November 2004 · Vol. 16, No. 11Ectopic pregnancy:
A 5-step plan for medical management
Two experts describe a multidose methotrexate regimen, the first choice for unruptured, uncomplicated ectopics.
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Fast Track
Proceed to surgery if cardiac activity is detected in an adnexal mass.
If treatment is unsuccessful after 4 doses of methotrexate, proceed to surgery.
Laparoscopy is the preferred surgical approach.
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John
E.
Buster,
MDProfessor of Ob/Gyn, Director of Reproductive Endocrinology and Infertility, Baylor College of Medicine
Houston, Tex Kurt
Barnhart,
MD, MSCEAssociate Professor of Ob/Gyn and Epidemiology, University of Pennsylvania
Philadelphia
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KEY POINTS
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In properly selected cases, medical therapy and surgery produce similar outcomes, but medicine is less expensive.
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Surgery is still the first choice for hemorrhage, medical failure, rupture or near-rupture, and when medical therapy is contraindicated.
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Systemic methotrexate and laparoscopic salpingostomy produce similar success rates and long-term fertility.
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Single-dose methotrexate is associated with a higher risk of rupture than multiple doses.
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Although ectopic pregnancy remains a leading cause of life-threatening first-trimester morbidity, accounting for about 9% of maternal deaths annually,1 we now are able to diagnose and treat most cases well before rupture occurs—in some cases, as early as 5 weeks’ gestation. As a result, medical therapy with systemic methotrexate has become the first-line treatment, with surgery reserved for hemorrhage, medical failures, neglected cases, and circumstances in which medical therapy is contraindicated.
Early diagnosis not only makes medical therapy possible, it also is cheaper, since it avoids rupture, blood loss, and surgery; preserves fertility; and minimizes lost productivity. This is important because ectopic pregnancy is an expensive condition, with an annual health-care bill exceeding $1 billion.2
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