hCG values and gestational sac size as indicators of successful systemic methotrexate treatment in cesarean scar pregnancy.

OBJECTIVE: To retrospectively investigate cesarean scar pregnancy (CSP) patients who received systemic methotrexate (MTX) and to clarify the criteria for administering systemic MTX to CSP patients. MATERIALS AND METHODS: Fifteen CSP patients who were initially treated with systemic MTX (50 mg/m2/week) were included. Nine patients, who needed a uterine artery embolization (UAE) or a laparotomy, including a transabdominal hysterectomy (TAH), were defined as the unsuccessful MTX group. Six patients who did not require UAE or a laparotomy were defined as the successful MTX group. Furthermore, the hCG cut-off value and the GS cut-off size at the time of CSP diagnosis, which differentiated successful and unsuccessful patients, were defined. MTX success rates were investigated by combining the hCG and gestational sac (GS) size cut-off values. RESULTS: The hCG cut-off value was 17757.0 mIU/mL, and the GS cut-off size was 10.4 mm. In patients with hCG values less than 17757.0 mIU/mL, the MTX success rate was 75.0%. Fewer patients needed UAE or a laparotomy compared to patients with hCG values higher than 17757.0 mIU/mL (P = 0.007). In patients with a GS size less than 10.4 mm, the MTX success rate was 80.0%. Fewer patients among them needed UAE or a laparotomy compared to those among patients with a GS size greater than 10.4 mm (P = 0.089). In patients with hCG values and GS sizes lower than the cut-off values, the MTX success rate was 80.0%. Fewer patients among them needed UAE or a laparotomy compared to those among patients with hCG values and/or GS sizes higher than the cut-off values, respectively (P = 0.010). CONCLUSION: Patients with hCG values less than 17757.0 mIU/mL and GS sizes less than 10.4 mm may have a greater chance of successful systemic MTX treatment when it is used as the first line of treatment for CSP.

Splenic pregnancy treated with transcatheter embolization and methotrexate.

BACKGROUND: Primary splenic pregnancy is a rare entity, usually treated with splenectomy. CASE PRESENTATION AND REVIEW OF THE LITERATURE: We report the first case of conservative management of splenic pregnancy with selective embolization and intramuscular methotrexate administration. Postoperative treatment was uneventful. We have further systematically reviewed the literature upon the treatment options in case of splenic pregnancy. It has been evident that most cases were treated with spleenectomy, especially in case of active hemorrhage. Spleen preservation is rarely achieved, only in cases of hemodynamically stable, uncomplicated patients. CONCLUSION: Splenic selective embolization could be a treatment option in case of uncomplicated splenic pregnancy with the benefit of splenic preservation.

Analyzing the clinical significance of postoperative methotrexate in the management of early abdominal pregnancy: analysis of 10 cases.

OBJECTIVES: To assess the clinical value and treatment outcomes of postoperative methotrexate (MTX) therapy in themanagement of early abdominal pregnancy. MATERIAL AND METHODS: We retrospectively analyzed ten (10) cases of early abdominal pregnancy at our hospital between7th August, 2006 and 20th April, 2017. RESULTS: Out of the ten (10) cases identified, six (6) patients and four (4) patients underwent surgery (laparotomy or laparoscopy)only and surgery (laparotomy or laparoscopy) plus IM 50 mg/m2 methotrexate (MTX) within 24 hours of surgeryrespectively. The gestation age and serum ß-HcG levels were significantly lower (p < 0.05, 6.0 ± 1.82 and 8073.2 ± 9561.0)in the surgery plus MTX group in comparison to (7.33 ± 3.61 and 15625 ± 21275.2) for the surgery only group. Ultrasoundimaging findings reported extra uterine pregnancy in all cases and diagnostic surgery was necessary to locate precise siteof implantation to plan further treatment. Days of hospitalization were shorter in the surgery + MTX group than in thesurgery only group (3.00 ± 0.816 versus 5.66 ± 2.80). CONCLUSIONS: Earliness in diagnosis coupled with the appropriate (methotrexate) MTX regime could help prevent unwantedcomplications that could arise from delayed or misdiagnosis.

Successful management of a spontaneous viable monochorionic diamniotic twin pregnancy on cesarean scar with systemic methotrexate: A case report.

