Surgery should be considered only in women who are hemodynamically stable and whose transvaginal ultrasound (TVUS) examination shows a tubal ectopic pregnancy or an adnexal mass suggestive of ectopic pregnancy. If TVUS does not show an abnormality, it is unlikely that an ectopic pregnancy will be visualized or palpated at surgery.
Moreover, when we need to treat surgically, we can and should use minimally invasive techniques whenever possible.
Alternatives to Surgery
Expectant management is the least desirable option because of the risk of tubal rupture. I take this approach only when I suspect ectopic pregnancy but TVUS fails to show the location of the gestational sac, and the serum levels of β-HCG are low and declining. Because of the possibility of tubal rupture, these patients must be carefully monitored until the serum β-HCG concentration falls below 15 IU/L; at this point, almost all ectopic pregnancies resolve spontaneously, without rupture.
Expectant management is never the best treatment when we have a diagnosis of ectopic pregnancy.
With an expectant management approach, we must monitor patients closely with serial β-HCG measurements every 2–3 days and also employ TVUS. The combination can provide us with information on whether we're dealing with an ectopic pregnancy or a miscarriage. A serum β-HCG concentration that is low and fails to double over 2–3 days suggests that we are dealing with either an ectopic pregnancy or failing intrauterine pregnancy.
Be aware that tubal rupture has been reported in women with low, declining, or even undetectable β-HCG levels. Rupture is mainly a result of blood distending the tube.
Some physicians will do a D&C when they're unsure about an ectopic pregnancy, but I would argue against this. First, it's surgery. Second, methotrexate (MTX) treatment has minimal side effects. Because a single intramuscular injection of methotrexate is safe, I would argue that it is the better alternative.
It can even be reasonably argued that MTX administration is a better approach to management than is expectant management. However, we have to make sure that the possibility of viable intrauterine pregnancy has been eliminated.
When MTX is administered to properly selected patients, it has a success rate up to 94%. Several randomized studies have even found that MTX treatment in selected patients with ectopic pregnancy was as effective as laparoscopic treatment.
MTX should be given to women who are hemodynamically stable and who are willing and able to comply with posttreatment monitoring; who have an initial serum β-HCG concentration lower than 5,000 IU/L; and who have no ultrasound evidence of fetal cardiac activity.
The main factor in determining who is a candidate for MTX is the level of β-HCG. A fairly recent metaanalysis of data for 1,327 women with ectopic pregnancy who were treated with MTX showed that success of the therapy was inversely associated with β-HCG levels, and that increasing levels were significantly correlated with treatment failure.
In general, if the β-HCG level is higher than 5,000 IU/L, the failure rate of therapy is significantly higher.
But other factors are important as well. Treatment failure is also associated with fetal cardiac activity. And you most certainly do not want to give MTX to a patient whom you won't see for 3 months.
Recent evidence suggests that tubal diameter or fetal size does not predict the success of medical treatment.
Laparoscopy: It's Clear
For those who do not meet the criteria for MTX administration—as well as for women who do not have timely access to a medical institution for management of tubal rupture and, of course, for women who have a ruptured ectopic pregnancy—surgery is necessary.
Three good prospective, randomized trials with a total of 231 women have compared laparotomy with laparoscopy, and have found that laparoscopic surgery is superior. Laparoscopic treatment of ectopic pregnancy resulted in less blood loss, lower analgesic requirements, shorter operative times, and briefer hospital stays. The studies also showed similar reproductive outcomes—subsequent uterine pregnancy and repeat ectopic pregnancy—after salpingostomy by either approach.
A Cochrane review published in 2000 also concluded that laparoscopic surgery is the best treatment. It reported a higher rate of persistent trophoblast with laparoscopic surgery, but concluded this was outweighed by the benefits of the more conservative laparoscopic approach. As I see it, the incidence of persistent trophoblast is related to the laparoscopic experience of the surgeon.
When a patient is unstable or in shock, I stabilize the patient first and then consult with the anesthesiologist to see if he or she is comfortable with my doing laparoscopy. In my experience, most will offer their support for a laparoscopic approach.