Previous ectopic pregnancy as a predictor of failure of systemic methotrexate therapy

OBJECTIVE: To investigate whether a history of previous ectopic pregnancy is an independent risk factor for failure of methotrexate therapy in subsequent ectopic pregnancies and whether the previous treatment method influenced failure. SETTING: Inner-city teaching hospital. DESIGN: Retrospective case review. PATIENT(S): Five hundred four consecutive patients treated with "single-dose" methotrexate for ectopic pregnancy. Nine patients electing surgery after beginning medical therapy were excluded from analysis. INTERVENTION(S): Systemic methotrexate 50 mg/m(2). MAIN OUTCOME MEASURE(S): Failure of methotrexate therapy. RESULT(S): Twenty-one (18.6%) of 113 of previous ectopic patients and 26 (6.8%) of 382 first-time ectopic patients failed methotrexate therapy (odds ratio, 3.12). The overall success rate was 90.5% (448/495 patients). Univariant analysis showed that treatment hCG and progesterone (P) levels and ectopic cardiac activity were significantly different between successful and failed therapy. Logistic regression analysis for these four variables showed that only hCG and history of previous methotrexate remained significant risk factors for failure of methotrexate therapy. The likelihood of failure in patients with a previous ectopic was not influenced by previous treatment with salpingostomy, salpingectomy, or medical treatment. CONCLUSION(S): A history of previous ectopic pregnancy appears to be an independent risk factor for failure of systemic methotrexate treatment, but failure is not affected by previous treatment method.     

Risk factors for recurrent ectopic pregnancy following single-dose methotrexate treatment

Objective: Our study aimed to investigate the predisposing factors for recurrence of an ectopic pregnancy (EP) following single-dose methotrexate (MTX) treatment for a primary EP.

Methods: This was a retrospective cohort study performed in a tertiary care medical centre including all patients diagnosed with primary EP and treated with a single-dose regimen of intramuscular MTX. EPs with future recurrence were compared with first time only EPs, to identify risk factors for recurrent EP. Forward stepwise multivariate logistic regression analyses were subsequently carried out.

Results: The study included 272 women. Of those, 22 (8.1%) had a recurrent EP. Women in the recurrent EP group had a higher rate of abortions (45.5% vs 32.7%; p?=?0.02), previous pelvic surgery (45.5% vs 6.5%; p?<?0.001) and both pelvic and uterine surgery (4.5% vs 1.6%; p?<?0.001). Conception by assisted reproductive technology (ART) was more common among the non-recurrent EP group (23.0% vs 4.5%; p?=?0.04). Success of single-dose MTX treatment was lower in the recurrent EP group compared with the non-recurrent EP group (36.4% vs 65.7%; p?=?0.006). A history of pelvic surgery was independently associated with recurrent EP (adjusted odds ratio [OR] 17.6; 95% confidence interval [CI] 4.9, 63.2; p?=?0.001). Treatment success of single-dose MTX was independently protective for recurrent EP (adjusted OR 0.25; 95% CI 0.08, 0.76; p?=?0.02).

Conclusions: Among women with an EP, attention should be paid to those with previous pelvic surgery. Efforts should be made to achieve medical treatment success to prevent recurrent EP.     

Spontaneous bilateral tubal ectopic pregnancy and failed methotrexate therapy: A case report

Spontaneous bilateral ectopic pregnancy is extremely rare. An unsuspected case of spontaneous bilateral ectopic pregnancy with failure of single-dose methotrexate is presented. We question whether the recommended dose of methotrexate for unilateral ectopic pregnancy is adequate for bilateral tubal pregnancy.(Am J Obstet Gynecol 1997;177:1545-6.)     

Cervical ectopic pregnancy: surgical or medical treatment?

