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

Transvaginal ultrasound-guided methotrexate instillation for failed medical management of ectopic pregnancies in subfertile women

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.

Ultrasound-guided intrasacular injection of methotrexate in the management of ectopic pregnancies with embryo. A 12 year experience report in a tertiary hospital

OBJECTIVE

To evaluate the efficacy and safety of combined-therapy with ultrasound guided intrasacular injection of 50 mg of methotrexate (MTX) and a 50 mg/m² dose of systemic MTX in uncomplicated ectopic pregnancies with ultrasonographic evidence of embryonic structures in the gestational sac.

STUDY DESIGN

We designed a retrospective study including 60 patients to assess the efficacy of combined MTX treatment and to determine which clinical or ultrasonographic variables could be associated with successful medical treatment. Failed medical treatment was defined when surgery was needed. For statistical analysis, we developed a descriptive analysis and a univariate logistic regression study.

RESULTS

Medical approach was effective in 73.3 % of patients. MTX treatment was successful in 32 (68.1 %) out of 47 tubal pregnancies None of the 4 cervical or 2 abdominal pregnancies required surgery. Six (85.7 %) out of 7 cornual pregnancies were successfully treated. No statistically significant differences were found in the success rates according to clinical data, ultrasound or analytic characteristics of women.

CONCLUSION

Combined MTX therapy could be an effective and safe alternative in ectopic pregnancies with embryo in hemodynamically stable women. Clinical, ultrasound or analytic characteristics of patients should not entail a contraindication. In locations where surgery implies a technical difficulty, this option may decrease morbimortality rates frequently associated to a more invasive alternative.

Clinical effectiveness of multiple-drug injection treatment in unruptured ectopic pregnancies: a retrospective study

OBJECTIVES

To study the effect of local interventional treatment of unruptured ectopic pregnancies with multiple-drug injection guided by color Doppler sonography.

METHODS

In this retrospective analysis, 49 patients with an unruptured ectopic pregnancy were treated with two different local injection methods administered under sonographic guidance. The patients were divided into single-drug (n = 23) and multiple-drug (n = 26) injection groups, and they received a locally administered injection of methotrexate alone or a combination including methotrexate, hemocoagulase, antibiotics, and anti-inflammatory drugs, respectively. Overall, local injection treatment was successful in 44 patients. The 5 patients with failed treatment underwent laparotomy about 1 week after single-drug injection. Serum β-human chorionic gonadotropin (β-hCG ) levels, ectopic pregnancy mass sizes, blood flow at various points after treatment, the incidence of pelvic bleeding, and the time for serum β-hCG levels to return to normal and the mass to resolve were analyzed in the remaining 44 patients.

RESULTS

Single-drug treatment was successful in 18 patients; 10 of 23 had low to moderate pelvic bleeding after treatment, and 5 were referred for surgery. All 26 patients were successfully treated by multiple-drug injection. Only 2 patients had a small amount of pelvic bleeding. Differences between groups were statistically significant (P < .05) for surgery rates, the incidence of pelvic bleeding, transient increases in serum β-hCG levels, mean days to normal β-hCG levels, mean days of mass resolution, and mean mass diameters 1 to 6 weeks after treatment.

CONCLUSIONS

Local multiple-drug injection under color Doppler guidance is a new, safe, and effective method for treating unruptured ectopic pregnancies. It accelerates the serum β-hCG decline and facilitates mass resolution. This regimen is associated with a very low rate of pelvic bleeding, improves the success rate of conservative treatment, and, therefore, has value as an important clinical application.

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.

Medical therapy of ectopic gestation: contemporary paradigms

There has been an increase in the incidence of ectopic pregnancy to epidemic proportions in many developed countries in the past two decades. In 1989, ectopic pregnancy accounted for 1.6% of all pregnancies in the United States of America. This trend may be explained by an increase in the incidence of established risk factors as well as a dramatic improvement in diagnostic tools and advances in reproductive technology. Technologic advances such as highly sensitive radioimmunoassays for the β-subunit of human chorionic gonadotropin (βhCG), the development of high-resolution ultrasound and a heightened physician awareness have revolutionized the clinical management of ectopic pregnancy, leading to earlier and more consistent diagnoses and consequently reduced maternal mortality rates. 1,3–13 Unfortunately, ectopic pregnancy is still associated with a significant morbidity and mortality and contributes substantially to health-care costs. For example ectopic pregnancy complications accounted for 13% of all pregnancy-related deaths and were the leading cause of maternal mortality in African- American women in 1989. Financially, an estimated 1.1 billion dollars was spent in the United States of America alone for the management of ectopic pregnancy in 1990.

Combined local and systemic methotrexate treatment of viable ectopic pregnancy: outcomes of 31 cases

PURPOSE

Medical treatment of viable unruptured ectopic pregnancies by systemic methotrexate (MTX) is controversial due to elevated failure rates. This study describes a combined local and systemic MTX administration and compares the outcomes between viable ectopics in different locations.

METHODS

This retrospective study evaluated 31 patients treated with combined local (sonographically guided) and systemic MTX for viable, unruptured ectopic pregnancies. Success was defined by pregnancy resolution without surgical intervention. Details on subsequent pregnancies were obtained via telephone questionnaires.

