Misme H, Agostini A, Dubernard G, Tourette C
Service de gynécologie-obstétrique de l'hôpital de la Croix-Rousse, hospices civils de Lyon, 103, Grand rue de la Croix-rousse, 69004 Lyon, France.
Service de gynécologie-obstétrique, CHU de La Conception, 147, boulevard Baille, 13385 Marseille cedex 05, France.
J Gynecol Obstet Biol Reprod (Paris). 2015 Mar;44(3):220-9. doi: 10.1016/j.jgyn.2014.12.015. Epub 2015 Feb 7.
The objective of this work is to discuss the indications for methotrexate in gynecology outside the first-line treatment of tubal ectopic pregnancy. In tubal ectopic pregnancy, the prophylactic use of systemic methotrexate can be discussed when performing laparoscopic salpingotomy. In case of failure of salpingotomy, administration seems justified especially if it avoids re-intervention. The combination of methotrexate with other therapies such as mifepristone, potassium chloride or gefitinib is not recommended in the treatment of ectopic pregnancy. For non-tubal ectopic pregnancy, the intramuscular or local administration of methotrexate is an acceptable treatment for uncomplicated interstitial pregnancies. For uncomplicated cervical or cesarean scar pregnancies, the local administration of methotrexate should be considered as a first-line treatment. For ovarian pregnancies, methotrexate should not be a first-line treatment, surgical treatment remains the standard. Asymptomatic women presenting with a pregnancy of unknown location and plateauing serum hCG concentration<2000 UI/L can be managed expectantly: it is recommended to take an additional quantitative hCG serum level after 48 hours. Thus, methotrexate is not recommended in the first intention. Other gynecological indications were discussed: methotrexate is not recommended in the management of first-trimester miscarriages or in the management of placenta accreta.
本研究的目的是探讨甲氨蝶呤在输卵管异位妊娠一线治疗之外的妇科应用指征。在输卵管异位妊娠中，进行腹腔镜输卵管切开术时可讨论全身应用甲氨蝶呤的预防性使用。如果输卵管切开术失败，给药似乎是合理的，特别是如果能避免再次干预。不推荐甲氨蝶呤与其他疗法如米非司酮、氯化钾或吉非替尼联合用于异位妊娠的治疗。对于非输卵管异位妊娠，甲氨蝶呤的肌肉注射或局部给药是单纯性间质部妊娠的可接受治疗方法。对于单纯性宫颈或剖宫产瘢痕妊娠，甲氨蝶呤的局部给药应被视为一线治疗方法。对于卵巢妊娠，甲氨蝶呤不应作为一线治疗方法，手术治疗仍是标准方法。血清人绒毛膜促性腺激素（hCG）水平<2000 UI/L且无症状、妊娠部位不明且hCG水平稳定的女性可进行期待治疗：建议在48小时后再次检测血清hCG定量水平。因此，不建议首选甲氨蝶呤。还讨论了其他妇科应用指征：不推荐甲氨蝶呤用于早期流产的治疗或胎盘植入的处理。
