{"paper_id":"53e94d95-876d-4ee9-b20e-5de60098d5c3","body_text":"~ 364 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2021; 5(1): 364-365 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2021; 5(1): 364-365 \nReceived: 22-11-2020 \nAccepted: 24-12-2020 \n \nDr. Shazia Nisar \nSenior Resident, Department of \nObstetrics and Gynecology, \nSKIMS, Soura, Srinagar,  \nJammu and Kashmir, India \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nDr. Shazia Nisar \nSenior Resident, Department of \nObstetrics and Gynecology, \nSKIMS, Soura, Srinagar,  \nJammu and Kashmir, India \n \nA study on medical management of ectopic pregnancy \nusing methotrexate \n \nDr. Shazia Nisar \n \nDOI: https://doi.org/10.33545/gynae.2021.v5.i1f.840 \n \nAbstract \nEctopic pregnancy is defined as one where fertilised ovum  implants outside the normal uterine cavity  the \nmain sites for  implantation include tubes, ovaries, cervix, rudimentary horn  of a bicornuate uterus and \ncesarean scar. Risk factors being PID tuberculosis of pelvis, use of progesterone contraception, \nendometriosis of tube, congenital anomalies of tube. Diagnosis  is being  made by T VS and serum beta \nHCG. Treatment depends on hemodynamic stability of patient. In unstable patients surgical  management is \nbest but in stable patients medical management with methotrexate is done. Our study is aimed at medical \nmanagement of ectopic.  \nMethodology and results: 70 unruptured ectopic patients were included in study. 12 patients were kept for \nobservation. 58 patients were selected for medical management i.e. methotrexate treatment. No. Of patients \nwith Successful single dose methotrexate treatmen t were 42  (72.4%) No. Of patients required multidose  \nmethotrexate were 10(17.24%) No. Of patients with failed methotrexate treatment and requiring  surgical \nintervention were 2(3.4%) No. Of patients with tubal rupture 4(6.8%). \nConclusion: Medical management of patients with ectopic pregnancy who are hemodynamic stability with \nmethotrexate offers promising results and avoids surgical morbidity and offers a good obstetric future to \nthe patients. \n \nKeywords: medical management, ectopic pregnancy, methotrexate \n \nIntroduction  \nEctopic pregnancy is one where ovum implants outside the normal uterine cavity. The common \nsites for implantation are tubal  (90%) Ovarian, cornual, abdominal, cervical, cesarean scar \nectopic. Most  Common predisposing fac tors for ectopic pregnancy are PID, congenital \nanomalies of tube, previous tubal surgery, use of progesteronal contraceptives  Tuberculosis of \ntube, use of emergency contraceptives, transperitoneal migration of ovum, endometriosis of tube \nand long term infertility [1, 2].  \nWhen a women on progesterone only contraceptives conceives an ectopic  Pregnancy should \nalways be considered [3, 4, 5].  \nNowadays the incidence of ectopic pregnancy is on rise because of early diagnosis,  use of \nartificial reproductive techniques (ART) and increased incidence of PID. Ectopic pregnancy can \npresent as ruptured ectopic which manifests as acute abdomen, subacute or chronic ectopic. \nDiagnosis of ectopic is made on the basis of TVS and serum Beta HCG and since 1980 this has \nmade diagnosis of ectopic easier [1]. A paired serum Beta HCG is taken at least 48 hours apart, if \nserum beta HCG increases less than 66% then ectopic is suspected. TVS should make out \nGestational sac when beta HCG is 1500 I. U/ml, if it fails to detect intrauter ine gestational sac at \nthis discriminatory zone of beta HCG then laparoscopy is advised.  \nUse of colour doppler TVS  assess increased blood flow in adnexal mass indicating active \ntrophoblastic tissue in adnexa  Which correlates with beta HCG titre (Kurjak et al. 1994). There \nare different modalities of treatment for ectopic pregnancy depending  on beta HCG titres and \nclinical condition of patient. Conservative  and medical managem ent saves a woman from \nsurgical morbidity and at the same time saves h er tube. Med ical management of ectopic with  \nmethotrexate has been found to safe and effective [6]. Depending on the size of ectopic and beta \nHCG levels methotrexate can be given as single or multidose regimen. \n \nMethodology \nIt was a prospective study carried over a period of one year August 2016-May 2017.  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 365 ~ \nSeventy (70) unruptured ectopic pregnancy were included in this \nstudy. Diagnosis was made by TVS.  \nAll baseline investigations were done CBC, KFT,  LFT, \nmeasurement of height and weight. \n \nInclusion criteria \n1. Patients with stable, unruptured ectopic diagnosed by TVS. \n2. Beta HCG titre <10000miu/ml. \n3. Size of ectopic mass <4 cm. \n4. Absence of fetal cardiac activity. \n5. Patient giving consent for medical treatment. \n \nExclusion criteria \n1. Patient who are unstable with hemoperitoneum. \n2. Size of sac >4cm with cardiac activity with cardiac activity  \npresent. \n \nNow patients were divided based on their beta HCG level, those  \nWith beta HCG level <500mi.u/ml, where kept for observation  \nand their beta HCG was repeated after 4 8hours, their beta HCG \nshowed a falling titre and had complete resolution. Patients  \nwhose beta HCG >500 but < 5000 we're given a single dose of  \nmethotrexate regimen 50mg /metre square (calculated on the  \nbasis of height and weight). Beta HCG was measured on day 4  \nand day 7. 