Ectopic pregnancy treatment using pelviscopic or vaginosonographically-guided intrachorionic injection of methotrexate and POR 8

Abstract

It is believed by some that the basis of modern first-trimester pregnancy care should involve screening for ectopic pregnancy using vaginal ultrasonography. This has led to this condition being diagnosed in most cases at an earlier stage than has previously been possible. This advance in diagnostic ability has introduced the concept of conservative management for this condition. The authors describe the conservative management of nine cases of ectopic pregnancy using intrachorionic injection of either methotrexate alone or in combination with POR 8. In all cases less than 9 weeks had passed since the last menstrual period, and the ectopic pregnancies treated under ultrasound control were all thought to be viable. Five cases were treated using pelviscopy, whilst in another four the needle was guided using vaginal ultrasonography. There were no procedure-related complications. Following therapy, the women were followed up using serial levels of serum beta-hCG. In seven cases there was a gradual reduction to normal levels. There were two treatment 'failures'. In both these cases methotrexate alone, rather than in combination with POR 8, was used for injection. Although formal tests of tubal patency have not been performed in all cases, one woman in the series has since conceived and has a normal intrauterine pregnancy. It is concluded that vaginal instillation of methotrexate is an alternative treatment for early ectopic pregnancy. It should be limited to viable ectopic pregnancies whose chorionic cavities are less than 2.0 cm in diameter. A plan for the management of ectopic pregnancy is presented, involving selection for both ultrasound-guided injection and pelviscopic surgery. Laparotomy is not considered to be a treatment option in the majority of cases.