Tubal patency and fertility outcome after expectant management of ectopic pregnancy

Fertility and reproductive outcome after tubal ectopic pregnancy: comparison among methotrexate, surgery and expectant management

Purpose

To compare fertility and reproductive outcome after surgical, medical, and expectant management for tubal ectopic pregnancy (EP).

Methods

133 of 228 patients, who were managed between January 2012 and December 2017 for a tubal EP, tried to conceive immediately after treatment: 86 out of 173 (49.7%) underwent surgical treatment; 38 (21.9%) were treated with methotrexate (MTX), and 49 (28.3%) had expectant management. Clinical data were retrieved by medical records, fertility outcomes were obtained by phone follow-up. The cumulative incidence (CI) of intrauterine clinical pregnancy (CP), miscarriage, live birth (LB), and recurrent EP, and the time between treatment and first intrauterine CP were compared between women treated with MTX, surgery and expectant management.

Results

The CI of intrauterine CP starting from 12 months after the EP was 65.3% for the expectant management, 55.3% for the MTX group, and 39.5% for surgery (p = 0.012). Post-hoc analysis showed expectant management having higher intrauterine CP and LB, and shorter time between treatment and first intrauterine CP compared to surgery (p < 0.05). The CI of recurrent EP was comparable between the 3 groups. The analysis stratified per βhCG cut-off of 1745 mUI/mL and EP mass cut-off of 25 mm reported consistent results.

Conclusions

Women successfully managed by expectation appear to have better reproductive outcomes compared to women who underwent surgery, with the shortest time to achieve a subsequent intrauterine CP. Therefore, if safely applicable the expectant management should be considered in the case of tubal EP. The fact that the chosen treatment was primarily guided by the βhCG value and EP mass diameter based on the protocol, which is intrinsically related to the characteristics of the EP, represents the main limitation of the present study. Indeed, we cannot completely exclude that the observed differences between treatments are related to the EP itself instead of the treatment.

The impact of expectant management, systemic methotrexate and surgery on subsequent pregnancy outcomes in tubal ectopic pregnancy

BACKGROUND

The most common treatment modalities of ectopic pregnancy may influence long-term subsequent fertility outcomes in women who previously treated for ectopic pregnancy.

AIMS

Our objective was to compare long-term subsequent fertility outcomes after treatment with expectant management, systemic methotrexate (MTX) and surgery in tubal ectopic pregnancy.

METHODS

We searched our database for all women diagnosed with tubal ectopic pregnancy between January 2007 and January 2011 who were managed expectantly, with systemic MTX and with surgery. Treatment success and spontaneous pregnancy rates were compared in patients who desire to conceive following a tubal pregnancy.

RESULTS

One hundred twelve of 151 women desired to conceive following tubal ectopic pregnancy. Twenty-seven of 112 (24.1 %) patients were managed expectantly. Fifty-three (47.3 %) and 32 (28.5 %) patients were managed with systemic MTX or surgery, respectively. All patients in expectant and surgery groups were managed successfully. Two (3.7 %) patients had surgery after failed treatment with systemic MTX. Spontaneous intrauterine pregnancy rates were 62.9 % in expectantly managed women, 58.4 % in women with systemic MTX and 68.7 % in women with surgery (p > 0.05).

CONCLUSIONS

Treatment of ectopic pregnancy with either expectant management or systemic MTX is equally effective as compared to surgery. Spontaneous intrauterine pregnancy rates were comparable in expectant management, systemic methotrexate and surgery.

Serum Human Chorionic Gonadotropin (β- hCG) Clearance Curves in Women with Successfully Expectantly Managed Tubal Ectopic Pregnancies: A Retrospective Cohort Study

OBJECTIVE

To establish clearance curves for serum β -hCG in women with successfully expectantly managed tubal ectopic pregnancies.

DESIGN

Retrospective cohort study. Non- viable tubal ectopic pregnancy was diagnosed on transvaginal ultrasound. If initial serum β hCG was less than 5000 IU/L and patients were asymptomatic, expectant management was offered. Patients underwent serial β hCG measurements until serum β hCG was less than 20 IU/l, or the urine pregnancy test was negative.

SETTING

Early Pregnancy and Gynaecology Assessment Unit, Kings College Hospital, London (December 1998 to July 2006).

