Int J Gynecol Obstet, 1992, 37: 297-299
International
Federation
of Gynecology
291
and Obstetrics
A new nonsurgical technique for termination of intrauterine pregnancy associated with large multiple uterine leiomyomas K. Buckshee Department
and A.J. Dhond
of Obstetrics and Gynaecology.
(Received June 2nd, 1991) (Revised and accepted September
All India Institute
of Medical
Sciences, New Delhi I IO 029 (India)
9th, 1991)
Abstract Medical termination of a first trimester intrauterine pregnancy associated with large and multiple leiomyomas posed a unique problem because the sac was inaccessible per vaginum for surgical or vacuum evacuation. The use of prostaglandins was contraindicated due to a past history of bronchial asthma. But intraamniotic and intraplacental instillation of methotrexate, 25 mg at each site, under ultrasound guidance resulted in termination of pregnancy. No side effects or complications were observed after the procedure.
Keywords: Abortion; Methotrexate; uterine pregnancy; Leiomyoma.
history of amenorrhea for 8 weeks and a past history of bronchial asthma. Examination revealed a firm uterus irregularly enlarged to 32-34 weeks size. Ultrasonography of the abdomen confirmed large multiple leiomyomas of the uterus with a gestation sac with fetal heart activity at the antero-superior end of the fundus (Fig. 1). The uterine cavity was irregularly enlarged. Two weeks following this the patient reported back with threatened abortion. Bleeding per vaginum stopped after 4 days and repeat ultrasound revealed a live fetus. Initially the patient wanted to continue
Intra-
Introduction Termination of intrauterine pregnancy in a uterus with large multiple leiomyomas may sometimes pose unique problems which neccessitate a management protocol different from the routine. A new method for medical termination of pregnancy by intraplacental and intraamniotic instillation of methotrexate is described. Case report
Fig. 1. Ultrasound
A 33-year-old multipara 0020-7292/92/$05.00 0 1992 International Federation Printed and Published in Ireland
reported
with a
large leiomyoma
uterus with
gestation sac and 8 week fetus at the antero-superior body of the uterus.
scan showing
part of the
Case Report of Gynecology
and Obstetrics
298
Buckshee and Dhond
her pregnancy as she had only one living issue but she changed her mind and requested a medical termination of pregnancy. The possibility of vacuum aspiration was ruled out due to the inaccessible position of the gestation sac. The use of prostaglandins was contraindicated due to the history of bronchial asthma. The patient refused hysterotomy/ hysterectomy. Thus she was considered for the new technique described here. Under ultrasound guidance, methotrexate (25 mg) was injected into the intraamniotic cavity using a 22 G 20 cm long needle transabdominally. A further 25 mg of methotrexate was injected into the anteriorly placed placenta. She aborted a complete gestation sac with a macerated fetus at home 8 days following the procedure. Bleeding per vaginum lasted for 1 day and the patient made an uneventful recovery. Postabortal ultrasonography revealed an empty endometrial cavity (Fig. 2). Histopathology of the abortus revealed products of gestation (placenta and .fetal parts).
Fig. 2. Ultrasound scan showing leiomyoma uterus following the abortion. Int J Gynecol Obster 37
Serum hCG done on the day of the procedure was 27 000 mIU/ml and returned to an undectable level after 4 weeks. Discussion This case presented a unique problem of medical termination of intrauterine pregnancy in a uterus with large multiple leiomyomas. Such cases are associated with the inherent risk of incomplete abortion, retained placenta, postabortal hemorrhage and infection especially with the use of saline, urea and mannitol because their failure rates are high. We feel that the method described here of intraplacental and intraamniotic instillation of methotrexate resulted in the death of the embryo and regression of the trophoblasts. This facilitated the complete expulsion of the products of gestation without the above mentioned complications. Several authors have suggested nonsurgical management of ectopic pregnancy using various substances such as methotrexate, prostaglandins and potassium chloride [2-71 but to the best of our knowledge, this is the first reported case of intraplacental and intraamniotic instillation of methotrexate for intrauterine pregnancy termination. Although methotrexate pneumonitis is more common in patients with respiratory diseases, the risk is much less than that with prostaglandins. Moreover the patient had a past history of bronchial asthma only with no active respiratory disease, so methotrexate was considered. Methotrexate is a toxic drug and several deaths have been reported with its systemic use before leucovorin was available. With the availability of leucovorin, use of low dosage of methotrexate and its local instillation into the gestation sac and placenta is not that toxic, although minor side effects have been reported. However, this new technique may be recommended in special cases of pregnancy termination where surgical methods and prostaglandins are contraindicated.
