Interstitial Ectopic Pregnancy: The Role of Mifepristone in the Medical Treatment

Interstitial pregnancy is defined as the presence of a gestational sac in the most proximal section of the fallopian tube. Management of interstitial pregnancy remains a debated topic. Depending on hemodynamic stability, size of pregnancy, depth of surrounding myometrium, and desires for future fertility, interstitial pregnancy can be managed medically or surgically. We reviewed the literature in December 2020 using keywords “interstitial pregnancy”, “medical treatment”, “methotrexate”, and “mifepristone”. Articles published from January 1991 until 2020 were obtained from databases EMBASE, SCOPUS, and PUBMED. We describe the case of a patient with an interstitial pregnancy that was managed with a total medical approach in August 2020 at Burlo Garofolo Hospital. The patient was asymptomatic and hemodynamically stable, with a high level of serum β-hCG (22,272 mUi/mL). We used the combination of methotrexate (MTX) and mifepristone. Medical therapy was effective leading to interstitial pregnancy resolution in 51 days without collateral effects for the patient. We found seven previous cases reported in the literature. Our purpose is to underline the efficacy of medical therapy with systemic multidose MTX associated with a single oral dose of mifepristone and also folinic acid when is present a viable fetus and a high serum β-hCG level.

Diagnostic Criteria and Treatment Modalities of Ectopic Pregnancies: A Literature Review

Background: Ruptured ectopic or extrauterine pregnancy (EP) is responsible for 6% of maternal deaths in the first trimester. This review was designed to summarise the diagnostic criteria and treatment modalities of EPs. Methods: Recent guidelines of the international societies of obstetrics and gynaecology, including the Royal College of Obstetricians and Gynaecologists (RCOG), the American College of Obstetricians and Gynecologists (ACOG), and the European Society of Human Reproduction and Embryology (ESHRE), were reviewed to summarise the diagnostic criteria and treatment modalities of EPs. Results: A minimum β-human chorionic gonadotropin (β-hCG) rise of ≥35% in 48 hours was suggested to diagnose intrauterine pregnancy. A β-hCG rise <35% in 48 hours has 96.2% positive predictive value, 69.7% negative predictive value, and 80.2% overall accuracy in predicting EPs. The blob sign has >90% positive predictive value in diagnosing EPs in symptomatic females with positive β-hCG and no definite intrauterine gestational sac by transvaginal sonography. The interstitial ectopic pregnancy and cornual pregnancy are two separate entities of EPs. Interstitial line sign has 80% sensitivity and 98% specificity in diagnosing interstitial ectopic pregnancy. A meta-analysis reported 89% overall success rate for methotrexate in treatment of EPs; the multi-dose regimen was significantly more successful than the single-dose regimen. Conclusion: Institutes and healthcare providers should follow clear guidelines and/or protocols for the management of EPs. Institutes should implement competency-directed training programmes to increase healthcare providers’ skills to diagnose and treat EP variants using different modalities.