Methotrexate pneumonitis after systemic treatment for ectopic pregnancy

Nanomedicines for Improved Management of Ectopic Pregnancy: A Narrative Review

Ectopic pregnancy (EP) - the implantation of an embryo outside of the endometrial cavity, often in the fallopian tube - is a significant contributor to maternal morbidity and leading cause of maternal death due to hemorrhage in first trimester. Current diagnostic modalities including human chorionic gonadotropin (hCG) quantification and ultrasonography are effective, but may still misdiagnose EP at initial examination in many cases. Depending on the patient's hemodynamic stability and gestational duration of the pregnancy, as assessed by history, hCG measurement and ultrasonography, management strategies may include expectant management, chemotherapeutic treatment using methotrexate (MTX), or surgical intervention. While these strategies are largely successful, expectant management may result in tubal rupture if the pregnancy does not resolve spontaneously; MTX administration is not always successful and may induce significant side effects; and surgical intervention may result in loss of the already-damaged fallopian tube, further hampering the patient's subsequent attempts to conceive. Nanomaterial-based technologies offer the potential to enhance delivery of diagnostic imaging contrast and therapeutic agents to more effectively and safely manage EP. The purpose of this narrative review is to summarize the current state of nanomedicine technology dedicated to its potential to improve both the diagnosis and treatment of EP.

Ectopic Pregnancy

Ectopic pregnancy occurs in 2% of all pregnancies and is a potentially life-threatening emergency. A high level of clinical suspicion is required for any pregnant patient who presents with vaginal bleeding and/or pelvic pain. Workup should begin with immediate triage based on vital signs, a pregnancy test, and transvaginal ultrasound. Ectopic pregnancy can be treated either medically with methotrexate or surgically with either salpingectomy or salpingostomy. Carefully counseled, asymptomatic patients may be candidates for expectant management.

Nucleoside transporter-guided cytarabine-conjugated liposomes for intracellular methotrexate delivery and cooperative choriocarcinoma therapy

Gestational trophoblastic tumors seriously endanger child productive needs and the health of women in childbearing age. Nanodrug-based therapy mediated by transporters provides a novel strategy for the treatment of trophoblastic tumors. Focusing on the overexpression of human equilibrative nucleoside transporter 1 (ENT1) on the membrane of choriocarcinoma cells (JEG-3), cytarabine (Cy, a substrate of ENT1)-grafted liposomes (Cy-Lipo) were introduced for the targeted delivery of methotrexate (Cy-Lipo@MTX) for choriocarcinoma therapy in this study. ENT1 has a high affinity for Cy-Lipo and can mediate the endocytosis of the designed nanovehicles into JEG-3 cells. The ENT1 protein maintains its transportation function through circulation and regeneration during endocytosis. Therefore, Cy-Lipo-based formulations showed high tumor accumulation and retention in biodistribution studies. More importantly, the designed DSPE-PEG2k-Cy conjugation exhibited a synergistic therapeutic effect on choriocarcinoma. Finally, Cy-Lipo@MTX exerted an extremely powerful anti-choriocarcinoma effect with fewer side effects. This study suggests that the overexpressed ENT1 on choriocarcinoma cells holds great potential as a high-efficiency target for the rational design of active targeting nanotherapeutics.

Pregnancy of unknown location

Pregnancy of unknown location is a situation in which a positive pregnancy test occurs, but a transvaginal ultrasound does not show intrauterine or ectopic gestation. One great concern of pregnancy of unknown location is that they are cases of ectopic pregnancy whose diagnosis might be postponed. Transvaginal ultrasound is able to identify an ectopic pregnancy with a sensitivity ranging from 87% to 94% and a specificity ranging from 94% to 99%. A patient with pregnancy of unknown location should be followed up until an outcome is obtained. The only valid biomarkers with clinical application and validation are serum levels of the beta fraction of hCG and progesterone. A single serum dosage of hCG is used only to determine whether the value obtained is above or below the discriminatory zone, that means the value of serum hCG above which an intrauterine gestational sac should be visible on ultrasound. Serum progesterone levels are a satisfactory marker of pregnancy viability, but they are unable to predict the location of a pregnancy of unknown location: levels below 5 ng/mL are associated with nonviable gestations, whereas levels above 20 ng/mL are correlated with viable intrauterine pregnancies. Most cases are low risk and can be monitored by expectant management with transvaginal ultrasound and serial serum hCG levels, in addition to the serum progesterone levels. To minimize diagnostic error and intervene during progressive intrauterine gestation, protocol indicates active treatment only in situations when progressive intrauterine pregnancy is excluded and a high possibility of ectopic pregnancy exists.

