PDF herunterladen
Semin Reprod Med 2007; 25(2): 099-115
DOI: 10.1055/s-2007-970049
Copyright © 2007 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Local Treatment of Ectopic Pregnancy

Moune Jabre Raughley1 , Gary Nathan Frishman1
  • 1Department of Obstetrics and Gynecology, Women & Infants' Hospital, Brown Medical School, Providence, Rhode Island
Weitere Informationen

Publikationsverlauf

Publikationsdatum:
22. März 2007 (online)

    Lizenzen und Reprints

ABSTRACT

The treatment of ectopic pregnancies has evolved from a purely surgical route with routine removal of the fallopian tube to one with multiple options. Medical treatment can be administered systemically or via local injection. Local delivery of chemotherapeutic agents is a safe and proven modality that is especially indicated for pregnancies in which a laparoscopic approach is not ideal and systemic therapy either has failed or is not desired. Local therapy has the potential to document immediately the cessation of fetal heart activity. Nontubal ectopic pregnancies may be ideally suited to local therapy, especially when there is a fetal heart present. Transvaginal ultrasound is the preferred mode for guidance and laparoscopic guidance has a limited role. Although a multitude of agents have been proposed, methotrexate, KCl, and hyperosmolar glucose are the most widely used and readily available. Local therapy has an important place in the armamentarium of the treatment of ectopic pregnancies.

KEYWORDS

Potassium chloride - methatrexate - local treatment - transvaginal ultrasound - ectopic pregnancy

