COMMENTARY

Medical or Surgical Treatment for Tubal Pregnancies?

Peter Kovacs, MD

Disclosures

January 05, 2010

Success and Spontaneous Pregnancy Rates Following Systemic Methotrexate Versus Laparoscopic Surgery for Tubal Pregnancies: A Randomized Trial

Moeller LB, Moeller C, Thomsen SG, et al
Acta Obstet Gynecol Scand. 2009;88:1331-1337

Background

About 1%-2% of pregnancies implant outside of the uterine cavity. In about 97% of these cases, the extrauterine implantation takes place in the fallopian tube. Ovarian, cervical, or abdominal ectopic pregnancies are rare. A pregnancy that implants in the tube is able to develop initially, but once it can no longer expand, it may lead to the rupture of the tube. This is an emergency situation that requires immediate surgical intervention and is associated with significant morbidity and mortality. With the availability of sensitive serum pregnancy tests and improved ultrasound imaging, ectopic pregnancies can often be diagnosed while they are intact. To make an early diagnosis, one has to consider the possibility of extrauterine pregnancy, especially in high-risk cases. Women with previous pelvic infection, previous pelvic or tubal surgery, those who smoke, those who are diagnosed with infertility, and, most important, those who have a history of a previous ectopic pregnancy, are at risk. In high-risk cases, monitoring by repeat serum tests and by early ultrasound is important. In normal pregnancies, the beta-human chorionic gonadotropin (HCG) follows a certain trend by doubling every 48 hours.[1] When the increase is abnormal, one must try early to locate the pregnancy. Lower abdominal pain and spotting or light bleeding can also signal abnormal implantation. If the beta-HCG exceeds 1500 IU/L and an intrauterine sac cannot be found, one should carefully scan the adnexal region for ectopic pregnancy.

Once the diagnosis is made, one can choose from 3 treatment options.[2] If the patient is stable, has access to immediate medical care, and understands the risks associated with expectant treatment, this option can be offered, especially when the HCG level is low. However, in most cases, medical or surgical intervention is recommended. Methotrexate (a single or repeat dose) results in successful treatment in 65%-95% of cases.[3,4] Hemodynamically stable patients, with adnexal masses < 3.5 cm and no significant amount of free fluid, are potential candidates for medical therapy. Patients who have contraindications to the use of methotrexate or who do not wish to maintain fertility should be treated surgically. Surgery can be conservative (salpingotomy) or definitive (salpingectomy). The tubal status at surgery, the patient's desire for future fertility, the condition of the contralateral tube, and the availability of assisted reproductive technology services influence the decision. Success rates and subsequent spontaneous pregnancy rates have been comparable with methotrexate and conservative surgery.[4,5]

Study Summary

This prospective randomized study assessed success and subsequent pregnancy rates after the medical vs surgical treatment of extrauterine pregnancies. Patients with intact extrauterine pregnancies < 3.6 cm and no contraindication to the use of methotrexate were eligible. Patients who did not desire future pregnancies were excluded. Of the 1265 women with ectopic pregnancies, 106 were randomly assigned to methotrexate (1 mg/kg) or to laparoscopy. All patients were followed by serial HCG measurements. Success was defined as HCG level < 5 IU/L. Information on subsequent pregnancies was collected by questionnaire and by searching birth registry databases. Baseline characteristics of the patients were similar. In terms of outcome, 87% of the surgeries and 76% of the methotrexate treatments were considered successful, and 17% of the surgical patients and 45% of the medically treated patients had to be seen for postintervention complaints. The median follow-up for subsequent pregnancy was 8.6 years. During the follow-up period, 73% of the women in the methotrexate group and 62% of the women in the surgery group conceived spontaneously (hazard ratio: 1.41; 95% confidence interval: 0.88-2.26, P = not significant).

Viewpoint

According to this randomized study, medical and surgical treatment of small intact extrauterine pregnancies lead to similar success and subsequent spontaneous pregnancy rates. Success and subsequent fertility are important findings, but other aspects of the treatments need to be considered as well. At the time of surgery, one has the chance to assess the contralateral tube. If it does not look intact, the patient can be counseled to consider assisted reproductive technology to improve her chances for pregnancy. Surgery also provides an opportunity to check for other pelvic pathology such as endometriosis. After surgery, there is no need for repeat follow-up visits for HCG monitoring. However, methotrexate does not require anesthesia and an invasive procedure with the associated risks. Because there is no surgical procedure involving the tube, there is less chance for damage related to scar formation. Methotrexate may induce inflammatory changes and compromise tubal function, but these effects are likely to be less pronounced when compared with surgery. Obviously, the decision about which method to use will be made individually on the basis of the condition of the pregnancy (size, and intact or not) and the patient, the desire for future fertility, the availability of appropriate monitoring, and access to immediate medical care should the medical therapy fail. All of these factors are considered when the decision is made with the patient. One important piece of information to share with her is that success and subsequent fertility rates appear to be similar with both approaches.

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