Medical Treatment Of Ectopic Pregnancy By Methotrexate Versus Other Modalities Of Treatment:

Tamer Mohammed El-baset

Ectopic pregnancy is an issue that plagues women’s health, and is a significant cause of maternal mortality. A clear understanding of the contributing factors responsible for E. P. and of effective modern methods for their earlier diagnosis is essential. There are so many etiological factors of ectopic pregnancy that act as a mechanical factors as tubal stenosis due to P.I.D caused by chlamydia and other variable organism, peritubal adhesions and previously induced abortion. Functional factors as external migration of the ovum, hormonal changes and new advents of ART (IVF, GIFT, and ZIFT), endometriosis, also failed contraception was found to be an important cause of ectopic pregnancy. Secondly, there has been a major break through in the various investigatory methods used in the diagnosis of ectopic pregnancy that include; more sensitive beta subunit human chorionic gonadotrophin assays, ultrasonographic machines with higher resolution as well as the introduction of the transvaginal ultrasonic approach. New techniques and diagnostic modalities in pelvic and vaginal U/S recently have excellent results in the diagnosis of ectopic pregnancy using vaginal color and pulsed Doppler U/S and so the need for invasive tests such as endometrial curettage and culdocentesis has decreased dramatically, while laparoscopy remains the standard, the best invasive procedure for diagnosis of an ectopic pregnancy. Finally the increased experience in laparoscopy gained by most gynecologists as well as the advancement in laparoscopic techniquesSummary and Conclusion-83-over the years lead to decreased maternal mortality. The main aim ofrecent trends in treatment of ectopic pregnancy is preservingreproductive function.Medical treatment was introduced by Tanaka in 1983 when hesucceeded for the first time in treating a case of tubal pregnancy withmethotrexate. Medical treatment for residual tissue after the removal ofthe ectopic gestation procedure however was mentioned before this forthe acceleration of resorption of the placenta that is left in the patient incases of abdominal pregnancy where the placenta could not be removed.Methotrexate is the main drug in the line of treatment of ectopicpregnancy. Many protocols exist for this drug and a single dosemethotrexate regimen has been reported with excellent results. A varietyof other drugs have been described including; Actinomycin D, the antiprogesteroneagent RU 486 and trichosanthin, yet these drugs have nevergained the glamour of methotrexate.The forerunner of medical treatment is methotrexate, a folic acidanalogue, which induce tubal abortion or dissolve a proliferating ectopicpregnancy instead of employing surgical intervention, and isadministered either systemically (1M, IV and Orally) or locally. IMinjection of MTX appeared as an attractive alternative to laparoscopy forthe treatment of UEP because of its high efficacy, its simplicity and itscost-effectiveness. On other hand, single-dose MTX did not appear to besatisfactory in some cases. The use of MTX, whose aim is to treat UEPwithout sophisticated equipment, anesthesia, surgery dramaticallyreduced the morbidity and cost related to the treatment.Pre-treatment B-hCG levels appeared as strong prognostic factorfor MTX effectiveness. Selection of patients is mandatory to guaranteeSummary and Conclusion-84-high success rates with a short follow up. UEP with β-hCG level < 5000MIU/ml are the best indication for MTX. Success rate of MTX is 100%in correctly selected cases and the pre-treatment B-hCG level seems to bethe strongest factor. MTX resulted in a significant dramatic decrease inthe number of general anesthesia and surgical acts.For the patient who is needing fertility, medical treatment shouldbe tried. A problem lies in the patient who has only one fallopian tubeand presents with a recurrent ectopic pregnancy after a previousconservative surgical technique. The role of medical treatment appearshere especially laparoscopic guided treatment which can be done at thesame time with diagnostic laparoscopy.Conservative treatment of tubal pregnancy includes expectantmanagement in which cases were selected as having intact fallopiantubes, no evidence of active bleeding and stable vital signs. Most ofthem were monitored with serial (B-hCG) determinations, haematocrit,and ultrasound.Acute