REFERENCES

  • 1 Hreshchyshyn M M, Naples Jr J D, Randall C L. Amethopterin in abdominal pregnancy.  Am J Obstet Gynecol. 1965;  93 286-287
    PubMedGoogle Scholar
  • 2 Tanaka T, Hayashi H, Kutsuzawa T, Fujimoto S, Ichinoe K. Treatment of interstitial ectopic pregnancy with methotrexate: report of a successful case.  Fertil Steril. 1982;  37(6) 851-852
    PubMedGoogle Scholar
  • 3 Feichtinger W, Kemeter P. Conservative treatment of ectopic pregnancy by transvaginal aspiration under sonographic control and methotrexate injection.  Lancet. 1987;  1(8529) 381-382
    PubMedGoogle Scholar
  • 4 Dimitry E S, Subak-Sharpe R, Mills M, Margara R, Winston R. Nine cases of heterotopic pregnancies in 4 years of in vitro fertilization.  Fertil Steril. 1990;  53(1) 107-110
    PubMedGoogle Scholar
  • 5 Parente J T, Ou C S, Levy J, Legatt E. Cervical pregnancy analysis: a review and report of five cases.  Obstet Gynecol. 1983;  62(1) 79-82
    PubMedGoogle Scholar
  • 6 Ushakov F B, Elchalal U, Aceman P J, Schenker J G. Cervical pregnancy: past and future.  Obstet Gynecol Surv. 1997;  52(1) 45-59
    CrossrefPubMedGoogle Scholar
  • 7 Barnhart K, Spandorfer S, Coutifaris C. Medical treatment of interstitial pregnancy. A report of three unsuccessful cases.  J Reprod Med. 1997;  42(8) 521-524
    PubMedGoogle Scholar
  • 8 Voigt R R, van der Veen F, Karsdorp V H, Hogerzeil H V, Ketting B W. Treatment of interstitial pregnancy with methotrexate: report of an unsuccessful case.  Hum Reprod. 1994;  9(8) 1576-1579
    PubMedGoogle Scholar
  • 9 Bai S W, Lee J S, Park J H et al.. Failed methotrexate treatment of cervical pregnancy. Predictive factors.  J Reprod Med. 2002;  47(6) 483-488
    PubMedGoogle Scholar
  • 10 Timor-Tritsch I E, Monteagudo A, Mandeville E O, Peisner D B, Anaya G P, Pirrone E C. Successful management of viable cervical pregnancy by local injection of methotrexate guided by transvaginal ultrasonography.  Am J Obstet Gynecol. 1994;  170(3) 737-739
    PubMedGoogle Scholar
  • 11 Frishman G N. Transvaginal ultrasound-guided methotrexate injection of cornual ectopic pregnancy.  J Am Assoc Gynecol Laparosc. 2004;  11(1) 1
    CrossrefPubMedGoogle Scholar
  • 12 Perez J A, Sadek M M, Savale M, Boyer P, Zorn J R. Local medical treatment of interstitial pregnancy after in-vitro fertilization and embryo transfer (IVF-ET): two case reports.  Hum Reprod. 1993;  8(4) 631-634
    PubMedGoogle Scholar
  • 13 Stovall T G, Ling F W, Buster J E. Reproductive performance after methotrexate treatment of ectopic pregnancy.  Am J Obstet Gynecol. 1990;  162(6) 1620-1623 , [discussion 3-4]
    PubMedGoogle Scholar
  • 14 Medical management of tubal pregnancy. ACOG Practice Bulletin Number 3, December 1998. Clinical management guidelines for obstetrician-gynecologists. American College of Obstetricians and Gynecologists.  Int J Gynaecol Obstet. 1999;  65(1) 97-103
    CrossrefPubMedGoogle Scholar
  • 15 Kooi S, Kock H C. Treatment of tubal pregnancy by local injection of methotrexate after adrenaline injection into the mesosalpinx: a report of 25 patients.  Fertil Steril. 1990;  54(4) 580-584
    PubMedGoogle Scholar
  • 16 Gjelland K, Hordnes K, Tjugum J, Augensen K, Bergsjo P. Treatment of ectopic pregnancy by local injection of hypertonic glucose: a randomized trial comparing administration guided by transvaginal ultrasound or laparoscopy.  Acta Obstet Gynecol Scand. 1995;  74(8) 629-634
    PubMedGoogle Scholar
  • 17 Darai E, Benifla J L, Naouri M et al.. Transvaginal intratubal methotrexate treatment of ectopic pregnancy. Report of 100 cases.  Hum Reprod. 1996;  11(2) 420-424
    PubMedGoogle Scholar
  • 18 Merz E, Bahlmann F, Weber G et al.. Unruptured tubal pregnancy: local low-dose therapy with methotrexate under transvaginal ultrasonographic guidance.  Gynecol Obstet Invest. 1996;  41(2) 76-81
    PubMedGoogle Scholar
  • 19 Mesogitis S A, Daskalakis G J, Antsaklis A J, Papantoniou N E, Papageorgiou J S, Michalas S K. Local application of methotrexate for ectopic pregnancy with a percutaneous puncturing technique.  Gynecol Obstet Invest. 1998;  45(3) 154-158
