Change in serum beta-human chorionic gonadotropin after abortion with methotrexate and misoprostol

Serum human chorionic gonadotropin decline following aspiration abortion in early pregnancy less than 42 days gestation

OBJECTIVE

To define serum human chorionic gonadotropin (hCG) decline following complete aspiration abortion.

STUDY DESIGN

We performed a secondary analysis of 86 patients who underwent uncomplicated aspiration abortion for ultrasound-confirmed pregnancy ≤42 days gestation and had serum hCG at the time of aspiration and within 3 days postprocedure.

RESULTS

Median hCG declines were 72.9% by day 1 (n = 14), 87.6% by day 2 (n = 50), and 92.8% by day 3 (n = 22). Ninetieth percentile declines were 67.8%, 81.5%, and 90.8%. Minimum hCG declines were 56.2%, 77.3%, and 83.2%. Trends did not vary by gestational age or by initial hCG <3000 mIU/mL.

CONCLUSION

Postprocedure hCG trend varies over the first few days in early gestation. At ≤42 days gestation, serial hCG decline at 1 day after completed aspiration abortion is greater than 50%, consistent with the decline observed in medication abortion.

IMPLICATIONS

This study confirms previously estimated human chorionic gonadotropin decline after aspiration abortion of at least 50% at 24 hours for completed procedure in very early gestations. Minimum declines on days 2 and 3 are approximately 70% and 80%.

Serum hCG threshold to assess medical abortion success

OBJECTIVES

The main aim of the study was to establish a threshold for serum human chorionic gonadotropin (hCG) level that ruled out ongoing pregnancy after induced medical abortion (MA). The secondary aim was to discover risk factors for the need for uterine aspiration.

METHODS

This prospective study included women who underwent MA with mifepristone-misoprostol at ≤9 weeks of gestation between 2012 and 2014. Serum hCG levels were measured 14-21 days after MA. The main outcome measure, ongoing pregnancy, was defined as the presence of an embryo with cardiac activity on transvaginal ultrasonography after MA. The receiver operating characteristic curve was plotted to determine the optimal serum hCG threshold. Risk factors for the need for uterine aspiration were calculated using multivariate logistic regression and expressed as odds ratios (ORs) with 95% confidence intervals (CIs).

RESULTS

The study included 814 women. Mean gestational age was 46.5 ± 7.4 days for ongoing pregnancies and 44.2 ± 4.8 days for MA success (p = .43). The ongoing pregnancy rate after MA was 0.9%. A serum hCG threshold ≥900 IU/l to diagnose ongoing pregnancy gave 100% sensitivity and 81.5% specificity, compared with 85.7% sensitivity and 83.5% specificity using a threshold ≥1000 IU/l. Independent risk factors for uterine aspiration requirement were: gravidity (OR 3.8; 95% CI 1.1, 13.2; p = .001), gestational age >6 weeks (OR 6.0; 95% CI 1.8, 6.0; p = .006) and previous surgical abortion (OR 2.4; 95% CI 1.1, 5.2; p < .001).

CONCLUSION

Serum hCG measurement <900 IU/l, 14-21 days after MA, is an efficient strategy for excluding ongoing pregnancy after first trimester MA.

Controversies in family planning: persistently elevated serum human chorionic gonadotropin levels after aspiration abortion

Low but rising serum human chorionic gonadotropin (hCG) levels occur infrequently after an induced abortion. Because this scenario rarely occurs after suction aspiration, clinicians may have higher suspicion for an uncommon diagnosis. The differential diagnosis includes both common and uncommon diagnoses, such as incomplete abortion, heterotopic or ectopic pregnancy, a new intrauterine pregnancy and gestational trophoblastic neoplasia. The etiology of this presentation may be unclear, especially in the absence of abnormal bleeding or pain which would suggest incomplete abortion, or when significant time has passed since the procedure. We describe two cases of an uncommon presentation of retained products of conception after aspiration abortion in which hCG levels were low but rising.