Cervical pregnancies are one of the rarest forms of ectopic gestations. The incidence of cervical ectopic pregnancies ranges between 1 in 1,000 to 95,000 gestations (Parente et al., Obstet Gynecol 62:79–82, 1983). Prior surgical trauma, including dilatation and curettage of the cervix, has been identified as one of the leading risk factors (Pisarska et al., Lancet 351:1115–1120, 1998; Yankowitz et al., Obstet Gynecol Surv 45:405–414, 1990). Cervical ectopic pregnancies are especially feared due to their associated life-threatening hemorrhage. Therefore, massive blood transfusions and emergency hysterectomy have often been required previously. Nevertheless, general guidelines for clinical management are lacking. In case reports medical and surgical treatment modalities are described. Overall, conservative management of an asymptomatic cervical ectopic pregnancy using methotrexate or potassium chloride seems to be superior to surgical intervention. The treatment of choice in patients suffering from symptomatic cervical ectopic pregnancy is still under discussion. In the case reported here, a combination of surgical and medical treatment conserving the patient’s childbearing capacity was successfully implemented. However, severe hemorrhage occurred and consecutive blood transfusions were urgently necessary. Emergency hysterectomy could be avoided.     

米非司酮联合甲氨蝶呤治疗异位妊娠

目的 探讨米非司酮联合甲氨蝶呤治疗异位妊娠的效果。方法 78例输卵管妊娠患者随机分为A、B两组，A组42例给予米非司酮，3次／d，口服，每次50mg，连续3天，同时给予甲氨蝶呤60mg一次性肌肉注射。B组36例，给予甲氨蝶呤60mg一次性肌肉注射。定期检测血β—HCG、血常规、肝、肾、凝血功能、B超。结果 米非司酮联合甲氨蝶呤治疗异位妊娠成功率为88．09％，明显高于对照组。治疗效果与用药方案及治疗前血β—HCG水平有关。结论 米非司酮联合甲氨蝶呤治疗异位妊娠安全有效，早期诊断、严格掌握适应证是治疗成功的关键。     

Cervical ectopic pregnancy after endometrial ablation: a case report

Case report A 44-year-old woman, with prior endometrial ablation, complaining of heavy vaginal bleeding was diagnosed with cervical ectopic pregnancy. Two doses of intramuscular methotrexate were administered as conservative treatment of the cervical pregnancy. Close follow-up in a dedicated early pregnancy unit allowed successful management on an outpatient basis. Conclusion The urine pregnancy test maintains a crucial role in the investigation of abnormal vaginal bleeding in a sexually active patient. Conservative management of a cervical pregnancy can reduce the potential morbidity and mortality associated with the surgical treatment option.     

Single-dose methotrexate for the treatment of unruptured ectopic pregnancy

Objective The objective of this study was to review our experience with single dose intramuscular methotrexate (MTX) for the treatment of ectopic pregnancy and to evaluate major confounding factors that relate to the success of therapy.Patients and methods The selection criteria were patients who had a stable hemodynamic status and an ectopic gestational mass of <4 cm. on ultrasound. Patients were not excluded from MTX therapy either by a baseline serum -hCG titer or by the presence of fetal cardiac activity demonstrated on ultrasonography. Thirty- four of 86 patients diagnosed with ectopic pregnancy and treated with single-dose MTX between July 1999 and November 2001 were reviewed retrospectively.Results The mean pre-treatment -hCG level was 2,490±2,912 mIU/ml. Twenty-two patients (73.3%) were successfully treated with a single-dose of MTX. Eight patients (26.6%) required a second dose 1 week after the first injection and 2 patients received three doses. Thirty of the 34 patients (88%) were successfully treated with MTX. The mean pre-treatment -hCG level was significantly lower in patients who were successfully treated with MTX than in patients who failed MTX therapy (1,932±2,361 mIU/ml vs. 6,955±2,690 mIU/ml respectively, p<0.05). The mean pre-treatment serum -hCG level was higher in patients who had a second MTX injection as compared to patients who were successfully treated with a single injection of MTX (3,272±3,551 mIU/ml vs. 1,280±2,273 mIU/ml respectively, p>0.05). The mean time to resolution of -hCG was 26.5 days (10 to 37 days) with MTX. All 3 patients who failed medical therapy had -hCG level >4,000 mIU/ml and 2 of them had positive fetal cardiac activity.Conclusion In conclusion, this study showed that medical treatment of ectopic pregnancy with systemic single-dose methotrexate seems to be an option for some patients with unruptured tubal pregnancy.     

