Single-dose methotrexate for the treatment of ectopic pregnancy: Northwestern Memorial Hospital three-year experience

OBJECTIVE: Our purpose was to evaluate the effectiveness of single-dose intramuscular methotrexate in the treatment of ectopic pregnancies by physicians in the Department of Obstetrics and Gynecology of Northwestern Memorial Hospital and to compare the results with those of previously published studies. STUDY DESIGN: A retrospective chart review was performed of 50 patients with ectopic pregnancies treated with single-dose methotrexate according to the protocol of Stovall et al. from January 1992 to February 1995. RESULTS: The mean pretreatment level of β-human chorionic gonadotropin was 1896.4 ± 2399 mIU/ml. Only 32 women (64%) were successfully treated with a single dose of methotrexate. An additional 7 women required a second or third injection. The combined success rate for medical management of ectopic pregnancy with one to three doses of methotrexate was 78% (39 women). Pretreatment β-human chorionic gonadotropin levels were significantly lower in women who responded to single-dose therapy than in those who required either two or three doses or who had failure of medical management (p = 0.0011). The mean time to resolution of β-human chorionic gonadotropin was 26.5 ± 17 days. Higher pretreatment levels correlated with longer resolution time (r = 0.83, p < 0.001). Eleven women (22%) with failure of medical management required surgery. CONCLUSIONS: In our series single-dose methotrexate was only 64% successful. Women with a pretreatment β-human chorionic gonadotropin level >5000 mIU/ml had a greater probability of requiring either surgical intervention or multiple doses of methotrexate. The potential for emergency surgery remains an important risk. (Am J Obstet Gynecol 1996;174:1840-8.)     

Treatment of viable cesarean scar ectopic pregnancy with suction curettage.

OBJECTIVE: Pregnancy in previous cesarean scar is the rarest form of ectopic pregnancy. All reported cases in the literature that were treated with uterine curettage either become unsuccessful or complicated. We aimed to present a case of cesarean scar ectopic pregnancy that was successfully treated with suction curettage without any additional therapy. CASE: A 32-year-old asymptomatic woman, gravida 2, para 1 was referred to our hospital with the possible diagnosis of cervical ectopic pregnancy. Transvaginal and transabdominal sonographic examination revealed the diagnosis of viable ectopic pregnancy in a previous cesarean scar. Suction curettage with carman canulles was performed under transabdominal ultrasonographic guidance. beta-hCG decreased progressively postoperatively. CONCLUSION: Suction curettage under ultrasonography guidance can be used in termination of selected cases (early diagnosed, without symptoms that necessitates emergency intervention) of cesarean scar pregnancy.     

Plasma creatine phosphokinase level may predict successful treatment after a single injection of methotrexate for ectopic pregnancy

Our finding that creatine phosphokinase level was significantly higher in women successfully treated for ectopic pregnancy with only a single injection of methotrexate suggests that this indicator predicts this outcome.     

Predictors of failure of the commonly used single-dose methotrexate protocol for treating tubal ectopic pregnancies

Objectives

This study identified patients who would benefit from an earlier additional medical intervention and/or continuing close surveillance even if commonly used parameters indicated sufficient medical treatment to determine markers of treatment failure.

Laparoscopic removal of a large 8-cm ectopic pregnancy with a negative pregnancy test

Ectopic pregnancy has been increasing in frequency over the past years. The first step in the diagnosis of ectopic pregnancy is the demonstration of pregnancy by performing a sensitive qualitative urine test; hence, a negative urine pregnancy test will generally exclude ectopic pregnancy from the differential diagnosis. The following is a report of a patient presenting with abnormal vaginal bleeding for 8 weeks with a negative urine pregnancy test and transvaginal scan suggesting a large 8-cm ectopic pregnancy. This case report demonstrates the importance of keeping the diagnosis of ectopic pregnancy in our mind even with negative urine pregnancy but with atypical presentation and how such large ectopic pregnancies can still be managed laparoscopically.     

