levoleucovorin and Pregnancy--Ectopic

Gestational choriocarcinoma associated with ectopic pregnancy is an extremely rare event. We report a case of a choriocarcinoma arising from a cornual pregnancy.. The patient is a 35-year-old G8 P2052 who was referred to our department due to failure of treatment for a suspected ectopic pregnancy. The patient had initially been treated with methotrexate injection but her beta-hCG levels reached a plateau 3 weeks later and, despite another two methotrexate injections, started to rise. The patient underwent dilation and curettage that did not reveal any trophoblastic tissue. A diagnostic hysteroscopy that followed demonstrated occluded ostia of the left tube. The patient subsequently underwent diagnostic laparoscopy that revealed a mass in the left cornua, which was removed with wedge-wide resection. Histologic evaluation revealed choriocaricnoma.. Appropriate monitoring of beta-hCG titers following conservative management of suspected ectopic pregnancy is important, not only to diagnose persistent ectopic gestation, but also to rule out the presence of malignant trophoblastic disease, albeit the latter is a rare diagnosis.

Topics: Adult; Antineoplastic Combined Chemotherapy Protocols; Choriocarcinoma; Chorionic Gonadotropin, beta Subunit, Human; Fallopian Tube Neoplasms; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic

During the past 25 years, the incidence of ectopic pregnancy has progressively increased while the morbidity and mortality have substantialy decreased, and the treatment has progressed from salpingectomy by laparotomy to conservative surgery by laparoscopy and more recently to medical therapy with Methotrexate or expectant management. This therapeutic transition from surgical emergency to non surgical managment has been attributed to early diagnosis through the use of sensitive assays for hCG and the high definition of vaginal ultrasound. By using these sensitive diagnostic tools, we are now able to select those patients who are most likely to respond to expectant or medical managment versus those who are at high risk of rupture and require surgery. We have reviewed the scientific literature on ectopic pregnancy published over the past 20 years, with the aim to assess the value of non surgical managment of etopic pregnancy. Predictor factors of expectant managment are discussed. Medical therapy with methotrexate: results, indications, Unpleasant side effects and complications are detailed. Several protocols are defined and therapeutic supervision is etablished. The authors offred several recommandations for OB/GY wich will optimize the effectivness of non invasive methods for treatment of ectopic pregnancy.

Topics: Adult; Animals; Chorionic Gonadotropin; Clinical Protocols; Enzyme Inhibitors; Female; Folic Acid Antagonists; Humans; Leucovorin; Methotrexate; Patient Selection; Pregnancy; Pregnancy, Ectopic; Prognosis; Rabbits; Rats; Risk Factors; Time Factors; Ultrasonography

Topics: Administration, Oral; Drug Therapy, Combination; Female; Humans; Injections, Intramuscular; Injections, Intravenous; Laparoscopy; Leucovorin; Methotrexate; Nucleic Acid Synthesis Inhibitors; Pregnancy; Pregnancy, Ectopic; Time Factors; Treatment Outcome

Recent reports describe successful treatment of interstitial ectopic pregnancies using methotrexate. While the number of reported cases is increasing, no consensus exists regarding the management of this complication of pregnancy. We present the successful use of combined systemic and direct intrasac injection of methotrexate for an interstitial pregnancy with the highest yet reported initial beta-human chorionic gonadotrophin concentration (102,000 mIU/ml). We also describe the use of Doppler ultrasound for monitoring treatment progression. Through a review of the current literature, we propose to facilitate management decisions and increase outcome success by summarizing previously reported treatment regimens and by describing enhanced parameters for patient selection and monitoring.

Topics: Adult; Chorionic Gonadotropin, beta Subunit, Human; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Ultrasonography

Methotrexate with folinic acid rescue was used to terminate a clinically diagnosed cervical pregnancy while preserving reproductive capability in a young female patient. The chemotherapy was well tolerated except for transient elevation of liver enzymes. Beta HCG titers fell rapidly and became negative by 13 days. This is the first report showing successful treatment of a cervical pregnancy with single-dose chemotherapy. The literature is reviewed and discussed.

Topics: Abortion, Therapeutic; Adult; Cervix Uteri; Drug Therapy, Combination; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic

The nonoperative management of unruptured tubal ectopic pregnancy by either chemotherapy or expectant observation may be appropriate in a select group of patients, as outlined above. The routine use of these management modalities as a replacement for conservative surgery is not yet justified.

