Obstetrical Mostafa

Atri,

MD

Patrice

#{149}

M. Bret, MD

Togas

Ectopic Pregnancy: with Transvaginal A prospective

T ing

tration

i,000,

Nineteen

patients (76%) had positive responses to this treatment, and six (24%) had to undergo surgery: five because of increasing abdominal pain and one because of vaginal bleeding. The ultrasonographic (US) resolution of the EP was long and lagged behind the resolution at testing of levels of beta subunit of human chorionic gonadotropin (-hCG) in all patients. The fallopian tube in 12 (63%) of the responding group initially increased in diameter from a mean of 222 cm to a mean of 3.84 cm. In 13 (68%) of the responding group, it became more vascular at color Doppler examinalion. Eleven (92%) of the 12 EPs that increased in size also became more vascular. The increase in tubal size and vascularity, in spite of the falling

3-hCG

level,

represents

process and should about the follow-up

a healing

cause no concern of these patients.

HE prevalence

nancy

than

Radiology

1992;

185:749-753

#{149} Mary

in the

4.5 per

and

pregnancies EP is mostly

decade,

to 16.5

constitutes

(1). This attributed

ris-

1% of all rate

of

in-

creased frequency of contributing factors such as pelvic inflammatory disease. The presentation of EP has also profoundly changed in recent years. The change in clinical features is mainly a result of earlier diagnosis due to the increased sensitivity of the radioimmunoassay

unit

for

of human

the

ehorionie

tropin

(3-hCG)

means

of transvaginal

and

beta

sub-

gonado-

localization

by

ultrasound

sac

servative

treatments

of EP has more eon-

to preserve

the

affected fallopian tube (2). Conservative surgical treatments traditionally included partial salpingectomy or salpingostomy,

ment

but

with

recent

different

approaches of

with

and

advocated

study

(3-7).

outlines

methotrexate

on the initial

the

transvaginal

follow-up

US

and

color

examinations

for

3-hCG

level

< .05).

of the

three

were among

groups

An Acuson 128 (Acuson, Mountain View, Calif) 5-MHz transvaginal probe (with lowest-velocity color sensitivity of I cm/see) was used for the diagnosis and

treatment

of these

EPs. Real-time

imaging

and color Doppler examination were performed in all patients, at the time of both the initial US examination and the follow-up transvaginal US. The degree of vascularity of the hematosalpinx at color Doppler US was arbitrarily quantified as moderate,

or severe

changes

low-up

to allow

us

in the vascularity

examinations.

Color

to

at fol-

Doppler

flow

was limited to less than one-third the circumference of the maximum plane of vascularity of EP in mild cases, less than twothirds in two-thirds

moderate cases, and in severely vascular

presence

of vascularity

more EPs.

than The

was also evaluated

with real-time imaging. This vaseularity was manifest as a visible, low-velocity nous flow. Limitations of color Doppler

equipment may this

to detect

have

resulted

flow

very

at Doppler

ye-

low velocities

in failure

to recognize

examination.

EP was diagnosed

appearance

mIU/mL

(P

of with

by identifying

an ex-

trauterine live embryo, a gestational sac (defined as an extraovanan saclike structure surrounded by a thick rind), or a hematosalpinx (defined as an extraovarian, round or elongated, solid adnexal mass [8]). Subsequently, the maximum diameter

as related to the success rate, and changes that should be expected at pler

2,178

the

our

treatment injection,

transvaginal

emphasis

treat-

substances

has been

prospective

results

medical

and

a hematosalpinx. There significant differences

monitor

The increased prevalence produced a trend toward

only

those with statistically

mild,

(US).

EP

mean 3-hCG level for EP with a living embryo was 10,744 mlU/mL, as compared with 4,376 mIU/mL for those with a gestational

per

increased to the

MD

Senterman,

Treatment

pregmore

past

1,000

now

K.

after

of ectopic has increased

(EP)

threefold from

This Index terms: Fallopian tubes, US, 853.12984 Methotrexate #{149} Pregnancy, ectopic, 85.823 Pregnancy, US, 85.12984, 85.823 #{149} Ultrasound (US), Doppler studies, 85.12984

MD

Evolution Methotrexate’

study was performed with 25 patients with ectopic pregnancies (EPs) who underwent treatment with transvaginal adminisof methotrexate.

Tulandi,

#{149}

Ultrasound

Dop-

of these

patients.

of EP was measured.