Utility of βhCG monitoring in the follow-up of medical management of miscarriage

OBJECTIVE

To evaluate the percentage change in total βeta-unit human chorionic gonadotropin (βhCG) levels (%ΔβhCG) in the prediction of treatment outcomes following intravaginal misoprostol for missed miscarriage before 13 weeks.

METHODS

A secondary analysis of a randomised controlled study of medical management of miscarriage was performed. Total βhCG levels were collected before misoprostol (baseline) and after a planned seven day interval (follow-up), when a transvaginal ultrasound (TVUS) reported a gestational sac as present or not. If no sac at TVUS, surgery was indicated on clinical criteria. %ΔβhCG ((baseline βhCG - follow-up βhCG)/baseline βhCG × 100) was evaluated in the prediction of a sac at TVUS and surgery on clinical criteria.

RESULTS

%ΔβhCG was calculated for cases with βhCG levels within two days of misoprostol and TVUS; calculation interval determined case number. The median %ΔβhCG for 24 cases with a persistent sac (6-9 day interval) was significantly lower than for 145 with no sac (58.75% (interquartile range (IQR): 37.59-76.69; maximum 86.54) vs 97.65% (IQR: 95.44-98.43); P < 0.0001). The median %ΔβhCG for eight cases needing surgery on clinical criteria (5-9 day interval) was significantly lower than for 140 cases with no sac not needing surgery (79.68% (IQR: 64.63-91.15; maximum 94.06) vs 97.68% (IQR: 95.61-98.50); P < 0.0001). The area under the receiver-operator curve was 0.975 for prediction of a persistent sac and 0.944 for prediction of surgery on clinical criteria, respectively. %ΔβhCG > 87% predicted no sac at TVUS. %ΔβhCG > 94.5% predicted no surgery on clinical criteria.

CONCLUSION

%ΔβhCG calculation over one week reliably predicted treatment outcomes after medical management of missed miscarriage.

Medical Abortion

OBJECTIVE

This guideline reviews the evidence relating to the provision of first-trimester medical induced abortion, including patient eligibility, counselling, and consent; evidence-based regimens; and special considerations for clinicians providing medical abortion care.

INTENDED USERS

Gynaecologists, family physicians, registered nurses, midwives, residents, and other healthcare providers who currently or intend to provide pregnancy options counselling, medical abortion care, or family planning services.

TARGET POPULATION

Women with an unintended first trimester pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, MEDLINE, and Cochrane Library between July 2015 and November 2015 using appropriately controlled vocabulary (MeSH search terms: Induced Abortion, Medical Abortion, Mifepristone, Misoprostol, Methotrexate). Results were restricted to systematic reviews, randomized controlled trials, clinical trials, and observational studies published from June 1986 to November 2015 in English. Additionally, existing guidelines from other countries were consulted for review. A grey literature search was not required.

VALUES

The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force for Preventive Medicine rating scale (Table 1).

BENEFITS, HARMS AND/OR COSTS

Medical abortion is safe and effective. Complications from medical abortion are rare. Access and costs will be dependent on provincial and territorial funding for combination mifepristone/misoprostol and provider availability.

SUMMARY STATEMENTS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care

RECOMMENDATIONS

Introduction Pre-procedure care Medical abortion regimens Providing medical abortion Post-abortion care.

Early serum human chorionic gonadotropin (hCG) trends after medication abortion

OBJECTIVES

Despite increased reliance on human chorionic gonadotropin (hCG) for early pregnancy monitoring, there is limited information about hCG trends soon after medication abortion. The purpose of this study was to determine if there is a predictable decline in serum hCG values shortly after medication abortion.

STUDY DESIGN

This is a retrospective study of women with early intrauterine pregnancies who underwent medication abortion with mifepristone and misoprostol and had a serum hCG level on Day 1 (day of mifepristone) and a repeat value on Day 2 to 6. The percent hCG decline was calculated from baseline to repeat measure, with repeat values from the same patient accounted for through repeated measure analysis of variance.