RATIONALE: Cesarean scar twin pregnancy is exceedingly rare and it remains to be a life-threatening condition even in the early weeks of gestation. Because of its rare occurrence, there is no consensus on the treatment modality of cesarean ectopic pregnancy. PATIENT CONCERNS: A 41-year-old, woman, gravida 7, para 6, with a history of low transverse cesarean section 2 years back presented with an estimated 6 weeks gestational age and viable spontaneous twin, monochorionic diamniotic gestation. The patient presented to the Emergency Department with complaints of vaginal bleeding and mild lower abdominal pain for 5 days. DIAGNOSES: An ultrasound examination was performed demonstrating a single intrauterine gestational sac with 2 viable embryos (monochorionic diamniotic) implanted in the lower uterine segment at the level of the prior cesarean section scar. A diagnosis of viable cesarean scar twin pregnancy was made. INTERVENTIONS: A 2 doses of 50 mg/m methotrexate (MTX) was given intramuscularly. The response to the treatment was monitored by serial beta-human chorionic gonadotropin (ß-hCG) and ultrasound. OUTCOMES: Patient was followed up with ß-hCG weekly levels which became 0 after 68 days of treatment. During the follow-up, the patient was asymptomatic, no side effects of MTX were noticed. LESSONS: We reported a rare case of viable monochorionic diamniotic twin pregnancy on a cesarean scar that was successfully treated with systemic MTX without any additional therapy. Additionally, the decline of ß-hCG in twin ectopic cesarean scar pregnancy appears to be similar to a singleton ectopic pregnancy.

Embarazo ectópico abdominal, presentación de un caso y revisión de la literatura / Abdominal ectopic pregnancy: case report and literature review

ANECEDENTES El embarazo ectópico abdominal es raro; con baja incidencia y ausencia de sintomatología especifica que dificulta el diagnóstico y no existan criterios para el diagnóstico y tratamiento. OBJETIVO se presenta un caso de embarazo intra-ligamentario de 16 semanas de gestación y se hacer una revisión de la literatura sobre el manejo y comparación de los resultados. CASO CLÍNICO Mujer de 32 años de edad, gestas 3 partos 2; desconoce fecha de ultima menstruación; y control de la fertilidad con condón; acude por presentar dolor abdominal, sin datos de irritación peritoneal; se le realiza ultrasonido y se diagnostica embarazo de 16 semanas con muerte fetal; con sospecha embarazo abdominal; se realiza laparotomía exploradora para extracción fetal, dejando la placenta in situ, y manejo con metotrexate dejando la placenta in situ y egresado al tercer día sin complicaciones. CONCLUSIÓN el embarazo abdominal es raro, de difícil diagnostico; que requiere la extracción quirúrgica y dejar la placenta in situ y manejo adyuvante con metrotexate; reportándose buenos resultados; pero, existe escasa información sobre la fertilidad futura.

BACKGROUND The abdominal ectopic pregnancy is rare; with low incidence and absence of specific symptomatology diagnosis difficult and there are no criteria for the diagnosis and treatment. OBJECTIVE a case of intra-ligament 16 weeks of gestation pregnancy occurs and a review of literature on the handling and comparison of results is done. CASE REPORT Female 32 years old, deeds 3 births 2; known last menstrual period; and fertility control with a condom; comes because of abdominal pain without peritoneal irritation; Ultrasound was performed 16 weeks pregnant and diagnosed with fetal death; abdominal suspected pregnancy; laparotomy for fetal extraction is performed, leaving the placenta in situ, and leaving management methotrexate placental site and discharged on the third day uncomplicated. CONCLUSION abdominal pregnancy is rare, difficult to diagnose; requiring surgical removal and leave the spot and adjuvant use with methotrexate placenta; good results being reported; but there is little information on future fertility.

Ultrasound-Guided Percutaneous Management of Splenic Ectopic Pregnancy.