PATIENTS

We included 161 women with diagnosed non-viable tubal ectopic pregnancy who underwent successful expectant management.

MAIN OUTCOME MEASURE

Serum β hCG level.

RESULTS

Mean initial serum β- hCG was 488 IU/L (41 - 4883) and median serum β hCG clearance time was 19 days (5 - 82). The average half-life of β hCG clearance was 82.5 hours (±SD 50.2) in patients with steadily declining serum β- hCG levels compared to 106.7 hours (±SD 72.0) in patients with primarily plateauing β-hCG levels in the declining phase. However, these differences were not significant (p>0.05).

CONCLUSION

We identified a median follow-up of 19 days until serum β hCG clearance in women with tubal ectopic pregnancy and successful expectant management. Although non- significant, women with initially plateauing serum β hCG showed a longer follow-up time until clearance compared to women with steadily declining β hCG levels. This information may serve as a guideline enabling clinicians to predict the length of follow-up for women with tubal ectopic pregnancy and expectant management.

Assessment of β-human chorionic gonadotropin level as a reliable predictor of tubal patency confirmed with transvaginal ultrasound-guided selective salpingography (TVSSG) following conservative treatment of tubal pregnancy

OBJECTIVE

To try putting the β-hCG level as a reliable predictor for tubal patency for women, who had previously undergone expectant treatment or who had received systemic methotrexate injection because of tubal pregnancy, and to simply check their tubal patency using a newly proposed procedure, a transvaginal ultrasound guided selective salpingography (TVSSG).

METHODS

One hundred and sixty patients were submitted to TVSSG after tubal pregnancy treatment. TVSSG was subsequently performed in the follicular phase of the menstrual cycle after the clinical treatment of tubal pregnancy. One hundred patients received expectant management and 60 were treated with single-dose methotrexate (50 mg/m(2) intramuscularly).

RESULTS

Of 160 patients (235 fallopian tubes examined), the affected tube was observed to be patent by TVSSG in 84 and 78%, respectively (P > 0.05). The contralateral tube was patent in 93%. Forty patients became pregnant and were thus not subsequently assessed with laparoscopy. Ten of these pregnancies ended in a miscarriage and five in a recurrent tubal pregnancy. The concordance of 86% for Fallopian tubes was achieved between the TVSSG and laparoscopy by the gold standard method. After the logistic regression was performed, it was observed that the levels of β-hCG > 5,000 mUI/ml were directly related to the tubal obstruction risk, odds ratio = 11.7 (95% CI = 2.27-61.32).

CONCLUSIONS

In the current study, the probability of ipsilateral tubal obstruction depends on the β-hCG levels. The increase in β-hCG levels is followed by an enhancement in tubal obstruction risk. Therefore, assessment of the β-hCG may be an effective tool for the prognosis of the reproductive future of these patients.

Is it necessary to operate on all women with an acute abdomen following medical treatment of tubal ectopic pregnancy?

The main objective of this retrospective study is to evaluate the question of whether it is necessary to perform surgery for patients who develop an acute abdomen after methotrexate administration in cases of tubal ectopic pregnancy. A total of 26 women with tubal ectopic pregnancy who required emergency surgical evaluation after a single dose of methotrexate treatment were included. The surgical findings were tubal abortion (10 cases, 38.4%); tubal rupture (12 cases, 46.2%) and tubal haematoma (4 cases, 15.4%). The average time for initiation of severe abdominal pain following single dose methotrexate treatment was 6.12 +/- 2.10 days (range, 2-10). The most common site of implantation was isthmus (50.0%) and 38.5% (five patients) of the patients had tubal abortion from this part of the tube, while 46.1% of women (six patients) with isthmic localisation had a tubal rupture. Following medical treatment of ectopic pregnancy, surgery may be an option in the presence of symptoms/signs of acute abdomen (in the presence or absence of haemodynamic instability) and free pelvic fluid on sonography for only patients with isthmic tubal ectopic pregnancy, or if the isthmic localisation of tubal ectopic pregnancy is suspected on sonography.

[Fertility after ectopic pregnancy]

BACKGROUND

The subsequent fertility of women who had experienced ectopic pregnancy (EP) is the best criteria of the effectiveness of the treatment. In the absence of randomised trials comparing laparotomy, laparoscopy, medical treatment by methotrexate (MTX) and expectative, the only way to compare treatments is to make use of data from observational studies.

