Comprehensive management approach for ectopic pregnancy

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COMMITTEE ON PRACTICE BULLETINS-GYNECOLOGY Practice Bulletin #193: Tubal Ectopic Pregnancy. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018; 131:e91–103. Full text of Practice Bulletin #193 is available to ACOG members at http://www.acog.org/Resources-and-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Tubal-Ectopic-Pregnancy

TUBAL ECTOPIC PREGNANCY
Ectopic pregnancy is defined as a pregnancy that occurs outside of the uterine cavity. The most common site of ectopic pregnancy is the fallopian tube. Most cases of tubal ectopic pregnancy that are detected early can be treated successfully either with minimally invasive surgery or with medical management using methotrexate. 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.

The interim update of the ACOG Practice Bulletin on Tubal Ectopic Pregnancy¹ provides a review of information on the current understanding of tubal ectopic pregnancy and offers comprehensive guidelines for timely diagnosis and management options. Compared to the previous publication, the current bulletin provides comprehensive management options for ectopic pregnancy by incorporating new guidance on pregnancy of unknown location and on surgical management of ectopic pregnancy, as well as revised guidance on use of hCG levels for diagnosis.

ACOG recommends not using serum hCG values alone to diagnose an ectopic pregnancy and that they be correlated with the patient’s history, symptoms, and ultrasound findings. If the concept of the hCG discriminatory level is to be used as a diagnostic aid in women at risk of ectopic pregnancy, the value should be conservatively high (eg, as high as 3500 mIU/mL) to avoid the potential for misdiagnosis and possible interruption of an intrauterine pregnancy that a woman hopes to continue.

 Overall, in this Practice Bulletin, ACOG is advocating use of a comprehensive approach and more conservative guidelines to avoid the potential for misdiagnosis, possible interruption of an intrauterine pregnancy or unnecessary medical treatment that could lead to teratogenicity in surviving pregnancies. 

While this Practice Bulletin specifically and clearly emphasizes the importance of discussion of risks versus benefits with patients in determining treatment method, there are also other logistical issues that may arise and affect decisions about treatment. Most ectopic pregnancies are managed in the outpatient setting and with minimal variation in the team involved. However, depending on individual hospital and office setup, if different laboratories and/or hCG assays are used for trending hCG levels, it is possible that these inter-assay/laboratory variabilities in hCG values could significantly affect the clinical decision-making process. In addition, the issue concerning insured and uninsured patients deserves special consideration. It has been shown that there exists substantial insurance-related variation in treatment.²Uninsured women and Medicaid recipients were less likely to receive treatment with methotrexate and were less likely to undergo salpingostomy. In the same article², the authors also discuss the disparity in that black and Hispanic women were less likely to receive tube-conserving surgery.²

Some of the recent changes that have facilitated a more conservative approach in treatment of tubal ectopic pregnancy include wider availability of methotrexate, use of early sonography and management of pregnancy of unknown location with uterine aspiration to distinguish between early intrauterine pregnancy loss and ectopic pregnancy. These factors are leading to earlier diagnosis of the disease and subsequent growth in medical management in the outpatient setting. When indicated, surgical management with minimally invasive surgical techniques is preferable to laparotomy. It is important to note that ACOG recommends that the decision to perform a salpingostomy or salpingectomy for treatment of ectopic pregnancy be guided by the patient’s clinical status, her desire for future fertility, and the extent of damage to the fallopian tube. 

There has been a decline in rates of salpingostomy compared to salpingectomy.³ Although cumulative rates of intrauterine pregnancy and recurrence of ectopic pregnancy in patients who had salpingostomy versus salpingectomy are not statistically significantly different in randomized controlled trials, the move towards salpingectomy is increasing.³This is likely due to a combination of many factors, including patient history, intraoperative findings, physician preference and comfort with the procedure as well as increased availability of in vitro fertilization. As the number of salpingostomies being performed nationwide continues to decrease,³it is possible that over time, younger physicians will become unskilled in performing the procedure and the frequency could drop even more drastically. Furthermore, recent publications favoring opportunistic salpingectomy for risk reduction of ovarian cancer may be leading physicians towards complete tubal removal whenever feasible.⁴

Disclosures:

The author reports no potential conflicts of interest with regard to this article.

References:

• Tubal ectopic pregnancy. ACOG Practice Bulletin No. 193. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2018;131:e91-103.
• Hsu JY, Chen L, Gumer AR, Tergas AI, et al. Disparities in management of ectopic pregnancy. Am J Obstet Gynecol. 2017 July;217(1):49.e1-49.
• Mikhail E, Salemi JL, Schickler R, Salihu HM, Plosker S, Imudia AN. National rates, trends and determinants of inpatient surgical management of tubal ectopic pregnancy in the United States, 1998-2011. J Obstet Gynaecol Res. 2018 Apr;44(4):730-738.
• Yoon SH, Kim SN, Shim SH, Kang SB, Lee SJ. Bilateral salpingectomy can reduce the risk of ovarian cancer in the general population: A meta-analysis. Eur J Cancer. 2016 Mar;55:38-46.