Treatment of tubal pregnancy by local injection of methotrexate after adrenaline injection into the mesosalpinx: a report of 25 patients

Laparoscopic methotrexate treatment of ectopic pregnancy: feasibility, efficacy, safety and intrauterine pregnancy rates

We set out to investigate efficacy, methotrexate (MTX) plasma concentrations, and toxicity following a single injection of MTX into the gestational site in the treatment of ectopic pregnancy. This was a non-randomised, non-blinded prospective clinical trial. Eighteen women with unruptured tubal pregnancies and in stable haemodynamic condition were studied. MTX 1 mg/kg was injected into the ectopic pregnancy guided by laparoscopy. Serum betahCG levels were estimated before MTX treatment and on days 1, 4 and 13. In 14 patients plasma MTX was determined 1 h and 6 h after the injection. We found an adequate decline in betahCG was achieved in 17 (94%) patients, and tubal surgery avoided in 15 (83%). At 6 hours following drug administration, mean plasma MTX concentration (0.36+/-0.21 microM) was only 12% of mean peak level (3.1+/-1.0 microM). Six (39%) demonstrated slightly elevated, but completely reversible liver enzymes. None reported any subjective adverse effects. At the 4-7 year follow-up nine of 12 (75%) women had delivered healthy babies. It is concluded that intratubal injection of 1 mg/kg MTX appears to be an effective and safe treatment of ectopic pregnancy.

Nonsurgical treatment of ectopic pregnancy

Expectant management and medical treatment of ectopic pregnancy either systemically or locally are reviewed. Because of the risks of tubal rupture, this nonsurgical management should be done with utmost care. To date, surgical removal of an ectopic pregnancy remains the method of choice and this can be safely done by laparoscopy. Alternate treatments should be carefully evaluated in clinical trials.

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 from surgical emergency to medical management

During the past 25 years, the incidence of ectopic pregnancy has progressively increased while the morbidity and mortality have substantially decreased, and the treatment has progressed from salpingectomy by laparotomy to conservative surgery by laparoscopy and more recently to medical therapy. This therapeutic transition from surgical emergency to medical management has been attributed to early diagnosis through the use of sensitive assays for hCG and the high definition of vaginal ultrasound. By using these sensitive diagnostic tools, we are now able to select those patients who are most likely to respond to medical management versus those who are at high risk of rupture and require surgery. Besides being less invasive and associated with significantly lower risks, medical therapy with methotrexate results in significant cost savings, which have been calculated to be approximately $3,000 per treated patient. Our goal is to identify those patients with ectopic pregnancy who are most likely to respond to methotrexate therapy and least likely to develop significant side effects. Recent studies have helped us define the predictors of success with methotrexate treatment in women with ectopic pregnancy. The reported success rates of treating ectopic pregnancy with methotrexate vary from 71% to 100%. The highest success rates have been reported from institutions that have detailed diagnostic and therapeutic protocols, readily available assays for serum hCG levels, high-resolution vaginal probe ultrasound, and support staff that can closely monitor clinical response. The importance of developing specific protocols to create a clinical environment that supports the effective use of medical therapy for ectopic pregnancy is confirmed by the associated cost savings, decreased morbidity, and patient preference. Modern diagnostic advances and minimally invasive treatments coupled with improved success rates for assisted reproductive technologies should reduce the morbidity and mortality associated with ectopic pregnancy and offer the affected couple a much more optimistic outlook for subsequent reproductive potential.

Can noninvasive diagnostic tools predict tubal rupture or active bleeding in patients with tubal pregnancy?

OBJECTIVE

To evaluate the ability of noninvasive diagnostic tools to predict tubal rupture and active bleeding in patients with tubal pregnancy.

DESIGN

Prospective cohort study.

SETTING

Two large teaching hospitals in Amsterdam, The Netherlands.

PATIENT(S)

Consecutively seen patients with suspected tubal pregnancy who were scheduled to undergo confirmative laparoscopy.

MAIN OUTCOME MEASURE(S)

Tubal rupture and/or active bleeding confirmed at laparoscopy.

RESULT(S)

Sixty-five (23%) of 288 patients had tubal rupture and/or active bleeding at laparoscopy. Abdominal pain, rebound tenderness on abdominal examination, fluid in the pouch of Douglas at transvaginal ultrasound examination, and a low serum hemoglobin level were independent predictors of tubal rupture and/or active bleeding. Pregnancy achieved with the use of IVF-ET and the presence of an ectopic gestational sac or an ectopic mass at ultrasound examination reduced the risk of tubal rupture. Abdominal pain was the most sensitive predictor, with a sensitivity of 95%.

