Three conservative approaches to treatment of interstitial pregnancy

Interstitial pregnancy is among the most dangerous types of ectopic pregnancy. Four such pregnancies in three women were treated by three conservative modalities with favorable results. A 10-week interstitial pregnancy was successfully treated by laparoscopic-guided local methotrexate (MTX) injection into the gestational sac. Six years later the same woman had a repeat unruptured interstitial pregnancy at 9 weeks' gestation, with the gestational sac located in the same location as the previous one. Laparoscopic cornuostomy was performed. An asymptomatic woman in the eighth week of an interstitial pregnancy was treated with systemic MTX, but despite decreasing beta-human chorionic gonadotropin levels, cornual rupture occurred. The patient was successfully treated by laparoscopic cornuostomy. The final patient was admitted in hypovolemic shock and hemoperitoneum and was treated successfully for ruptured 8-week interstitial pregnancy by laparoscopic cornuostomy. (J Am Assoc Gynecol Laparosc 8(1):154-158, 2001)     

Direct Methotrexate Injection into the Gestational Sac for Nontubal Ectopic Pregnancy: A Review of Efficacy and Outcomes from a Single Institution

Study ObjectiveTo evaluate the efficacy of nontubal ectopic pregnancy (NTEP) management with direct methotrexate (MTX) injection into the gestational sac.DesignA retrospective chart review.SettingA tertiary academic and teaching hospital.PatientsAll cases of confirmed NTEP were retrospectively identified from 2012 to 2017.InterventionsUltrasound-guided direct injection of MTX into the fetal pole and surrounding gestational sac and a single dose of systemic MTX with or without fetal intracardiac injection of potassium chloride.Measurements and Main ResultsTreatment failure, complications from treatment, operating time, and days to negative serum human chorionic gonadotropin (hCG) after treatment were measured. Fourteen women (age 34 ± 5.2 years) with NTEP underwent direct MTX injection (cesarean scar, n = 4; interstitial, n = 6; cervical, n = 4). The mean estimated gestational age was 49 ± 11, CI (43, 56 days). One patient required laparoscopic intervention with a failure rate of 1 of 14 (a double interstitial, heterotopic pregnancy). There were no other major complications. The time in the operating room was similar for all NTEP types. The average time to negative serum hCG was not different for cesarean scar (84.5 ± 36 days), cervical pregnancies (70.5 ± 19 days), or interstitial pregnancies (45.3 ± 38 days, p = .15).ConclusionDirect MTX injection into the gestational sac for NTEP treatment is safe and effective. The failure rate of 7% is considerably lower than what was previously reported for a failure of systemic MTX in similar cases (25%). Resolution of serum hCG after treatment can be quite prolonged even in uncomplicated cases.     

Conservative management of ectopic pregnancy: prospective randomized clinical trial of methotrexate versus prostaglandin sulprostone by combined transvaginal and systemic administration

In a prospective randomized study, 21 patients with an unruptured tubal pregnancy were treated with local and systemic injection. On the day of diagnosis, methotrexate (MTX) (1 mg/kg) or sulprostone (500 micrograms) were injected into the gestational sac under transvaginal sonographic control. The systemic component consisted of an intramuscular injection of MTX (1 mg/kg) 3, 5, and 7 days after local injection or of sulprostone (500 micrograms) on the 1st 2 postlocal injection days. Methotrexate therapy was successful in 8 of 12 patients and sulprostone therapy in 6 of 9. Laparoscopy was then performed on the 7 unsuccessful patients: 3 of them had pain and hemoperitoneum and 4 of them had rising human choriogonadotropin (hCG) levels. One stomatitis after MTX and one cramping abdominal pain were observed. Thirteen of 14 successfully treated patients had initial hCG levels less than 5,000 mIU/mL. At subsequent hysterosalpinography, 13 of 14 patients had normal tubal configuration and patency. Three of 10 patients who desired another pregnancy had already achieved a normal intrauterine pregnancy. These results suggest that MTX and sulprostone were equally effective, and medical approach for the unruptured ectopic pregnancy may be restricted to patients with hCG less than 5,000 mIU/mL.     

