How is ectopic pregnancy treated?
Several options exist for the treatment of ectopic pregnancy. The chosen treatment depends on the size and the site of ectopic pregnancy, the experience of the surgeon, the facilities available and the general condition of the patient.
The options include:
- Surgical treatment by laparoscopy or laparotomy.
- Medical treatment with drugs.
- Expectant treatment, awaiting the spontaneous resolution of the ectopic pregnancy.
If early diagnosis can be made before the tube is ruptured and the appropriate facilities are available, a less invasive procedure can be offered such as a keyhole surgery or treatment with drugs. This may not only speed the recovery of the patient from the operation but may also increase the woman’s chance of future fertility. Fortunately, most ectopic pregnancies achieved after IVF treatment are diagnosed early.
Before the tube rupture, it may be possible for the surgeon, using the laparoscope to slit the tube, and remove the pregnancy leaving the tube (salpingotomy). Alternatively, a drug called Methotrexate, which prevents the rapid division of cells in early pregnancy, may be used. The drug is generally safe and effective and can cure the problem in about 70-95% of cases. About 2-20% of patients will experience some side effects. The drug can either be given directly into the ectopic pregnancy under ultrasound or laparoscopic guidance or injected intramuscularly and is absorbed into the blood stream and reaches the ectopic pregnancy. The risk of side effects is reduced when the drug is given locally into the ectopic pregnancy.The most widely used protocol is a single intramuscular injection Follow-up after medical treatment requires repeated blood tests to measure HCG levels until it declines to a very low concentrations. Approximately about one in twenty patient treated with methotrexate will experience ruptrue of the tube during the follow up. Following treatment with Methotrexate, the patient needs to delay future pregnancy for a minimum of three months.
There are certain circumstances where methotrexate may be preferable to surgery. These include cervical pregnancy, where surgical intervention may be associated with a high risk of severe bleeding and in cases where ectopic pregnancy co-exists with ovarian hyperstimulation syndrome where the pelvic organs are vascular and surgical intervention may be better avoided. On the other hand, in heterotopic pregnancy, Methotrexate drug can not be given because it can damage the intrauterine pregnancy. Another drug so-called “potassium chloride” (KCL) can be injected directly into the ectopic pregnancy to stop the fetal heart. Methotrexate is also not recommended when the ectopic pregnancy is associated with significant pain, the size of ectopic pregnancy exceeds 35 mm and when the level of hCG exceeds 5000IU/L.
It is now accepted that surgical treatment of ectopic pregnancy should be by laparoscope whenever possible taking into account the condition of the patient and the complexity of the case. Laparoscopy is associated with a shorter duration of hospital stay, and shorter convalescence times compared with open surgery (Laparotomy). The treatment involve removal of the affected fallopian tube (salpingectomy) if the remaining tube looked normal. However, if the remaining tube appeared damaged at surgery, then salpingotomy (removal of ectopic pregnancy through a small cut in the tube thereby conserving the tube) should always be attempted to preserve fertility. (guidelines from the Royal College of Obstetricians and Gynaecologists and NICE Guidelines in the United Kingdome). Salpingotomy is associated with persistent trophoblast necessitating additional medical and surgical treatment in 1 in 5 women. In addition to repeat ectopic pregnancy. For women who have had a salpingotomy, they need to have blood tests to check the serum evels of hCG at 7 days after surgery, then 1 serum hCG measurement per week until a negative result is obtained.
Laparotomy and removal of the tube (salpingectomy) remains a necessity in emergency cases with ruptured ectopic pregnancy and also in women who have large uterine fibroids which could make insertion of the laparoscope technically difficult and potentially hazardous.
Rhesus negative women who have a surgical procedure to manage an ectopic pregnancy should be offered anti-D rhesus prophylaxis at a dose of 250 IU. Anti-D rhesus prophylaxis is not offered to women who receive solely medical management for an ectopic pregnancy
Expectant management of ectopic pregnancy is only recommended as an alternative to medical management in selected cases when the patient is in stable condition with low hormones levels and a small non viable ectopic (less than 3 cm). Spontaneous resolution occurs in about 70% of cases and can take up to 4 weeks. During this time the patient must have weekly blood tests to check the hormone levels and ultrasound scan.
Patients often ask whether their ectopic pregnancy could be taken out of the tube and replaced immediately into the womb. Unfortunately, this is not possible at present. Although the embryo may be normal, its blood supply can not regrow. It has been reported that half of the intrauterine components of the heterotopic pregnancies lead to live birth, the others aborted.
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