MATERIALS The

study

was

the

Ethics

Committee

by

General I From the Departments of Diagnostic Radiology (MA., P.M.B.), Obstetrics and Gynecology (T.T.), and Pathology (M.K.S.), McGill University, Montreal. From the 1991 RSNA scientific assembly. Received May 19, 1992; revision requested June 17; revision received July 13; accepted July 27. Address reprint requests to MA., Department of Diagnostic Radiology, Montreal General Hospital, 1650 Cedar Aye, Montreal, Que, Canada H3G 1A4. RSNA, 1992

,

AND

study

aged

Hospital, population

24-42

reviewed

McGill

and of the

32.7)

of EP

and

eight

approved

ing

had

with

The

serum

tured

matosalpinx

ectopic

a

selected

only selection

3-hCG

for this

if they criteria

(

levels

manage-

fulfilled

strict

included 15%

ris-

increase

in

the presence of an unrupEP (defined as a well-delineated he-

24 hours)

The

of transvagifour had

were

protocol

criteria.

of 25 patients years

pregnancy proved by means nal US. Among these patients, history

ment

Montreal

University.

consisted

(mean,

Patients

METHODS

and

with

no pelvic

fluid or a small

amount limited to the cul-de-sac). was no size limitation. All patients

There were

in

undergone

salpingoplasty. The gestational age in these patients varied from 4.4 to 9 (mean, 6.4) weeks, and 3-hCG levels ranged from 60 to 21,000 (mean, 5,798) mIU/mL (seeond standard international unit). The

Abbreviations: man chorionic pregnancy.

1-hCG gonadotropin,

=

beta subunit EP

=

of hu-

ectopic

749

b.

a. Figure

1.

Enlargement

of hematosalpinx

ruary 16 shows the hematosalpinx scan obtained February 26 shows serum 3-hCG level. (c) Transvaginal 1 cm in diameter.

after

(arrows) measuring the hematosalpinx US scan obtained

stable condition and had no pain or only mild discomfort. By using a transvaginal approach and transvaginal

US guidance,

1 mg/kg

meth-

otrexate was injected in the fallopian tube through a 22-gauge or 19-gauge needle. The injection was made inside the gestational

sac if a sac was

present

or in the he-

matosalpinx if no sac was evident. Attempts were made to aspirate the sac content before not be performed

the injection, but this in half the patients.

could Two

of the patients

with

in

a living

embryo

their EP received potassium chloride (2 mEq/mL) in addition to methotrexate. The procedure was performed on an outpatient basis with the use of intravenous se-

dation. The vital signs

of patients

were

moni-

tored for 2-4 hours before patients were discharged home. A positive response was confirmed by means of at least a 15% drop

in serum

3-hCG

second

level in 24-48

injection

was

hours.

performed

A

in eight

patients because of a rising 3-hCG level. The patients with positive responses were monitored twice per week by means of transvaginal US with the color Doppler technique and serum 3-hCG measurements

until

able.

Blood

serum

liver function counts

were

second

terosalpingography 3-6 months

was

undetect-

also

drawn

tests and for complete

every

patients

3-hCG

samples

was resolution

after

who

day

desired

for

blood

2 weeks.

performed of EP

Hys-

about in Il

RESULTS

2.75)

cm.

Eight

EPs

of the hema1.3 to 6 (mean,

contained

a live

embryo, 10 showed a gestational sac but no live embryo, and seven showed only a hematosalpinx. Eight were nonvascular at color Doppler US,

and

17 showed

different

degrees

of vascularity. Six (75%) of eight EPs with a live embryo, six (60%) of 10 750

Radiology

#{149}

with

methotrexate

in a patient

aged

25 years.

(a) Transvaginal

US scan

obtained

Feb-

less than 1.5 cm in diameter on the day of methotrexate injection. (b) Transvaginal US (arrows) 3 cm in diameter 10 days after injection of methotrexate, in spite of a drop in the April 16 demonstrates a substantial decrease in the size of the hernatosalpinx to less than

with a gestational sac, and five (71%) of seven with a hematosalpinx were vascular at the initial US examination. Successful

treatment

of EP with

methotrexate was achieved in 19 (76%) of the 25 patients in our study group. Of these, six received two injections because of a rising 3-hCG level within the first 48 hours. Their serum 3-hCG levels reached zero in 12-69 (mean, 40) days after the initial injection. Of the successfully treated cases,

five

% ) of seven

(71

with a living injections, as (14%) of seven tional sac and tients with a mean 3-hCG two injections

difference levels

bryo,

patients

embryo required two compared with one patients with a gestanone (0%) of five pahematosalpinx. The levels of those requiring was 12,665 mIU/mL,

compared with those requiring

likely

4,337 mIU/mL one injection.

reflects

in the patients most of whom

higher

tosalpinx increased from a mean pretreatment value of 2.22 cm to a mean posttreatment value of 3.84 cm. The number of days for the fallopian tube to reach maximum distention ranged

from

for This

success

rate

ance of the EP were results are summarized

and

initial

compared; in Table

days.

em-

also

appearthese 1.

