Unruptured unilateral twin ectopic pregnancy: a rare case report

Unilateral twin ectopic pregnancy is a rare entity with an incidence of 1 in 125,000 pregnancies. This is a case of a 26-year-old primigravida with a spontaneous unilateral twin ectopic gestation, diagnosed on transvaginal ultrasound, treated laparoscopically by doing unilateral salpingectomy and confirmed with histopathology. The doubt for ectopic pregnancy was raised when the serum β-HCG level was constantly >1500 mIU/ml and serum progesterone level was <5 pg/ml and no intrauterine pregnancy was seen. On a follow-up scan, twin gestational sac was noted in right adnexa along with a large haemorrhagic cyst in the right ovary. On post-surgery follow-up, patient was found to have had complete recovery. This case report discusses the incidence and rarity, yet possibility of twin ectopic gestations, the need for early diagnosis and its management.

Comparison of blood methotrexate level according to the route of administration in non-surgical treatment of ectopic pregnancy / 대한산부인과학회지

OBJECTIVE: This study was performed to compare the pharmacokinetics of methotrexate (MTX) in unruptured ectopic pregnancy according to the injection route. METHODS: Between May 2005 and August 2009, thirty-five patients of unruptured ectopic pregnancy in Chungbuk National University Hospital were treated medically either by intramuscular (IM) or intraamniotic (IA) injection of MTX according to the presence of fetal heart beat. Serum concentration of MTX was measured by fluorescent immunoassay using the blood samples withdrawn serially after its injection. RESULTS: The peak plasma MTX level was achieved at the 30-minute after injection sample in both groups. The mean peak plasma level of MTX in IM group was significantly higher than that of IA in 60-minute (2.296+/-0.64 umol/L vs 1.535+/-0.31 umol/L; p<0.006), 90-minute (1.9+/-0.51 umol/L vs 1.225+/-0.21 umol/L; p<0.002), and 240-minute (1.443+/-0.33 umol/L vs 1.077+/-0.18 umol/L; p<0.011) samples. The mean pretreatment plasma beta-hCG level was significantly higher in IA group, both tubal pregnancy (48,405+/-37,811.7 IU/L vs 18,452.05+/-19,205.34 IU/L; p<0.007) and cervical pregnancy (94,574.2+/-45,037.1 IU/L vs 42,446+/-34,778.12 IU/L; p<0.037), than those of IM group. But neither plasma MTX level nor pretreatment beta-hCG level were related to the treatment outcome. CONCLUSION: The plasma level of MTX increased rapidly in both IM and IA groups; the peak level reached at 30 minutes, and decreased to less than 1 umol/L after 240 minutes. Moreover, it was higher in IM group than IA group. Nevertheless, IA injection may be useful in patients who had high beta-hCG level or fetal heart beat, which are not usually indicated to medical treatment.

A Clinical Study of Unruptured Ectopic Pregnancies with the Treatment of Systemic or Local Methotrexate Injecton / 대한산부인과학회잡지

OBJECTIVE: To evaluate safety and efficacy of systemic or local methotrexate(MTX) injection to patients with unruptured ectopic pregnancy METHODS: From October 1995 to October 1999, 35 unruptured ectopic pregnancies were eligible for the conservative management. 25 tubal pregnancies, 4 cervical pregnancies, 4 pregnancies of previous cesarean section scar, and 2 cornual pregnancies diagnosed by ultrasonography & serumbeta-hCG were evaluated. Patients were treated with one of following three protocols : (1) A single-dose of 50mg/m2 of intramuscullar(IM) MTX(7 cases) (2) Two to four doses of 1.0mg/kg of IM MTX with citrovorum rescue(20 cases) (3) Transvaginal ultrasonogram-guided intra-amniotic instillation of 50mg methotrexate (8 cases) The mean age of these patients was 30.8 yrs (range 24-42) and gestational age at diagnosis ranged from 22-75 days (mean 47). Initial level of serumbeta-hCG ranged from 166.4-55363.8 mIU/mL (mean 9069.2). Patients were monitored with serumbeta-hCG titers three times per week ,and then weekly until the serumbeta-hCG level was less then 10 mIU/mL. RESULT: 31 of 35 patients (88.6%) were successfully treated and remaining 4 patients failed conservative therapy and so required surgery. Mean duration of resolution was 38.5 days (range 11-105). Side effect rate was 45.7% but severity of symptoms were so mild that no treatment was needed in most cases. CONCLUSION: Nonsurgical conservative management of MTX appears to be effective and safe treatment modality for some selected unruptured ectopic pregnancy. But further comparative studies and long-term follow-up are needed to evaluate reproductive outcome and reduce side effects of MTX.