CONCLUSION(S)

Because the nonsurgical management of tubal pregnancy should be used only when the risk of tubal rupture and/or active bleeding is low, it can be safely applied in only a limited number of patients.

Current status of surgical and nonsurgical management of ectopic pregnancy

OBJECTIVES

To review the efficacy, safety, costs, and subsequent reproductive outcome of surgical and nonsurgical management of ectopic pregnancy (EP).

DESIGN

Pertinent studies were identified through computer Medline search. The rates of intrauterine pregnancy (IUP) and EP were calculated from the raw data in the original publications so that the denominator would be consistent.

RESULT(S)

The efficacy of laparoscopic treatment of EP is similar to that by laparotomy. The rate of persistent EP after conservative surgery ranges from 3% to 20%. Based on a review of 1,514 patients attempting to conceive after linear salpingostomy, the IUP and recurrent EP rates were 61.4% and 15.4%, respectively, among patients who had laparotomy, and 61% and 15.5%, respectively, among patients who had laparoscopic procedure. Of 3,584 patients who had partial or total salpingectomy, the subsequent IUP rate was 38.1% and the recurrent EP rate was 9.8%. Of 540 patients treated with a single-dose methotrexate, 84% did not require further treatment and, among 215 patients who attempted to conceive, 54% had subsequent IUP and 8% had recurrent EP. The success rate of expectant management was 69.2% in 347 patients reviewed.

CONCLUSION(S)

There is no difference in the reproductive outcome after treatment of EP by laparotomy and by laparoscopy. Salpingostomy is associated with higher subsequent IUP and recurrent EP rates compared with salpingectomy. Methotrexate is a viable alternative to laparoscopic salpingostomy for a selected group of patients.

Limited role for intratubal methotrexate treatment of ectopic pregnancy

OBJECTIVE

To test the effectiveness of laparoscopic intratubal methotrexate (MTX) injection or salpingostomy in the treatment of ectopic pregnancy (EP).

DESIGN

Prospective predefined protocol.

SETTING

Department of Obstetrics and Gynecology of a university-affiliated hospital.

PATIENTS AND INTERVENTIONS

Between January 1988 and December 1993, we treated 342 women with EP, of which 99 were treated by either laparoscopic salpingostomy (n = 55) or intratubal MTX injection (n = 44).

MAIN OUTCOME MEASURES

The success and failure rates were calculated for each treatment protocol. Also analyzed were subsequent tubal patency and fertility rates.

RESULTS

Salpingostomy was successful in 51 of 55 patients (92.7%), whereas intratubal MTX injection was successful in only 27 of 44 women (61.4%). Methotrexate injection particularly was unsuccessful if the initial hCG was > 2,000 mIU/mL (conversion factor to SI unit, 1.00) or the size of the tubal mass was > 2.0 cm as measured during laparoscopy. There was no difference in the subsequent tubal patency rates of fertility rates between women undergoing MTX injection or salpingostomy.

CONCLUSIONS

These results suggest that salpingostomy is effective in the treatment of EP. Methotrexate injection failed in more patients despite preferential selection criteria, suggesting that its use should be limited to the subgroup of women with initial hCG < 2,000 mIU/mL and size at laparoscopy < 2.0 cm.

Single injection of methotrexate for treatment of ectopic pregnancies

OBJECTIVE

Our purpose was to evaluate the efficacy of single-dose methotrexate as a treatment option for ectopic pregnancies.

STUDY DESIGN

Patients were recruited from a tertiary teaching hospital setting. They had (1) a gestational sac < 3.5 cm, (2) no fetal cardiac activity, and (3) no significant pelvic pain or signs consistent with hemoperitoneum. Patients excluded were those who did not desire future fertility or who had evidence of renal or liver disease. Sixty-one patients meeting these criteria were selected and treated with a single intramuscular injection of methotrexate at a dosage of 50 mg/m2.

RESULTS

Of the 61 patients treated, 16 required a second injection and nine required surgical intervention. Fifty-two (85%) were successfully treated as outpatients with methotrexate alone.

CONCLUSION

Nonsurgical treatment of ectopic pregnancies with single-dose methotrexate is an option for some patients, but more studies are needed to establish the safety, efficacy, and effect on fertility.

