Methotrexate treatment guided by transvaginal ultrasonography in cervical pregnancy

To evaluate the feasibility of transvaginal intra-amniotic injection of methotrexate for viable cervical pregnancies, we describe our experience in three patients with early ultrasonographic diagnosis and fertility-preserving treatment. A single dose of methotrexate, 50 mg, was administered intra-amniotically through a 20-gauge needle under transvaginal ultrasonic guidance. The diagnosis of cervical pregnancy and the therapeutic effect were established and followed by serial serum β-human chorionic gonadotropin (β-hCG) assays and high-resolution transabdominal and transvaginal color Doppler ultrasound. Serum bilirubin and liver transaminase levels were obtained before and after methotrexate treatment. Gestational age at diagnosis ranged from 42 to 58 days (from the last menstrual period), and the maximum serum β-hCG measured among these three patients was 128,700 mIU/mL (the first International Reference Preparation). The time required for return of serum β-hCG to normal levels ranged from 26 to 49 days. All injections were performed after single needle pass. Two patients required only one dose, while one had another bolus a week later because of a persistently high serum β-hCG level. None suffered any procedure-related complications or side-effects, nor required hysterectomy. As a result of our experience, we would like to emphasize the value of ultrasonography in the diagnosis and management of this unusual event, and suggest that transvaginal ultrasonographically guided intra-amniotic injection of methotrexate may be an effective therapeutic procedure, allowing preservation of the uterus and thus maintaining potential fertility.