After an ectopic pregnancy
Your senior obstetrician will advise you on the most appropriate treatment for you.
Which treatment is the best?
- How many weeks pregnant are you
- Your symptoms, and what the doctor discovers during the examination
- Ultrasound and blood test results
- Your personal opinions and preferences
- Options available at your hospital
Treatment options may include:
- Anticipatory measure (“wait and see” approach)
- The medical treatment
- surgical treatment
- Anticipatory management (“wait and see” approach)
This means waiting and seeing if the ectopic pregnancy will end on by its own. You will be carefully monitored with the frequent blood tests. This option is only suitable if the ectopic pregnancy is in a very early stage.
Call your doctor promptly if you develop any symptoms. You will usually be given a direct contact number for the emergency department or the gynecology department of the maternity hospital if you develop any symptoms.
If expectant management does not work, your doctor will suggest the medical or the surgical treatment options.
The medical treatment
Medical treatment is an injection of a drug called methotrexate. This prevents an ectopic pregnancy from developing. You don’t have to have the fallopian tube removed or part of the tube removed, and you don’t need general anesthesia.
You may need to return to the clinic or ward after a few days. You will be told who to contact if you experience any symptoms.
The main advantage of methotrexate treatment is that you do not have to undergo surgery. It may be your safest option if your BMI is very high or if you had previous surgery on your tummy (tummy).
The disadvantages include that you need to be followed up by your obstetrician for a longer period of time, perhaps three weeks. Also, 15% of the women will need a second injection of the methotrexate. Seven out of every 100 women (7%) will need surgery.
This means an operation under general anesthesia to remove the ectopic pregnancy. This is usually a laparoscopy, which is a type of keyhole surgery. A small incision is made in your abdomen and the fertilized egg is removed. The fallopian tube or part of the fallopian tube is usually removed as well.
The Open surgery (known as a laparotomy) may be needed if there is internal bleeding or in an emergency situation. This is done through a larger incision in your abdomen.
The medical team will send any tissue removed during the procedure to a laboratory for testing. Talk to the maternity hospital about what happens next.
The advantages of surgical treatment are that it treats an ectopic pregnancy more quickly and you may not need to follow up for an extended period of time. However, it does mean surgery. The recovery time from laparoscopic surgery is usually 4 to 6 weeks.
Discuss your treatment with your doctor
After you have been diagnosed with an ectopic pregnancy, unless it is an emergency, your doctor should discuss treatment options with you to allow you to make an informed decision.
Make sure you understand:
- All treatment options available to you
- No risks from a particular treatment
- Effects of a particular treatment on future pregnancies
- Don’t be afraid to ask for more information if there’s something you don’t understand.
Medical treatment protocols
The use of methotrexate to treat ectopic pregnancy was first cited in 1982.4 Several studies have followed this study and shown successful treatment of ectopic pregnancy using alternating doses of methotrexate and leucovorin.5-7 This protocol, known as the multiple dose protocol, was modified from the treatment of cancer placenta; The multiple dose regimen consisted of intramuscular injection of 1 mg/kg methotrexate with rescue factor leucovorin 0.1 mg/kg after 24 hours. Leucovorin is folinic acid, which is the active form of the folic acid.
It is used to protect cells from the effects of methotrexate and reduce its side effects. Continue this regimen on alternating days until the hCG level drops by 15% over two days. Up to 4 doses may be given to one patient, but not all 4 doses must be given. In a study by Stovall et al, 796 of 100 patients were successfully treated and none required more than four doses. The overall success rate for multidose therapy was reported in a meta-analysis by Barnhart et al of 92.7% (241 of 260 patients) with a 95% CI of 89–96%.
In 1991, a single dose protocol was proposed, but this protocol is a misnomer because more than one dose is often needed. Their protocol consisted of 50 mg/m2 of methotrexate given on day 0. Serial HCG values are plotted and compared between days 4 and 7 after treatment.