METHODS

The databases consulted were Medline, Cochrane Library, National Guideline Clearinghouse and Health Technology Assessment Database. Keywords used for research: fertility; ectopic pregnancy; expectative; methotrexate; salpingectomy; salpingotomy.

RESULTS

Twenty-four papers of randomised control trial (RCT) or observational studies were analysed. No difference between laparotomy and laparoscopy for fertility was found. Tubal suture does not modify the subsequent fertility. The risk of normal pregnancy or ectopic recurrence is similar between salpingotomy or salpingectomy when controlateral tube is normal. Conversely, in case of altered tube, the fertility appears higher after conservative treatment. Between conservative treatments, surgical or medical, no difference appears.

CONCLUSIONS

Conservative surgical treatment is the gold standard. However, the fertility seems similar with the other treatments. Three ongoing RCT could answer to the three main questions: Which is the best fertility between medical and conservative surgical treatment? Which is the best fertility between radical and conservative surgical treatment? Which is the best fertility between MTX and expectative?

Retrospective analysis of laparoscopic salpingostomy and conservative expectant management of tubal ectopic pregnancy

Purpose

To identify predictive factors for successful expectant management of ectopic pregnancy and to evaluate the prognosis for fertility after expectant management and laparoscopic salpingostomy.

Methods

Forty-six cases of expectant management and eighty cases of laparoscopic salpingostomy for tubal ectopic pregnancy were retrospectively analyzed. Subjects were classified in three groups: those who underwent laparoscopic salpingostomy, those treated by expectant management only, and those treated by expectant management but requiring additional treatment.

Results

The rates of tubal patency, intrauterine pregnancy and repeated ectopic pregnancy in the laparoscopic salpingostomy group were 75, 40, and 16%. The rates in the expectant management group were not significantly different: 72, 42 and 15%. Finally, the rates in the extra treatment group were 75, 39 and 15%. Success rate of expectant management was 54%. In 93% of cases expectant management was successfully completed when the initial levels of urinal hCG were less than 3000 mIU/ml and the levels of hCG 48 h later were less than 80% of the initial levels. However, expectant management alone was insufficient and required extra treatment in 90% of cases when the initial levels of hCG were 3000 mIU/ml and above or when the levels of hCG level 48 h later was 80% of initial levels and above.

Conclusions

Expectant management in combination with salpingostomy is not only minimally invasive but also a useful way to preserve fertility. Initial urine hCG levels and their variation over time can help predict whether expectant management will succeed.

Does tubal ectopic pregnancy with hemoperitoneum always require surgery?

OBJECTIVE

Hemoperitoneum is accepted as an indication for surgery in women with tubal ectopic pregnancy. The aim of this pilot study was to evaluate the feasibility of managing such women non-surgically.

METHODS

This was a prospective observational study. Women with tubal ectopic pregnancy and hemoperitoneum detected on transvaginal sonography (TVS) were managed as inpatients either expectantly or with methotrexate (MTX). Inclusion criteria for conservative management were: compliance, clinical stability, absence of acute abdomen, stable hemoglobin level on two measurements (0 and 12-24 h apart), serum human chorionic gonadotropin (hCG) < 5000 IU/L, absence of fetal cardiac activity on TVS and absence of significant hemoperitoneum, defined as blood above the level of the uterine fundus and/or in Morison's pouch (hepatorenal space). Subsequent management was based upon the hCG ratio at 48 h. All the women were managed as inpatients until the abdominal pain settled and the serum hCG levels were falling.

RESULTS

Forty-one women with tubal ectopic pregnancy presented between November 2006 and March 2008. Eight women (20%) fulfilled the entry criteria. The median gestational age at diagnosis was 49 (interquartile range, 38-52.5) days. All women presented with lower abdominal pain/right iliac fossa or left iliac fossa pain. Hemoglobin levels ranged from 11.2 to 14.2 g/dL at presentation and from 12.0 to 14.8 g/dL after 12-24 h. 6/8 (75%) women were managed expectantly and 2/8 (25%) received MTX. All women had resolution of their ectopic pregnancy within 3 weeks with no complications.

