Expectant management in ectopic pregnancy

Expectant management in ectopic pregnancy

Seek expert advice.

Some women with ectopic pregnancies may resolve spontaneously through regression or tubal abortion (1,2).

NICE state:

Expectant management can be offered as an option to women who:

• are clinically stable and pain free and
• have a tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on transvaginal ultrasound scan and
• have serum hCG levels of 1,000 IU/L or less and
• are able to return for follow-up

Expectant management should be considered as an option for women who:

• are clinically stable and pain free and
• have a tubal ectopic pregnancy measuring less than 35 mm with no visible heartbeat on transvaginal ultrasound scan and
• have serum hCG levels above 1,000 IU/L and below 1,500 IU/L and
• are able to return for follow-up

For women with a tubal ectopic pregnancy being managed expectantly, repeat hCG levels on days 2, 4 and 7 after the original test and:

• if hCG levels drop by 15% or more from the previous value on days 2, 4 and 7, then repeat weekly until a negative result (less than 20 IU/L) is obtained or
• if hCG levels do not fall by 15%, stay the same or rise from the previous value, review the woman's clinical condition and seek senior advice to help decide further management.

Women should be adivised that, based on limited evidence, there seems to be no difference following expectant or medical management in:

• the rate of ectopic pregnancies ending naturally
• the risk of tubal rupture
• the need for additional treatment, but that they might need to be admitted urgently if their condition deteriorates
• health status, depression or anxiety scores

Women should be advised that the time taken for ectopic pregnancies to resolve and future fertility outcomes are likely to be the same with either expectant or medical management.

In women with

• pregnancies of unknown location (PUL) (2)
  • 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
• 3. NICE (September 2023).Ectopic pregnancy and miscarriage: diagnosis and initial management