1
|
Abstract
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.
Collapse
Affiliation(s)
- T Tulandi
- Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada
| |
Collapse
|
2
|
Debby A, Golan A, Sadan O, Zakut H, Glezerman M. Fertility outcome following combined methotrexate treatment of unruptured extrauterine pregnancy. BJOG 2000; 107:626-30. [PMID: 10826577 DOI: 10.1111/j.1471-0528.2000.tb13304.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess the effectiveness of systemic treatment with methotrexate in combination with local injection for unruptured tubal pregnancy, and to evaluate reproductive function following treatment. DESIGN Prospective, open clinical study. SETTING University clinic. POPULATION Sixty-seven women with unruptured tubal pregnancy. METHODS Systemic methotrexate (intramuscular methotrexate 0.5 mg/kg for up to five days) in combination with local application of 12.5 mg methotrexate via laparoscopy. MAIN OUTCOME MEASURES The subsequent surgical intervention required and future fertility. RESULTS In 89.6% of women no further surgical intervention was required and 47 women (81%) experienced subsequently an intrauterine pregnancy. In 39 of 40 women who underwent hysterosalpingography following treatment, patency of the affected tube was observed. CONCLUSIONS Combined local and systemic methotrexate treatment for unruptured tubal pregnancy seems to be more effective than each therapeutic modality alone.
Collapse
Affiliation(s)
- A Debby
- Department of Obstetrics and Gynaecology, The Edith Wolfson Medical Center, Holon and Sackler Medical School, Tel Aviv, Israel
| | | | | | | | | |
Collapse
|
3
|
UNDP/UNFPA/WHO/World Bank Special P. Methotrexate for the termination of early pregnancy: a toxicology review. REPRODUCTIVE HEALTH MATTERS 1997. [DOI: 10.1016/s0968-8080(97)90020-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
4
|
Maiolatesi CR, Peddicord K. Methotrexate for nonsurgical treatment of ectopic pregnancy: nursing implications. J Obstet Gynecol Neonatal Nurs 1996; 25:205-8. [PMID: 8683354 DOI: 10.1111/j.1552-6909.1996.tb02426.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Early diagnosis of ectopic pregnancy can provide women an alternative to surgical therapy. Nonsurgical treatment using methotrexate is cost-effective, restores subsequent fertility, and decreases the morbidity and morality intrinsic to traditional surgical procedures. This article reviews the risk factors, signs and symptoms, diagnostic techniques, and nursing care for medically treated ectopic pregnancy.
Collapse
|
5
|
Shalev E, Peleg D, Bustan M, Romano S, Tsabari A. Limited role for intratubal methotrexate treatment of ectopic pregnancy. Fertil Steril 1995; 63:20-4. [PMID: 7805915 DOI: 10.1016/s0015-0282(16)57290-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
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.
Collapse
Affiliation(s)
- E Shalev
- Department of Obstetrics and Gynecology, Central Emek Hospital, Afula, Israel
| | | | | | | | | |
Collapse
|
6
|
Klein M, Graf A, Kiss H, Czerwenka K, Beck A, Egarter C, Husslein P. The relation between depth of trophoblastic invasion and beta-HCG levels in tubal pregnancies. Arch Gynecol Obstet 1995; 256:85-8. [PMID: 7541981 DOI: 10.1007/bf00634713] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
beta-HCG (human chorionic gonadotropin) values of over 2500 I.U./l are associated with higher failure rates for therapy with prostaglandin F2 alpha in tubal pregnancies. The purpose of our study was to ascertain if the 2500 I.U./l limit correlates with histopathology. We therefore compared the pre-operative beta-HCG-values and intraluminal and extraluminal trophoblast growth in tubal pregnancy. Purely intraluminal trophoblast was significantly more frequent in patients of group I (beta-HCG < 2500 I.U./l), while group II patients (beta-HCG > 2500 I.U./l) almost exclusively had extraluminal growth (P = 0.0045). Since the efficacy of prostaglandin F2 alpha therapy depends on intact tubal musculature the correlation of the beta-HCG threshold level with histopathologic findings may explain the high failure rate in patients with beta-HCG values above 2500 I.U./l.
Collapse
Affiliation(s)
- M Klein
- Department of Gynecology, Hanusch-Krankenhaus, Vienna, Austria
| | | | | | | | | | | | | |
Collapse
|
7
|
Asnat G. Authors' reply. BJOG 1993. [DOI: 10.1111/j.1471-0528.1993.tb15197.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
8
|
Affiliation(s)
- S A Carson
- Department of Obstetrics and Gynecology, University of Tennessee, Memphis 38163
| | | |
Collapse
|
9
|
Laatikainen T, Tuomivaara L, Käär K. Comparison of a local injection of hyperosmolar glucose solution with salpingostomy for the conservative treatment of tubal pregnancy. Fertil Steril 1993; 60:80-4. [PMID: 7685719 DOI: 10.1016/s0015-0282(16)56040-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
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.
