DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20212331

A novel approach in non-surgical management of tubal ectopic: combination of minimally invasive technique under ultrasound guidance with systemic methotrexate based on initial beta-HCG levels

Mayoukh Kumar Chakraborty, Shalini Gainder, Subhas Chandra Saha, Rashmi Bagga

Abstract


Background: Single dose methotrexate is the most preferred method of non-surgical management of unruptured tubal ectopic. A 2-dose regimen is suggested to treat tubal ectopic with higher trophoblastic cell load. Minimally invasive technique of ultrasound guided intracardiac KCL instillation along with systemic methotrexate has been in use even for live ectopic pregnancy. Objective of the study was to evaluate the success rate of single dose regimen of MTX (Methotrexate), 2-dose regimen of MTX and ultrasound guided instillation of intracardiac KCl in three different cohort of unruptured tubal ectopic pregnancy with an attempt to increase success of non-surgical management.

Methods: Fifty-eight women with unruptured tubal ectopic pregnancy were assigned to treatment protocols according to the initial β-HCG levels and presence/absence of FCA (fetal cardiac activity). Group 1: presence of FCA in the tubal ectopic; Group 2: initial β-HCG ≤5000 IU/ml; Group 3:  initial β-HCG ≥5000 IU/ml without FCA. Women in group 1 were treated with ultrasound guided instillation of intracardiac KCl combined with systemic MTX. While women in group 2 were administered single dose regimen of MTX and group 3 received 2-dose regimen of MTX.

Results: Overall success rate of non-surgical management was 89.3% across all groups. Success rate in Group 1 was 78.6%. Success rate was 93.1% in group 2 while 92.3% in group 3. Rupture rate was 1.7% in the present study.

Conclusions: For non-surgical management categorizing and treating is an option with good result. Women with presence of cardiac activity can opt for non-surgical option with likely resolution in 78% cases.


Keywords


Ectopic, Methotrexate, Potassium Chloride, Pregnancy, Tubal, Ultrasound

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References


Lipscomb GH, Stovall TG, Ling FW. Non-surgical treatment of ectopic pregnancy. N Engl J Med. 2000;343:1325-9.

Practice Committee of American Society for Reproductive Medicine. Non-surgical treatment of ectopic pregnancy: a committee opinion. Fertil Steril. 2013;100:638-44.

Mavrelos D, Nicks H, Jamil A, Hoo W, Zauniaux E, Jurkovic D. Efficacy and safety of a clinical protocol for expectant management of selected women diagnosed with a tubal ectopic pregnancy. Ultrasound Obstet Gynecol. 2013;42:102-7.

Yao M, Tulandi T. Current status of surgical and non-surgical management of ectopic pregnancy. Fertil Steril. 1997;67:421-33.

Sowter M, Farquhar C, Gudex G. An economic evaluation of single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured ectopic pregnancy. Br J Obstet Gynaecol. 2001;108:204-12.

Mol B, Hajenius P, Engelsbel S, Ankum W, Hemrika D, Van der Veen F et al. Treatment of tubal pregnancy in the Netherlands: an economic comparison of systemic methotrexate administration and laparoscopic salpingostomy. Am J Obstet Gynecol. 1999;181:945-51.

Keefe KA, Wald JS, Goldstein DP, Bernstein M, Berkowitz RS. Reproductive outcome after methotrexate treatment of tubal pregnancies. J Reprod Med. 1998;43:28-32.

Oriol B, Barrio A, Pacheco A, Serna J, Zuzuarrregui JRL, Garcia Velasco JA. Systematic methotrexate to treat ectopic pregnancy does not affects ovarian reserve. Fertil Steril. 2008;90:1579-82.

Rodi IA, Sarier MV, Gorill MJ, Bustillo M, Gunning JE, Marshall JR et al. The non-surgical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: preliminary experience. Fertil steril. 1986;46(5);811-3.

Stoval TG, Ling FW, Gary LA. Single dose methotrexate for treatment of ectopic pregnancy. Obstet Gynecol. 1991;77(5):754-57.

Barnhart K, Hummel AC, Sammel MD. Use of “2- dose” regimen of methotrexate to treat ectopic pregnancy. Fertil Steril. 20210;87:250.

Barnhart KT, Gosman G, Ashby R, Sammel M. The non-surgical management of ectopic pregnancy:a meta-analysis comparing "single dose" and "multidose" regimen. Obstet Gynecol. 2003;101(4):778-84.

