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.     

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)     

Intravenous methotrexate for treatment of interstitial pregnancy: a case report

BACKGROUND: Ectopic pregnancy is the leading cause of first-trimester maternal death, accounting for 9% of pregnancy-related deaths. Interstitial (cornual) pregnancies represent 6% of all ectopics but account for a disproportionately higher mortality rate. Surgical management has been the treatment of choice for interstitial pregnancies. A very limited number of articles pre have explored the use of intravenous methotrexate to treat cornual pregnancy as a possible conservative first-line therapy in selected, hemodynamically stable patients. CASE: A patient with a confirmed interstitial pregnancy was treated with intravenous methotrexate. The patient's beta-hCG levels decreased to zero within 9 weeks. CONCLUSION: Intravenous methotrexate was used successfully in the treatment of an interstitial pregnancy without complications.     

Sonographic evolution of cornual pregnancies treated without surgery.

Transvaginal sonography allows early and accurate diagnosis of cornual pregnancy, as well as providing a means for puncture injection treatment of certain ectopic pregnancies. We describe four cases of cornual pregnancy managed nonsurgically and followed with transvaginal sonography for 47-64 weeks. Sonographic evidence of cornual pregnancy persisted throughout the period of follow-up, despite resumption of normal menstrual cyclicity. We conclude that some early live cornual pregnancies can be managed by puncture injection, and cornual pregnancies in which the embryo has died can be followed conservatively.     

Successful management of a cornual pregnancy with a single high-dose laparoscopic methotrexate injection

Cornual (interstitial) pregnancy, a very rare form of ectopic pregnancy, accounts for 2–4% of all tubal pregnancies in which conception is located in the proximal interstitial portion of the fallopian tube. Cornual resection by laparotomy is generally the preferred method of treatment, although more conservative approaches have also been described. We report a case of cornual pregnancy that was successfully treated with a single dose of 100 mg methotrexate injected into the mass of the ectopic cornual pregnancy. The serum human chorionic gonadotropin (hCG) level decreased to undetectable levels on the 60th post-operative day.     

Cornual gestation: a systematic literature review and two case reports of a novel treatment regimen

STUDY OBJECTIVE: To introduce a novel tubal-sparing regimen for the treatment of nonruptured cornual pregnancies. DESIGN: Case report and systematic review of the literature. SETTING: Tertiary Care University setting. PATIENTS: Two patients referred for care in our subspecialty clinic. INTERVENTIONS: Laparoscopic surgery, dilation and evacuation, and postoperative methotrexate injection. Systematic review of the literature. MEASUREMENTS AND MAIN RESULTS: Both medical and surgical treatments for cornual gestation exist; however, each is not without its shortcomings. Medical treatment is associated with failure rates that may result in uterine rupture and catastrophic hemorrhage. Surgical treatment that involves hysterectomy causes a loss of future childbearing capability. Surgical treatment that involves resection of the involved cornual region is associated with decreased fertility rates and increased rates of uterine rupture in future pregnancies. Our treatment regimen is safe and effective and conserves future fertility. CONCLUSION: A cornual gestation is one of the most hazardous types of ectopic gestation. The diagnosis and treatment of such a pregnancy is challenging and constitutes an urgent medical situation. We herein introduce a novel regimen for the treatment of nonruptured cornual pregnancies. The existing treatment regimens are also systematically reviewed.     

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.     

甲氨蝶呤治疗输卵管妊娠后的再孕率分析

目的 总结甲氨蝶呤（MTX）治疗输卵管妊娠后的再孕率。方法 收集我院1985年3月至1999年8月确诊为未破裂输卵管妊娠、有生育要求的患者129例,中期60例为MTX全身治疗成功,69例为患侧输卵管切除,按每5年1个时间段回顾分析,随诊1－15年。结果 MTX治疗者,宫内妊娠73％（44例）,异位妊娠8％（5例）;输卵管切除者,宫内妊娠70％（48例）,异位妊娠4％（3例）。两者比较,差异无显著性（P＞0．05）。结论 MTX保守治疗的效果和一侧输卵管切除术相似,没有提高再孕率。     

Recurrent cornual pregnancy after heterotopic cornual pregnancy successfully treated with systemic methotrexate

This report concerns a recurrent spontaneous cornual pregnancy 2 years after selective feticide of a heterotopic cornual pregnancy which occurred after IVF for tubal pathology. The recurrent cornual pregnancy was treated successfully with systemic methotrexate. Assisted reproductive techniques, especially in patients with tubal pathology, and non-invasive management of cornual pregnancies may lead to a higher incidence of recurrence.     

