Treating ectopic pregnancy with the combination of mifepristone and methotrexate: a phase II nonrandomized study

Medical Management of Cesarean Scar Ectopic Pregnancy: A Unique Approach

One of the rarest types of ectopic pregnancy, with an incidence of 1:1,800, is cesarean scar ectopic pregnancy. Here, we report the case of a 28-year-old woman who had undergone two previous cesarean sections. She arrived at our labor room with per vaginal spotting and abdominal pain with an ultrasound that revealed a cesarean scar ectopic pregnancy. The initial beta-human chorionic gonadotropin (β-hCG) value upon admission was 27,133 mIU/mL. Her ultrasound findings were confirmed with magnetic resonance imaging. Opting for combined medical management, we successfully treated her using systemic methotrexate and mifepristone, avoiding surgical intervention despite high β-hCG values. There is currently no established standardized treatment for cesarean scar ectopic pregnancies, and we feel that treatment must be tailored to every patient's individual needs. Our experience suggests that combining mifepristone and systemic methotrexate can be an effective approach with better curative effects, emphasizing the need for further research.

Evaluation of Guidelines and Consensus on Ectopic Pregnancy Based by AGREE II Method

Introduction

To evaluate the methodological quality of diagnosis and treatment guidelines/consensus related to ectopic pregnancy.

Materials and methods

Use the "Appraisal of Guidelines and Research and Evaluation" (AGREE II) method to evaluate the differences among the guideline/consensus.

Results

We appraised 9 clinical practice guidelines for ectopic pregnancy (9 clinical practice guidelines from 5 countries) including the United States, United Kingdom, Ireland, Canada, and China. The guidelines received the highest scores for clarity of presentation (82.72%) and lowest scores for editorial independence (30.56%). The comprehensive recommendations of the 7 guidelines were Grade B, the other 2 guidelines were Grade C.

Conclusion

The overall quality of the ectopic pregnancy guidelines had room for improvement. It is recommended to supplement and improve the four fields of "independence", "rigor", "participants" and "application", especially the "independence" and "application" fields.

Have we overlooked the role of mifepristone for the medical management of tubal ectopic pregnancy?

Ectopic pregnancy is a risk of both spontaneous and assisted reproduction pregnancies. The majority of ectopic pregnancies abnormally implant within a fallopian tube (extrauterine pregnancies). In haemodynamically stable women, medical or expectant treatment can be offered. Currently accepted medical treatment is using a drug called methotrexate. However, methotrexate has potential adverse effects, and a significant proportion of women will still require emergency surgery (up to 30%) to remove the ectopic pregnancy. Mifepristone (RU-486) has anti-progesterone effects and has a role in managing intrauterine pregnancy loss and termination of pregnancy. On reviewing the literature and given progesterone's pivotal role in sustaining pregnancy, we propose that we may have overlooked the role of mifepristone in the medical management of tubal ectopic pregnancy in haemodynamically stable women.

The indication and treatment outcome predictors of mifepristone treating ectopic pregnancy

OBJECTIVE

Ectopic pregnancy is a life-threatening disease and is an important cause of pregnancy-related mortality. MTX is the primary conservative treatment medicine of ectopic pregnancy, and mifepristone is also a promising medicine. Through studying the ectopic cases at the third affiliated hospital of Sun Yat-Sen University, the study aims to analyze the indication and treatment outcome predictors of mifepristone.

METHODS

The data of 269 ectopic pregnancy cases treated with mifepristone during the year 2011-2019 were retrospectively collected. Logistic-regression analysis was used to analyze the factors affiliated with the treatment outcome of mifepristone. Then ROC curve was used to analyze the indication and predictors.

RESULTS

Through logistic-regression analysis, HCG is the only factor related to the treatment outcome of mifepristone. The AUC of ROC curve predicting treatment outcome with pre-treatment HCG is 0.715, and the cutoff value of ROC curve is 372.66 (sensitivity 0.752, specificity 0.619). The AUC of 0/4 ratio predicting the treatment outcome is 0.886, and the cutoff value is 0.3283 (sensitivity 0.967, specificity 0.683). The AUC of 0/7 ratio is 0.947, and the cutoff value is 0.3609 (sensitivity 1, specificity 0.828).

