Ectopic pregnancy is an urgent obstetrical complication that should be considered when a reproductive-aged female presents with any combination of amenorrhea, vaginal bleeding, and pelvic pain. It is important to remember that one cannot rely on symptoms and physical findings alone to rule out ectopic pregnancy. Early ectopic diagnosis in the adolescent age group relies on a thorough and confidential sexual history that leads to specific evaluation for pregnancy. Initial evaluation includes obtaining a last menstrual period LMP , last date of sexual activity especially unprotected sexual activity , and urine pregnancy testing. If there are concerns about ectopic pregnancy based on symptoms, then transvaginal ultrasound TV-US and serial beta human chorionic gonadotropin b-hCG levels should be performed.
Does use Hcg levels in a tubal pregnancy a strict algorithm decrease the incidence of tubal rupture? Is there a need to definitively diagnose the location of a pregnancy Hcg levels in a tubal pregnancy unknown location? Transvaginal sonography in the management of ectopic pregnancy. Beta-human chorionic gonadotropin levels and the likelihood of ectopic pregnancy in emergency department patients with abdominal pain or vaginal bleeding. If you have symptoms of a possible ectopic pregnancy, you will have: A pelvic exam, which can detect tenderness in the uterus or fallopian tubes, less enlargement of the uterus than expected for a pregnancy, or a mass in the pelvic area. All rights reserved. Previous ectopic pregnancy. How can tubal pregnancy be prevented? When the possibility of a progressing intrauterine gestation has Lovers underwater reasonably excluded, uterine aspiration can help to distinguish early intrauterine pregnancy loss from ectopic pregnancy by identifying the presence or absence of intrauterine chorionic villi. What can you expect after an ectopic pregnancy?
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If tests show that you have had simply one low hCG level, another explanation could be that you are still very early along in Transgender prisons Hcg levels in a tubal pregnancy. In many Slavery petion, your doctor will then recommend you have an ultrasound sometime between 8 and 12 Hcg levels in a tubal pregnancy as part of first trimester pregnancy care. Ann Emerg Med ; A medical professional will be able pregbancy determine the cause of your late cycle and may be able to suggest an appropriate treatment. If a Fallopian tube is tjbal via salpingectomy and the other tube is healthy, many women will be able to conceive again. What really levls is the change over time. Does it begin when the sperm first penetrates the egg? Patients should be advised to avoid folic acid supplements, foods that contain folic acid, and nonsteroidal antiinflammatory drugs during therapy because these products may decrease the efficacy of methotrexate. One study 29 noted N Engl J Med ;— Tuubal important factor to consider with doubling times is the starting hCG value. Answer: I am glad you are receiving frequent care from a physician.
Committee on Practice Bulletins—Gynecology.
- An ectopic pregnancy is a pregnancy in which the fertilized egg implants somewhere outside the uterus the womb.
- Human chorionic gonadotropin hCG is a hormone produced by the body during pregnancy.
- I am a mother of two who has gone through the experience a tubal pregnancy.
- An ectopic pregnancy can be life-threatening, so it's important to seek medical help if you notice any of the symptoms of an ectopic pregnancy.
Increases in the availability and use of hormonal markers, coupled with advances in formal and emergency ultrasonography have changed the diagnostic approach to the patient in the emergency department with first-trimester bleeding or pain. Advances in surgical and medical therapy for ectopic pregnancy have allowed the proliferation of minimally invasive or noninvasive treatment. Guidelines for laparoscopy and for methotrexate therapy are provided.
The incidence in the United States has increased greatly in the last few decades, from 4. In up to half of all women with ectopic pregnancy presenting to an emergency department, the condition is not identified at the initial medical assessment.
The availability of newer hormonal markers and ultrasound imaging has increased the complexity of the diagnostic workup in patients suspected of having an ectopic pregnancy, and the evolution of less invasive surgical techniques and noninvasive medical management has altered the treatment landscape.