Acute methotrexate toxicity presenting as multiorgan failure and acute pneumonitis: A rare case report

Acute methotrexate toxicity rarely presents as medical emergency in form of multiorgan failure. Acute pneumonitis following low-dose methotrexate is rarely reported in literature. It is important to recognize this, as the drug must be discontinued immediately and rescue measures in form of folinic acid and hydration instituted promptly.

Do you need to definitively diagnose the location of a pregnancy of unknown location? The case for "yes"

Pregnancy of unknown location (PUL) is a common diagnostic challenge. The primary diagnostic goal is to ensure that the PUL is nonviable prior to proceeding with any invasive procedures. In nonviable PUL, there are several diagnostic and treatment strategies, which are generally quite safe. However, the management option that provides the most definite diagnosis is uterine curettage. We advocate use of uterine curettage in all cases of nonviable PUL because it limits exposure to a chemotherapeutic agent to only those who need it and it allows for the most accurate information for counseling the patient on prognosis of future pregnancies.

Methotrexate: the pharmacology behind medical treatment for ectopic pregnancy

Previously established as a chemotherapeutic agent for decades, methotrexate has been adapted for use as a medical therapy for unruptured ectopic pregnancies. Its mechanism of action, competitive inhibition of folate-dependent steps in nucleic acid synthesis, effectively kills the rapidly dividing ectopic trophoblast. However, the same action on normal cells is the basis for many of its adverse effects.

Role of routine monitoring of liver and renal function during treatment of ectopic pregnancies with single-dose methotrexate protocol

OBJECTIVE

To assess whether or not baseline serum transaminases and creatinine measurements, before administration of methotrexate, identified significant liver or kidney disease, which have the potential to alter the management plan for the treatment of ectopic pregnancies.

DESIGN

This is a retrospective study of patients treated for ectopic pregnancy.

SETTING

Women's emergency room and reproductive endocrinology office at a teaching hospital over a 3-year period.

PATIENT(S)

Women presenting for treatment of ectopic pregnancy.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Assessment of baseline serum transaminases and creatinine measurements before administration of methotrexate to identify significant liver or kidney disease.

RESULT(S)

A total of 383 patients were managed for ectopic pregnancy from January 2006 to December 2008. Of these, 320 patients received methotrexate as part of their treatment. No patient was denied treatment with methotrexate secondary to concerns regarding liver or renal function. No complication related to methotrexate administration was documented. A subgroup of 81 patients had pre- and postadministration labs, and no significant difference was noted upon comparing the values.

CONCLUSION(S)

Routine measurement of serum aspartate aminotransferase and creatinine levels may not be necessary before instituting a single-dose methotrexate treatment regimen for the management of ectopic pregnancy.

Medical termination of pregnancy in the early first trimester

Surgical abortion using vacuum aspiration or dilatation and curettage has been the method of choice for termination of pregnancy up to 63 days' gestation since the 1960s. Over the last three decades many studies have explored the use of medical methods for inducing abortion at these gestations. Earlier regimens assessed the systemic and intrauterine injection of prostaglandins. This was followed in the 1980s by the introduction of the antiprogesterone, mifepristone. Since its introduction, the uptake of medical abortion has been steadily increasing in countries where it has been available for routine use. Most current clinical protocols require the use of prostaglandins in combination with anti-progesterones or antimetabolites. The safety, efficacy and acceptability of the medical regimen are now well established at all gestations of pregnancy. Provision of medical abortion increases the choice available to women, in particular those wishing to avoid surgery.

