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© 2005 by the American Institute of Ultrasound in Medicine
J Ultrasound Med 24:591-598 • 0278-4297

Presence of a Yolk Sac on Transvaginal Sonography Is the Most Reliable Predictor of Single-Dose Methotrexate Treatment Failure in Ectopic Pregnancy

Sarah Bixby, MD, Richard Tello, MD and Ewa Kuligowska, MD

Department of Radiology, Boston University Medical Center, Boston, Massachusetts USA.

Address correspondence to Sarah Bixby, MD, Department of Radiology, Boston University Medical Center, 1 Boston Medical Center Pl, Boston MA 02115 USA. E-mail: sdbixby{at}alumni.princeton.edu

Objective. The purpose of this study was to determine which imaging characteristics can be used as prognostic indicators in conjunction with ß-human chorionic gonadotropin (ß-hCG) levels in the treatment of ectopic pregnancy (EP) with single-dose methotrexate (MTX). Methods. A retrospective study was performed on 62 patients (age range, 16–47 years; mean, 29 years) treated with MTX for EP from November 2000 to August 2003. The transvaginal sonographic findings in each case were analyzed for the presence and size of an extraovarian mass or a pseudogestational sac, amount of free fluid, presence of a yolk sac, and fetal heart motion. Patient age and ß-hCG level were also noted. Success of treatment was defined as a single dose of MTX that resulted in appropriate lowering of ß-hCG levels. Results. Of 62 patients, 17 (27%) had single-dose MTX treatment failure. A yolk sac was identified in 15 (88%) of the 17 treatment failures and in none of the cases in which treatment was successful (positive predictive value, 100%). The average ß-hCG level in the cohort of patients who had single-dose treatment failure was 3282 mIU/mL compared with 1544 mIU/mL in the treatment success cohort. The presence of fetal heart motion was seen in only 1 patient, and this patient had treatment failure. The age of the patient, size of the extraovarian mass, presence of a pseudogestational sac, and amount of free fluid did not correlate with outcome. Conclusions. The presence of a yolk sac was always associated with treatment failure in single-dose MTX treatment of EP and was the most reliable predictor of failure among all features analyzed. The ß-hCG level was a useful adjunct. A prediction rule was created correlating the probability of treatment success with the ß-hCG level.

Key Words: ectopic pregnancy • methotrexate • yolk sac

Abbreviations: EP, ectopic pregnancy • hCG, human chorionic gonadotropin • MTX, methotrexate • TVUS, transvaginal ultrasonography




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M. F. Reeves, S. Bixby, and E. Kuligowska
Prediction of Methotrexate Treatment Failure in Ectopic Pregnancy * Reply
J. Ultrasound Med., August 1, 2005; 24(8): 1167 - 1168.
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