pelvic pain, occurring a few days after the injection, is one ofthe main problems in the follow up. The follow-up after MTX requiringexcessive repetition of clinical examination, biological tests andsonograms. Laparoscopy still remains the best approach to investigatethe tubes and allow a meticulous peritoneal toilette. When comparedwith other treatment protocols, intramuscular MTX appears to be thebest alternative to laparoscopic surgery.Pathologically the fertilized ovum may implant in any portion ofthe fallopian tube giving rise to ampullary, isthmus and interstitial tubalpregnancy, this is from the gross point of view, microscopically isfinding of chorionic villi in the tubal lumen or wall. Natural history ofSummary and Conclusion-85-tubal pathology include tubal abortion, tubal rupture also may end inchronic ectopic -pregnancy, persistent ectopic pregnancy or evenspontaneous resolution. Many types of ectopic pregnancy have beenreported as tubovarian, tubouterine, tuboabdominal pregnancy. Othersubtypes as cervical, ovarian and abdominal pregnancies. .The clinical manifestations of an ectopic pregnancy are highlyvariable on one hand a woman ’may have no signs or symptoms,similar to a routine early pregnancy, on the other hand, woman mayhave an acute abdomen or present with abnormal uterine bleeding andhemorrhagic shock i.e. triad of ectopic pregnancy which include pain,vaginal bleeding and amenorrhoea.Therefore the goals remain to diagnose the condition as early aspossible to minimize anatomic distortion, in order to prevent furtherclinical deterioration, to stop the progression of the condition, and toprevent long term morbidity while maximizing the options available fortherapy. A major advance in the diagnosis of ectopic pregnancy occurswith the development and wide spread availability of quantitative assayof serum β-hCG and transvaginal ultrasound.Finally medical treatment (IM injection of MTX) appeared as analternative for laparoscopy for the treatment of UEP because of its highefficacy, its simplicity and its cost effectiveness. A rigorous selection ofthe patients for the treatment option is mandatory to guarantee highsuccess rates.Summary and Conclusion-86-Conclusion:The incidence of ectopic pregnancy is increasing and its diagnosismay not be straight forward. Symptoms may be similar to a spontaneousmiscarriage or even pelvic inflammatory disease. Obvious risk factorsneed not be present, therefore any sexually active women who presentswith an interval of amenorrhoea followed by vaginal bleeding andabdominal pain need to have an ectopic pregnancy ruled out.A combination of ultrasonography and measurement of serumconcentration of human chorionic gonadotrophin, carried out serially ifectopic pregnancy is suspected. A diagnostic laparoscopy is necessary ifthe clinical situation cannot be clarified or if the patient’s conditiondeteriorated. Women with a history of ectopic pregnancy should haveearly access to ultrasonography to verify a viable intrauterine pregnancyin their subsequent pregnancy because of their increased risk of recurrentectopic pregnancy.Medical management of ectopic pregnancy is an effective optionand should be considered in selected cases as long as adequate facilitiesfor monitoring are available. Although systemic methotrexateadministration is safe and effective for the treatment of tubal pregnancy,it does not necessarily reduce cost, systemic methotrexate therapy couldreduce costs if administered to patients with low initial serum (β-hCG)concentrations without confirmatory laparoscopy.If surgery is necessary, salpingostomy seems to give better rates offuture fertility although there is a higher incidence of persistent ectopicwhich may require further intervention. After salpingostomy, monitoringof serum concentrations of human chorionic gonadotrophin is necessaryto ensure that there is no persistent trophoblast. The decision to performSummary and Conclusion-87-salpingectomy or salpingostomy should be made on an individual basis,taking into account the patient’s wishes for future fertility and her riskfactors for recurrence of ectopic pregnancy.Medical treatment, with methotrexate has largely replaced theradical surgical option, and the treatment of ectopic pregnancy mostobviously moving to the direction of these conservative medicalapproaches.The efficacy of medical treatment of ectopic pregnancy yet the rateof success ranges between 75-96%.