CONCLUSIONS

Mifepristone can be used to treat ectopic pregnancy. HCG is the only factor related to the treatment outcome of mifepristone. Patients with HCG less than 372.66 U/L can be treated by mifepristone. If HCG descends more than 67.18% on the 4th day or 63.91% on the 7th day, it is more likely to have a successful treatment outcome. It is more precise to retest on the 7th day.

The efficacy of mifepristone combined with methotrexate for the treatment of ectopic pregnancy: a systematic review and meta-analysis

OBJECTIVE

Systematically evaluate the clinical efficacy of mifepristone combined with methotrexate therapy for ectopic pregnancy (EP), analyze the experimental designs, put forward improvement ideas.

METHODS

RCTs of mifepristone combined with mifepristone for EP until January 2022 in six databases were searched. The primary outcome indicator was the cure rate. RevMan 5.4 was used to analyse and the online GRADEpro tool was used to assess the certainty of the evidence.

RESULTS

Twenty-five RCTs involved 2263 patients. The cure rate was higher in the investigational group (OR = 4.09, 95%CI: [3.20, 5.22]), time of vagina stopped bleeding (MD = -11.21, 95%CI: [-11.85, -10.57]) and time of abdominal pain disappeared (MD = -6.24, 95%CI: [-6.63, -5.86]) were shorter in the investigational group, β-HCG level (MD = -585.32, 95%CI: [-609.62, -561.03]) was lower and diameter of the mass (MD = -1.23, 95%CI: [-1.40, -106]) was smaller in the investigational group. The certainty of the evidence for most outcomes was moderate or high, and only one was low.

CONCLUSIONS

The combination of mifepristone and methotrexate can improve the efficacy of ectopic pregnancy without amplifying the toxic side effects. Larger scale and better design of the randomized controlled trials are needed.KEY MESSAGESIn recent years, the increase in ectopic pregnancies and their impacts on female fertility makes physicians have to find an effective medical treatment as soon as possible that can avoid surgery.The mifepristone combined with methotrexate therapy for EP has better curative effects on improving the cure rate, lowering β-HCG level, reducing the mass, and alleviating symptoms of abdominal pain and bleeding, without amplifying the toxic side effects.Literature with high quality is lacking, and well-designed, large-scale and high-quality multicenter randomized controlled trials are needed.

Clinical Utility of Mifepristone: Apprising the Expanding Horizons

Mifepristone is a progesterone and glucocorticoid receptor antagonist. Medical abortion with mifepristone and prostaglandin has revolutionized the abortion process extending abortion care to the doors of females. From as low as 2 mg/day to doses extending to 600 mg, from daily dosing to single dosage treatment, mifepristone has a wide perspective in the treatment of various pathologies. Cervical dilatation and myometrial contractility have made the utility of mifepristone feasible for second-trimester termination of pregnancy and induction of labor awaiting Food and Drug Administration approvals. Its anti-progesterone action on the menstrual cycle has a new dimension of use as a contraceptive, as well as use as a menstruation inductive agent. Its role in endometriosis, ectopic pregnancy, and adenomyosis requires more intensive research. Apoptotic action of mifepristone, interference of heterotypic cell adhesion to the basement membrane, cell migration, growth inhibition of various cancer cell lines, decreased epidermal growth factor expression, suppression of invasive and metastatic cancer potential, increase in tumor necrosis factor, downregulation of cyclin-dependent kinase 2, B-cell lymphoma 2, and Nuclear factor kappa B have opened its potential to be explored as anti-cancer treatment and its effects on leiomyoma. The drug needs to be studied more for the prospectus of its anti-glucocorticoid actions in a wider dimension beyond its acquiescence for the treatment of Cushing syndrome.