RESULTS

The ectopic pregnancies were located in the fallopian tube (n = 23), cesarean section scar (n = 5), and intramural portion of the tube (interstitial pregnancy) (n = 3). beta-Human chorionic gonadotropin levels and gestational weeks were similar. The combined treatment was successful in 73.9%, 100%, and 66.7% of cases, respectively (p > 0.05). Details regarding reproductive outcomes were available for 28 women (90.3%). Eighteen of the 24 women attempting to conceive became pregnant, and 15 of these had at least one live birth. There were three subsequent tubal pregnancies, all in patients with previous tubal pregnancies.

CONCLUSION

Combined MTX administration is effective and safe for treating viable cesarean scar pregnancies but is less successful for viable tubal or interstitial pregnancies. Reproductive outcomes following the combined MTX treatment are comparable to other treatment modalities for ectopic pregnancy.

Prognostic value of human chorionic gonadotropin changes after methotrexate injection for ectopic pregnancy

Because early prediction of clinical outcome (one or more injections or surgery) of methotrexate treatment of ectopic pregnancy could ease the intensity of follow-up and patient compliance required, we studied the relationship between the change in hCG levels after methotrexate injection and outcome in 129 consecutive patients. A 20% decline in hCG levels between days 1 and 4 during methotrexate treatment has a positive predictive value of 97%.

The nonsurgical management of ectopic pregnancy

PURPOSE OF REVIEW

This review discusses the diagnosis and nonsurgical management of ectopic pregnancy.

RECENT FINDINGS

In the majority of cases the diagnosis of ectopic pregnancy should be made on transvaginal ultrasonography. Those for which the diagnosis is not made on the first scan may initially be classified as pregnancies of unknown location. There are now a number of strategies and mathematical models to predict ectopic pregnancy in this pregnancy of unknown location population. Reported success rates for expectant and medical management of ectopic pregnancy vary due to different inclusion criteria. A number of predictors of success have been studied: maternal age, previous obstetric history, gestational age, ultrasound features, human chorionic gonadotrophin levels, progesterone levels and the change in human chorionic gonadotrophin over time. At present the initial human chorionic gonadotrophin level probably remains the single most important predictor of success. Nonsurgical management is also particularly important for nontubal ectopic pregnancies: interstitial, cervical and caesarean section scar pregnancies.

SUMMARY

The majority of ectopic pregnancies can be visualized by ultrasound and so can be considered for conservative treatment. Nonsurgical management can be safe and effective. Appropriate selection criteria remain an issue, however, and a consensus needs to be reached on the predictors of success and failure to optimize management.

Imaging of pelvic pain in the first trimester of pregnancy

Pelvic pain during the first trimester of pregnancy can pose a challenge to the clinician. The noninvasive nature, safety, and reliability of ultrasonography make it the diagnostic method of choice for pregnant patients who have pelvic pain. Sonography provides information that allows for diagnosis of both pregnancy-related pain, such as a ruptured ectopic pregnancy, miscarriage, or threatened abortion; and may be useful in the diagnosis of pain unrelated to pregnancy, such as that seen in appendicitis and nephrolithiasis.

Interventions for tubal ectopic pregnancy

BACKGROUND

Treatment options for tubal ectopic pregnancy are; (1) surgery, e.g. salpingectomy or salpingo(s)tomy, either performed laparoscopically or by open surgery; (2) medical treatment, with a variety of drugs, that can be administered systemically and/or locally by various routes and (3) expectant management.

OBJECTIVES

To evaluate the effectiveness and safety of surgery, medical treatment and expectant management of tubal ectopic pregnancy in view of primary treatment success, tubal preservation and future fertility.

SEARCH STRATEGY

The Cochrane Menstrual Disorders and Subfertility Group's Specialised Register, Cochrane Controlled Trials Register (up to February 2006), Current Controlled Trials Register (up to October 2006), and MEDLINE (up to October 2006) were searched.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing treatments in women with tubal ectopic pregnancy.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment was done independently by two reviewers. Differences were resolved by discussion with all reviewers.

MAIN RESULTS

Thirty five studies have been analysed on the treatment of tubal ectopic pregnancy, describing 25 different comparisons.

SURGERY

Laparoscopic salpingostomy is significantly less successful than the open surgical approach in the elimination of tubal ectopic pregnancy (2 RCTs, n=165, OR 0.28, 95% CI 0.09, 0.86) due to a significant higher persistent trophoblast rate in laparoscopic surgery (OR 3.5, 95% CI 1.1, 11). However, the laparoscopic approach is significantly less costly than open surgery (p=0.03). Long term follow-up (n=127) shows no evidence of a difference in intra uterine pregnancy rate (OR 1.2, 95% CI 0.59, 2.5) but there is a non significant tendency to a lower repeat ectopic pregnancy rate (OR 0.47, 95% 0.15, 1.5). Salpingostomy alone is significantly less successful than when combined with a prophylactic single shot methotrexate (2 RCTs, n=163, OR 0.25, 95% CI 0.08-0.76) to prevent persistent trophoblast.