Mifepristone and misoprostol for early abortion when no gestational sac is present

The study was conducted to determine whether the administration of mifepristone followed by vaginal misoprostol can induce an abortion in early pregnancy when no gestational sac is present on sonogram. This report presents a prospective, pilot study of 30 healthy adult women, pregnant and seeking an abortion, and with no gestational sac on sonogram. All women had a baseline serum chorionic gonadotropin (hCG) level measured prior to using mifepristone 200 mg orally followed by misoprostol 800 mcg vaginally 48 h later, and then returned up to 4 days later for a repeat sonogram and serum hCG level. Women with initial hCG levels > 2000 IU/L were evaluated for ectopic pregnancy. At the first follow-up visit, if the hCG decreased by >50%, the women were followed with home pregnancy (25 IU/L) tests weekly until negative. If the levels did not decrease by 50%, a second dose of misoprostol was given. Surgical intervention was indicated for persistent hCG levels or excessive bleeding. Of the 30 women enrolled, the mean number of days of amenorrhea was 40 (SD 9) days. Two women had surgical intervention for continuing pregnancy, 2 had ectopic pregnancies, and 1 was lost to follow-up. Complete medical abortions occurred in 25/30 (88%) women, but when recalculated, in 25/27 (93%) women who completed the protocol and who did not have an ectopic pregnancy. There was 1 adverse event in a woman with an ongoing pregnancy who then received methotrexate. She was hospitalized a day later with a complicated pelvic infection and likely methotrexate-induced pneumonitis. Twenty-three women had a decrease in hCG at first follow-up visit of >50%. All 27 women who completed the protocol found the overall regimen acceptable. Mifepristone followed at 48 h by vaginal misoprostol were effective and acceptable in inducing an abortion in very early pregnancy. There may be a higher incidence of failure in very early pregnancies. Documentation of a complete abortion by hCG level is necessary to ensure the pregnancy is neither ongoing nor ectopic.

Alternatives to mifepristone regimens for medical abortion

Alternatives to regimens with mifepristone and a prostaglandin analog for medical abortion emerged because of the need for accessible, effective, and safe options in areas of the world where mifepristone was unavailable. Studies of oral or intramuscular methotrexate combined with misoprostol have demonstrated complete abortion rates in the same range as mifepristone regimens at </=49 days' gestation. The overall abortion process with methotrexate and misoprostol takes longer, however, with 20% to 30% of women requiring from 1 to 5 weeks for the abortion to occur. Multiple investigators have confirmed the safety, efficacy, and acceptability of various methotrexate and misoprostol regimens. Recent reports suggest that misoprostol alone may have similar efficacy, but with significantly higher rates of side effects. Randomized trials are needed to directly compare the clinical efficacies and acceptabilities of available medical abortion regimens.

Single high dose of local methotrexate for the management of relatively advanced ectopic pregnancies

OBJECTIVE

To evaluate the limits of the conservative management of relatively advanced ectopic pregnancies (EPs) with local methotrexate given at a higher than standard dose.

DESIGN

Nonrandomized prospective study.

SETTING

A tertiary teaching hospital and an affiliated infertility center.

PATIENT(S)

We treated 118 EPs of up to 56 days' gestation (8 weeks) regardless of the presence of fetal heart activity, the size of the gestational mass, and the initial beta-hCG levels.

INTERVENTION(S)

Transvaginal intraamniotic or laparoscopic intratubal injection of 100 mg of methotrexate as a single dose.

MAIN OUTCOME MEASURE(S)

beta-hCG levels, red and white blood cell count, and liver function tests before and after methotrexate injection, followed by repeat transvaginal color Doppler assessments.

RESULT(S)

Treatment was successful in 105 (88.98%) of the 118 patients included in the study. In 7 of them with persistent fetal cardiac activity after the methotrexate injection, treatment was concluded with a complementary intracardiac injection of 10% KCl. No grade 3 or important clinical, hematologic, or biochemical toxicities occurred.

CONCLUSION(S)

Local administration of a single high dose of methotrexate (100 mg) proved safe and effective in the medical management of relatively advanced and unselected EPs, including cases with fetal heart activity, with high initial beta-hCG levels, and with a gestational mass beyond the standard maximum of 3.5 cm. Complementary hypertonic KCl proved to be effective in cases with persistent cardiac activity.

Surgical and medical management of tubal and non-tubal ectopic pregnancies

This article highlights recent findings in the diagnosis and management of ectopic pregnancy. While the search for the ideal biochemical marker for ectopic pregnancy continues, new protocols have been described for the management of persistent ectopic pregnancy. The role of nuclear marker Ki-67 in trophoblastic proliferation and the only randomized trial to date involving systemic methotrexate and laparoscopic surgery are discussed. The management of cervical, interstitial and heterotopic pregnancies are reviewed.