In this review we summarize the current literature examining the impact of recent advances in the diagnosis and treatment of ectopic pregnancy. Ectopic pregnancy is usually diagnosed in the first trimester of pregnancy. Documentation of risk factors Table 1 9 , 17 , 18 is an essential part of history-taking, and asymptomatic clinic patients with risk factors may benefit from routine early imaging. The physical findings depend on whether tubal rupture has occurred.
Women with intraperitoneal hemorrhage present with significant abdominal pain and tenderness, along with various degrees of hemodynamic instability.
However, women without rupture may also present with pelvic pain or vaginal bleeding, or both. It is important to confirm pregnancy. This hormone is detectable in urine and blood as early as 1 week before an expected menstrual period. However, if pregnancy is strongly suspected, even when the urine test has a negative result, serum testing will be definitive. In general, no. Falling levels confirm nonviability but do not rule out ectopic pregnancy. Invasive diagnostic testing e.
Transvaginal ultrasonography has transformed the assessment of women with problematic early pregnancy, allowing earlier, clearer visualization of both normally developing embryos and abnormalities.
A normal gestational sac, an ovoid collection of fluid adjacent to the endometrial stripe, can be visualized by means of the transvaginal probe at a gestational age of about 5 weeks. It can often be seen when 2 or 3 mm in diameter and should be consistently seen at 5 mm. Once the sac is implanted within the endometrium, its position relative to the endometrial wall changes, producing the intradecidual-sac sign and then the double decidual-sac sign.
Cardiac activity can be seen with endovaginal scanning when the embryo reaches 4 to 5 mm in diameter, at a gestational age of 6—6. Although this phenomenon is exceedingly rare in the general population estimated frequency 1 per to 30 pregnancies , 38 in the setting of assisted reproduction it may occur in 1 in pregnancies.
The spectrum of sonographic findings in ectopic pregnancy is broad. Identification of an extrauterine gestational sac containing a yolk sac with or without an embryo confirms the diagnosis.
Suggestive findings include an empty uterus, cystic or solid adnexal or tubal masses including the tubal-ring sign, representing a tubal gestational sac , hematosalpinx and echogenic or sonolucent cul-de-sac fluid Fig.
Because expertise in transvaginal ultrasonography is not available in all hospitals and may not be quickly available in some larger centres, there have been several studies of ultrasonography performed by emergency physicians in the assessment of patients with first-trimester bleeding or pain. Ultrasonography in the emergency department ED-based ultrasonography has evolved over the last decade and is now part of the diagnostic work-up for many clinical problems in major Canadian centres, as well as in a large number of smaller community emergency departments Dr.
Ray Wiss, Emergency Department Echo course director: personal communication, Is there free pelvic or intra-abdominal fluid? Several studies have documented the ability of emergency physicians to quickly and accurately identify both intrauterine pregnancy and intra-abdominal free fluid by means of ED-based ultrasonography after brief standardized training.
Transvaginal ultrasonography should therefore be the initial investigation for pregnant patients presenting to the emergency department with first-trimester bleeding or pain. No combination of history-taking, physical examination and laboratory tests can make the same claim. The use of ED-based ultrasonography offers rapid bedside detection of a viable intrauterine pregnancy or a high risk of ectopic pregnancy.
Emergency physicians without access to bedside ED-based ultrasonography should arrange formal ultrasonography for all patients with early-pregnancy complaints. This investigation can be performed during the initial visit or, if the patient is stable and has minimal symptoms, the next day in an outpatient visit.
However, in the case of outpatient investigation, mechanisms for timely follow-up, re-examination and further investigation must be in place. Ectopic pregnancy can resolve spontaneously through regression or tubal abortion. Surgical management of ectopic pregnancy should be reserved for patients who refuse or have contraindications to medical treatment, those in whom medical treatment has failed and those who are hemodynamically unstable. Three randomized studies have demonstrated that, compared with laparotomy, laparoscopic treatment of ectopic pregnancy is associated with lower cost, shorter hospital stay, less operative time, less blood loss, less analgesic requirement and faster recovery.
