Applied Evidence

Ectopic pregnancy: Expectant management an immediate surgery?

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An algorithm to improve outcomes.


 

References

Practice recommendations
  • Expectant management may be offered to asymptomatic patients with small adnexal masses (≤3 cm) lower beta-human chorionic gonadotropin (β-hCG) levels (<1000 mIU/mL), evidence of spontaneous resolution (eg, falling β-hCG levels) who are willing to accept the risk of tubal (A).
  • Systemic methotrexate administration resolves ectopic pregnancy in 87% to 95% of cases, maintains tubal patency in 75% to 81%, and results in subsequent successful pregnancy in about 58% to 61% of patients. Hemodynamically stable patients with adnexal mass≤3.5 cm, β-hCG levels <5000 mIU/mL, no adnexal yolk sac and normal hematologic, liver, and kidney functions are ideal candidates for methotrexate therapy (A).

Management strategies for patients with ectopic pregnancy have evolved rapidly, with ambulatory medical therapy becoming an option for more patients.1 In part 1, published in the May 2006 JFP, using a practical decision protocol, we discuss the physical findings that most reliably suggest ectopic pregnancy, describe sensible use of laboratory and imaging studies, and explain what to do when results are equivocal.

Management choices

Once the diagnosis of ectopic pregnancy has been made, options include surgical, medical, or expectant management (FIGURE). The goal of treatment is to minimize disease-and treatment-related morbidity while maximizing reproductive potential.

Administer Rhogam to all Rh-negative women.

Clinical prediction tools have been developed to aid management decision making. Fernandez et al developed a score based on gestational age, β-hCG level, progesterone level, abdominal pain, hemoperitoneum volume, and hematosalpinx diameter.2 A score <12 predicts a >80% success with expectant or nonsurgical management (TABLE 1). Similarly, to predict response to a single-dose of methotrexate, Elito et al3 developed a score based on β-hCG level, ultrasound findings, have size of the mass (cm), and color Doppler image aspects (TABLE 1). In a small study of for 40 patients, those with scores >5 had a the 97% success rate.3

FIGURE
Deciding which management option is best for your patient with ectopic pregnancy

TABLE 1
Predictive score for successful treatment of ectopic pregnancy

Predictive score for expectant management and several nonsurgical treatments (Fernandez 1991)
CRITERION1 POINT2 POINT3 POINT
β-hCG (mIU/mL)<10001000–5000>5000
Progesterone (ng/mL)<55–10>10
Abdominal painAbsentInducedSpontaneous
Hematosalpinx (cm)<11–3>3
Hemoperitoneum (mL)01–100>100
Score <12: 80% success with various nonsurgical treatments, including expectant management.
Predictive score for single dose methotrexate (50 mg/m2 IM) (Elito 1999)
PARAMETERS0 POINTS1 POINTS2 POINTS
β-hCG (mIU/mL)>50001500–5000<1500
Aspects of the imageLive embryoTubal ringHematosalpinx
Size of the mass>3.0–3.52.6–3.0<2.5
Color DopplerHigh riskMedium riskLow risk
Score≥5: 97% success with single-dose methotrexate.
Sources: Fernandez et al 1991,2 Elito et al 1999.3

Surgical management

Surgery is preferred for ruptured ectopic pregnancy. Surgery is also indicated for patients with evidence of hemodynamic instability, anemia, pain for longer than 24 hours, β-hCG levels greater than 5000 mIU/mL, or with a gestational sac that measures more than 3.5 to 4 cm on ultrasound.1,4,5

Laparoscopic techniques minimize the trauma and morbidity of salpingectomy or salpingostomy. Compared with older procedures, they lessen blood loss, decrease the need for analgesia, and allow a shorter hospital stay and an earlier return to work.6

Salpingostomy removes the ectopic pregnancy while preserving the Fallopian tube. Weekly quantitative β-hCG testing is required to rule out persistent ectopic pregnancy, which occurs in 5% to 8% of patients following salpingostomy.7 The likelihood of persistent ectopic pregnancy following salpingostomy increases with an ectopic pregnancy <2 cm in diameter, salpingostomy performed <6 weeks from the last menstrual period, a β-hCG level >3000 mIU/mL, or progesterone level over 35 nmol/L combined with a daily change in β-hCG over 100 mIU/mL.8,9

Expectant management possible when β-hCG levels <1000 mIU/mL

Expectant management may be offered to asymptomatic women with small adnexal masses, lower β-hCG levels, and evidence of spontaneous resolution (eg, falling β-hCG levels) who are willing to accept the risk of tubal rupture.10 Rising β-hCG levels, pain, hemodynamic instability, or hemoperitoneum on ultrasound dictate switching to active management.11

Eighty percent of women with initial β-hCG levels <1000 mIU/mL experience spontaneous resolution (TABLE 2).1,4,5,11-17 In one study, women with initial β-hCG levels <1000 mIU/mL, adnexal masses <4 cm, no fetal heartbeat, and <100 mL of fluid in the pouch of Douglas were managed by serial ultrasound and β-hCG levels obtained twice-weekly for 2 weeks; the result was an 88% chance of spontaneous resolution.18 Women (n=9) with initial β-hCG levels ≤1000 mIU/mL with subsequent rising titers experienced no spontaneous resolution.

TABLE 2
Treatment options for ectopic pregnancy

MODALITYDESCRIPTIONEP RESOLUTION (%)TUBAL PATENCY (%)FUTURE IUP (%)EP (%)ADVERSE EVENTS
Salpingectomy Open or laparoscopicExcision of ectopic pregnancy and tube100NA42–82*6–13Hemorrhage Infection Adhesions
LaparoscopicExcision of ectopic pregnancy with repair of tube93765713Incomplete removal (persistent EP) Analgesic needed Lost work time
Expectant managementTwice-weekly β-hCG, ultrasound obtained for 2 weeks67–6876–7768–867–13Persistent EP 25% need medical or surgical management
β-hCG <100088
β-hCG ≥100048
Methotrexate Multidose1 mg/kg IV or IM with 0.1 mg/kg folic acid on alternating days. Stop when >15% drop in β-hCG observed or 4 doses administered93–9575587Mucositis (stomatitis, gastritis, diarrhea) Dermatitis Bone marrow suppression Hepatic dysfunction Pleuritis
Single doseInjection of 50 mg/m2. β-hCG levels days 4 and 7. Repeat dose if no drop.87–9081618Reversible alopecia Photosensitivity Pulmonary fibrosis
Oral50 mg daily for 5 days or 60 mg/m2 (one time in 2 divided doses)86
Direct injectionUltrasound or laparoscopic guidance of 12.5–25 mg7680576
EP, ectopic pregnancy; IUP, intrauterine pregnancy; NA, not applicable; IM, intramuscular; IV, intravenous.
*82% if contralateral tube normal.

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