Methotrexate injection for interstitial pregnancy: Hysteroscopic conservative mini-invasive approach.

Abstract

Background: Interstitial localisation of ectopic pregnancy is associated with high rates of maternal morbidity and mortality. Considering the rarity of interstitial pregnancy, the optimal treatment regimen remains unclear. We propose the management of interstitial pregnancy with local methotrexate injection using a combined hysteroscopic and ultrasonographic approach. Technique: Hysteroscopy was performed under local anaesthesia in the operating room, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope with a 4.3-mm inner sheath and 5 FR instruments. A needle was pushed into the cornual region injecting methotrexate solution directly into the gestational sac and into the myometrial tissue tangentially at the four cardinal points. A contemporary transabdominal ultrasound (US) was performed in order to reduce risks of complications. Experience: Five patients with an US diagnosis of interstitial ectopic pregnancy admitted to our department between January 2016 and September 2019 were managed with a local hysteroscopic injection of methotrexate. The technique was effective in all patients and no surgical complications occurred during or after the procedure. Three patients were evaluated for tubal patency with contrast ultrasonography confirming bilateral tubal patency 9 months from treatment, while one patient had a spontaneous birth 22 months from their initial surgery. Conclusion: The hysteroscopic ultrasound-guided approach combined with the local injection of methotrexate is a minimally invasive conservative approach that seems to be promising in the management of interstitial ectopic pregnancy.

Successful hysteroscopic management of two cases of interstitial pregnancy

“…In a case series of laparoscopic-assisted hysteroscopic removal of IP, Niu et al concluded that if the mass distent the uterine cornua with a tunnel connecting the mass and the cornua, hysteroscopic resection is likely to be successful 13 . In a series of five patients, Casadio et al successfully treated IP with local hysteroscopic MTX injection 14 . Hysteroscopic assisted local MTX injection could minimize adverse systemic effects of MTX 14,15 .…”

“…In a series of five patients, Casadio et al successfully treated IP with local hysteroscopic MTX injection 14 . Hysteroscopic assisted local MTX injection could minimize adverse systemic effects of MTX 14,15 . This modality, combined with our report of two cases, seems promising for the management of IP.…”

Uterine artery chemoembolization for management of unruptured interstitial pregnancy diagnosed in the early first trimester

“…In replacing traditional laparotomy, early diagnosis of interstitial pregnancy before rupture makes various minimally invasive methods of treatment possible [3]. These medical management approaches include expectant management [3]; laparoscopic surgery [9] with reversible occlusion of uterine arteries and cornuostomy for advanced cases [18]; hysteroscopic management [6,10,14]; medical cytotoxic management [11] with mifepristone [12]; and endovascular therapy [8] with cytotoxic infusional chemotherapy [4].…”

“…If rupture occurs in the interstitial portion of the uterus, which includes abundant blood supply from a complex pelvic vascular network composed of the uterine artery and anastomosing ovarian artery, definitive management involves life-saving intervention either by laparotomy or, more recently, laparoscopy [3]. However, for the management of hemodynamically stable cases without rupture, a wide range of surgical and non-surgical procedures are available [3][4][5][6][7][8][9][10][11][12][13][14].…”

Interstitial Pregnancy Treated with Mifepristone and Methotrexate with High Serum β-hCG Level in a Patient Wishing to Preserve Fertility: Time to Define Standardized Criteria for Medical/Surgical Therapy?

“…MTX and mifepristone act synergistically and promote lysis of the trophoblast cells [ 19 ]. Alternatives to medical therapy are mentioned in the literature, namely, hysteroscopy combined with medical treatment [ 15 , 20 ], laparoscopic cornual resection [ 21 ], laparoscopic cornuostomy [ 22 , 23 ], and in the more severe cases laparotomic hysterectomy [ 24 ]. Minimally invasive surgery is indicated for elective procedures.…”