Treatment of interstitial pregnancy with methotrexate: report of an unsuccessful case

Voigt, R; Veen, Fulco van der; Karsdorp, V. H. M.; Hogerzeil, H. V.; Ketting, B.W.

doi:10.1093/oxfordjournals.humrep.a138752

Cited by 27 publications

(13 citation statements)

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“…It is noteworthy that a regular decline in serum hCG levels is not always associated with the resolution of ectopic pregnancy. Rupture of the ectopic pregnancy can still occur, resulting in severe intra-abdominal haemorrhage, which is a life-threatening event, especially in interstitial pregnancy [23][24][25]. It has been a clinical experience that after application of methotrexate diffuse self-limiting abdominal pain can occur, imitating rupture of ectopic pregnancy [26].…”

Section: Discussionmentioning

confidence: 99%

Suitable laparoscopic surgery in the treatment of ectopic interstitial pregnancy

2005

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Interstitial or cornual pregnancies represent a small fraction of ectopic gestations. They are located in the interstitial part of the fallopian tube. Interstitial pregnancies are especially feared due to their associated life-threatening intra-abdominal haemorrhage. General guidelines for clinical management are lacking. This article describes important specialities in the differentiation between interstitial and classical tubal pregnancies and will further offer a special minimally invasive procedure for the safe management of this rare type of ectopic pregnancy. We favour a special endoscopic operative procedure using a combination of the encircling suture and endoloop techniques. This method provides an excellent tourniquet effect resulting in effective haemostasis. In addition to the different endoscopic treatments, other therapeutic options, such as primary methotrexate application, will be discussed.

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Section: Discussionmentioning

confidence: 99%

Suitable laparoscopic surgery in the treatment of ectopic interstitial pregnancy

2005

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“…The treatment modalities range from conservative medical management to more invasive surgical techniques. The use of systemic methotrexate has been described in several case reports 3–5 and some larger series 6,7 . Local injection of methotrexate, potassium chloride or prostaglandin has also been described, either under ultrasound guidance or under direct vision by laparoscopy or hysteroscopy 2,6,8 .…”

Section: Discussionmentioning

confidence: 99%

Hysteroscopic management of cornual ectopic pregnancy

Pal

Akinfenwa

Harrington³

2003

BJOG

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A 32 year old woman attended the accident and emergency department with a two day complaint of vaginal bleeding and cramping lower abdominal pain, and a brown vaginal discharge since her last menstrual period which was 24 days prior to presentation. She had discontinued the combined oral contraceptive pill two months prior to her last menstrual period. Her urine pregnancy test (Guest Medical, UK) was positive. On abdominal examination, there was tenderness noted in the right iliac fossa. Vaginal examination revealed no cervical excitation but there was right adnexal tenderness. A transabdominal and transvaginal ultrasound scan (Diagnostic Sonar, multifrequency abdominal probe and 6.5 Hz transvaginal probe) revealed an empty uterus with an endometrial thickness of 11 mm. There was a right-sided ovarian cyst measuring 77 Â 54 Â 66 mm and a small amount of free fluid in the pouch of Douglas. Her serum h-hCG quantitative assay (Immulite 2000, immunoassay calibrated to WHO 3rd International Standard) at that point was 2830 IU/mL. A diagnostic laparoscopy was performed the following day to exclude an ectopic pregnancy.At laparoscopy, the finding of a right ovarian cyst was confirmed, with normal tubes, uterus and left ovary. A laparoscopic right ovarian cystectomy was performed as this was presumed to be the cause of her pain. A repeat h-hCG level the following day (48 hours after admission) was 3116 IU/mL. A repeat ultrasound scan two days later (four days after admission) showed what was presumed to be a viable intrauterine pregnancy, which was high within the uterine fundus. The possibility of a cornual pregnancy was raised. It was decided to rescan her in two weeks.A repeat ultrasound scan two weeks later revealed a left-sided cornual ectopic pregnancy, with a 25 mm gestational sac containing a 6 mm fetal pole. There was a large vascular signature from the surrounding decidual reaction, no fetal heart activity was seen and there was no free fluid in the pouch of Douglas. The serum h-hCG level at this stage was 15,208 IU/mL. Management options were discussed with the patient and she opted for surgical management.The following day, a laparoscopy and hysteroscopy were performed. The laparoscopy confirmed the diagnosis of a left-sided cornual ectopic pregnancy. A dilute solution of vasopressin (20 units in 20 mL of normal saline) was injected around the pregnancy. A hysteroscopy (5 mm, 30j forward angled scope) with normal saline showed a pregnancy beyond the left tubal ostium. The hysteroscope was advanced beyond the dilated left ostium and the sac was ruptured. The fetus was seen floating in the irrigation fluid. The hysteroscope was then withdrawn and a No. 6 flexible suction cannula (Rocket Medical, UK) inserted into the uterine cavity. Under transabdominal ultrasound guidance, the flexible suction cannula was advanced into the cornual gestation. Suction was then applied under direct laparoscopic control to ensure that the cannula did not perforate the uterine cornu. The suction evacuation yielded products of conc...

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“…Perhaps we did not wait long enough for the ß-hCG to decrease after the local treatment. However, Voigt et al [35] stated that a slow decline in the ß-hCG concentration and a continuous growth of the CS during MTX treatment represent imminent signs of therapy failure. Hajenius et al [30] reported of eight interstitial pregnancies treated systemically with MTX (1 mg/kg i.m.…”

Section: Discussionmentioning

confidence: 99%

Interstitial Pregnancy Treated with Local and Systemic Methotrexate

Bruyne

Tutschek²,

Hucke³

et al. 1998

Gynecol Obstet Invest

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We present a case of an intact interstitial pregnancy at 6 postmenstrual weeks and 4 days, which was successfully treated by combined local and systemic methotrexate administration. The embryonic cardiac activity stopped within 1 min after uneventful ultrasound-guided puncture and methotrexate instillation of the chorionic sac. While the β-hCG serum values returned to normal 59 days after local, and 52 days after systemic treatment, the echogenic lesion has reduced in size by 50%, but is still sonographically detectable 7 months after the procedure. This report shows that medical treatment of interstitial pregnancy may be an effective alternative to the surgical approach.

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Treatment of interstitial pregnancy with methotrexate: report of an unsuccessful case

Cited by 27 publications

References 0 publications

Suitable laparoscopic surgery in the treatment of ectopic interstitial pregnancy

Suitable laparoscopic surgery in the treatment of ectopic interstitial pregnancy

Hysteroscopic management of cornual ectopic pregnancy

Interstitial Pregnancy Treated with Local and Systemic Methotrexate

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