Surgical Treatment Following Failed Medical Treatment of an Interstitial Pregnancy

Interstitial pregnancy (IP) is a type of ectopic pregnancy in which the embryo implants in the interstitial part of the Fallopian tube. It accounts for 2% of all ectopic pregnancies. Signs and symptoms appear later than the other forms of ectopic pregnancies because of its peculiar location. The gold standard for its diagnosis is transvaginal ultrasound. The treatment can be medical or surgical. Medical treatment is based on the systemic or local injection of methotrexate (MTX); a dose of mifepristone can be added with a reported 85–90% success rate. The surgical option is laparoscopic unilateral cornuostomy or unilateral salpingectomy. The therapeutic choice is based on symptoms, serum β-human chorionic gonadotropin (β-hCG) values, and sonographic features. Furthermore, the patient’s fertility perspectives should be considered. We report a case of IP in a Caucasian woman of 29 years old, with a previous salpingectomy for ectopic pregnancy medically treated by a double dose of intramuscular MTX 50 mg/m² combined with a single dose of leucovorin 15 mg and a single dose of mifepristone 600 mg orally. Medical therapy failed as suggested by the sudden onset of intense pelvic pain after 10 days. Because of the clinical symptoms and the sonographic suspicious of pregnancy rupture due to the modest amount of fluid in the pouch of Douglas, clinicians decided on an urgent unilateral laparoscopic salpingectomy. The hemoperitoneum was drained. The patient was discharged two days later and β-hCG serum levels became negative after 45 days. The advantages of fertility sparing should be weighted according to the patient’s reproductive perspectives. Appropriate counseling is therefore key in managing the treatment of interstitial pregnancy.

Interstitial Ectopic Pregnancy: The Role of Mifepristone in the Medical Treatment

Interstitial pregnancy is defined as the presence of a gestational sac in the most proximal section of the fallopian tube. Management of interstitial pregnancy remains a debated topic. Depending on hemodynamic stability, size of pregnancy, depth of surrounding myometrium, and desires for future fertility, interstitial pregnancy can be managed medically or surgically. We reviewed the literature in December 2020 using keywords “interstitial pregnancy”, “medical treatment”, “methotrexate”, and “mifepristone”. Articles published from January 1991 until 2020 were obtained from databases EMBASE, SCOPUS, and PUBMED. We describe the case of a patient with an interstitial pregnancy that was managed with a total medical approach in August 2020 at Burlo Garofolo Hospital. The patient was asymptomatic and hemodynamically stable, with a high level of serum β-hCG (22,272 mUi/mL). We used the combination of methotrexate (MTX) and mifepristone. Medical therapy was effective leading to interstitial pregnancy resolution in 51 days without collateral effects for the patient. We found seven previous cases reported in the literature. Our purpose is to underline the efficacy of medical therapy with systemic multidose MTX associated with a single oral dose of mifepristone and also folinic acid when is present a viable fetus and a high serum β-hCG level.

Evaluation of treatment of previous cesarean scar pregnancy with methotrexate: a systematic review and meta-analysis

BACKGROUND

Previous caesarean scar pregnancy is one type of ectopic pregnancy in myometrium and fibrous tissue of previous caesarean scar. One of the therapeutic methods of this type of ectopic pregnancy is treatment with methotrexate. Given various findings on the treatment of caesarean scar pregnancy with methotrexate and lack of global report in this regard, we aimed to achieve a global report on the treatment of CSP with methotrexate through related literature review and analysis of the results of the studies, to enable more precise planning to reduce complications of CSP.

METHOD

This review study extracted information through searching national and international databases of SID،, Embase, ScienceDirect, ، Scopus, ، PubMed, Web of Science (ISI) between 2003 and January 2020. To perform the meta-analysis, random-effects model and heterogeneity of the studies with I² index were investigated. Data were sanalysed using Comprehensive Meta-Analysis version 2.

RESULTS

In total, 26 articles with a sample size of 600 individuals were enrolled in the meta-analysis. According to the results of the study, the mean level of β-hCG was 28,744.98 ± 4425.1 mIU/ml before the intervention and was 23,836.78 ± 4533.1 mIU/ml after the intervention. The mean intraoperative blood loss (ml) was 4.8 ± 3.76 ml, mean hospital stay (days) was 11.7 ± 1.2 days, mean time for serum-hCG normalization (days) was 41.6 ± 3.2 days, success was 90.7% (95% CI: 86.7-93.5%), and complication was 9% (95% CI: 6.3-12.8%).