Alternative to surgery of treatment of unruptured interstitial pregnancy: 15 cases of medical treatment

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^R) 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.     

Laparoscopic cornuostomy for interstitial pregnancy. A case report

BACKGROUND: With recent advances in laparoscopic surgery, many reports have described laparoscopic cornual resection for interstitial pregnancy as a safe alternative to laparotomy. We report a laparoscopic cornuostomy for unruptured interstitial pregnancy with myometrium reconstruction. CASE: A 32-year-old woman presented with complaints of abdominal cramps and vaginal spotting after 6 weeks of amenorrhea. Ultrasonographic examination revealed a gestational sac 7 mm in diameter in the left uterine corner. There was clear separation between the endometrium and gestational sac. A 3-mm periumbilical trocar for the laparoscope and a 3-mm trocar in the lower abdomen were used, and the left interstitial pregnancy was confirmed. An additional, 5-mm trocar was used in the lower abdomen for the laparoscopic surgery. The patient underwent a laparoscopic cornuostomy. Myometrium reconstruction was performed by suturing and tying with a laparoscopic technique. CONCLUSION: In this case, minilaparoscopy was useful in the diagnosis and treatment of interstitial pregnancy.     

Treatment of interstitial pregnancy with methotrexate via hysteroscopy.

We present a case in which treatment of interstitial pregnancy with local MTX administration was performed successfully through hysteroscopic vision, without the need to operate. Decreased gestational sac dimension and increased or low beta-hCG level ( < 1,400 mIU/mL) facilitates the success rate. The follow-up showed disappearance of the gestational sac and decrease of beta-hCG levels to < 10 mIU/mL. We conclude that local MTX administration via hysteroscopy after tubal ostium visualization is feasible. The procedure should be considered in women during the reproductive age, especially in rare cases of interstitial pregnancy.     

Three-dimensional transvaginal sonographic diagnosis of early and asymptomatic interstitial pregnancy

Context The interstitial gestation is a rare form of tubal pregnancy which is associated with high morbidity. The diagnosis of an interstitial gestation can be reached through a bidimensional transvaginal ultrasonography (2D-TVUS), however, sometimes when making use of this technique it is not possible to appropriately evaluate the position of the gestational sac in relation to the uterine cavity. The three-dimensional transvaginal ultrasonography (3D-TVUS) allows accessibility to plans that the bidimensional does not, thus it makes it possible to reach a more accurate diagnosis and it also allows for an appropriate therapeutic planning. Case report We present a case of interstitial gestation diagnosed in the sixth week in an asymptomatic woman, who had a previous diagnosis of primary infertility. The 2D-TVUS revealed the presence of a gestational sac outside of the uterine cavity; moreover the colored Doppler and the power Doppler indicated a thriving vascular ring. The 3D-TVUS in the surface and transparency mode demonstrated that the gestational sac was located in the interstitial region of the uterine tube, and the niche mode accurately evaluated the relationship between the gestational sac and the uterine cavity. The patient was successfully treated with a local injection of methotrexate guided by a transvaginal ultrasonography. The 3D-TVUS was of great importance to confirm the diagnosis, to allow appropriate therapeutic choices and to decrease the morbidity.     

血绒毛膜促性腺激素β在异位妊娠病情监测中的应用

目的探讨监测绒毛膜促性腺激素-β（human chorionic gonadotropin,β-hCG）在异位妊娠（ectopic pregnancy,EP）病情监测中的应用。方法对123例具有相同保守治疗指征的EP患者,保守治疗前均常规监测β-hCG,间隔48h复测一次。按50mg/m2计算给药,采用甲氨蝶呤（methotrexate,MTX）单次肌肉注射,用药后第4d（96h）再次监测β-hCG下降情况,每周一次,至β-hCG降到正常（β-hCG〈100U/L）。EP保守治疗成功组93例根据β-hCG上升或下降分为A组37例、B组56例,EP保守治疗失败的30例为C组（保守后改手术治疗）。结果三组在年龄、孕龄、EP包块直径大小间比较,无统计学意义（P〉0.05）;第一次测定血的β-hCG值结果A与B组比较无统计学意义（P〉0.05）。间隔48h测定,A组β-hCG有所下降,B组升高,A与B组比较有统计学意义（P〈0.01）。应用MTX治疗后A组β-hCG下降幅度〉15%,B组β-hCG有不同程度的升高,与A组比较差异有统计学意义（P〈0.01）。C组因在观察中改行手术治疗,保守治疗失败未做比较。三组β-hCG降至正常的时间B组较A组长,C组最短,差异有统计学意义（P〈0.01）。结论EP保守治疗前后监测β-hCG值的高低有助于判断治疗效果和时间。     