Treatment of unruptured tubal pregnancy with methotrexate: pharmacokinetic analysis of local versus intramuscular administration

OBJECTIVE

To determine the optimal dose and route of methotrexate (MTX) in the treatment of ectopic pregnancy (EP).

DESIGN

Prospective randomized study.

SETTING

Department of Obstetrics and Gynecology (A. Béclère Public Hospital, Clamart, France, Paris-Sud University).

PATIENTS AND METHODS

Forty-eight patients with unruptured EP clearly visualized by ultrasound were randomly allocated into four groups of treatment (12 patients in each group): group 1, 1 mg/kg injected locally in the ectopic gestational sac and 1 mg/kg by IM administration 48 hours later; group 2, 1 mg/kg locally; group 3, 0.5 mg/kg locally; group 4, 1 mg/kg by IM administration. Inclusion criteria used a pretherapeutic score < or = 12. Blood samples were collected at time 0.25, 0.5, 1, 2, 6, 12, 24, 36, and 48 hours after MTX administration. Pharmacokinetics of MTX plasma levels were measured by fluorescence polarization immunoassay. Kinetic parameters were compared by Wilcoxon test and Mann-Whitney test. Plasma hCG concentrations were assessed on days 2, 5, and 10 and then weekly until they returned to undetectable levels.

RESULTS

Success rate was 12 of 12, 11 of 12, 10 of 12, and 10 of 12 in groups 1, 2, 3, and 4, respectively. Six patients in group 3 required an additional MTX IM injection because of an inadequate decrease of hCG plasma levels. Five patients underwent surgery for abdominal pain or inadequate decrease of hCG. Area under the curve decreased more rapidly after injection in the gestational sac alone than after IM injection and was similar in groups 1 and 2 after local injection and lower in group 3. Terminal half-life and mean residence time remained similar in the four groups. Systemic side effects of MTX therapy occurred in three cases in groups 1 and 4. The regression curve of hCG plasma levels appeared similar in the four groups with a decrease to pretreatment values between days 6 and 8 after an initial rise after MTX was given.

CONCLUSION

Area under the curve found after injection in the ectopic sac may be related to a decrease in bioavailability of MTX that links to trophoblastic cells. Patients in group 3 were clearly undertreated by 0.5 mg/kg MTX and required additional therapy. Residual values of MTX plasma levels were always below the limit of detection of our assay and confirmed that citrovarum factor rescue is unnecessary. Injection of 1 mg/kg of MTX in the ectopic sac appears as effective as systemic (IM) injection with less side effects for the patients.

Transvaginal intra-amniotic injection of methotrexate in early ectopic pregnancy. Advantages over the laparoscopic approach

Methotrexate (MTX, 100 mg) was administered to 36 patients with early ectopic pregnancy locally, either under laparoscopic control into the distended fallopian tube (group A, n = 16), or transvaginally into the gestational sac directly, under ultrasound guidance (group B, n = 20). In cases with persistent beta-hCG levels (n = 7), an additional 50 mg of MTX solution was instilled into the affected tube, following transuterine tubal catheterization. Comparing the two different routes of MTX administration, it was shown that the resolution time (beta-hCG < 20 mIU/ml) in group B was significantly shorter (2.4 +/- 1.1 weeks vs. 4.1 +/- 1.9 weeks in group A, P < 0.05), with a better success rate (100% and 88%, respectively). Serum MTX levels were found within a low range and no systemic side effects were noticed. In conclusion, direct intraovular MTX injection under ultrasound guidance proved superior to the laparoscopically-controlled 'blind' intratubal injection. A relatively high dose of MTX (100 mg) seems justified in order to shorten the resolution period, especially in cases with high initial beta-hCG levels and/or fetal heart motion present.

Systemic treatment of ectopic pregnancies with single-dose methotrexate

STUDY OBJECTIVE

To evaluate the success rate, side effects, reproductive outcome, and possible pitfalls of systemic low-dose methotrexate (MTX) for treatment of ectopic pregnancy (EP).

DESIGN

Longitudinal, nonrandomized trial Setting. Department of Obstetrics and Gynaecology at a teaching hospital in Germany.

PATIENTS AND INTERVENTIONS

Forty women with EP were treated with a single dose of MTX 20 to 40 mg intravenously. The highest pretreatment human chorionic gonadotropin (hCG) titer was 21,100 mIU/ml.