Tube-sparing salpingostomy in which the gestational sac is removed, without the tube, through a 1-cm-long incision on the tubal wall is preferred to salpingectomy removal of the tube , as the former is less invasive but has comparable rates of subsequent fertility and ectopic pregnancy.
Regardless of the type of surgery, contralateral tubal abnormalities predispose the patient to recurrent ectopic pregnancy.
In summary, salpingostomy is preferred, particularly for women who wish to have another pregnancy. Salpingectomy may be necessary for women with uncontrolled bleeding, recurrent ectopic pregnancy in the same tube, a severely damaged tube or a tubal gestational sac greater than 5 cm in diameter.
Fetal cardiac activity was also associated with MTX treatment failure. However, tubal diameter, a measure of fetal size, is unrelated to outcome. Our protocol for using MTX in the management of ectopic pregnancy is shown in Box 1. Patients in whom laparoscopy may be challenging including those with many previous laparotomies and scarring may have a better outcome with MTX treatment.
Patients treated with MTX should be followed closely. An increased level is uncommon 3 to 4 d after MTX administration. Patients may experience abdominal pain from tubal abortion or tubal distention due to hematoma formation. Severe abdominal pain, however, can be a sign of actual or impending tubal rupture. Several randomized studies found that MTX treatment in selected patients with ectopic pregnancy was as effective as laparoscopic treatment Table 4. Ectopic pregnancy is a common and serious problem, with a significant morbidity rate and the potential for maternal death.
Many patients have no documented risk factors and no physical indications of ectopic pregnancy. Surgical treatment is particularly appropriate for women who are hemodynamically unstable or unlikely to be compliant with post-treatment monitoring and those who do not have immediate access to medical care.
The choice of treatment should be guided by the patient's preference, after a detailed discussion about monitoring, outcome, risks, and benefits of the 2 approaches. This article has been peer reviewed. Contributors: Heather Murray and Trevor Bardell reviewed the relevant literature and wrote the first draft of the diagnosis section of the manuscript. Hanadi Baakdah and Togas Tulandi reviewed the relevant literature and wrote the first draft of the treatment section of the manuscript.
All of the authors provided revisions and approved the final content of the manuscript. Correspondence to: Dr. National Center for Biotechnology Information , U.
Author information Copyright and License information Disclaimer. Baakdah, Tulandi. This article has been cited by other articles in PMC. Diagnosis Historical features and physical findings Ectopic pregnancy is usually diagnosed in the first trimester of pregnancy.
Open in a separate window. Table 3. Ultrasound imaging Transvaginal ultrasonography has transformed the assessment of women with problematic early pregnancy, allowing earlier, clearer visualization of both normally developing embryos and abnormalities. Treatment Expectant management Ectopic pregnancy can resolve spontaneously through regression or tubal abortion.
Surgical management Surgical management of ectopic pregnancy should be reserved for patients who refuse or have contraindications to medical treatment, those in whom medical treatment has failed and those who are hemodynamically unstable. Ability and willingness of the patient to comply with post-treatment monitoring.
Absence of ultrasound evidence of fetal cardiac activity. Box 1. Surgical versus medical treatment Several randomized studies found that MTX treatment in selected patients with ectopic pregnancy was as effective as laparoscopic treatment Table 4. Conclusions Ectopic pregnancy is a common and serious problem, with a significant morbidity rate and the potential for maternal death. Supplementary Material [Expanded Appendix] Click here to view. Footnotes This article has been peer reviewed.
Competing interests: None declared. References 1. Surveillance for ectopic pregnancy — United States, — Ectopic pregnancy — United States, — Spontaneous resolution of ectopic tubal pregnancy: natural history. Fertil Steril ; Expectant management of tubal ectopic pregnancy: prediction of successful outcome using decision tree analysis.