CONCLUSION

The results of the current study show methotrexate significantly reduces β-hCG levels and can be effective in treating caesarean scar pregnancy and its complications.

Conservative Treatment of Interstitial Ectopic Pregnancy with the Combination of Mifepristone and Methotrexate: Our Experience and Review of the Literature

Introduction

Interstitial pregnancy (IP) is an ectopic pregnancy (EP) located in the portion of the fallopian tube that penetrates the uterine muscular layer. Incidence increased in the last two decades with the widespread use of the assisted reproductive techniques. It is estimated in 1-6% of all the EPs, with a maternal mortality rate of 2.0-2.5%. Clinical presentation, gestational age at diagnosis, beta-human chorionic gonadotropin (β-hCG) levels, ultrasound features, and patient preference, should be considered to determine the best management: surgical, medical treatment, or close observation. We report two cases of IP successfully managed with systemic MTX and Mifepristone: in one case β-hCG was >10.000 mIU/mL and a vital embryo was present.

Materials and Methods

A literature search was carried out on MEDLINE, EMBASE, and PUBMED. We identified two cases of IP referred to the Institute for Maternal and Child Burlo Garofolo, Trieste. Data related to clinical presentation, β-hCG, and ultrasound scan at the moment of the diagnosis were recorded. In one of the cases, the β-hCG level was >10.000 mIU/mL, and a vital embryo was testified at an ultrasound scan. The patient was asymptomatic and she was treated using multidose systemic Methotrexate (MTX) combined with Mifepristone. In the second case, in the presence of a clinically stable patient with β − hCG > 10.000 mIU/mL, it was chosen that the administration of Mifepristone combined with a double dose of MTX. β-hCG levels and ultrasound examinations were performed weekly until a complete resolution of the IP.

Results

In the first case, β-hCG dropped down in 5 days and became undetachable in 30 days. In the second case, β-hCG became undetectable in 47 days. The first-line therapy in asymptomatic women could be addressed to a combined protocol, consisting of a systemic multidose MTX regimen with a single oral dose of Mifepristone.

Conclusions

Clinical management of IP remains a debated topic. In selected cases, a systemic multidose MTX regimen combined with a single oral dose of Mifepristone could be considered also in the presence of high serum β-hCG.

Feasibility and effectiveness of unintended pregnancy prevention with low-dose mifepristone combined with misoprostol before expected menstruation

STUDY QUESTION

What is the efficacy of maintaining or restoring non-pregnant status with low-dose mifepristone combined with misoprostol administered before expected menstruation?

SUMMARY ANSWER

Low-dose mifepristone and misoprostol administered at the time of expected menstruation was effective and safe in maintaining or restoring non-pregnant status, with no obvious menstrual disturbance.

WHAT IS KNOWN ALREADY

Menstrual regulation involves the medical or mechanical stimulation of uterine sloughing in women with up to 2-3 weeks of menstrual delay. Low-dose mifepristone plus misoprostol is efficacious for termination of ultra-early pregnancy (≤ 35 days of amenorrhoea) with no obvious menstrual disturbance.

STUDY DESIGN, SIZE, DURATION

A total of 678 women fulfilled all criteria and were recruited. Seventeen women dropped out after deciding to remain pregnant and 11 others were lost to follow-up. Thus, data from 650 women who completed the procedure were included in analyses. Participants were enrolled at any time during their menstrual cycle and administered medication 1 day before expected menstruation. The end of the study was defined on a per-patient basis as the date of completion of the post-treatment menstrual cycle. The primary outcome was the efficacy of abortion induction (for pregnant women) or menstrual regulation (for non-pregnant women).

PARTICIPANTS, SETTING, METHODS

Women with regular menstrual cycles (25-35 days) were voluntarily recruited for this study between February 2012 and December 2014. Serum β-hCG was measured before mifepristone intake. Mifepristone (50 mg) was administered orally 1 day before expected menstruation and 200 µg misoprostol was administered orally on the day of expected menstruation. Efficacy, disturbance in bleeding patterns in the treatment and post-treatment cycles, satisfaction with the treatment, and subsequent contraception preference were analysed.