MEASUREMENTS AND MAIN RESULTS

Thirty-seven patients (92.5%) were treated successfully. Thirty-four (85%) received a single dose of MTX. Six (15%) required a second dose about a week later. Three patients (7. 5%) required surgical intervention. Serum MTX levels decreased below 0.1 micromol/L (45.4 microg/L) within 24 hours. In 53.8% of women hCG levels decreased directly after treatment; in 46.2% levels increased within the first 5 days after treatment.

CONCLUSIONS

In selected patients, systemic low-dose MTX is an effective way to treat EP, and has no demonstrable side effects.

Current status of endoscopic surgical management of tubal pregnancy

A worldwide increase in the incidence of ectopic pregnancy has been reported in the last two decades. Recently developed diagnostic tools markedly improved the early diagnosis capability. These include: 1, rapid and sensitive beta hCG and progesterone assays; 2, improved ultrasonographic visualization of the pelvic organs; 3, the wide application of diagnostic laparoscopy. Today, most cases are diagnosed before a rupture occurs. Accordingly, treatment has shifted from an immediate, life-saving intervention to conservative methods of management, directed at preserving fertility and reducing morbidity. Endoscopic surgical techniques have also rapidly improved in the last decade, thus, this treatment option apparently became the treatment of choice in most centers. Laparoscopic conservative treatment of tubal pregnancy is as effective and safe as treatment with laparotomy and has the advantage of decrease in hospital stay, cost, and delay in return to normal activity. This review will focus on the endoscopic surgical procedures and their place in view of the other surgical and non-surgical options.

Beta HCG levels after conservative treatment of ectopic pregnancy: is a plateau normal?

In 32 women with unruptured tubal ectopic pregnancies we undertook conservative laparoscopic treatment [local injection of 20 mg methotrexate (n = 18), laser salpingotomy (n = 14)]. The results of serial quantitative beta HCG measurement were followed until either a negative level was reached or until rising levels necessitated alternative/additional therapy. Plateaued values of beta HCG were observed in both the successful (n = 16) and the unsuccessful cases (n = 5). To test the hypothesis that daily variation in the assay could account for some or all of the observed plateaued results in successful cases, the sera were retested serially on the same 'run'. In only one case did laboratory variation account for the observed plateau. The clinical implications of the findings are discussed. We conclude that serially monitored beta HCG results after conservative treatment of ectopic pregnancy may show plateaued values without indicating failure of treatment.

Serum hCG decline following salpingotomy or salpingectomy for extrauterine pregnancy

Twenty-five women with ectopic pregnancy were surgically treated, fifteen by conservative salpingotomy and ten by radical salpingectomy. All patients showed a clinically normal postoperative course. Serum human chorionic gonadotropin (hCG) levels were determined serially before and after the surgical procedure until non-pregnant values (< 5 mI.U./ml) were reached. Serum hCG decline was compared between patients treated by salpingotomy versus salpingectomy, using calculated hCG half-life times. We observed a significantly slower decline of serum hCG levels during the early phase of hCG disappearance in patients treated by salpingotomy versus patients treated by salpingectomy.

Comparison of a local injection of hyperosmolar glucose solution with salpingostomy for the conservative treatment of tubal pregnancy

OBJECTIVE

To compare a local injection of hyperosmolar glucose and salpingostomy for the laparoscopic treatment of tubal pregnancy in terms of immediate success and postoperative tubal patency.

DESIGN

Prospective. PATIENTS, SETTING: Forty women with an unruptured tubal pregnancy were enrolled from among 117 women with ectopic pregnancies (EPs) admitted consecutively to the university clinic. The inclusion criteria were as follows: [1] concentration of beta-hCG in the serum < or = 5,000 IU/L; [2] no living fetus in the EP; and [3] unruptured tubal pregnancy at laparoscopy.

INTERVENTIONS

After randomization, 20 of these patients were treated with a local injection of hyperosmolar (50%) glucose solution and 20 women by salpingostomy. Tubal patency was evaluated at relaparoscopy or by hysterosalpingography 6 to 13 months after the primary treatment.

