Transabdominal Ultrasound-Guided Injection of Methotrexate in the Treatment of Ectopic Interstitial Pregnancies Marialuisa Framarino-dei-Malatesta, MD,1 Maria Grazia Piccioni, MD,1 Martina Derme, MD,1 Nicoletta Fabiana Polidori, MD,1 Valentina Tibaldi, MD,1 Isabella Iannini, MD,1 Gabriele Masselli, MD2 1
Department of Gynaecological, Obstetrical, and Urological Sciences, Umberto I Hospital, University of Rome Sapienza, Italy 2 Radiology Dea Department, Umberto I Hospital, University of Rome Sapienza, Italy Received 26 March 2013; accepted 22 May 2014
ABSTRACT: Purpose. In a retrospective observational study, we evaluated the feasibility and safety of medical therapy with transabdominal ultrasoundguided injection of methotrexate (MTX) into the gestational sac (GS) in patients with interstitial ectopic pregnancies. Methods. Fourteen interstitial ectopic pregnancies were treated with transabdominal ultrasound-guided injection of MTX (25 mg). All patients were hemodynamically stable. In all patients, the 10-cm distance between the GS and vaginal fornices was 10 cm, making transvaginal injection difficult. To evaluate feasibility and safety of the procedure, we assessed complications clinically and with imaging during a 1year follow-up. Results. In all 14 patients, MTX injected locally into the GS successfully terminated the interstitial pregnancy, thereby avoiding surgery. There was no complications during follow-up. Conclusions. The successful outcome in our patients suggests that the transabdominal route is feasible and safe as a nonsurgical option for terminating an ectopic interstitial pregnancy in patients in whom the transvaginal route is contraindicated or difficult, provided the patients are properly selected and operators have sufficient experience with the techC 2014 Wiley Periodicals, Inc. J Clin Ultrasound nique. V 42:522–526, 2014; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/ jcu.22185 Keywords: ectopic pregnancy; interstitial pregnancy; methotrexate; ultrasound; obstetrics
Correspondence to: M. Framarino-dei-Malatesta C 2014 Wiley Periodicals, Inc. V
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ctopic pregnancies most commonly arise within the isthmic or ampullar sections of the Fallopian tube.1 An interstitial pregnancy is rare (1–6% of all ectopic pregnancies) with a mortality of 2.5%, which is seven times higher than that of ectopic pregnancies in general.2–4 Although in the past, interstitial ectopic pregnancies were diagnosed late, they can now be diagnosed earlier, thanks to advances in transvaginal ultrasound (US) imaging together with the rapid serum b-human chorionic gonadotropin (b-hCG) assay.5 An early diagnosis means that patients can undergo nonsurgical treatment, thus minimizing morbidity and mortality, with the folic acid antagonist methotrexate (MTX) injected parenterally or locally through the vaginal route.6 Local injection has the advantage of reducing the required total MTX dose.7 In the case of interstitial ectopic pregnancies, the myometrial thickness that surrounds the sac reduces the risk of tubal wall rupture.8 We have already reported two cases of angular live ectopic pregnancies (one in the left cornua and the other in the right cornua of the uterus) treated successfully with transabdominally injected MTX.9 No study has investigated whether interstitial pregnancies respond to MTX injected locally through the abdominal route. Having this information would provide an alternative treatment option for patients in whom the transvaginal route is contraindicated or difficult. We reviewed a series of consecutive patients with interstitial ectopic pregnancies treated in JOURNAL OF CLINICAL ULTRASOUND
MTX IN INTERSTITIAL ECTOPIC PREGNANCIES
the gynecological clinic of our tertiary referral center, with direct transabdominal US-guided injections of MTX into the gestational sac (GS). Our primary aim was to find out whether such medical therapy provided a safe and successful outcome. Outcome measures included the successful termination of the pregnancy and the presence of complications during a 1-year follow-up with clinical evaluation and US imaging.
MATERIALS AND METHODS
From a consecutive series of 180 patients with ectopic pregnancies treated medically at the Department of Gynaecological, Obstetrical, and Urological Sciences, Umberto I Hospital, Sapienza University Rome, between January 2007 and December 2012, we identified 14 consecutive patients, all of whom met the Tulandi criteria for interstitial pregnancies10 and received direct MTX injections into the GS under transabdominal US guidance. During this period, another two patients with interstitial pregnancies, who had no contraindication for the transvaginal approach, were treated with transvaginal US-guided MTX injection. All 14 patients were hemodynamically stable, had a b-hCG concentration 5,000 mIU/mL, and an ectopic GS no larger than 5 cm. They were willing and able to comply with posttreatment follow-up and gave informed consent. In only two cases, the embryo showed cardiac activity. During the pretreatment diagnostic workup to confirm the ectopic pregnancy, all patients had a serum b-hCG test. In all 14 patients, transvaginal US documented an empty uterus and a GS extending from the most lateral edge and surrounded by a myometrial layer.11 The distance between the GSs and vaginal fornices exceeded 10 cm, thus making the transvaginal route difficult and possibly risky: this increased distance was the result of uterine myomas in five patients, of pelvic adhesions in another five patients, of a high body mass index (BMI; mean of 29) and of both pelvic adhesions and a high BMI in one patient. Pelvic adhesions resulted in blurred ovarian margins, ovary fixed to the uterus, and poorly defined pelvic structures.12 We used a Voluson 730 Expert scanner (GE Healthcare, Milwaukee, WI) equipped with a three-dimensional transabdominal and transvaginal transducers coupled with a disposable puncture guide. MTX was injected with a 21-gauge 20-cm-long Chiba needle. After the VOL. 42, NO. 9, NOVEMBER/DECEMBER 2014
transabdominal transducer had located the GS, MTX (25 mg in 5 mL saline) was injected into the sac or the embryo. The patient was prepped in a sterile manner and the probe was covered with a sterile sheath. Local anesthesia was applied with lidocaine spray. We did not aspirate any fluid from the GS before injecting MTX. No procedure necessitated more than one puncture. The puncture site was checked with US for 10 minutes to detect early bleeding, and the patient was clinically monitored (blood pressure, heart rate, and body temperature) every 30 minutes for the following 3 hours. After discharge from the clinic, all the patients were followed up for 1 year with twice weekly quantitative b-hCG serum levels for 2 weeks, then once a week until levels were