The efficacy and safety of managing ectopic pregnancies with transvaginal ultrasound-guided local injections of absolute ethanol

Abstract

Purpose: To describe the efficacy and safety of managing ectopic pregnancies (EP) with ultrasound-guided local injections of absolute ethanol (AE).

Methods: 69 cases of EP following IVF performed in our clinic were treated with a local injection of 0.3 ml AE with a 23-gauge needle under transvaginal ultrasonic guidance. The efficacy was evaluated comparing serum beta-human chorionic gonadotropin (beta-hCG) levels before and after the injection.

Results: In the 60 successful cases (87%), the serum beta-hCG level decreased by 10-30% in two hours postinjection. Of these, 46 were effective with a single injection and the half-life of beta-hCG was achieved within 4 days in 45 cases. In 56 cases (including repetitive administration) serum beta-hCG levels decreased to 20 mIU/mL within 20 days. The treatment showed no side effects and could be given on an outpatient basis without anesthesia.

Conclusions: This method was shown to be a safe, effective new approach to treating EP.

Fig. 1.

The case was of a 38-year-old, nulligravid woman who underwent IVF-ET. The GS was found inside the left fallopian tube on 5 weeks 3 days GA (A). The serum β-hCG level before the injection was 6694 mIU/ml. Absolute ethanol 0.3 ml was directly injected into the GS and its surrounding area using a 23-gauge needle under transvaginal ultrasonic guidance. After the injection, although GS fluid was absorbed and became invisible, the injected site could be clearly seen on the ultrasonic image as a high-intensity mass (B). The serum β-hCG level measured 2 hours post-injection was 4993 mIU/ml, showing a decrease of 28.6%. The level continued to decrease to 1374 mIU/ml, 668 mIU/ml, and 25 mIU/ml on 2 days, 6 days, and 2 weeks post-injection, respectively. During the follow-up, the injected site continued to be visible as a high-intensity area.

Fig. 2.1.

Post-injection course of serum β-hCG level in the cases treated with single local injection of AE. This figure shows the post-injection course of the higher (≥2000 mIU/ml; n=18) and lower (<2000 mIU/ml; n=28) serum β-hCG level groups, both of which responded effectively to a single administration of local injection. In all cases, the half-life was achieved within 4 days.

Fig. 2.2.

Post-injection course of serum β-hCG level in the cases that required repeated local injections. This figure shows the post-injection course of the 14 cases in which the level of β-hCG decreased once but rose again. They responded effectively after repeated local injections. The local injection was administered when the level rose (marked with o). One case, in which the presence of a tubal hematoma was observed before the injection, resulted in laparotomy because a hemorrhage developed after the injection (marked with △).

Fig. 3.

Histological findings after alcohol injection (HE stained). The case was that of a 33-year-old nulligravid woman who underwent IVF-ET. Two 5-cell embryos (G1 and G2) were transferred on day 2, resulting in pregnancy. As no intrauterine GS was observed but a tubal GS was observed in the left ampulla of the fallopian tube on 6 weeks 4 days, 0.3 ml of AE was directly injected to the GS under transvaginal ultrasonic guidance. On the following day, as the serum β-hCG level was not reduced, laparoscopy was carried out and bilateral tubal pregnancies in both the left and right ampulla were confirmed. The right fallopian tube was removed. Linear salpingostomy was carried out to the left fallopian tube, extracting the fertile ovum, and salpingoplasty was carried out. Photograph A shows the histological finding of chorionic tissue (HE stained) after the alcohol injection and Photograph B shows the villous tissue (HE stained) in the tubal pregnancy on the right fallopian tube.