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.     

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.     

Low-dose methotrexate treatment for interstitial pregnancy. A case report

BACKGROUND: Only a small number of case reports have described medical treatment of interstitial ectopic pregnancies. Almost all of the reported patients were treated with repeated high doses (1 mg/kg) of methotrexate. CASE: At 6 weeks of gestation, a 31-year-old woman, gravida 5, para 4, was diagnosed with a 0.96 x 1.36-cm right cornual pregnancy. As the patient desired future fertility, she received 100 mg of intramuscular methotrexate (50 mg/m2). She was then followed on an outpatient basis, with serum human chorionic gonadotropin values appropriately declining. Serial ultrasound also showed decreasing size of the gestational sac. Twenty-one days after the methotrexate dose, the patient experienced rupture of the right posterior cornu, necessitating exploratory laparotomy. CONCLUSION: Extreme caution should be used when treating interstitial gestations with single-dose methotrexate. All patients should be extensively counseled regarding the significantly increased risk of failure, possibility of rupture and need for emergency surgery.     

Management of cervical pregnancy: risk factors for failed systemic methotrexate

Cervical pregnancy is a rare obstetrical complication. Conservative management with systemic methotrexate has been reported to be successful, obviating the need for surgical treatment which entails a risk for hysterectomy. We report the case of a nulliparous patient with a cervical pregnancy diagnosed at 9 weeks' gestation who after systemic methotrexate treatment necessitated conservative surgical management. This patient highlights the utility of identified risk factors for failure of methotrexate treatment.     

Successful treatment of a live cervical pregnancy with methotrexate and folinic acid. A case report

A case of cervical pregnancy with a fetal pole, fetal cardiac activity and a serum beta-human chorionic gonadotropin level reaching a peak of 60,000 mIU/mL was treated successfully with methotrexate and folinic acid. These criteria have been considered a contraindication to conservative medical management. Serial beta-human chorionic gonadotropin levels and sonography were used to diagnose the pregnancy and monitor therapy. Complications were limited to transient conjunctivitis and blood loss anemia. The patient's fertility potential was preserved.     

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.)     

Failed methotrexate termination of pregnancy: a case report.

We report a case of a fetus with shortened proximal long bones, ambiguous genitalia, intrauterine growth restriction and abnormal umbilical artery Doppler velocities observed on antenatal ultrasound exam. At 34 weeks the patient revealed methotrexate/misoprostol exposure at 6 weeks gestational age in attempted medical termination of pregnancy. On newborn exam, the baby had dysmorphic facial features, a short torso, scoliosis, a micropenis (phallus <1 cm) and shortened proximal long bones both upper and lower extremities. X-ray exam revealed a hemivertebra at T10 level, rib abnormalities, shortened proximal long bones, an absent pubic bone and bilateral knee ossification centers. With methotrexate exposure, improved counseling and surveillance could potentially avoid these significant abnormalities and prevent psychological distress.     

Transverse myelitis following methotrexate treatment of ectopic pregnancy: a case report

Objective: Ectopic pregnancy is a common condition in the field of gynaecology, often treated with methotrexate. Adverse effects are common and usually mild. Severe adverse events are rare amongst patients treated with MTX for this condition.

Case: A 26-year-old healthy woman was admitted and treated medically with MTX for an ectopic pregnancy. The patient was treated in the standard drug labelled protocol with an intramuscular injection of 78?mg of MTX according to body surface area. Soon after, the patient presented to the emergency department with symptoms of bilateral paresthesia of the lower limbs which ascended to the pelvis. After a thorough work up and imaging via MRI a diagnosis of transverse myelitis was made. Treatment was successful with corticosteroids and symptoms subsided.

Conclusions: We propose that MTX should be used with caution and severe toxicity should be kept in mind with high index of awareness for any symptom development following treatment, especially neurological one.     

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.     

Failed treatment of abdominal pregnancy with methotrexate. A case report

BACKGROUND: Methotrexate is an effective, safe, low-cost alternative to surgery for treating tubal pregnancies. To our knowledge, there have only been two other reported attempts at treating abdominal pregnancy with methotrexate. CASE: Despite two courses of treatment with methotrexate, the pregnancy persisted, and laparoscopy permitted a tissue diagnosis of abdominal pregnancy. CONCLUSION: Although treatment with methotrexate was not successful in this case, its potential use in abdominal pregnancies merits further investigation.     

