o_1977r8vv9vk1ts2ms0kd8pksa.pdf

586 I. Zalud
[60]. If a 50-mg dose is used, it is usually followed by
a single dose of folinic acid to prevent systemic side
effects. When using KCl, approximately 0.25±0.5 ml of
the solution (2 mEq/l) is injected in the area of the
beating fetal heart and observed for 10 min.
At completion of the procedure and after an observation
period of 2±3 h, the pelvic structures and cul
de sac are observed sonographically to detect possible
internal bleed or any other complication.
An automated puncture device is more accurate
and potentially less painful than manual needle introduction.
This spring-loaded device, when mated to
the shaft of the vaginal probe, provides extreme accuracy
and precision and its high-velocity release makes
the procedure virtually painless thus obviating the
need for anesthesia.
Interstitial Pregnancy
Systemic chemotherapy with MTX can be used for
nonsurgical management of interstitial pregnancy.
MTX or KCl solution can also be used for local injection
into the gestational sac under sonographic guidance.
Some additional sonographic parameters have
been defined to refine patient selection and posttreatment
monitoring [68]. These are: (a) Peritrophoblastic
blood flow ± a solid ªring of fireº sign suggests a
highly vascularized implantation which may respond
better to direct intrasac therapy than systemic MTX.
Color flow Doppler may also indicate resolution if
blood flow can be shown to decrease with treatment
[69]. Persistent trophoblastic blood flow may be associated
with increased risk of spontaneous rupture and
deferral of subsequent pregnancy might be considered
until the blood flow pattern returns to normal.
(b) Myometrial thickness assessed akin to that described
for lower uterine segment thickness in patients
with previous cesarean section [70]. When it is
less than 3.5 mm the patient may be at an increased
risk for rupture and this may be a pertinent parameter
for guiding the management. The precise predictive
value of these parameters is, however, uncertain
and requires further evaluation.
Cervical Pregnancy
Local intrasac injection of MTX or KCl has been described.
Paltzi et al. used a combination of MTX given
intracervically followed by intramuscular injection
[71]. Kaplan et al. used transabdominal sonography
to guide injection of MTX into the amniotic sac of a
cervical pregnancy [72]. Timor-Tritsch et al. used
transvaginal sonography-guided MTX injection with
an automated puncture device and 21G needle in five
cases of viable cervical pregnancy [73]. Frates et al.
used TVS-guided injection of KCl into the embryo or
gestational sac in six cases of cervical pregnancy of
less than 7.9 weeks' gestation [74]. Success was reported
in all the cases. Thus, when cervical pregnancy
is diagnosed early, ultrasound-guided local
therapy is safe and effective. It involves minimal patient
discomfort and recovery time and preserves the
patient's reproductive potential.
Ovarian Pregnancy
Traditional treatment for ovarian pregnancy involves
ipsilateral oophorectomy. Koike et al. reported the
first successful case of an unruptured ovarian pregnancy
treated medically by local injection of 0.5 mg
prostaglandin F2 with an additional dose of prostaglandin
E2 (dinoprostone) administered orally for 14
postoperative days [75]. Subsequently systemic MTX
has been used for medical management of ovarian
pregnancies [76]. The response to treatment can be
assessed by ultrasound imaging, as described for tubal
pregnancy.
Heterotopic Pregnancy
Ultrasonography helps in conservative management
of heterotrophic pregnancies. Unlike MTX, KCl is
only embryotoxic and not antitrophoblastic therefore
ultrasound-guided local injection of KCl into the ectopic
sac is used to avoid harm to the coexistent intrauterine
pregnancy.
Ultrasound Monitoring
of Conservative Management
Ultrasonography is crucial to follow up along with
b-hCG estimations every 3±5 days. Real-time sonography
is carried out to observe the decrease in size of
the adnexal mass. Color Doppler is used to assess
vascularity and normalization of the RI. Disappearance
of adnexal/ectopic pregnancy mass usually
occurs by day 30±40, with the RI normalizing by day
5±20. b-hCG levels gradually fall rapidly to normal
levels by 2 weeks to a maximum of 8 weeks. Following
systemic or intratubal MTX, a visible adnexal
mass may persist on TVS for more than 3 months,
even after a b-hCG test yields negative results. It is
not uncommon for these to transiently enlarge and
have increased Doppler flow signal [67].
Ultrasound imaging thus helps in monitoring the
response to treatment and evaluation of potential complications
both during and after the therapy. In the literature,
a few patients treated by salpingocentesis underwent
hysterosalpingography and were found to have
patent fallopian tubes [60]. A rise in b-hCG levels and
an increase in ectopic pregnancy mass associated with