Successful rescue of an early interstitial pregnancy after failed systemic methotrexate treatment: a case report

BACKGROUND: Interstitial (cornual) pregnancy is a rare and life-threatening disease. Although systemic treatment with methotrexate (MTX) in an unruptured interstitial pregnancy has been used to preserve the entirety of the uterus, surgery is often used as a rescue method in failed cases. Use of an ultrasound-guided local injection can be a good alternative to surgery. CASE: A 30-year-old woman, gravida 1, para 0, with an interstitial pregnancy at 10 weeks of gestation, was successfully treated with an ultrasound-guided 100-mg MTX injection after a failed response to 3-dose intramuscular 100-mg MTX treatment (300 mg in total). Regular menstruation occurred 1 month after the local MTX injection. The serum beta-human chorionic gonadotropin level was undetectable 49 days later, and the residual mass had disappeared 6 months later, CONCLUSION: Local injection of MTX may be a good means of managing an unruptured interstitial pregnancy to preserve the entirety of the uterus after failed systemic MTX treatment. Use of a local MTX injection may be a better choice than that of systemic MTX treatment.     

Cornuostomy and Cornuectomy: Laparoscopic Management of Interstitial Ectopic Pregnancies

ObjectiveTo demonstrate and contrast 2 techniques of laparoscopic management of interstitial ectopic pregnancies.DesignStepwise demonstration of the technique with narrated video footage.SettingTertiary referral center in Manchester, United Kingdom.InterventionsNontubal ectopic pregnancies typically involve the cervix, ovary, myometrium, cesarean scar, and the interstitial portion of the fallopian tube. Interstitial ectopic pregnancies account for 2% of all ectopic pregnancies [1] and are caused by implantation of a fertilized embryo within the proximal and intramural portion of the fallopian tube [2]. They represent specific challenges in diagnosis and management and are associated with increased morbidity and mortality when compared with tubal ectopic pregnancies [3].The techniques for minimal access surgical management includes laparoscopic cornuectomy and cornuostomy. We present 2 cases of interstitial ectopic pregnancies managed laparoscopically using the 2 different techniques.Case 1: A 33-year-old women, para 2+1, presented at 8 weeks’ gestation with lower abdominal pain, vaginal bleeding, and an episode of loss of consciousness. An ultrasound scan showed a gestational sac lateral and posterior to the endometrial cavity with the interstitial line sign present. A yolk sac and a 2-mm fetal pole were noted with fetal heart action present. At laparoscopy, an 800 mL hemoperitoneum was noted, and a laparoscopic cornuectomy was performed (Fig. S1). Operating time was 80 minutes, and she was discharged on day 1 postoperation.Case 2: A 34-year-old women, para 1, presented at 6 weeks’ gestation to her local hospital with symptoms of vaginal bleeding and intermittent abdominal pain. A diagnosis of an interstitial ectopic pregnancy was suspected on the ultrasound scan, and conservative management was started because the diagnosis was uncertain. A follow-up scan 7 days later confirmed the diagnosis of a live interstitial ectopic pregnancy, and after consultation, she presented herself to a tertiary referral unit. Serum human chorionic gonadotropin was greater than 11 000 IU/L and 2-dimensional ultrasound scan confirmed the presence of a gestational sac with a yolk sac and fetal pole within the left interstitial space. A slow fetal heart action was seen. A diagnosis of a left interstitial ectopic pregnancy was further confirmed on 3-dimensional ultrasound scan. A laparoscopic cornuostomy was performed as demonstrated in the attached video (Figs. S2-S3). Operating time was 38 minutes with minimal blood loss. At day 7, serum human chorionic gonadotropin level was 364 IU/L.ConclusionAlthough more research is needed to determine the optimal surgical technique for the management of interstitial ectopic pregnancies, the potential risks and benefits of different techniques should be discussed with the patient, and an individual decision should be made. This decision often depends on the desire for future fertility and previous gynecologic history.     

