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.     

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.     

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。     

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.     

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.     

Pre- and post-treatment patterns of human chorionic gonadotropin for early detection of persistence after a single dose of methotrexate for ectopic pregnancy

OBJECTIVE: Given the great variability of human chorionic gonadotropin (HCG) levels after a single dose of methotrexate (MTX) for ectopic pregnancy, it remains complicated to identify cases undergoing persistence until a week from treatment. We evaluated whether pre-treatment patterns of HCG levels could be useful for an earlier detection of persistent trophoblast. STUDY DESIGN: A retrospective study on 62 patients treated by a systemic single dose of methotrexate (50 mg/m(2)) for an ectopic pregnancy. Samples for HCG detection were obtained on days -2 and 0 before the therapy, on days +3, +7 and then weekly until values were undetectable. Patients were divided into three groups: Group U (up, meaning "increasing") and Group D (down, meaning "decreasing") when HCG levels on day 0 were respectively higher or lower than day -2 level of more than 20% and Group P (plateau) when the difference between day -2 HCG level and the level on day 0 was less than 20%. RESULTS: All the patients of Group D underwent a complete resolution, with a percentage of 33.3% of cases who underwent an initial rise of HCG levels on day +3. The percentage of cases undergoing an initial rise of HCG levels in Group U patients was significantly higher than in Group P patients (60.0% versus 28.6%), but the resolution rate resulted similar in the two groups. For patients of Group P, an increase of HCG levels on day +3 was significantly correlated to the failure of the therapy. Indeed, comparing the cases with an immediate increase of HCG levels to the cases with immediate decrease of HCG levels on day +3, the persistence rate was 80% for the former and 12% for the latter (P < 0.0001). CONCLUSION: An initial rise of HCG levels after the therapy does not seem to have a clinical relevance in Group D and Group U patients, it well correlates to trophoblastic persistence in Group P patients.     

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.     

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.     

Evaluation of the relationship between endometrial thickness and failure of single-dose methotrexate in ectopic pregnancy

Objective: To test the hypothesis that endometrial stripe thicker than 12 mm increases treatment failure of single-dose methotrexate for the management of ectopic pregnancy. Study design: Seventy-three patients with ectopic pregnancy and measured pretreatment endometrial stripe were divided into two groups based on the endometrial stripe thickness (>12 mm or ≤12 mm). All patients were candidates for single-dose methotrexate treatment. Variables analyzed between the two groups were endometrial stripe thickness, initial beta human chorionic gonadotropin level (hCG), size of the ectopic mass, presence of fetal heart tones, previous ectopic pregnancy, and clinical outcomes. Results: Sixty patients had endometrial stripe thickness ≤12 mm and 13 patients >12 mm. The two groups were similar in initial hCG, size of ectopic mass, presence of fetal heart tones and rate of previous ectopic pregnancy. The failure rate was significantly higher in the group with endometrial stripe >12 mm compared to the group ≤ 12 mm (n=7, 53% vs. n=3, 5%, P<0.01). The endometrial stripe was significantly thicker in the group with endometrial stripe thickness >12 mm compared to the group ≤12 mm (mean ± SD, 17.64±5.82 mm vs. 7.69±2.82 mm, P<0.01). Conclusion: Endometrial stripe thicker than 12 mm increases the risk for treatment failure with single-dose methotrexate.     

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。     

Human chorionic gonadotropin level as a predictor of trophoblastic infiltration into the tubal wall in ectopic pregnancy: a blinded study

OBJECTIVE: To determine the relationship between gestational age, tubal ultrasonographic diameter, and serum hCG levels and different stages of trophoblastic infiltration of the tubal wall in ectopic pregnancy. DESIGN: Blinded prospective study. SETTING: University-based clinic in Italy. PATIENT(S): Thirty-seven consecutive patients with an ampullary ectopic pregnancy. INTERVENTION(S): Laparoscopic salpingectomy. MAIN OUTCOME MEASURE(S): Gestational age, diameter of the tubal mass as determined by transvaginal ultrasonography. and hCG level on the day of surgery. Ectopic pregnancy was classified according to the depth of trophoblastic infiltration: trophoblast limited to the tubal mucosa (stage I), extension to the tubal muscularis (stage II), or complete tubal wall infiltration up to the serosa discontinued by trophoblastic cells (stage III). RESULT(S): Fifteen patients (40.5%) had stage I tubal infiltration, 14 (37.8%) had stage II infiltration, and 8 (21.6%) had stage III infiltration. Gestational age and diameter of the tube did not differ among the three groups. The median hCG level was 1,710.5 mIU/mL (range, 113-5,635 mIU/mL) for patients with stage I infiltration. 4,690.0 mIU/mL (range, 150-21,531 mIU/mL) for patients with stage II infiltration, and 15,700.0 mIU/mL (range, 13,809-21,650 mIU/mL) for patients with stage III infiltration. All the patients with hCG levels > 6,000 mIU/mL had stage II or III invasion. CONCLUSION(S): These findings may explain why the conservative treatment of ectopic pregnancy is less successful in patients with high hCG levels than in patients with low levels. Use of radical procedures may be justified in the former group.     

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.     

Single dose methotrexate therapy: application to interstitial ectopic pregnancy

A woman with a small (6-mm gestational sac) interstitial pregnancy had complete resolution after medical therapy alone. A single cycle of methotrexate 50 mg/m² was used as outpatient treatment without any operative procedure either for diagnosis or intervention. The guidelines that have evolved for selection of women for single dose methotrexate treatment for both intrauterine and tubal ectopic pregnancies may be applicable to interstitial ectopic pregnancy as well. A suggested framework for treatment decisions is presented.