CONCLUSIONS

This pilot study suggests that the finding of hemoperitoneum on ultrasound examination may not be an absolute contraindication to conservative management of tubal ectopic pregnancy.

Fertility outcomes following expectant management of tubal ectopic pregnancy

OBJECTIVES

To evaluate fertility outcome after the expectant management of tubal ectopic pregnancy.

METHODS

Our dedicated early pregnancy database was searched for all women diagnosed with a tubal ectopic pregnancy between January 1999 and June 2003 who were either managed expectantly or underwent a salpingectomy. They were contacted to enquire about their ability to conceive following the ectopic pregnancy and about the outcomes of any subsequent pregnancies.

RESULTS

Four hundred and forty-four women had a diagnosis of tubal ectopic pregnancy, and 173 (39%) were successfully contacted. A total of 146/173 (84.4%; 95% CI, 79-89.8%) tried for another pregnancy: 49/59 (83.1%; 95% CI, 73.4-92.6%) in the expectant management and 97/114 (85.1%; 95% CI, 78.4-91.6%) in the salpingectomy group (P > 0.05). Spontaneous intrauterine pregnancy occurred in 41/49 (83.7%; 95% CI, 73.3-94.2%) women managed expectantly and in 62/97 (63.9%; 95% CI, 54.4-73.5%) women managed surgically (odds ratio 2.89; 95% CI, 1.22-6.86%). The risk of recurrent ectopic pregnancy was not significantly different between the two management groups.

CONCLUSIONS

Fertility outcomes following the expectant management of tubal ectopic pregnancy are comparable to those following salpingectomy.

Comparison of the effect of single-dose and multiple-dose methotrexate therapy on tubal patency

OBJECTIVE

To compare tubal patency by using hysterosalpingography (HSG) in women with unruptured ectopic tubal pregnancy who were treated with either single-dose or multiple-dose methotrexate (MTX) regimen.

DESIGN

A case series with a retrospective statistical analysis.

SETTING

Maternity and teaching hospital in Turkey.

PATIENT(S)

Sixty-one patients treated with MTX therapy for unruptured tubal ectopic pregnancy.

INTERVENTION(S)

Thirty-one patients received single-dose and 30 multiple-dose MTX treatment. The HSG was performed 4 to 6 months after treatment to assess tubal patency.

MAIN OUTCOME MEASURE(S)

Ipsilateral and contralateral tubal obstruction rates.

RESULT(S)

Free passage through the ipsilateral tube was observed in 17 of 30 cases (56.7%) after multiple-dose, and 26 of 31 cases (83.9%) after single-dose MTX therapy. Patency of the contralateral tube was higher after single-dose than multiple-dose MTX treatment, although the value was not statistically significant. Binary logistic regression analysis was used to evaluate the parameters of age, gravida, parity, initial titers of beta human chorionic gonadotropin, size of the adnexal mass, and MTX regimen and their correlation with the HSG results after the clinical treatment for unruptured ectopic pregnancy. Only the type of MTX regimen was found to be used as a predictor of ipsilateral tubal obstruction.

CONCLUSION(S)

In terms of ipsilateral tubal obstruction, multiple-dose MTX therapy appears to have a greater negative effect on tubal patency than single-dose therapy.

The nonsurgical management of ectopic pregnancy

PURPOSE OF REVIEW

This review discusses the diagnosis and nonsurgical management of ectopic pregnancy.

RECENT FINDINGS

In the majority of cases the diagnosis of ectopic pregnancy should be made on transvaginal ultrasonography. Those for which the diagnosis is not made on the first scan may initially be classified as pregnancies of unknown location. There are now a number of strategies and mathematical models to predict ectopic pregnancy in this pregnancy of unknown location population. Reported success rates for expectant and medical management of ectopic pregnancy vary due to different inclusion criteria. A number of predictors of success have been studied: maternal age, previous obstetric history, gestational age, ultrasound features, human chorionic gonadotrophin levels, progesterone levels and the change in human chorionic gonadotrophin over time. At present the initial human chorionic gonadotrophin level probably remains the single most important predictor of success. Nonsurgical management is also particularly important for nontubal ectopic pregnancies: interstitial, cervical and caesarean section scar pregnancies.

