Kucera E, Helbich T H, Klem I, Schurz B, Sliutz G, Leodolter S, Joura E A
Department of Gynecology and Obstetrics, University of Vienna, Austria.
Wien Klin Wochenschr. 2000 Sep 15;112(17):772-5.
Interstitial pregnancy occurs in 2-4% of ectopic pregnancies and is defined as implantation of the trophoblast in the interstitial part of the tuba uterina. Therefore the term intramural pregnancy can also be found in the literature. In 20% of the cases that progress beyond 12 weeks of amenorrhea a potentially life-threatening rupture of the uterus occurs, leading to a maternal mortality rate of 2.5%. According to the literature until a few years ago diagnosis was mainly made intraoperatively, and resulted in cornual resection or hysterectomy per laparotomy. Better methods of diagnosis and treatment of interstitial pregnancy can help to decrease morbidity and mortality associated with this condition.
We describe two cases of interstitial pregnancies that were eventually diagnosed and also monitored by magnetic resonance imaging (MRI) after systemic methotrexate treatment. Both patients were uniparous and experienced their second spontaneous pregnancy.
Treatment consisted of four doses (50 mg/m2 body surface area) of systemic intramuscular methotrexate alternating with four doses (6 mg) of intramuscular folic acid. When beta-hCG levels were undetectable, MRI results were compared with pre-therapeutic MRI findings.
In patients A and B, beta-hCG levels were undetectable 64 and 88 days after initiation of methotrexate treatment, while magnetic resonance imaging revealed nearly equally persisting interstitial pregnancies. They initially presented as hyperintense lesions with hypointense zones and changed into a hypointense lesion with a central hyperintense area for patient A, and a completely hyperintense lesion for patient B at the time of negative beta-hCG levels in follow-up MRI.
Systemic methotrexate treatment with an intramuscular regimen is effective in the treatment of interstitial pregnancy. MRI has the ability of correct tissue differentiation and objective three-dimensional measuring of interstitial pregnancy. We therefore propose this imaging modality as a valuable tool for monitoring systemic methotrexate treatment of interstitial pregnancy that should be used additionally to beta-hCG clearance curves.
间质部妊娠占异位妊娠的2% - 4%，定义为滋养层植入子宫输卵管的间质部。因此，文献中也可见“壁内妊娠”这一术语。在闭经超过12周的病例中，20%会发生危及生命的子宫破裂，导致孕产妇死亡率为2.5%。根据文献，直到几年前，诊断主要在术中进行，结果是经剖腹手术行宫角切除术或子宫切除术。更好的间质部妊娠诊断和治疗方法有助于降低与此病症相关的发病率和死亡率。
我们描述了两例间质部妊娠病例，最终经全身甲氨蝶呤治疗后通过磁共振成像（MRI）进行诊断和监测。两名患者均为初产妇，经历的是第二次自然妊娠。
治疗包括四剂（50 mg/m²体表面积）全身肌肉注射甲氨蝶呤与四剂（6 mg）肌肉注射叶酸交替进行。当β - hCG水平检测不到时，将MRI结果与治疗前的MRI表现进行比较。
在患者A和B中，甲氨蝶呤治疗开始后64天和88天β - hCG水平检测不到，而磁共振成像显示间质部妊娠几乎同样持续存在。在随访MRI中β - hCG水平为阴性时，它们最初表现为具有低信号区的高信号病变，对于患者A变为具有中央高信号区的低信号病变，对于患者B变为完全高信号病变。
肌肉注射方案的全身甲氨蝶呤治疗对间质部妊娠有效。MRI能够正确进行组织鉴别并对间质部妊娠进行客观的三维测量。因此，我们建议将这种成像方式作为监测间质部妊娠全身甲氨蝶呤治疗的有价值工具，应与β - hCG清除曲线一起使用。
