Gilbert SB, et al. - The outcomes and safety of conservative management of nontubal ectopic pregnancies (NTEP) with direct methotrexate (MTX) injection into the gestational sac are assessed in this study. Based on these outcomes, direct MTX injection into the gestational sac for the treatment of NTEP is safe and successful with appropriate patient selection and experienced providers. Resolution of serum human chorionic gonadotropin (HCG) after treatment is varied by type of NTEP and can be quite prolonged even in uncomplicated cases. Understanding of this trend may prevent unwarranted repeat systemic MTX administration.

Methods

• For this research, they designed a retrospective cohort study.
• This study was conducted at a tertiary hospital.
• They retrospectively identified all the confirmed NTEP cases at the University of Colorado Hospital from 2012 to 2017.
• This institutional protocol consists of an ultrasound-guided direct injection of MTX into the fetal pole (25mg) and surrounding gestational sac (25mg) and a single dose systemic MTX (25mg) alone or combined with fetal intracardiac injection of potassium chloride (KCl).
• All procedure were performed in the OR suite under anesthesia with transvaginal ultrasound guidance with an 18 gauge oocyte retrieval needle.
• The treatment protocol excluded patients with hemodynamic instability, gestational age over 11 weeks, heavy vaginal or abdominal bleeding or with contraindications to MTX.
• The treatment failure was characterized as a surgical procedure to treat the NTEP.
• Treatment related information were examined with descriptive statistics and by NTEP type with Kruskal- Wallis H test, including total operating time and days to negative serum HCG after treatment.

Results

• In this study, they found 12 women (age 34 + 5.6 yrs) with NTEP underwent direct MTX injection (cesarean scar, n=3; interstitial or cornual, n=5; cervical, n=4).
• Mean estimated gestational age was 7 weeks and 3.5 days + 11 days.
• Utilization of KCl for fetal cardiac activity was 66.7%.
• One patient required a laparoscopic intervention because of hemodynamic instability, with the failure rate of 1/12 or 8.3% (a double interstitial, hetero-ectopic pregnancy).
• There were no other significant complications.
• The time in the OR and patient exposure to anesthesia was minimal and similar for all NTEP types (overall mean = 20 + 14 minutes, p=0.37).
• The average time to negative serum HCG varied was significantly longer for the cesarean scar (82.5 + 26 days) and cervical NTEP (70.5+ 19 days) vs. interstitial or corneal pregnancies (30.6+ 12.2 days, p =0.046).