Efficacy and safety of a clinical protocol for expectant management of selected women diagnosed with a tubal ectopic pregnancy

Objective: To validate the efficacy and safety of our clinical protocol for expectant management of selected women diagnosed with tubal ectopic pregnancy.

Methods: This was a prospective observational study carried out in the early pregnancy unit of a London inner-city university teaching hospital from 1(st) January 2008 to 31(st) May 2011. All women presenting with suspected early pregnancy complications were assessed clinically and by transvaginal ultrasound. Those with a conclusive ultrasound diagnosis of tubal ectopic pregnancy were selected for either surgical or expectant management. Selection criteria for expectant management were clinical stability with no or minimal abdominal pain, no evidence of significant hemoperitoneum on ultrasound scan, ectopic pregnancy measuring < 30 mm in mean diameter with no evidence of embryonic cardiac activity, serum β-human chorionic gonadotropin (β-hCG) < 1500 IU/L and the woman's consent. All women selected for expectant management were followed up as outpatients until the ectopic pregnancy regressed spontaneously (resolution of clinical symptoms, serum β-hCG < 20 IU/L/negative urine pregnancy test) or surgical intervention was required. We recorded the rate of interventions, complications and length of follow-up.

Results: During the study period 339/11 520 (2.9% (95% CI, 2.59-3.21%)) women were diagnosed with tubal ectopic pregnancy. Six women opted to participate in an ongoing randomized controlled trial and were excluded from further analysis. One hundred and sixty-five (49.5% (95% CI, 44.2-55.0%)) of the 333 remaining women met the criteria for expectant management; 146/333 (43.8% (95% CI, 38.5-49.1%)) of them opted for expectant management and 104/333 (31.2% (95% CI, 26.2-36.2%)) of all tubal ectopics resolved without requiring any intervention. All women with failed expectant management were treated by laparoscopic salpingectomy/salpingotomy and none of them required a blood transfusion.

Conclusion: Our clinical protocol for expectant management of tubal ectopic pregnancies eliminates the need for medical or surgical treatment in more than a third of women diagnosed with tubal ectopic pregnancy with a minimum risk of adverse outcome.