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.     

Human chorionic gonadotropin patterns after a single dose of methotrexate for ectopic pregnancy

Objective: The great variability in human chorionic gonadotropin (HCG) levels after a single dose of methotrexate (MTX) for ectopic pregnancy makes it difficult to predict treatment failure. We describe different patterns of HCG levels. Study design: Fifty patients were injected i.m. with 50 mg/m² of MTX for an ectopic pregnancy. Venous blood samples for HCG detection were obtained on the day of treatment (day 0), day 3 and day 7 and weekly until values were undetectable. Patients were classified as: group 1, persistent pathology (n=11); group 2, complete resolution with a decrease of HCG levels at day 3 (n=30); group 3, complete resolution after a rise of HCG values at day 3 (n=9). Statistical analysis was performed using the Mann–Whitney non-parametric test with 95% confidence intervals. Results: Values of day 0 were similar for all the groups. HCG levels of group 3 decreased rapidly after day 3 and at day 7 they were significantly different from levels of group 1. Differences in HCG levels between groups 2 and 3 became indistinguishable from day 21. Conclusion: The observation of patients undergoing resolution after an initial increase of HCG levels justify an expectant management for 1 week in clinically stable patients. The strategy to separate HCG curves in patients undergoing resolution may shed light on the different clinical responses to therapy for ectopic pregnancies. However, the phenomenon of the immediate rise of HCG should be better investigated.     

Serum concentrations of interleukin-2R (IL-2R), IL-6, IL-8, and tumor necrosis factor alpha in patients with ectopic pregnancy

OBJECTIVE: To investigate the diagnostic relevance of serum cytokine concentrations in ectopic pregnancy (EP). DESIGN: Cohort study. SETTING: University hospital. PATIENT(S): Seventeen women with EP, 22 women with miscarriage, and 33 women with normal intrauterine pregnancy, at comparable stages of gestation. INTERVENTION(S): Interleukin (IL)-2 receptor, IL-6, IL-8, and tumor necrosis factor alpha (TNF-alpha) determination by immunoradiometric assay. MAIN OUTCOME MEASURE(S): Serum concentrations of progesterone, beta-hCG, IL-2R, IL-6, IL-8, and TNF-alpha. RESULT(S): Serum levels of IL-6 were higher in women with EP than in those with miscarriage and normal pregnancy. Serum levels of TNF-alpha were higher in women with EP than in those with miscarriage and normal pregnancy. Serum levels of IL-8 were higher in women with EP than in those with miscarriage and normal pregnancy. An IL-8 cutoff of >40 pg/mL predicted EP with a sensitivity of 82.4%, a specificity of 81.8%, and positive and negative predictive values of 58.3% and 93.8%. No difference in serum IL-2R levels was found among the groups. CONCLUSION(S): Serum IL-8, IL-6, and TNF-alpha concentrations are higher in women with EP than in those with miscarriage and normal pregnancy. Further studies are needed to determine their diagnostic value.     

Laparoscopic management of a cornual ectopic pregnancy associated with persistant gestational throphoblastic disease: a case report

A 30-year-old woman underwent laparoscopy for diagnosis and treatment of ectopic pregnancy. A dark-red bulging mass was observed in the right uterine horn. Laparoscopic hysterotomy was performed. The histological examination revealed a hydatidiform mole, which was confirmed by DNA ploidy analysis showing triploidy (69 XXY) as apartial hydatidiform mole after the cytogenetic examination. On the third postoperative day, the thoracic computed tomography scan revealed punctuate lesions. These lesions disappeared after single-agent chemotherapy with methothrexate. To the best of our knowledge, this is the first case of cornual persistent gestational trophoblastic neoplasia managed by laparoscopic surgery.     