Pregnancy and multiple uterine leiomyomas
References Calebresi P, Chabner BA, Gilman AC, RaIl TW, Nies AS, Taylor P: The Pharmacologic Basis of Therapeutics (eds Goodman and Gilman), 8th edn, 227 pp. Pergamon Press, New York, 1990. Choliner HC: Non-surgical management of ectopic pregnancy associated with severe hyperstimulation syn-
6
7
prostaglandin F2 alpha injection for termination of ectopic pregnancy. Lancet i: 776, 1987. Ory SJ, Villanueva AL, Sand PK. Tamura RK: Conservative treatment of ectopic pregnancy with methotrexate. Am J Gynecol 154: 1299, 1986. Porrero RP, Burke MS, Porlier DW: Selective embryocide in the non-surgical management of combined intrauterine extrauterine
pregnancy.
Obstet
Gynecol
drome. Obstet Gynecol 66: 740, 1985. Fernandez H, Rainhorn JD, Papiernik E, Bellet D, Frydman R: Spontaneous resolution of ectopic pregnancy. Obstet Gynecol 71: 171, 1988.
Address for reprints:
Kojima E, Morita M, Hirakawa S: The treatment of unruptured tubal pregnancy with intratubal methotrexate injections under laparoscopic control. Obstet Gynecol 75: 723. 1990.
K. Buckshee Department of Obstetrics and Gynaecology All India Institute of Medical Sciences Ansari Nagar
Lindblom
New Delhi 110 029, India
B, Mahlin
M. Kallfelt
B, Hamberger
L: Local
299
7.r: 498. 1990.
Case Report
International
Federation
of Gynecology
291
and Obstetrics
A new nonsurgical technique for termination of intrauterine pregnancy associated with large multiple uterine leiomyomas K. Buckshee Department
and A.J. Dhond
of Obstetrics and Gynaecology.
(Received June 2nd, 1991) (Revised and accepted September
All India Institute
of Medical
Sciences, New Delhi I IO 029 (India)
9th, 1991)
Abstract Medical termination of a first trimester intrauterine pregnancy associated with large and multiple leiomyomas posed a unique problem because the sac was inaccessible per vaginum for surgical or vacuum evacuation. The use of prostaglandins was contraindicated due to a past history of bronchial asthma. But intraamniotic and intraplacental instillation of methotrexate, 25 mg at each site, under ultrasound guidance resulted in termination of pregnancy. No side effects or complications were observed after the procedure.
Keywords: Abortion; Methotrexate; uterine pregnancy; Leiomyoma.
history of amenorrhea for 8 weeks and a past history of bronchial asthma. Examination revealed a firm uterus irregularly enlarged to 32-34 weeks size. Ultrasonography of the abdomen confirmed large multiple leiomyomas of the uterus with a gestation sac with fetal heart activity at the antero-superior end of the fundus (Fig. 1). The uterine cavity was irregularly enlarged. Two weeks following this the patient reported back with threatened abortion. Bleeding per vaginum stopped after 4 days and repeat ultrasound revealed a live fetus. Initially the patient wanted to continue
Intra-
Introduction Termination of intrauterine pregnancy in a uterus with large multiple leiomyomas may sometimes pose unique problems which neccessitate a management protocol different from the routine. A new method for medical termination of pregnancy by intraplacental and intraamniotic instillation of methotrexate is described. Case report
Fig. 1. Ultrasound
A 33-year-old multipara 0020-7292/92/$05.00 0 1992 International Federation Printed and Published in Ireland
reported
with a
large leiomyoma
uterus with
gestation sac and 8 week fetus at the antero-superior body of the uterus.