A pilot study of the effect of methotrexate or combined oral contraceptive on bleeding patterns after induction of abortion with mifepristone and a prostaglandin pessary

Although a combination of mifepristone and a prostaglandin is a safe, acceptable alternative to vacuum aspiration for inducing abortion in early pregnancy, the longer period of vaginal bleeding after medical abortion is a disadvantage. The present study investigated whether administration of the combined oral contraceptive pill (COC) or the injection of methotrexate at the time of abortion would shorten the period of vaginal bleeding after medical abortion. After having a medical abortion induced with mifepristone (200 mg) and 0.5 mg gemeprost pessary, 80 women were randomized to four groups of 20 women each; Group A, COC; Group B, control; Group C, 50 mg/m2 methotrexate; and Group D, placebo injection. There was no significant difference in the duration of bleeding between Groups A and B (median 14 and 17 days) or between Groups C and D (18 and 15 days), or in the amount of bleeding (4 days of heavy bleeding in each group). The first period occurred sooner in Group A who took the COC (median/range: 25/15-54 control group versus 32/16-46 days, p < 0.04). The administration of methotrexate was associated with a temporary elevation in liver enzyme concentration in one woman. It is concluded that women who wish to use COC can start immediately after medical abortion. Addition of methotrexate after abortion has no significant beneficial effect on patterns of bleeding and cannot be recommended.

Single-dose methotrexate for unruptured ectopic pregnancy

OBJECTIVES

To compare the effectiveness of single-dose methotrexate (MTX) and laparoscopic salpingostomy in the treatment of unruptured ectopic pregnancy (UEP).

METHODS

75 patients entered a prospective non-randomized study. Thirty-seven women were submitted to a single-dose methotrexate (Group 1) and 38 underwent laparoscopic salpingostomy (Group 2). Methotrexate (1 mg/kg) was given intramuscularly on an out-patient basis if the beta-hCG level was < 5000 IU/I and the hematosalpinx diameter was < 3 cm and the peritoneal fluid < 300 cm3 on TVS. The follow-up consisted of serial clinical examinations, beta-hCG assays, liver tests and blood cell counts. Laparoscopic salpingostomy was decided in other cases of UEP or when patients refused or could not comply with the follow-up.

RESULTS

Group 1 patients (91.8%) were cured with 1-3 doses of MTX, the remainder required a laparoscopy. Seventy-three percent of them were treated on an out-patient basis. The mean time to resolution of hCG was 26.7 days. The initial beta-hCG level significantly correlated with the necessity of a surgical option and the time to resolution of beta-hCG. Whenever beta-hCG was < 3600 IU/l, all patients were cured with a single injection, without hospitalization and with a follow-up of < 27 days. Group 2 patients (81.6%) were cured with laparoscopy and 15.8% required a MTX injection for persistent EP. The mean hospital stay was significantly longer than for those that required the MTX injection (2.7 vs. 0.6; P = 0.0001), but the follow-up was shorter and required significantly less clinical examinations, sonograms and biologic tests. Finally the effectiveness of single-dose MTX and laparoscopic salpingostomy were similar (P = 0.2, 95% CI of the difference: -0.15-0.04).

CONCLUSIONS

Single-dose MTX was as effective as laparoscopy in the treatment of UEP. A rigorous selection of the patients for the treatment option is mandatory to guarantee high success rates, in an out-patient basis and a short follow-up.

A systematic review of single-dose intramuscular methotrexate for the treatment of ectopic pregnancy

The use of single-dose intramuscular methotrexate for the primary treatment of ectopic pregnancy is increasing in frequency in many countries. We performed a systematic review of all available studies and case reports of intramuscular methotrexate to examine the therapeutic efficacy, side-effects and complication rates of this new treatment approach. The pooled data show a successful resolution rate of 71% (95% confidence interval 58% to 81%) after a single dose of intramuscular methotrexate and 84% (95% confidence interval 77% to 90%) after 1 or 2 doses. Side-effects were experienced by 24% (95% confidence interval 9% to 47%) of patients and 10% (95% confidence interval 7% to 14%) had a ruptured ectopic pregnancy. The pooled data show that single-dose intramuscular methotrexate is associated with a high failure rate. Follow-up is prolonged and there is a significant incidence of minor side-effects. Serious complications and side-effects have occurred. The use of intramuscular methotrexate should be confined to clinical trials until more evidence is obtained to support its more widespread use.