Direct Methotrexate Injection into the Gestational Sac for Nontubal Ectopic Pregnancy: A Review of Efficacy and Outcomes from a Single Institution.

STUDY OBJECTIVE: To evaluate the efficacy of nontubal ectopic pregnancy (NTEP) management with direct methotrexate (MTX) injection into the gestational sac. DESIGN: A retrospective chart review. SETTING: A tertiary academic and teaching hospital. PATIENTS: All cases of confirmed NTEP were retrospectively identified from 2012 to 2017. INTERVENTIONS: Ultrasound-guided direct injection of MTX into the fetal pole and surrounding gestational sac and a single dose of systemic MTX with or without fetal intracardiac injection of potassium chloride. MEASUREMENTS AND MAIN RESULTS: Treatment failure, complications from treatment, operating time, and days to negative serum human chorionic gonadotropin (hCG) after treatment were measured. Fourteen women (age 34 ± 5.2 years) with NTEP underwent direct MTX injection (cesarean scar, n = 4; interstitial, n = 6; cervical, n = 4). The mean estimated gestational age was 49 ± 11, CI (43, 56 days). One patient required laparoscopic intervention with a failure rate of 1 of 14 (a double interstitial, heterotopic pregnancy). There were no other major complications. The time in the operating room was similar for all NTEP types. The average time to negative serum hCG was not different for cesarean scar (84.5 ± 36 days), cervical pregnancies (70.5 ± 19 days), or interstitial pregnancies (45.3 ± 38 days, p = .15). CONCLUSION: Direct MTX injection into the gestational sac for NTEP treatment is safe and effective. The failure rate of 7% is considerably lower than what was previously reported for a failure of systemic MTX in similar cases (25%). Resolution of serum hCG after treatment can be quite prolonged even in uncomplicated cases.

Laparoscopic ovariectomy in dogs in late gestation.

BACKGROUND: Surgical sterilization of stray dogs is the most widely used technique to control stray dog population. Although ovariectomy is an effective technique for elective sterilization of female dogs, most stray dog population control programs generally utilize ovariohysterectomy for spaying female dogs. In the context of stray dog sterilization, laparoscopic ovariectomy has been utilized and reported to be cost-effective compared to programs utilizing open surgical approaches. However, when pregnant stray dogs are encountered either conventional ovariohysterectomy is performed or surgery is deferred altogether. It is reported that ovariectomy at any stage during canine pregnancy results in fetal resorption or abortion, however, clinical outcomes following laparoscopic ovariectomy in dogs in late gestation have not been previously reported. The purpose of this study was to investigate the outcome of laparoscopic ovariectomy with intra-gestational sac injection (IGSI) of potassium chloride (KCl) in dogs in late gestation. RESULTS: Eight client owned dogs in the gestational age range of 40-50 days underwent laparoscopic ovariectomy with IGSI of KCl. Laparoscopic ovariectomy resulted in decreased serum progesterone from 11.6 ± 2.6 ng/ml on day 0 to 1.3 ± 0.4 ng/ml 24 h' post-surgery. IGSI of KCl did not result in immediate fetal death and fetal death temporally closely followed the drop in serum progesterone noted 24 h post-ovariectomy. Viscous brown vulvar discharge preceded fetal expulsion by 12 h and all the fetuses were dead when expelled. Uterine evacuation was documented within 45 ± 20 h (1-3.5 days) in all dogs without any clinically significant complications. CONCLUSION: Laparoscopic ovariectomy enables elective termination of pregnancy and simultaneous neutering of dogs in late gestation and has potential applications in high volume stray dog sterilization programs which utilize laparoscopy. Utility of IGSI of KCl in this regard is unclear.

Successful treatment of cesarean scar pregnancy with transvaginal injection of absolute ethanol around the gestation sac via ultrasound.

BACKGROUND: This study aims to evaluate the curative effect and complications in cesarean scar pregnancy (CSP) patients treated with a transvaginal injection of absolute ethanol (AE) around the gestation sac (GS) under ultrasound guidance. METHODS: This retrospective clinical investigation analyzed 26 CSP patients treated at the Affiliated Hospital of Guilin Medical University in Guilin, Guangxi, China, between January 1, 2018 and January 30, 2019. Outcomes and complications were analyzed following treatment with AE. RESULTS: Out of the entire group, 20 patients were successfully treated with a single AE injection, while the remaining six patients required two or three repeat injections. In 21 patients, the serum beta-human chorionic gonadotropin (ß-hCG) level was reduced to > 50% 1 day after a single AE injection; in 19 patients, the serum ß-hCG level was reduced to > 80% 4 days after a single AE injection. In all patients, the average time for serum ß-hCG to reduce to normal levels (< 3.0 mIU/mL) was 36.50 ± 12.54 days. The overall cure rate of CSP by AE injection was 100%. Average length of hospitalization was 6.73 ± 3.66 days, with Patient 2 having the longest hospitalization at 17 days, and Patient 3 the shortest at 2 days. No adverse effects on hematopoietic, hepatic or renal function were observed in the short term. CONCLUSION: The study demonstrated that transvaginal injection of AE around the gestation sac under ultrasound guidance had good clinical effects, fewer complications, and merit as a novel treatment for CSP. However, larger multi-center trials are needed to confirm the safety and effectiveness of this treatment.