MAIN RESULTS AND THE ROLE OF CHANCE

Retrospective analysis of serum β-hCG levels at admission indicated that 23.3% (158/678) of the women were pregnant. The success rate for pregnancy termination was 98.6% (136/138). Two women (1.5%, 2/138) had ongoing pregnancy that was subsequently terminated surgically. The overall bleeding induction rate within 7 days was 98.3% (639/650), with 100% (138/138) in pregnant participants and 97.9% (501/512) in non-pregnant participants. Most pregnant and non-pregnant participants experienced no significant menstrual disturbance during the treatment [96.3% (131/136) versus 97.6% (489/501)] or post-treatment [97.8% (133/136) versus 98.4% (493/501)] menstrual cycle. The general rate of satisfaction with the treatment was 96.7% (618/639). Generally, 36.0% (230/639) of participants preferred to use the regimen as a routine contraception method versus the 64.0% (409/639) who preferred to use it as a remedy for pregnancy prevention after unprotected sex (P < 0.001).

LIMITATIONS, REASONS FOR CAUTION

Study participants were recruited from a single region; further studies should include participants from multiple centres in different cities and nations. Given the uncertain efficacy of regimen reuse, the assessment of efficacy was based solely on the first treatment administration. Studies with larger samples and long-term follow-up may provide more data on whether repeated use of this regimen hampers its efficacy.

WIDER IMPLICATIONS OF THE FINDINGS

Menstrual regulation with low-dose mifepristone and misoprostol at expected menstruation can be efficacious and highly acceptable to maintain or restore non-pregnant status, which may have potential for routine contraception.

[Indications for methotrexate in gynecology outside the first-line treatment of ectopic tubal pregnancies]

The objective of this work is to discuss the indications for methotrexate in gynecology outside the first-line treatment of tubal ectopic pregnancy. In tubal ectopic pregnancy, the prophylactic use of systemic methotrexate can be discussed when performing laparoscopic salpingotomy. In case of failure of salpingotomy, administration seems justified especially if it avoids re-intervention. The combination of methotrexate with other therapies such as mifepristone, potassium chloride or gefitinib is not recommended in the treatment of ectopic pregnancy. For non-tubal ectopic pregnancy, the intramuscular or local administration of methotrexate is an acceptable treatment for uncomplicated interstitial pregnancies. For uncomplicated cervical or cesarean scar pregnancies, the local administration of methotrexate should be considered as a first-line treatment. For ovarian pregnancies, methotrexate should not be a first-line treatment, surgical treatment remains the standard. Asymptomatic women presenting with a pregnancy of unknown location and plateauing serum hCG concentration<2000 UI/L can be managed expectantly: it is recommended to take an additional quantitative hCG serum level after 48 hours. Thus, methotrexate is not recommended in the first intention. Other gynecological indications were discussed: methotrexate is not recommended in the management of first-trimester miscarriages or in the management of placenta accreta.

Laparoscopic salpingocentesis using methotrexate in combination with oral mifepristone for successful treatment of interstitial pregnancy: a case report

OBJECTIVE

To report two cases of women who presented with amenorrhea, lower abdominal pain, and vaginal bleeding and who were diagnosed with advanced interstitial pregnancy after initial negative laparoscopies.

DESIGN

Case report.

SETTING

Early pregnancy unit of district general hospital.

PATIENT(S)

A 39-year-old woman with a history of right salpingectomy for ectopic pregnancy and a 28-year-old woman with a history of miscarriage.

INTERVENTION(S)

Laparoscopic salpingocentesis with methotrexate (50 mg/m(2)) after aspiration of an equivalent amount of amniotic fluid. The remainder, based on the calculated dose, was given intramuscularly. Oral mifepristone (200 mg) was given postoperatively.

MAIN OUTCOME MEASURE(S)

Complete resolution of interstitial pregnancy in both instances with two subsequent, successful intrauterine pregnancies delivered at term in the second patient. There were no intraoperative or postoperative complications.

