Current management of ectopic pregnancy

Ectopic pregnancy continues to be one of the most common gynecologic emergencies and is the leading cause of pregnancy-related first-trimester death in the United States. The rate of ectopic pregnancy continues to rise because of increases in the incidences of its risk factors. However, improved modalities of early diagnosis and treatment have reduced both mortality and morbidity of this condition. In this article, the authors present an evidence-based review of the risk factors and presentation of ectopic pregnancy, including the utility of various diagnostic techniques, and compare the appropriateness and effectiveness of different therapeutic approaches.     

Conservative medical and surgical management of interstitial ectopic pregnancy.

OBJECTIVE: To review the definition and diagnosis of interstitial and heterotopic interstitial pregnancy and to evaluate the conservative management of these conditions. DESIGN: A MEDLINE computer search was used to identify relevant studies. The mean values for the duration of amenorrhea, serum beta-hCG level, size of the ectopic mass, and success rates of the various treatment modalities were calculated from the raw data in the original publications. RESULT(S): A review of 41 patients with interstitial pregnancy who were treated with methotrexate systemically, locally, or in combination revealed an overall success rate of 83%. The mean duration of amenorrhea, mean serum beta-hCG level, and mean size of the ectopic mass were 54 days, 15,127 mIU/mL, and 23 mm, respectively. Among 22 patients with interstitial pregnancy who were treated with conservative laparoscopic techniques, the overall success rate was 100%. In this group, the mean duration of amenorrhea, mean serum beta-hCG level, and mean size of the ectopic mass were 54 days, 7,572 mIU/mL, and 31 mm, respectively. There were nine cases of heterotopic interstitial pregnancy. Seven patients were managed with potassium chloride injected into the ectopic pregnancy, and two patients were treated by laparoscopy. Overall, 67% of the coexisting intrauterine pregnancies resulted in successful deliveries and the remainder ended in spontaneous abortions. CONCLUSION(S): Cornual resection or hysterectomy with a laparotomy should no longer be the first line of treatment for a hemodynamically stable patient with an interstitial pregnancy. In selected cases, methotrexate and laparoscopy can be used successfully in treating early interstitial pregnancy.     

Reproductive outcomes after medical and surgical management of ectopic pregnancy

Ectopic pregnancies have a negative impact on future fertility. Prompt diagnosis is paramount to preserve tubal function and reproductive potential. Expectant, medical, and surgical management of ectopic pregnancies have similar efficacy in properly selected patients. Medical management has emerged as a safe alternative to surgery and holds promise for preservation of future fertility. Laparoscopic salpingostomy or salpingectomy remains the preferred means of surgical removal of ectopic pregnancies. The most predictive factor of future fertility is the health of the contralateral tube.     

Current trends in management of ectopic pregnancy in the United Kingdom.

The potential advantages of laparoscopic management of ectopic pregnancy include lower morbidity, faster return to work, and less impact on reproductive health. This study aimed to investigate the current management of ectopic pregnancy in the United Kingdom. Thirty-five per cent of ectopic pregnancies are currently managed laparoscopically. Units that tended to operate laparoscopically were more likely to attempt to preserve the fallopian tube at surgery. Ninety per cent of units in the UK feel that they potentially could manage ectopic pregnancies laparoscopically but in practice only 60% managed any of the last three ectopic pregnancies by this technique.     

Medical management of ectopic pregnancy

The use of medical management of ectopic pregnancy has become an accepted alternative to surgical therapy. Methotrexate, a folic acid antagonist, is the most widely studied agent. The most commonly used protocol consists of methotrexate 50 mg/m of actual body weight. Assessment of human chorionic gonadotropin (hCG) levels is repeated on days 4 and 7. Repeat methotrexate dosing is performed for hCG drops < 15%. Contraindications include hemodynamically unstable patients or those with elevated liver enzymes, low white blood count, or abnormal renal function. hCG levels are most predictive of success. A success rate of above 90% is achievable.     

Contemporary management of ectopic pregnancy

Over the five years 1975-79 at Yale-New Haven Hospital, ectopic pregnancy changed from a disease requiring acute emergency are utilizing radical surgery for a ruptured ectopic to a disease requiring chronic, observant care utilizing conservative treatment for the unruptured ectopic. One hundred ninety-five cases of ectopic pregnancy have been retrospectively reviewed to determine how laparoscopy, ultrasound and beta pregnancy testing have affected this change. Over the reviewed period of time, the rate of diagnosed and treated unruptured ectopic pregnancies increased from 8% to 35%. Those patients with ectopic pregnancies having laparoscopy prior to laparotomy rose from 11% to 29.5%. Ultrasound diagnosed intrauterine pregnancy in 13% of those patients suspected of having an ectopic pregnancy by defining an intrauterine gestational sac and demonstrated a mass in 85% of patients diagnosed as having an ectopic pregnancy, although the mass was not always the ectopic pregnancy. Beta pregnancy testing, available only over the past two years, was positive in 99%, with only one false negative. One hundred twenty-eight culdocenteses were done, with 85% positive, and was the most important factor in deciding on emergency versus expectant care. These factors have allowed us to treat ectopic pregnancy expectantly, making the diagnosis sooner and more accurately, leading to an increase in conservative treatment and employing salpingostomy as opposed to salpingectomy as the rate of unruptured ectopic pregnancy increases.     