MEDICAL TREATMENT

Systemic methotrexate in a fixed multiple dose intramuscular regimen has a non significant tendency to a higher treatment success than laparoscopic salpingostomy (1 RCT, n=100, OR 1.8, 95% CI 0.73, 4.6). No significant differences are found in long term follow-up (n=74): intra uterine pregnancy (OR 0.82, 95% CI 0.32, 2.1) and repeat ectopic pregnancy (OR 0.87, 95% CI 0.19, 4.1). One single dose intramuscular methotrexate is significantly less successful than laparoscopic salpingostomy (4 RCTs, n=265, OR 0.38, 95% CI 0.20, 0.71). With a variable dose regimen treatment success rises, but shows no evidence of a difference compared to laparoscopic salpingostomy (OR 1.1, 95% CI 0.52, 2.3). Long term follow-up (n=98) do not differ significantly (intra uterine pregnancy OR 1.0, 95% CI 0.43, 2.4, ectopic pregnancy OR 0.54, 95% CI 0.12, 2.4). The efficacy of systemic single dose methotrexate alone is significantly less successful than when combined with mifepristone (2 RCTs, n=262, OR 0.59, 95% CI 0.35, 1.0). The same goes for the addition of traditional Chinese medicine (1 RCT, n=78, OR 0.08, 95% CI 0.02, 0.39). Local medical treatment administered transvaginally under ultrasound guidance is significantly better than a 'blind' intra-tubal injection under laparoscopic guidance in the elimination of tubal ectopic pregnancy (1 RCT, n=36, methotrexate OR 5.8, 95% CI 1.3, 26; 1 RCT, n=80, hyperosmolar glucose OR 0.38, 95% CI 0.15, 0.93). However, compared to laparoscopic salpingostomy, local injection of methotrexate administered transvaginally under ultrasound guidance is significantly less successful (1 RCT, n=78, OR 0.17, 95% CI 0.04, 0.76) but with positive long term follow up (n=51): a significantly higher intra uterine pregnancy rate (OR 4.1, 95% CI 1.3, 14) and a non significant tendency to a lower repeat ectopic pregnancy rate (OR 0.30, 95% CI 0.05, 1.7). EXPECTANT MANAGEMENT: Expectant management is significantly less successful than prostaglandin therapy (1 RCT, n=23, OR 0.08, 95% CI 0.02-0.39).

AUTHORS' CONCLUSIONS

In the surgical treatment of tubal ectopic pregnancy laparoscopic surgery is a cost effective treatment. An alternative nonsurgical treatment option in selected patients is medical treatment with systemic methotrexate. Expectant management can not be adequately evaluated yet.

Comparison of success rates in the medical management of ectopic pregnancy with single-dose and multiple-dose administration of methotrexate: a prospective, randomized clinical trial

OBJECTIVE

To assess whether success rate differs in single-dose versus multiple-dose administration of methotrexate (MTX) in medical management of unruptured ectopic pregnancies.

DESIGN

Prospective randomized clinical trial.

SETTING

Tertiary university hospital.

PATIENT(S)

The study population included 108 patients presenting with unruptured ectopic pregnancies who fulfilled the criteria for medical management.

INTERVENTION(S)

A single dose (study group) or multiple doses (control group) of MTX were administered IM.

MAIN OUTCOME MEASURE(S)

Success rate of medical management in each group.

RESULT(S)

Of the 54 patients on the single-dose protocol, treatment was considered successful in 48 patients (88.9%). Of the 54 patients on the multiple-dose protocol, 50 participants responded to the treatment (92.6%). The difference between success rates in the two groups was not statistically significant (P=.7; odds ratio 0.64; 95% confidence interval 0.17-2.4). In the single-dose and multiple-dose groups, 15 (27.8%) and 20 (37%) patients, respectively, had complications (P=.3).

CONCLUSION(S)

The results of our study showed that single-dose treatment with MTX could be as successful as multiple doses. The incidence of complications did not differ between the two groups. It appears that single-dose treatment could be the first line of treatment in selected patients.

The non-surgical management of ectopic pregnancy

Ectopic pregnancy can now be detected at earlier gestations in asymptomatic women. As a consequence conservative treatment strategies may be more appropriate than surgical intervention. This review aims to discuss the diagnosis and the non-surgical management options for ectopic pregnancy, in particular expectant management and the use of methotrexate.

Ectopic pregnancy: a review

Ectopic pregnancy is a major clinical problem, occurring in 75,000 cases per year in the United States. With in vitro fertilization, embryo transfer, microsurgical techniques, and better early diagnosis, the rates of ectopic pregnancies have increased. Transvaginal sonography along with beta-human chorionic gonadotrophin monitoring are the standards for evaluation of suspected ectopic pregnancy. When ectopic pregnancy is present, transvaginal sonography most often demonstrates an adnexal finding directly related to the extra-uterine gestation itself, a hematoma caused by it, or both. Although tubal location is most common, it is important to recognize unusual locations of ectopic pregnancy such as isthmic, cervical, ovarian, and abdominal. Ultrasound is the mainstay of diagnosis, but magnetic resonance imaging can be helpful in unusual or complicated cases. Current therapeutic options for an ectopic pregnancy are expectant management, systemic methotrexate injections, sonographically guided minimal invasive treatment, and surgery. This review encompasses diagnosis, treatment, and management of ectopic pregnancy.

Single-dose methotrexate for the treatment of unruptured ectopic pregnancy

OBJECTIVE

The objective of this study was to review our experience with single dose intramuscular methotrexate (MTX) for the treatment of ectopic pregnancy and to evaluate major confounding factors that relate to the success of therapy.

PATIENTS AND METHODS

The selection criteria were patients who had a stable hemodynamic status and an ectopic gestational mass of <4 cm. on ultrasound. Patients were not excluded from MTX therapy either by a baseline serum beta-hCG titer or by the presence of fetal cardiac activity demonstrated on ultrasonography. Thirty- four of 86 patients diagnosed with ectopic pregnancy and treated with single-dose MTX between July 1999 and November 2001 were reviewed retrospectively.