MRI and methotrexate in the management of a cornual ectopic pregnancy

Cornual ectopic pregnancies are rare but can be fatal. Use of a magnetic resonance imaging (MRI) scan has been reported in the diagnosis of a cornual ectopic pregnancy, but this is not commonplace. Intramuscular methotrexate is commonly used to treat cornual ectopic pregnancies; however, this is not recommended if the human chorionic gonadotropin (HCG) level is greater than 3,000 IU/l. We describe a case where MRI was used to make a diagnosis and intramuscular methotrexate was successfully administered at an HCG level greater than 3,000 IU/l.     

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.     

Cornual heterotopic pregnancy: conservative treatment with transvaginal embryo reduction

Objective The objective was to discuss a case of heterotopic cornual pregnancy managed with transvaginal embryo reduction.Methods A 22-year-old woman with heterotopic cornual pregnancy was treated with ultrasonographically guided transvaginal injection of potassium chloride into the thorax of ectopic fetus.Results Sixteen days after the procedure, the patient presented with pelvic pain and miscarriage ensued. Control examination 1 month and 3 months later revealed normal uterine cavity and partially resorbed ectopic material.Conclusion This minimally invasive approach in a hemodynamically stable patient can be considered in the management of a first trimester heterotopic cornual pregnancy. However the patient must be informed for the risk of abortion related to the procedure. Nevertheless this approach can be a treatment option in cornual pregnancies without a simultaneous intrauterine gestation.     

Heterotopic pregnancy after in vitro fertilization-embryo transfer.

OBJECTIVE: A ruptured cornual pregnancy is a rare and challenging problem. We present two cases of cornual pregnancies after in vitro fertilization and embryo transfer (IVF-ET) treated by cornual resection, with an excellent perinatal outcome for the intrauterine pregnancy in both cases. A literature review of cornual pregnancy after IVF-ET is also included. CASE REPORTS: Two women had undergone IVF-ET because of tubal problems. Emergent laparotomy was performed because of internal bleeding at 12 weeks of gestation in one case and 17 weeks in the other, and in both cases, ruptured cornual pregnancies were found. Cornual resection and primary repair were performed. The women were discharged on the 6th and 7th postoperative day, respectively, and they underwent an elective cesarean delivery at 37 weeks of pregnancy. They were delivered of healthy babies, one weighing 2700 g and the other 2310 g. CONCLUSION: These cases illustrate that good perinatal outcomes can be achieved by surgical intervention in heterotopic pregnancies, even in the event of a ruptured cornu.     

Laparoscopic methotrexate treatment of ectopic pregnancy: feasibility, efficacy, safety and intrauterine pregnancy rates.

We set out to investigate efficacy, methotrexate (MTX) plasma concentrations, and toxicity following a single injection of MTX into the gestational site in the treatment of ectopic pregnancy. This was a non-randomised, non-blinded prospective clinical trial. Eighteen women with unruptured tubal pregnancies and in stable haemodynamic condition were studied. MTX 1 mg/kg was injected into the ectopic pregnancy guided by laparoscopy. Serum betahCG levels were estimated before MTX treatment and on days 1, 4 and 13. In 14 patients plasma MTX was determined 1 h and 6 h after the injection. We found an adequate decline in betahCG was achieved in 17 (94%) patients, and tubal surgery avoided in 15 (83%). At 6 hours following drug administration, mean plasma MTX concentration (0.36+/-0.21 microM) was only 12% of mean peak level (3.1+/-1.0 microM). Six (39%) demonstrated slightly elevated, but completely reversible liver enzymes. None reported any subjective adverse effects. At the 4-7 year follow-up nine of 12 (75%) women had delivered healthy babies. It is concluded that intratubal injection of 1 mg/kg MTX appears to be an effective and safe treatment of ectopic pregnancy.     

