Success Rates

Reported success rates for expectant management vary from 48 to 100%.1-8 Table 9.1 summarizes studies published between 1992 and 2004.9

The largest study to date is on 118 ectopic pregnancies. In this particular study, the overall success rate for expectant management was 65.3% (77/118).2 Transvaginal ultrasound scans (TVS) and serum hCG determinations were performed every 1-3 days until the hCG was less than 10 IU/L. The mean time to resolution was 20 days (range 4-67 days). The initial serum hCG level was much lower in those with successful expectant management compared to those with failed expectant management, 374 IU/L (range, 20-10 762 IU/L) compared to 741 IU/L (range, 165-14 047 IU/L). An estimate of the likely success of an expectant management strategy can be made on the basis of a single measurement of serum hCG. There was an 88% success rate when the initial hCG level was <200 IU/L but only 25% at levels of >2000 IU/L. A more recently published study has shown similar success rates, with 96% success when the hCG was <175 IU/L.8 However, limiting expectant management to ectopic pregnancies with such relatively low hCG levels would restrict this approach to only a few cases.

Different inclusion criteria for expectant management led to variations in success rates. For example some studies include pregnancies of unknown location (PULs) rather than laparo-scopically or sonographically visualized ectopic

Table 9.1. Expectant management: inclusion criteria and short-term outcome

Author and

Year

n =

Overall

Mean hCG -

Mean hCG -

Time to

Comments on entry criteria

Other comments

reference

success

success

failure (IU/L)

resolution

(IU/L)

(days)

Ylostalo1

1992

83

69%

Decreasing hCG

(57/83)

Korhonen2

1994

118

65.3%

374

741

20

88% success if hCG <200 IU/L

(77/118)

(20-10 762)

(165-14 047)

(4-67)

25% success if hCG >2000 IU/L

Cacciatore3

1995

71

69%

583

470

25

Decrease in hCG over

(49/71)

(64-2542)

(161-2525)

(8-60)

48 hours

Adnexal mass <5 cm

diameter

Trio3

1995

67

73%

455

2000

31 ± 19

39% not positively

88% success if hCG <1000 IU/L

(49/67)

(36-16 400)

(93-22 300)

identified on TVS

Ectopic <4 cm diameter

Shalev5

1995

60

47.7%

Confirmed laparoscopically

60% success if hCG <2000 IU/L

(28/60)

Declining hCG level

7% success if hCG >2000 IU/L

Lui6

1997

17

100%

17

Tubal diameter <3 cm

(17/17)

Free fluid <100 ml

No fetal cardiac activity

Haemodynamic stability

Olofsson7

2001

17

82.4%

(14/17)

Elson8

2004

107

70%

246

628

15

Haemodynamic stability

96% success if hCG <175 IU/L

(75/107)

(99-536)

(254-1402)

(3-66)

No fetal cardiac activity

66% success if hCG 175-1500 IU/L

No haemoperitoneum

21% success if hCG >1500 IU/L

0% success if hCG >1500 IU/L and

>42 days pregnant

From Kirk E, Condous G, Bourne T. Non-surgical management of ectopic pregnancy.9

pregnancies. There is no doubt that this group will contain some ectopic pregnancies but it may also contain some missed failed intrauterine pregnancies. The number of ectopic pregnancies in a population of PULs has been reported to be as low as 7-8%.1011 In the majority of studies, a single cut-off level of serum hCG has been used as the main criterion for inclusion. Selection for expectant management on the basis of single serum hCG and progesterone levels will lead to variations in success rates. Units only managing ectopic pregnancies expectantly with very low hCG levels (e.g. <200IU/L) are likely to have much higher success rates than if a higher cut-off hCG level is used. Exclusion criteria that have been cited for expectant management include an ectopic mass of >3 cm, haemoperitoneum, positive fetal cardiac activity, pain and an increasing hCG level. Not all of these are absolute contraindications and each case must be judged on its merits.

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