Collapse
Affiliation(s)
- T Laatikainen
- Department of Obstetrics and Gynecology, Oulu University Central Hospital, Finland
| | | | | |
Collapse
|
10
|
Lindblom B, Bengtsson G, Bryman I, Thorburn J. Medical treatment of ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 1993; 49:80-2. [PMID: 8365527 DOI: 10.1016/0028-2243(93)90125-v] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- B Lindblom
- Dept of Obstetrics & Gynecology, Huddinge University Hospital, Sweden
| | | | | | | |
Collapse
|
11
|
Goldenberg M, Bider D, Oelsner G, Admon D, Mashiach S. Treatment of interstitial pregnancy with methotrexate via hysteroscopy. Fertil Steril 1992; 58:1234-6. [PMID: 1281118 DOI: 10.1016/s0015-0282(16)55575-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- M Goldenberg
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | | | | | | | | |
Collapse
|
12
|
Bider D, Oelsner G, Admon D, Levran D, Goldenberg M, Mashiach S. Unsuccessful methotrexate treatment of a tubal pregnancy with a live embryo. Eur J Obstet Gynecol Reprod Biol 1992; 46:154-7. [PMID: 1451894 DOI: 10.1016/0028-2243(92)90262-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Two cases with unsuccessful local and systemic methotrexate (MTX) therapy of tubal pregnancy with fetal heart rate activity are reported. The three modes of therapy, the first with local potassium chloride solution injection, the second with local MTX injection, and the third with systemic MTX injection, failed in the resolution of viable ectopic pregnancy. Therapy of MTX in cases of tubal pregnancy with demonstrable fetal heart rate beats, should be reconsidered.
Collapse
Affiliation(s)
- D Bider
- Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | | | | | | | | | | |
Collapse
|
13
|
Abstract
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.
Collapse
Affiliation(s)
- J Thorburn
- Department of Obstetrics and Gynaecology, University of Göteborg, Sweden
| |
Collapse
|
14
|
Ylöstalo P, Cacciatore B, Koskimies A, Kääriäinen M, Lehtovirta P, Mäkelä P, Siegberg R, Stenman UH, Tenhunen A, Ylikorkala O. Conservative treatment of ectopic pregnancy. Ann N Y Acad Sci 1991; 626:516-23. [PMID: 1829344 DOI: 10.1111/j.1749-6632.1991.tb37943.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- P Ylöstalo
- Department of Obstetrics and Gynecology, University of Helsinki, Finland
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Pansky M, Golan A, Bukovsky I, Caspi E. Nonsurgical management of tubal pregnancy. Necessity in view of the changing clinical appearance. Am J Obstet Gynecol 1991; 164:888-95. [PMID: 1825903 DOI: 10.1016/0002-9378(91)90535-y] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The incidence of ectopic pregnancy is definitely increasing. Ectopic pregnancies are diagnosed earlier these days because of the improvement in diagnostic means and the increasing awareness of the condition. It seems that there is a dramatic change in the clinical presentation of this disease; it used to be a grave and life-threatening condition, and now it is a more benign presentation. The vast majority of the diagnosed ectopic pregnancies are unruptured. This has stimulated various investigators to attempt nonsurgical methods of treatment such as systemic administration of methotrexate or RU 486 (mifepristone) or local injection of methotrexate, potassium chloride, or prostaglandins under laparoscopic or ultrasonographic guidance. Most of these conservative, nonsurgical measures proved efficient in 80% to 90% of cases. Expectant management, which was practiced in some cases, proved to be equally successful. We believe that the ideal mode of treatment in early unruptured ectopic pregnancy is still to be determined. The answer probably lies in proper selection.
Collapse
Affiliation(s)
- M Pansky
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, Zerifin, Israel
| | | | | | | |
Collapse
|
16
|
|
17
|
Kooi S, Kock HC. Treatment of tubal pregnancy by local injection of methotrexate after adrenaline injection into the mesosalpinx: a report of 25 patients. Fertil Steril 1990; 54:580-4. [PMID: 2209877 DOI: 10.1016/s0015-0282(16)53811-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Twenty-five patients with a tubal pregnancy were treated by an injection of methotrexate (MTX) into the tubal swelling after vasoconstriction of the mesosalpinx with adrenaline. Twenty-four of the 25 patients had an uneventful clinical course. In one case, the tube ruptured despite falling serum human chorionic gonadotropin (hCG) concentrations. In 17 of 24 patients, the dose of 100 mg that was locally injected was sufficient. Seven patients were given additional systemic injections. In 3 of the 4 patients with high initial serum hCG levels (greater than 10.000 mIU/mL), the clinical course was uneventful. The side effects of MTX and adrenaline were minimal. Whether this way of treatment guarantees better chances of fertility in the future is unknown. Therefore a prospective, case-controlled study comparing the fertility rates in different ways of treatment is needed.
Collapse
Affiliation(s)
- S Kooi
- Department of Gynaecology and Obstetrics, Maria Hospital, Tilburg, The Netherlands
| | | |
Collapse
|