Efficacy of In Situ Methotrexate Injection in the Treatment of Nontubal Ectopic Pregnancies: A Retrospective Multicenter Study.

STUDY OBJECTIVE: Evaluation of the efficacy of different injection sites of methotrexate in the treatment of nontubal ectopic pregnancies. DESIGN: Retrospective multicenter study. SETTING: Multicenter, including 3 teaching hospitals, an intercommunal hospital, and a clinic. PATIENTS: A total of 106 patients with nontubal ectopic pregnancies, including 59 interstitial, 39 cesarean scar, and 8 cervical or isthmic. INTERVENTIONS: Overall, 58 patients received methotrexate via intramuscular injection (IM group), 35 received methotrexate via in situ injection (IS group), and 13 received a combination of both in situ and intramuscular injections of methotrexate (IS + IM group). MEASUREMENTS AND MAIN RESULTS: The main end point of this study was measured via the primary success rate (defined as a negative ß-human chorionic gonadotropin level without recourse to any additional treatment) of treatment with methotrexate according to injection site. The primary success rate was 46.55% in the IM group, 60% in the IS group, and 61.54% in the IS + IM group, respectively. In the multivariate analysis, the primary success rate of treatment was significantly correlated to the in situ injection of methotrexate, either solely or in conjunction with an intramuscular injection of methotrexate administered the following day, (odds ratio = 2.7; 95% confidence interval, 1.03-7.14). CONCLUSION: Solely an intramuscular injection of methotrexate is a less efficient first-line treatment strategy for the conservative management of nontubular ectopic pregnancy. The use of an in situ injection of methotrexate should therefore be preferred.

Surgical management of isthmocele symptom relief and fertility.

OBJECTIVE: To describe symptoms and fertility and quality of life outcomes after isthmocele surgery. STUDY DESIGN: We conducted a retrospective study on from January 2012 to December 2017 in two tertiary referral centers in Rennes (France). All the patients diagnosed with isthmocele and operated were included. They all underwent isthmocele surgery by hysteroscopy, vaginal way or laparotomy. RESULTS: The following data were collected: surgical procedure, symptoms and fertility before and after surgery, patient satisfaction about the surgery, and quality of life after surgery. Eighteen patients were included. The mean duration of follow-up was 15 months. Surgical procedures consisted of hysteroscopy (n = 5/18, 27.8%), vaginal surgery (n = 8/18, 44.4%) and laparotomy (n = 5/18, 27.8%). Surgical indications were: secondary infertility (n = 10/18, 55 %), pelvic pain (n = 5/18, 28%) and abnormal uterine bleeding (n = 3/18, 17%). Among patients with abnormal uterine bleeding, improvement was obtained after hysteroscopy, laparotomy and vaginal surgery for 83.3%, 75% and 50%, respectively. Among those with pelvic pain, improvement was obtained after hysteroscopy, laparotomy and vaginal surgery for 80%, 81% and 66%, respectively. One patient (1/18, 5.5%) had post-operative complication. Of the 12 patients who wished to conceive eleven pregnancies were obtained (91.7%). Of the 10 patients with secondary infertility, six became pregnant (60%). Five pregnancies (5/11, 45.4%) were carried to full term, including four in patients whose surgical indication was infertility. Among these, one patient had a vaginal delivery (after vaginal surgery) without obstetric complication. All patients operated on by hysteroscopy would recommend this surgery versus 75% of patients with vaginal surgery and 60% of patients with laparotomy (p = 0.24). Pain and quality-of-life scores were comparable between the three groups. CONCLUSION: Isthmocele surgery is effective for abnormal uterine bleeding, pain and infertility regardless of the surgical route.

Effectiveness of conservative medical treatment for non-tubal ectopic pregnancies: a multicenter study.

OBJECTIVE: To assess the effectiveness of conservative treatment for the management of non-tubal ectopic pregnancies (NTEP) METHODS: Retrospective cohort study in three centers (two referral centers) of patients managed for NTEP diagnosed by 2D or 3D ultrasonograhy. Patients underwent one of the following: expectant management, systemic methotrexate (MTX) injection, local MTX injection, combined MTX injection (local and systemic), local injection of hyperosmolar glucose, or misoprostol administration. The primary endpoint was final success defined by resolution of hCG level without need for emergency surgical treatment. Sixty-four patients diagnosed with NTEP were included: 37 (57%) had an interstitial pregnancy, 23 (35.9%) a cesarean scar pregnancy, two (3.1%) a cervical pregnancy and two (3.1%) an ovarian pregnancy. RESULTS: Six patients (9.4%) underwent expectant management, 24 (37.5%) a systemic MTX injection, 28 (43.8%) a local injection of MTX, three (4.7%) a combined MTX injection, one (1.6%) a local injection of hyperosmolar glucose (1.6%), and two (3.1%) were administered misoprostol. The median age was 32 years (22-45) and mean follow-up was 41 months. The final success rate overall was 92.2%: 100% for expectant management, 87.5% for systemic MTX, 96.4% for local MTX, 100% for combined injection of MTX, 100% for local injection of hyperosmolar glucose, and 50% for misoprostol. No patient required a hysterectomy. Nine (14.1%) patients required surgery, including five (7.8% (5/64)) following a rupture of the NTEP. CONCLUSIONS: Our results suggest that conservative medical management of NTEP is effective and safe and should be the first-line treatment for pauci-symptomatic patients with an NTEP.

Using an Elastic Band Device After a Severe Obstetric Pubic Symphyseal Separation: Clinical and Imaging Evaluation.

BACKGROUND: Severe separation of the pubic symphysis is a rare delivery complication. Facing this pathology, we decided to study a new elastic band device. METHOD: To evaluate the elastic band device, clinical (pain-rated) and imaging (magnetic resonance imaging and radiography) evaluations with and without the device were performed. The elastic band device is a European Conformity-certified medical device, which is made of neoprene straps, that reduces the mobility of the pelvis and the use of the internal rotator muscles. EXPERIENCE: Once the elastic band device was in place, on postpartum day 1, radiography showed a decrease of the pubic width from 41 to 12 mm. Furthermore, pain decreased from 10 of 10 to 2 of 10 in 2 days, allowing the patient to ambulate and avoid surgery. After 1 month, the pubic width (6 mm) and anatomy were recovered but minor pain was still present with hip rotatory movements. The elastic band device was worn 24 hours a day from postpartum days 1-90 and 12 hours a day from postpartum days 90 to 150; afterward, the patient returned to normal life without the elastic band device. CONCLUSION: Use of an elastic band device was associated with a reduction of the pubic width and pain associated after obstetric pubic symphysis separation.