氨甲喋呤单次静脉注射治疗异位妊娠63例分析

探讨氨甲喋呤单次静脉注射治疗异位妊娠的效果和适应证。方法对６３例患者随机分成Ａ、Ｂ两组。Ａ组３１例采用ＭＴＸ１００ｍｇ加生理盐水２０ｍｌ静注,不用甲酰四氨叶酸解毒。Ｂ组３２例应用同剂量ＭＴＸ后１２－２４小时内用ＣＦ１０－１２ｍｇ解毒。定期测血β－ｈＣＧ直至正常。     

Medical therapy (methotrexate and mifepristone) alone or in combination with another type of therapy for the management of cervical or interstitial ectopic pregnancy

Objective

To describe cases of cervical or interstitial ectopic pregnancy managed conservatively with combined medical treatment (methotrexate and mifepristone) alone or in association with other minimally invasive strategies.

Study design

We describe four cervical and two interstitial ectopic pregnancies at our hospital between 2006 and 2010. All received combined treatment with methotrexate and mifepristone. A search of MEDLINE is also described.

Results

The literature search identified only four previous cases of cervical ectopic pregnancies and no cases of interstitial ectopic pregnancy managed with combined therapy. In our study, all patients were successfully treated and had no adverse reactions with intramuscular methotrexate 50 mg/m² and oral mifepristone 600 mg, either alone or in association with minimally invasive treatment (uterine artery embolization and evacuation dilation and curettage). All patients remained asymptomatic with β-HCG levels that decreased and became negative within 14–49 days: the median hospital stay was 5.5 days. We also describe the first patient with a cervical ectopic pregnancy treated with methotrexate and mifepristone, followed by vaginal misoprostol 800 mcg for cervical evacuation.

Conclusion

Methotrexate–mifepristone, either alone or in combination with other minimally invasive strategies, could be considered an option for the treatment of both cervical and interstitial ectopic pregnancy. An individualized approach should be used in each patient, however, given the wide variety of possible clinical situations and the potential seriousness of ectopic pregnancy.     

Treatment of a cervical viable pregnancy with a single intraamniotic methotrexate injection: a case report

Introduction. Cervical pregnancy is a rare condition, constituting <1% of all ectopic pregnancies. Case report. We report here, the successful management of a viable 7 weeks gestation cervical pregnancy. Feticide with 2 ml of potassium chloride 15% was performed under the guidance of transvaginal ultrasonography. Then 70 mg methotrexate (50 mg/m²) was injected through this spinal needle in to the amniotic cavity. Also serial changes in the color Doppler imaging after the methotrexate injection were emphasized.     

Cervical pregnancy: a case report of hysteroscopic resection and balloon compression combined with systematic methotrexate treatment

ObjectiveCervical pregnancy is a rare type of ectopic pregnancy. When the pregnancy is terminated, it will sometimes lead to persistent bleeding. In some cases, hysterectomy is inevitable and the patient loses fertility. Therefore, early diagnosis and targeted management with systemic or local injection of methotrexate is the first-line treatment. Multiple interventions of cervical pregnancy were used to prevent massive hemorrhage, including dilatation and curettage, laparoscopic resection, hysteroscopic resection combined with uterine artery embolization, or uterine artery clip.Case reportWe report a case of cervical pregnancy with a high beta-hCG level accompanied by a visible fetal heartbeat that was successfully treated with hysteroscopic cervical tissue resection and balloon compression combined with systemic administration of methotrexate.ConclusionEfficacy and safety with preserved fertility were important issues in the management of cervical pregnancy. We provide a safe, simple and effective treatment of cervical pregnancy.     

