Unruptured tubal pregnancy: local low-dose therapy with methotrexate under transvaginal ultrasonographic guidance

Thirty patients with unruptured ectopic pregnancy (4-10 weeks' gestation) were treated locally with methotrexate (MTX) under sonographic guidance. The transvaginal puncture was performed under analgesic sedation using an automatic puncturing device. Local MTX therapy was successful in 25 patients (83.3%). Eighteen of these patients had received a single MTX instillation with a total dose of 10 mg, 7 patients had received a second instillation with 10 mg because of plateauing hCG levels after the first instillation. In 5 patients MTX therapy was unsuccessful. Surgical intervention was necessary within 4 h to 15 days after MTX treatment, due to severe tubal bleeding (n = 1) or the development of an increasing peritubal hematoma (n = 4). Patients with an outer trophoblast diameter < or = 1.5 cm could be treated successfully in all cases (25/25). In patients with hCG values > 5,000 mIU/ml the success rate was 70% (7/10) and in patients with demonstration of cardiac activity of the embryo 63% (5/8). The fluid aspirated from the ectopic cavity showed an average hCG concentration that was 53 times higher than in the serum. The decline in hCG to values below 10 mIU/ml ranged between 7 and 75 days (mean 28 days). The hysterosalpingography performed 4-6 months after MTX therapy showed tubal patency on both sides in 85.7% of the patients examined. In the meantime 4 of these patients gave birth to healthy children.