Nonsurgical Management Of Ectopic Pregnancy Research Articles

Methotrixate for nonsurgical management of ectopic pregnancy

Systemic Methotrexate has been widely used to treat ectopic pregnancy.The aim of current study were to evaluate the safety and efficacy of single dose intramuscular methotrexate as a treatment option for early unruptured ectopic pregnancies. From 1st of January 2007 to 1st of January 2009 at Maternity teaching Hospital-Erbil, a case cohort prospective study was conducted on 60 patients with small unruptured ectopic pregnancies treated as in-patients with single dose of Methotrexate therapy.
 Ectopic pregnancy was diagnosed by both transvaginal ultrasound for the size and volume of the gestational mass and β- HCG measurement. Intramuscular methotrexate 50 mg/m2 was administered on days 1 and Serial ß-hcg was repeated on days 4 and 7, If the β-HCG on day 7was at least 15% lower than that on day 4, the patient was regarded as treatment success, and Followup serum ß-HCG was performed weekly until become negative ( value of <15 mIU/ml). while additional doses(second dose) of methotrexate were given on day 7 If the ß-HCG level on day 7 was the same or higher or less than 15% lower than that on day 4. The success rate of systemic methotrexate (single dose) was 75%(n 45), 25%(n=15) exposed to 2 or more doses of methotrexate ,16.6%(n=10) of patients exposed to multidose methotrexate respond to treatment, remain only 8.3%(n=5) not respond to multidose treatment they were treated surgically ,in which 2 cases of them operation done for them on their request after one dose of methotrexate, and other 3 cases were failed to respond to medical treatment after receiving 3 dose of methotrexate. The over all success rate of treatment in our study(medical treatment) was 91%(n=55).Success rate was higher in patients whom with β-HCG was ≤ 1500 mIU .Treatment was well-tolerated; most side effects were reported as mild and transient. All cases respond to methotrexate reported satisfaction with this regimen. Within two years follow up visit 38 cases become pregnant , 2 of them developed recurrent ectopic pregnancy.

Almost a tragedy: severe methotrexate toxicity in a hemodialysis patient treated for ectopic pregnancy

Methotrexate (MTX), an antimetabolite of folic acid, is the drug of choice for the nonsurgical management of ectopic pregnancy. MTX-related toxicity may include leukopenia, thrombocytopenia, pancytopenia, nausea, vomiting, stomatitis, mucositis, and liver and lung toxicity, depending primarily on the dosage of the drug and patients' renal function. Currently, the use of MTX in hemodialysis patients, even at a low dosage, is controversial, and no clear-cut guidelines are available. We report here a rare case of a life-threatening complication characterized by severe pancytopenia and skin and mucosal injury, which developed in a young patient on hemodialysis after oral treatment with MTX for ectopic pregnancy. We conclude that even low-dose MTX administration is not to be used in patients with renal insufficiency, and when no other therapeutic options are available we suggest taking several clinical measures to prevent or treat myelosuppression.

Non-surgical management of ectopic pregnancy: appropriate risk management must be in place

Advances in technology have facilitated early diagnosis of ectopic pregnancy, which in turn has increased the scope for non-surgical treatment. Unfortunately risks associated with such management, including maternal death, are coming to the fore. This paper highlights the risks and how they could be avoided. The risks include rupture of ectopic pregnancy during treatment with methotrexate or during expectant management, inadvertent administration of methotrexate to viable early intrauterine pregnancy, methotrexate embryopathy, allergic reaction to methotrexate, development of methotrexate pneumonitis and fatal administration of methotrexate to a woman with a concurrent medical problem. There is an urgent need for appropriate risk management procedures to be applied in units where non-surgical (i.e. expectant or medical) management of ectopic pregnancy is offered. Risk management should address organisational issues such as safe handling of the chemotherapeutic agent, prescription and supply, consent (informed choice), documentation and adequacy of follow-up arrangements. Women undergoing non-surgical management should have ready access (for example by telephone) to professional advice and to surgical intervention in the event of an emergency.

The nonsurgical management of ectopic pregnancy

This review discusses the diagnosis and nonsurgical management of ectopic pregnancy. In the majority of cases the diagnosis of ectopic pregnancy should be made on transvaginal ultrasonography. Those for which the diagnosis is not made on the first scan may initially be classified as pregnancies of unknown location. There are now a number of strategies and mathematical models to predict ectopic pregnancy in this pregnancy of unknown location population. Reported success rates for expectant and medical management of ectopic pregnancy vary due to different inclusion criteria. A number of predictors of success have been studied: maternal age, previous obstetric history, gestational age, ultrasound features, human chorionic gonadotrophin levels, progesterone levels and the change in human chorionic gonadotrophin over time. At present the initial human chorionic gonadotrophin level probably remains the single most important predictor of success. Nonsurgical management is also particularly important for nontubal ectopic pregnancies: interstitial, cervical and caesarean section scar pregnancies. The majority of ectopic pregnancies can be visualized by ultrasound and so can be considered for conservative treatment. Nonsurgical management can be safe and effective. Appropriate selection criteria remain an issue, however, and a consensus needs to be reached on the predictors of success and failure to optimize management.