Topics: Abortifacient Agents, Steroidal; Drug Therapy, Combination; Estrenes; Female; Humans; Leucovorin; Methotrexate; Mifepristone; Pregnancy; Pregnancy, Ectopic

Unruptured tubal pregnancies diagnosed at laparoscopy were treated with either methotrexate/citrovorum factor (MTX/CF) (n = 21) or observation (n = 5). Entry criteria required that the ectopic pregnancy be visualized, less than or equal to 3 cm in diameter, with intact serosa and no active bleeding. Treatment selection was based upon preoperative levels of beta-human chorionic gonadotropin (beta-hCG), with MTX/CF given to subjects exhibiting a plateaued or rising pattern and observation alone given to those with falling levels. Twenty-five of 26 ectopic pregnancies resolved without need of laparotomy. Two subjects received blood transfusions and one required a second operation for intra-abdominal bleeding. In both cases, fetal cardiac activity was noted pretreatment on ultrasound. The authors conclude the following: (1) MTX/CF may be safely used to treat selected unruptured ectopic pregnancy; (2) many ectopic pregnancies resolve spontaneously; and (3) ectopic pregnancies that form fetal elements, as evidenced on ultrasound, should not be managed medically.

Topics: Adult; Chorionic Gonadotropin; Chorionic Gonadotropin, beta Subunit, Human; Clinical Trials as Topic; Drug Therapy, Combination; Female; Humans; Leucovorin; Methotrexate; Peptide Fragments; Pregnancy; Pregnancy, Ectopic; Recurrence

Methotrexate is an anticancer drug from the antimetabolite class. It is also used in gynecology and obstetrics for the medical treatment of ectopic pregnancies. Low-dose methotrexate-induced adverse toxic effects are rare. We report a case of toxic effect associated with severe renal insufficiency induced by LD-MTX (Low-Dose Methotrexate) for ectopic pregnancy.. A 46-year-old Chinese woman was in an operation for an ectopic pregnancy of tubal interstitial pregnancy. The embryo villus was so little that we were not sure if it was evacuated, then it was followed with 50 mg methotrexate injection of intramuscular adjacent the uterine horn in the operation. 48 hour later after injection the patient presented with renal failure. The personalized genetic testing showed that MTHFR (677C > T) and ABCB1 (3435T > C) were detected. Gradually, the symptoms improved after calcium leucovorin (CF) rescue, continuous renal replacement therapy (CRRT), promoting blood system regeneration, and multiple supportive treatments.. When toxic effects are suspected, detecting the polymorphisms of an MTHFR gene and monitoring MTX concentration in blood could assist us to formulate individualized and active treatments. The management should be multidisciplinary and as much as possible within an intensive care unit.

Topics: Abortifacient Agents, Nonsteroidal; Female; Humans; Leucovorin; Methotrexate; Middle Aged; Polymorphism, Genetic; Pregnancy; Pregnancy, Ectopic

Methotrexate is an anticancer drug from the antimetabolite class. It is also used in gynecology and obstetrics and is the molecule of choice for the medical treatment of ectopic pregnancies. We report a case of toxidermia associated with severe pancytopenia induced by methotrexate for ectopic pregnancy.. A 30-year-old Malagasy (African) woman was admitted to the Emergency and Intensive Care Department for probable toxidermia following injection of 75 mg of methotrexate for an ectopic pregnancy. She had developed generalized erythema, which started 48 hours after the injection. The secondary onset of phlyctenular maculopapular skin lesions, generalized purpura, and erosions of the oral mucosa in a context of febrile jaundice prompted her hospitalization. On admission, the patient presented with febrile neutropenia, pancytopenia, renal failure, and hepatic cytolysis. She received transfusions of fresh whole blood, erythromycin, and amphotericin B. The course was fatal within 2 days of hospitalization. The patient died of multiple organ failure.. Our case is mainly distinguished by the lack of use of granulocyte growth factors and folinic acid. In the event of severe reactions to methotrexate, the management should be multidisciplinary and as much as possible within an intensive care unit.

Topics: Adult; Female; Humans; Immunosuppressive Agents; Leucovorin; Methotrexate; Pancytopenia; Pregnancy; Pregnancy, Ectopic

We describe our experience with serial uterine artery embolization (UAE) combined with standard weekly methotrexate and a eight-day methotrexate/folinic acid (MTX/FA) treatment regimen in the management of placenta accreta spectrum (PAS) disorder at 7 weeks of gestation.. A 38-year-old woman, gravida 2 para 0, with a history of myomectomy, was referred for ultrasound (US) evaluation due to suspected cervico-isthmic pregnancy. Transvaginal US image showed a viable embryo with a disproportionately bigger placenta encircling the fetus and completely covering the internal os of the cervix at 7 weeks of gestation. Color Doppler imaging revealed diffuse intraplacental and periplacental vascularity. Patient chose to terminate the pregnancy but attempted to preserve the uterus for future fertility following counseling. Serial UAE procedures were performed using Gelfoam and metallic microcoils. Two courses of a standard weekly MTX and a eight-day MTX/FA treatment regimen were administered to accelerate placental regression. The beta-hCG gradually decreased to a normal level, and an ultimate resolution of the PAS disorder was observed at 110 days after treatment.. Early diagnosis of the PAS disorder could result in better obstetric outcome through earlier intervention using serial UAE combined with standard weekly and a eight day MTX//FA regimen in the first trimester of pregnancy.