Live birth after treatment of a heterotopic cornual pregnancy with fetal intrathoracic KCI. A case report

BACKGROUND: Heterotopic pregnancy, in which an ectopic gestation coexists with an intrauterine one, occurs more frequently following in vitro fertilization than with spontaneous conception. However, it is rare to find an ectopic gestation in the interstitial (or cornual) portion of the fallopian tube. This scenario poses challenges in diagnosis as well as difficulties in managing the cornual pregnancy while maintaining the viability of the intrauterine gestation. CASE: A 29-year-old nulligravida with stage IV endometriosis completed in vitro fertilization for primary infertility. A heterotopic pregnancy involving the right interstitial portion of the fallopian tube as well as a viable singleton intrauterine pregnancy was diagnosed using serial ultrasound. Successful termination of the cornual pregnancy was accomplished by transabdominal fetal intrathoracic injection of KCl under ultrasound guidance. CONCLUSION: Pregnancy reduction of a heterotopic cornual gestation using KCl is a treatment alternative for this uncommon but potentially devastating complication of in vitro fertilization.     

Heterotopic pregnancy: successful management with aspiration of cornual/interstitial gestational sac and instillation of small dose of methotrexate

OBJECTIVES: Terminating a corneal pregnancy without jeopardizing a coexistent intrauterine pregnancy. METHODS: A 29-year-old woman with a 4-year history of primary infertility became pregnant after in-vitro fertilization and embryo transfer. A heterotopic pregnancy with a left cornual and intrauterine sacs was confirmed by early transvaginal scan examinations. The ectopic sac was aspirated under ultrasound guidance followed by local injection of 12.5 mg methotrexate. This was followed by serial ultrasound scans and serum betahCG assays. RESULTS: The fetal pole in the ectopic pregnancy disappeared following the procedure. She had no significant vaginal bleeding or any other unusual symptoms. The intrauterine pregnancy progressed satisfactorily until spontaneous onset of labour and vacuum extraction delivery at 39 weeks. The baby weighed 2.9 kg. CONCLUSIONS: Local injection of low-dose methotrexate following aspiration of a cornual pregnancy proved effective in halting the ectopic trophoblasts' growth without adversely affecting a coexistent intrauterine pregnancy. The injected ectopic trophoblasts resolved quickly despite the small dose of methotrexate used. This technique avoided a more costly surgical treatment with its associated risks in subsequent pregnancies.     

Laparoscopic management of cornual pregnancy without sutures

Introduction Cornual pregnancy is a rare form of ectopic pregnancy. The incidence is reported as 3% of all ectopic pregnancies accounting 20% of deaths due to ectopic pregnancy. When an unruptured cornual pregnancy is diagnosed, there are a variety of management options. Many successful endoscopic management options for cornual pregnancy have been reported. Case report In this case, cornual resection was performed. Discussion The other possible treatment options were reviewed.     

A new technique in the laparoscopic resection of cornual ectopic pregnancies: a case series

Cornual ectopic pregnancies are a challenging dilemma faced in the early pregnancy setting. They are associated with high morbidity and mortality rates when compared to standard tubal ectopic pregnancies mainly due to their late presentation and significant haemorrhage and hysterectomy risk. Laparoscopic resection has been described successfully; however, the procedure can be technically very challenging and can carry significant potential risks of bleeding and conversion to laparotomy. Carboprost is a synthetic prostaglandin analogue, used widely in the management of obstetric haemorrhage, with its main mode of action being myometrial contractions. We present a series of four cases where intramyometrial carboprost injection was used successfully, prior to the laparoscopic resection of cornual ectopic pregnancies, to produce consistent and reproducible surgical benefits including prolonged myometrial contractions and subsequent reduced uterine blood flow. This results in a significant reduction in intraoperative blood loss as well as a clearer demarcation of the ectopic pregnancy and a technically easier resection.     

Curetaje cornual como tratamiento conservador del embarazo ectópico accidentado

The classical treatment of cornual ectopic pregnancy is cornual resection or hysterectomy. Currently, a more conservative approach is feasible. We describe a case of cornual ectopic pregnancy treated with tubal cornual curettage and review the various options in the management of this entity. This technique may reduce the risk of uterine rupture in future pregnancies, even though studies on this topic are lacking.     

Laparoscopic management of heterotopic pregnancy: a review

Laparoscopic management of ectopic pregnancies is becoming more common. Having recently successfully treated one case of heterotopic pregnancy by laparoscopy in our department, the object of the present paper is to review the literature regarding laparoscopically treated cases of heterotopic pregnancy in order to assess benefits, complications and safety of this procedure. A Medline search yielded 10 additional cases with ampullary, interstitional or cornual tubal pregnancy, respectively. All surgical procedures were uncomplicated and all in utero pregnancies progressed normally. Despite a small number of cases, lack of complications in these reports is encouraging feasibility of laparoscopic management of heterotopic pregnancy.