Is liver function testing necessary prior to methotrexate treatment for ectopic pregnancy?

Study objectives: Methotrexate is used extensively for the nonsurgical management of ectopic pregnancy. Hepatic function testing, specifically aminotransferase testing, was part of the initial methotrexate safety profile and continues to be routinely required before treatment with methotrexate. We seek to determine the incidence of abnormal aminotransferase values among emergency department (ED) patients with ectopic pregnancy. We examine risk factors for liver disease (eg, history of hepatitis, alcohol abuse) among patients with abnormal aminotransferase values and the time spent waiting for aminotransferase testing before methotrexate treatment. Methods: ED medical records were examined over a 4-year period for all patients with an International Classification of Diseases, Ninth Revision diagnosis of ectopic pregnancy. Patients with ectopic pregnancy were included if aminotransferase testing was performed during the ED visit. The medical record was reviewed for risk factors for liver disease if aminotransferase values were elevated. If a patient was treated with methotrexate, the time between orders for aminotransferase and methotrexate was recorded. Results: Over a 4-year period, 205 patients were diagnosed with ectopic pregnancy. Of these patients, the study group consisted of 121 patients who also had serum aminotransferase testing. In the study group, 42 patients were treated with methotrexate, and 79 were treated surgically. Two of the 121 (1.2%) patients had abnormal aminotransferase values. One patient had a normal aspartate aminotransferase (AST) level and an alanine aminotransferase (ALT) level of 43 U/L (reference range 15 to 40 U/L). This patient had a history of hepatitis C. The second patient had a normal ALT level and an AST level of 81 U/L (reference range 15 to 65 U/L). This patient had a history of alcohol abuse. Of the 42 patients treated with methotrexate, the mean time between orders for aminotransferase testing and methotrexate administration was 102 minutes (95% confidence interval 94 to 109 minutes). Conclusion: Among patients with ectopic pregnancy being considered for methotrexate treatment, the incidence of aminotransferase abnormalities is low. Aminotransferase testing significantly prolonged ED treatment time among patients receiving methotrexate. Further prospective study may identify a majority of patients who may be treated with methotrexate without previous aminotransferase testing.

Nonsurgical management of ectopic pregnancy with ultrasound-guided local injection and IM methotrexate

Nonsurgical management of ectopic pregnancy with ultrasound-guided local injection and IM methotrexate

Extra-uterine pregnancy following assisted conception treatment.

Ectopic pregnancy may be the only life-threatening disease in which prevalence has increased as mortality has declined. The most prominent theory to explain this phenomenon involves increased sensitivity of serum beta-human chorionic gonadotrophin (HCG) immunoassay and improved quality of transvaginal ultrasound, combined with a heightened awareness and increased suspicion of the condition among clinicians which has allowed early detection of ectopic pregnancy. Laparotomy, once the standard treatment of ectopic pregnancy, has been replaced almost entirely by operative laparoscopy. This is associated with a shorter hospital stay, fewer post-operative analgesic requirements, reduced costs and lower risk of adhesion formation. Laparotomy, however, remains necessary in cases with haemodynamic instability and with exceptional locations, e.g. cervical, abdominal and interstitial implantation. In selected cases, non-surgical management has also obtained high success rates. Among medical therapies, the most common is systemic or local administration of methotrexate. The other option is expectant management involving follow-up using serial serum HCG measurements and ultrasound scans. Thus, life-threatening ectopic pregnancy is now evolving into a medical disease, with the possibility of lower-cost treatment, faster recovery and higher subsequent fertility. In this review we assess the risk of extra-uterine implantation after assisted conception treatment, the accuracy of various diagnostic tools and focus on the efficacy, safety and the fertility outcomes of surgical and nonsurgical management of ectopic pregnancy.