RESULTS

The mean pre-treatment beta-hCG level was 2,490+/-2,912 mIU/ml. Twenty-two patients (73.3%) were successfully treated with a single-dose of MTX. Eight patients (26.6%) required a second dose 1 week after the first injection and 2 patients received three doses. Thirty of the 34 patients (88%) were successfully treated with MTX. The mean pre-treatment beta-hCG level was significantly lower in patients who were successfully treated with MTX than in patients who failed MTX therapy (1,932+/-2,361 mIU/ml vs. 6,955+/-2,690 mIU/ml respectively, p<0.05). The mean pre-treatment serum beta-hCG level was higher in patients who had a second MTX injection as compared to patients who were successfully treated with a single injection of MTX (3,272+/-3,551 mIU/ml vs. 1,280+/-2,273 mIU/ml respectively, p>0.05). The mean time to resolution of beta-hCG was 26.5 days (10 to 37 days) with MTX. All 3 patients who failed medical therapy had beta-hCG level >4,000 mIU/ml and 2 of them had positive fetal cardiac activity.

CONCLUSION

In conclusion, this study showed that medical treatment of ectopic pregnancy with systemic single-dose methotrexate seems to be an option for some patients with unruptured tubal pregnancy.

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.

Sonographically guided minimally invasive treatment of unusual ectopic pregnancies

OBJECTIVE

To present our experience with sonographically guided treatment of unusual ectopic pregnancies, defined as heterotopic pregnancies and pregnancies occurring at ectopic locations other than the extracornual portion of the fallopian tube.

METHODS

We retrieved and reviewed all cases of unusual ectopic pregnancies that underwent sonographically guided therapy at our institution. Twenty-seven cases were identified, from 1992 through 2003, including 18 cervical, 6 cornual, 1 tubal heterotopic, and 2 cesarean scar implantations.

RESULTS

All of the cervical ectopic, cornual ectopic, and tubal heterotopic pregnancies were treated by sonographically guided injection of potassium chloride into the ectopic gestational sac or fetus. Guidance was via transvaginal sonography in all 18 cervical pregnancies, 3 of the 6 cornual pregnancies, and the tubal heterotopic pregnancy, and via transabdominal sonography in 3 cornual ectopic pregnancies. One of the cesarean scar pregnancies was treated by transvaginally guided potassium chloride injection, and the other was treated via transabdominally guided dilation and evacuation. Treatment was successful in 25 of the 27 patients, including all 23 patients with an ectopic pregnancy and no concomitant intrauterine pregnancy. Four patients had concomitant intrauterine and ectopic pregnancies (1 cervical, 2 cornual, and 1 tubal); in 3 the intrauterine fetuses resulted in live-born infants, and in the fourth the intrauterine pregnancy was electively terminated. Eight of the 27 patients had subsequent intrauterine pregnancies.

CONCLUSIONS

Sonographically guided minimally invasive treatments of unusual ectopic pregnancies are safe and effective alternatives to surgical and systemic medical therapy. These treatments ablate the ectopic pregnancy, permit normal continuation of a concomitant intrauterine pregnancy, and preserve the uterus for subsequent pregnancies.

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.

Successful management of a heterotopic Caesarean scar pregnancy: potassium chloride injection with preservation of the intrauterine gestation: case report

Caesarean scar pregnancy (CSP), in which the pregnancy is located in the scar of a previous Caesarean section, is a rare situation that carries a high risk of uterine rupture. Improved ultrasound imaging allows early diagnosis of this condition, but there is no standard management. We report the first case of CSP associated with a normal intrauterine pregnancy. Potassium chloride administered under transvaginal ultrasonographic guidance terminated cardiac activity in the CSP. The CSP resolved, and a healthy infant was delivered at 36 weeks. When the diagnosis is early and the patient asymptomatic, surgery can be avoided, the CSP can be terminated selectively and the intrauterine pregnancy thereby preserved.

Reproductive outcome after laparoscopic instillation of hyperosmolar glucose into unruptured tubal pregnancies

OBJECTIVE

To determine intrauterine and ectopic pregnancy rates after local instillation of 50% glucose into unruptured tubal pregnancies.

DESIGN

Retrospective cohort of 183 patients, who were observed for 16 to 108 months (median, 64 months).

SETTING

University hospital.

PATIENT(S)

One hundred eighty-three women who underwent laparoscopic instillation of hyperosmolar glucose for unruptured tubal pregnancies.

INTERVENTION(S)

Completion of questionnaires.

MAIN OUTCOME MEASURE(S)

Pregnancy rate, tubal recurrence rate.

RESULT(S)

A total of 124 women returned the questionnaire and had a desire for spontaneous conception. The conception rate and the intrauterine pregnancy rate were 79% and 73%, respectively. Seventy percent of all women with desire for spontaneous conception had live births. The rate of subsequent ectopic pregnancies was 12%. Tubal patency of the treated tube was demonstrated in 69% of 39 women at hysterosalpingography.

CONCLUSION(S)

The long-term prognosis for conception after laparoscopic instillation of hyperosmolar glucose for unruptured tubal pregnancy is favorable and comparable to that of other conservative treatments.

A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy

OBJECTIVE

To compare single dose systemic methotrexate (50 mg/m2) with laparoscopic surgery for the treatment of unruptured tubal pregnancy.

DESIGN

An open, pragmatic, prospective randomised trial.

SETTING

Departments of obstetrics and gynaecology at three hospitals in Auckland, New Zealand.

