Re: Ectopic pregnancy
From: Bernard Cristalli (bcrist@club-internet.fr)
Sun May 24 15:28:26 1998
Efrain Ramirez MD wrote:
>
> That patient could have been a good candidate for methotrexate, if the
> mass was 3cms or less, no FHR were seen and was hemodynamically stable.
> Yes, vasopressin works OK.
>
> At Sun, 24 May 1998, BNJShelton wrote:
> >
> >I would be interested to learn what other methods of conservative treatment
> >for an ectopic pregnancy in a fallopian tube are used. Other means than a
> >laparoscopic linear salpingostomy or systemic methotrexate.
> >
--
Local injection of methotrexate under US (it may be done through
laparoscopy too).
Transvaginal intratubal methotrexate treatment of ectopic pregnancy.
Report of 100 cases.
Darai E; Benifla JL; Naouri M; Pennehouat G; Guglielmina JN; Deval B;
Filippini F; Crequat J; Madelenat P
Department of Obstetrics and Gynaecology, Hopital Bichat, Paris, France.
Hum Reprod, 1996 Feb, 11:2, 420-4
Abstract
Between November 1988 and December 1993, 100 patients with
a
common, unruptured ectopic pregnancy were treated with 1
mg/kg
injection of intratubal methotrexate under transvaginal
sonographic control. Patients were not excluded from this
series on
the basis of the size of the adnexal mass, the term of
ectopic
pregnancy or initial beta-human chorionic gonadotrophin
(HCG)
concentrations. Patients were excluded following uncertain
diagnosis, signs of a ruptured ectopic pregnancy, or a
significant
haemoperitoneum on ultrasound scans. The mean age of the
patients was 29.5 years (range 20-41). The mean
gestational age
and initial HCG concentration were 7.5 weeks (5-11) and
11,614
mIU/ml (192-105,000 respectively). Of the 100 patients, 22
(22%)
had an ectopic pregnancy with active cardiac activity.
Complete
resolution was obtained in 78 out of these 100 ectopic
pregnancies.
Of these, 66 patients (85%) needed only one intratubal
methotrexate injection, and 12 patients (15%) required a
second
i.m. methotrexate injection of 1 mg/kg. In this study,
local
treatment with one single intratubal methotrexate
injection was
successful in only 66% of patients. The mean resolution
time for
reduction of beta-HCG concentrations was 23.5 days (range
7-40).
There was no statistically significant correlation between
initial
beta-HCG concentrations and outcomes after methotrexate
treatment of ectopic pregnancy in our study. Where
embryonal
heart beats were observed, the success rate of the
procedure was
40.9% (nine out of 22 cases). In the absence of cardiac
activity, or
when ultrasound examination showed no embryo, the success
rate
achieved was 84.6% (66 out of 78 cases) (P < 0.01). In
all, 34
patients were considered to be incompletely cured after
only one
intratubal methotrexate injection: 12 patients required a
second
i.m. injection, a stagnation of beta-HCG concentrations
was
observed in 15 patients, abdominal pain occurred in six
patients,
and one patient suffered tubal rupture with
haemoperitoneum. A
total of 22 patients required secondary surgical
management
(salpingectomy). No biochemical or clinical side-effects
of
methotrexate treatment occurred. Tubal alteration
ascribable to
methotrexate injection occurred in one patient in our
study. Out of
75 patients in this series who wished to conceive, 21
(28%) became
pregnant within 1 year with the following outcomes: 11
pregnancies at term, three miscarriages, one induced
abortion and
six recurrent ectopic pregnancies (four occurred on the
same side).
Our findings suggest that treatment of common unruptured
ectopic
pregnancy without prior selection of patients, by a single
intratubal
methotrexate administration was associated with a 66%
success
rate. This was dependent only on the presence of embryonal
heart
beats and there was no correlation between the success
rate and
initial beta-HCG concentrations. Successful outcome after
methotrexate administration for ectopic pregnancy could be
perfected by way of an improved selection of patients
based on
inactive embryonal hearts and absence of a visualized
embryo.
Alternative to surgery of treatment of unruptured interstitial
pregnancy: 15 cases of medical treatment.
Benifla JL; Fernandez H; Sebban E; Darai E; Frydman R; Madelenat P
Department of Obstetrics and Gynecology, Hopital Bichat, Paris, France.
Eur J Obstet Gynecol Reprod Biol, 1996 Dec, 70:2, 151-6
Abstract
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.
--
Bernard Cristalli MD CNGOF
AIHP - ACCA
Paris - France
http://www.obgyn.net/corresp/cristalli.htm
