Ectopic pregnancy: expectant management or immediate surgery? An algorithm to improve outcomes

Journal of Family Practice, June, 2006 by Kalyanakrishnan Ramakrishnan, Dewey C. Scheid

Practice recommendations

* Expectant management may be offered to asymptomatic patients with small adnexal masses ([less than or equal to]3 cm), lower betahuman chorionic gonadotropin ([beta]-hCG) levels (<1000 mIU/mL), evidence of spontaneous resolution (eg, falling [beta]-hCG levels) who are willing to accept the risk of tubal rupture (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 [less than or equal] 3.5 cm, [beta]-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.

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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, [beta]-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 al (3) developed a score based on [beta]-hCG level, ultrasound findings, size of the mass (cm), and color Doppler image aspects (TABLE 1 ). In a small study of 40 patients, those with scores >5 had a 97% success rate. (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, [beta]-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 [beta]-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 [beta]-hCG level >3000 mIU/mL, or progesterone level over 35 nmol/L combined with a daily change in [beta]-hCG over 100 mIU/mL. (8,9)

Expectant management possible when [beta]-hCG levels <1000 mIU/mL

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

Eighty percent of women with initial [beta]-hCG levels <1000 mIU/mL experience spontaneous resolution (TABLE 2). (1,4,5,11-17) In one study, women with initial [beta]-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 [beta]-hCG levels obtained twice-weekly for 2 weeks; the result was an 88% chance of spontaneous resolution. (18) Women (n=9) with initial [beta]-hCG levels <1000 mIU/mL with subsequent rising titers experienced no spontaneous resolution.

Medical management an option for about 25% of patients

Methotrexate depletes tetrahydrofolate cofactors required for DNA and RNA synthesis and cell replication, and thereby inhibits the rapidly growing trophoblasts in patients with ectopic pregnancy.

Methotrexate may be used for primary treatment of ectopic pregnancy, for persistent ectopic pregnancy following tubal sparing surgery, as prophylaxis to reduce persistent ectopic pregnancy following salpingostomy, and in cornual and cervical pregnancies. (11,13,19)

Who qualifies. Patients eligible for methotrexate administration are those without hemodynamic instability or evidence of tubal rupture (clinical or ultrasound), desiring future fertility, having a gestational sac <3.5 cm, a [beta]-hCG level less than 5000 mIU/mL, no fetal cardiac motion on ultrasound, and the ability and willingness to comply with post-treatment monitoring. (10,14)

Systemic methotrexate successfully resolves ectopic pregnancy in 90% of patients. Subsequent tubal patency rates approximate 80% and pregnancy rates 60% with recurrent ectopic pregnancy rates 8%. (10,13,15,16) The cost of treatment for systemic methotrexate was $5721 per patient compared with $4066 for salpingostomy. (20) Hematologic, liver, and renal functions should be assessed before treatment.