Direct Methotrexate Injection into the Gestational Sac for Nontubal Ectopic Pregnancy: A Review of Efficacy and Outcomes from a Single Institution

The no-man's land of nontubal ectopic and cesarean section scar pregnancies

Nontubal ectopic pregnancy (NTEP) and cesarean section scar pregnancy (CCSP) are a relatively uncommon but potentially very dangerous conception event. If diagnosed early, they can be treated very effectively. Cesarean section scar ectopic is unique in that expectant management may allow them to persist longer, but with overwhelmingly catastrophic consequences. Reproductive endocrinologists are uniquely positioned to diagnose and treat NTEP/CCSP early, thereby avoiding long-term catastrophic consequences.

A Case of Ruptured Left Interstitial Ectopic Pregnancy

Although rare, interstitial ectopic pregnancy poses a challenge in diagnosis and management. The pregnancy is implanted in the interstitial part of the fallopian tube, i.e., the proximal intramural portion. When ruptured, it results in a catastrophic event; the rupture can involve the uterine wall, as in this case, which puts the prognosis of future pregnancies at risk. Here, a case of a 35-year-old primigravida who conceived after ovulation induction is reported. Her diagnosis of ectopic pregnancy was missed; it was misdiagnosed as incomplete abortion followed by dilatation and evacuation. Post-evacuation severe pain and hemodynamic instability, and subsequent ultrasonography (USG) lead to the diagnosis of left interstitial ectopic pregnancy. Emergency laparotomy, left salpingo-oophorectomy, and cornual resection with repair were done.

Nontubal ectopic pregnancies: overview of diagnosis and treatment

Nontubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal ectopic pregnancies. Diagnostic and management options may be limited, especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for nontubal ectopic pregnancies.

“In Situ” Methotrexate Injection Followed by Hysteroscopic Resection for Caesarean Scar Pregnancy: A Single-Center Experience

Background: We evaluated the efficacy of local methotrexate (MTX) treatment followed by hysteroscopic resection for caesarean scar pregnancy and its impact on future fertility. Methods: Monocentric, prospective, observational study performed in the Haykel Hospital between June 2016 and December 2020. Twenty-one women with caesarean scar pregnancy underwent a transcutaneous ultrasound-guided direct injection of MTX into the gestational sac in an outpatient setting. Hysteroscopic resection of residual trophoblastic retention was then performed according to perisaccular blood flow. Main results: Two patients had complete spontaneous trophoblast expulsion after MTX injection, and hysteroscopy was performed in 19 patients for residual trophoblastic retention 1 to 12 weeks after MTX injection. Successful preservation of a healthy uterus with the combined procedure was obtained in 94.8% of patients. Hemostatic hysterectomy was required in one patient. Mean hospitalization duration was 1.5 days. Three patients had spontaneous pregnancy after the procedure. Conclusion: Direct MTX injection into the gestational sac for caesarean scar pregnancy followed by hysteroscopic resection was an effective technique with a short hospitalization, fertility preservation and a low major complication rate compared with other modalities of treatment reported in the literature. Further larger prospective comparative studies are needed to confirm the efficacy of this procedure.

A 10‐year retrospective cohort study of non‐tubal ectopic pregnancy management outcomes in an Australian tertiary centre

Introduction

Non-tubal ectopic pregnancy (NTEP) is a rare but significant early pregnancy complication which can result in maternal morbidity and mortality. There is however a lack of evidence-based guidelines for the management of NTEP.

Purpose

To evaluate the success rates of expectant, medical and surgical management in the treatment of NTEP at our tertiary centre.

Methods

Retrospective cohort study from 2010 to 2020. All NTEP were classified by ectopic sites. Primary management was classified by expectant, medical [systemic methotrexate (Sys-MTX) and/or local ultrasound-guided injection of MTX and/or KCl intra-sac (L-MTX, L-MTX/KCl)] or surgical. Primary management was considered successful if no change in intervention was required. Treatment complications were compared.

Results

Twenty-four NTEP were identified, which included 14 interstitial pregnancies (IP), 9 caesarean scar pregnancies (CSP) and 1 ovarian pregnancy (OP), which gave NTEP an incidence of 7.12% among all EP (4.15% for IP, 2.67% for CSP and 0.30% for OP). The success of primary surgical management was 100% (7/7), primary medical management was 76.9% (10/13) and primary expectant management was 33.3% (1/3). Primary medical management had a non-statistically significant greater mean time to serum ß-human Chorionic Gonadotrophin <5 IU/L, mean length of hospitalisation, mean number of follow-up visits and hospital re-presentation/readmissions compared to primary surgical management. There was no other difference in complication rates between the treatment management groups.

Conclusion

Surgery remains the most effective way to manage NTEP. However, medical management can be a safe and effective alternative option in carefully selected cases.

Evaluation of the recurrence and fertility rate following salpingostomy in patients with tubal ectopic pregnancy

Background

Ectopic pregnancy is one of the leading causes of pregnancy-related mortality; the treatment strategies associated with this condition entail complications, such as recurrence of ectopic pregnancy or infertility. The objective of this study was to evaluate the recurrence and fertility rate after salpingostomy in patients with tubal ectopic pregnancy.