RESULTS

Eighty-eight women with a mean gestational age of 5.5 weeks and median baseline hCG of 5220 IU met study criteria over a 3-year period. The mean decline (±SD) in hCG from the Day 1 baseline value was 56.9%±29.5% on Day 3, 73.5%±38.6% on Day 4, 86.1%±8.8% on Day 5, and 92.9%±3.4% on Day 6. Eighty-two women (93% of the cohort) had a complete abortion without further intervention. The least square means hCG decline among these women was 57.6% [95% confidence interval (CI): 50.3-64.9%] on Day 3, 78.9% (95% CI: 75.0-82.8%) on Day 4 and 86.2% (95% CI: 81.3-91.1%) on Day 5.

CONCLUSION

There is a rapid decline in serum hCG within the first few days after early medication abortion. Further research is needed to delineate how soon after medication abortion this decline may be specific enough to confirm abortion completion.

IMPLICATIONS

This study provides the largest cohort of patients followed with serial hCG values in the first few days after medication abortion. Our findings demonstrate the trend in hCG decline in this population, which may be predictable by Day 5.

Simplified medical abortion using a semi-quantitative pregnancy test for home-based follow-up

OBJECTIVE

To simplify follow-up after medical abortion by examining whether women could use a semi-quantitative pregnancy test at home to screen for ongoing pregnancy.

METHODS

Three hundred women seeking medical abortion at a tertiary hospital in Vietnam participated in the study. Participants used a semi-quantitative pregnancy test at the hospital to estimate baseline human chorionic gonadotropin (hCG) levels and administered another test at home 2 weeks later for comparison. Women interpreted the test result at home and then returned to hospital for follow-up care. At this visit, self-assessment was verified. To assess further the feasibility of the test as a follow-up tool in service delivery, 200 additional women completed a user comprehension survey.

RESULTS

The tests identified all 11 ongoing pregnancies among study participants (100% sensitivity; 89.7% specificity). Women reported that the test was easy to use (255/292 [87.3%]) and that provider instructions helped them to use the test (291/292 [99.7%]).

CONCLUSION

Semi-quantitative pregnancy tests offer high sensitivity and negative predictive value. If user instructions can be further simplified, the tests could be used in lieu of transvaginal ultrasound and/or serum hCG at clinic-based follow-up or by women themselves for home-based follow-up. Clinical trials.gov:NCT01150279.

Effectiveness of early medical abortion using low-dose mifepristone and buccal misoprostol in women with no defined intrauterine gestational sac

BACKGROUND

The study was conducted to assess the effectiveness of early medical abortion (EMA) in women with early pregnancy and no defined intrauterine gestational sac (IUGS) on ultrasound.

STUDY DESIGN

Retrospective, multicenter, observational study of oral mifepristone 200 mg and buccal misoprostol 800 mcg administered 24-48 h later for EMA (gestations ≤ 63 days). Odds ratios (ORs) [95% confidence intervals (CIs)] of EMA failure and continuing pregnancy for women with no defined IUGS vs. those with confirmed IUGS were calculated.

RESULTS

Women with no defined IUGS were more likely to experience EMA failure [9.0% (6/67) vs. 3.5% (465/13,345); OR (95% CI)=2.72 (1.17-6.33), p=.041] and continuing pregnancy [7.5% (5/67) vs. 0.6% (83/13,345); OR (95% CI)=12.72 (4.98-32.46), p<.001].

CONCLUSION

EMA failure is more likely in women with early pregnancy and no defined IUGS than those with gestations ≤ 63 days and confirmed IUGS.

Alternatives to ultrasound for follow-up after medication abortion: a systematic review

BACKGROUND

Requiring a follow-up visit with ultrasound evaluation to confirm completion after medication abortion can be a barrier to providing the service.

