Choosing a treatment for ectopic pregnancy

hCG: human chorionic gonadotropin; TVUS: transvaginal ultrasound; MTX: methotrexate.

* Severe or persistent lower abdominal pain and/or evidence of hemoperitoneum.

¶ Some clinicians treat with MTX for patients with hCG >5000 to ≤10,000 mIU/mL if the following criteria are met: no pathologic levels of free fluid in the pelvic cul-de-sac or abdomen, TVUS meets criteria for MTX, and the patient has minimal pelvic or abdominal pain.

Δ Ectopic mass diameter <3 to 4 cm is also commonly used as a patient selection criterion; however, this has not been confirmed as a predictor of successful treatment.

◊ Patients may also reasonably choose surgery if they need a concurrent surgical procedure or if they value a treatment that is of shorter duration and involves less follow-up and are willing to take the risks and recovery time associated with surgery.

§ A small portion of patients may be candidates for expectant management. For such patients, all of the following criteria must be present:

• Asymptomatic
• Low serum hCG (eg, ≤200 mIU/mL) and decreasing
• No fetal cardiac activity or signs of impending ectopic mass rupture
• Willing and able to attend posttreatment follow-up appointments and have access to emergency medical services within a reasonable time frame in case of a ruptured fallopian tube

Expectant management includes measurement of serum hCG every two days for three measurements. If hCG is decreasing and the patient remains asymptomatic, serum hCG is obtained weekly until hCG is undetectable (usually within 10 weeks). All other patients are managed with surgery or MTX.