Egger M, Low N, Smith GD, et al [Univ of Bristol, England; King’s college School of Medicine and Dentistry, London; Univ Hsop. Uppsala, Sweden; et al]
Screening for Chlamydial Infections and the Risk of Ectopic Pregnancy in a County in Sweden: Ecological Analysis
BMJ 316:1776-1780, 1998
In the 1980s, the rates of chlamydial infection and associated pelvic inflammatory disease [PID] declined in Sweden. This decrease has been attributed to policies introduced through that decade to prevent chlamydial infection. Because chlamydial infection screening among women in Uppsala has been extensive and because ectopic pregnancy management is provided in only 1 hospital, this country provided an excellent opportunity for an ecologic study of the relationship between genital chlamydial infection and ectopic pregnancy.
Conclusions – The decreasing rates of genital chlamydial infection have probably resulted in a decline in the rate of ectopic pregnancies. The timing of this decline varies with age. In younger women, declining chlamydial infection rates have been accompanied by an immediate decrease in ectopic pregnancy rates.
Editorial comments by D.R. Mishell, Jr., MD
It is beneficial to screen sexually active young women and men to determine whether they are infected with chlamydia. Antimicrobial treatment can help reduce the chances of development of salpingitis with its sequelae of infertility and ectopic pregnancy.
Resolution of Hormonal Markers of Ectopic Gestation : A randomised Trial Comparing Single-Dose Intramuscular Methotrexate With Salpingostomy
Saraj AJ, Wilcox JG, Najmabadi S, et al [Univ of Southern California, Los Angeles]
Obstet Gynecol 92:989-994, 1998
The object of this study was that the resolution pattern of hormonal markers of ectopic pregnancy in patients receiving single-dose intramuscular [IM] methotrexate or undergoing laparoscopic salpingostomy was evaluated.
Hemodynamically stable women with unruptured ectopic pregnancies were randomly allocated to receive surgical therapy with salpingostomy in 37 patients or single-dose [1 mg/kg] IM methotrexate in 38 patients. Success was defined as a human chorionic gonadotropin [hCG] level less than 15 Miu/ml without the need for an alternative treatment.
Result – The results of this study shows that the decrease in progesterone levels was significantly faster than was the decrease in hCG levels. Success rates and ipsilateral tubal patency rates 3 months after pregnancy were similar for both groups. Pregnancy rates 9 months later for those who wished to conceive were similar. There wee 2 treatment failures in the methotrexate group and 3 in the salpingostomy group.
Conclusion – Resolution of ectopic pregnancy was significantly shorter for laparoscopic salpingostomy than for methotrexate treatment, but methotrexate treatment produced acceptable success rates. Serum progesterone levels less than 1.5 ng/ml. predicted resolution with more accuracy than did hCH levels.
Single High Dose of Local Methotrexate for the Management of Relatively Advanced Ectopic Pregnancies
Tzafettas JM, Stephanatos A, Loufopoulos A, et al [Aristotle Univ, Thessaloniki, Greece
Fertil Steril 71:1010-1013, 1999
Surgical intervention is usually not necessary for most women with unruptured ectopic pregnancy. Tubal patency and future fertility performance seem to be similar with conservative management using methotrexate and the salpingostomy techniques. When the gestational mass was more than 35 mm or when cardiac activity was visible, medical management of ectopic pregnancy has rarely been used; however, this may be from an inadequate amount of methotrexate given. The standard dose has been 50 mg or up to 1 mg/kg body weight in specifically selected women. A larger dose [100 mg] of methotrexate as a single local injection was used in women with ectopic pregnancies o assess the limits of local methotrexate treatment.
Results – The results shows that the in 105 [88.98%] of the 118 patients in the study, treatment was successful. Seven women had persistent fetal cardiac activity after the methotexate injection, and their treatment concluded with the complementary intracardiac injection of 10% KCI. There were no grade 3 or important hematologic, clinical or biochemical toxicities.