There was no significant statistical difference among the groups (P> .05). Sixteen (76%) of 21 of the EPs smaller than 3 cm in diameter responded, as compared with three (75%) of four of those larger than 3 cm in diameter. Among the 19 responding patients, 12 (63%) showed an initial enlargement of the fallopian tube, which then gradually decreased in diameter (Fig 1). This included five (71%) of seven with a live embryo, four (57%) of seven with a gestational sac, and three (60%) of five with a hematosal-

pinx at the initial US examination. The maximum diameter of the

18.6)

in-

3-hCG

with a living required two

4 to 37 (mean,

Among the successfully treated eases, 11 tubes (58%) became more vascular (Fig 2) and nine of these 11

jections.

The for

to conceive.

The largest dimension tosalpinx ranged from

C.

treatment

hema-

increased

low-up

period.

creased

visible

of these

also

13 (68%)

in size Eleven

venous increased

of the

EPs demonstrated ity (as indicated

through

the

showed

flow

and

in size.

19 successfully increased by visible

fol-

in-

nine In total,

treated vascularvenous

flow or increased color flow) at follow-up examination. Increasing vaseularity after treatment, as related to the initial US appearance of these EPs, occurred in six (86%) of seven of those with a live embryo, five (71%) of seven with a gestational sac, and two

(40%) of five with a hematosalpinx. By using the described criteria of increasing color Doppler flow and visible venous flow at real-time US to indicate the degree of vascularity, 11 (92%) of the 12 EPs that increased in size also became more vascular (Table 2). The two patients who subse-

December

1992

a.

b.

Figure 2. matosalpinx a substantial

C.

Same patient as in Figure 1. Transvaginal US scans obtained with the color Doppler technique show increased vasculanty of the heafter treatment with methotrexate. (a) Scan obtained on the day of methotrexate injection. (b) Scan obtained February 26 shows increase in vasculanty of the hematosalpinx, mostly in the periphery of the enlarging hematosalpinx. (c) The hematosalpinx is

completely

avascular

at the

April

16 examination.

The

color

sensitivity

is maintained

at the

same

mented. At follow-up examination of the responding hematosalpinxes, nine maintained their initial, mostly solid appearance and 10 developed areas (Fig 3) corresponding oping venous spaces.

Six patients developed creased amounts of pelvic

new or influid. Of

these

bleeding

after

quently required surgical intervention also showed increase in the size and vaseularity of the fallopian tube in the responding treatment.

phase

of the

In all responding

methotrexate

patients,

as the

3-hCG levels declined to undetectable levels, the hematosalpinx resolved at a slower rate on the US images. In all patients, the serum 3-hCG level reached undetectable levels before the disappearance of the hematosal-

pinx

at US. At follow-up

of the

re-

sponding group, nine patients continued to undergo reexamination until the hematosalpinx disappeared or measured less than 0.7 cm in diameter, when it was barely visible. The time from injection to undetectable or

barely

visible

hematosalpinx

ranged

from 20 to 147 (mean, 83) days. Complete resolution of EP was confirmed with transvaginal US to occur at 102285 days in another six patients who did not undergo a continuous followup, and therefore, the exact duration

of resolution Volume

185

could Number

#{149}

not

be docu3

cystic to devel-

patients,

three

methotrexate

had

injection

and

Six patients went

pain, cause

bright four hours. tured was tion. one with 160 went

failed

Five of these

to have

Of this

bleeding after 35 days with a level down to 23 from a preinjection level of 2,850 mIU/mL. The former patient had a vascular EP at color Doppler examination on the day of surgery. Pathologic examination revealed an ampullary EP composed of degenerated and necrotic chorionic villi and trophoblast cells (Fig 4).