RESULTS

The mean decrease in beta-hCG concentration from the preoperative value to the first postoperative day was 37% and 52% in the glucose and salpingostomy groups, respectively, and the mean resolution time was 13 and 12 days, respectively. Human chorionic gonadotropin showed a persistent EP in 4 women (20%) in the glucose group and 2 (10%) in the salpingostomy group. A patent treated tube was found in 9 of 13 women in the glucose group and 9 of 10 in the salpingostomy group at re-examination. During a follow-up of 6 to 20 months 4 women in the glucose group and 4 women in the salpingostomy group had an intrauterine pregnancy.

CONCLUSION

A local injection of hyperosmolar glucose is a reasonable method treating tubal pregnancy in selected cases but does not seem to offer any advantage over salpingostomy concerning persistent trophoblastic disease rate.

Tubal damage after intratubal methotrexate treatment

We report on a case of seriously hampered tubal repair 6 months after local MTX treatment. Histopathological examination showed destruction of tubal mucosa and remnants of the EP.

Methotrexate treatment of ectopic pregnancy: 100 cases treated by primary transvaginal injection under sonographic control

OBJECTIVE

To evaluate safety and efficacy of intrasaccular methotrexate (MTX) for treatment of ectopic pregnancy (EP).

DESIGN

Longitudinal nonrandomized trial of MTX treatment of EP.

SETTING

Department of Obstetrics and Gynecology (A. Béclère Public Hospital, Clamart, France Paris-Sud University).

PATIENTS

One hundred patients with an EP visualized by sonography. Patients were 31.4 +/- 4.8 years old, para 0 to 4, and gravida 0 to 7. Twelve patients had a past history of EP, and 18 had previously undergone tubal surgery. Inclusion score for proposed medical treatment used six criteria graded from 1 to 3: gestational age, initial hCG level, P level, existence of abdominal pain, size of hemoperitoneum, and diameter of hematosalpinx. Eleven patients had an EP with cardiac activity. Treatment consisted of MTX, 1 mg/kg, given locally under transvaginal sonographic control.

RESULTS

Eighty-three of 100 patients were considered to be completely cured (return of hCG to < 10 mIU/mL). The success rate was 92.8% with an initial hCG level < 5,000 mIU/mL and 87% when the score was < or = 12. Seven of the 11 patients with an EP with cardiac activity were treated successfully, including 5 of 7 when the initial score was < or = 12, and all failures concerned cases with an initial score > 12. Twenty-eight of 83 patients treated successfully required more than one injection of MTX (additional doses being given intramuscularly) because of nonresolution of hCG levels. Follow-up hysterosalpingography was performed in 80 patients showing 90% tubal patency on the side of the treated EP. Of 58 patients wishing pregnancy, 34 pregnancies occurred, including 25 ongoing or delivered. We observed a low recurrence rate of EP (3 with 1 on the same side).

CONCLUSION

Treatment by initial transvaginal injection of MTX under sonographic control appears to be simple and effective, with no demonstrable untoward effects. The tubal patency and subsequent fertility obtained appear satisfactory. The highest success rate is observed when hCG level is under 5,000 mIU/mL and/or a pretherapeutic score < or = 12 when EP is visualized by sonography.

Ectopic pregnancy in King Fahad Hofuf Hospital: A five year experience

Out of a total of 45,836 deliveries over a five-year period (1986-1990), 128 cases of ectopic pregnancy (0.28% incidence) managed during this period was compared with other previously published data in terms of presentation and management. There were no maternal deaths among the cases treated. The age distribution was 16-144 years with higher incidence 46 (36%) occurring in the range of 25-30. One hundred thirty (93%) were multipara. The presenting complaints included pain (100%), vaginal bleeding (78.4%) and amenorrhea (39.8%). The most consistent clinical findings was cervical excitation tenderness (88%). Ultrasonography (88%) and laparoscopy (50%) were adjunctive only to history and physical examination which was found to be the most important in the diagnosis. Detection of an adnexal mass separate from the ovaries with or without hemoperitoneum was diagnostic of ectopic pregnancy. One hundred two (79.6%) diagnosed as rupture, 17 (13%) as aborted and five (3.9%) as intact. With the changing picture of ectopic pregnancy, one case each was initially diagnosed as appendicitis, urinary tract infection and anemia and admitted in the medical ward before further review confirmed the diagnosis of ectopic pregnancy. The sites of implantation included 123 in ampulla (96%), one each in ovary, cornual and cervix with two diagnosed as having abdominal pregnancy. The predisposing factors include pelvic inflammatory disease (22.6%), previous ectopic (10.2%) and recent IUCD (9%), but none insitu at the time of ectopic. Our treatment of choice is salpingectomy but 12% had salping-oophorectomy for various reasons, while total abdominal hysterectomy was performed for the cervical pregnancy for uncontrollable hemorrage.

