Successfully Treated Abdominal Pregnancy Causing Hemoperitoneum Using Combined Surgical and Systemic Methotrexate Therapy: A Case Report and Review of Cases Treated at Kyushu University Hospital

Abstract

Abdominal pregnancy is a rare condition that accounts for only 1% of all ectopic pregnancies but results in high maternal morbidity and mortality. We present a case of abdominal pregnancy with massive peritoneal bleeding successfully treated using systemic methotrexate (MTX). A 34-year-old woman with amenorrhea for 8 weeks and a positive pregnancy test was referred for evaluation of ectopic pregnancy. Transvaginal ultrasonographic scan showed a gestational sac measuring 25 mm in diameter containing a viable embryo in the cul-de-sac and a considerable amount of free fluid in the patient's lower abdomen and pelvis. Laboratory parameters showed that her hemoglobin concentration was 5.8 g/dl and serum human chorionic gonadotropin concentration was 13,195 mIU/ml. Emergency surgery revealed an abdominal pregnancy in the cul-de-sac and a massive intra-abdominal hemorrhage. After a hemostasis procedure, the patient was successfully treated using systemic MTX. We also present the review of abdominal pregnancy cases treated using systemic MTX at our institution over 10 years. Systemic MTX treatment for abdominal pregnancy is safe and effective and makes it possible to avoid the risk of excessive bleeding by surgical resection of the implantation site.

Interstitial Pregnancy: A ‘Road Map' of Surgical Treatment Based on a Systematic Review of the Literature

“…Combined surgical and systemic MTX treatment has been successfully used in a case of abdominal pregnancy causing hemoperitoneum. Moreover, MTX may avoid the risk of excessive bleeding by surgical resection of the implantation site [73]. Nevertheless, MTX (20 mg intramuscular injection daily for 5 consecutive days) has proved to be successful in nonruptured retroperitoneal EP before operation [74].…”

Persistent omental trophoblastic implantation following salpingostomy, salpingectomy and methotrexate for ectopic pregnancy: A case report

“…There is limited definitive data on the effect of intramuscular methotrexate as a treatment for omental implants. Several cases studies suggest that treatment with methotrexate can prevent sudden haemorrhagic shock and that it is a safe treatment option [ 5 , 17 ]. Bora et al suggest that post-operative methotrexate can reduce the proportion of patients with persistent trophoblastic tissue following salpingostomy from 15% to 2% and would arguably reduce the rates of omental trophoblastic implants that result in acute haemoperitoneum [ 18 ].…”

Late Abdominal Pregnancies (≥20 Weeks Gestation): A Review from 1965 to 2012

“…If the placenta is left in situ, it may be managed expectantly or the patient may be given MTX. Yasutake et al [21] reported a review from their own institution of the treatment of abdominal pregnancies with systemic MTX and observed that it was safe and avoided the excessive bleeding that may accompany surgical removal of the implantation site. In this review, the use of MTX was associated with higher incidences of intra-abdominal abscess formation (66.7%).…”