A case of molar ectopic pregnancy

OBJECTIVE: To evaluate the occurrence of molar pregnancy in tubal ectopic pregnancy. DESIGN: Case report. SETTING: Outpatient clinic. PATIENT(S): A 27-year-old woman. INTERVENTION(S): Salpingectomy. MAIN OUTCOME MEASURE(S): Molar ectopic pregnancy. RESULT(S): Ectopic partial molar pregnancy. CONCLUSION(S): Molar pregnancy can occur in ectopic pregnancy. Molar pregnancy clinically mimics normal tubal ectopic pregnancy.     

Comparison of multidose and single-dose methotrexate protocols for the treatment of ectopic pregnancy

OBJECTIVE: The purpose of this study was to compare success rates of 643 patients who had ectopic pregnancy from the same database who were treated with multidose or single-dose methotrexate protocols. STUDY DESIGN: We compared demographics, gestational age, serum human chorionic gonadotropin, progesterone levels, ectopic sac size and volume, overall ectopic mass size and volume, ectopic cardiac activity, history of ectopic pregnancy, number of treatment days, methotrexate doses, and outcome in consecutive patients with ectopic pregnancy who were treated with methotrexate. RESULTS: Success rates were comparable between patients with multidose and single-dose therapy (95% vs 90%, respectively) as were human chorionic gonadotropin and progesterone levels, history of ectopic pregnancy (21.4% vs 21.7%, respectively), number of treatment days, gestational age, ectopic size, ectopic volume, and ectopic mass volume. Patients who received single-dose therapy were significantly heavier (146 vs 159 pounds), had greater ectopic cardiac activity (3.1% vs 10.3%), and received fewer methotrexate doses. CONCLUSION: This study suggests single-dose methotrexate therapy is as effective as multidose methotrexate therapy for the treatment of ectopic pregnancy.     

Ovarian ectopic pregnancy after ICSI-ET: a case report and literature review

INTRODUCTION: Primary ovarian ectopic pregnancy (OEP) is one of the the rarest form of extratubal pregnancies and its pathophysciological mechanism is not fully understood. On the other hand, OEP after intra-cytoplasmic sperm injection with embryo transfer (ICSI-ET) is even more rare and just a few cases have been reported in literature. MATERIALS AND METHODS: A case with OEP after ICSI-ET presented and managed by conservative laparoscopic approach. Also, literature associated with OEP after ICSI-ET have been summarized. Pubmed search using "Ovarian ectopic pregnancy" and "ICSI-ET" keywords revealed four similar case in the literature. CONCLUSION: Underlying pathophysiological mechanism of OEP after ICSI-ET is unclear. Indeed, gynecologists should be aware about the development of the OEP after ICSI-ET. Early diagnosis will give the opportunity to use conservative managements for these infertile patients.     

甲氨蝶呤联合米非司酮与中药宫外孕I号方治疗异位妊娠疗效的对比观察

目的观察比较甲氨蝶呤（MTX）联合米非司酮与配伍中药治疗有生育要求且未破裂型异位妊娠的临床疗效。方法：把入选的126例患者随机分为A、B两组,A组采用MTX联合米非司酮杀胚,B组采用MTX配伍中药保守治疗,比较两组临床疗效。结果在血β-HCG水平降至正常,治愈的时间及包块消失时间等方面比较,A组显著优于B组（P〈0．05）。而在治愈率、输卵管再通率、妊娠成功率等方面比较,两组差异无统计学意义（P〉0．05）。结论：MTX联合米非司酮可以缩短患者住院时间,见效快,值得临床推广。     

Intramural ectopic pregnancy: a case and review of the literature

An intramural ectopic is a rare type of ectopic pregnancy in which the gestational sac is implanted within the myometrium, separate from the endometrial cavity and Fallopian tubes. There are only 53 cases in the published literature. We report a case of intramural ectopic pregnancy treated surgically and review the published data on this rare type of ectopic pregnancy, with respect to aetiology, diagnosis and management.