Expectant management may be appropriate in ectopic pregnancy

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1. Approximately 40% of cases of ectopic pregnancy in hemodynamically stable women resolved on their own.

2. Among women whose β-hCG levels rose with serial measurement, treatment with methotrexate was effective but at lower rates than previously reported. 

Evidence Rating Level: 2 (Good)            

Study Rundown: Ectopic pregnancy is a medical emergency and, given the risk of rupture, is actively managed with either surgical or medical treatment at the time of diagnosis. In general, hemodynamically stable women with β-hCG levels <5,000 and no fetal cardiac activity are usually treated with a single or multi- dose regimen of methotrexate. Under the current guidelines, expectant management is recommended only for women with β-hCG ≤200 mIU/mL. In this study, investigators sought to evaluate rates of spontaneous resolution of ectopic pregnancy as well as success rates of methotrexate therapy among hemodynamically stable women who did not achieve spontaneous resolution of ectopic pregnancy with expectant management.

Authors found that with expectant management, many cases of ectopic pregnancy spontaneously resolved. For women whose β-hCG levels did not drop with expectant management, methotrexate was effective in terminating most pregnancies, but success rates were lower than previously reported. This finding suggests that when cases are treated initially with methotrexate, treatment success may be confounded by spontaneous resolution in some women. Additionally, because average β-hCG levels in many women were significantly greater than 200mIU/mL, the study results suggest that expectant management may be appropriate for more women than current guidelines suggest.

Limitations of this study include retrospective design and lack of a comparison group, which limit internal validity. Furthermore, it is unknown whether this study population comprised of Israeli women differed from that of previous investigations and whether results from the current investigation can be generalized to other populations. Randomized controlled trials are needed to determine whether expectant management yields decreased morbidity and comparable overall success rates.

Click to read the study in AJOG

Relevant Reading: Nonsurgical treatment of ectopic pregnancy

In-Depth [retrospective cohort]: This study evaluated the success rate of expectant management of ectopic pregnancy in 1083 hemodynamically stable women and the success rate of methotrexate in women whose β-hCG did not spontaneously decline (n=409). Outcomes evaluated included spontaneous resolution, success with one or two doses of methotrexate and treatment failure.

In 39.5% of study participants, β-hCG spontaneously declined and patients required no further treatment. Among women requiring further intervention, 87% were successfully treated with methotrexate; 86% of these cases required only one injection. 13% of participants required surgical therapy. Women who were successfully treated with methotrexate had lower β-hCG levels than those eventually requiring surgery (p<0.0001).

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