Inevitable hysterectomy despite conservative surgical management in advanced cervical pregnancy: a case report.

A 35-year-old woman was diagnosed to have cervical pregnancy of 10.2 weeks duration. Methotrexate therapy was not chosen due to the presence of active tuberculosis. Since the patient had gradually increasing vaginal hemorrhage, she was taken to the operating room. A dilatation and curettage could not control the hemorrhage. A laparotomy was performed and the uterine arteries were ligated. A cervical hysterotomy was also performed to evacuate the products of conception. There was active bleeding in the cervix although no products of conception were observed. Two purse string sutures were placed, but the persistence of profuse bleeding despite these measures necessitated total hysterectomy.     

Multidose methotrexate treatment of cervical pregnancy

BackgroundCervical pregnancy is a rare form of ectopic pregnancy. The treatment ranges from medical treatment with methotrexate to hysterectomy.CasesWe report two cases of cervical pregnancy with fetal cardiac activity that were successfully treated with multidose methotrexate.ConclusionDue to the possible severe complications of cervical pregnancy and its surgical management, multidose methotrexate treatment in hemodynamically stable women is an appropriate option.     

Methotrexate for cervical pregnancy. A case report

BACKGROUND: The incidence of cervical pregnancy is 1:1,000-95,000 pregnancies and represents < 1% of all ectopic pregnancies. Evacuation of the pregnancy by curettage does not always stop the bleeding because there is little contractile muscle in the cervix. If there is uncontrollable bleeding, hysterectomy is necessary. In selected cases, nonsurgical management offers high success rates. Among medical treatments, the most common is systemic or local administration of methotrexate. CASE: A 36-year-old woman, gravida 2, para 2, presented with vaginal bleeding and subacute pain in the lower abdomen. The patient was 7 weeks' pregnant according to her last menstrual period. Transvaginal ultrasonography showed a gestational sac of approximately 5 weeks' gestational age implanted in the wall of the cervix. Fifty milligrams of methotrexate was injected into the gestational sac and another 50 mg administered intramuscularly. The hCG level decreased continuously and was no longer detectable after 35 days. CONCLUSION: The use of methotrexate for cervical pregnancy is safe and effective and preserves fertility.     

Oral methotrexate for persistent ectopic pregnancy. A case report.

Persistent ectopic pregnancy complicates a significant percentage of conservative tubal pregnancy procedures. The optimal treatment of persistent trophoblast has yet to be determined. Most reported cases have been treated by reoperation and removal of the affected tube. Use of methotrexate may avoid the need for reoperation and permit tubal salvage. We report on a case of persistent ectopic pregnancy treated successfully using an oral methotrexate regimen originally described for treating nonmetastatic gestational trophoblastic neoplasia. Oral methotrexate provides a simple, convenient, outpatient treatment option for cases of persistent ectopic pregnancy diagnosed by a rise or plateau in human chorionic gonadotropin levels following conservative surgery.     

Failed methotrexate treatment of cervical pregnancy. Predictive factors

OBJECTIVE: To determine the risk factors when primary methotrexate treatment of cervical pregnancy fails. STUDY DESIGN: From January 1985 to December 1999, 32 women with cervical pregnancy were treated with methotrexate intramuscularly according to a repeated intramuscular injection protocol. For evaluation of the efficacy of therapy, pretreatment serum concentrations of human chorionic gonadotropin, size of the gestational mass, fetal cardiac activity and presence of fluid in the peritoneal cavity were measured. These findings were analyzed and compared in terms of success and failure by means of the chi 2 test, Fisher's exact test, receiver operating characteristic curve and Student's t test. RESULTS: There was no relation between the women's age, parity, size of the conceptus or presence of fluid in the peritoneal cavity to the efficacy of treatment. In a cervical pregnancy that presented with a serum human chorionic gonadotropin concentration of > or = 10,000 mIU/mL, fetal cardiac activity was associated with a higher failure rate of primary methotrexate treatment. CONCLUSION: In cervical pregnancies, a high serum human chorionic gonadotropin concentration and fetal cardiac activity were the most important factors associated with failure of treatment using methotrexate.     

Successful treatment of a viable cervical pregnancy with methotrexate

Cervical pregnancies usually result in early spontaneous abortion, and most forms of conservative treatment are not recommended beyond 8 weeks' gestation. We present a case of a 9-week viable cervical pregnancy that is successfully managed with methotrexate.     

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.