Methotrexate Versus Salpingotomy

Methotrexate Versus Salpingotomy

H. Fernandez

South Paris University, Department of Obstetrics and Gynecology

Hפpital Antoine Beclere, Clamart, France

Early diagnosis of ectopic pregnancy is now possible, thanks to the development of radioiummunoassays and antiserum that together allow sensitive and specific assays of the -subunit of human chorionic gonadotropin (hCG), the use of serum progesterone, andhigh resolution ultrasonography with vaginal probes. Ectopic pregnancy is now often discovered before any clinical symptoms and laparoscopy is no longer essential for diagnosis.

Linear salpingotomy by laparoscopy remains the treatment of choice for tubal prengancy (Pouly et al., 1986). This procedure preserves the Fallopian tube but carries a risk of persistent trophoblast. Over the past 10 years, many uncontrolled series have reported the results of conservative medical treatment. One such treatment is methotrexate, which has been administered by i.m. or i.v. injection with one to four doses (Tanaka et al, 1982; Stovall et al, 1993) or by local injection under laparoscopic or sonographic control (Feichtinger and Kemeter, 1987; Pansky et al, 1989 Fernandez et al, 1991) when appropriate inclusion criteria are used (Fernandez et al, 1991) methotrexate failure rates have been similar to those reported in previous series of laparoscopicsurgery

Three prospective randomized trials have compared laparoscopic salpingotomy with local methotrexate by laparoscopy. Mottla et al (1992) reported a randomized trial that was discontinued because of poor results in the group treated by methotrexate. The doses of methotrexate used were unusually low (12.5 mg) and the criteria used to judge treatment failure were unclear. O’Shea et al. (1994) reported a success rate of 89.7% for local methotrexate under laparoscopic guidance (n = 29) and 87.5% for CO2 laser laparoscopic salpingotomy. Zilber et al (1996) found a lower incidence of persistent trophoblastic activity (4.2% compared with 16.7%)in the salpingostomy group; this difference was not statistically significant. Laatikainen et al (1993) compared local injection of hyperosmolar glucose solution by laparoscopy (n = 20) with salpingostomy (n = 20). There were 4 and 2 failures, respectively. This difference was not significant, but of course, one major difficulty of this type of study is the large number of patients needed to observe a significant difference. A recent (Hajenius et al, 1997) prospective randomized trial compared systemic methotrexate (n = 51) and laparoscopic salpingostomy (n = 49). Both methods were successful in treating the majority of cases. The authors reported a fairly high rate of failure after salpingotomy: 8% of the patients required a salpingectomy, even after treatment of persistent trophoblast by methotrexate. Moreover, all of the patients treated by IM methotrexate underwent a laparoscopy before medical treatment, and 14% subsequently required surgical intervention. In our experience (Fernandez 1998), one hundred patients were randomized into 2 groups using a random number table. Inclusion criteria were an ectopic pregnancy visualized by ultrasound with a pre-therapeutic score < 13. The treatments were either 1 mg/kg of mthotrexate injected transvaginally into the ectopic pregnancy without anזsthesia or administered i.m. when the prengnacy could not safely or easily be punctured (group 1), or laparosocopic salpingotomy (group 2).

Treatment was successful for 45 of 51 patients in group 1 (88.2%) and 47 of 49 in group 2 (95.9%). Medical treatment was significantly (p < 0.05) associated with shorter postoperative stay (24 compared with 46 hours) but hCG returned to normal more quicklyafter laparoscopic treatment (13 compared with 29 days). Spontaneous reproductive performance was similar in both groups, but overall intrauterine pregnancy was higher, and repeat ectopic pregnancy lower, after methotrexate treatment.

For practical purposes, when an ectopic sac is found at laparoscopy, either a linear salpingotomy, removing the trophoblast, or removal of the tube should be performed immediately. In these cases, IM methotrexate is indicated only when high serum hCG levels persist. For patients who meet the inclusion criteria defined in our study, local methotrexate treatment at the same time that the ectopic sac is visualized by ultrasound appears both safe and efficient. In these cases, surgical treatment is required only rarely, for cases of unusual abdominal pain, with increasing hematosalpinx observed sonographically, or when the hCG level continues to rise after an additional IM methotrexate injection.

The potential cost effectiveness, already reported (Yao et al, 1996), may become a determinative factor in selecting among various treatments. Moreover, methotrexate may be superior because of its simplicity: in those situations where laparoscopic salpingotomy failure rates exceed 15% , it may be desirable to use a technique for which laparoscopic surgery skills are not required.References

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