Splenic ectopic pregnancies are a rare cause of abdominal pain in reproductive-age women. A 21-year-old woman with worsening abdominal pain and a positive pregnancy test presented with hemoperitoneum and no intrauterine pregnancy on transvaginal ultrasound. After 2 nondiagnostic laparoscopies, a splenic pregnancy was diagnosed by computed tomography scan and abdominal ultrasound. Currently, diagnosis and treatment of splenic pregnancies involve exploratory surgery and splenectomy. We report the successful treatment of this splenic ectopic pregnancy with combined intramuscular plus ultrasound-guided percutaneous methotrexate injection, with preservation of the patient's spleen. Abdominal implantation must be considered in patients with pregnancy of unknown location, and in carefully selected patients splenic ectopic pregnancy can be successfully managed by minimally invasive methods.

Complicated abdominal pregnancy with placenta feeding off sacral plexus and subsequent multiple ectopic pregnancies during a 4-year follow-up: a case report.

BACKGROUND: Abdominal pregnancy (pregnancy in the peritoneal cavity) is a very rare and serious type of extrauterine gestation that accounts for approximately 1.4% of all ectopic pregnancies. It also represents one of the few times an ectopic pregnancy can be carried to term. Early strategic diagnosis and management decisions can make a critical difference with regards to severity of morbidity and mortality risk. After an extensive search of the English language medical literature, we are unaware of any case of abdominal pregnancy in which the placenta was receiving its vascular supply from the sacral plexus. CASE PRESENTATION: A 26-year-old African-American woman, primigravida, at 16 weeks 4 days' gestation, presented to our Emergency Department with abdominal pain. She did not complain of any vaginal bleeding. A physical examination revealed mild abdominal tenderness and no blood in the vaginal vault. Laboratory findings corresponded to an increased level of beta human chorionic gonadotropin; magnetic resonance imaging confirmed an abdominal pregnancy. She underwent feticide, administration of methotrexate and a laparotomy was done which was immediately deferred due to perceived increased bleeding risk. She was found to have an intra-abdominal ectopic pregnancy with the placenta attached to her omentum, cul-de-sac and rectosigmoid, with unusual and extensive vascularity from the sacral plexus. A repeat laparotomy was performed 11 weeks later, aimed at removal of the gestational sac and placenta that were left in situ on the first laparotomy. This time, we achieved successful removal of the peritoneal gestation, lysis of adhesions, ligation of vascular supply and cautery of the diminished vasculature. Subsequently, she had two ectopic pregnancies, which were managed with both medical and surgical interventions. CONCLUSIONS: Ectopic pregnancies should be identified early and evaluated for the etiology of the presentation. Rarely, an ectopic pregnancy implants at an extratubal location. Today, early intervention saves lives and reduces morbidity, but ectopic pregnancy still accounts for 4 to 10% of pregnancy-related deaths and leads to a high incidence of ectopic site gestations in future pregnancies. Medical management has emerged as a safe alternative to surgery and holds promise for preservation of future fertility; however, surgery remains an acceptable modality. We found that careful and strategic choice of management pathway can make all the difference to a favorable outcome. As emergency physicians, we need to be aware of the possibility of abdominal ectopic pregnancy in such presentations and its severe consequences if it remains undiagnosed.

Successful Treatment of a Pararenal Pregnancy Using High-Dose Methotrexate Regimen: A Case Report.

Background: Upper abdominal pregnancy is rare. Most patients present with hemoperitoneum, requiring emergency laparotomy. Case: A 32-year-old woman presented with acute abdominal pain and an elevated beta-human chorionic gonadotropin (ß-hCG) level. Ultrasound, computerized tomography (CT) scans, and laparoscopy failed to locate the source of elevated hCG. Subsequent positron emission tomography (PET)-CT demonstrated a cystic mass in the left pararenal region with no increased uptake. Repeated ultrasound scan revealed a live fetus implanted laterally to the abdominal aorta. After failing to respond to methotrexate at the usual dosage, a regimen used in gestational trophoblastic neoplasia was given. The pregnancy underwent miscarriage afterwards, and the hCG level gradually returned to normal. Conclusion: The site of an ectopic pregnancy should be sought thoroughly to avoid missing an abdominal pregnancy and hence disastrous hemoperitoneum. While medical therapy with high-dose methotrexate is not a standard treatment, it can be considered after failing the traditional therapy, provided that there is adequate treatment monitoring and expertise in handling the side effects of the medication.