    CrossrefPubMedGoogle Scholar
  • 20 Yeko T R, Mayer J C, Parsons A K, Maroulis G B. A prospective series of unruptured ectopic pregnancies treated by tubal injection with hyperosmolar glucose.  Obstet Gynecol. 1995;  85(2) 265-268
    CrossrefPubMedGoogle Scholar
  • 21 Fernandez H, Yves Vincent S C, Pauthier S, Audibert F, Frydman R. Randomized trial of conservative laparoscopic treatment and methotrexate administration in ectopic pregnancy and subsequent fertility.  Hum Reprod. 1998;  13(11) 3239-3243
    CrossrefPubMedGoogle Scholar
  • 22 Ory S J, Villanueva A L, Sand P K, Tamura R K. Conservative treatment of ectopic pregnancy with methotrexate.  Am J Obstet Gynecol. 1986;  154(6) 1299-1306
    PubMedGoogle Scholar
  • 23 Kooi S, van Etten F H, Kock H C. Histopathology of five tubes after treatment with methotrexate for a tubal pregnancy.  Fertil Steril. 1992;  57(2) 341-345
    PubMedGoogle Scholar
  • 24 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(5) 943-947
    PubMedGoogle Scholar
  • 25 Schiff E, Shalev E, Bustan M, Tsabari A, Mashiach S, Weiner E. Pharmacokinetics of methotrexate after local tubal injection for conservative treatment of ectopic pregnancy.  Fertil Steril. 1992;  57(3) 688-690
    PubMedGoogle Scholar
  • 26 Pansky M, Bukovsky I, Golan A et al.. Local methotrexate injection: a nonsurgical treatment of ectopic pregnancy.  Am J Obstet Gynecol. 1989;  161(2) 393-396
    PubMedGoogle Scholar
  • 27 Pansky M, Bukovsky J, Golan A et al.. Reproductive outcome after laparoscopic local methotrexate injection for tubal pregnancy.  Fertil Steril. 1993;  60(1) 85-87
    PubMedGoogle Scholar
  • 28 Tulandi T, Bret P M, Atri M, Senterman M. Treatment of ectopic pregnancy by transvaginal intratubal methotrexate administration.  Obstet Gynecol. 1991;  77(4) 627-630
    PubMedGoogle Scholar
  • 29 Hoek A, Broekmans F J, Verheijen R H, Schats R. Successful treatment of an advanced interstitial pregnancy by sequential systemic and local administration of methotrexate.  Hum Reprod. 1995;  10(7) 1864-1865
    PubMedGoogle Scholar
  • 30 Fernandez H, Benifla J L, Lelaidier C, Baton C, Frydman R. Methotrexate treatment of ectopic pregnancy: 100 cases treated by primary transvaginal injection under sonographic control.  Fertil Steril. 1993;  59(4) 773-777
    PubMedGoogle Scholar
  • 31 Hwu Y M, Hsu C Y, Yang H Y. Conservative treatment of caesarean scar pregnancy with transvaginal needle aspiration of the embryo.  BJOG. 2005;  112(6) 841-842
    PubMedGoogle Scholar
  • 32 Evans M I, Britt D W. Fetal reduction.  Semin Perinatol. 2005;  29(5) 321-329
    CrossrefPubMedGoogle Scholar
  • 33 Monteagudo A, Tarricone N J, Timor-Tritsch I E, Lerner J P. Successful transvaginal ultrasound-guided puncture and injection of a cervical pregnancy in a patient with simultaneous intrauterine pregnancy and a history of a previous cervical pregnancy.  Ultrasound Obstet Gynecol. 1996;  8(6) 381-386
    PubMedGoogle Scholar
  • 34 Fernandez H, Lelaidier C, Doumerc S, Fournet P, Olivennes F, Frydman R. Nonsurgical treatment of heterotopic pregnancy: a report of six cases.  Fertil Steril. 1993;  60(3) 428-432
    PubMedGoogle Scholar
  • 35 Timor-Tritsch I, Baxi L, Peisner D B. Transvaginal salpingocentesis: a new technique for treating ectopic pregnancy.  Am J Obstet Gynecol. 1989;  160(2) 459-461
    PubMedGoogle Scholar
  • 36 Doubilet P M, Benson C B, Frates M C, Ginsburg E. Sonographically guided minimally invasive treatment of unusual ectopic pregnancies.  J Ultrasound Med. 2004;  23(3) 359-370
    PubMedGoogle Scholar
  • 37 Lang P F, Tamussino K, Honigl W, Ralph G. Treatment of unruptured tubal pregnancy by laparoscopic instillation of hyperosmolar glucose solution.  Am J Obstet Gynecol. 1992;  166(5) 1378-1381
    PubMedGoogle Scholar
  • 38 Makhlouf A M, Al-Hussaini T K, Habib D M, Makarem M H. Second-trimester pregnancy termination: comparison of three different methods.  J Obstet Gynaecol. 2003;  23(4) 407-411
