Early Ectopic Pregnancy Refractory to Methotrexate Treatment: A Case Report

Abstract

Methotrexate (MTX) is known as a systemic treatment for early ectopic pregnancy with low serum beta-human chorionic gonadotropin (βhCG) levels. Here we present our experience of an unsatisfactory outcome following MTX treatment for early tubal pregnancy. The case is a 39-year-old female with left tubal ectopic pregnancy and a history of one right tubal ectopic pregnancy and an uneventful episode of delivery. In the absence of any contraindications, the patient underwent initial MTX treatment. At first, her serum βhCG level was 1,258 mIU/mL but remained elevated. Then she underwent a second and third dose of MTX. After a month, the serum βhCG level had not declined to within an acceptable range. The ectopic mass was enlarged as determined by transvaginal ultrasonography and hemoperitoneum. A laparoscopic salpingectomy was performed. Early ectopic tubal pregnancy can be managed medically with a high success rate. However, repeat ectopic pregnancy indicates an increased risk of treatment failure to medical treatment, and should be mentioned to the patient when discussing their treatment options.

Keywords: general gynecology; laparoscopic salpingostomy; laparoscopic surgery; methotrexate; ruptured tubal ectopic pregnancy; serum beta hcg; transvaginal ultrasonography; tubal ectopic pregnancy.

Figure 1. TVUS on the first OPD day and initial MTX day.

A: TVUS on the first OPD day. A left tubal ectopic mass measuring 2.4 x 1.58 cm was observed. There was no yolk sac or fetal pole formation. B: TVUS on the day of initial MTX treatment (nine days after first OPD). The left tubal ectopic mass measured 2.3 x 1.3 cm. TVUS: transvaginal ultrasonography; OPD: outpatient department; LT: left. R/O: rule out. PREG: pregnancy.

Figure 2. The βHCG level throughout the treatment course.

The βHCG level was gradually increased since the first day the patient visited the OPD. When the level reached 1,258 mIU/mL, she received the first MTX injection (day one). On day four, her βHCG level elevated to 1,573 mIU/mL, with a 25% elevation. Then she received the second MTX injection. On day seven, the βHCG level was 1,564 mIU/mL. She received the third MTX injection because of the inadequate decreased ratio (<1%). After the three doses of MTX, the βHCG level decreased gradually and stopped decreasing after one month. βHCG: beta-human chorionic gonadotropin; MTX: methotrexate; OPD: outpatient department; LMP: last menstrual period.

Figure 3. TVUS at the emergency department.

Left tubal ectopic mass measuring 1.9 x 1.5 cm. Compared with the previous TVUS images, the size of the mass had shrunk after three doses of MTX. TVUS: transvaginal ultrasonography; MTX: methotrexate.

Figure 4. TVUS after one month from the first OPD visit.

TVUS two weeks after the third MTX injection. Left tubal ectopic mass with the peripheral flow, measuring 4.9 x 4.3 x 4 cm. Some fluid accumulated in the cul-de-sac, measuring 5 x 1.7 cm. TVUS: transvaginal ultrasonography; OPD: outpatient department; MTX: methotrexate; LT: left; CDS: cul-de-sac.

Figure 5. Operative findings of the laparoscopic salpingostomy.

Left tubal ectopic mass measuring about 5 x 4 cm. About 200 ml of blood accumulated in the cul-de-sac.