Successfully treated abdominal pregnancy causing hemoperitoneum using combined surgical and systemic methotrexate therapy: a case report and review of cases treated at Kyushu University Hospital.

Abdominal pregnancy is a rare condition that accounts for only 1% of all ectopic pregnancies but results in high maternal morbidity and mortality. We present a case of abdominal pregnancy with massive peritoneal bleeding successfully treated using systemic methotrexate (MTX). A 34-year-old woman with amenorrhea for 8 weeks and a positive pregnancy test was referred for evaluation of ectopic pregnancy. Transvaginal ultrasonographic scan showed a gestational sac measuring 25 mm in diameter containing a viable embryo in the cul-de-sac and a considerable amount of free fluid in the patient's lower abdomen and pelvis. Laboratory parameters showed that her hemoglobin concentration was 5.8 g/dl and serum human chorionic gonadotropin concentration was 13,195 mIU/ml. Emergency surgery revealed an abdominal pregnancy in the cul-de-sac and a massive intra-abdominal hemorrhage. After a hemostasis procedure, the patient was successfully treated using systemic MTX. We also present the review of abdominal pregnancy cases treated using systemic MTX at our institution over 10 years. Systemic MTX treatment for abdominal pregnancy is safe and effective and makes it possible to avoid the risk of excessive bleeding by surgical resection of the implantation site.

Nonsurgical management of heterotopic abdominal pregnancy.

BACKGROUND: Heterotopic abdominal pregnancies with coexisting intrauterine pregnancies pose unique therapeutic challenges, and management options, particularly nonsurgical approaches, are limited. CASE: We present a case in which selective reduction of a heterotopic abdominal pregnancy during the second trimester using fetal intracardiac injection with potassium chloride enabled subsequent vaginal delivery of the intrauterine pregnancy at term. In addition, we summarize nine cases of nonsurgical management of heterotopic abdominal pregnancies, four of which involve potassium chloride selective reduction. Our case is unique in that the abdominal fetus remained as a stable lithopedion, allowing the uncomplicated conception and vaginal delivery of a second intrauterine pregnancy without need for surgical intervention. CONCLUSION: Our case report and literature review demonstrate the use of selective potassium chloride reduction in managing heterotopic abdominal pregnancy nonsurgically.

Management of ectopic pregnancies with poor prognosis through ultrasound guided intrasacular injection of methotrexate, series of 14 cases.

PURPOSE: The purpose of this study is to describe our experience in cases of tubal ectopic pregnancy with heartbeat, abdominal, interstitial (corneal) and cervical ectopic pregnancies treated with intrasacular injection of methotrexate (MTX) administered under ultrasound guidance associated with a single systemic dose of MTX. METHODS: Descriptive retrospective study of 14 cases of extrauterine pregnancies treated with intrasacular injection of MTX under ultrasound control, attended in the Maternal-Fetal Medicine Unit of the Miguel Servet University Hospital, in Zaragoza, Spain, between January of 2009 and June of 2010. RESULTS: Of the 14 ectopic pregnancies, 7 were tubal with heartbeat, 3 cornual, 2 cervical and 2 abdominal. The average gestational age was 7 + 3 weeks and the average ß-hCG value on the date of puncture was 22,885.69 mIU/mL. Surgical treatment was required in two cases, the first due to post-puncture haemoperitoneum and the second as a consequence of the rupture of the corneal ectopic pregnancy. In post-treatment monitoring, an asymptomatic increase of ß-hCG on the seventh day post-puncture was observed in two cases. The success rate of the treatment was 92.96%. CONCLUSIONS: Ultrasound guided intrasacular injection of MTX associated with a systemic dose adjusted to the body surface of the patient is a minimally invasive, safe and effective treatment in the cases of tubal ectopic pregnancy with heartbeat, abdominal, cornual or cervical ectopic pregnancy.

Successful operative management of an intact second trimester abdominal pregnancy with additional preoperative selective catheter embolization and postoperative methotrexate therapy.

