FERTILITY AND STERILITY
Vol. 58, No.6, December 1992
Copyright f) 1992 The American Fertility Society
Printed on acid-free paper in U.S.A.
Treatment of interstitial pregnancy with methotrexate via hysteroscopy
Mordechai Goldenberg, M.D.* David Bider, M.D. Gabriel Oelsner, M.D.
Dahlia Admon, M.D. Shlomo Mashiach, M.D.
The Chaim Sheba Medical Center, Tel Hashomer, Israel
Conservative, nonsurgical management of ectopic pregnancies (EPs), in an effort to preserve fertility and to avoid surgical procedures under anesthesia, has become increasingly popular (1). Today, methotrexate (MTX) is widely proposed as a mode of conservative medical treatment of EPs in selected patients. The main advantage of local MTX administration is that a lower dose than that given parenterally can be used, producing no systemic side effects. Different modes of local MTX administration were proposed: injection into the ectopic gestational sac under transvaginal sonographic control, during laparoscopy, or during retrograde tubal cannulation (1, 2). We describe a recent treatment of interstitial pregnancy with MTX that was administered locally via hysteroscopic vision. CASE REPORT
A 34-year-old, gravida 5, para 2 patient was admitted because of abdominal pain and vaginal bleeding. Her cycles were usually regular, but she was admitted after amennorrhea of 6 weeks. At the age of 27 years, she underwent a left salpingectomy after a left ampullar pregnancy. On admission, gynecological examination demonstrated a small, anteverted uterus, and normal adnexa without tenderness with no vaginal bleeding. Serum i3-human Received June 1, 1992; revised and accepted August 26, 1992.
* Reprint requests: Mordechai Goldenberg, M.D., Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.
1234
Goldenberg et aI.
Communications-in-brief
chorionic gonadotropin (i3-hCG) level on admission was 278 mIU /mL. Ultrasonography revealed a normal uterine cavity, no adnexal mass, and no fluid in the pouch of Douglas. The patient was hospitalized and remained clinically stable without additional complaints. However, serum i3-hCG level increased gradually to 1,200 mIU /mL over the following 7 days. We suspected an extrauterine pregnancy and therefore performed diagnostic laparoscopy under general anesthesia. A normal right fallopian tube with two normal ovaries was observed. The abdominal cavity was free from blood, and no peritoneal signs of EP were observed. The i3-hCG levels increased from 1,200 mIU/mL to 1,280 mIU/mL the day after the procedure and then increased to 1,400 mIU/mL 2 days later. A repeated ultrasonographic evaluation at this stage demonstrated a corneal pregnancy of 7 mm in diameter (Fig. 1). After consultation with the patient, we decided to inject MTX during diagnostic hysteroscopy and direct vision of the internal tubal os. A double-channel operative hysteroscope with Albran bridge (OFS, 8 mm; Olympus Optical Co. GmBH, Hamburg, Germany) was introduced into the uterine cavity under local anesthesia, using lidocaine 1 % and cervical dilatation to Hegar 8 mm. A guide-assembling, cornusshaped catheter (Ova bloc; Europe BV, Leiden, The Netherlands) was introduced via the operative channel. There was no presence of blood in the uterine cavity. The operative hysteroscope was then introduced as far as the internal tubal ostium. Through the catheter, 25 mg of MTX, diluted in 2.5 mL saline,
Fertility and Sterility
Figure 1
Interstitial pregnancy.
was injected into the interstitial portion of the tube as described by others (3, 4). The day after the procedure, the serum ,B-hCG level increased to 2,000 mIU jmL and then decreased gradually to 200 mIU jmL during the 2 weeks of hospitalization after the procedure. The patient was discharged from the hospital after 48 hours and was followed up with advice to pay attention to abdominal pain or vaginal bleeding and to return to the hospital with any complaint. The serum ,B-hCG level a week later was undetectable «10 mIUjmL). Ultrasonographic examination failed to demonstrate the previously seen interstitial sac. No side effects were recorded that were connected with the use ofMTX.
DISCUSSION
Conservative management of interstitial pregnancy is a particularly attractive method. The management is always surgical, and laparotomy is almost inevitable. Laparoscopic surgery is rarely possible. Recently, local or systemic administration of MTX has gained widespread attention as a new regimen for the treatment of ectopic tubal pregnancies. Treatment of an interstitial pregnancy with MTX to hasten the involvement of the trophoblast was reported in the past with encouraging success: Fernandez et al. (5) described conservative MTX therapy of six interstitial pregnancies with a 50% success rate. They concluded that MTX is a viable alternative to surgery, and when the initial level of ,B-hCG is
Vol. 58, No.6, December 1992
Copyright f) 1992 The American Fertility Society
Printed on acid-free paper in U.S.A.