STUDY DESIGN

The PubMed (including MEDLINE), Cochrane Central Register of Controlled Trials and POPLINE databases were systematically searched in October and November 2009 for studies related to alternative follow-up modalities after first-trimester medication abortion to diagnose ongoing pregnancy or retained gestational sac. We calculated the sensitivity, specificity, positive predictive value and negative predictive value compared with ultrasound or clinician's exam. We also calculated the proportion of cases in each study with a positive screening test.

RESULTS

Our search identified eight articles. The most promising modalities included serum human chorionic gonadotropin measurements, standardized assessment of women's symptoms combined with low-sensitivity urine pregnancy testing and telephone consultation. These follow-up modalities had sensitivities ≥90%, negative predictive values ≥99% and proportions of "screen-positives" ≤33%.

CONCLUSIONS

Alternatives to routine in-person follow-up visits after medication abortion are accurate at diagnosing ongoing pregnancy. Additional research is needed to demonstrate the accuracy, acceptability and feasibility of alternative follow-up modalities in practice, particularly of home-based urine testing combined with self-assessment and/or clinician-assisted assessment.

Feasibility of telephone follow-up after medical abortion

BACKGROUND

This study was conducted to assess the feasibility of using telephone calls combined with high-sensitivity urine pregnancy testing as a primary method of follow-up after medical abortion.

METHODS

We enrolled 139 women up to 63 days of gestation to receive mifepristone 200 mg orally and misoprostol 800 mcg vaginally or buccally, per their choice. Participants were contacted by phone one week after mifepristone administration and interviewed using standardized questions. If the subject or clinician thought the pregnancy was not expelled, the subject returned for an ultrasound examination. Otherwise, subjects performed high-sensitivity home urine pregnancy testing 30 days after the mifepristone and were called within 3 days of the test. Those with positive pregnancy tests returned for an ultrasound examination. Those with negative tests required no further follow-up.

RESULTS

Six of the 139 (4.3%, 95% CI 1.6-9.1%) subjects presented prior to Phone Call 1 for an in-person visit. All 133 (100%, 95% CI 97.8-100%) subjects eligible for their first telephone follow-up were contacted. Eight of the 133 (6.1%, 95% CI 2.6-11.5%) women were asked to return for evaluation and all did so (100%, 95% CI 63.1-100%). Eight of the 133 women eligible for the 30 day phone call presented for an interim visit prior to the call. After 30 days, 116 of the 117 (99.1%, 95% CI 97.5-100%) eligible subjects were contacted. One subject was not reached for the day 30 phone call. Twenty-seven of the 116 (23.3%, 95% CI 15.6-31.0%) subjects had a positive pregnancy test and required follow-up. Two of these subjects (7.4%, 95% CI 1.0-24.2%) did not return for in-person follow-up. Two of the 116 (1.7%, 95% CI 0.2-6.1%) subjects had inconclusive pregnancy tests and were asked to return for follow-up. One of these subjects (50%, 95% CI 1.2-98.7%) did not return. Complete follow-up was achieved in 135 of the 139 subjects (97.1%, 95% CI 94.3-99.9%). None of the 26 women evaluated for a positive or inconclusive pregnancy test had a gestational sac or continuing pregnancy.

CONCLUSION

Telephone follow-up combined with urine pregnancy testing after medical abortion is a feasible alternative to routine ultrasonography or serial serum hCG measurements.

Change in quantitative human chorionic gonadotropin after manual vacuum aspiration in women with pregnancy of unknown location

OBJECTIVE

To determine whether the change in human chorionic gonadotropin after manual vacuum aspiration is predictive of an early abnormal intrauterine pregnancy in women with pregnancy of unknown location.

