**5. Conclusions**

234 Ectopic Pregnancy – Modern Diagnosis and Management

stabilized by the measures such as Foley balloon tamponade, large vessel ligation, or angiographic embolization. In the clinically stable cases, measures are categorized into three groups by ultrasound examination. 1) Systemic MTX is recommended at less than 9 weeks of gestation with no cardiac activity. 2) Intra-amniotic potassium chloride with systemic MTX is chosen at 9 to 12 weeks or less than 9 weeks with cardiac activity. 3) Primary hysterectomy is indicated at more than 12 weeks. That is, at an advanced gestational age or

In our case, serum β-hCG levels were over 10,000 IU/L and ultrasound examination showed positive fetal cardiac activity. Therefore, systemic MTX administration was chosen to treat

With regards to MTX administration, Barnhart pointed out that mainly two protocols were used for medical management for unruptured ectopic pregnancy: "single dose" regimen and "multidose" regimen. MTX can be given using a "multidose" regimen of 1mg/kg intramuscularly, alternating with 0.1 mg/kg of leucovorin intramuscularly for up to four daily doses of each drug[33]. Alternatively, methotrexate can be administered using a "single dose" method, based on body surface area, at 50 mg/m2 without the need for leucovorin rescue. It is concluded that "single dose" regimen is milder than in side effect but has higher failure rate than "multidose" regimen. This "multidose" regimen has been used for a long time as MTX-leucovorin rescue regimen for the patients with low-risk gestational trophoblastic disease and it has slightly lower remission rate than 5-days MTX regimen[34]. Five-days MTX regimen, in which MTX is administered in a dose of 0.4mg/kg intramuscularly for five days with cycles repeated every 14 days, is another protocols that is frequently used for low-risk gestational trophoblastic disease[35]. With above consideration, we applied 5 days MTX regimen for our patient. The serum β-hCG level fell slowly to 4 mIU/mL before surgery, just as following the normal regression curve of β-hCG after molar evacuation[36]. However, it became undetected at the next day after surgery. According to Kamrava, the serum clearance of hCG by radioimmunoassay may take place at least up to 24 days after surgery if the lesion can be removed completely and the initial tilter of hCG is a significant factor in determining the length of time that it can be detected in the serum postoperatively[37]. In this means, the surgical excision of the trophoblastic tissue was

Although the surgery in our case was considered to be fairly long, i.e., 6 h (it was initiated as an emergency operation, late at night (21:00), due to continuous bleeding from the vagina), partial trachelectomy could be completed in less time upon improved techniques. In consideration of the new treatment option of partial trachelectomy, the treatment algorism should be revised to include more chances to preserve fertility, especially in difficult cases. Indications for partial trachelectomy include: 1) when measures for massive hemorrhage such as Foley balloon tamponade, large vessel ligation, and/or angiographic embolization are ineffective; 2) when MTX is ineffective indicating primary hysterectomy for cases at gestational age > 12 weeks; or 3) when systemic MTX plus intra-amniotic potassium is ineffective as a complete cure and additional surgical measures like curettage or suction evacuation are necessary. However, this surgical option might be accompanied with various risks, including relapse, premature delivery, and surgical wound rupture, although the risk should be less than that for radical trachelectomy indicated for the increasing number of cases of cervical cancer patients. Further studies are needed to determine the benefits and risks of partial trachelectomy before establishing it as a treatment for patients with cervical

after treatment failure, pregnancy should be terminated by hysterectomy.

considered to be complete with this procedure.

ectopic pregnancy.

the patient.

In conclusion, "partial trachelectomy" is a new procedure that shares many similarities to previous procedures. It differs in the following two respects: 1) exact ligation or cut of the descending branch of the bilateral uterine artery and 2) excision of the spindle shapedcervical wall of the implantation site under direct vision by temporally detaching the vaginal wall and cervix. This procedure preserves fertility under any condition although with more risk of complication for future pregnancies compared to previous methods in which fertility preservation is not always successful. However, it is less invasive compared to radical trachelectomy which is a common method of fertility preservation for cancer patients with non-cervical pregnancy.