BACKGROUND: Abdominal pregnancy is a rare condition that may lead to severe complications. CASE REPORT: The authors report the case of a 17-week intact abdominal pregnancy diagnosed in the course of an investigation of lower abdominal pain. Ultrasonography and MR examination revealed an intact abdominal pregnancy. Subsequent angiography was performed to occlude the supportive artery of the pregnancy by selective embolization. The pregnancy was terminated safely by laparotomy a day later. The placenta was left in the abdominal cavity because of the high risk of massive and often uncontrollable bleeding, and treatment with methotrexate was applied postoperatively. CONCLUSIONS: Preoperative embolization and the postoperative methotrexate therapy facilitate the safe surgical treatment of abdominal pregnancy.

Laparoscopic management of primary hepatic pregnancy.

A 30-year-old woman presented with epigastric pain with elevated serum human chorionic gonadotropin level (hCG), absence of intrauterine gestational sac and absence of an abnormal adnexal mass on pelvic ultrasonography. Laparoscopy revealed a ruptured hepatic ectopic pregnancy. This was removed by laparoscopic suctioning and haemostasis secured with Surgicel((R)) Fribrilla Absorbable Hemostat. Intramuscular methotrexate was administered post-operatively. Patient recovered uneventfully and serum hCG returned to normal.

Conservative treatment of an early ectopic pregnancy in a cesarean scar with systemic methotrexate--case report.

PURPOSE OF INVESTIGATION: Pregnancy implanted in a cesarean scar is rare, and is a life-threatening condition due to high risk of uterine rupture, hemorrhage, hysterectomy, and maternal mortality. CASE REPORT: We describe a 26-year-old woman who presented with five weeks of amenorrhea and a serum hCG level of 10,440 mIU/ml. Transvaginal sonography revealed a gestational sac of 15 x 11 mm containing a yolk sac located in a previous cesarean scar. She was successfully treated conservatively with multi-dose methotrexate. No side-effects were encountered. The serum hCG levels were undetectable in 58 days. The patient had normal menstrual cycles afterwards. CONCLUSIONS: In the view of increasing cesarean rates, healthcare professionals should be aware of the possibility of a scar pregnancy and the potentially life threatening sequelae. Early diagnosis by transvaginal sonography can improve outcome and minimize the need for emergent surgery. Conservative treatment with systemic methotrexate is an effective option in selected patients.

Failed treatment of abdominal pregnancy with methotrexate. A case report.

BACKGROUND: Methotrexate is an effective, safe, low-cost alternative to surgery for treating tubal pregnancies. To our knowledge, there have only been two other reported attempts at treating abdominal pregnancy with methotrexate. CASE: Despite two courses of treatment with methotrexate, the pregnancy persisted, and laparoscopy permitted a tissue diagnosis of abdominal pregnancy. CONCLUSION: Although treatment with methotrexate was not successful in this case, its potential use in abdominal pregnancies merits further investigation.

Contribution to the choice of therapy in abdominal pregnancy.

The goal of our study was to offer our contribution to the selection of the most suitable therapy to treat abdominal pregnancy. We discuss three patients affected with this pathology, which was diagnosed early by laparoscopy. The patients were treated with 50 mg/m2 of methotrexate administered intravenously. The abdominal pregnancy was terminated in all three patients. Since the outcome involved termination of the pregnancy, it is important to emphasize that methotrexate therapy, must be considered elective. Operative laparoscopy can be limited only to cases in which the ovum has not become implanted in the intestinal interstices and is not near sites susceptible to complications.

Surgical and medical management of tubal and non-tubal ectopic pregnancies.

This article highlights recent findings in the diagnosis and management of ectopic pregnancy. While the search for the ideal biochemical marker for ectopic pregnancy continues, new protocols have been described for the management of persistent ectopic pregnancy. The role of nuclear marker Ki-67 in trophoblastic proliferation and the only randomized trial to date involving systemic methotrexate and laparoscopic surgery are discussed. The management of cervical, interstitial and heterotopic pregnancies are reviewed.

Abdominal pregnancy as a result of gamete intrafallopian transfer (GIFT) and subsequent treatment with methotrexate: case report.

A patient underwent a minilaparotomy for gamete intrafallopian transfer (GIFT), and subsequently developed an abdominal pregnancy. The patient was treated with methotrexate, and a good resolution was obtained, with total disappearance of beta-hCG titers after 22 days from the beginning of therapy.