PARTICIPANTS

Clinically stable women with an unruptured tubal pregnancy diagnosed by transvaginal ultrasound and quantitative serum beta-hCG measurement. Inclusion criteria included a serum beta-hCG concentration < 5,000 IU/L, and a tubal pregnancy of < 3.5 cm diameter.

MAIN OUTCOME MEASURES

Treatment success, physical and psychological functioning, side effects, and subsequent ipsilateral tubal patency.

RESULTS

Two hundred and eighteen women with ectopic pregnancies were seen at the three hospitals. 79 women (36% eligibility rate) were eligible for trial entry and 62 women (78% recruitment rate) were recruited. Twenty-six of the 28 women (93%) randomised to laparoscopic surgery required no further treatment, compared with 22 of the 34 women (65%) randomised to methotrexate (95% CI of difference in success rate 10 - 47%; P < 0.01). Two women (7%) in the laparoscopic surgery group had persistent trophoblast. Nine women (26%) in the methotrexate group required more than one dose of methotrexate and five women (15%) underwent laparoscopy during follow up. In the laparoscopy group three women (11%) had negative laparoscopies and two women (7%) had were found to have a ruptured fallopian tube at the time of surgery. Women treated with methotrexate had significantly better objective physical functioning scores but there were no differences in any other psychological outcomes. Women treated with methotrexate experienced greater and more prolonged vaginal bleeding. The likelihood of methotrexate treatment failure was greater at higher serum beta-hCG concentrations. Ipsilateral tubal patency rates were similar in each group.

CONCLUSION

This trial shows that in the treatment of tubal pregnancy single dose systemic methotrexate is a less effective treatment than laparoscopic salpingotomy. It is well tolerated, but should only be offered as an alternative to surgery to women who have mild symptoms and present at low serum beta-hCG concentrations. In our population this likely to be no more than a quarter of women presenting with a tubal pregnancy.

Fertility following radical, conservative-surgical or medical treatment for tubal pregnancy: a population-based study

OBJECTIVE

To investigate the factors influencing the choice of treatment for ectopic pregnancy and to compare the subsequent fertility rates of radical, conservative-surgical or medical treatments.

DESIGN

Population-based study of 835 ectopic pregnancies registered between 1992 and 1996.

SETTING

Auvergne Ectopic Pregnancy Register (France).

SAMPLE

Four hundred and seventy-six women with tubal ectopic pregnancy who were not using contraception at the time of conception. Subsequent fertility was studied for the 291 women who attempted to conceive again.

METHODS

Comparison of reproductive outcomes according to ectopic pregnancy treatment. Cumulative fertility curves were calculated by the Kaplan-Meier estimator and compared by log rank test for univariate analysis and by Cox regression to take into account confounding variables.

MAIN OUTCOME MEASURE

Recurrence and fertility rates after ectopic pregnancy.

RESULTS

The first treatment given was 'radical' for 178 women (37%), 'conservative-surgical' for 262 (55%), and 'medical' for 35 (8%). The treatment failed in 1% for radical treatment, 5% for conservative-surgical treatment, and 36% for medical treatment. The two-year cumulative rate of recurrence was 27% with no significant difference between treatments. For women with previous infertility factors (in particular diseased contralateral tube), the treatments differed significantly, with the rate of intrauterine pregnancy lower for radical treatment and higher for medical treatment than for conservative-surgical treatment. For women with no infertility factor, there was no significant difference between treatments.

CONCLUSIONS

These results should be confirmed in a controlled trial. The results of this study provide the elements necessary to plan such a trial.

Interventions for tubal ectopic pregnancy

BACKGROUND

The diagnosis of ectopic pregnancy can now often be made by non-invasive methods due to sensitive pregnancy tests (in urine and serum) and high resolution transvaginal sonography, which have been integrated in diagnostic algorithms. These algorithms, in combination with the increased awareness and knowledge of risk factors among both clinicians and patients, have enabled an early and accurate diagnosis of ectopic pregnancy. As a consequence, the clinical presentation of ectopic pregnancy has changed from a life threatening disease to a more benign condition. This in turn has resulted in major changes in the options available for therapeutic management. Many treatment options are now available to the clinician in the treatment of tubal pregnancy: surgical treatment, which can be performed radically or conservatively, either laparoscopically or by an open surgical procedure; medical treatment, with a variety of drugs, that can be administered systemically and/or locally by different routes (transvaginally under sonographic guidance or under laparoscopic guidance); expectant management. The choice of a treatment modality should be based on short-term outcome measures (primary treatment success and reinterventions for clinical symptoms or persistent trophoblast) and on long-term outcome measures (tubal patency and future fertility).

OBJECTIVES

In the treatment of tubal pregnancy various types of treatments are available: surgical treatment, medical treatment and expectant management. In this review the effects of various treatments are summarized in terms of treatment success, need for reinterventions, tubal patency and future fertility.

SEARCH STRATEGY

The Cochrane Menstrual Disorders and Subfertility Group trials register and MEDLINE were searched.

SELECTION CRITERIA

Randomized controlled trials comparing treatments in women with ectopic pregnancy.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data extracted independently by two reviewers. Differences were resolved by discussion with all reviewers.