Successful treatment of a persistent mole with myometrial invasion by direct injection of methotrexate.

For patients with persistent or invasive gestational trophoblastic disease (GTD), systemic injection of chemotherapy is the treatment of choice if fertility is to be preserved. To prevent serious adverse effects after systemic use and possibly achieve better effects, direct local injection of chemotherapy into the tumor site, especially when in the myometrium, seems a reasonable alternative. A patient with a persistent molar pregnancy with myometrial invasion is presented. A plateau of beta-hCG (human chorionic gonadotropin) level around 550 mIU/mL was noticed for three weeks though systemic methotrexate (MTX) injection and repeat suction curettage had been performed. During the same period, a well-defined invasive complex with multiple vesicles in the myometrium was documented using transvaginal ultrasound (TVUS). Sonar-guided injection to the tumor using 50 mg MTX was performed uneventfully. An obvious shrinkage of the mass and declining beta-hCG level were demonstrated after the procedure. The patient restored her menses after the operation and a fertility evaluation including serial beta-hCG levels and hysterosalpingography showed them to be within the reference ranges. The successful outcome of this case encouraged us to treat localized invasive GTD using direct injection of MTX with the guidance of TVUS. Since no identical cases were found in our review of the English literature, more cases and similar regimens are needed to establish the safety and efficacy of this procedure.     

Subserosal intramural ectopic pregnancy in an adenomyotic area following assisted reproduction treatment

A 38-year-old woman presented for early pregnancy ultrasound scanning 6 weeks and 4 days following an assisted reproduction treatment cycle. She had ß human chorionic gonadotrophin (ßhCG) blood level of 10,853 IU/L 2 weeks before presentation. She gave previous history of termination of pregnancy, myomectomy and bilateral salpingectomy. The uterus was retroverted with multiple fibroids and non-homogenous myometrium in many areas. The endometrium was 21.1 mm thick with no intrauterine pregnancy. An initial diagnosis of cornual/interstitial ectopic pregnancy was made. However, 3D images rendering and the multiplanar technique showed a 27.5-mm gestation sac, medial and above the interstitial part of the right tube, with 7.6-mm-long foetal pole. ßhCG and progesterone blood levels on the same day were 19,551 IU/L and 43.2 nmol/l, respectively. The patient opted against methotrexate treatment. An ectopic pregnancy bulging out of the fundal area was excised laparoscopically. Histopathological assessment showed chorionic villi surrounded by myometrium, as well as foci of adenomyosis, reaching the outer serosa. To our knowledge, this is the second case of subserosal intramural ectopic pregnancy to be reported and the first in a subserosal area of adenomyosis.     

