International Journal of Clinical Case Reports 2017, Vol.7, No.13, 53-57
56
Methotrexate (MTX) is the cornerstone of medical management with different routes of injection (Misme et al.,
2015): intramuscular, “in situ” with ultrasound or “in situ” by laparoscopy at a dose of 1 mg / kg. Other molecules
are also used, alone or in combination with methotrexate: KCl in situ (5 mmol) (especially in heterotopic
pregnancies or in case of contraindication or failure of treatment with methotrexate), mifepristone when Initial
progesteroneemia is greater than 9 ng / mL (Rozenberg et al., 2003).
The most frequent regimen in the literature is the multi-dose regimen (MTX 1 mg / kg IV / IM on day 1, 3, 5 and
7 with Leucovorin 0.1 mg / kg oral on day 2, 4, 6 and 8 Re-administer therapy 7 days after the last dose) (Jermy et
al., 2004) associated with surgical treatment in the event of deterioration of clinical condition. The success rate
reported is 66% (Jermy et al., 2004). If, in the case of conventional tubal ectopic pregnancies, a single injection of
MTX has become the standard, it appears that repeated interstitial doses are more interesting (Jermy et al., 2004;
Moawad et al., 2010) for interstitial pregnancies. There is as yet no consensus on the protocol to be followed for
the multidose regimen. There is no consensus regarding the limiting level of HCG or the presence of cardiac
activity (Moawad et al., 2010).
Treatment by local injection of methotrexate by endovaginal route under ultrasound control, or especially by
laparoscopic route, as well as injection supplements of IM methotrexate in addition to the in situ injection, appears
to obtain better results compared to MTX by the general route (Jourdain et al., 2003; Jermy et al., 2004).
It is important to follow the decay of HCG until it is negated. The mean duration of undetectable HCG in serum is
43 +/- 64 days (Jourdain et al., 2003). An interstitial mass or heterogeneous area with persistent vascularization on
ultrasound has been reported (Tang et al., 2006). Subject to negativity complete of HCG, they do not constitute a
therapeutic failure (Tang et al., 2006).
In our team the management of interstitial pregnancy outside the context of rupture is a celioscopic injected
injection of MTX associated on the same day with a single injection of MTX by IM (1 mg / kg), but concerning
this patient; The size, the scalability of the pregnancy and the celioscopic observation of signs prelude to rupture,
parinaminci, ecchymotic spots (Figures) should have directed us towards surgical treatment in first intention.
3 Conclusions
Interstitial pregnancy is a rare but dangerous localization of ectopic pregnancy, which should be considered during
an intra-uterine localization eccentric to more than one centimeter of the lateral wall of the cavity, with a fine
myometrial circumference. The reference treatment is laparoscopic surgery (in the absence of haemodynamic
disorder). Medical treatment is more and more used; in the absence of a clear consensus, selection of patients must
be discussed on a case-by-case basis to avoid a hazardous evolution.
Authors’ contributions
Ragmoun Houssem: Editing and supervision,
read and approved the final manuscript;
Daadoucha Abdrahmen: Participated in the
drafting of the observation,
read and approved the final manuscript;
Benhlima Najeh: Participated in the drafting of the discussion,
read and approved the final manuscript;
Ajili Abir: Checking references. All authors read and approved the final manuscript.
Acknowledgments
We thank the anatomopathology department of Ibn El Jazzar Hospital, Kairouan.
References
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Filhastre M., Dechaud H., Lesnik A., and Taourel P., 2005, Interstitial pregnancy: role of MRI, European radiology, 15(1): 93-95
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