RESULT(S)

Expected decline in beta human chorionic gonadotropin (beta-hCG) levels without the need for any further intervention(s).

CONCLUSION(S)

Interstitial pregnancy may be successfully and safely managed by the use of laparoscopic salpingocentesis with methotrexate and mifepristone despite high initial beta-hCG levels.

Ultrasound assessment of haemoperitoneum in ectopic pregnancy: derivation of a prediction model

Background

To derive an ultrasound-based prediction model for the quantification of haemoperitoneum in ectopic pregnancy (EP).

Methods

Retrospective study of 89 patients operated upon EP between January 1999 and March 2003 in a French Gynaecology and Obstetrics department in a university hospital. Transvaginal sonograms, clinical and biological variables from patients with haemoperitoneum ≥ 300 ml at surgery were compared with those from patients with haemoperitoneum < 300 ml or no haemoperitoneum. Sensitivity, specificity, positive and negative likelihood ratios were calculated for each parameter after appropriate dichotomization. Multiple logistic regression analysis was used to select the best combination at predicting haemoperitoneum ≥ 300 ml.

Results

Three parameters predicted haemoperitoneum ≥ 300 ml independently: moderate to severe spontaneous pelvic pain, fluid above the uterine fundus or around the ovary at transvaginal ultrasound, and serum haemoglobin concentration < 10 g/dL. A woman with none of these three criteria would have a probability of 5.3% for haemoperitoneum ≥ 300 ml. When two or more criterias were present, the probability for haemoperitoneum ≥ 300 ml reached 92.6%.

Conclusion

The proposed model accurately predicted significant haemoperitoneum in patients diagnosed to have EP.

Ectopic pregnancy

Ectopic pregnancy is an important cause of morbidity and mortality worldwide. Use of transvaginal ultrasonography and quantitative measurement of the beta subunit of human chorionic gonadotropin (beta-hCG) has led to a reduction in the need for diagnostic laparoscopy. Furthermore, with earlier diagnosis, medical therapy with methotrexate can be offered and surgery avoided in some women, though the best regimen remains unclear. In the surgical management of ectopic pregnancy, the benefits of salpingectomy over salpingostomy are uncertain. Although there have been advances in the management of ectopic pregnancy there are still questions to be answered.

[Present and potential uses of mifepristone in gynecology, obstetrics and other medical specialties]

Mifepristone, a derivative of norethindrone, a first generation synthetic progestative, has a very potent antiprogestative activity and to a lesser degree antiandrogenic and antiglucocorticoid activities. This action makes it potentially useful in the treatment of multiple hormone dependent diseases in obstetrics-gynecology as well as in a variety of medical specialties such as neurology, ophthalmology, and oncology. Nevertheless, the label of abortive pill has incited numerous ethical and political debates concerning the permission to market this drug, and this has contributed to the delay in the assessment of the potential indications of mifepristone. Largely under-utilized in practice despite its increasing theoretical benefit, clinical studies should now de conducted. Thus, based on an international review of literature during the last ten years, we have shed light on the present and potential indications of mifepristone in medical practice.

[Medical treatment of ectopic pregnancy: a randomized clinical trial comparing metotrexate-mifepristone and methotrexate-placebo]

BACKGROUND

Medical treatment of ectopic pregnancy is widespread. To increase the efficacy of methotrexate, combination with mifepristone has been proposed.

METHODS

We performed a large prospective multicentre double-blind sequential randomized trial in order to compare the efficacy of methotrexate and mifepristone (600 mg given orally) versus methotrexate and placebo.

RESULTS

Two hundred twelve ectopic pregnancies were randomized. There was no significant difference in the initial characteristics between the 2 groups. There was no significant difference in the success rate of medical treatment between the methotrexate-mifepristone (n=113) and the methotrexate-placebo group (n=99): 79.6% (90/113) vs 74.2% (72/97) respectively, RR [95% CI]: 1.07 [0.92-1.25], p=0.41. However, there was a quantitative interaction between progesterone level and effect of treatment: when progesterone level was 10 ng/l, the efficacy of the combination of mifepristone and methotrexate was significantly higher than the combination of methotrexate and placebo, with a 83.3% success rate (15/18) vs 38.5% (5/13) respectively.

