Ectopic%20pregnancy Treatment
Principles of Therapy
- 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
Pharmacotherapy
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
- β-hCG level should be followed up until it becomes undetectable or decreases to <15 IU/L
- Patients who underwent Methotrexate therapy must wait for at least 3 months before attempting to become pregnant again
Expectant Management
- 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
Anti-D Immunoglobulin
- 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)