Editorial comments by D.R. Mishell, Jr, MD
The authors did not provide data regarding the success rate when the gestational mass size was larger than 35 mm in diameter, a criterion limiting use of systemic methotrexate. However when cardiac activity was present, 20% of the ectopic pregnancies failed to resolve with local therapy in this study. Futhermore, in one third of the women, the methotraxate needed to be injected under laparoscopic visualization, at which time surgical excision of the ectopic pregnancy could have been performed.
Analysis of Three Hundred Fifteen Ectopic Pregnancies Treated with Single-Dose Methotrexaste
Lipscomb GH, Bran D, McCord ML, et al [Univ of Tennessee, Memphis]
Am J Obstet Gynecol 178:1354-1358, 1998
Single-dose methotrexate [50mg/m2 im/body weight] was administered to 315 patients with unruptured ectopic pregnancies between March 21, 1990 and March 1, 1997. If human chorionic gonadotropin [hCG] levels failed to drop by 15% or more between 4 and 7 days. A second dose of methotrexate was administered. Repeat dosing was performed on each successive week that hCG levels failed to decline.
The results of the 260 patients receiving only one dose of methotrexate, 236 were successfully treated. Of the 50 patients receiving 2 doses, there were 47 successes. All 4 patients receiving 3 doses were successfully treated. One patient receiving 4 doses failed treatment.
Conclusion – The success rate for methotrexate treatment was almost 93% if patients electing surgery were excluded.
Management of Separation Pain after Single-dose Methotrexate Therapy for Ectopic Pregnacy
Lipscomb GH, Puckett KJ, Bran D et al [Univ of Tennessee, Memphis]
Obstet Gynecol 93:590-593, 1999
258 patients were treated with single dose methotrexate. All those who came to the emergency department for treatment of abdominal pain were included in the conservative management study if they were hemodynamically stable and had no more than a moderate amount of free fluid in the abdominal cavity on US. Pelvic examinations were not performed, and patients with mild symptoms were discharged.
Of the 53 patients with 64 episodes of severe abdominal pain, 22 outpatient evaluations and 31 hospitalizations were available for comparison. Seven [21%] of 34 hospitalised patients had surgery. The remainder wee discharged within 24 hours of admission.
Conclusion – The majority of patients with separation pain can be treated conservatively even if peritoneal fluid and rebound pain is present.
Editorial comments by D.R. Mishell, Jr, MD
The first study [Abstract 18-4] summarizes the results of the largest series of patients with unruptured ectopic pregnancies treated with a single dose of methotrexate. The success rate of 91% indicates this method of treatment can be used instead of surgical therapy are present in an individual patient. Many women experience moderate to severe pelvic pain within a few days after receiving methotrexate. As shown in the second study [Abstract 18-5], clinicians need to be aware that the presence of of moderate of severe pelvic pain does not mean tubal rupture has occurred or surgical exploration is necessary. The majority of patients who have pelvic pain can be treated expectantly if they are hamodynamically stable and have peritoneal fluid confined to the pelvis., even if they have abdominal wall rebound tenderness and a mild decrease in hematocrit measurement. It is important to note that the authors advise not performing bimanual pelvic examination on these women to avoid rupture of a tubal hematoma.
Heard K, Kendall J, Abbott J [Denver Health Med Ctr; Univ of Colorado, Denver]
Rupture of Ectopic Pregnancy After Medical Therapy With Methotrexate : A Case Series
J Emerg Med 16:857-860, 1998
11 of 86 patients previously treated with methotrexate at 1 center subsequently underwent surgery.
Editorial comments by D.R. Mishell, Jr., MD –
Clinicians should be aware of the fact that tubal rupture of the ectopic pregnancy can occur after treatment with methotrexate. Therefore, close posttreatment follow-up is essential. Of the 11 women in this series, three had elevated hCG levels for more than 2 months after initiation therapy. The presence of persistent ectopic pregnancy after either surgical or medical treatment of unruptured ectopic pregnancy is a risk factor for rupture. Therefore, if hCG levels do not decline shortly after initial treatment, additional therapy [either medical or surgical ] should be used.