Medical management

Medical management of ectopic pregnancy has grown in popularity in recent years following several observational studies which reported success rates with a single dose systemic methotrexate in excess of 90% [33]. However, the diagnosis of ectopic pregnancy was based in many cases on monitoring the dynamics of serum hCG and progesterone, rather than on direct visualization of ectopic on ultrasound scan or at laparoscopy. It is therefore possible that in a significant number of cases intrauterine miscarriages were misdiagnosed as ectopics, contributing to the high success rates. Nevertheless there are some obvious attractions of medical treatment such as the possibility

Table 14.3 Selection criteria for conservative management of ectopic pregnancy

Minimal clinical symptoms Certain ultrasound diagnosis of ectopic No evidence of embryonic cardiac activity Size <5 cm

No evidence of haematoperitoneum on ultrasound scan Low serum hCG (methotrexate <3000 IU/l; expectant <1500 IU/l)

to manage patients on an outpatient basis and avoidance of surgery. However, due to the need for prolonged follow up and increased failure rate in women presenting with higher initial hCG measurements, medical treatment is only cost effective in ectopics with serum hCG <1500 IU [34].

Selection criteria for treatment with methotrexate are usually strict and they are listed in Table 14.3. Two randomized trials which compared methotrexate to surgery showed that only one third of all tubal ectopics satisfied these criteria and were suitable for medical treatment with the success rates between 65 and 82% [35,36]. The overall contribution of methotrexate to successful treatment of tubal ectopic was between 23 and 30% while all other women required surgery. The other problem with methotrexate is the risk of tubal rupture and blood transfusion, which occurred significantly more often in women receiving methotrexate compared to those who had surgery, this emphasizes the need for a very close follow up [35]. There is also a risk of side effects such as gastritis, stomatitis, alopecia, headaches, nausea and vomiting. Disturbances in hepatic and renal function and leukopenia or thrombocytopaenia may also occur.

In view of this, the overall role of methotrexate in the management of ectopic pregnancy is limited, but it may be offered on an individual basis to highly motivated women with small unruptured ectopics and a serum hCG level of 1500-3000 IU/l, who are likely to comply with well-organized follow-up.

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