Ultrasound Obstet Gynecol ; Under-reporting of maternal mortality in Canada: a question of definition. Chronic Dis Can ; Ectopic pregnancy. N Engl J Med ; Comments in N Engl J Med ; Prompt diagnosis of ectopic pregnancy in an emergency department setting.
Obstet Gynecol ; History and physical examination to estimate the risk of ectopic pregnancy: validation of a clinical prediction model. Ann Emerg Med ; Comment in Ann Emerg Med ; Predictive value of history and physical examination in patients with suspected ectopic pregnancy.
Well done, Leah. Cornual heterotopic pregnancy: contemporary management options. Patients treated with methotrexate should be counseled about the risk of ectopic pregnancy rupture; about avoiding certain foods, supplements, or drugs that can decrease efficacy; and about the importance of not becoming pregnant again until resolution has been confirmed. My first HCG test was on the 17th of June. What do you think?
Hcg levels in a tubal pregnancy. The Ultimate Guides
An ectopic pregnancy is a pregnancy in which the fertilized egg implants somewhere outside the uterus the womb. But an ectopic pregnancy could also implant on the cervix, an ovary, or elsewhere in a woman's abdomen. Sadly, an ectopic pregnancy can't survive. In fact, if it's not treated, a fallopian tube might rupture and the mother could experience blood loss so severe that it could end her life.
As a result, ectopic pregnancies must be terminated. When you're pregnant, your body releases a hormone called human chorionic gonadotropin hCG. Remember that although a slow-rising or low hCG level is a warning sign of ectopic pregnancy, it doesn't mean that you definitely have an ectopic pregnancy. If no gestational sac appears inside the uterus by around week five of gestation, that is a red flag that may signal an ectopic pregnancy. The physician may also do a pelvic exam to feel for a mass in the fallopian tube and to see if you're experiencing any pain or tenderness.
If you do have an ectopic pregnancy, your doctor can usually terminate the pregnancy using an injectable drug or minimally invasive surgery. Get diet and wellness tips delivered to your inbox. Here are some other possible explanations:. You're not very far along in your pregnancy.
If tests show that you have had simply one low hCG level, another explanation could be that you are still very early along in the pregnancy. You can see whether the level is rising, and if so, how quickly it's increasing. You're further along in your pregnancy. So if you are further along in your pregnancy, those levels may be considered normal and there may be no cause for concern. If an embryo is located outside the uterus, a treatment plan is made based on the mother's overall health, where the embryo is located, and the mother's hCG levels a falling level can indicate that the pregnancy is resolving on its own.
If an embryo is not located, doctors continue to monitor the pregnancy until a diagnosis can be made. In some cases the diagnosis will be confirmed by inserting a laparoscope — a very small viewing instrument — into the abdomen through a small incision below the navel.
Ectopic Pregnancy. Everyday Health Pregnancy Ectopic Pregnancy. Abdominal pain and abnormal bleeding may be symptoms of an ectopic pregnancy. The pain may come and go and may vary in intensity. When to Seek Help An ectopic pregnancy can be life-threatening, so it's important to seek medical help if you notice any of the symptoms of an ectopic pregnancy.
Ectopic Pregnancy Diagnosis When an ectopic pregnancy is suspected, the first step may be to do a pregnancy test, or qualitative hCG test, if the woman has not already had a positive pregnancy test. Using Ultrasound for Diagnosis Another step in diagnosing a suspected ectopic pregnancy is using ultrasound to locate the implanted embryo. Sign up for our Women's Health Newsletter! Thanks for signing up for our newsletter!
You should see it in your inbox very soon. Please enter a valid email address Subscribe We respect your privacy. Ectopic Pregnancy; Mayo Clinic. Ectopic Pregnancy Ectopic Pregnancy Treatment Prompt treatment of an ectopic pregnancy is needed to protect the health of the pregnant woman.
Diagnosis and treatment of ectopic pregnancy
Committee on Practice Bulletins—Gynecology. This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology.
