Intended for healthcare professionals

Practice Easily Missed?

Ectopic pregnancy

BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3770 (Published 30 July 2010) Cite this as: BMJ 2010;341:c3770

Easily missed when ectopic pregnancy is suspected ?

So far, methotrexate is considered as a major treatment of ectopic
pregnancy. Although active pulmonary disease represents an absolute
contraindication to medical management of ectopic pregnancy with systemic
methotrexate, a normal chest X-ray or CT scan is never mentioned among the
selection criteria for methotrexate therapy (1).

We report the case of a 36 year-old multiparous (3 pregnancies, the
last one 5 years before) woman without history of smoking who was admitted
to the hospital for potential ectopic pregnancy. Initial serum chorionic
gonadotropin concentration was 1000 IU / L and transvaginal
ultrasonography did not find a gestational mass. The patient underwent
dilatation and curettage but no placental villi were present in the
curettage specimen. She received a first dose of 100 mg of intramuscular
methotrexate. As serum chorionic gonadotropin concentration failed to
decline, a coelioscopy and another curettage were done 2 weeks later, but
were not contributive. Among subsequent explorations, a chest X-ray was
performed and a lung mass of the middle lobe was incidentally found
(figure 1). The CT scan confirmed a localized lung mass of 5 cm in
diameter in the middle lobe and fiberoptic bronchoscopy was normal. A
lobectomy was performed and the tumor was histologically diagnosed as
choriocarcinoma. Serum chorionic gonadotropin rapidly fell down to
undetectable level 2 weeks after surgery. Two years after the lobectomy,
the patient had one more pregnancy. Seven years after the lobectomy, she
remains without evidence of residual disease on routine follow-up (figure
1).

We think that a normal chest X-ray must be included in the inclusion
criteria of methotrexate therapy when ectopic pregnancy is suspected,
because of potential extragonadal non gestational choriocarcinoma
involving the lung (2,3).

REFERENCES

1. Barnhart KT. Ectopic pregnancy. N Engl J Med 2009 ;361:379-87

2. Aparicio J, Oltra A, Martinez-Moragon E, Llorca C, Gomez-Aldaravi
L, Pastor M. Extragonadal nongestational choriocarcinoma involving the
lung : a report of three cases. Respiration 1996 ;63:251-3.

3. Ikura Y, Inoue T, Tsukuda H, Yamamoto T, Ueda M, Kobayashi Y.
Primary choriocarcinoma and human chorionic gonadotropin-producing giant
cell carcinoma of the lung : are they independent entities ?
Histopathology 2000 ; 36:17-25.

Competing interests:
None declared

Patient consent obtained

Competing interests: No competing interests

09 August 2010
Marcel Bonay
senior lecturer
Service de Physiologie-Explorations Fonctionnelles, Hôpital Bichat, 75870 Paris cedex 18, France