CONCLUSION

Our study failed to demonstrate any benefit of the addition of mifepristone to methotrexate. By contrast, the quantitative interaction between treatment effect and base line serum progesterone suggested that this combination could be reserved to ectopic pregnancies associated with high serum progesterone concentrations.

Ectopic pregnancy: an update

PURPOSE OF REVIEW

This review discusses recent publications that investigate the epidemiology, diagnosis and treatment of ectopic pregnancy.

RECENT FINDINGS

Transvaginal ultrasound is being used with increasing confidence for the diagnosis of ectopic pregnancy, and methotrexate now has an established role in the treatment of ectopic pregnancy. No serum markers have been found that can reliably differentiate intrauterine from extrauterine pregnancy. As more experience has been gained with medical therapy, it is apparent that it is possible to identify a subgroup of women in whom it is unlikely to succeed. The use of adjunctive therapy such as mifepristone does not appear to increase the effectiveness of methotrexate. Screening for ectopic pregnancy in at-risk women has been suggested, but it may be of only limited value. In the surgical management of ectopic pregnancy the effect on fertility of salpingotomy and salpingectomy remains uncertain, although recent cohort studies suggest that salpingotomy may be associated with a better subsequent intrauterine pregnancy rate than salpingectomy. A number of case reports of pregnancies at unusual sites continue to be published, but in the last 2 years there has been a dramatic increase in the number of caesarean scar pregnancies reported.

SUMMARY

Medical therapy now has an established role in the treatment of ectopic pregnancy, but it is clear that careful patient selection is essential. In the surgical management of ectopic pregnancy the effects of salpingotomy and salpingectomy on subsequent fertility are uncertain and need further investigation.

Predictors of success in methotrexate treatment of women with unruptured tubal pregnancies

OBJECTIVE

The use of methotrexate (MTX) for the treatment of tubal ectopic pregnancy (EP) has become common practice, although the factors associated with a favorable outcome are not totally clear. The aim of this study was to investigate the predictors of successful MTX treatment.

METHODS

One hundred and thirty-seven women with unruptured tubal EP in whom the hematosalpinx could be directly visualized by pelvic ultrasound were studied. Women who met the inclusion criteria were treated with MTX either: 50 mg/m(2) intramuscularly (n = 70) or with 1 mg/kg injected directly into the hematosalpinx under sonographic guidance (n = 67). The associations between the outcome of the treatment and different factors studied (human chorionic gonadotropin (hCG) level, progesterone level, hematosalpinx diameter, hemoperitoneum volume and mode of MTX administration) were analyzed.

RESULTS

The overall success rate, defined by a post-treatment normal hCG level (< 10 mIU/mL), was 79.6%. The initial hCG level and the route of administration of MTX appeared to be two independent factors that predicted success. Multivariate analysis demonstrated that the success rate was significantly better when MTX was administered locally: the odds ratio (OR) was 9.7 (95% CI, 3.1-30), and was significantly poorer when the hCG level was >/= 1000 mIU/mL (P < 0.002): the OR was 0.10 (95% CI, 0.07-0.49).

CONCLUSION

Among selected women with tubal EPs, the route of administration of MTX and the initial level of serum hCG are the most important factors associated with the success of medical treatment.

Ectopic pregnancy

Ectopic pregnancy occurs in approximately 2% of all pregnancies in the United States, and is the nation's leading cause of first trimester maternal death. Its incidence has increased sixfold in the past 25 years, despite significant improvements in techniques for early diagnosis and management. This article reviews the epidemiology, risk factors, and common clinical presentations of ectopic pregnancy. Both traditional and newly developed strategies for diagnosis and management are described. The primary care physician is in an excellent position to screen for and diagnose ectopic pregnancy, and to counsel patients regarding treatment options and future risks. With the increasing trend toward outpatient nonsurgical management of ectopics, it is expected that the roll of the primary care physician in managing patients with ectopic pregnancy will continue to increase.