학술상 수상 (Prized Paper)
Single-dose methotrexate therapy for prevention of persistent ectopic pregnancy after laparoscopic conservative surgery for tubal pregnancy

Sung-Tack Oh, M.D., Ph.D.

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Introduction

In tubal pregnancy, conservative surgery had been used for future pregnancy in infertility or in women who want to conceive more. Furthermore recently according to development of laparoscopy, conservative surgery has been usually performed by laparoscopic operation. However in some cases of conservative operations for tubal pregnancy, persistent tubal pregnancies were found and more treatments were needed. Recently it was reported that methotrexate (MTX) is useful as medical treatment for ectopic pregnancy. However this treatment is not always succeed, so its use usually has been limited and used in only selected cases. Therefore we can guess that persistent tubal pregnancy rate after conservative surgery will be decreased if we inject the MTX after surgery. This study was performed to evaluate the effect of this single-dose MTX treatment for prevention of persistent ectopic pregnancy after laparoscopic conservative surgery for tubal pregnancy.

Material and Method

Material

This study was performed in 56 patients who received the conservative operation for tubal pregnancy with high risk of persistent ectopic pregnancy.

The criteria of high risk were as follows;

1) Gestational sac was not easily detached from the tube during operation.

2) Hematosalpinx was larger than 3 cm.

3) Fimbrial milking cases.

4) Preoperative serum progesterone level was more than 35 nmol/L.

5) Preoperative daily increase of serum beta-hCG level was more than 100 mIU/ml or more than 40% of prior day level.

6) Preoperative serum beta-hCG level was greater than 3,000 mIU/ml.

( Kemman et al, 1994; Hagstrom et al, 1994, Pouly et al, 1986)

Results

Persistent tubal pregnancies were found in 10 of 20 Group II control patients (50%), but no case of persistent tubal pregnancy was found in 36 Group I patients who were treated with MTX after surgery (0%).

* In 10 persistent tubal pregnancy of Group II, 8 patients were treated by sytemic 5-doses MTX therapy and the other 2 patients were treated by laparosocopic re-operation due to failed MTX therapy.

Therefore persistent tubal pregnancy was significantly decreased by single injection of MTX 1.0 mg/kg after conservative surgery in high risk group of persistent tubal pregnancy (p<0.01). In only one case after MTX treatment, side-effect (elevated LFT) was developed and it was recovered after 1 week.

Comment

Kemmann et al.(1994) reported that the persistent tubal pregnancy rate after laparoscopic conservative surgery was 18% , others also reported 3-20% (Bruhat et al, 1980; Pouly et al, 1986; Cartwright et al, 1986; Silva, 1988; Vermesh et al, 1989; Henderson, 1989). If preoperative serum beta-hCG level is more than 3,000 mIU/ml or serum beta-hCG level increases more than 40% per day, persistent ectopic pregnancy rate is increased due to lesser necrotic gestational sac and more invasiveness of trophoblast. Persistent ectopic pregnancy rate is also increased in patients with more severe bleeding tendency during the operation ( Kemmann et al, 1994; Lunorff et al, 1991). Hagstrom et al.(1994) reported that persistent ectopic pregnancy rate was increased if preoperative serum progesterone level was more than 35 nmol/L and daily change of serum beta-hCG level was more than 100 mIU/ml. Treatment after development of persistent ectopic pregnancy is very stressful to patients economically and psychologically. Therefore prevention of its development after operation in high risk group is better than treatment after development. We used the MTX therapy just after conservative surgery for this purpose. MTX has been used for early ectopic pregnancy after MTX systemic treatment report for cornual pregnancy by Tanaka et al.(1982). There are three types of MTX treatments for ectopic pregnancy; lesional injection, single-dose MTX treatment and one cycle of 5-doses MTX treatment with citovorum rescue factors. Hoppe et al.(1994) reported that single-dose MTX treatment is sufficient for cure of persistent ectopic pregnancy. Therefore we used the single-dose MTX injection for prevention of persistent ectopic pregnancy in high risk group. In our investigation of high risk group within previously described criteria, 50% of patients without preventive MTX injection were suffered from persistent ectopic pregnancy and persistent ectopic pregnancy was not developed in patients with preventive single-dose MTX injection.

Conclusion

The single-dose MTX treatment just after conservative laparoscopic surgery in high risk group of persistent tubal pregnancy was suggested as an effective preventive method for persistent ectopic pregnancy.

References

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