15% or more fall in beta HCG between day 4 and day \n7 was considered satisfactory and successful. If there was <15%  \nfall in beta HCG then methotrexate was repeated on day 7 and \nbeta HCG was measured between day 7 and day 11. \nThose with beta HCG >5000 we're given mu ltidose regimen  \n(1mg/kg) on day 1,3,5,7 with folinic acid rescue on day 2, 4, 6, \n8. Beta HCG was detecte d in between days 15% or more of fall \nin between the days was considered satisfactory. After  \nadministration of methotrexate patients were instructed to avoid \nvitamins, folic acid, travel, NSAIDS, exposure to sunlight.  \n \nResults \nNo. Of patients with unruptured ectopic pregnancy = 70. \nNo. Of patients kept for observation with beta HCG <500 = 12. \nResolution of ectopic = 12 patients 100%. \nNo. Of patients kept for medical management = 58. \nNo. Of patients with successful single dose methotrexate therapy \n= 42 (72.4%). \nNo. patients requiring more than one d ose of methotrexate = 10 \n(17.24%). \nNo. Of patients with failed medical therapy requiring surgical  \nIntervention = 2 (3.4%). \nNo. Of patients with tubal rupture requiring emergency \nlaparotomy = 4 (6.8%). \n \nDiscussion \nEctopic pregnancy is a major cause of maternal mortality and  \nmorbidity in first trimester of pregnancy. Nowadays because of  \nbetter antenatal care and US G facilities mortality due to ectopic  \npregnancy has reduced a lot. There are various treatment  \nmodalities for ectopic pregnancy ob servation, treatment, \nsurgical. \nMedical treatment for ectopic introduced since 1980  [1] has \nfacilitated management of ectopic pregnancy. Medical treatment \nwith methotrexate either as single dose or multiple doses has  \nhelped to manage patient s even without exposing them to \nsurgical management. In earlier times multidose dose was used  \nbut later because of refinement and modificatio n single dose  \ntherapy is nowadays preferred and that too on OPD basis [6, 7]. \nMedical treatment with methotrexate has many advantages  as it \nis effective, less costly, simple and preferable to surgery  (Das et \nal. 2001) Methotrexate is given on the b asis of body weight and \nheight from which surface area is calculated. In single dose \ntherapy 50mg/metre square is given on day zero and beta HCG \nis measured on day 4 and day 7. If beta HCG decreases by 15% \nor more from day 4 to day 7 then beta HCG is done weekly till it \nbecomes negative. If there is <15% decrease from day 4 to day 7 \nthen a repeat dose of methotrexate is given on day 7 and beta  \nHCG is measured between day 7 to day 11.This is known as  \nSecond dose regimen. Single dose methotrexate treatment  has \ngot less side effects however Glock et al. [8] reported more side \neffects like nausea, diarrhea, dryness of mouth even  with single \ndose of methotrexate. \nIn multidose regimen met hotrexate is given in dose of 1 mg/kg \non day 1,3,5,7 with folinic acid on day 2, 4, 6, 8. In our study 58 \npatients were kept for medical management. In our study  Single \ndose of methotrexate was s uccessful in 72.4% of patients, \n17.24% patient’s required 2 dose r egimen or multidose regimen. \nIn our study there were 2 patients (3.4%) that requ ired surgical \nintervention despite giving medical management. 4 patients \nwere those had that tubal rupture and required emergency \nsurgery.  \n \nConclusion \nWith the introduction of use of methotrexate in  management of \nectopic, we have been able to manage ectop ic patients even on \nOPD basis. Although failure is there with use of  this period but \nstill it is number one treatment option for hemodynamic stable \nectopic patients with beta HCG <10000. \nUse of medical management offers a better obstetric future to \nthe patient and saves her from surgical morbidity.  \n \nReferences \n1. Chi Tj, Dyne PL. Emergency management of ectopic \npregnancy. Available at http://em edicine.medscape. \nCom/article /796451-overview. \n2. Majhi AK, Roy N, Karmakar KS,  Banerjee PK. Ectopic \npregnancy-an analy sis of 180 cases. Journal of the Indian \nMedical Association 2007;105(6):308-10. \n3. Harrison-Woolrych M, woolley J. Progestogen onl y \nemergency contraception and ectopic pregnancy (editorial). J \nFam. Plann. Reprod. Health care 2003;29(1):5-6. \n4. Canis M, Savary D,  Ponly JL, Wattiez A, Mage G. Ectopic \npregnancy: Criteria to decide between medical and \nconservative Surgical treatment? J Gynecol. Obstet. Biol \nReprod (Paris) 2003;32(7):S54-63. \n5. Pereira PP, Cabar FR, Raiza LC, Roncaiglia MT, Zugaib M.  \nEmergency contraception and ectopic pregnancy: report of 2 \ncases. Clinics 2005;60(6):497-500. \n6. Barnhart KT. Gosman G, Ashby R, Sanmel M. The medical \nmanagement of ectopic pregnancy: a meta -analysis \ncomparing Single dose and multidose regimen obstet \nGynecol 2003;101(4):778-84. \n7. Guvendag Guven ES, Dilbaz S, Dilbaz B, Aykan Yildirin B, \nAkdag D, Haberal A. A comparison of single and multiple \ndose methotrexate therapy for unruptured tubal ectopic \npregnancy: a prospective randomized study. Acta obstetricia \net Gynecologica Scandinavica 2010;89(7):889-95. \n8. Glock JL, Johnson JV, Brumsted JR. Efficiency and safety of \nsingle dose systemic methotrexate in treatment of ectopic \nPregnancy. Fertil Steril 1994;62:716-21.","source_license":"CC0","license_restricted":false}