REDUCTION OF ECTOPIC PREGNANCY BY ULTRASOUND METHODS

1524 transient leucopenia was due to sequestration of white cells within the lungs (fig 2). These results were obtained with a yeast-derived product in which there are many glycosylation differences from the native factor. It will be important to determine whether a similar event occurs with rhGM-CSF produced in alternative systems. None of these patients had pulmonary infections at the time of study, which might have predisposed to irreversible infiltration of the lungs with phagocytes and adult respiratory distress syndrome.5 We feel that great care should be exercised when giving this factor to patients with normal neutrophil counts and pulmonary sepsis. Because the transient leucopenia only occurs at the start of each GM-CSF infusion, continuous infusion should help to reduce this risk by avoiding repeated episodes of pulmonary sequestration.

Our initial experience5 with

prostaglandin F2’l has also resulted in patients requiring subsequent laparotomy. A really effective conservative approach to the treatment of unruptured ectopic pregnancy is one which lessens the need for major surgery in patients who are already emotionally distressed by this complication some

of pregnancy.

London NW8 9LE

1. Grant A. The effect of ectopic pregnancy on fertility, Clin Obstet Gynecol 1962; 5: 861. 2. Craft IL, McLeod F, Edmonds K. Embryo transfer, ectopic pregnancy, and preliminary tubal occlusion Lancet 1981; ii: 1421. 3. de Cherney AH, Romero R, Naftolin F. Surgical management of unruptured ectopic pregnancy. Fertil Steril 1981; 35: 35-21. 4. Feichtinger W, Kemeter P. Conservative treatment of ectopic pregnancy by transvagmal aspiration under sonographic control and methotrexate injection Lancet 1987; i. 381. 5. Hahlin M, Kallfelt B, Lindblom B. Local injection of prostaglandin F2&agr; into the oviduct and corpus luteum for termination of ectopic pregnancy. Reported at the third meeting of European Society for Human Reproduction and Embryology,

Supported by the Kay Kendall Leukaemia Fund. GM-CSF was supplied by the Immunex Corporation, Seattle. Departments of Haematology, Nuclear Medicine, and Radiotherapy and Oncology, Middlesex Hospital, London W1

S. DEVEREUX D.C. LINCH D. CAMPOS COSTA M. F. SPITTLE A. M. JELLIFFE

(Cambridge, 1987). 6 Robertson

HJ, Osman S, et al. Clinical experience with 99mTchexamethylpropyleneamineoxime for labelling leucocytes and imaging

Changing concepts of

REDUCTION OF ECTOPIC PREGNANCY BY ULTRASOUND METHODS

to

unruptured ectopic

pregnancy,

using

ultrasound methods, in patients who are usually less than 8 weeks pregnant. Of the 12 patients so treated, 1 patient had conceived naturally and the others were assisted conception (4 by GIFT, 7 by IVF). Potassium chloride may still have some value for the management of patients who have a concurrent intrauterine and extrauterine pregnancy, in whom methotrexate is contraindicated.

al. Reduction of ectopic pregnancy by 1987; i 974-75.

SIR,-Advanced primary idiopathic myelofibrosis is difficult to manage.’ Parmeggiani et al2 treated two patients with interferon alpha-2c at a dose of 3x 106 Ujm2 daily, subcutaneously. Despite a decrease in spleen size and a disappearance of splenic pain and

317: 593-98. 4 Peters AM, Danpure

non-surgical approach

et

ALPHA-INTERFERON IN PRIMARY IDIOPATHIC MYELOFIBROSIS

1987; 236: 1229-37. 3. Groopman JE, Mitsuyashi RT, DeLeo MJ, Oette DH, Golde DW. Effect of recombinant human granulocyte macrophage colony stimulating factor on myelopoiesis m the acquired immunodeficiency syndrome. N Engl J Med 1987;

