Diagnosis and treatment of ectopic pregnancy by retrograde selective salpingography and intraluminal methotrexate injection: work in progress

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.

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.

Transcervical tubal cannulation, past, present, and future

OBJECTIVE

To evaluate publications that introduced novel diagnostic and therapeutic transcervical procedures on the fallopian tubes.

DESIGN

Major studies that conceptually changed the therapeutic approach to the fallopian tubes were reviewed. Minor publications were also included if they introduced a new concept or contributed to the topic. Clinical publications were selected if they involved transcervical diagnosis and treatment of fallopian tubes.

RESULTS

Transcervical tubal catheterization procedures for diagnosis of tubal disease, tubal obliteration, tubal recanalization, and tubal medication are minimally invasive procedures that can improve our understanding and diagnostic accuracy of tubal disease. These procedures allow transcervical treatment of proximal tubal occlusion. Further improvements in equipment and methodology are promising. Transcervical tubal occlusion, gamete and embryo deposition, and treatment of ectopic pregnancy may all be performed using the transcervical approach.

CONCLUSION

Transcervical tubal catheterization can replace microsurgery and IVF in selected patients with proximal tubal occlusion, improve the diagnostic accuracy of tubal disease, and deliver medications to the fallopian tubes. Cumulative knowledge suggests that transcervical tubal catheterization should become a universally accepted, taught, and practiced approach in the diagnosis and treatment of the fallopian tubes.

Treatment of interstitial pregnancy with methotrexate via hysteroscopy

We present a case in which treatment of interstitial pregnancy with local MTX administration was performed successfully through hysteroscopic vision, without the need to operate. Decreased gestational sac dimension and increased or low beta-hCG level ( < 1,400 mIU/mL) facilitates the success rate. The follow-up showed disappearance of the gestational sac and decrease of beta-hCG levels to < 10 mIU/mL. We conclude that local MTX administration via hysteroscopy after tubal ostium visualization is feasible. The procedure should be considered in women during the reproductive age, especially in rare cases of interstitial pregnancy.

Transcervical cannulation of the fallopian tube for the management of ectopic pregnancy: prospective multicenter study

OBJECTIVE

To determine the efficacy of transcervical tubal cannulation and intraluminal methotrexate injection for the management of tubal ectopic pregnancy (EP).

DESIGN

Prospective multicenter study of 33 patients with tubal pregnancies.

SETTING

Four university-based gynecology and radiology departments in three different countries: France, England, and Germany.

PATIENTS

Thirty-three patients who presented with a clinical diagnosis of EP.

INTERVENTIONS

Patients underwent transcervical tubal cannulation under fluoroscopic or ultrasound control and local injection of methotrexate (up to 50 mg).

MAIN OUTCOME MEASURES

We evaluate the feasibility of transcervical tubal cannulation for the management of tubal pregnancy.

RESULTS

Two patients elected to withdraw from the protocol. In the remaining 31 patients there was complete resolution of the EP in 27 (87%). Surgery was performed in 4 patients. Seventeen patients, 14 of whom desired pregnancies, were available for follow-up to assess the return of reproductive potential. Seven of 7 patients who subsequently underwent hysterosalpingography had patency of the affected tube. Five patients later had an intrauterine pregnancy. One patient had an early miscarriage, two have given birth, and two singleton pregnancies are still ongoing. The remaining patients are symptom free.

CONCLUSIONS

This study demonstrates that transcervical tubal catheterization in patients with tubal pregnancies is feasible and can be performed without anesthesia or analgesia in most cases. Intraluminal methotrexate per se is capable of causing regression of the EP. This approach offers a new alternative for the treatment of selected patients with tubal EP.

Hysteroscopic diagnosis of ectopic pregnancy

Although vaginal ultrasonography combined with plasma beta-hCG determination can provide a reliable diagnosis and location of ectopic pregnancy, the results can be difficult to interpret in the early stages when hCG levels are low. Hysteroscopy can be used in such cases to differentiate between ectopic pregnancy and non-viable uterine pregnancy when viable uterine pregnancy has been ruled out. General anaesthesia and laparoscopy are avoided. We performed 60 hysteroscopic procedures between January 1989 and December 1990 in patients with suspected ectopic pregnancies. The pregnancy had been located by means of vaginal ultrasonography in every case in which the hCG was above 1500 IU/ml and in 36% of cases in which the beta-hCG was below this level. Hysteroscopy was hindered by metrorrhagia in three cases and was inconclusive in one, necessitating laparoscopy. Diagnosis was possible in all the remaining cases, as follows: ectopic pregnancy in 41 cases, with an empty uterus and occasional bleeding from an ostium; non-viable uterine pregnancy in 18 cases, with the presence of material within the cavity. Hysteroscopy therefore confirmed the diagnosis in 55% of the cases and was itself diagnostic in a further 43% of cases. Its sensitivity for the diagnosis of ectopic pregnancy was 100% and its specificity 95%. We propose a diagnostic decision tree.

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 effect of tubal injection of methotrexate on fertility in the rabbit

OBJECTIVE

To investigate the fertility of rabbits after tubal injection of methotrexate (MTX).

DESIGN

The side of injection of MTX was randomly decided in a prospective experimental trial.

PARTICIPANTS

Fourteen female New Zealand White Rabbits were believed to be of normal reproductive status.

INTERVENTIONS

Methotrexate or Ringer's solution were injected into the tubes of the rabbits. The nidation index was used to measure the fertility of the animals.

RESULTS

The average nidation index of the control tubes was not statistically different of the one of the tubes treated with MTX.

CONCLUSION

Tubal injection of MTX has no adverse effect on fertility of rabbits. It seems ethical to investigate tubal injection of MTX as an alternative to laparoscopic management of unruptured ectopic pregnancy in the human.

Conservative treatment of ectopic pregnancy

As a conservative nonsurgical treatment of an early ectopic pregnancy, local prostaglandin, parenteral or local methotrexate, local hyperosmolar glucose, and also expectant management have been used successfully in selected cases. The success rate of conservative treatment has been 71%-100% and that of tubal patency after different kinds of conservative treatment 72-93% of patients. In the present study of expectant management in early ectopic pregnancy in patients with decreasing serum hCG levels, spontaneous resolution was observed in 64.6% of patients and in the total series of 207 ectopic pregnancies in 15.0% of patients. Expectant management of early ectopic pregnancy is recommended when emergency surgery is not needed on admission and the serum hCG level is decreasing as noted in two consecutive estimations with an interval of 1-2 days.