Benifla J L, Fernandez H, Sebban E, Darai E, Frydman R, Madelenat P
Department of Obstetrics and Gynecology, Hôpital Bichat, Paris, France.
Eur J Obstet Gynecol Reprod Biol. 1996 Dec 27;70(2):151-6. doi: 10.1016/s0301-2115(95)02589-8.
To evaluate medical treatment of interstitial pregnancy.
This series was a retrospective study of medical treatment of interstitial pregnancies which was managed in two French Departments of Obstetrics and Gynecology (Bichat public Hospital. Paris and A. Béclère public Hospital, Clamart, France). Fifteen patients with clear evidence of an unruptured interstitial pregnancy were treated by injection of methotrexate (MTX) or potassium chloride (KCL) without surgery since January 1988. The diagnosis was established either by sonography and laparoscopic confirmation in eight cases or by only transvaginal ultrasound in seven cases. Three out of 15 cases in this series, had a heterotopic pregnancy who were treated by transvaginal ultrasound-guided injection of KCL. Others received systemic MTX injection in four cases, and local MTX injection in eight cases under either laparoscopy or transvaginal ultrasound guidance. Four different protocols of MTX (Ledertrexate) administration was performed in this series with time: at the beginning of our experience, MTX1 protocol, 15 mg i.m. daily for 5 days was used; and after MTX2 protocol, 1 mg/kg body weight i.m. daily for 4 days; MTX3 protocol, 1 mg/kg body weight intratubal associated with 1 mg/kg body weight i.m. daily for 3 days; and now MTX4 protocol, only intratubal 1 mg/kg body weight is especially used. The success was defined as declining serum human chorionic gonadotropin (hCG) to undetectable levels, and no further surgical management was required. Outcome of subsequent fertility was also evaluated.
Complete resolution was obtained in 13 (86.6%) out of 15 interstitial pregnancies. Two out of 15 patients, with medical treatment's failure required secondary surgery. No severe side effects of medical treatment were observed. Follow-up hysterosalpingography was performed in 12 patients showing 91.7% tubal patency on the side of interstitial pregnancy. Outcome of intra-uterine pregnancy of the three patients who had heterotopic gestation, was two miscarriages and one delivery at term. Out of the other 12 patients in this series, nine became pregnant within 1 year: eight pregnancies at term, and one induced abortion. At present, among the last three patients, two have no desire to conceive.
Our results suggest that unruptured interstitial pregnancies now can be managed with local MTX administration of 1 mg/kg body weight under transvaginal ultrasound or under laparoscopy procedure. This approach is particularly attractive in these patients, where the only alternative to therapy is laparotomy with cornual resection.
评估间质部妊娠的药物治疗效果。
本研究为一项回顾性研究，对法国两个妇产科科室（巴黎比夏特公立医院和法国克拉马尔的A. 贝克莱尔公立医院）间质部妊娠的药物治疗情况进行分析。自1988年1月起，15例确诊为未破裂间质部妊娠的患者接受了甲氨蝶呤（MTX）或氯化钾（KCL）注射治疗，未进行手术。其中8例通过超声检查和腹腔镜检查确诊，7例仅通过经阴道超声确诊。15例患者中有3例合并异位妊娠，采用经阴道超声引导下注射KCL治疗。其余患者中，4例接受全身MTX注射，8例在腹腔镜或经阴道超声引导下接受局部MTX注射。本研究采用了4种不同的MTX（Ledertrexate）给药方案：在研究初期，采用MTX1方案，即每日肌内注射15 mg，共5天；之后采用MTX2方案，即每日肌内注射1 mg/kg体重，共4天；MTX3方案，即输卵管内注射1 mg/kg体重，同时每日肌内注射1 mg/kg体重，共3天；目前采用MTX4方案，即仅输卵管内注射1 mg/kg体重。治疗成功的定义为血清人绒毛膜促性腺激素（hCG）降至无法检测的水平，且无需进一步手术治疗。同时评估后续生育情况。
15例间质部妊娠中，13例（86.6%）完全治愈。15例患者中有2例药物治疗失败，需进行二次手术。未观察到严重的药物副作用。12例患者接受了子宫输卵管造影随访，间质部妊娠侧输卵管通畅率为91.7%。3例合并异位妊娠的患者中，2例发生流产，1例足月分娩。在本研究的其他12例患者中，9例在1年内怀孕：8例足月妊娠，1例人工流产。目前，最后3例患者中有2例暂无生育意愿。
我们的研究结果表明，对于未破裂的间质部妊娠，现在可以在经阴道超声或腹腔镜引导下，采用局部注射1 mg/kg体重的MTX进行治疗。在这些患者中，这种方法特别有吸引力，因为唯一的替代治疗方法是子宫角切除术剖腹手术。