STUDY DESIGN

This is a prospective cohort study of 23 clinically stable patients with an early abnormal pregnancy who had abnormally rising human chorionic gonadotropins and absence of sonographic evidence of an intrauterine pregnancy or ectopic pregnancy. The change in human chorionic gonadotropin within 24 hours after manual vacuum aspiration was compared with the pathologic diagnosis and the ultimate clinical diagnosis.

RESULTS

Ten patients had > or = 50% decrease (mean, 74%; range, 58-80%) in human chorionic gonadotropin after manual vacuum aspiration with confirmed chorionic villi on pathology results. Two patients had a > 50% drop in human chorionic gonadotropin but absence of chorionic villi, clinically consistent with complete spontaneous abortion. The remaining 10 patients who had either rising or < 50% decrease in human chorionic gonadotropin post manual vacuum aspiration all had no chorionic villi on pathology results. The sensitivity, specificity, positive predictive value, and negative predictive value of a > or = 50% decrease in human chorionic gonadotropin after manual vacuum aspiration in predicting an abnormal intrauterine pregnancy were 92% (95% confidence interval [CI], 0.62-0.99), 100% (95% CI, 0.62-1.0), 100% (95% CI, 0.70-1.0), and 90% (95% CI, 0.54-0.99), respectively.

CONCLUSION

A > or = 50% decrease in human chorionic gonadotropin within 24 hours after manual vacuum aspiration is predictive of an abnormal intrauterine pregnancy, thereby excluding an ectopic pregnancy and expediting the management of women with pregnancy of unknown location.

Endometrial Thickness- a Practical Prospective Marker for the Risk of Surgical Intervention after RU486 Induced Abortion

Background

Medical termination of pregnancy [TOP] during the early first trimester is commonly used. However, treatment failure which warrants surgical intervention occurs in small proportion of patients. Our objective was to examine the effectiveness and predictive value of sonographic measurement of endometrial thickness during a follow up visit after medical abortion as an accurate predictor of the necessity of curettage for completion of pregnancy termination.

Methods

Women who opted for medical TOP where treated by single dose of RU486 followed by a single dose of misoprostol. Endometrial thickness was evaluated by transvaginal U.S. at 14 days after misoprostol tretament. The data was collected prospectively for this cohort study which includes all the women undergoing medical abortion in the first seven weeks of gestation.

Results

In 34.7% of the patients the endometrial width was > 11 mm on the follow-up visit. Surgical intervention was performed in 18% of these patients, for a failure rate of the medical termination of pregnancy [TOP] of 6.25%, as compared with no failure rate in those with endometrium < 11 mm, P < 0.001. In the patients where the endometrium was 11-12 mm on follow-up, the failure rate was 5%, and if > 12 mm the failure was 5.9%. In cases where the endometrium was 12-13 mm the failure rate was 27.3%, and if >13 mm the failure was 18.9%. When the endometrium was 13-14 mm the failure rate was 10%, and when >14 mm the failure was 23.7%. Half of the 18 patients who had undergone dilatation and curettage [D&C] for completion of the TOP, had endometrium > 14 mm, one to two weeks after the medical abortion.

Conclusion

Measurement of endometrial width after medical TOP is beneficial in segregating patient to low or high risk for surgical treatment of retained product of conception [POC]. Using a cutoff of 11 mm during the follow-up visit after medical TOP, 18% of the patients may need dilatation and curettage to complete the pregnancy termination, and if it is >14 mm, half of them may need surgical intervention. There is no difference between 11 and 14 mm regarding the risk of surgical intervention after medical TOP.

Clinical utility of urine pregnancy assays to determine medical abortion outcome is limited

BACKGROUND

Determining medical abortion outcome commonly includes a costly evaluation such as ultrasonography or serial serum hCG testing. Urine pregnancy testing may represent a less costly alternative.

METHODS

This prospective diagnostic test evaluation study was part of a multisite randomized trial of 1080 women undergoing medical abortion up to 63 days' gestation who returned 1 and 2 weeks after receiving mifepristone. Low-sensitivity (LS) and high-sensitivity (HS) urine pregnancy tests were performed at each visit, and the results were compared to ultrasonography. Sensitivity, specificity, predictive values and likelihood ratios of each urine test were determined.

