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Rule Out Ectopic Before Starting Methotrexate, Physician Says


 

SAN FRANCISCO — Empiric treatment with methotrexate for presumed ectopic pregnancy is a thing of the past, or should be, Dr. Amy “Meg” Autry said.

“You need to do a D&C before you treat with methotrexate” unless a definitive ectopic pregnancy is seen on ultrasound, she said at a conference on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The D&C will help rule out ectopic pregnancy and avoid giving the chemotherapy drug to the 71% of women with indeterminate ultrasound results who actually have an intrauterine pregnancy, said Dr. Autry of the university.

Multiple studies support the need for doing a D&C before beginning methotrexate treatment, she noted. Besides the data that found chorionic villi in 71% of 245 women who underwent a D&C after indeterminate ultrasounds (Acad. Emerg. Med. 1999;6:1024-9), the results of a separate study of 112 women showed that a presumed diagnosis of ectopic pregnancy (without D&C results) was inaccurate in 38% of cases (Am. J. Obstet. Gynecol. 2002;100:505-10). Another study found that empiric treatment with methotrexate did not reduce complications or save money (Fertil. Steril. 2005;83:376-82). An endometrial Pipelle biopsy was not a sufficient substitute for a suction D&C to diagnose ectopic pregnancy in a separate, blinded prospective study of 32 patients (Am. J. Obstet. Gynecol. 2003;188:906-9).

The accumulated evidence is “compelling,” Dr. Autry said. “I would imagine for some of you in this room, this is practice changing, and I think you should change.”

In a separate practice-changing development, there is now “pretty good evidence to show that it's cost effective and tubal protective” to give methotrexate prophylactically to women scheduled for salpingostomies for ectopic pregnancy, Dr. Autry said.

When choosing surgery for ectopic pregnancy, she said she may take out the fallopian tube with the ectopic pregnancy but leave the other tube if it looks normal.

Salpingostomy is associated with persistent trophoblastic disease in 5%-20% of cases, however, without prophylactic methotrexate. Compared with no prophylaxis, giving methotrexate at the time of salpingostomy reduced the risk of tubal rupture (0.4% vs. 3.7%) or future procedures (1.9% vs. 4.7%) and lowered overall cost ($67.55 less on average), one study found (Fertil. Steril. 2001;76:1191-5). Patients with ectopic pregnancies who are most at risk for persistent trophoblastic tissue after salpingostomy are those with very early gestations, ectopic pregnancies less than 2 cm in size, or very high starting HCG levels, Dr. Autry said.

Dr. Autry said she has no conflicts of interest related to these topics.

'I would imagine for some of you … this is practice changing, and I think you should change.'

Source Dr. Autry

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