SIR,-Ectopic pregnancy is life-threatening whether it results from spontaneous or assisted conception. Treatment of the acute case, especially where the ectopic pregnancy has ruptured, usually involves laparotomy with partial or complete removal of the affected fallopian tube or salpingotomy and evacuation. Such radical treatment may compromise future fertility and there is the further risk of another ectopic pregnancy on the same or contralateral side.’ Laparoscopic procedures have been described but some surgical damage is inevitable. Some gynaecologists recommend closure of the proximal fallopian tube when in-vitro fertilisation (IVF) is done, to prevent ectopic pregnancy.2 Others think that such a policy could adversely affect the chance of natural conception, with the fallopian tubes open, or the success of gamete intrafallopian transfer (GIFT). Conservative management of unruptured ectopic pregnancies has been suggested3-5 to spare the patient unnecessary surgery and to preserve a fallopian tube which may be functional in future. Earlier this year we reported’ using potassium chloride in 3 patients, treated by injection of the ectopic gestation sac under ultrasound control and then methotrexate to destroy trophoblastic tissue in a further 9 patients, as described by Feichtinger and Kemeter. The pregnancy sacs were punctured with a 22G spinal needle under ultrasound control and with a transvesical freehand technique. After aspiration of the sac’s contents potassium chloride (20% w/v) was instilled to cause fetal cardiac asystole and the sac was emptied before injection of methotrexate. However, of the 12 patients treated, 2 of the 3 receiving potassium chloride and 5 of the 9 receiving methotrexate have required laparotomy 6-8 weeks later for persistence of a pelvic mass due to residual trophoblastic activity. In other cases the sac has resorbed over 2 months. We therefore wish to introduce a note of caution about the

DE, Smith W, Moye MA,

injection under ultrasound control. Lancet

1. Metcalf D. The molecular biology and functions of the granulocyte-macrophage colony-stimulating factors. Blood 1986; 67: 257-67. 2. Clarke SC, Kamen R. The human hemopoietic colony-stimulating factors Science

inflammation. Lancet 1986; ii: 946-49. 5. Rinaldo JE, Rogers RM. Adult respiratory distress syndrome: lung injury and repair N Engl J Med 1982; 306: 900-09.

D. E. ROBERTSON W. SMITH IAN CRAFT

Fertility and IVF Unit, Humana Hospital Wellington,

.

pressure symptoms the blood count deteriorated in both cases. We report on a splenectomised patient with primary idiopathic myelofibrosis whose haemoglobin level improved rapidly after treatment with interferon alpha-2b (’Intron-A’). In February, 1984, a 58-year-old man was found to have a leucoerythroblastic anaemia (Hb 9.1 g/dl) with tear-drop poikilocytes, hepatomegaly, and splenomegaly. His white cell, neutrophil, and platelet counts were, respectively, 2-7, 14, and 144 x 109/l. The bone marrow was hypercellular with an increase in megakaryocytes and a marked excess of reticulin; there was no osteosclerosis. The total serum protein was 93 g/1 due to an increase in globulins. The serum IgG level was 35g/1 (normal 6 4-13 54) and the increase was polyclonal. The splenomegaly worsened and the Hb fell, and regular blood transfusions were needed from October, 1984. 1,25-dihydroxycholecalciferol 0-25 µg daily was administered between November, 1984, and April, 1985, and 50 mg azathioprine between January and March, 1985, but transfusion requirements increased and he had two episodes of septicaemia which responded to antibiotics. By January, 1985, he required 6-10 units of packed red cells every two weeks. On splenectomy in April, 1985, the spleen weighed 2370 g and measured 22 x 9 x 34 cm. Histology revealed sinusoidal hyperplasia and extramedullary haemopoiesis; there was no evidence of malignancy. No further transfusions were required until January, 1986, when the Hb had fallen to 7-2 g/dl and 4 units packed red cells per month were given. Further enlargement of the liver resulted in abdominal pain and pressure symptoms. In March, 1986, ascites was noted and treated by a single paracentesis followed by diuretics. 1,25-dihydroxycholecalciferol and azathioprine were tried again for 8 months without benefit. A positive direct antiglobulin test (with C3c, C3d, and IgG on the red cells) was noted between July and September, 1986, but there was no alterati6n in the blood transfusion requirement during this period. By June, 1987, the liver had enlarged to 22 cm below the costal margin and the patient felt tired, unwell, and depressed. Interferon alpha-2b 3-5 x 106 units subcutaneously three times a week was started on July 1 immediately after his monthly transfusion of packed red cells. Since then no blood transfusions have been required, and the patient’s haemoglobin has been 10.7-11.8g/dl for the past 4 months. The liver decreased in size (15 cm on Oct 16). His neutrophil and platelet counts, which had increased postsplenectomy to 2.4-3.9 and 255-466 x 109/1, respectively, were unaffected by the interferon therapy. 6 weeks after the start of interferon a painful mass over the left scapula developed, followed