Topics: Abortion, Induced; Adult; Combined Modality Therapy; Drug Administration Schedule; Drug Therapy, Combination; Female; Fertility Preservation; Humans; Leucovorin; Medical Illustration; Methotrexate; Placenta Accreta; Pregnancy; Pregnancy, Ectopic; Uterine Artery Embolization

Cervical ectopic pregnancy is an uncommon form of ectopic pregnancy. The spectrum of treatment options includes systemic medical therapy, local injection with methotrexate and/or potassium chloride, surgery, or a combination of these modalities.. A 29-year-old woman, gravida 3, aborta 2, was found to have a cervical ectopic pregnancy on ultrasound at 5+6 weeks' gestation. She presented to the hospital with vaginal bleeding. Treatment was initiated with multidose methotrexate and leucovorin rescue. She subsequently developed Gram-negative septicemia, with blood cultures growing Escherichia coli. This was managed successfully by surgical removal of the ectopic pregnancy and antimicrobial therapy.. A cervical ectopic pregnancy can be complicated by E. coli septicemia.

Topics: Abortifacient Agents, Nonsteroidal; Adult; Cervix Uteri; Escherichia coli Infections; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Sepsis

A 25-year-old primigravida was diagnosed to be suffering from unruptured ectopic pregnancy. The serum β-human chorionic gonadotropin levels were 2851 mIU/l and the ectopic gestational sac was 2.7×2.7 cm without any fetal pole. It was decided to manage her by expectant therapy. But she received medical therapy with multidose methotrexate because of misinterpretation of expectant therapy as medical therapy. She suffered from methotrexate toxicity, which manifested as high-grade fever, vomiting, melena, oral ulcerations, pneumonitis, subconjunctival haemorrhages and skin pigmentation. She developed severe third space fluid collection and shock, which was mistaken for rupture ectopic gestation. Her haematological picture showed severe neutropaenia and thrombocytopaenia which confirmed the clinical picture to be due to methotrexate toxicity. She also developed septicaemia and candidal infection secondary to immunosuppression. She was managed in intensive care unit with ventilatory support, high-dose leucovorin and injection filgastrim. She responded well to the therapy with dramatic recovery in 4 days.

Topics: Abortifacient Agents, Nonsteroidal; Abortion, Therapeutic; Adult; Female; Filgrastim; Granulocyte Colony-Stimulating Factor; Humans; Leucovorin; Medical Errors; Methotrexate; Neutropenia; Pregnancy; Pregnancy, Ectopic; Recombinant Proteins; Respiration, Artificial; Sepsis; Shock; Thrombocytopenia; Vitamin B Complex

A case report of a primary interstitial ovarian pregnancy is presented. A 37-year-old married woman with two children after two Cesarean sections and a spontaneous abortion, with a contraceptive intrauterine device (IUD) inserted three years before, presented at five weeks plus five days amenorrhea with a positive pregnancy test and lower abdominal pain but with no vaginal bleeding. Her previous menstrual cycles had been regular. She was hemodynamically stable. On bimanual examination, the uterus was of normal size, and there was an approximate four-cm tender right adnexal mass. Serum beta-human chorionic gonadotropin (b-hCG) was confirmed positive. Ultrasound revealed a well-positioned IUD in the uterus and a right adnexal mass with normal vascular flow on Doppler, that contained a well-defined gestational sac, well-distinct from the quiescent hemorrhagic corpus luteum. There was no fetal node or cardiac activity or free fluid. The patient received four injections of methotrexate intramuscularly using the multidose regimen that involves the administration of methotrexate calculated according to body weight, alternated with 0.1 mg/kg of leucovorin calcium per os after 30 hours until the values of 3-hCG had decreased by 15%. The patient's post-treatment period was uneventful with a full restoration of ovarian morphology and the complete absorption of the gestational sac. This case is the first where diagnosis was made by endovaginal sonography and treatment was made by multidose methotrexate. Spiegelberg criteria for the diagnosis of ovarian pregnancy are obsolete; new ultrasound and laboratory criteria are needed for a diagnosis as early as possible without the need of surgery.

Topics: Abortifacient Agents; Adult; Chorionic Gonadotropin, beta Subunit, Human; Female; Humans; Injections, Intramuscular; Intrauterine Devices; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Ultrasonography

To evaluate the use of uterine artery embolization (UAE) in conjunction with methotrexate in the conservative treatment of cervical ectopic pregnancy (CEP).. Case series.. Tertiary-care university hospital.. Cases of CEP treated at Hutzel Women's Hospital between January 1997 and December 2008.. Multidose methotrexate treatment with or without UAE and intra-amniotic potassium chloride injection (KCl).. Beta-human chorionic gonadotropin level, vaginal bleeding, length of hospital stay, and future fecundity.. A retrospective analysis of 15 patients with CEP treated conservatively using methotrexate with leucovorin rescue (MTx/Leu) alone (group 1, five cases), with UAE as an adjunctive therapy (group 2, six cases), or also having received intra-amniotic KCl before UAE (group 3, four cases) is reported. There was no significant difference in age, parity, or gestational age among treatment groups. The median β-hCG level on presentation was 9,606 mIU/mL for group 1, 26,516 mIU/mL for group 2, and 130,464 mIU/mL for group 3. The difference was found to be statistically significant. No patients developed complications from UAE. Of the 10 patients who underwent UAE, 2 subsequently had confirmed viable pregnancies.. Uterine artery embolization with methotrexate is an option for minimally invasive intervention in the treatment of CEP.