RESULTS

In the first week following abortion, 14.8% of the LS tests and 7.9% of the HS tests correctly predicted outcome. None of the LS tests and only 0.2% of the HS tests were falsely negative; however, 85.2% of the LS tests and 91.8% of the HS tests were falsely positive. In the second week following abortion, 39.1% of the LS tests and 33.8% of the HS tests correctly predicted the medical abortion outcome. Only 0.2% of the LS tests and 0.3% of the HS were falsely negative; however, 60.8% of the LS tests and 65.8% of the HS tests were falsely positive.

CONCLUSIONS

Both LS and HS urine pregnancy assays reliably assess clinical outcomes of medical abortions in cases of negative test results. However, the clinical utility of urine assay testing is limited because of the high rate of false-positive results.

Can mifepristone medical abortion be simplified? A review of the evidence and questions for future research

Mifepristone medical abortion has been a valuable addition to the reproductive health options of women. Aspects of its provision have however sometimes limited its accessibility and use. This article summarizes existing evidence for simplifying the provision of medical abortion and thus increasing its availability. We identify three ways through which medical abortion provision might be simplified based on existing evidence and suggest five additional simplifications that require further research to confirm their safety and efficacy.

Medication abortion employing routine sequential measurements of serum hCG and sonography only when indicated

OBJECTIVES

This study was designed to demonstrate the safety and efficacy of providing medication abortion in a primary care site without routine use of pre- and postprocedure transvaginal sonography.

METHODS

We performed a retrospective record review of 172 consecutive patients choosing medication abortion at our clinic. Our protocol used sonography only as needed for specific indications. All patients were intended to be followed up with serum human chorionic gonadotropin (hCG) testing pre- and posttreatment.

RESULTS

Of the 151 patients not lost to follow-up, 96 (63%) had pretreatment sonography according to protocol or physician preference and 55 did not. Ninety-nine percent (95/96) of those receiving initial sonography had a successful, and uneventful, medication abortion treatment, while 98.2% (54/55) of those not receiving an initial sonography did so. This difference was not statistically significant (.597 by one-sided Fisher's Exact Test). All 119 of the women who did not receive postabortion sonography aborted completely. Only 4 of the 91 women who had both pre- and postprocedure hCG measurements, all of whom aborted successfully, had follow-up-to-initial hCG ratios of greater than 0.2 (20%).

CONCLUSION

Using a clinical protocol that involves obtaining pre- and posttreatment serum hCG measurements, with sonograms only when indicated, has similar outcomes to a protocol that uses mandatory pre- and posttreatment sonograms.

Prostaglandins for first-trimester termination

Since the 1980s, when mifepristone combined with a prostaglandin was found to be safe and effective for early abortion, many studies have refined the regimens and investigated alternatives such as methotrexate plus misoprostol, and misoprostol alone. Evidence now demonstrates that more than 200 mg of mifepristone provides no additional benefit, that vaginal misoprostol is superior to oral, especially between 7 and 9 weeks' gestation, and that misoprostol may be safely self-administered at home. Buccal and sublingual routes of administration of misoprostol also are promising. Absolute contraindications to medical abortion arise infrequently. Gastrointestinal and other side-effects occur in about one-third of women, primarily after administration of the prostaglandin. Careful assessment before and after medical abortion is essential and can be accomplished in various ways, depending on the skills of the clinician.