scan showing
part of the
Case Report of Gynecology
and Obstetrics
298
Buckshee and Dhond
her pregnancy as she had only one living issue but she changed her mind and requested a medical termination of pregnancy. The possibility of vacuum aspiration was ruled out due to the inaccessible position of the gestation sac. The use of prostaglandins was contraindicated due to the history of bronchial asthma. The patient refused hysterotomy/ hysterectomy. Thus she was considered for the new technique described here. Under ultrasound guidance, methotrexate (25 mg) was injected into the intraamniotic cavity using a 22 G 20 cm long needle transabdominally. A further 25 mg of methotrexate was injected into the anteriorly placed placenta. She aborted a complete gestation sac with a macerated fetus at home 8 days following the procedure. Bleeding per vaginum lasted for 1 day and the patient made an uneventful recovery. Postabortal ultrasonography revealed an empty endometrial cavity (Fig. 2). Histopathology of the abortus revealed products of gestation (placenta and .fetal parts).
Fig. 2. Ultrasound scan showing leiomyoma uterus following the abortion. Int J Gynecol Obster 37
Serum hCG done on the day of the procedure was 27 000 mIU/ml and returned to an undectable level after 4 weeks. Discussion This case presented a unique problem of medical termination of intrauterine pregnancy in a uterus with large multiple leiomyomas. Such cases are associated with the inherent risk of incomplete abortion, retained placenta, postabortal hemorrhage and infection especially with the use of saline, urea and mannitol because their failure rates are high. We feel that the method described here of intraplacental and intraamniotic instillation of methotrexate resulted in the death of the embryo and regression of the trophoblasts. This facilitated the complete expulsion of the products of gestation without the above mentioned complications. Several authors have suggested nonsurgical management of ectopic pregnancy using various substances such as methotrexate, prostaglandins and potassium chloride [2-71 but to the best of our knowledge, this is the first reported case of intraplacental and intraamniotic instillation of methotrexate for intrauterine pregnancy termination. Although methotrexate pneumonitis is more common in patients with respiratory diseases, the risk is much less than that with prostaglandins. Moreover the patient had a past history of bronchial asthma only with no active respiratory disease, so methotrexate was considered. Methotrexate is a toxic drug and several deaths have been reported with its systemic use before leucovorin was available. With the availability of leucovorin, use of low dosage of methotrexate and its local instillation into the gestation sac and placenta is not that toxic, although minor side effects have been reported. However, this new technique may be recommended in special cases of pregnancy termination where surgical methods and prostaglandins are contraindicated.
Pregnancy and multiple uterine leiomyomas
References Calebresi P, Chabner BA, Gilman AC, RaIl TW, Nies AS, Taylor P: The Pharmacologic Basis of Therapeutics (eds Goodman and Gilman), 8th edn, 227 pp. Pergamon Press, New York, 1990. Choliner HC: Non-surgical management of ectopic pregnancy associated with severe hyperstimulation syn-
6
7
prostaglandin F2 alpha injection for termination of ectopic pregnancy. Lancet i: 776, 1987. Ory SJ, Villanueva AL, Sand PK. Tamura RK: Conservative treatment of ectopic pregnancy with methotrexate. Am J Gynecol 154: 1299, 1986. Porrero RP, Burke MS, Porlier DW: Selective embryocide in the non-surgical management of combined intrauterine extrauterine
pregnancy.
Obstet
Gynecol
drome. Obstet Gynecol 66: 740, 1985. Fernandez H, Rainhorn JD, Papiernik E, Bellet D, Frydman R: Spontaneous resolution of ectopic pregnancy. Obstet Gynecol 71: 171, 1988.
Address for reprints:
Kojima E, Morita M, Hirakawa S: The treatment of unruptured tubal pregnancy with intratubal methotrexate injections under laparoscopic control. Obstet Gynecol 75: 723. 1990.
K. Buckshee Department of Obstetrics and Gynaecology All India Institute of Medical Sciences Ansari Nagar
Lindblom
New Delhi 110 029, India
B, Mahlin
M. Kallfelt
B, Hamberger
L: Local
299
7.r: 498. 1990.
Case Report
