Direct Methotrexate Injection into the Gestational Sac for Nontubal Ectopic Pregnancy: A Review of Efficacy and Outcomes from a Single Institution

Abstract Study Objective To evaluate the efficacy of nontubal ectopic pregnancy (NTEP) management with direct methotrexate (MTX) injection into the gestational sac. Design Retrospective Chart Review Setting Tertiary academic and teaching hospital Patients All cases of confirmed NTEP were retrospectively identified from 2012 to 2017. Intervention Ultrasound-guided direct injection of MTX into the fetal pole and surrounding gestational sac and a single dose of systemic MTX with or without fetal intracardiac injection of potassium chloride (KCl). Measurements Treatment failure, complications from treatment, operating time, and days to negative serum hCG (human chorionic gonadotropin) after treatment were measured. Main Results Fourteen women (age 34 ± 5.2 yrs) with NTEP underwent direct MTX injection (cesarean scar, n=4; interstitial, n=6; cervical, n=4). Mean estimated gestational age was 49 [41, 57] days. One patient required laparoscopic intervention, with the failure rate of 1/14 (a double interstitial, hetero-ectopic pregnancy). There were no other major complications. Time in OR was similar for all NTEP types. Average time to negative serum hCG was not different for cesarean scar (84.5 ± 36 days), cervical (70.5± 19 days) or interstitial pregnancies (45.3± 38 days, p =0.15). Conclusion(s) Direct MTX injection into the gestational sac for NTEP treatment is safe and effective. The failure rate of 7% is considerably lower than what previously reported for a failure of systemic MTX in similar cases (25%). Resolution of serum hCG after treatment can be quite prolonged even in uncomplicated cases.