Topics: Abortifacient Agents, Nonsteroidal; Adult; Cervix Uteri; Combined Modality Therapy; Embolization, Therapeutic; Female; Humans; Infertility, Female; Leucovorin; Methotrexate; Potassium Chloride; Pregnancy; Pregnancy, Ectopic; Retrospective Studies; Uterine Artery; Vitamin B Complex

Topics: Abortifacient Agents, Nonsteroidal; Adult; Cesarean Section; Chorionic Gonadotropin, beta Subunit, Human; Cicatrix; Contraceptive Agents, Female; Female; Humans; Intrauterine Devices, Medicated; Leucovorin; Levonorgestrel; Methotrexate; Pregnancy; Pregnancy, Ectopic

Medical treatment of the rare interstitial ectopic pregnancy with methotrexate has been considered an alternative to surgical resection.. To determine the treatment success rate with a single-dose intravenous methotrexate/folinic acid regimen and to identify predictors of treatment outcome.. A 5-year audit (April 2000-August 2005) was carried out, collecting clinical imaging data and serum beta-human chorionic gonadotrophin (beta-hCG). Time taken for complete beta-hCG resolution was recorded, and a negative beta-hCG result was used as an endpoint of successful outcome.. Of the 13 cases, two required urgent surgery for rupture on presentation. In the remaining 11 cases, intravenous methotrexate (300 mg) was used, with oral folinic acid rescue (15 mg x 4 doses). There were no side-effects. Complete beta-hCG resolution was achieved in 10 of the 11 medically treated cases (91% success rate), requiring 21-129 days. Successful outcome was seen with initial beta-hCG level as high as 106 634 IU/L and gestation sac as large as 6 cm and a live fetus.. The methotrexate/folinic acid regimen used as a one-dose treatment is safe and effective for unruptured interstitial pregnancy, with no side-effects and the advantage of avoiding invasive surgery. Subsequent tubal patency and reproductive function are yet to be ascertained.

Topics: Abortifacient Agents, Nonsteroidal; Adult; Cohort Studies; Dose-Response Relationship, Drug; Female; Gestational Age; Humans; Infusions, Intravenous; Leucovorin; Magnetic Resonance Imaging; Maternal Age; Methotrexate; Pregnancy; Pregnancy Outcome; Pregnancy, Ectopic; Radiography; Retrospective Studies; Risk Assessment; Ultrasonography, Prenatal

Cervical pregnancy is an uncommon ectopic pregnancy that accounts for approximately <1% of extrauterine gestations. This condition is associated with an extremely high risk of massive hemorrhage and previously often required hysterectomy. Current early ultrasonographic diagnosis and medical management in conjunction with other conservative measures, which include uterine artery embolization and intracervical balloon tamponade, have enabled conservation of the uterus. A young nulliparous patient ultrasonographically diagnosed with a cervical pregnancy and early fetal demise at 11 and 4/7 weeks gestation was managed with high-dose methotrexate and folinic acid rescue treatment. On the second day after treatment was initiated she spontaneously passed an intact gestational sac accompanied by minimal hemorrhage. Treatment was continued, with decreasing serum beta subunit of human chorionic gonadotropin levels and subsiding hemorrhage. Subsequent surgical measures were not required. This case suggests that complete abortion of a cervical pregnancy not necessitating surgical measures can occur.

Topics: Abortifacient Agents, Nonsteroidal; Abortion, Induced; Adult; Female; Fetal Death; Gestational Age; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy Trimester, First; Pregnancy, Ectopic; Time Factors; Treatment Outcome; Ultrasonography, Prenatal; Uterine Hemorrhage

We describe two cases which demonstrate methotrexate (mtx) to be an effective alternative to surgery in two serious complications of early pregnancy, namely placenta accreta diagnosed at attempted evacuation of retained products of conception and interstitial cornual pregnancy diagnosed at laparoscopy.

Topics: Adult; Chorionic Gonadotropin, beta Subunit, Human; Female; Gestational Age; Humans; Leucovorin; Methotrexate; Placenta Accreta; Pregnancy; Pregnancy, Ectopic; Treatment Outcome

Cervical pregnancy is a rare condition that can become life-threatening if heavy bleeding occurs.. Grace (pseudonym) is a 32-year-old woman who was admitted to hospital at approximately 6 weeks' gestational age after several days of heavy bleeding. Ultrasonographic examination revealed the presence of cervical pregnancy. She received multiple doses of methotrexate with folinic acid rescue, and did not require surgical intervention. Nine months after the resolution of the cervical pregnancy, Grace again became pregnant. She had an uncomplicated gestation and a normal vaginal delivery of a healthy baby at term.. Multiple-dose methotrexate with folinic acid rescue was a safe option for the medical treatment of ectopic cervical pregnancy in this case. Long-term toxicity studies and case reports are required to provide more information regarding safety and for clinicians to individualize treatment regimens.

