8
Conservative management of tubal ectopic pregnancy

https://doi.org/10.1016/j.bpobgyn.2008.12.007Get rights and content

In this chapter an overview is given of the best available evidence on the conservative treatment for tubal ectopic pregnancy, i.e., expectant management and medical treatment with systemic methotrexate. From the two randomized controlled trials on expectant management, no conclusions can be drawn yet. It may be that women with low serum hCG levels need not be treated at all, but more research needs to be done in this subgroup of women to reach firm conclusions. Systemic methotrexate in a fixed multiple-dose i/m regimen can be recommended for hemodynamically stable women with an unruptured tubal ectopic pregnancy and no signs of active bleeding presenting with serum hCG concentrations < 3,000 IU/l. In women with serum hCG concentrations < 1,500 IU/l, a single-dose methotrexate regimen can be considered.

Section snippets

The pioneers

In 1955, Lund was the first to practice expectant management in women with ectopic pregnancy. This study has been frequently quoted as being the first randomized controlled trial in the treatment of ectopic pregnancy. However, this study is a retrospective comparative study comparing expectant management versus open surgery. In one department, treatment for “subacute women with a typical course of ectopic pregnancy and a positive pregnancy test, who had no demonstrable hemoperitoneum on

Funding

This work was supported by the Netherlands Organization for Health Research and Development (Clinical Fellow Grant 90700154).

Practice points

Systemic methotrexate in mixed multiple-dose regimen

  1. Diagnosis of tubal ectopic pregnancy

  2. No sign of tubal rupture

  3. Serum hCG <3,000 IU/l

Systemic methotrexate in a single-dose regimen:
  1. Diagnosis of tubal ectopic pregnancy

  2. No sign of tubal rupture

  3. Serum hCG <1,500 IU/l

Research agenda

  • Expectant management versus systemic methotrexate

  • Dosage schemes of systemic methotrexate, including: side effects, patients' quality of life and costs

References (39)

  • T.G. Stovall et al.

    Outpatient chemotherapy of unruptured ectopic pregnancy

    Fertil Steril

    (1989 Mar)
  • B.W.J. Mol et al.

    The treatment of tubal pregnancy in The Netherlands: an economic evaluation of systemic methotrexate and laparoscopic salpingostomy

    Am J Obstet Gynecol

    (1999)
  • P.T. Nieuwkerk et al.

    Systemic methotrexate therapy versus laparoscopic salpingostomy in patients with tubal pregnancy. Part I. Impact on patients' health related quality of life

    Fertil Steril

    (1998)
  • P.T. Nieuwkerk et al.

    Systemic methotrexate therapy versus laparoscopic salpingostomy in tubal pregnancy. Part II patient preferences for systemic methotrexate

    Fertil Steril

    (1998)
  • M.C. Sowter et al.

    A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured ectopic pregnancy

    Br J Obstet Gynecol

    (2001)
  • A. Alleyassin et al.

    Comparison of success rates in the medical management of ectopic pregnancy with single-dose and multiple-dose administration of methotrexate: a prospective, randomized clinical trial

    Fertil Steril

    (2006)
  • W.M. Ankum et al.

    Suspected ectopic pregnancy. What to do when human chorionic gonadotropin levels are below the discriminatory zone

    J Reprod Med

    (1995)
  • G. Condous et al.

    The use of a new logistic regression model for prediciting the outcome of pregnancies of unknown location

    Hum Reprod

    (2004)
  • B.W. Mol et al.

    Implementation of probabilistic decision rules improves the predictive values of algorithms in the diagnostic management of ectopic pregnancy

    Hum Reprod

    (1999)
  • Cited by (17)

    • Methotrexate pharmacology

      2015, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
    • Compliance with follow-up in an inner-city population treated with intramuscular methotrexate for suspected ectopic pregnancy

      2013, International Journal of Gynecology and Obstetrics
      Citation Excerpt :

      Having more than 4 follow-up visits was a significant factor for compliance (P < 0.001). Medical management with methotrexate is an appropriate therapy for hemodynamically stable patients with confirmed or suspected ectopic pregnancy [7,8]. A meta-analysis of 15 trials evaluating the use of surgery (laparoscopy/laparotomy), expectant management, and systemic methotrexate determined that, compared with other management methods, the use of systemic methotrexate was cost effective only when serum concentrations of β-hCG were below 3000 IU/L for multiple-dose regimens, and below 1500 IU/L for single-dose regimens [7].

    • Comparison of double- and single-dose methotrexate protocols for treatment of ectopic pregnancy

      2012, International Journal of Gynecology and Obstetrics
      Citation Excerpt :

      Indeed, the term “single-dose protocol” is a misnomer because it includes the possibility of repeating the dose at weekly intervals in poor responders. The cumulative success rate after 1, 2, 3, and 4 single doses has been reported as 77%, 92%, 93%, and 94%, respectively [14]. Repeating dosages are associated with longer treatment and follow up duration, more adverse effects, and less compliance—disadvantages that are typical disadvantages of the multi-dose regimen [7,10].

    • Ectopic pregnancy

      2021, Contemporary Obstetrics and Gynecology for Developing Countries: Second Edition
    View all citing articles on Scopus
    View full text