    CrossrefPubMedGoogle Scholar
  • 39 Hahlin M, Bokstrom H, Lindblom B. Ectopic pregnancy: in vitro effects of prostaglandins on the oviduct and corpus luteum.  Fertil Steril. 1987;  47(6) 935-940
    PubMedGoogle Scholar
  • 40 Vejtorp M, Vejerslev L O, Ruge S. Local prostaglandin treatment of ectopic pregnancy.  Hum Reprod. 1989;  4(4) 464-467
    PubMedGoogle Scholar
  • 41 Vejtorp M, Vejerslev L O, Ruge S. Treatment of tubal pregnancy by local injection of prostaglandin: selection of patients and evaluation of subsequent tubal patency.  Eur J Obstet Gynecol Reprod Biol. 1991;  41(2) 85-90
    CrossrefPubMedGoogle Scholar
  • 42 Lindblom B, Hahlin M, Lundorff P, Thorburn J. Treatment of tubal pregnancy by laparoscope-guided injection of prostaglandin F2 alpha.  Fertil Steril. 1990;  54(3) 404-408
    PubMedGoogle Scholar
  • 43 Ali A F. Local danazol injection for treatment of unruptured tubal pregnancy (preliminary experience).  Eur J Obstet Gynecol Reprod Biol. 1993;  49(3) 137-141
    CrossrefPubMedGoogle Scholar
  • 44 Kusaka M, Tanaka T, Fujimoto S. Local etoposide injection for treatment of tubal pregnancy with cardiac activity.  Int J Fertil Menopausal Stud. 1994;  39(1) 11-13
    PubMedGoogle Scholar
  • 45 Yildizhan B. Diagnosis and treatment of early cervical pregnancy: a case report and literature review.  Clin Exp Obstet Gynecol. 2005;  32(4) 254-256
    PubMedGoogle Scholar
  • 46 Tasdemir M, Tasdemir S. Minimally invasive treatment of live ectopic pregnancy.  Clin Exp Obstet Gynecol. 1997;  24(2) 92
    PubMedGoogle Scholar
  • 47 Yazici G, Aban M, Arslan M, Pata O, Oz U. Treatment of a cervical viable pregnancy with a single intraamniotic methotrexate injection: a case report.  Arch Gynecol Obstet. 2004;  270(1) 61-63
    PubMedGoogle Scholar
  • 48 Hung T H, Shau W Y, Hsieh T T, Hsu J J, Soong Y K, Jeng C J. Prognostic factors for an unsatisfactory primary methotrexate treatment of cervical pregnancy: a quantitative review.  Hum Reprod. 1998;  13(9) 2636-2642
    CrossrefPubMedGoogle Scholar
  • 49 Kung F T, Chang S Y. Efficacy of methotrexate treatment in viable and nonviable cervical pregnancies.  Am J Obstet Gynecol. 1999;  181(6) 1438-1444
    CrossrefPubMedGoogle Scholar
  • 50 Lang P F, Weiss P A, Mayer H O, Haas J G, Honigl W. Conservative treatment of ectopic pregnancy with local injection of hyperosmolar glucose solution or prostaglandin-F2 alpha: a prospective randomised study.  Lancet. 1990;  336(8707) 78-81
    CrossrefPubMedGoogle Scholar
  • 51 Batioglu S, Haberal A, Yesilyurt H, Ekici E. Successful treatment of cornual pregnancy by local injection of methotrexate under laparoscopic and transvaginal ultrasonographic guidance.  Gynecol Obstet Invest. 1997;  44(1) 64-66
    PubMedGoogle Scholar
  • 52 Natofsky J G, Lense J, Mayer J C, Yeko T R. Ultrasound-guided injection of ectopic pregnancy.  Clin Obstet Gynecol. 1999;  42(1) 39-47
    CrossrefPubMedGoogle Scholar
  • 53 Brown D L, Doubilet P M. Transvaginal sonography for diagnosing ectopic pregnancy: positivity criteria and performance characteristics.  J Ultrasound Med. 1994;  13(4) 259-266
    CrossrefPubMedGoogle Scholar
  • 54 Laatikainen T, Tuomivaara L, Kaar K. Comparison of a local injection of hyperosmolar glucose solution with salpingostomy for the conservative treatment of tubal pregnancy.  Fertil Steril. 1993;  60(1) 80-84
    PubMedGoogle Scholar
  • 55 Porpora M G, Oliva M M, De Cristofaro A, Montanino G, Cosmi E V. Comparison of local injection of methotrexate and linear salpingostomy in the conservative laparoscopic treatment of ectopic pregnancy.  J Am Assoc Gynecol Laparosc. 1996;  3(2) 271-276
    CrossrefPubMedGoogle Scholar
  • 56 Mottla G L, Rulin M C, Guzick D S. Lack of resolution of ectopic pregnancy by intratubal injection of methotrexate.  Fertil Steril. 1992;  57(3) 685-687
    PubMedGoogle Scholar