Any updates to this document can be found on www. ACOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither ACOG nor its officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.
Ectopic pregnancy is defined as a pregnancy that occurs outside of the uterine cavity. However, tubal ectopic pregnancy in an unstable patient is a medical emergency that requires prompt surgical intervention.
The purpose of this document is to review information on the current understanding of tubal ectopic pregnancy and to provide guidelines for timely diagnosis and management that are consistent with the best available scientific evidence. However, the true current incidence of ectopic pregnancy is difficult to estimate because many patients are treated in an outpatient setting where events are not tracked, and national surveillance data on ectopic pregnancy have not been updated since 1.
Despite improvements in diagnosis and management, ruptured ectopic pregnancy continues to be a significant cause of pregnancy-related mortality and morbidity. In —, ruptured ectopic pregnancy accounted for 2. An ectopic pregnancy also can co-occur with an intrauterine pregnancy, a condition known as heterotopic pregnancy.
The risk of heterotopic pregnancy among women with a naturally achieved pregnancy is estimated to range from 1 in 4, to 1 in 30,, whereas the risk among women who have undergone in vitro fertilization is estimated to be as high as 1 in 5 , 6. One half of all women who receive a diagnosis of an ectopic pregnancy do not have any known risk factors 3. Women with a history of ectopic pregnancy are at increased risk of recurrence. Other important risk factors for ectopic pregnancy include previous damage to the fallopian tubes, factors secondary to ascending pelvic infection, and prior pelvic or fallopian tube surgery 3, 7.
Among women who become pregnant through the use of assisted reproductive technology, certain factors such as tubal factor infertility and multiple embryo transfer are associated with an increased risk of ectopic pregnancy 8 , 9. Women with a history of infertility also are at increased risk of ectopic pregnancy independent of how they become pregnant 7.
Other less significant risk factors include a history of cigarette smoking and age older than 35 years 7. Women who use an intrauterine device IUD have a lower risk of ectopic pregnancy than women who are not using any form of contraception because IUDs are highly effective at preventing pregnancy.
Factors such as oral contraceptive use, emergency contraception failure, previous elective pregnancy termination, pregnancy loss, and cesarean delivery have not been associated with an increased risk of ectopic pregnancy 3, 7, 11 , The minimum diagnostic evaluation of a suspected ectopic pregnancy is a transvaginal ultrasound evaluation and confirmation of pregnancy. Serial evaluation with transvaginal ultrasonography, or serum hCG level measurement, or both, often is required to confirm the diagnosis.
Women with clinical signs and physical symptoms of a ruptured ectopic pregnancy, such as hemodynamic instability or an acute abdomen, should be evaluated and treated urgently.
Early diagnosis is aided by a high index of suspicion. Every sexually active, reproductive-aged woman who presents with abdominal pain or vaginal bleeding should be screened for pregnancy, regardless of whether she is currently using contraception 13 , Women who become pregnant and have known significant risk factors should be evaluated for possible ectopic pregnancy even in the absence of symptoms. Although an early intrauterine gestational sac may be visualized as early as 5 weeks of gestation 17 , definitive ultrasound evidence of an intrauterine pregnancy includes visualization of a gestational sac with a yolk sac or embryo Visualization of a definitive intrauterine pregnancy eliminates ectopic pregnancy except in the rare case of a heterotopic pregnancy.
Measurement of the serum hCG level aids in the diagnosis of women at risk of ectopic pregnancy. Accurate gestational age calculation, rather than an absolute hCG level, is the best determinant of when a normal pregnancy should be seen within the uterus with transvaginal ultrasonography 23 , An intrauterine gestational sac with a yolk sac should be visible between 5 weeks and 6 weeks of gestation regardless of whether there are one or multiple gestations 25 , In the absence of such definitive information, the serum hCG level can be used as a surrogate for gestational age to help interpret a nondiagnostic ultrasonogram.
