Ectopic%20pregnancy Treatment

• Treatment decision should be made on an individual basis
• For heterotopic pregnancy, the IUP must be considered when planning management 

Surgical Management

• Surgical treatment remains the preferred approach for most ectopic pregnancies

Surgical management is indicated if:

• The patient’s condition deteriorates
• β-hCG levels are rising or plateaued and ectopic mass >3-4 cm
• Unreliable patient who may not be available for close follow-up

Medical Management

• Success is greatest if gestation <6 weeks and tubal mass <3.5 cm in diameter
• Serial measurements of β-hCG are necessary in patients being managed medically

Medical management may be an option if:

• Patient is hemodynamically stable with normal hemogram and normal liver and renal function
• Ectopic pregnancy has been confirmed by US
• Ectopic mass has not ruptured and is <3-4 cm in diameter by US
• Absence of active bleeding or signs of hemoperitoneum
• Patients with β-hCG levels <5000 IU/L (5000 mIU/mL) are more likely to respond to therapy
• Patient is willing to comply with close follow-up

Medical management is contraindicated if:

• Breastfeeding
• Presence of fetal cardiac activity
• Presence of fluid in the cul-de-sac
• Immunodeficiency
• β-hCG levels >5000 IU/L (5000 mIU/mL)
• Presence of contraindications related to Methotrexate use
• Ruptured ectopic pregnancy
• Active pulmonary or peptic ulcer disease

Expectant Management

• May be considered if the patient remains stable, is reliable and is willing to accept the potential risk of tubal rupture
• Evidence of resolution eg declining β-hCG levels
• 68-77% of ectopic pregnancies resolve without intervention but clinical markers to identify these patients have not been defined
• Spontaneous resolution is more likely in patients with β-hCG levels <1000 IU/L (1000 mIU/mL)
• Risk of rupture will remain until pregnancy is completely resolved
• Serial measurements of β-hCG are necessary in patients being managed expectantly

Expectant management may be an option if:

• β-hCG levels are <1000 IU/L (1000 mIU/mL) and are declining
• Vaginal sonography shows no evidence of intra-abdominal rupture or bleeding
• Patient is willing to comply with close follow-up

 Methotrexate

• Action: Methotrexate is a folic acid antagonist that interferes with DNA synthesis in rapidly dividing cells like the trophoblastic tissue
• Effects: Reported success rates are between 65-95%
  • Treatment success rates following Methotrexate therapy are comparable to surgery
  • Failure rates are higher with larger ectopic pregnancies, evidence of fetal cardiac activity and higher β-hCG levels
  • Studies have shown that a single-dose protocol may have similar efficacy to a multidose protocol
    • Failure rate is lower with multidose Methotrexate

• Patients for Methotrexate therapy must be hemodynamically stable with serum β-hCG level of <5000 IU/L, has no demonstrated US evidence of fetal cardiac activity or IUP and no abdominal pain that is severe or persistent
• Methotrexate treatment of tubal ectopic pregnancy has no effect on ovarian reserve  
• Muscle relaxation training may be of help to patients on Methotrexate therapy 
• Patients treated with Methotrexate may experience self-limiting abdominal pain which may mimic acute ectopic rupture, a transient rise in β-hCG levels, and vaginal spotting or bleeding
• Side effects are infrequent with short regimen but can also be mitigated by co-administration of Leucovorin
• Patient must be willing and available for close follow-up which may take as long as 7 weeks
  • β-hCG level should be followed up until it becomes undetectable or decreases to <15 IU/L
    • If hCG level increases or plateaus, patient may be given another dose of Methotrexate
  • Patient should also be made aware that medical therapy fails in approximately 5-10% of patients and will lead to surgery
• Patients who underwent Methotrexate therapy must wait for at least 3 months before attempting to become pregnant again

• Expectant management with close observation may be undertaken in an attempt to increase possible future tubal patency in carefully selected patients
• This option should be offered only when transvaginal US fails to locate the gestational sac and the serum levels of β-hCG and progesterone are low and declining
  • Candidates must be asymptomatic and clinically stable with declining β-hCG levels, initially <1500 IU/L

• Serum β-hCG should be monitored on weekly basis while transvaginal US is done on weekly interval to confirm reduction in hCG level and decrease in the adnexal mass size in 7 days
  • Thereafter, serum β-hCG and transvaginal US monitoring are done on a weekly basis until serum hCG concentration is no longer detectable since there are reports of tubal rupture at low levels of β-hCG

• This method of treatment tends to be discouraged due to persistence of the risk of rupture until the pregnancy has been completely resolved

• Based on expert opinion, anti-D immunoglobulin is recommended in nonsensitized patients who are rhesus negative and who have ectopic pregnancy
• Anti-D prophylaxis may be offered to women who had surgical removal of an ectopic pregnancy or if bleeding is heavy, repeated or with abdominal pain 
• Suggested dose is 250 IU (50 mcg)