Methods

This cross-sectional retrospective study was conducted at four referral centers of Obstetrics and Gynecology, under the supervision of Shiraz University of Medical Sciences (Iran). The medical records of 125 patients with tubal pregnancy were reviewed. These patients underwent laparoscopic salpingostomy from April 2009 to March 2016.Data on maternal age, BMI, history of previous EP, genital tract infection, IUD insertion, history of previous surgery, and infertility were further obtained. The patients were followed up for approximately 1 to 7 years. The recurrence of EP and subsequent pregnancy rate were assessed during the follow-up period.

Results

There was no statistically significant relationship between post-salpingostomy recurrence and maternal age, previous abdominopelvic surgery, and history of infertility(P = .425); however, the post-salpingostomy recurrence of EP was correlated with BMI (P = 0.001), previous history of EP (P = 0.001), genital tract infection (P = 0.001), and IUD insertion (P = 003). Among 95 women who had no contraception, pregnancy occurred in 51 cases (53.6%) and recurrence of EP was observed in 16 patients (12.8%).

Conclusions

Our results suggest that salpingostomy is a safe method with a low risk of recurrence and good fertility outcomes for women who consider future pregnancy.

An updated guide to the diagnosis and management of cesarean scar pregnancies

PURPOSE OF REVIEW

To review the current literature on the diagnosis and management of cesarean scar pregnancies RECENT FINDINGS: The incidence of cesarean scar pregnancies (CSPs) is increasing as a result of the increasing cesarean section rate, improved diagnostic capabilities, and a growing awareness. CSPs are associated with significant morbidity and early diagnosis is key. Diagnosis is best achieved with transvaginal ultrasound. Sonographic diagnostic criteria have been developed over decades and recently endorsed by the Society for Maternal-Fetal Medicine and other professional societies. The current categorization system differentiates CSPs that are endogenic or 'on the scar' from those that are exogenic or 'in the niche'. Following diagnosis, the challenge remains in determining the optimal management as multiple modalities can be considered. Studies have demonstrated the favorable outcomes with combined local and systemic methotrexate, surgical excision through multiple routes, and adjunctive therapies, such as uterine artery embolization or uterine balloons. The current evidence is insufficient to identify a single best treatment course and a combined approach to treatment is often required.

SUMMARY

Successful outcomes while minimizing complications can be achieved with a multidisciplinary, collaborative effort. Guidelines for cesarean scar pregnancies will continue to evolve as the published reports grow.

Methotrexate injection for interstitial pregnancy: Hysteroscopic conservative mini-invasive approach

Background

Interstitial localisation of ectopic pregnancy is associated with high rates of maternal morbidity and mortality. Considering the rarity of interstitial pregnancy, the optimal treatment regimen remains unclear. We propose the management of interstitial pregnancy with local methotrexate injection using a combined hysteroscopic and ultrasonographic approach.

Technique

Hysteroscopy was performed under local anaesthesia in the operating room, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope with a 4.3-mm inner sheath and 5 FR instruments. A needle was pushed into the cornual region injecting methotrexate solution directly into the gestational sac and into the myometrial tissue tangentially at the four cardinal points. A contemporary transabdominal ultrasound (US) was performed in order to reduce risks of complications.

Experience

Five patients with an US diagnosis of interstitial ectopic pregnancy admitted to our department between January 2016 and September 2019 were managed with a local hysteroscopic injection of methotrexate. The technique was effective in all patients and no surgical complications occurred during or after the procedure. Three patients were evaluated for tubal patency with contrast ultrasonography confirming bilateral tubal patency 9 months from treatment, while one patient had a spontaneous birth 22 months from their initial surgery.

Conclusion

The hysteroscopic ultrasound-guided approach combined with the local injection of methotrexate is a minimally invasive conservative approach that seems to be promising in the management of interstitial ectopic pregnancy.

A case report of cervical pregnancy after in vitro fertilization complicated by tuberculosis and a literature review

Although female genital tuberculosis may lead to infertility, pregnancy is still possible, especially through in vitro fertilization (IVF). In this eventuality, even latent tuberculosis (TB) infection is prone to reactivate. Because some of the symptoms of TB overlap with those of pregnancy, diagnosis and treatment may be delayed. We report the case of a 30-year-old infertile woman with repeated genital tuberculosis (GTB) who underwent two laparoscopic surgeries and anti-TB treatments. The woman conceived through IVF and, unfortunately, a cervical pregnancy was diagnosed, together with a third recurrence of GTB. When the condition became stable after anti-TB treatment, the pregnancy was terminated using oral mifepristone in combination with an ultrasound-guided local injection of methotrexate. The gestational sac was expelled 4 days later with minimal blood loss. In view of the reciprocal influence and interconnection between IVF, pregnancy, and TB, we conducted a literature review to provide valuable information for early diagnosis and treatment, as well as for routine screening before IVF of TB in infertile patients.