Topics: Abortifacient Agents, Nonsteroidal; Adult; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Safety; Treatment Outcome; Uterine Hemorrhage

To describe the monitoring of a case of cervical and simultaneous cervico-isthmic pregnancy.. University of Bari (Italy), Department of Obstetrics and Gynecology.. A 30-year-old white woman, nulliparous, at 8 weeks of amenorrhoea.. Methotrexate and folinic acid administered systemically.. Treatment success was defined as elimination of the cervical and cervico-isthmic pregnancy, with non-invasive treatment and preservation of the uterus and normal ovarian activity restored.. Methotrexate and folinic acid were administered, elimination of a twin pregnancy with declining serum beta-hCG levels and with ultrasound was observed. The patient had only occasional dark vaginal bleeding and temporary movement of the transaminase.. This case report shows that methotrexate is a valid, conservative and non-invasive treatment for a patient affected by cervical pregnancy who wishes to keep fertility.

Topics: Abortifacient Agents, Nonsteroidal; Adult; Cervix Uteri; Chorionic Gonadotropin, beta Subunit, Human; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic

Systemic methotrexate therapy for interstitial pregnancy has an increased failure rate as compared to other ectopic locations. No case of interstitial pregnancy with a retained intrauterine device (IUD) has been reported on before.. An asymptomatic, 21-year-old woman presented with a positive pregnancy test and a retained IUD. Vaginal ultrasound revealed a left interstitial pregnancy. Diagnostic laparoscopy was followed by a single dose of methotrexate (50 mg/m2). Five days later, a marked increase in the human chorionic gonadotropin level was followed by a second course (four doses) of methotrexate, 1 mg/kg, alternating with 0.1 mg/kg of leucovorin. Concomitant Chlamydia was treated with azithromycin, and the IUD was expelled spontaneously.. Medical management of interstitial pregnancy may prevent surgery that limits future fertility, but the evidence suggests that more than one dose of methotrexate may be required.

Topics: Abortifacient Agents, Nonsteroidal; Abortion, Induced; Adult; Anti-Bacterial Agents; Azithromycin; Chlamydia Infections; Diagnosis, Differential; Drug Therapy, Combination; Female; Humans; Intrauterine Devices; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Vaginal Diseases

Cervical pregnancy is a rare form of ectopic pregnancy and at present there is no consensus as to the most appropriate treatment. A patient with a 6-week cervical pregnancy was successfully treated with a single intravenous administration of methotrexate and oral folinic acid without any adjuvant therapy Her recovery was uncomplicated. She subsequently conceived and was delivered by Caesarean section of a live healthy male baby. The efficacy of the described regimen in the management of a cervical pregnancy requires further assessment. This modality of treatment does not appear to adversely affect fertility and future pregnancies.

Topics: Administration, Oral; Adult; Australia; Cervix Uteri; Cesarean Section; Drug Therapy, Combination; Female; Humans; Injections, Intravenous; Leucovorin; Methotrexate; Monitoring, Physiologic; Pregnancy; Pregnancy Outcome; Pregnancy Trimester, First; Pregnancy, Ectopic; Ultrasonography, Prenatal

Data concerning medical treatment of interstitial ectopic pregnancies are scarce. These pregnancies are characterized by late and serious clinical manifestations. We report a case of advanced interstitial pregnancy treated successfully by combining methotrexate (MTX) and hysteroscopy.. A routine ultrasonic evaluation of a 10-week pregnancy revealed a right interstitial gestational sac 58 mm in diameter and containing an embryo with a crownrump length of 29 mm and embryonic heartbeats. Serum beta-human chorionic gonadatropin (hCG) level was 97,950 mIU/mL. The patient was treated with a systemic MTX/leucovorin regimen. At the end of the one-week course, no embryonic cardiac activity was detected, and a decrease in beta-hCG levels commenced. Persistent trophoblastic tissue, manifested by a low (26 mIU/mL) beta-hCG level in plateau, was successfully removed by way of hysteroscopy.. Early detection of interstitial pregnancy may facilitate conservative medical treatment.

Topics: Abortifacient Agents, Nonsteroidal; Adult; Antidotes; Endoscopy; Fallopian Tubes; Female; Humans; Hysteroscopy; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Ultrasonography; Uterus

Cervical pregnancy has traditionally been treated by hysterectomy. Recent reports of the use of methotrexate have been encouraging as a potential conservative approach. We present a case of a cervical pregnancy diagnosed at 8 weeks' gestation in a woman who greatly desired fertility. She was treated successfully with a combination of multidose intramuscular methotrexate (1 mg/kg/day) and citrovorum rescue. When profuse bleeding developed on day 8, angiographic embolization was used to obviate surgery. The beta-hCG titer peaked at 58,362 IU/mL and was undetectable by postchemotherapy day 30. No blood transfusion was required, and reproductive capacity was spared. Four months after the cervical pregnancy, the patient became pregnant and had a healthy infant. Medical management of cervical pregnancy is an option when reproductive capacity is desired in selected patients with appropriate counseling.