腹腔镜保守性手术治疗输卵管妊娠的效果及其影响因素分析

目的 探讨腹腔镜保守性手术治疗输卵管妊娠的效果及其影响因素.方法 2003年1月至2008年12月,对北京安贞医院妇产科226例输卵管妊娠者行腹腔镜保守性手术治疗,152例于术后3～6个月行子宫输卵管造影,其中6例接受了再次腹腔镜探查,以评价手术侧输卵管是否通畅.第1次腹腔镜手术成功207例,手术失败19例;术后3～6个月行子宫输卵管造影,第1次腹腔镜手术成功的207例患者中,患侧输卵管通畅者89例(A组);第1次腹腔镜手术失败、术中及术后改行输卵管切除术(19例)及手术后随访检查患侧输卵管不通者(63例)共计82例(B组).再以妊娠包块最大径线5 cm或血清人绒毛膜促性腺激素(hCG)水平≤2000 IU/L,>2000～<5000 IU/L,≥5000 IU/L为界,分别计算输卵管通畅率.两组患者年龄、孕次、停经时间、输卵管妊娠的侧别及部位、是否破裂、是否合并盆腔粘连等方面比较,差异均无统计学意义(P>0.05).结果 226例患者中,207例患者第1次腹腔镜手术成功,手术成功率为91.6%(207/226),术后3～6个月随访152例,失访55例.A、B组患者术前血清hCG中位水平分别为980(55～12 000)、3150(570～40 000)IU/L,两组比较,差异有统计学意义(P<0.01);A、B组患者输卵管妊娠包块最大径线分别为(3.4±1.3)、(5.0±1.7)cm,两组比较,差异也有统计学意义(P<0.01).A组患者术前中位腹腔内出血量为200(0～1500)ml,B组为300(0～1600)ml,A组活胎率为2%(2/89),B组为11%(9/82),两组比较,差异均有统计学意义(P<0.05).两组共171例患者中,妊娠包块最大径线<5 cm者103例,术后患侧输卵管通畅率为65%(67/103),妊娠包块最大径线≥5 cm者68例,术后患侧输卵管通畅率为32%(22/68),两者比较,差异有统计学意义(P<0.01);血清hCG水平≤2000 IU/L、>2000～<5000 IU/L、≥5000 IU/L者术后患侧输卵管通畅率分别为72%(73/102)、29%(12/42)和15%(4/27),3者分别比较,差异也有统计学意义(P<0.05);logistic回归分析结果显示,术前血清hCG水平(OR=0.277,P<0.01)、输卵管妊娠包块最大径线(OR=0.577,P<0.01)、腹腔内出血量(OR=0.999,P<0.05)均为手术成功率的影响因素.结论 腹腔镜保守性手术对输卵管妊娠希望保留输卵管功能的患者具有安全性和可行性;术前血清hCG水平、输卵管妊娠包块大小及腹腔内出血量是影响手术效果的重要因素.     

Sonographic monitoring of systemic and local methotrexate (MTX) therapy in patients with intact interstitial pregnancies

OBJECTIVE: After the confirmation of an intact interstitial pregnancy through sonographic diagnosis and laparoscopy, systemic and local methotrexate therapy is a well established conservative treatment to preserve the uterus. The parameters of successful treatment are the course of serum hCG value and sonographic changes. In this case series we describe sonographic monitoring under methotrexate (MTX) application and the residual sonographic findings after completing therapy. METHODS: Three consecutive patients (two singleton and one twin pregnancy) with intact interstitial pregnancies were diagnosed and treated with MTX between 2000 and 2004. During the treatment we recorded the hCG values, maximum size of the interstitial lesion, vitality of the pregnancy, and vascularization. RESULTS: In all patients the sonographic diagnosis of an interstitial pregnancy was confirmed by laparoscopy. Following systemic MTX therapy, the hCG values normalised within 8 weeks in the singleton pregnancies and in 10 weeks in the twin pregnancy. During conservative therapy vascularization in the lesion withered continuously. The size of the primary myometrial lesion decreased at a slow rate and part of the lesion persisted in all three patients. CONCLUSION: Despite decreasing hCG levels, residual sonographic patterns of an interstitial ectopic pregnancy persist in the uterine wall.     

Treating cornual pregnancy with a single methotrexate injection: a report of 3 cases

BACKGROUND: Cornual pregnancy is a rare type of ectopic pregnancy. Methotrexate (MTX) has been used successfully for the treatment of tubal pregnancies; however, its use for interstitial pregnancies is less common. CASES: Three cases of cornual pregnancy were successfully treated with a single MTX injection (50 mg/m2), without complications. CONCLUSION: A single MTX injection as medical treatment is an alternative to surgical treatment of cornual pregnancies.     

Treatment of ectopic pregnancy by transvaginal intratubal methotrexate administration

Twelve women with tubal pregnancies were treated with intratubal transvaginal methotrexate injection (1 mg/kg body weight). Serum beta-hCG levels decreased in all patients, and the resolution time from injection to undetectable beta-hCG levels was 14-120 days. In spite of declining serum beta-hCG and unruptured tubal pregnancy, two patients subsequently requested definitive treatment for their ectopic pregnancies and underwent surgery. Four of six women found to have a living embryo in their gestational sacs required a repeat methotrexate injection; one of these also required a local potassium chloride injection. The tubal pregnancies resolved in nine patients treated with methotrexate alone. During resolution, we noted a gradually increasing resistance index of the blood flow in the region of the gestation, but the tube became distended to 4.4 +/- 0.4 cm before gradually decreasing in size. No complications or side effects were encountered. These findings suggest that intratubal transvaginal methotrexate administration can provide a safe alternative to surgical treatment for patients with early unruptured tubal ectopic pregnancy. However, the presence of a living embryo makes the ectopic pregnancy more resistant to methotrexate treatment.     