Costs of NHS maternity care for women with multiple pregnancy compared with high-risk and low-risk singleton pregnancy

Objective  To compare antenatal and obstetric costs for multiple pregnancy versus singleton pregnancy risk groups and to identify factors driving cost differentials.
Design  Observational study over 15 months (2001–02).
Setting  Four district hospitals in southeast England.
Population  Consecutive women with multiple pregnancy and singleton women with risk factors for fetal congenital heart disease (CHD) (pregestational diabetes, epilepsy, or family history of CHD) or Down syndrome, and a sample of low-risk singleton women.
Methods  Clinical care was audited from the second trimester anomaly scan until postnatal discharge, and the resource items were costed. Multiple regression analysis determined predictors of costs.
Main outcome measures  NHS mean costs of antenatal and obstetric care for different types of pregnancy.
Results  A total of 959 pregnancies were studied. Three percent of 243 women with multiple pregnancy reached 40 weeks of gestation compared with 54–55% of 163 low-risk and 322 Down syndrome risk women and 36% of 231 cardiac risk women. Antenatal costs for cardiac risk (£1,153) and multiple pregnancy (£1,048) were nearly double the costs for other two groups ( P < 0.001). As 63% of multiple births were delivered by caesarean section, the obstetric cost for multiple pregnancy (£3,393) was £1,000 greater overall. Pregestational diabetes was the most influential factor driving singleton costs, resulting in similar total costs for multiple pregnancy women (£4,442) and for women with diabetes (£4,877).
Conclusions  Our analyses confirm that multiple pregnancies are substantially more costly than most singleton pregnancies. Identifying women with diabetes as equally costly is pertinent because of the findings of the Confidential Enquiry into Maternal and Child Health that standards of maternal care for diabetics often are inadequate.     

Ruptured ectopic pregnancy: risk factors for a life-threatening condition

Introduction  Ectopic pregnancy is a significant cause of maternal morbidity and mortality. The widely used features to establish the diagnosis of ectopic pregnancy are not always sufficient to predict rupture. Problem  To determine the risk factors for rupture of an ectopic pregnancy to help physicians identify those women who are at greatest risk. Materials and methods  The study group comprises the cases of ectopic pregnancy who were treated in the gynecologic department of the General Hospital “George Gennimatas” in Athens, Greece, from January 1988 to December 2006. The following parameters were retrospectively examined: rupture status, past history of pelvic infection or ectopic pregnancy, use of IUCD, operations for infertility treatment/tubal surgery, parity and gestational age. The study group was divided into two subgroups: ruptured ectopic pregnancies and unruptured ectopic pregnancies. Where appropriate, Student’s t test, Mann–Whitney–Wilcoxon test for independent samples, Pearson’s chi-square and Fisher’s exact test were applied. Statistical analysis was performed with STATA 8.0 statistical software. Results  Two hundred and twenty-three cases of ectopic pregnancy were retrieved in the studied period. One hundred and forty-four (65%) of them were cases with ruptured ectopic pregnancies and 79 (35%) were cases with unruptured ectopic pregnancies. Fifty-five of the 144 patients (38.2%) with ruptured ectopic pregnancy and 18 of the 79 (22.8%) patients with unruptured ectopic pregnancy had a past history of ectopic pregnancy (P = 0.019, Pearson’s chi-square). Moreover, there was a statistically significant positive association between rupture and parity (1.19 ± 1.02 for ruptured cases vs. 0.85 ± 0.89 for unruptured cases; P = 0.015, Mann–Whitney–Wilcoxon test for independent samples). A positive association of borderline significance existed between rupture and gestational age (53.9 ± 4.7 vs. 52.9 ± 4.9 days; P = 0.093, Mann–Whitney–Wilcoxon test for independent samples). No statistically significant associations were found concerning past history of pelvic infection, use of IUCD and operations for infertility treatment–tubal surgery. Conclusions  Previous history of ectopic pregnancy and parity seem to be significant risk factors for rupture of an ectopic pregnancy.