Medicine is an ever-changing discipline when it comes to practice. Experts continuously update the practice recommendations as new evidence emerges. Management of ectopic pregnancy is no exception.
Medical (methotrexate) or surgery (salpingectomy or salpingotomy) are the mainstays when treating ectopic pregnancy. The new update wants to change this. We look at the other treatment modality, known as expectant management.
Ectopic pregnancy is a condition where a pregnancy implants and grows outside the endometrial cavity, most notably the Fallopian tubes. It occurs in approximately 1.1% of the pregnancies.
It is emotionally and physically devastating for the woman and her family. Expectant management was never a recommendation when managing ectopic pregnancy, but now, there’s a glimmer of hope due to emerging evidence. Who meets the criteria for this treatment modality is what will be summarized below.
The NICE (National Institute for Health and Care Excellence) bases the recommendations on systemic reviews of the best available evidence, not forgetting the cost-effectiveness. When the available evidence is minimal, experts on the committees discuss opinions on what constitutes an acceptable practice – that’s what it publishes as recommendations.
According to the new updates, expectant management of ectopic pregnancy can be appropriate, safe and effective in a few clinical scenarios.
New recommendations have given guidance on which women to have expectant management and when, after a diagnosis of ectopic pregnancy has been made. These include women with no pain, have small tubal ectopic pregnancies plus their serum hCG is low. Such women should meet all the criteria below.
- Offer expectant management as an option for women who are: clinically stable and pain-free; they have a tubal pregnancy that measures less than 35 mm and no visible heartbeat on a transvaginal ultrasound scan; have serum hCG levels ≤1000 IU/L, and can return for follow-up.
- Consider expectant management as an option for women who are: clinically stable and pain-free; have a tubal pregnancy that measures less than 35 mm with no visible heartbeat on a transvaginal ultrasound scan; have serum hCG levels ≥1000 IU/L but ≤ 1500 IU/L, and can return for follow-up.
If they do not meet the above conditions, women should undergo either medical or surgical treatment according to existing practice guidelines.
Read this article: Ovarian cancer: A silent killer you can manage.
When women are under expectant management, NICE recommends that the clinicians monitor the hCG levels in the following manner.
- Serum hCG levels should be repeated on days 2, 4, and 7 after the original test, when managing women with tubal pregnancy expectantly. If levels drop by 15% on days 2, 4, and 7, repeat them weekly until a negative result (less than 20 IU/L) is achieved. If the serum hCG levels don’t fall by 15%, remain the same or rise from the previous value, reassess the woman’s clinical condition: seek help from an expert for further management.
Advise the women on expectant management that based on limited evidence: there seems to be no difference following medical or expectant management in the rate of; ectopic pregnancies ending naturally, risk of tubal rupture, health status, depression or anxiety scores, and the need for additional treatment. However, tell them that an admission may be imminent when the clinical condition deteriorates.
As we conclude, it is paramount to note that this kind of management is only achievable if women can seek out for reproductive health services early and promptly. As we enter the new era of 8 antenatal care visits or more, we can be able to detect ectopic pregnancies earlier and be able to seek expert help wherever a need arises.
Download the full PDF about all the updated NICE guideline recommendations about the management of miscarriage and ectopic pregnancy here.
Don’t forget to share.