3-hCG

One pain have

patient

developed

after 23 days a hemorrhagic

treated

and

substantial

was found cyst, which

conservatively.

to was

Increasing

pain in another patient was the development of transient salpinx. Thirteen patients underwent low-up hysterosalpingography, of these, 10 (77%) had patent

due to hydrofoland tubes

and three (23%) showed hydrosalpinx. There were two subsequent

in-

trauterine and one ectopic pregnancy. Liver function tests and complete blood count remained unchanged. The serum methotrexate level was elevated in the first 24 hours in five patients (0.3-4.54 mol/L) but returned to less than 0.05 mol/L the following day. There were no recorded side effects from methotrexate injection.

full re-

patients

DISCUSSION

under-

surgery because of increasing and one underwent surgery of substantial transvaginal

red bleeding.

vaginal

un-

derwent conservative treatment. Twenty days after injection, one patient developed a new fluid collection that was presumably caused by an aborting EP. The other two developed pelvic fluid following ovulation after a new cycle. Three patients developed hydrosalpinx. Of these three patients, one had a transient hydrosalpinx and two had persistent hydrosalpinx. The latter two cases were confirmed at the time of hysterosalpingography. In patients who presented at the time of the initial injection with a corpus luteum cyst, their cysts subsequently disappeared with the decline of serum 3-hCG level. New ovarian cysts developed in 16 patients, indicating the start of each patient’s new cycle. Seven of these cysts appeared before 3-hCG reached undetectable levels.

sponses.

level.

be-

group,

underwent surgery within 24 One of these four EPs was rupat surgery and, in retrospect, probably ruptured before injecOf the two remaining patients, underwent surgery after 9 days a 3-hCG level falling from 660 to mIU/mL, and the other undersurgery because of substantial

In the past few years, the diagnostic approach to evaluating suspected EP has substantially changed, primarily

because sensitive and,

of the introduction of a highly 3-hCG radioimmunoassay

more

transvaginal substantially

accuracy series

recently, US.

the

improved

of EP before show

(8,9) if one

sensitivity

looks

routine

Transvaginal the

surgery.

use of US has

diagnostic

Recent

of 88.8%-93%

for a hematosalpinx

with or without a gestational sac as an indication of an EP. As a consequence, much higher number of EPs are de-

Radiology

#{149} 751

a

Figure

3.

(a) Static,

(c) duplex ination

(b) color

US images performed

methotrexate cystic

early

show

spaces

Doppler,

after

exam-

injection

development

after

and

of a transvaginal

treatment

of

of vascular with

methotrex-

ate in a patient aged 29 years. (a) Static image shows multiple cystic areas outside the central gestational sac (arrowheads). Most of these cystic spaces proved to be vascular on the color image (b) and were confirmed as venous

on

the

pulsed

Doppler

image

(c). The

only cystic space that did not fill on the color Doppler image (arrow in b) showed visible flow with a velocity less than that sensitively detected with the color Doppler imager. Transvaginal

(d)

US scan

obtained

in another

patient (aged 32 years) late after injection of methotrexate shows development of multiple cystic areas (arrows) that showed venous flow earlier in their development.

a.

b.

tected as intact or unruptured and, therefore, the clinical picture of EP has dramatically changed from a drastic lifethreatening condition to a more benign

and

less dangerous

series,

98%

problem

of the

transvaginal

US

cases were

(10). In this

diagnosed

with

clinically

mild

cases that did not require immediate surgery. As a result, there is a new trend to a more conservative management of EP to preserve the fallopian tube. Medical treatment of EP has been attempted

by using

different

substances

including

prostaglandin F,,, , KCI, hypertonic glucose, and methotrexate. With the exception of methotrexate, which is used in both intratubal and intramuscular injections, the other substances are injected locally either by means of transvaginal or laparoscopic guidance. Among these substances, methotrexate is the most widely used agent because its meehanism of action against actively dividing cells makes it effective against the rapidly proliferating trophoblastic tissue.

