Prognostic factors for an unsatisfactory primary methotrexate treatment of cervical pregnancy: a quantitative review

Abstract

To determine the risks when the primary methotrexate (MTX) treatment of cervical pregnancy has an unsatisfactory outcome, we conducted a Medline search on relevant literature published from January 1983 to June 1997. The search yielded 28 publications of 48 cases of cervical pregnancy. These and four new cases from our institutions were used in our study. A cervical pregnancy that presented with a serum beta-human chorionic gonadotrophin concentration of > or = 10,000 mIU/ml [odds ratio (OR) 10.82, 95% confidence interval (CI) 2.59, 45.14], gestational age at > or = 9 weeks (OR 6.44, 95% CI 1.46, 28.52), embryonic cardiac activity (OR 14.29, 95% CI 2.95, 76.92), and crown-rump length of >10 mm (OR 13.33, 95% CI 1.46, 120.48) was considered to be associated with a higher unsatisfactory rate of primary MTX treatment. A concomitant feticide was found to enhance the therapeutic effect of MTX treatment if embryonic cardiac activity was evident (OR 0.13, 95% CI 0.02, 0.68). Administration of a high dose of MTX did not seem to be more effective than a lower one. Our findings supported some previous observations and, more importantly, provided useful clinical information in selecting appropriate candidates for MTX treatment in cases of cervical pregnancy.

The conservative management of cervical ectopic pregnancies

“…The overall success rate of primary systemic methotrexate treatment was 83% (5/6). This compares favorably with a meta-analysis of 52 cases published in 1998, which showed an overall success rate of 62%, and success rates of 40% and 91% for cervical pregnancies with and without cardiac activity, respectively 42 . A more recent study of 31 cervical ectopic pregnancies, of which 22 were treated with systemic methotrexate, showed a success rate of only 12/22 (54.5%) for systemic methotrexate alone 37 .…”

“…In retrospect our management of this case could be considered sub-optimal. Fetal cardiac activity has been shown to be associated with a higher rate of primary methotrexate failure; so too has an initial serum hCG level > 10 000 IU/L, a gestational age of > 9 weeks and a crown-rump length of > 10 mm 42 . In the case that failed treatment with both single and multiple dose regimens of methotrexate, there was success with intra-amniotic injection of potassium chloride, which is thought to enhance the therapeutic effect of methotrexate.…”

Conservative treatment of cervical pregnancy with selective unilateral uterine artery embolization

“…Case reports may add new knowledge, particularly on new ways of minimizing the risk of hysterectomy, which may be disastrous for a young woman. Chemotherapy and uterine artery embolization can be used alone or in combination, but after 9-week gestation, when a fetal heartbeat is present, with a fetal crown-rump length of more than 10 mm or maternal serum b-hCG level of more than 10 000 IU/mL, systemic methotrexate is not likely to be effective (2). However, exceptions have been described, and some authors suggest that it may be worthwhile to start treatment with intramuscular methotrexate (3), because direct puncture of the amniotic cavity may provoke incomplete abortion with life-threatening hemorrhage (4).…”

Cervical ectopic pregnancy: surgical or medical treatment?

“…Risk factors for unsuccessful conservative medical management have been identified [25][26][27]. First, a serum β-HCG level of more than 10,000 mlU/ml and cardiac activity were found to be associated with higher treatment failure of MTX [25].…”

“…First, a serum β-HCG level of more than 10,000 mlU/ml and cardiac activity were found to be associated with higher treatment failure of MTX [25]. Second, Hung et al have added two more prognostic factors indicating an elevated risk of treatment failure of MTX: ≥9 weeks gestation and CRL >10 mm [26,27]. On the other hand, a review of the current literature reveals that there are some cases of advanced CEP with poor prognostic factors but an excellent clinical outcome after conservative medical treatment [9,11,22,28,29].…”