MAIN RESULTS

Laparoscopic conservative surgery is significantly less successful than the open surgical approach in the elimination of tubal pregnancy due to a higher persistent trophoblast rate of laparoscopic surgery. Long term follow-up shows similar tubal patency rates, whereas the number of subsequent intrauterine pregnancies is comparable, and the number of repeat ectopic pregnancies lower, although these differences are not statistically significant. The laparoscopic approach is less costly as a result of significantly less blood loss and analgesic requirement, and a shorter duration of operation time, hospital stay, and convalescence time. Compared to laparoscopic conservative surgery (salpingostomy) local methotrexate is not a treatment option. Injection of this drug, both under laparoscopic guidance and under ultrasound guidance, is significantly less successful in the elimination of tubal pregnancy. Systemic methotrexate in a single dose intramuscular regimen is not effective enough in eliminating the tubal pregnancy compared to laparoscopic salpingostomy. This as a result of inadequately declining serum hCG concentrations after one single dose of methotrexate necessitating additional methotrexate injections or surgical interventions. If methotrexate primarily given in a multiple dose intramuscular regimen is compared with laparoscopic salpingostomy no large differences are found in medical outcomes, both short term and long term. However, this treatment regimen is associated with a greater impairment of health related quality of life and is more expensive, due to surgical interventions for clinical signs of tubal rupture, generating additional direct costs due to prolonged hospital stay. Furthermore, indirect costs due to productivity loss are higher. Only in patients with low initial serum hCG concentrations systemic methotrexate leads to costs savings compared to laparoscopic salpingostomy.

Predictive score for the systemic treatment of unruptured ectopic pregnancy with a single dose of methotrexate

OBJECTIVE

To evaluate the efficacy of a predictive score for the systemic treatment of unruptured ectopic pregnancy with a single dose of methotrexate in order to select the best cases for the medical treatment.

METHOD

Our study included 40 patients. The inclusion criteria were: hemodynamic stability; adnexal mass < or = 3.5 cm; desire of future pregnancy; and a written permission to participate in the study. All patients were treated with a single dose of methotrexate (50 mg/m2 i.m.). A predictive score was elaborated based on four parameters: initial levels of beta-hCG, aspects of the image at ultrasound (hematosalpinx, tubal ring or live embryo), size of the mass, vascular flow of the color Doppler. Each parameter received a grade from 0 to 2. Grade 0 represented an unfavorable situation, grade 1 a borderline situation and grade 2 a favorable situation.

RESULTS

The success rate with a single dose of methotrexate was 75% (30/40). In the present study the cut off grade was 5, because the majority of patients with grade > or = 5 were treated successfully (29/30 - 97%), while those with grade < 5 failed.

CONCLUSION

The predictive score helps us to indicate the best cases for the medical treatment. Therefore, we do not advise it when the grade is < 5. However, we can predict a good evolution of the treatment when the grade is > or = 5. Federation of Gynecology and Obstetrics.

Current treatment of ectopic pregnancy

The incidence of ectopic pregnancy showed a sharp increase in the industrialized countries in the late 1970s. This resulted in an epidemic of ectopic pregnancy in the 1980s. At present the incidence of ectopic pregnancy has levelled off or even decreased. In the meantime the diagnosis of ectopic pregnancy has improved markedly, which means that the detection of this disease can take place very early in the first trimester of pregnancy. This has led to the use of more conservative treatment modalities and to a better prognosis for further pregnancies. Medical treatment, especially with methotrexate, has largely replaced the radical surgical option, and the treatment of ectopic pregnancy is most obviously moving to the direction of these conservative, medical approaches.

Ultrasound-guided injection of ectopic pregnancy

Preliminary studies have demonstrated that salpingocentesis is a safe and effective treatment for unruptured ectopic pregnancies that are visible by transvaginal ultrasound. So far, experience with this technique has been confined to only a few centers around the world. The most promising results of these studies has been the virtual absence of side effects associated with local injection of either methotrexate or hyperosmolar glucose. Large prospective trials comparing efficacy, safety, and overall cost of salpingocentesis against systemic methotrexate will be necessary to better define the role of salpingocentesis in the management of ectopic pregnancy. Patient recruitment for this type of clinical trial would be feasible and acceptable to patients because both treatment arms would avoid surgery.

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.

Fertility after radical surgery for tubal pregnancy

OBJECTIVE

To evaluate fertility after salpingectomy performed for ectopic pregnancies (EPs).

DESIGN

Retrospective cohort study.

SETTING

Tertiary care university hospital.

PATIENT(S)

Three hundred forty patients (213 with surgery by laparoscopy and 127 by laparotomy) between January 1985 and July 1994, with a mean follow-up period of 73 months (36-162 months).

INTERVENTION(S)

Salpingectomy performed either by laparotomy or by laparoscopy as indicated.

MAIN OUTCOME MEASURE(S)

Rate of intrauterine pregnancy (IUP), live births, and recurrent EP.

RESULT(S)

Forty-seven (13.8%) patients were lost to follow-up, and 68 (20%) did not want to become pregnant. The overall rate of spontaneous conception was 70.4% in the laparoscopy group and 53.2% in the laparotomy group. The rate of live births was 50% and 37%, respectively; the mean time until conception was 11 and 17.2 months; and the rate of recurrent EP, 10.6% and 9.6%. The multivariate analysis showed a rate of IUP of 82.1% among women younger than 30 years of age with a normal contralateral tube, laparoscopic surgery, and no history of infertility.

CONCLUSIONS

In this study of fertility after salpingectomy for EP, laparoscopic treatment was superior to laparotomic treatment. Fertility was equivalent to that after conservative treatment in a subgroup of young patients treated with laparoscopy and with no history of tubal pathology.