  • 57 Fernandez H, Pauthier S, Doumerc S et al.. Ultrasound-guided injection of methotrexate versus laparoscopic salpingotomy in ectopic pregnancy.  Fertil Steril. 1995;  63(1) 25-29
    PubMedGoogle Scholar
  • 58 Hajenius P J, Mol B W, Bossuyt P M, Ankum W M, Van Der Veen F. Interventions for tubal ectopic pregnancy.  Cochrane Database Syst Rev. 2000;  2 CD000324
    PubMedGoogle Scholar
  • 59 Tzafettas J, Anapliotis S, Zournatzi V, Boucklis A, Oxouzoglou N, Bondis J. Transvaginal intra-amniotic injection of methotrexate in early ectopic pregnancy. Advantages over the laparoscopic approach.  Early Hum Dev. 1994;  39(2) 101-107
    CrossrefPubMedGoogle Scholar
  • 60 Cohen D R, Falcone T, Khalife S. Methotrexate: local versus intramuscular. [comment].  Fertil Steril. 1996;  65(1) 206-207
    PubMedGoogle Scholar
  • 61 Goldenberg M, Bider D, Oelsner G, Admon D, Mashiach S. Treatment of interstitial pregnancy with methotrexate via hysteroscopy.  Fertil Steril. 1992;  58(6) 1234-1236
    PubMedGoogle Scholar
  • 62 Risquez F, Mathieson J, Pariente D et al.. Diagnosis and treatment of ectopic pregnancy by retrograde selective salpingography and intraluminal methotrexate injection: work in progress.  Hum Reprod. 1990;  5(6) 759-762
    PubMedGoogle Scholar
  • 63 Kiss H, Egarter C, Wenzl R, Husslein P. Falloposcopic instillation of prostaglandin in tubal pregnancy.  Lancet. 1993;  342(8862) 54
    PubMedGoogle Scholar
  • 64 Kaya H, Babar Y, Ozmen S et al.. Intratubal methotrexate for prevention of persistent ectopic pregnancy after salpingotomy.  J Am Assoc Gynecol Laparosc. 2002;  9(4) 464-467
    CrossrefPubMedGoogle Scholar
  • 65 Graczykowski J W, Mishell Jr D R. Methotrexate prophylaxis for persistent ectopic pregnancy after conservative treatment by salpingostomy.  Obstet Gynecol. 1997;  89(1) 118-122
    CrossrefPubMedGoogle Scholar
  • 66 Fujishita A, Ishimaru T, Masuzaki H et al.. Local injection of methotrexate dissolved in saline versus methotrexate suspensions for the conservative treatment of ectopic pregnancy.  Hum Reprod. 1995;  10(12) 3280-3283
    PubMedGoogle Scholar
  • 67 Egarter C, Kiss H, Vavra N, Husslein P. Reproductive performance after local and systemic prostaglandin for ectopic pregnancy.  Arch Gynecol Obstet. 1992;  252(1) 45-48
    CrossrefPubMedGoogle Scholar
  • 68 Bonatz G, Lehmann-Willenbrock E, Kunstmann P, Semm I, Hedderich J, Semm K. Management of patients with persistent beta-hCG values following laparoscopic surgical and local drug treatment for ectopic pregnancy.  Int J Gynaecol Obstet. 1994;  47(1) 33-38
    CrossrefPubMedGoogle Scholar
  • 69 Honigl W, Pickel H, Tamussino K, Lang P F. Histopathology of the fallopian tube after local instillation of hyperosmolar glucose solution for unruptured tubal pregnancy.  Fertil Steril. 1993;  59(6) 1316-1318
    PubMedGoogle Scholar
  • 70 Klinkert J, van Geldorp H J, Chadha-Ajwani S, Huikeshoven F J. Tubal damage after intratubal methotrexate treatment.  Fertil Steril. 1993;  59(4) 926-927
    PubMedGoogle Scholar
  • 71 Buster J E, Carson S A. Ectopic pregnancy: new advances in diagnosis and treatment.  Curr Opin Obstet Gynecol. 1995;  7(3) 168-176
    PubMedGoogle Scholar
  • 72 Timor-Tritsch I E, Monteagudo A, Matera C, Veit C R. Sonographic evolution of cornual pregnancies treated without surgery.  Obstet Gynecol. 1992;  79(6) 1044-1049
    PubMedGoogle Scholar
  • 73 Hajenius P J, Mol B W, Ankum W M, van der Veen F, Bossuyt P M, Lammes F B. Suspected ectopic pregnancy: expectant management in patients with negative sonographic findings and low serum hCG concentrations.  Early Pregnancy. 1995;  1(4) 258-262
    PubMedGoogle Scholar
  • 74 Ankum W M, Van der Veen F, Hamerlynck J V, Lammes F B. Suspected ectopic pregnancy. What to do when human chorionic gonadotropin levels are below the discriminatory zone.  J Reprod Med. 1995;  40(7) 525-528
    PubMedGoogle Scholar

Gary Nathan FrishmanM.D. 

Department of Obstetrics and Gynecology, Women & Infants' Hospital, Brown Medical School

101 Dudley Street, Providence, RI 02905

eMail: Gary.Frishman@Brown.edu

      >