Clinicians' perception of sonogram indication for mifepristone abortion up to 63 days

One barrier in the US to wider acceptance of mifepristone for abortion is the additional cost of the routine use of two sonograms, that is, for pregnancy dating and confirmation of a complete abortion. The purpose of this study is to document how the accuracy of medical abortion clinicians experienced with pelvic exams and dating pregnancies in assessing gestational age at the first visit compared with sonograms, and to identify the factors influencing whether they perceive that sonograms are desired or indicated at the first and follow-up visits. This was a prospective study of 1016 women wanting to participate in a medical abortion trial. After informed consent, clinicians (1) dated the pregnancy before routine sonography and (2) determined whether a sonogram was indicated. Women with sonographic pregnancies of less than 63 days were eligible for mifepristone followed by misoprostol 48 h later. Women returned on Day 4 to Day 8, and clinicians performed a clinical assessment of whether the abortion was complete and determined whether a sonogram was indicated. Fifteen sites participated. Advanced-level providers performed 56% of the assessments. When clinicians assessed a pregnancy under 43 days gestation, they perceived that a sonogram was "not indicated" in 60% of these women. This percentage increased to 66% at 43-49 days gestation, and declined to 46% of women assessed at more than 49 days. Clinicians correctly assessed gestational age as no more than 63 days in 87% of women. In only 1% (14/1013) of their assessments did clinicians underestimate gestational age. In 7/24 (29%) women with a persistent gestational sac, clinicians did not indicate the need for sonography when it was likely indicated. We conclude that the clinicians in our study felt confident in not using sonography in most cases. If clinicians monitor hCG levels to identify any ectopic or continuing pregnancies, medical abortion can be safely performed without sonography.

The roles of clinical assessment, human chorionic gonadotropin assays, and ultrasonography in medical abortion practice

The clinical assessment of patients who request early medical abortion includes confirmation of the diagnosis of pregnancy and estimation of gestational age. Accurate gestational dating is essential, because the efficacies of medical abortion regimens decline as pregnancy advances. Whereas medical abortion researchers in the United States have relied on routine ultrasonography for gestational dating, abortion providers experienced with mifepristone and prostaglandin regimens outside the United States have reported high efficacy and safety primarily with clinical dating parameters. Diligent follow-up of patients allows clinicians to confirm that complete abortion has occurred without complications. In cases of uncertain outcome or suspected ectopic pregnancy, transvaginal ultrasonography and beta-human chorionic gonadotropin assays can assist in prompt diagnosis and management. As medical abortion with mifepristone and misoprostol becomes more prevalent in the United States, studies will be needed to further evaluate the effects of these modalities on medical abortion outcomes.

Single high dose of local methotrexate for the management of relatively advanced ectopic pregnancies

OBJECTIVE

To evaluate the limits of the conservative management of relatively advanced ectopic pregnancies (EPs) with local methotrexate given at a higher than standard dose.

DESIGN

Nonrandomized prospective study.

SETTING

A tertiary teaching hospital and an affiliated infertility center.

PATIENT(S)

We treated 118 EPs of up to 56 days' gestation (8 weeks) regardless of the presence of fetal heart activity, the size of the gestational mass, and the initial beta-hCG levels.

INTERVENTION(S)

Transvaginal intraamniotic or laparoscopic intratubal injection of 100 mg of methotrexate as a single dose.

MAIN OUTCOME MEASURE(S)

beta-hCG levels, red and white blood cell count, and liver function tests before and after methotrexate injection, followed by repeat transvaginal color Doppler assessments.

RESULT(S)

Treatment was successful in 105 (88.98%) of the 118 patients included in the study. In 7 of them with persistent fetal cardiac activity after the methotrexate injection, treatment was concluded with a complementary intracardiac injection of 10% KCl. No grade 3 or important clinical, hematologic, or biochemical toxicities occurred.

CONCLUSION(S)

Local administration of a single high dose of methotrexate (100 mg) proved safe and effective in the medical management of relatively advanced and unselected EPs, including cases with fetal heart activity, with high initial beta-hCG levels, and with a gestational mass beyond the standard maximum of 3.5 cm. Complementary hypertonic KCl proved to be effective in cases with persistent cardiac activity.

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.