Expectant management in ectopic pregnancy

Seek expert advice.

Some women with ectopic pregnancies may resolve spontaneously through regression or tubal abortion (1).

Expectant management should be offered to women

• who are clinically stable, with minimal or no symptoms and who have pregnancy of unknown location
• who are asymptomatic and clinically stable and with an ectopic pregnancy diagnosed on ultrasound with a
  • decreasing serum hCG of less than 1000 iu/l on initial presentation (2)
  • without any evidence of blood in the pouch of Douglas
  • less than 100ml of fluid in the pouch of Douglas (2)

In women with

• pregnancies of unknown location (PUL)
  • five observational studies found out that, 44-69% of women with PUL resolved spontaneously with expectant management
  • 23-29% of cases required interventions
• pregnancies with an ultrasound diagnosis of ectopic pregnancy
  • seven observational studies found out that 67% of women had successful outcomes with expectant pregnancies
  • a successful outcome was more likely
    • when the initial hCG level was less than 1000 iu/l
    • in rapidly decreasing hCG level
    • when the diameter of the adnexial mass is reduced by the seventh day (2)

All women who undergo expectant management should be followed with

• serial hCG measurements twice a week - to demonstrate rapidly decreasing hCG levels
• transvaginal examinations weekly - to show a reduction in the size of adnexal mass (2)

Patients should be followed up weekly thereafter with hCG and transvaginal ultrasound examinations till the serum hCG levels reach 20 iu/l or less since there have been cases where tubal rupture occurring at low levels of beta hCG (2). Women should also be adviced about the importance of attending follow up regularly (2).

Reference:

• 1. Murray H, Baakdah H et al. Diagnosis and treatment of ectopic pregnancy. CMAJ. 2005;173(8):905-12
• 2. Royal College of Obstetricians and Gynaecologists (2004). The management of tubal pregnancy