Medical management of ectopic pregnancy

In selected patients who are hemodynamically stable with an unruptured tubal pregnancy, systemic methotrexate has success rates comparable to laparoscopic salpingostomy. Larger randomized studies are necessary to adequately assess subsequent fertility. Local injection of methotrexate or other agents requires a sonographically visible ectopic as well as technical skills, and has less consistent success rates than that of systemic MTX therapy.

Effect of intramuscular sulfadoxine-pyrimethamine on pregnant Wistar rats

BACKGROUND

Sulfadoxine-pyrimethamine preparations are used commonly for the treatment and or prevention of malaria in the endemic regions of Sub-Sahara Africa. Pyrimethamine alone has been shown to be teratogenic in rats, mice and hamsters, and others animals.

METHODS

Pregnant Wistar rats were divided into three groups. The first group received a therapeutic dose of sulfadoxine-pyrimethamine (0.72 mg/kg body weight) intramuscularly (1.m) on the 5th, 12th, and 19th of gestation (3 doses). The second group received a similar dose on the 10th and 17th days of gestation (2 doses); the third group received the same dose on the 15th and 22nd days of gestation (2 doses). Controls for each group received 2 ml of physiological saline through the same route on similar days instead of the drugs.

RESULTS

All control animals produced normal litters (average 5.6), but group 3a animals produced litters with no obvious congenital malformations (average 4.8). Animals in groups 1a and 2a produced no litters. When they were sacrificed, they showed implantation sites in their uterine horns. Histological sections of these implantation sites showed that the embryos had been resorbed.

CONCLUSIONS

Therapeutic dose of sulfadoxine-pyrimethamine (0.72 mg/kg body weight) administered early in gestation resulted in complete embryo resorption in Wistar rats. The use of these preparations in early pregnancy in man demands caution.

Misoprostol 3, 4, or 5 days after methotrexate for early abortion. A randomized trial

A randomized trial was conducted including 287 pregnant women seeking elective abortion to compare the efficacy of misoprostol given 3, 4, or 5 days after methotrexate for abortion at < or = 63 days' gestation. Subjects received 50 mg/m2 methotrexate intramuscularly and were randomly allocated to self-administer vaginally 800 micrograms of misoprostol 3, 4, or 5 days after the methotrexate. The misoprostol dose was repeated 48 and 96 h later if the abortion did not occur. Outcome measures included successful abortion (complete abortion without requiring a surgical procedure), and side effects. Eighty-six cases (93%; 95% confidence interval [CI] 85%-97%) aborted in Group I; 90 cases (92%; 95% CI 84%-96%) aborted in Group II (relative risk [RR] = 1.09; RR 95% CI 0.38-3.14); and 89 (93%; 95% CI 86%-97%) cases aborted in Group III (RR = 0.97; RR 95% CI 0.33-2.87). No significant statistical differences were obtained for the success rates when misoprostol was given days 3, 4, or 5 after the administration of methotrexate (p = 0.97) nor with any of the characteristics of the subjects. Complete abortion occurred in 265/287 (92%; 95% CI 89%-95%) patients. Twenty-two cases (8%; 95% CI 5%-11%) resulted in failure. Side effects for methotrexate were minimal while for misoprostol they were moderate. This combination could be an alternative to surgical abortion or the use of antiprogestins and prostaglandins for medical abortion.

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.

Alternative to surgery of treatment of unruptured interstitial pregnancy: 15 cases of medical treatment

OBJECTIVE

To evaluate medical treatment of interstitial pregnancy.

METHODS

This series was a retrospective study of medical treatment of interstitial pregnancies which was managed in two French Departments of Obstetrics and Gynecology (Bichat public Hospital. Paris and A. Béclère public Hospital, Clamart, France). Fifteen patients with clear evidence of an unruptured interstitial pregnancy were treated by injection of methotrexate (MTX) or potassium chloride (KCL) without surgery since January 1988. The diagnosis was established either by sonography and laparoscopic confirmation in eight cases or by only transvaginal ultrasound in seven cases. Three out of 15 cases in this series, had a heterotopic pregnancy who were treated by transvaginal ultrasound-guided injection of KCL. Others received systemic MTX injection in four cases, and local MTX injection in eight cases under either laparoscopy or transvaginal ultrasound guidance. Four different protocols of MTX (Ledertrexate) administration was performed in this series with time: at the beginning of our experience, MTX1 protocol, 15 mg i.m. daily for 5 days was used; and after MTX2 protocol, 1 mg/kg body weight i.m. daily for 4 days; MTX3 protocol, 1 mg/kg body weight intratubal associated with 1 mg/kg body weight i.m. daily for 3 days; and now MTX4 protocol, only intratubal 1 mg/kg body weight is especially used. The success was defined as declining serum human chorionic gonadotropin (hCG) to undetectable levels, and no further surgical management was required. Outcome of subsequent fertility was also evaluated.

RESULTS

Complete resolution was obtained in 13 (86.6%) out of 15 interstitial pregnancies. Two out of 15 patients, with medical treatment's failure required secondary surgery. No severe side effects of medical treatment were observed. Follow-up hysterosalpingography was performed in 12 patients showing 91.7% tubal patency on the side of interstitial pregnancy. Outcome of intra-uterine pregnancy of the three patients who had heterotopic gestation, was two miscarriages and one delivery at term. Out of the other 12 patients in this series, nine became pregnant within 1 year: eight pregnancies at term, and one induced abortion. At present, among the last three patients, two have no desire to conceive.