Current status of surgical and nonsurgical management of ectopic pregnancy

To review the efficacy, safety, costs, and subsequent reproductive outcome of surgical and nonsurgical management of ectopic pregnancy (EP). Pertinent studies were identified through computer Medline search. The rates of intrauterine pregnancy (IUP) and EP were calculated from the raw data in the original publications so that the denominator would be consistent. The efficacy of laparoscopic treatment of EP is similar to that by laparotomy. The rate of persistent EP after conservative surgery ranges from 3% to 20%. Based on a review of 1,514 patients attempting to conceive after linear salpingostomy, the IUP and recurrent EP rates were 61.4% and 15.4%, respectively, among patients who had laparotomy, and 61% and 15.5%, respectively, among patients who had laparoscopic procedure. Of 3,584 patients who had partial or total salpingectomy, the subsequent IUP rate was 38.1% and the recurrent EP rate was 9.8%. Of 540 patients treated with a single-dose methotrexate, 84% did not require further treatment and, among 215 patients who attempted to conceive, 54% had subsequent IUP and 8% had recurrent EP. The success rate of expectant management was 69.2% in 347 patients reviewed. There is no difference in the reproductive outcome after treatment of EP by laparotomy and by laparoscopy. Salpingostomy is associated with higher subsequent IUP and recurrent EP rates compared with salpingectomy. Methotrexate is a viable alternative to laparoscopic salpingostomy for a selected group of patients.

Management of early ectopic pregnancy

OBJECTIVE: Management of early ectopic pregnancy was investigated in a multicenter, prospective study. METHODS: Serum β-hCG levels were monitored after therapy and correlated to the type of management, gestational age, and initial serum β-hCG levels in 119 patients with ectopic pregnancies detected at 5–7 postmentrual weeks. RESULTS: Salpingectomy was performed in 16 patients. No postoperative complications were reported. After conservative laparoscopic surgery of 51 ectopic pregnancies, 9 (18%) had delayed decrease or an increase of serum β-hCG levels. Re-operations were performed in 4 (7%) patients. Similar findings were noted in 216 patients after conservative operations performed by laparotomy. Intrachorionic injection treatment was sucessful in 17/18 ectopic pregnancies, and expectant management in 7/8 patients with initial serum β-hCG levels below 250 mIU/ml. CONCLUSIONS: Persistence of trophoblastic activity is a potential complication of conservative surgical treatment of ectopic pregnancy. A detailed diagnosis as early as 6–7 postmenstrual weeks may be the key for future nonsurgical management of ectopic pregnancy.

Conservative Treatment of Ectopic Pregnancy and Its Effect on Corpus luteum Activity

Corpus luteum activity was monitored in 15 women undergoing nonsurgical management of ectopic pregnancy with local methotrexate injection followed by alternating oral methotrexate and citrovorum factor (group A, n = 8) or local methotrexate injection alone (group B, n = 7). All patients initially demonstrated a viable corpus luteum (plasma progesterone ranged from 1.4 to 19 ng/ml). The treatment was successful in 14, with the exception of one whose tube ruptured 11 days after local administration of methotrexate, despite a continuous decrease in beta human chorionic gonadotropin, 17 beta-estradiol and plasma progesterone levels. There seems to be no correlation between the success of the treatment and the behavior of beta human chorionic gonadotropin, 17 beta-estradiol and plasma progesterone. Three patients from group A and two from group B displayed an initial rise in beta human chorionic gonadotropin following the initiation of the therapy, but the corpus luteum response differed. In group B patients, 17 beta-estradiol and plasma progesterone levels increased in parallel with beta human chorionic gonadotropin. Group A patients displayed a continuous decrease in 17 beta-estradiol and plasma progesterone levels despite the elevation of beta human chorionic gonadotropin, suggesting a possible effect of the systemic methotrexate on corpus luteum activity.

The use of a pretherapeutic, predictive score to determine inclusion criteria for the non-surgical treatment of ectopic pregnancy

Non-surgical management of ectopic pregnancy has recently become an alternative to surgery. We have investigated a pretherapeutic score to define the indication for non-surgical and surgical treatment in 61 patients with ectopic pregnancy. The score was performed before the patients' inclusion in a nonsurgical management scheme. The score used six criteria which were evaluated on a scale from 1 to 3: gestational age, human chorionic gonadotrophin (HCG) level, progesterone level, abdominal pain, haemoperitoneum volume and haematosalpinx diameter (estimated by laparoscopy or transvaginal ultrasound). Three scores, 10, 11 and 12, were studied in order to define a threshold beyond which surgical treatment should be performed. For each one, sensitivity, specificity and positive and negative predictive values were analysed. The success rate of non-surgical treatment was 75% (46/61). For patients undergoing medical treatment with a score less than or equal to 12, the success rate was significantly higher compared with a success rate of 50% when the score was greater than 12. We conclude that a score less than or equal to 12 permits non-surgical management with a success rate of 82%. A score greater than 12 indicates that laparoscopic surgery may be more suitable. The choice between different non-surgical approaches, did not influence the success rate. When ultrasound reveals embryo heart activity, medical treatment is always possible if the score is less than or equal to 12.

The nonsurgical management of ectopic pregnancy.

The nonoperative management of unruptured tubal ectopic pregnancy by either chemotherapy or expectant observation may be appropriate in a select group of patients, as outlined above. The routine use of these management modalities as a replacement for conservative surgery is not yet justified.