Our

series

demonstrates

that

trans-

vaginal injection of methotrexate has the advantage of causing no systemic side effects. The 76% success rate in our series

is comparable

to

that

in

a smaller

series that was limited to smaller-sized EPs with lower 3-hCG levels (Ii) and indicates that this technique has a similar success rate irrespective of the initial size of the EP or 3-hCG level at the time of presentation. Consequently, our series confirmed that there is no relation-

ship

between

the initial

hematosalpinx

size

Success been

tion

rates

reported

with

and

as high

3-hCG the

as 94%

for methotrexate

laparoscopic

level

success

guidance

or rate.

have injec-

(12)

and 96.7% for intramuscular injection of methotrexate (13). Also, no substantial statistical difference between the stage of development or vascularity of EP and the success rate was indicated by means of a similar response obtained in the group with a live embryo, a gestational sac, or a hematosalpinx. The EPs with a

752

Radiology

#{149}

C.

a.

living embryo, however, appeared to be more difficult to treat, and most required two injections. We injected KCI in addition to methotrexate in two of

the EPs with

a living

embryo

that

re-

quired a second dose. We did not inject only KC1 in EPs with a living embryo because, although KC1 causes cardiac arrest in the embryo, it has no effect on the placental tissue, which may continue to proliferate in the absence of a live embryo. The routine use of KCI in combination with methotrexate may decrease the number of double injections in this group. When a sac is

present,

aspiration

of its content

be-

Figure tamed

4. Slide of histologic specimen in a patient aged 32 years shows

generated arrows) (curved

sclerosed

fore injection does not appear to increase the success rate but should be attempted, as it would reduce distention of the sac and decrease pain after injection of methotrexate. Only a small number of cases could be followed up until the hematosalpinx completely disappeared, but it appears that the larger and more advanced EPs (as indicated

nal magnification,

by

of the fallopian with methotrexate

the

presence

of embryonic

elements)

take longer to resolve (Fig 5). The size of the hematosalpinx in 63% (12 of 19) of the successfully treated EPs was initially increased at follow-up transvaginal US. A similar phenomenon with intramuscular treatment of EP was

chorionic

and degenerated arrows) in the

reported

as

obde-

villi (straight

trophoblast fallopian tube

cells (origi-

x260).

well

(14).

In

addition,

our

series showed increased vascularity in 68% of the responding EPs. Subsequently, we observed that 92% of the tubes that increased in size also showed

increased

vascularity.

to be caused

tube

This

enlargement

after treatment has been presumed

by bleeding

into

the fallo-

pian tube (12). Additional information obtained with the color Doppler technique in our series indicated that in the

majority

of the patients,

distention December

of 1992

a. Figure

5.

jection mately

(May 4 cm.

pinx

(arrowheads).

the

Late resolution 26) demonstrate (c) Transvaginal

fallopian

tube

increased

b. EP in a patient

of an advanced

an advanced EP with an embryo US scan obtained August 6 shows

was

associated

with

vaseularity.

Our histopathologic correlation one patient who required salpingectomy

suggests

3-hCG

that

C.

aged

despite

in

30 years.

(arrow in a) a substantial

moderate in the size

quently,

we had

two

intrauterine

EP in this

group

and

Another important issue in both intratubal and intramuscular treatment of EP is the duration of the treatment. Our series reports a maximum of 69 days for the 3-hCG level to fall to zero and 147 days (in the documented cases) for the hematosalpinx to resolve. The majority

graphic

of these

resolution

always

which

the

zero. pinx

of the

slower serum

In some gradually

maintaining

3-hCG

initial

started

level

the

at

to normal injection

reached

hematosalin size while

multiple

cystic

areas,

to venous spaces, the hematosalpinx

corresponding

developed

rate

appearance,

in others,

mostly

the

patients, decreased its

whereas

hematosalpinx

than

before

resolving important

(Fig 3). No complications occurred in this group of patients. Of the six failures, four occurred within the first 24 hours of the treatment. These patients had to undergo surgery because of increasing

abdominal

revealed

that

tured. bly

pain.

only

one

In retrospect, ruptured

this

before

trexate.

The other

two

surgery level; one

in spite because

pain

and

vaginal

one fresh

due

to

bleeding.

rup-

EP was

injection

undergo 3-hCG

Laparotomy

EP was

proba-

had

to

of declining of increasing

substantial The

trans-

ception

in

the

fallopian

tube

at

the

Sonographic

pinx

site

of EP. The long-term patency of the fallopian tube is an important factor for these patients. The 77% tubal patency rate is slightly lower than that in other reported series although this could be due to our sampling bias, since half of our patients either had a previous EP or had undergone tuboplasty. Reported

185

Number

#{149}

3

after

the

pelvic

fluid

likely

due

serum

3-hCG

level

in size

This

and

its evolution

appears

become

after

to be a healing

non and should condition of the ble. #{149}

3.

4.

5.

6.

7.

8.