Lack of resolution of ectopic pregnancy by intratubal injection of methotrexate

Although reports of local injection of MTX in the treatment of EP appeared to be promising, our results do not confirm the efficacy of this approach. Our experience was sufficiently discouraging to prompt discontinuation of a randomized trail; our hope is that others will add to the accumulating data base so that the role of local injection of MTX can be clarified.

Histopathology of five tubes after treatment with methotrexate for a tubal pregnancy

OBJECTIVE

To investigate whether treatment with a local high dose of methotrexate (MTX) for a tubal pregnancy hampers tubal repair.

DESIGN

From a total of 67 cases treated with MTX for their tubal pregnancy, two tubes ruptured shortly after the MTX injection and were removed. One patient insisted on a removal of the affected tube in spite of the fact that serum human chorionic gonadotropin was negative. Two patients had her tube removed +/- 1 year after the MTX treatment during a salpingo-oophorectomy because of endometriosis and cystic enlarged ovary.

RESULTS

In the ruptured tubes there were no findings supporting the idea that tubal rupture occurred because of the injection of MTX into the tube. There were also no signs of a hampered tubal-tissue response to the insult of invading chorionic tissue. Macroscopic and microscopic evaluation of the unruptured tubes showed no residual tubal destruction. In the tubal wall, all layers were normal and continuous, all unruptured tubes were gracile without distention.

CONCLUSION

Methotrexate applied in a high local dose does not seem to hamper tubal response against the insult of invading chorionic tissue or to interfere with the ultimate tubal repair.

Advancing conservative treatment of ectopic pregnancy--laparoscopic and "non-surgical" management

Improvements in diagnostic measures have contributed to the earlier diagnosis of ectopic pregnancy which in turn has led to the development of new and alternative methods of managing tubal pregnancies. Laparoscopic salpingotomy offers advantages such as a reduction in operating time and shorter hospital stays and convalescence as compared with conventional abdominal surgery. Furthermore, neither the frequency of persistent trophoblasts nor of second operations is increased, and the subsequent fertility rate is at least equal to that after laparotomy. "Non-surgical" treatment of ectopic pregnancy, such as systemic administration of methotrexate and laparoscopic/transvaginal ultrasonic--guided local injection of methotrexate, prostaglandins or hyperosmolar glucose, are attractive alternative methods in selected cases. These methods are safe and effective and have a high success rate and promising results for fertility. Laparoscopy is preferred to conventional abdominal surgery for the treatment of ectopic pregnancy. In selected cases, "non-surgical" treatment can be an attractive alternative therapy.

The history of the diagnosis and treatment of ectopic pregnancy: a medical adventure

From its indirect reference by Abulcasis (936-1013) and until the 19th century the ectopic pregnancy was known as a universally fatal accident. By reporting successful treatment of tubal pregnancy with salpingectomy in 1884 Robert Lawson Tait (1845-1899) started an era of almost 70 years of exclusively extirpative treatment of ectopic pregnancy. The technologic revolution of the 20th century improved diagnostic capabilities so that diagnosis of unruptured ectopic pregnancy becomes feasible and even mandatory. Side by side our understanding of the natural history of ectopic pregnancy improved. Many patients with early-resolving ectopic pregnancies escape surgical treatment. Preservation of future fertility became possible with the introduction of conservative surgical procedures and with the use of methotrexate. The main achievement in the treatment of ectopic pregnancy over the past 110 years is the dramatic decrease in mortality rate: from 72-90% in 1880 to 0.14% in 1990.

Treatment of unruptured tubal pregnancy by local injection of methotrexate and prostaglandin F2 alpha in 52 patients

Uncomplicated tubal pregnancies were treated by local injection of methotrexate (25 to 50 mg) and PGF2 alpha (5 to 10 mg). Trophoblastic resorption occurred in 50 (96.1%) of 52 patients within 20 days after treatment and without side effects. Three months after treatment, the affected tube was patent in 43 (91.4%) of 47 patients continuing in the study, and the subsequent intrauterine pregnancy rate was 40.4%. The combined use of methotrexate and PGF2 alpha appears to be a promising treatment for tubal pregnancy and should be evaluated further.