Treatment of interstitial pregnancy with methotrexate via hysteroscopy
Mordechai Goldenberg, M.D.* David Bider, M.D. Gabriel Oelsner, M.D.
Dahlia Admon, M.D. Shlomo Mashiach, M.D.
The Chaim Sheba Medical Center, Tel Hashomer, Israel
Conservative, nonsurgical management of ectopic pregnancies (EPs), in an effort to preserve fertility and to avoid surgical procedures under anesthesia, has become increasingly popular (1). Today, methotrexate (MTX) is widely proposed as a mode of conservative medical treatment of EPs in selected patients. The main advantage of local MTX administration is that a lower dose than that given parenterally can be used, producing no systemic side effects. Different modes of local MTX administration were proposed: injection into the ectopic gestational sac under transvaginal sonographic control, during laparoscopy, or during retrograde tubal cannulation (1, 2). We describe a recent treatment of interstitial pregnancy with MTX that was administered locally via hysteroscopic vision. CASE REPORT
A 34-year-old, gravida 5, para 2 patient was admitted because of abdominal pain and vaginal bleeding. Her cycles were usually regular, but she was admitted after amennorrhea of 6 weeks. At the age of 27 years, she underwent a left salpingectomy after a left ampullar pregnancy. On admission, gynecological examination demonstrated a small, anteverted uterus, and normal adnexa without tenderness with no vaginal bleeding. Serum i3-human Received June 1, 1992; revised and accepted August 26, 1992.
* Reprint requests: Mordechai Goldenberg, M.D., Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel Hashomer 52621, Israel.
1234
Goldenberg et aI.
Communications-in-brief
chorionic gonadotropin (i3-hCG) level on admission was 278 mIU /mL. Ultrasonography revealed a normal uterine cavity, no adnexal mass, and no fluid in the pouch of Douglas. The patient was hospitalized and remained clinically stable without additional complaints. However, serum i3-hCG level increased gradually to 1,200 mIU /mL over the following 7 days. We suspected an extrauterine pregnancy and therefore performed diagnostic laparoscopy under general anesthesia. A normal right fallopian tube with two normal ovaries was observed. The abdominal cavity was free from blood, and no peritoneal signs of EP were observed. The i3-hCG levels increased from 1,200 mIU/mL to 1,280 mIU/mL the day after the procedure and then increased to 1,400 mIU/mL 2 days later. A repeated ultrasonographic evaluation at this stage demonstrated a corneal pregnancy of 7 mm in diameter (Fig. 1). After consultation with the patient, we decided to inject MTX during diagnostic hysteroscopy and direct vision of the internal tubal os. A double-channel operative hysteroscope with Albran bridge (OFS, 8 mm; Olympus Optical Co. GmBH, Hamburg, Germany) was introduced into the uterine cavity under local anesthesia, using lidocaine 1 % and cervical dilatation to Hegar 8 mm. A guide-assembling, cornusshaped catheter (Ova bloc; Europe BV, Leiden, The Netherlands) was introduced via the operative channel. There was no presence of blood in the uterine cavity. The operative hysteroscope was then introduced as far as the internal tubal ostium. Through the catheter, 25 mg of MTX, diluted in 2.5 mL saline,
Fertility and Sterility
Figure 1
Interstitial pregnancy.
was injected into the interstitial portion of the tube as described by others (3, 4). The day after the procedure, the serum ,B-hCG level increased to 2,000 mIU jmL and then decreased gradually to 200 mIU jmL during the 2 weeks of hospitalization after the procedure. The patient was discharged from the hospital after 48 hours and was followed up with advice to pay attention to abdominal pain or vaginal bleeding and to return to the hospital with any complaint. The serum ,B-hCG level a week later was undetectable «10 mIUjmL). Ultrasonographic examination failed to demonstrate the previously seen interstitial sac. No side effects were recorded that were connected with the use ofMTX.
DISCUSSION
Conservative management of interstitial pregnancy is a particularly attractive method. The management is always surgical, and laparotomy is almost inevitable. Laparoscopic surgery is rarely possible. Recently, local or systemic administration of MTX has gained widespread attention as a new regimen for the treatment of ectopic tubal pregnancies. Treatment of an interstitial pregnancy with MTX to hasten the involvement of the trophoblast was reported in the past with encouraging success: Fernandez et al. (5) described conservative MTX therapy of six interstitial pregnancies with a 50% success rate. They concluded that MTX is a viable alternative to surgery, and when the initial level of ,B-hCG is