Evidence-based management of ectopic pregnancy

In selected cases, medical treatment of ectopic pregnancy with methotrexate is as effective as laparoscopic surgery. However, medical treatment might have a more negative impact on the health-related quality of life than surgical treatment. This is partly because of the long resolution time after medical treatment. New evidence suggests that combining methotrexate and mifepristone can shorten this resolution time.     

Expectant management of ectopic pregnancy

This article will provide a review of the literature regarding expectant management of ectopic pregnancy. Detailed definitions and methods of evaluation are discussed, as well as pooled existing data on success rates of expectant management. A comparison of expectant management versus other treatment options is provided as well as a review of fertility outcomes after expectant management of ectopic pregnancy.     

Expectant management of ectopic pregnancy

Figure 2 outlines the management protocol used at the University of Tennessee. Expectant management either in the presence or absence of tubal abortion offers an alternative to surgical management of ectopic pregnancy. With proper patient selection and follow-up, surgery can be avoided in a significant number of patients who once would have required operative intervention.     

Surgical management of ectopic pregnancy

Laparoscopic salpingostomy remains the definitive and universal treatment of ectopic pregnancy in patients who are hemodynamically stable and who wish to preserve their fertility. The reproductive performance after salpingostomy appears to be equivalent or better than salpingectomy, but the recurrent ectopic pregnancy rate may be slightly greater. Expectant management has a poor efficacy and unproven benefit in subsequent reproductive outcome. Its use should be limited to situations in which the ectopic pregnancy is suspected but cannot be detected by transvaginal ultrasound. Methotrexate is an alternative to surgical treatment in selected patients who fulfill strict inclusion criteria, including compliance with follow-up evaluation. A large, prospective, randomized trial with significant power is needed, however, to study the prognostic factors for methotrexate success. The most practical and efficient method of methotrexate administration is a single intramuscular injection. Those who do not meet the criteria for methotrexate therapy should be treated surgically, which can be done by laparoscopy. Interstitial pregnancy also can be treated with methotrexate. Otherwise, a cornual resection or salpingotomy can be done. Although, it is feasible by laparoscopy, the laparoscopic approach should be done only by those who have an expertise in laparoscopic suturing. Abdominal and ovarian pregnancies are best treated surgically. Further, the diagnosis usually is established by laparoscopy, and an appropriate surgical treatment can be conducted at the same time.     

Endoscopic management of ectopic pregnancy

Ectopic pregnancy is a common problem usually diagnosed at an early stage and often in an emergency situation. Both medical and surgical treatments can be used for its management. In case of surgical treatment, laparoscopy rather than open surgery must be practiced. Concerning the choice between salpingostomy and salpingectomy, it depends of the controlateral tubal patency. In case of altered controlateral tube, if a sparing surgery is possible it should be preferred. However, this question is still debated if the controlateral tube seems patent.     

Surgical management of ectopic pregnancy

Surgery remains an acceptable, and sometimes necessary, modality for the treatment of ectopic pregnancy. Laparoscopy is the preferred method of access, yet controversy remains regarding the optimal procedure and postoperative management. Generally, salpingostomy is employed with the goal of maintaining fertility, although data to support this tenet are lacking. In most cases, the decision to perform conservative versus radical surgery is on the basis of the patient's history, her desire for future fertility, and surgical findings. The procedures of salpingostomy and salpingectomy, techniques to prevent and control blood loss at the time of surgery, and surgical options for nontubal ectopic pregnancies are reviewed.     

Modern management of ectopic pregnancy

The modern management of ectopic pregnancy has been influenced greatly by recent advances in human chorionic gonadotropin determination and ultrasound. Serum progesterone determination holds promise as a means of identifying abnormal gestations. Early diagnosis of tubal pregnancies has prompted conservative surgical treatment and the use of medical therapy in selected cases. Because of the improvement in diagnostic aids and conservative treatment, we are documenting a change in epidemiologic profiles. The incidence of ectopic pregnancy has increased, with a concomitant decrease in mortality. Fertility after conservative surgical procedures appears improved over that with radical treatment. However, women with ectopic pregnancies continue to have reduced fertility potential.     

Controversies in the management of ectopic pregnancy

Ectopic pregnancy is a common clinical problem, but there appears to be much controversy surrounding the surgical management of its occurence. This paper reviews the available evidence on the management of ectopic pregnancy. The discussion focuses initially around the choice of medical versus surgical treatment. Next, the question is addressed that if surgical management is deemed necessary, whether the approach should be laparoscopic or via open laparotomy. Lastly, if surgery is undertaken, should salpingectomy or salpingotomy be performed? Laparoscopy will remain the main method of treatment for women with ectopic pregnancy, as it provides obvious advantages over open surgery. On balance, salpingotomy should be the surgical treatment of choice for the majority of women with ectopic pregnancy, as it results in a higher subsequent pregnancy rate, although there is a slightly higher recurrent ectopic pregnancy rate and persistent trophoblastic disease rate when compared with women treated with salpingectomy. There is also a place for medical treatment of women with low concentrations of human chorionic gonadotrophin. A variable dosing methotrexate regimen is more effective compared with single dose regimen, and the fixed multiple regimen is associated with a high rate of side effects.