The patient is at high risk for ectopic pregnancy due to her sexu- ally transmitted disease and PID [1]. The history, symptoms, physi- cal exam as well as imaging studies are suggestive of an ectopic pregnancy and the diagnosis can be safely made. Medical treatment with methotrexate would result in high success rates (93 %) due to a relatively low level of beta-hCG [2]. One of the most important aspects of methotrexate treatment is the ability to follow the pa- tient. Persistent ectopic pregnancy or tubal rupture can occur. His- torically, up to 24 % of patients with persistent ectopic pregnancies have experienced rupture of the ectopic mass necessitating urgent treatment [3]. In a large number of patients with ectopic pregnancy who were hemodynamically stable and treated with a single dose of methotrexate, the failure rate was 13 % and an additional 14 % required a second dose of methotrexate [4]. The failure rate cor- relates with levels of beta-hCG [2, 5].
The patient described was an underprivileged individual. Her willingness to seek medical care was questionable and her compli- ance for follow-up had to be carefully assessed. Studies examining compliance with methotrexate protocols demonstrate that under- privileged inner-city populations do not comply with treatment sat- isfactorily. Watters et al. demonstrated that only 14.8 % of patients treated with methotrexate adhered to the protocol and concluded that patients’ follow-up and compliance rates were poor in the disadvantaged population of Cook county hospital [6]. Similarly, Carter et al. demonstrated 18.3 % compliance for follow-up among medically treated patients [7]. Dueñas-Garcia et al. had an 87.9 %
8 Compliance with Methotrexate Treatment for Ectopic Pregnancy 57
success rate for methotrexate therapy but only 10.1 % of their pa- tients were fully compliant with therapy [8]. In an inner-city hos- pital in Philadelphia, only 19.7 % of patients were fully compliant with therapy. It increased to 45.5 % after numerous reminders by telephone or letters [9].
The ACOG Practice Bulletin defines patients with the question- able ability to return to all follow-up visits as poor candidates for medical therapy. Patients who cannot return for follow-up after methotrexate administration should not be treated medically [10].
The compliance of adolescents receiving medical therapy for ectopic pregnancy was found to be similar to that of adults [11].
A study conducted among Canadian physicians demonstrated that about 50 % of them would probably withhold methotrexate treat- ment to adolescents who have a history of noncompliance with oral contraceptives or suffer from substance abuse [12].
Management
The main concern in treating this patient is compliance. It is ques- tionable whether the patient will adhere to the treatment protocol.
With serum beta-hCG levels of 1200 IU/mL, the chance of treat- ment success is over 90 % [2, 4, 13], but continued follow-up with serial serum hCG monitoring is mandatory. Our patient is a poor candidate for medical therapy with methotrexate. A comprehensive
“team” discussion involving social workers should be carried out with the patient. A decision regarding therapy should be taken after assessing the risks and benefits.
Our patient will benefit more from surgery and salpingectomy.
The benefits of a minimally invasive surgical procedure in this par- ticular patient are higher than the risks of rupture or persistent tro- phoblast that can be life-threatening.
Outcome
Considering all the factors stated above, the patient was treated sur- gically. Laparoscopy revealed a nonruptured left ectopic ampullary pregnancy and a left salpingectomy was carried out. The patient recovered fully and was discharged the following day.
Clinical Pearls/Pitfalls
• One in four patients with persistent ectopic pregnancies might eventually have tubal rupture.
• Compliance with follow-up treatment among underprivileged inner-city inhabitants is low (approximately 20 %).
• A careful assessment regarding the patients’ ability to comply with treatment protocol before deciding on the treatment should be performed.
• Poorly compliant patients should be treated surgically (Table 8.1).
Table 8.1 Compliance rate for methotrexate therapy in inner-city populations Author (Ref) Watters et al.
[6] Carter et al.
[7] Duenas-Garcia
et al. [8] Jaspan et al. [9]
Hospital Cook Coun- try Hospital, Northwestern University, Chicago, IL
Medstar Washington Hospital Cen- ter, Washing- ton DC
Bronx Lebanon Hospital Center, New-York City, NY
Albert Einstein Medical Center, Philadel- phia, PA Number of
patients 81 125 99 66
Patients completing follow-up (%)
14.8 18.3 10.1 19.7
Successful medical therapy (%)
29.6 NA 87.9 75
8 Compliance with Methotrexate Treatment for Ectopic Pregnancy 59
References
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3. Seifer DB. Persistent ectopic pregnancy: an argument for heightened vigi-8.
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6. Watters AN, et al. Methotrexate: an appropriate treatment for ectopic pregnancy in an inner-city population? Obstet Gynecol. 2014;123 Suppl 1:130S–1S.
7. Carter CM, et al. Patient adherence to medical management of ectopic pregnancy. Obstet Gynecol. 2014;123 Suppl 1:122S–3S.
8. Duenas-Garcia OF, et al. Compliance with follow-up in an inner-city population treated with intramuscular methotrexate for suspected ectopic pregnancy. Int J Gynaecol Obstet. 2013;120(3):254–6.
9. Jaspan D, et al. Compliance with methotrexate therapy for presumed ecto- pic pregnancy in an inner-city population. Fertil Steril. 2010;94(3):1122–
10. ACOG Practice Bulletin No. 94: medical management of ectopic preg-4.
nancy. Obstet Gynecol. 2008;111(6):1479–85.
11. McCord ML, et al. Methotrexate therapy for ectopic pregnancy in adoles- cents. J Pediatr Adolesc Gynecol. 1996;9(2):71–3.
12. Aggarwal A, et al. Methotrexate in the management of adolescents with ectopic pregnancies: a physician survey. J Obstet Gynaecol Can.
2009;31(3):254–62.
13. Lipscomb GH, et al. Comparison of multidose and single-dose metho- trexate protocols for the treatment of ectopic pregnancy. Am J Obstet Gy- necol. 2005;192(6):1844–7 (discussion 1847–8).
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