SUMMARY

The majority of ectopic pregnancies can be visualized by ultrasound and so can be considered for conservative treatment. Nonsurgical management can be safe and effective. Appropriate selection criteria remain an issue, however, and a consensus needs to be reached on the predictors of success and failure to optimize management.

Tubal patency following surgical and clinical treatment of ectopic pregnancy

CONTEXT AND OBJECTIVE

As there is little information about fertility outcomes among women following clinical treatment (methotrexate and expectant management) and surgery (salpingectomy) consequent to ectopic pregnancy, we evaluate the results from hysterosalpingography subsequent to treatment. The objective was to evaluate contralateral tubal patency using hysterosalpingography following surgery and clinical treatment of tubal pregnancy.

DESIGN AND SETTING

This was a prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center.

METHOD

Among 115 patients who underwent hysterosalpingography following surgery and clinical treatment of tubal pregnancy between April 1994 and February 2002, 30 were treated with a single intramuscular dose of methotrexate (50 mg/m(2)), 50 were followed up expectantly and 35 underwent salpingectomy.

RESULTS

The patency of the ipsilateral tube was 84% after methotrexate treatment and 78% after expectant management. In addition, contralateral tubal patency was 97% after methotrexate treatment, 92% after expectant management and 83% after salpingectomy. There were no statistically significant differences between the clinical treatment and surgery groups.

CONCLUSIONS

The findings from this study suggest similar contralateral tubal patency rates following salpingectomy, methotrexate treatment and expectant management.

The non-surgical management of ectopic pregnancy

Ectopic pregnancy can now be detected at earlier gestations in asymptomatic women. As a consequence conservative treatment strategies may be more appropriate than surgical intervention. This review aims to discuss the diagnosis and the non-surgical management options for ectopic pregnancy, in particular expectant management and the use of methotrexate.

Values of beta-human chorionic gonadotropin as a risk factor for tubal obstruction after tubal pregnancy

AIM

The hysterosalpingography (HSG) was evaluated after the clinical treatment of tubal pregnancy and the possible risk of tubal obstruction through the following parameters: beta-human chorionic gonadotropin (beta-hCG) levels, size of the adnexal mass, aspects of the image at ultrasound, and color Doppler.

METHODS

Eighty patients were submitted to HSG after tubal pregnancy treatment from April 1994 to February 2002. Fifty received expectant management and 30 were treated with single-dose methotrexate (MTX) (50 mg/m(2) intramuscularly).

RESULTS

The patency of the ipsilateral tube was 84% and 78% after the MTX and expectant treatments, respectively (P > 0.05). After the logistic regression was performed, it was observed that levels of beta-hCG >5000 mUI/ml were directly related to the tubal obstruction risk, odds ratio = 11.79 (95% CI = 2.27-61.32). Other variables were not directly related to the tubal obstruction risk.

CONCLUSIONS

In this study, the probability of ipsilateral tubal obstruction depends on the beta-hCG levels. The increase in beta-hCG levels is followed by an enhancement in tubal obstruction risk. Therefore, the beta-hCG may be effective for the prognostic of the reproductive future of these patients.

Tubal patency after clinical treatment of unruptured ectopic pregnancy

OBJECTIVE

To evaluate tubal patency using hysterosalpingography after clinical treatment of tubal pregnancy.

METHOD

Of 80 patients who underwent hysterosalpingography after clinical treatment of tubal pregnancy from April 1994 to February 2002, 30 were treated with a single 50 mg/m(2) dose of methotrexate intramuscularly (n=30) and 50 were followed up expectantly.

RESULTS

Patency of the ipsilateral tube was 84% after methotrexate treatment and 78% after expectant management. In addition, contralateral tubal patency was 97% after methotrexate treatment and 92% after expectant management. There were no statistically significant differences between the groups.

CONCLUSION

Findings from this study suggest similar tubal patency rates after methotrexate treatment and expectant management.

Expectant management of tubal ectopic pregnancy: prediction of successful outcome using decision tree analysis

OBJECTIVE

To establish whether a decision tree based on a combination of clinical, morphological and biochemical parameters could be constructed to help in the selection of women with tubal ectopic pregnancies for expectant management.

