Methotrexate用於子宮外孕之治療成效--非檢選病人(non-selectedofoutpatients)之觀察性研究

Methotrexate 用於子宮外孕之治療成效 -- 非檢選病人(non-selected of outpatients)之觀察性研究 Objective: 目前對於以Methotrexate治療子宮外孕，多半建議篩選早期未破裂之異位妊娠病人；本次實驗將所有不同條件的子宮外孕病人列入Methotrexate治療，期望得到non-selected of outpatients的治療結果，並得到新的臨床應用基礎。 Methods and Material: 於1999年1月1日至2000年12月31日期間，收集中山醫學院附設醫院婦產科之一門診單位就診病人，由病史、妊娠週數、血清b-hCG(Human chorionic gonadotropin)濃度、經陰道超音波檢查，確定診斷為子宮外孕者均收入此實驗。排除生命徵象危急(critical condition)、無法配合住院與治療流程、嚴重肝腎或血液異常、異常病史或藥物過敏史、其他化學藥物治療中或惡性腫瘤之病人。所有子宮外孕病人均入院治療，以Multiple-doses systemic Methotrexate protocol，於住院第1、3、5、7日肌肉注射每公斤體重1mg 的Methotrexate；在住院第2、4、6、8日予以肌肉注射每公斤體重0.1mg的Leucovorin，並於第8日注射完後予以出院，改為門診追蹤。住院期間記錄追蹤血清b-hCG濃度變化、CBC與GOT變化，嚴格監測生命徵象，住院中和出院前再予以超音波檢查。記錄病人的妊娠週數、血清b-hCG濃度、妊娠囊大小、胚胎心跳、骨盆腔內出血量以作為影響治療的因子評估。 Main Outcome Measure: 完成完整的Methotrexate治療後，不需再以手術介入，視為藥物治療成功。 Results: 實驗期間計收入33名子宮外孕病人，病人有不同的的妊娠週數、血清b-hCG濃度、妊娠囊大小、骨盆腔內出血量。平均年齡29歲，其中60 %未曾生育過。血清b-hCG濃度範圍128 mIU/mL到75,667 mIU/mL，大於15,000 mIU/mL有5人。33名病人中有2名子宮頸妊娠(Cervical pregnancy)及1名子宮角妊娠(Cornual pregnancy)，有2名病人的胚胎出現心跳。有4名病人在藥物治療後接受手術，Methotrexate治療成功率為87.88%。 Discussion: Systemic Methotrexate 治療子宮外孕的效果是令人滿意的，本次實驗得到與過去篩選過(selected patients)病人的治療成功率相當，雖然較高的血清b-hCG濃度是一個影響治療成功率的因子，但在嚴密的監測生命徵象與出血情形下，Methotrexate依然可作為子宮外孕治療的首要選擇。

Methotrexate treatment in ectopic pregnancy, a descriptive study in non-selected of outpatients Objective: Evaluation of the effectiveness of systemic methotrexate in non-selected outpatients with ectopic pregnancy. Methods and Material: Descriptive study. Between 1 January 1999 and 31 December 2000, patients visited to the Depart. Of OBS/GYN, Chung Shan Medical and Dental College Hospital. Patients were diagnosed ectopic pregnancies by their past history, present illness, gestational age, transvaginal sonography finding and serum b-hCG (human chorionic gonadotropin) concentration. The gestational age, size of the gestational mass, fetal cardiac activity, fluid (internal bleeding) in the peritoneal cavity was record for prognostic evaluation. All patients included when ectopic pregnancy was diagnosed, and received methotrexate treatment with a multiple-doses systemic protocol. Regular follow transvaginal sonography and serum b-hCG concentration change, closely monitored the vital sign, BP and CBC, serum GOT. Review the successful rate. Main outcome measure: Resolution of the ectopic pregnancy without surgical intervention. Results: Thirty-three patients with different gestation age, symptom / sign, serum b-hCG concentration, internal bleeding volume and gestational mass size. Mean age of patients was 29 years old; sixty percent of patients were nulliparas. The serum b-hCG concentration range was between 128 mIU/mL to 75,667 mIU/mL; five patients had the level above 15,000 mIU/mL. Two patients were cervical pregnancies and one was cornual pregnancy. Two gestational masses had fetal cardiac activity. Success rate of multiple-dose systemic methotrexate treatment was 87.88% (29/33), four patients received operation after methotrexate treatment caused of severe symptom / sign and non-response serum b-hCG concentration change. Four patients of success methotrexate treatment had normal pregnant and delivery at our department in 6 months follows up period. Discussion: Systemic methotrexate therapy for ectopic pregnancy is effective. In non-selected outpatients, successful rate of methotrexate treatment is consistent with previous studies in selected patients. High serum b-hCG concentration is still a most important factor associated with treatment failure. Methotrexate treatment could be used as the primary treatment in ectopic pregnancy under close monitor.