CONCLUSION

Our results suggest that unruptured interstitial pregnancies now can be managed with local MTX administration of 1 mg/kg body weight under transvaginal ultrasound or under laparoscopy procedure. This approach is particularly attractive in these patients, where the only alternative to therapy is laparotomy with cornual resection.

Single-dose methotrexate for the treatment of ectopic pregnancy: Northwestern Memorial Hospital three-year experience

OBJECTIVE

Our purpose was to evaluate the effectiveness of single-dose intramuscular methotrexate in the treatment of ectopic pregnancies by physicians in the Department of Obstetrics and Gynecology of Northwestern Memorial Hospital and to compare the results with those of previously published studies.

STUDY DESIGN

A retrospective chart review was performed of 50 patients with ectopic pregnancies treated with single-dose methotrexate according to the protocol of Stovall et al. from January 1992 to February 1995.

RESULTS

The mean pretreatment level of beta-human chorionic gonadotropin was 1896.4 +/- 2399 mlU/ml. Only 32 women (64%) were successfully treated with a single dose of methotrexate. An additional 7 women required a second or third injection. The combined success rate for medical management of ectopic pregnancy with one to three doses of methotrexate was 78% (39 women). Pretreatment beta-human chorionic gonadotropin levels were significantly lower in women who responded to single-dose therapy than in those who required either two or three doses or who had failure of medical management (p = 0.0011). The mean time to resolution of beta-human chorionic gonadotropin was 26.5 +/- 17 days. Higher pretreatment levels correlated with longer resolution time (r = 0.83, p < 0.001). Eleven women (22%) with failure of medical management required surgery.

CONCLUSIONS

In our series single-dose methotrexate was only 64% successful. Women with a pretreatment beta-human chorionic gonadotropin level >5000 mlU/ml had a greater probability of requiring either surgical intervention or multiple doses of methotrexate. The potential for emergency surgery remains an important risk.

Methotrexate and misoprostol to terminate early pregnancy

BACKGROUND

Although medical termination of pregnancy is available in Europe and China as an alternative to surgical termination, political and social factors have blocked medical approaches to pregnancy termination in the United States. Methotrexate, which is toxic to trophoblastic tissue, has been used safely to treat unruptured ectopic pregnancies. This report describes the use of a single low dose of methotrexate followed by intravaginal misoprostol for the medical termination of early pregnancy.

METHODS

Women seeking termination of pregnancy were selected for this study on the basis of their good general health, emotional stability, and a pregnancy of 63 days or less in duration. Each woman received an intramuscular dose of methotrexate (50 mg per square meter of body-surface area). Five to seven days later, 800 micrograms of misoprostol was administered intravaginally. If abortion did not occur after seven days, the women was offered a second dose of misoprostol or vacuum aspiration. Successful abortion was defined as a complete termination of pregnancy within seven days after the first or second administration of misoprostol.

RESULTS

A total of 171 of the 178 women enrolled in the study (96 percent) had successful medical abortions. Twenty-five women (14 percent) did not have an abortion after the first dose of misoprostol and received a second dose. Eighteen subsequently had complete abortions, but seven required suction curettage. In all seven women who required suction curettage, there was histologic evidence of disruption in the conceptus. No important side effects or complications were noted.

CONCLUSIONS

The combination of methotrexate and misoprostol represents a safe and effective alternative to invasive methods for the termination of early pregnancy.

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.

Selective salpingography for the diagnosis and treatment of early tubal pregnancy

OBJECTIVE

To determine whether selective salpingography can accurately diagnose and treat patients with early ectopic pregnancies (EPs).

DESIGN

Prospective clinical case study.

SETTING

Selective salpingography was performed in an outpatient setting under i.v. sedation.

PATIENTS

Selective salpingography was performed in 10 women who had clinical presentation suggestive of EP, two consecutive abnormal hCG measurements < 2,000 mIU/mL, and inconclusive vaginal probe sonogram.

INTERVENTION

Selective salpingography was performed under fluoroscopy. A cervical cannula was placed, and the tubal ostium was cannulated with a curved selective salpingography catheter (Bard Gynecology and Radiology, Covington, GA). Methotrexate (MTX) (25 or 50 mg) was injected into the affected tube through the selective salpingography catheter.

MAIN OUTCOME MEASURE

The accuracy of selective salpingography in the diagnosis of early EP was determined by the rate of fluoroscopic imaging of an ampullary radiolucency upon injection of contrast material through the selective salpingography catheter. Resolution of the EP after injection of MTX into the tube was detected by serial declining hCG measurements.

RESULTS

Selective injection of contrast material into the fallopian tubes detected seven ampullary pregnancies in 10 patients. Two patients demonstrated neither tubal pregnancy nor intrauterine pregnancy. One patient with apparent bilateral proximal cornual occlusions on selective salpingography underwent laparoscopy, followed by salpingostomy of an ampullary pregnancy. All 7 patients who received MTX through the selective salpingography catheter completely resolved the EP. Four patients demonstrated patent fallopian tubes on hysterosalpingograms performed 3 to 6 months later.

CONCLUSION

Selective salpingography may diagnose early tubal pregnancies of some patients with equivocal clinical, laboratory, and sonographic findings. These patients can be successfully treated at the same time with a single dose of MTX delivered into the affected tube. Selective salpingography reduced the need for laparoscopy and operative intervention. Selective salpingography is a simple and relatively inexpensive diagnostic and therapeutic alternative in patients with suspected early tubal pregnancy.

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.