Multiple-dose methotrexate for pregnancy in a cesarean section scar. A case report

BACKGROUND: Pregnancy developing in a cesarean section scar is a very rare but possibly life-threatening condition because of the risk of rupture and excessive hemorrhage. CASE: A woman with previous cesarean section had transvaginal sonography performed at 7 weeks of gestation that showed a gestational sac implanted in the anterior isthmus wall of the uterus with 3 mm of myometrium between the sac and bladder wall. A diagnosis of pregnancy in the cesarean section scar was made. The patient was asymptomatic, and her hemodynamic condition was stable. Two courses of multiple-dose systemic methotrexate-folinic acid (1 mg/kg methotrexate intramuscularly on days 1, 3, 5 and 7 with 0.1 mg/kg folinic acid intramuscularly on days 2, 4, 6 and 8) were given. The patient tolerated it and remained stable during treatment. The serum hCG dropped to < 5 IU/L on day 56. CONCLUSION: Treatment with methotrexate is a non-surgical option that can improve preservation of the uterus in patients who desire fertility. A multiple-dose regimen causes rapid interruption of the pregnancy. This is very important because the risk of rupture and hemorrhage directly correlates with the duration of the pregnancy.     

Safety and Efficacy of a Single Local Methotrexate Injection for Cesarean Scar Pregnancy

Study ObjectiveTo investigate the safety and efficacy of a single local methotrexate (MTX) injection for the treatment of cesarean scar pregnancy (CSP), assess reproductive outcomes after treatment, and confirm clinical outcomes after the treatment of CSP patients according to the presence of fetal cardiac activity or serum human chorionic gonadotropin (hCG) levels.DesignA retrospective cohort study.SettingA university hospital.PatientsWomen with CSP.InterventionsSingle local MTX injection under transvaginal ultrasound guidance.Measurements and Main ResultsA total of 45 CSP cases were identified; the mean (standard deviation, range) estimated gestational age was 7.7 (1.7, 5.4–12.5) weeks and the mean serum hCG level was 51 801 (40 761, 2307–187 898) mIU/mL. Three cases required additional treatment with MTX, and none of the cases needed uterine artery embolization or hysterectomy. The success rate for a single dose was 93.3%, and it was 100% if additional treatments with MTX were included. The mean time required for hCG normalization in those with fetal cardiac activity or with an initial level of hCG greater than 100 000 mIU/mL was not significantly longer than that in the controls (93.4 vs 77.1 days, p = .12; 113.7 days vs 83.6 days, p = .10). Of the 23 women who desired a subsequent pregnancy, 13 delivered 14 healthy newborns after treatment, 3 had an ongoing pregnancy, and 3 experienced recurrent CSP.ConclusionsA single local MTX injection is safe and effective for the treatment of CSP despite the presence of fetal cardiac activity or any initial level of hCG and may allow the possibility of a subsequent uneventful pregnancy.     

Successful treatment of a cervical pregnancy with a single low dose methotrexate regimen

Until very recently cervical pregnancies have been treated with surgery, usually hysterectomy. The development of endovaginal ultrasound, which allows early diagnosis, and methotrexate chemotherapy have opened up new therapeutic options. A 45-year-old multigravida presented at 8 weeks' gestation with vaginal bleeding. Endovaginal ultrasound demonstrated a cervical pregnancy with a fetal pole, 1.2 × 1.4 cm sac, no cardiac pulsations, and an empty uterus. After discussion with the patient, single low dose methotrexate 1.5 mg/m² was given intramuscularly. The patient's hCG titre was 5882 IU-(Third International Standard). Over a 5-week period the hCG titres fell, and the gestational sac disappeared. The patient experienced intermittent vaginal bleeding and cramping but was managed as an outpatient. Single low dose methotrexate may be a successful management option in selected cases of cervical pregnancy.