Topics: Adult; Antidotes; Arteries; Embolization, Therapeutic; Female; Folic Acid Antagonists; Gestational Age; Humans; Injections, Intramuscular; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Uterine Hemorrhage; Uterus

To review our experience with early ultrasonographic diagnosis and fertility-preserving complete medical treatment of cervical pregnancy.. From January 1989 to December 1994, 11 cases of cervical pregnancy diagnosed by ultrasonography and treated with methotrexate were evaluated. Patients were treated as follows: systemic administration of methotrexate with leucovorin rescue, a single dose of 50 mg of methotrexate intramuscular injection, or transvaginal ultrasonographically-guided intra-amniotic instillation of 50 mg of methotrexate.. The mean age of these patients was 33.3 +/- 6.2 years and gestational age at diagnosis ranged from 32 to 73 days. The maximal serum beta-hCG measured was 135,000 mIU/ml, and the time required for return to normal levels ranged from 20 to 157 days. The ectopic gestation was successfully ablated in all cases, and none required hysterectomy.. If a cervical pregnancy is present and diagnosed early, methotrexate treatment, administered either systemically or locally, is effective as the definitive therapy.

Topics: Adult; Cervix Uteri; Chorionic Gonadotropin, beta Subunit, Human; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Retrospective Studies; Ultrasonography

To evaluate short-term effectiveness of systemic methotrexate (MTX) in interstitial pregnancy.. Case series.. Two Dutch teaching hospitals.. Eight consecutive patients with an unruptured interstitial pregnancy.. Four doses of 1.0 mg/kg IM MTX alternated with 0.1 mg/kg oral folinic acid. Serum hCG concentrations were determined before the first MTX injection and followed until levels were undetectable. A second MTX course was started on day 14, if by then serum hCG concentrations were > 40% of the initial value. Serum hCG clearance curves of all patients in the present study were compared with those from our earlier studies, in which a different folinic acid regimen (15 mg orally) was used.. Serum hCG clearance curves.. All patients were treated successfully: five with one course and three with two courses. Serum hCG clearance curves of these patients tended to decline more rapidly than those successfully treated with the 15 mg folinic acid regimen.. Systemic MTX is an attractive therapeutic option in the conservative treatment of unruptured interstitial pregnancy. The regimen of four doses of 1.0 mg/kg IM MTX alternated with 0.1 mg/kg folinic acid is effective. Serum hCG clearance curves may serve as a guideline for monitoring MTX treatment, thus enabling a timely detection of impending treatment failure.

Topics: Adult; Chorionic Gonadotropin; Female; Humans; Leucovorin; Metabolic Clearance Rate; Methotrexate; Pregnancy; Pregnancy, Ectopic

The purpose of this article is to evaluate the effectiveness, side effects, and complications of high dose methotrexate infusion with leucovorin rescue in select patients with ectopic pregnancy. Between January 1991 and November 1994, 28 patients with ectopic pregnancies were prospectively treated with methotrexate (100 mg/m2 intravenous bolus followed by a 200 mg/m2 infusion over six hours) with leucovorin rescue. Twenty-seven of 28 patients (96%) were successfully treated. Only one patient (4%) required a second course of methotrexate to reach a normal hCG titer. One patient failed methotrexate infusion 45 days after treatment at a hCG titer of 12 mIU/mL. No Gynecologic Oncology Group grade 3 or 4 clinical, biochemical or hematologic toxicities occurred. Uterine bleeding and abdominal pain, not requiring transfusion or hospitalization, occurred in 71% and 56% of patients. The authors conclude that high dose methotrexate infusion with leucovorin rescue is a highly effective, well tolerated, nonsurgical treatment for select patients with ectopic pregnancy.

Topics: Abdominal Pain; Administration, Oral; Adult; Ambulatory Care; Antidotes; Chorionic Gonadotropin; Female; Folic Acid Antagonists; Follow-Up Studies; Hospitalization; Humans; Infusions, Intravenous; Injections, Intravenous; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Prospective Studies; Treatment Outcome; Ultrasonography; Uterine Hemorrhage

In twenty patients with ectopic pregnancy who received treatment using methotrexate-citrovorum factor in an individualized reduced dose regimen 17 cases were successfully treated, 4 required one course of therapy, 8 required two courses, 4 required three courses, only 1 required four courses, according to the difference in the speed of hCG reduction. The success rate was 85.0%, two cases got intrauterine pregnancy within 6 months after the treatment. Three ruptured cases during treatment were operated upon. The pathologic findings at the ectopic site were chorionic bleeding, necroses, with dissolution of trophoblastic cells.

