Expectant management

Expectant management has important advantages over medical treatment as it follows the natural history of the disease and is free from serious side effects of methotrex-ate. The progress of ectopic pregnancy is easier to monitor as serum hCG measurements accurately reflect tro-phoblastic activity of the ectopic pregnancy, with rising levels indicating an increased risk of rupture. This is different from medical treatment, which is characterized by an initial rise in serum hCG following administration of methotrexate in cases with both successful and unsuccessful outcomes. Therefore with medical treatment it is often impossible to be confident about the probability of successful treatment for up to a week following injection, which increases the risk of adverse outcomes in comparison to expectant management.

Expectant management requires prolonged follow-up and it may cause anxiety to both women and their carers. However, the main limiting factor in the use of expectant management is the relatively high failure rate and the inability to identify with accuracy the cases that are likely to fail expectant management. To minimize the risk of failure many authors have used very strict selection criteria for expectant management such as the initial hCG <250 IU [37]. The use of strict selection criteria has resulted in relatively high success rates of expectant management sometimes reaching 70-80% [38,39]. However, only a small minority of ectopics was considered suitable for expectant management resulting in a low overall contribution to successful management of tubal ectopic of only between 7 and 25%. Recent studies showed that by using more liberal selection criteria for expectant management up to 40% of all tubal ectopics may resolve spontaneously on expectant treatment [40]. This observation also reflects the increased sensitivity of modern ultrasound equipment, which enables detection of very small ectopics (Fig. 14.5). It is very likely that a large proportion of these small ectopics were undiagnosed in the

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Nyberg 1987 Thorsen 1990

Elson 2004

Fig. 14.5 Relative frequencies of different morphological types of ectopic pregnancies detected on ultrasound scan in the last two decades. The proportion of more severe forms such as live ectopics and well-formed gestational sacs is decreasing, while the proportion of mild forms such as small solid ectopics is increasing. This finding reflects the ability of modern equipment to detect tubal ectopics, rather than the change in the nature of the condition.

Nyberg 1987 Thorsen 1990

Elson 2004

Fig. 14.5 Relative frequencies of different morphological types of ectopic pregnancies detected on ultrasound scan in the last two decades. The proportion of more severe forms such as live ectopics and well-formed gestational sacs is decreasing, while the proportion of mild forms such as small solid ectopics is increasing. This finding reflects the ability of modern equipment to detect tubal ectopics, rather than the change in the nature of the condition.

past and treated as early intrauterine miscarriages. However, the sensitivity of equipment will probably improve further in the future and it is imperative for modern practice to continue efforts to refine the selection criteria for expectant management of tubal ectopics.

According to the current literature the success of expectant management may be determined by the serum hCG levels at the initial presentation. In general, if hCG is less than 1500 IU and the ectopic pregnancy is clearly visible on ultrasound scan the success of expectant management is 60-70% [40]. The addition of the serum progesterone and morphological features of ectopics on ultrasound scan enable further refinement in the prediction of the likely success of expectant management.

Long-term fertility outcomes in women treated expectantly are similar to those treated by conservative surgery or medically. Several authors examined reproductive outcomes in women with ectopic pregnancies following successful expectant management compared to those who required surgery. They found no significant differences in the ipsilateral tubal patency rates and the rates of subsequent intrauterine and extrauterine pregnancies [41]. Therefore the main advantage of expectant management is avoidance of any intervention, rather than an improvement in the reproductive outcomes.

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