9.

10.

We thank Carole Leduc in the preparation of this Lina Zitella for her secretarial

References 1.

Leads from the MMWR: ectopic pregnancy-United States, 1981-1983. JAMA 1986; 255:3221-3224. Pouly JL, Mahnes H, Mage C, Canis M, Bruhat MA. Conservative laparoscopic

AL, Sand treatment methotrexate.

Fertil

PK, Tamura of ectopic Am J Obstet

1987; 1:381-382. Timor-Tritsch I, Baxi L, Peisner DB. Transvaginal salpingocentesis: a new nique for treating ectopic pregnancy.

techAm

Obstet Gynecol 1989; 160:459-461. Pansky M, Bukovsky I, Golan A, et al. Local methotrexate injection: a nonsurgical treatment of ectopic pregnancy. Am J Obstet Gynecol 1989; 161 :393-396. Tulandi T, Bret PM, Atri M, Senterman

M.

by transadminis-

tration. Obstet Gynecol 1991; 77:627-630. Atri M, de StempelJ, Bret PM. Accuracy

ultrasound

for detection

of

hematosalpinx in ectopic pregnancy. JCU 1992; 20:255-261. Cacciatore B, Stenman UH, Ylostalo P. Diagnosis of ectopic pregnancy by vaginal ultrasonography in combination with a discriminatory serum 3-hCG level of 1000 lU/I (IRP). BrJ Obstet Gynecol 1990; 97: 904-908. Pansky M, Golan A, Bukovsky I, Caaspi E. Nonsurgical management of tubal preg-

necessity

clinical appearance. 1991; 164:888-895. Menard A, Crequat

in view of the changing Am J Obstet Gynecol

11.

J, Mandelbrot L, Hauuy JP, Madelenat P. Treatment of unruptured tubal pregnancy by local injection of methotrexate under sonographic control. Fertil Steril 1990; 54:47-50.

12.

Thompson

Methotrexate

13. Acknowledgments: for her assistance manuscript and assistance.

pregnancies.

Gynecol 1986; 154:1299-1306. Fleichtinger W, Kemeter P. Conservative treatment of ectopic pregnancy by transvaginal aspiration under sonographic control and methotrexate injection. Lancet

nancy:

vascu-

phenome-

SJ, Villaneuva Conservative pregnancy with

of endovaginal

treatment.

not cause concern if the patient remains sta-

Ory

in-

approxihematosal-

Treatment of ectopic pregnancy vaginal intratubal methotrexate

(1).

more

of methotrexate

in b) measuring some residual

RK.

to

In summary, the initial appearance of EP cannot be predictive of the response to methotrexate treatment. The EP may

on the day

treatment of 321 ectopic Steril 1986; 46:1093-1097.

of transvaginal

tubal abortion or bleeding secondary to erosion of the tubal mucosa, (c) development of a hemorrhagic ovarian cyst, and (d) pelvic fluid due to rupture of EP, which is known to occur in spite of

2.

Volume

findings

or free

lar during

examination demonstrated that one of these patients had an aborting EP and one had degenerated products of con-

can return

US in patients undergoing medical treatment for EP whose presenting symptoms were new or increasing pain included (a) distention of the fallopian tube with or without increased vascularity interpreted as evidence of healing and organization (resorption) phenomenon, (b) development of a hydrosal-

increase

pathologic

however,

activities 24 hours of methotrexate.

declining

of metho-

patients

patients,

obtained

vascularity (arrow of the EP but still

of pa-

the increase in size and vaseularity of the unruptured EP is part of the healing process and should cause no concern. A declining serum 3-hCG level was the only confirmation of a positive response to the medical treatment. In fact, in our series, the sonowas

levels,

that shows decrease

US scans

patency rates vary from 53% to 100%, with an average rate of 71% (10). Subseone repeated tients.

declining

(a, b) Transvaginal

14.

CR,

O’Shea

injection

RT, Seman

of tubal

E.

ectopic

pregnancy: a logical evolution? Med J Aust 1991; 154:469-471. Stovall TG, Ling FW, Gray LA. Singledose methotrexate for treatment of ectopic pregnancy. Obstet Gynecol 1991; 77:754757. Brown DL, Felker RE, Stovall TC, Emerson DS, Ling FW. Serial endovaginal sonography of ectopic pregnancies treated with

methotrexate.

Obstet

Gynecol

1991;

77:406-409.

Radiology

#{149} 753