The absence of a possible gestational sac on ultrasound examination in the presence of a hCG measurement above the discriminatory level strongly suggests a nonviable gestation an early pregnancy loss or an ectopic pregnancy. However, the utility of the hCG discriminatory level has been challenged 24 in light of a case series that noted ultrasonography confirmation of an intrauterine gestational sac on follow-up when no sac was noted on initial scan and the serum hCG level was above the discriminatory level 30— Women with a multiple gestation have higher hCG levels than those with a single gestation at any given gestational age and may have hCG levels above traditional discriminatory hCG levels before ultrasonography recognition A single hCG concentration measurement cannot diagnose viability or location of a gestation.
Serial hCG concentration measurements are used to differentiate normal from abnormal pregnancies 21, 22, 33 , Subsequent assessments of hCG concentration should be obtained 2—7 days apart, depending on the pattern and the level of change.
There is a slower than expected increase in serum hCG levels for a normal gestation when initial values are high. However, even hCG patterns consistent with a growing or resolving gestation do not eliminate the possibility of an ectopic pregnancy Decreasing hCG values suggest a failing pregnancy and may be used to monitor spontaneous resolution, but this decrease should not be considered diagnostic.
A woman with decreasing hCG values and a possible ectopic pregnancy should be monitored until nonpregnant levels are reached because rupture of an ectopic pregnancy can occur while levels are decreasing or are very low. A pregnancy of unknown location should not be considered a diagnosis, rather it should be treated as a transient state and efforts should be made to establish a definitive diagnosis when possible A woman with a pregnancy of unknown location who is clinically stable and has a desire to continue the pregnancy, if intrauterine, should have a repeat transvaginal ultrasound examination, or serial measurement of hCG concentration, or both, to confirm the diagnosis and guide management 22, The first step is to assess for the possibility that the gestation is advancing.
When the possibility of a progressing intrauterine gestation has been reasonably excluded, uterine aspiration can help to distinguish early intrauterine pregnancy loss from ectopic pregnancy by identifying the presence or absence of intrauterine chorionic villi.
If chorionic villi are found, then failed intrauterine pregnancy is confirmed and no further evaluation is necessary. If chorionic villi are not confirmed, hCG levels should be monitored, with the first measurement taken 12—24 hours after aspiration.
A plateau or increase in hCG postprocedure suggests that evacuation was incomplete or there is a nonvisualized ectopic pregnancy, and further treatment is warranted. One study 29 noted The other patients had resolving hCG levels, and were presumed to have failed intrauterine pregnancies.
There is debate among experts about the need to determine pregnancy location by uterine aspiration before providing methotrexate 42 , Proponents cite the importance of confirming the diagnosis to avoid unnecessary exposure to methotrexate and to help guide management of the current pregnancy and future pregnancies 37, Arguments against the need for a definitive diagnosis include concern about the increased risk of tubal rupture because of delay in treatment while diagnosis is established and the increased health-care costs associated with additional tests and procedures However, with close follow-up during this diagnostic phase, the risk of rupture is low.
In one large series with serial hCG measurement of women with pregnancies of unknown location, the risk of rupture of an ectopic pregnancy during surveillance to confirm diagnosis was as low as 0. In addition, presumptive treatment with methotrexate has not been found to confer a significant cost savings or to decrease the risk of complications The choice of performing a uterine aspiration before treatment with methotrexate should be guided by a discussion with the patient regarding the benefits and risks, including the risk of teratogenicity in the case of an ongoing intrauterine pregnancy and exposure to methotrexate.
Medical management with methotrexate can be considered for women with a confirmed or high clinical suspicion of ectopic pregnancy who are hemodynamically stable, who have an unruptured mass, and who do not have absolute contraindications to methotrexate administration These patients generally also are candidates for surgical management.
The decision for surgical management or medical management of ectopic pregnancy should be guided by the initial clinical, laboratory, and radiologic data as well as patient-informed choice based on a discussion of the benefits and risks of each approach.