METHODS

This was a prospective observational study in a tertiary referral early pregnancy unit in an inner city teaching hospital. The study group consisted of 179 women with ultrasound diagnosis of ectopic pregnancy. Demographic, clinical and ultrasound data were recorded in each case at the initial visit. In addition all women had a blood sample taken for the measurements of serum beta-human chorionic gonadotropin (beta-hCG) and progesterone. Clinically stable women with non-viable pregnancies and no signs of hematoperitoneum were managed expectantly on an outpatient basis until their serum beta-hCG declined to <20 IU/L. Women who developed pelvic pain during follow-up and those with non-declining serum beta-hCG were offered surgery.

RESULTS

A total of 107/179 (59.8%) tubal ectopics were considered suitable for expectant management. Ectopic pregnancy resolved spontaneously in 75/107 (70%) women, which was 41.9% of the total number of tubal ectopics. Maternal age, initial serum beta-hCG and progesterone were all significantly different in pregnancies that resolved spontaneously compared to those requiring surgery (P < 0.05). Initial serum beta-hCG level was the best predictor of the outcome of expectant management. These differences enabled a construction of a four-level decision tree to estimate the likelihood of successful expectant management.

CONCLUSIONS

There are significant differences in demographic, ultrasound and biochemical findings between spontaneously resolving ectopics and those requiring treatment. Decision tree analysis may be used as a guide to estimate the probability of successful expectant management in individual cases.

Endometrial thickness as an orienting factor for the medical treatment of unruptured tubal pregnancy

OBJECTIVES

To evaluate the efficacy of the endometrial thickness measurement through transvaginal ultrasound as an orienting factor for the medical treatment of unruptured tubal pregnancy with a single dose of methotrexate in order to select the best cases for the medical treatment.

METHODS

A prospective study, in which the largest measurement of endometrial thickness in millimeters was evaluated, along the longitudinal uterine axis, by means of transvaginal ultrasound. A total of 38 patients meeting the inclusion criteria for single-dose methotrexate treatment [50 mg/m2 intramuscularly (i.m.)] were included in the study. We observed whether there was any difference in mean value of endometrial thickness and initial beta-human choriongonadotropin levels, between the cases that evolved successfully with the treatment, and those that failed.

RESULTS

The mean value of endometrial thickness and initial beta-human choriongonadotropin (beta-hCG) levels, for patients evolving successfully with medical treatment (28 cases), were 6.39 mm and 1936.2 mUI/ml, respectively, while the mean values for failures were 11.70 mm and 6831.3 mUI/ml. We carried out statistical analysis using the 'Student's t-test', with p < 0.05.

CONCLUSIONS

The mean value of endometrial thickness, along the longitudinal uterine axis through transvaginal ultrasound, reflects hormonal action and has been demonstrated to be another important parameter in indicating the medical treatment of an unruptured tubal pregnancy.

Trends for inpatient treatment of tubal pregnancy in Maryland

OBJECTIVE

The purpose of this study was to determine the burden of tubal pregnancy in Maryland in hospitalized patients and to elicit treatment trends.

STUDY DESIGN

Patients who were admitted with tubal pregnancy from January 1, 1994, through March 31, 1999, were identified with the use of the Maryland Health Service Cost Review Commission discharge database. Combining this with census data, we calculated the incidence. Cases were then stratified by demographics, presentation, and surgeon volume. Outcome measures included type of medical treatment,conservative (salpingostomy or salpingotomy) or extirpative operation (salpingectomy, salpingo-oophorectomy, oophorectomy, hysterectomy), length of stay, charges, and disposition. The treatment groups were compared with the use of t tests and linear regression, and associations between demographics and type of operation were analyzed with logistic regression.

RESULTS

The database included 3729 cases, which yielded an annual incidence of 5.2 per 10,000 women aged 15 to 45 years. Subjects averaged 29.6 years old and were predominantly African American(52.6%) and white (43.3%). Most of the women (67.8%) were seen in the emergency department and were treated surgically (90.7%). Conservative operation was performed in 18.1% of the women; extirpative operation was performed in 81.9% of the women. Significant predictors for extirpative operation were emergency department admission (odds ratio, 1.44; 95% CI, 1.18-1.75), increasing age (odds ratio, 1.07; 95% CI, 1.06-1.09), African American race (odds ratio, 1.87; 95% CI, 1.51-2.31), higher surgeon volume (odds ratio, 1.28; 95% CI, 1.04-1.57), and market area. Length of stay and total charges were higher for the extirpative group(P <.0001). The study lacked the power to detect differences in outcomes for other nonwhite races (5% power), laparoscopy versus laparotomy (15% power), or operating room charges (14% power).