Topics: Adult; Chorionic Gonadotropin; Drug Therapy, Combination; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic

Corpus luteum activity was monitored in 15 women undergoing nonsurgical management of ectopic pregnancy with local methotrexate injection followed by alternating oral methotrexate and citrovorum factor (group A, n = 8) or local methotrexate injection alone (group B, n = 7). All patients initially demonstrated a viable corpus luteum (plasma progesterone ranged from 1.4 to 19 ng/ml). The treatment was successful in 14, with the exception of one whose tube ruptured 11 days after local administration of methotrexate, despite a continuous decrease in beta human chorionic gonadotropin, 17 beta-estradiol and plasma progesterone levels. There seems to be no correlation between the success of the treatment and the behavior of beta human chorionic gonadotropin, 17 beta-estradiol and plasma progesterone. Three patients from group A and two from group B displayed an initial rise in beta human chorionic gonadotropin following the initiation of the therapy, but the corpus luteum response differed. In group B patients, 17 beta-estradiol and plasma progesterone levels increased in parallel with beta human chorionic gonadotropin. Group A patients displayed a continuous decrease in 17 beta-estradiol and plasma progesterone levels despite the elevation of beta human chorionic gonadotropin, suggesting a possible effect of the systemic methotrexate on corpus luteum activity.

Topics: Adolescent; Adult; Chorionic Gonadotropin; Chorionic Gonadotropin, beta Subunit, Human; Corpus Luteum; Estradiol; Female; Humans; Leucovorin; Methotrexate; Peptide Fragments; Pregnancy; Pregnancy, Ectopic; Pregnancy, Tubal; Progesterone

Methotrexate therapy is a newly established treatment modality for ectopic pregnancy. We performed this study to determine the time frame for resolution of the sonographically identifiable mass during such therapy and to determine the role of sonography in the management of these patients. Eighteen patients treated with methotrexate for laparoscopically proven ectopic pregnancy consented to long-term follow-up with endovaginal sonography. These 18 patients constitute the study group. The time required for sonographic resolution of the mass was variable, although poor patient compliance with sonographic follow-up affected the conclusions regarding resolution time. One hundred eight days was the longest period accurately known for resolution of a mass. In seven patients, the mass persisted after a negative hCG titer. Enlargement of the adnexal mass during therapy did not necessarily predict treatment failure, as only two of ten such patients required surgery for rupture. Serial sonography did not alter the management of most patients and appears not to be warranted on a routine basis. Follow-up sonography was most useful when complications were suspected. All patients considered for methotrexate therapy should first have an endovaginal sonogram, as cardiac activity remains a relative contraindication to this treatment. We have determined that the mass of an ectopic pregnancy may remain after the hCG is negative. Therefore, a persistent mass should not be interpreted as treatment failure.

Topics: Female; Follow-Up Studies; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Time Factors; Ultrasonography

Persistent ectopic pregnancy is a recognized complication of conservative laparoscopic surgery. Three such cases were treated successfully with methotrexate and citrovorum factor rescue. All three patients experienced mild lower abdominal pain for a maximum of 36 hours; no other adverse effects were noted. More experience with this therapy will be necessary before subsequent fertility rates can be determined.

Topics: Abdominal Pain; Adult; Chorionic Gonadotropin; Chorionic Gonadotropin, beta Subunit, Human; Female; Humans; Laparoscopy; Leucovorin; Methotrexate; Peptide Fragments; Pregnancy; Pregnancy, Ectopic

The purpose of this study was to examine return of reproductive potential, hysterosalpingographic findings, and time to conception in patients treated with methotrexate and citrovorum factor for unruptured ectopic pregnancy. Fifty-seven patients with unruptured ectopic pregnancies less than 3.0 cm in greatest dimension were treated with methotrexate and citrovorum factor. The mean time from resolution of the ectopic pregnancy to return of menses was 26.0 (0 to 157) days. Forty-four patients were available for follow-up (2 to 15 months). Nineteen of 23 patients who had hysterosalpingograms demonstrated patency in the ipsilateral tube. Fourteen patients desired pregnancy; 11 of 14 (78.6%) were successful, with 10 of 11 (90.9%) having an intrauterine pregnancy, whereas one of 14 (9.1%) were extrauterine gestations. The mean time from first attempt to achieving pregnancy was 2.3 (1 to 4) months. We conclude that methotrexate and citrovorum factor treatment of unruptured ectopic pregnancy is associated with subsequent tubal patency and does not impair return of menses. Most importantly, the pregnancy rates after this form of therapy appear to be better than those achieved by traditional surgical methods, and are comparable to results after laparoscopic salpingostomy.

Topics: Adolescent; Adult; Female; Follow-Up Studies; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Pregnancy, Tubal; Reproduction

A case of cervical pregnancy with a fetal pole, fetal cardiac activity and a serum beta-human chorionic gonadotropin level reaching a peak of 60,000 mIU/mL was treated successfully with methotrexate and folinic acid. These criteria have been considered a contraindication to conservative medical management. Serial beta-human chorionic gonadotropin levels and sonography were used to diagnose the pregnancy and monitor therapy. Complications were limited to transient conjunctivitis and blood loss anemia. The patient's fertility potential was preserved.

