Ectopic Pregnancy: A Clinical Casebook

7. Medical Treatment of Ectopic Pregnancy

Togas Tulandi 

(1)

McGill University Health Center, 687 Pine Ave West, H3A 1A1 Montreal, QC, Canada

Togas Tulandi

Email: togas.tulandi@mcgill.ca

Keywords

Ectopic pregnancyTubal pregnancyMedical treatmentMethotrexate

Case Study

Patient was a 30-year-old infertile woman who conceived after two cycles of intrauterine inseminations (IUI). Serum human chorionic gonadotropin (hCG) level 3 weeks after the second IUI was 1200 mIU/mL. Two days later, the hCG level was 2000 mIU/mL. Repeat serum hCG level in another 2 days was 2500 mIU/mL Transvaginal ultrasound examination revealed an empty uterus and a gestational sac in the distal tube; the diameter of the affected tube was 2.8 cm. She had never been operated and was healthy otherwise. Serum Hgb level was 130.

My Management

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Diagnosis and Assessment

Our patient is a good candidate for medical treatment of her ectopic pregnancy. She was reliable and had complied with all previous infertility treatment. Her liver and renal function tests were normal. The serum hCG level was relatively low (2500 mIU/mL), the tubal diameter is less than 3 cm, and fetal cardiac activity was absent on the ultrasound examination.

Management

With early diagnosis, most women with ectopic pregnancy could be treated with MTX [1] . The overall success rate of medical treatment in properly selected women is nearly 90 % [24]. In a majority of cases with tubal ectopic pregnancy, a single dose treatment of MTX 50 mg/m2 intramuscularly is sufficient. A second dose of MTX might be needed (15–20 % of women) and patients should be made aware of this before the treatment [25]. For other types of ectopic pregnancy, including cervical or interstitial ectopic pregnancy, a multidose treatment is a better choice. The ideal candidates for MTX treatment of ectopic pregnancy are those who are hemodynamically stable, willing, and able to comply with posttreatment follow-up, have a beta-subunit hCG concentration ≤ 5000 mIU/mL, and have no fetal cardiac activity. Ectopic mass size less than 3–4 cm is also commonly used as a patient selection criterion; however, this has not been confirmed as a predictor of successful treatment [6]. Contraindications to MTX treatment include unstable patient; severe symptoms such as severe or persistent abdominal pain, renal or liver disease, immunodeficiency, active pulmonary disease, peptic ulcer, hypersensitivity to MTX, suspected intrauterine pregnancy, breast-feeding, poor compliance; or lives far from a medical institution (Fig. 7.1).

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Fig. 7.1

Methotrexate treatment protocol for tubal or interstitial ectopic pregnancy. (From Tulandi T: Methotrexate treatment of tubal and interstitial ectopic pregnancy. In: UpToDate (Eds. R.L. Barbieri and S.J. Falks))

After MTX injection, blood sampling is repeated either 4 or 7 days later. If the decrease in serum hCG level is less than 15 % from day 4 to day 7, a second dose of MTX is administered. It is common to see an increase in hCG levels in the first several days after MTX administration. A simpler protocol is to repeat the blood sampling on day 7 after the initial treatment, saving patient visit on day 4. A second dose of MTX is administered if the hCG level has not decreased by 25 % from day 1 level. Measurement of serum hCG level is repeated weekly until the level is undetectable (less than 10 mIU/mL).

Outcome

The patient received a single dose of MTX intramuscularly. Since she was Rh(D)-negative, she was also given Rhogam. She was instructed not to take folic acid (counteract with MTX), to avoid intercourse, and not to be exposed to sun to limit the risks of dermatitis. Serum hCG level 7 days after the injection was 2300 mIU/mL and she was given another dose of MTX. Two weeks later, the level was less than 10 mIU/mL. She spontaneously conceived 6 months after the MTX treatment. An ultrasound examination at 5 weeks gestation revealed an intrauterine pregnancy, and at 6 weeks, a single live fetus with cardiac activity.

Clinical Pearls/Pitfalls

·               The success rate of MTX treatment for ectopic pregnancy is close to 90 %.

·               The ideal candidates for MTX treatment of ectopic pregnancy are those who are hemodynamically stable, willing and able to comply with posttreatment follow-up, have a beta-subunit hCG concentration ≤ 5000 mIU/mL, and have no fetal cardiac activity

·               A second dose of MTX might be needed in 30 % of cases.

·               Treatment with MTX does not appear to compromise future fertility or pregnancy outcome, or increase the risk of recurrent ectopic pregnancy .

·               Before MTX administration, it is crucial to ascertain that there is no possibility of an intrauterine pregnancy.

·               Contraindications of MTX administration include breast-feeding.

References

1.

Oron G, Tulandi T. A pragmatic and evidence based management of ectopic pregnancy. J Minim Invasive Gynecol. 2013;20:446–54.CrossRefPubMed

2.

Barnhart KT, Gosman G, Ashby R, Sammel M. The medical management of ectopic pregnancy: a meta-analysis comparing “single dose” and “multidose” regimens. Obstet Gynecol. 2003;101:778.CrossRefPubMed

3.

Farquhar CM. Ectopic pregnancy. Lancet. 2005;366:583.CrossRefPubMed

4.

Morlock RJ, Lafata JE, Eisenstein D. Cost-effectiveness of single-dose methotrexate compared with laparoscopic treatment of ectopic pregnancy. Obstet Gynecol. 2000;95:407.CrossRefPubMed

5.

Lipscomb GH, Bran D, McCord ML, et al. Analysis of three hundred fifteen ectopic pregnancies treated with single-dose methotrexate. Am J Obstet Gynecol. 1998;178:1354.CrossRefPubMed

6.

Tulandi T.http://www.uptodate.com/ Accessed 2 Dec 2014.