Doubilet PM, Benson CB, Frates MC, Ginsburg E. Sonographically guided minimally invasive treatment of unusual ectopic pregnancies. J Ultrasound Med. 2004;23:359-70.

Wang M, Chen B, Wang J, Ma X, Wang Y. Non-surgical management of live tubal ectopic pregnancy by ultrasound-guided local injection and systemic methotrexate. J Min Invasive Gynecol. 2014;21:642-9.

Halperin R, Vaknin Z, Schneider D, Yaron M, Herman A. Conservative management of ectopic pregnancy with fetal cardiac activity by combined local (sonographically guided) and systemic injection of methotrexate. Gynecol Obstet Invest. 2003;56:148-51.

Fernandez H, Bourget P, Ville Y, Lelaidier C, Frydman R. Treatment of unruptured tubal pregnancy with methotrexate: Pharmacokinetic analysis of local versus intramuscular administration. Fertil Steril. 1994;62:943-7.

Dadhwal V, Deka D, Ghosh B, Mittal S. Successful management of live ectopic pregnancy with high-HCG titres by ultrasound-guided potassium chloride injection and systemic methotrexate. Arch Gynecol Obstet. 2009;280:799-801.

Monteagudo A, Minior VK, Stephenson C, Monda S, Timor-Tritsch IE. Non-surgical management of live ectopic pregnancy with ultrasound guided local injection: a case series. Ultrasound Obstet Gynecol. 2005;25:282-8.

Verma U, Jacques E. Conservative management of live tubal pregnancies by ultrasound guided potassium chloride injection and systemic methotrexate treatment. J Clin Ultrasound. 2005;33:460-3.

Alleyassin A, Khademi A, Aghahosseini M. Comparison of success rates in the non-surgical management of ectopic pregnancy with single-dose and multiple-dose administration of methotrexate: a prospective, randomized clinical trial. Fertil Steril. 2006;85:1661.

Lipscomb GH, McCord ML, Stovall TG, Huff G, Portera SG, Ling FW. Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies. N Engl J Med. 1999;341:1974-8.

Stovall TG, Ling FW. Single-dose methotrexate: An expanded clinical trial. Am J Obstet Gynecol. 1993;168:1759-65

Hamed HO, Ahmed SR, Algasham AA. Comparison of double- dose and single -dose methotrexate protocols for treatment of ectopic pregnancy. Int J Gynecol Obstet. 2012;116:67-71

Nyberg DA et al. Extrauterine findings of ectopic pregnancy of transvaginal US: importance of echogenic fluid. Radiology. 1991;178:823-6.

Fleischer AC. Ectopic pregnancy: features at transvaginal sonography. Radiology. 1990;174:375-8.

Potter MB, Lepine LA, Jamieson DJ. Predictors of success with methotrexate treatment of tubal ectopic pregnancy at Grady Memorial Hospital. Am J Obstet Gynecol. 2003;188:1192-4.

Elito J, Reichmann AP, Uchiyama MN, Camano L. Predictive score for the systemic treatment of unruptured ectopic pregnancy with a single dose of methotrexate. Int J Gynaecol Obstet. 1999;67(2):75-9.

Menon S, Collins J, Barnhart KT. Establishing a human chorionic gonadotrophin cut off to guide methotrexate treatment of ectopic pregnancy: a systematic review. Fertil Steril. 2007;87:481-4.

Taejong Song et al. Single-dose versus two-dose administration of methotrexate for the treatment of ectopic pregnancy: a randomized controlled trial. Hum Reprod. 2016;31(2):332-8.

Michelle C. Mergenthel. Non-surgical Management of ectopic pregnancy with single-dose and 2-dose methotrexate protocols: human chorionic gonadotrophin trends and patient outcomes. Am J Obstet Gynecol. 2016;215(5):590.

Nguyen Q. Are early human chorionic gonadotrophin levels after methotrexate therapy a predictor of response in ectopic pregnancy? Am J Obstet Gynecol. 2010;202:630.

Skubisz MM, Li J, Wallace EM, Tong S. Decline in HCG levels between days 0 and 4 after a single dose of methotrexate for ectopic pregnancy predicts treatment success: a retrospective cohort study. BJOG 2011;118:1665-68.