Women who choose methotrexate therapy should be counseled about the importance of follow-up surveillance. Methotrexate affects actively proliferating tissues, such as bone marrow, buccal and intestinal mucosa, respiratory epithelium, malignant cells, and trophoblastic tissue.
Systemic methotrexate has been used to treat gestational trophoblastic disease since and was first used to treat ectopic pregnancy in Although oral methotrexate therapy for ectopic pregnancy has been studied, the outcomes data are sparse and indicate that benefits are limited Box 1 lists absolute and relative contraindications to methotrexate therapy Before administering methotrexate, it is important to reasonably exclude the presence of an intrauterine pregnancy.
In addition, methotrexate administration should be avoided in patients with clinically significant elevations in serum creatinine, liver transaminases, or bone marrow dysfunction indicated by significant anemia, leukopenia, or thrombocytopenia. Because methotrexate affects all rapidly dividing tissues within the body, including bone marrow, the gastrointestinal mucosa, and the respiratory epithelium, it should not be given to women with blood dyscrasias or active gastrointestinal or respiratory disease.
However, asthma is not an exclusion to the use of methotrexate. Methotrexate is directly toxic to the hepatocytes and is cleared from the body by renal excretion; therefore, methotrexate typically is not used in women with liver or kidney disease. Relative contraindications for the use of methotrexate Box 1 do not serve as absolute cut-offs but rather as indicators of potentially reduced effectiveness in certain settings.
For example, a high initial hCG level is considered a relative contraindication. Systematic review evidence shows a failure rate of There are three published protocols for the administration of methotrexate to treat ectopic pregnancy: 1 a single-dose protocol 51 , 2 a two-dose protocol 52 , and 3 a fixed multiple-dose protocol 53 Box 2. The single-dose regimen is the simplest of the three regimens; however, an additional dose may be required to ensure resolution in up to one quarter of patients 54 , The two-dose regimen was first proposed in in an effort to combine the efficacy of the multiple-dose protocol with the favorable adverse effect profile of the single-dose regimen The two-dose regimen adheres to the same hCG monitoring schedule as the single-dose regimen, but a second dose of methotrexate is administered on day 4 of treatment.
The multiple-dose methotrexate regimen involves up to 8 days of treatment with alternating administration of methotrexate and folinic acid, which is given as a rescue dose to minimize the adverse effects of the methotrexate. Resolution of an ectopic pregnancy may depend on the methotrexate treatment regimen used and the initial hCG level. However, there is no clear consensus in the literature regarding the optimal methotrexate regimen for the management of ectopic pregnancy.
The choice of methotrexate protocol should be guided by the initial hCG level and discussion with the patient regarding the benefits and risks of each approach. Abbreviation: hCG, human chorionic gonadotropin. Single-dose methotrexate: an expanded clinical trial. Am J Obstet Gynecol ;; discussion —5. Fertil Steril ;—6. The medical treatment of unruptured ectopic pregnancy with methotrexate and citrovorum rescue: preliminary experience.
Fertil Steril ;—3. A systematic review and meta-analysis of three randomized controlled trials showed similar rates of successful resolution for the two-dose and single-dose protocols RR, 1.
However, in two of the three trials included in the review, the two-dose regimen was associated with greater success among women with high initial hCG levels. After administration of methotrexate treatment, hCG levels should be serially monitored until a nonpregnancy level based upon the reference laboratory assay is reached Close monitoring is required to ensure disappearance of trophoblastic activity and to eliminate the possibility of persistent ectopic pregnancy.
During the first few days after treatment, the hCG level may increase to levels higher than the pretreatment level but then should progressively decrease to reach a nonpregnant level Methotrexate treatment failure in patients who did not undergo pretreatment uterine aspiration should raise concern for the presence of an abnormal intrauterine gestation.
In these patients, uterine aspiration should be considered before repeat methotrexate administration or surgical management, unless there is clear evidence of a tubal ectopic pregnancy.