Conference Proceedings - Gynecology and Reproductive Endocrinology (2021) Volume 5, Issue 0

Successful management of live ectopic pregnancy with high B-hCG titres by systemic methotrexate injection

Our case was a 31 years old primigravid woman with a sonogram's report of 7 weeks, live ectopic pregnancy, which her initial serum B-hCG concentration was 26900. Her vital signs were stable and she did not agree with any operative intervention. She chose medical treatment. Due to high serum titers of B-hCG, the two-dose protocol was scheduled. Appropriate response to treatment was obtained after receiving the third dose. Negative serum B-hCG (< 1 mIu/ml) was achieved on day 80 without any related treatment complication on follow up. Use of methotrexate (MTX) as a nonsurgical management of unruptured ectopic pregnancies has been well accepted and used from 1982.There are some absolute contraindications to the methotrexate therapy, including intrauterine pregnancy, breastfeeding, bone marrow dysfunction, Sensitivity to methotrexate, Active pulmonary disease, Active peptic ulcer disease, clinically important hepatic and renal dysfunction and Inability to participate in follow-up. Besides, some conditions are mentioned as relative contraindications, such as presence of fetal cardiac activity, a high initial hCG concentration (greater than 5000 mIU/mL), Ectopic pregnancy greater than 4 cm in size in transvaginal ultrasonography. But take a look at different articles, we find out, these conditions actually only reduce the chances of successful treatment rate and these cut offs are only a suggestion regarding a value below which methotrexate therapy will be more successful .For example in one systematic review a higher failure rate of 14.3% in HCG levels higher than 5000 mIU/mL compared with 3.7% failure rate for HCG levels less than 5000 mIU/mL . Or in a large analysis of three hundred fifteen ectopic pregnancies , the presences of fetal cardiac activity was associated with the success rate of 88 percent. On the other hand, we agree with some authors that the type of methotrexate protocols used is another factor, which can affect the overall success rate of treatment. In our experiences, in situations that the success rate is questionable, we means the relative contraindications, the two dose protocols are superior to single-dose. We know and agree the fact that in presence of fetal heart activity, some interventions like Ultrasound-guided KCL injection, has been able to improve treatment success rate, and in most situations, we use them, but there are situations, we have to use the available facilities. As our hospital was a single-specialist, we did not have a specialist for KCL injection over the next week. Our patient was not satisfied for dispatching to another hospital, neither for laparoscopy nor for KCL injection so we chose two-dose MTX protocol. This is the message I want to convey at the end of my speech that relative contraindications for MTX therapy in ectopic pregnancy should be reviewed in some special situation. Although high initial titration in ectopic pregnancy may decrease the success of medical treatment, the use of a double-dose protocol may increase the chance of successful medical treatment and non-surgical management in fully selected patients.

Author(s): Asieh Maleki

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