Implementation of a Program for Combined Intra-Gestational and Systemic Methotrexate Injection to Treat Non-Tubal...

Non-tubal ectopic pregnancies (NTEP) are a rare and life-threatening subset of ectopic pregnancies, with their clinical management poorly defined. This study evaluated the effectiveness of combined methotrexate injection (intra-gestational/systemic) for NTEP in an outpatient setting. In this case series (January 2019-December 2023), our institution introduced a program to treat NTEP using ultrasound-guided transvaginal intra-gestational methotrexate injection (100 mg) and intramuscular methotrexate (25 mg) with fetal intracardiac potassium chloride, if cardiac activity present. The primary outcome was the resolution of hCG levels without emergency surgery while secondary outcomes included safety, residual products of conception and future fertility. Twenty patients with NTEP (cesarean scar, n = 11; cervical, n = 5; interstitial, n = 4) were treated. The success rate was 95% (19/20), with one patient requiring emergency uterine artery embolization for acute hemorrhage one-month post-procedure, despite decreasing hCG. Acute hemorrhage occurred in 10% (2/20) of patients but resolved without hysterectomy. The median time to negative hCG was 80 days (IQR 51-112) with cesarean scar pregnancy taking longer to resolve (p = 0.047). Residual products of conception were observed in all patients who had follow up ultrasound (10/10). Of those who attempted to conceive afterward, 78% (7/9) achieved pregnancy within the study period. In conclusion, combined methotrexate for treatment of NTEP is a safe, effective, and fertility-sparing approach with promising future pregnancy outcomes. Complications warrant close surveillance until pregnancy resolution. Fertility clinics are well-suited to offer this non-surgical treatment in an outpatient setting.