnancy in the right cornua 4 cm in size with a human chorionic gonadotropin (hCG) value of 14,438 international units per mL. The ectopic pregnancy was initially managed by intramuscular methotrexate. However, after 10 days, despite an hCG value drop to 409 international units per mL, an indication that methotrexate was working, the patient had a subsequent rupture with hemoperitoneum necessitating exploratory laparotomy and abdominal hysterectomy.