Topics: Adult; Cervix Uteri; Chorionic Gonadotropin; Drug Therapy, Combination; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Ultrasonography

This report describes an individualized, reduced dose, methotrexate (MTX) and citrovorum factor (CF) treatment regimen for outpatient management of unruptured ectopic pregnancy (EP). One hundred sixteen laparoscopically documented EPs, the majority (90%) of whom were symptomatic, were diagnosed from an Emergency Department population. Eighty of 116 (69%) were unruptured, 37 (46.3%) of whom were eligible for MTX-CF chemotherapy. One patient refused chemotherapy. Thirty-four of the 36 (94.4%) patients treated with MTX-CF had complete resolution of their ectopics, whereas 2 experienced rupture after chemotherapy, 1 of them 23 days after MTX initiation. While there were no major chemotherapy-related side effects, 3 of the 36 (8.3%) patients experienced minor side effects. The authors conclude that: (1) individualized dosing of outpatient MTX-CF chemotherapy for symptomatic EP can be safely managed, even in an indigent population; (2) rupture can occur up to 23 days after chemotherapy initiation; (3) fetal cardiac activity is an absolute contraindication to chemotherapy; (4) chemotherapy in patients with symptoms is of limited value because the disease is too far advanced; therefore, it is essential that the diagnosis of EP be established before symptom onset; and (5) chemotherapy offers no significant immediate advantages to outpatient laparoscopic surgery. However, increasingly reliable nonlaparoscopic diagnosis will soon give wider application to this approach.

Topics: Adult; Ambulatory Care; Aspartate Aminotransferases; Chorionic Gonadotropin; Drug Administration Schedule; Drug Therapy, Combination; Fallopian Tube Diseases; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Prospective Studies; Rupture, Spontaneous

A case is described with cervical pregnancy successfully treated by two 8-day courses of methotrexate and leucovorin rescue with cervical evacuation. The apparent beneficial outcome suggests that cervical evacuation after the use of methotrexate and leucovorin rescue will be considered for treatment of cervical pregnancy whenever uterine preservation is desirable.

Topics: Abortion, Therapeutic; Adult; Cervix Uteri; Combined Modality Therapy; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic

Topics: Adult; Fallopian Tubes; Female; Gamete Intrafallopian Transfer; Humans; Leucovorin; Methotrexate; Microsurgery; Pregnancy; Pregnancy, Ectopic

A case of cervical pregnancy was treated successfully with methotrexate. We used serial beta-human chorionic gonadotropin levels, magnetic resonance imaging, and sonography to diagnose the pregnancy and monitor therapy. Hysterectomy was avoided, and the patient's reproductive capability was preserved. Toxicity was limited to transient elevation of liver transaminases.

Topics: Adult; Cervix Uteri; Female; Humans; Leucovorin; Magnetic Resonance Imaging; Methotrexate; Pregnancy; Pregnancy, Ectopic; Ultrasonography

This is a report on the successful treatment of an unruptured tubal pregnancy with methotrexate (MTX). To our knowledge eighteen cases, including ours, have been reported in Western literature so far. The advantages and drawbacks of this therapy are discussed.

Topics: Adult; Female; Humans; Laparoscopy; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Ultrasonography

The incidence of ectopic pregnancy is increasing in the Western world, and this reproductive complication has had an adverse impact on subsequent fertility. Advances in the surgical treatment of ectopic pregnancies have been designed to preserve future reproductive potential, but conservative tubal surgery may fail to completely remove the trophoblast. Described is a case of persistent ectopic pregnancy successfully treated with methotrexate.

Topics: Adult; Fallopian Tubes; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Time Factors

Seven women with unruptured tubal pregnancies diagnosed on laparoscopy were treated with methotrexate and citrovorum rescue. Criteria for inclusion in the study were that the level of human chorionic gonadotropin (hCG) be plateaued or rising, that the ectopic pregnancy not exceed 3 X 3 cm, that the tubal serosa be intact, and that there be no active bleeding. The women were followed with serial measurements of hCG, complete blood counts, and liver function tests. All women responded to a single course of therapy. The median time to resolution (from the first day of treatment to when the hCG was undetectable) was 31 days (range, 5 to 50 days). Follow-up hysterosalpingograms were available for five women. Four women demonstrated tubal patency, and one showed a unilateral occlusion on the side of the ectopic. One woman was found to have an intrauterine pregnancy prior to the scheduled time of hysterosalpingogram.

Topics: Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic

Topics: Adult; Brain Neoplasms; Broad Ligament; Choriocarcinoma; Female; Humans; Leucovorin; Methotrexate; Pregnancy; Pregnancy, Ectopic; Rupture, Spontaneous; Uterine Neoplasms