Comparative costs of methotrexate and laparoscopic surgery

Treatment cost evaluation of extrauterine gravidity: a literature review of medical and surgical treatment costs

BACKGROUND

The diagnosis of extrauterine pregnancy is possible very early giving the patient and doctors treatment options. As the risks and success rate of medical and surgical treatment are similar, the decision is increasingly influenced by cost-effectiveness.

OBJECTIVE

The following article systematically reviews the known literature regarding cost, decision criteria and possible follow-up.

METHODS

Literature review of extrauterine gravity in combination with cost in the online National Library of Medicine since 1.1.1997 following the PRISMA recommendations.

RESULTS

Six articles were identified in which the cost of the laparoscopic versus medical treatment is reviewed. In five articles, the medical treatment was shown to be more cost effective and in the sixth article the costs were found to be equal. The cost saving varies between 18 and 88% depending on the consideration of direct and indirect costs. If indirect expenses are considered, the total sum increases with treatment failures. Failure rates are given as up to 27% depending on the type of failure (surgical or medical). These rates seem to be linked indirectly with the β-HCG levels. Predictive parameters for the successful medical treatment are missing.

CONCLUSIONS

The treatment of small extrauterine gravidities in haemodynamically stable patients (defined by HCG levels <1,500 IU/l) is medically successful and cost-effective. With HCG levels between 1,500 IU/l and 3,000 IU/l, the treatment costs are similar. HCG levels >5,000 IU/l favour the surgical treatment as being more cost-effective. A similar cut-off for the sonographic imaging is missing.

The management of early pregnancy complications

Early pregnancy complications include miscarriage, ectopic pregnancies, pregnancies of unknown location, adnexal masses and hydatidiform mole. The management of women with these complications has changed with the introduction of dedicated Early Pregnancy Units, with a shift away from a surgical approach to one based on an expectant or 'watch and wait' policy. This chapter describes the role of transvaginal sonography (TVS) in the management of these women and critically evaluates the different treatment modalities available for the management of these complications. The management of miscarriage has largely changed from a surgical to an expectant or medical approach. The treatment of ectopic pregnancy (EP) is also being managed in a similar way as the condition is increasingly detected earlier. We will argue that EP should not be diagnosed on the basis of the absence of an intrauterine pregnancy but rather by the positive visualization of an adnexal mass using TVS. If a pregnancy cannot be seen either inside or outside the uterus this should be described as a pregnancy of unknown location and managed expectantly until the outcome is confirmed.

Single high dose of local methotrexate for the management of relatively advanced ectopic pregnancies

OBJECTIVE

To evaluate the limits of the conservative management of relatively advanced ectopic pregnancies (EPs) with local methotrexate given at a higher than standard dose.

DESIGN

Nonrandomized prospective study.

SETTING

A tertiary teaching hospital and an affiliated infertility center.

PATIENT(S)

We treated 118 EPs of up to 56 days' gestation (8 weeks) regardless of the presence of fetal heart activity, the size of the gestational mass, and the initial beta-hCG levels.

INTERVENTION(S)

Transvaginal intraamniotic or laparoscopic intratubal injection of 100 mg of methotrexate as a single dose.

MAIN OUTCOME MEASURE(S)

beta-hCG levels, red and white blood cell count, and liver function tests before and after methotrexate injection, followed by repeat transvaginal color Doppler assessments.

RESULT(S)

Treatment was successful in 105 (88.98%) of the 118 patients included in the study. In 7 of them with persistent fetal cardiac activity after the methotrexate injection, treatment was concluded with a complementary intracardiac injection of 10% KCl. No grade 3 or important clinical, hematologic, or biochemical toxicities occurred.

CONCLUSION(S)

Local administration of a single high dose of methotrexate (100 mg) proved safe and effective in the medical management of relatively advanced and unselected EPs, including cases with fetal heart activity, with high initial beta-hCG levels, and with a gestational mass beyond the standard maximum of 3.5 cm. Complementary hypertonic KCl proved to be effective in cases with persistent cardiac activity.