A Novel Treatment for Cervical and Cesarean Section Scar Pregnancies by Transvaginal Injection of Absolute Ethanol to Trophoblasts: Efficacy in 19 Cases.

STUDY OBJECTIVE: To evaluate the efficacy of a nonsurgical treatment for cervical pregnancy (CP) and cesarean section scar pregnancy (CSP). DESIGN: Retrospective clinical study (Canadian Task Force classification III). SETTING: Private assisted reproductive technology practice. PATIENTS: Nineteen women with CP (n = 16) or CSP (n = 3), including 6 patients with positive fetal heartbeat. INTERVENTION: Transvaginal local injection of absolute ethanol (AE) into the hyperechoic ring (lacunar space) around the gestational sac under ultrasound guidance. MEASUREMENTS AND MAIN RESULTS: Serum beta-human chorionic gonadotropin (ß-hCG) was measured at frequent intervals, and ultrasound and/or magnetic resonance imaging was used to observe the gestational sac. In 9 patients, the serum ß-hCG level was effectively reduced with a single AE injection at 2 hours. In the remaining 10 patients, the level decreased but then increased in 4 and slowly decreased in the other 6; all of these 10 patients required 2 to 5 repeat AE injections. In all patients, serum ß-hCG level was reduced by 50% within 3 days and decreased to <10% of the initial level within 14 days. In 18 patients (95%), the level was decreased to 1.0 mIU/mL within 40 days. Seven patients were treated on an outpatient basis. Twelve patients received no anesthesia. Five patients subsequently became pregnant, and each had a live birth. There was no recurrent CP or CSP. The procedure was successful in all 19 patients. CONCLUSION: This procedure is an effective treatment for CP or CSP that could be used in place of conventional surgical interventions and medical treatment using MTX.

How Does Tobacco Smoke Affect Fetal Growth Potential in the First Trimester of Pregnancy as Measured by Volume Parameters of the Fetus, Trophoblast, and Gestational Sac?

We aimed to assess if tobacco smoke, as measured by the serum concentration of cotinine and blood concentration of cadmium, influences the fetal, sac, and trophoblast volume in the first trimester of pregnancy. We enrolled women in weeks 11 to 14 of pregnancy: 35 smokers, 24 passive smokers, and 98 nonsmoking healthy women. We found that the fetus volume was similar in all groups (18.70 ± 6.29, 17.11 ± 5.4, 18.97 ± 7.55 cm3). The trophoblast was significantly smallest in smokers (50.27 ± 19.56, 56.71 ± 23.50, 61.95 ± 22.94 cm3). The trophoblast volume was correlated with cotinine and cadmium concentration ( r = -0.54, r = -0.44). In passive smokers, gestational sac and trophoblast volume grew systematically and were correlated with the mean parental height. In smokers, only the gestational sac grew systematically and was correlated with the mean parental height. The fetus volume was independent of mean parental height and intensity of exposure to tobacco smoke. Volumetric changes of the fetus, trophoblast, and sac may be observed in the first trimester; however, their consequences require further research.

Hyperosmolar glucose injection for the treatment of heterotopic ovarian pregnancy.

BACKGROUND: Heterotopic pregnancy describes the relatively rare coexistence of one or more intrauterine gestations and one or more extrauterine (ectopic) gestations. We describe a unique clinical case involving successful treatment of an ovarian heterotopic pregnancy through gestational sac aspiration and injection of hyperosmolar glucose. CASE: A 31-year-old woman presented with an ovarian ectopic pregnancy and a viable intrauterine pregnancy after ovulation induction with oral medications. The ovarian gestational sac was aspirated and then injected transvaginally with a small volume of 50% glucose in water. The ectopic pregnancy resolved, and the intrauterine pregnancy was delivered at term without complication. CONCLUSION: Gestational sac aspiration and injection of hyperosmolar glucose into an ovarian ectopic pregnancy was simple and efficacious without compromising a coexisting intrauterine pregnancy.