CONCLUSION

These data are limited to hospitalized patients and probably underestimate the true incidence of tubal pregnancy. Most patients underwent extirpative operation. Acuity of presentation and increasing age were appropriate predictors of this group. However, physician volume and black race were also predictors. This may be due to differences in the prevalence of disease, unmeasured clinical factors, patient and physician preferences for treatment, barriers that delayed care, or other socioeconomic factors.

Ectopic pregnancy from surgical emergency to medical management

During the past 25 years, the incidence of ectopic pregnancy has progressively increased while the morbidity and mortality have substantially decreased, and the treatment has progressed from salpingectomy by laparotomy to conservative surgery by laparoscopy and more recently to medical therapy. This therapeutic transition from surgical emergency to medical management has been attributed to early diagnosis through the use of sensitive assays for hCG and the high definition of vaginal ultrasound. By using these sensitive diagnostic tools, we are now able to select those patients who are most likely to respond to medical management versus those who are at high risk of rupture and require surgery. Besides being less invasive and associated with significantly lower risks, medical therapy with methotrexate results in significant cost savings, which have been calculated to be approximately $3,000 per treated patient. Our goal is to identify those patients with ectopic pregnancy who are most likely to respond to methotrexate therapy and least likely to develop significant side effects. Recent studies have helped us define the predictors of success with methotrexate treatment in women with ectopic pregnancy. The reported success rates of treating ectopic pregnancy with methotrexate vary from 71% to 100%. The highest success rates have been reported from institutions that have detailed diagnostic and therapeutic protocols, readily available assays for serum hCG levels, high-resolution vaginal probe ultrasound, and support staff that can closely monitor clinical response. The importance of developing specific protocols to create a clinical environment that supports the effective use of medical therapy for ectopic pregnancy is confirmed by the associated cost savings, decreased morbidity, and patient preference. Modern diagnostic advances and minimally invasive treatments coupled with improved success rates for assisted reproductive technologies should reduce the morbidity and mortality associated with ectopic pregnancy and offer the affected couple a much more optimistic outlook for subsequent reproductive potential.

Different placentation patterns in viable compared with nonviable tubal pregnancy suggest a divergent clinical management

OBJECTIVE

In contrast to tubal abortions, viable ectopic pregnancies in color Doppler ultrasonography exhibit a signal-intensive ring around the gestational sac. We investigated the underlying differences in implantation and placentation.

STUDY DESIGN

Histologic sections of fallopian tubes carrying viable tubal pregnancies (13 patients) and tubal pregnancies that aborted (8 patients) were immunostained for cytokeratin, MIB-1, CD-34, and CD-68. The data were studied by computer-aided image analysis followed by statistical evaluation (Student t test, P <.05).

RESULTS

In contrast to tubal abortions, viable tubal pregnancies are characterized by implantation at the mesosalpingial rather than at the antimesosalpingial side of the organ. They exhibit deeper trophoblast invasion into the thickened tubal wall, more intense trophoblast proliferation (P <.001), and increased villous vascularization (P <.001).

CONCLUSION

The morphologic findings correlate with preoperative Doppler ultrasonography. They suggest that trophoblast invasion, placental growth, and the fate of tubal pregnancies depend on the implantation site. They encourage a conservative management of anti-mesosalpingially implanted, nonviable ectopic pregnancies in clinically stable patients.

Current treatment of ectopic pregnancy

The incidence of ectopic pregnancy showed a sharp increase in the industrialized countries in the late 1970s. This resulted in an epidemic of ectopic pregnancy in the 1980s. At present the incidence of ectopic pregnancy has levelled off or even decreased. In the meantime the diagnosis of ectopic pregnancy has improved markedly, which means that the detection of this disease can take place very early in the first trimester of pregnancy. This has led to the use of more conservative treatment modalities and to a better prognosis for further pregnancies. Medical treatment, especially with methotrexate, has largely replaced the radical surgical option, and the treatment of ectopic pregnancy is most obviously moving to the direction of these conservative, medical approaches.