Unruptured tubal pregnancy
different treatments for early and late diagnosis
Keywords:
Ectopic pregnancy, Methotre xate, Chorionic gonadotropin, Ultrasonography, AmenorrheaAbstract
CONTEXT AND OBJECTIVE: There is evidence that ectopic pregnancies present different behavioral patterns. These distinct evolutions of ectopic pregnancies represent two different natural histories. To evaluate these evolution patterns, we compared patients undergoing medical treatment and expectant management according to their gestational age and initial beta-hCG levels. DESIGN AND SETTING: Prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center. METHODS: Among 119 cases of unruptured ectopic pregnancies diagnosed from April 1999 to February 2004, 57 received systemic treatment with methotrexate 50 mg/m2 (body surface area) intramuscularly and 62 were managed expectantly. In this study we evalu- ated the beta-hCG levels at presentation and amenorrhea duration. RESULTS: There was a significant difference between the two groups regarding amenorrhea duration and initial beta-hCG levels (p < 0.001). The group with decreasing beta-hCG levels (man- aged expectantly) had longer amenorrhea (mean: 8.87 ± 1.71 weeks) and lower initial beta-hCG levels (mean: 648.8 ± 754.7 mIU/ml). On the other hand, the group treated with methotrexate had shorter amenorrhea (mean: 6.81 ± 1.88 weeks) and higher beta-hCG levels at presentation (2642.7 ± 2315.1 mIU/ml). CONCLUSIONS: The data suggest that ectopic pregnancies can be categorized into two groups: those with early diagnosis and shorter amenorrhea, increasing or maintained beta-hCG levels over 24 and 48-hour intervals and higher beta-hCG levels requiring medical treatment; and those with late diagnosis and longer amenorrhea, decreased beta-hCG levels over 24 and 48 hour intervals and lower beta-hCG levels requiring expectant management.
Downloads
References
Centers for Disease Control and Prevention (CDC). Ectopic pregnancy – United States, 1990-1992. MMWR Morb Mortal Wkly Rep. 1995;44(3):46-8.
Kadar N, DeVore G, Romero R. Discriminatory hCG zone: its use in the sonographic evaluation for ectopic pregnancy. Obstet Gynecol. 1981;58(2):156-61.
Cacciatore B, Stenman UH, Ylostalo P. Early screening for ectopic pregnancy in high-risk symptom-free women. Lancet. 1994;343(8896):517-8.
Ankum WM, Van der Veen F, Hamerlynck JV, Lammes FB. Transvaginal sonography and human chorionic go- nadotrophin measurements in suspected ectopic pregnancy: a detailed analysis of a diagnostic approach. Hum Reprod. 1993;8(8):1307-11.
Gracia CR, Barnhart KT. Diagnosing ectopic pregnancy: decision analysis comparing six strategies. Obstet Gynecol. 2001;97(3):464-70.
Barnhart K, Mennuti MT, Benjamin I, Jacobson S, Goodman D, Coutifaris C. Prompt diagnosis of ectopic pregnancy in an emer- gency department setting. Obstet Gynecol. 1994;84(6):1010-5.
Fylstra DL. Tubal pregnancy: a review of current diagnosis and treatment. Obstet Gynecol Surv. 1998;53(5):320-8.
Elito J Jr, Reichmann AP, Uchiyama MN, Camano L. Predic- tive score for the systemic treatment of unruptured ectopic pregnancy with a single dose of methotrexate. Int J Gynaecol Obstet. 1999;67(2):75-9.
Stovall TG, Ling FW, Gray LA, Carson SA, Buster JE. Metho- trexate treatment of unruptured ectopic pregnancy: a report of 100 cases. Obstet Gynecol 1991;77(5):749-53.
da Costa Soares R, Elito J Jr, Han KK, Camano L. Endometrial thickness as an orienting factor for the medical treatment of unruptured tubal pregnancy. Acta Obstet Gynecol Scand. 2004;83(3):289-92.
Lipscomb GH, McCord ML, Stovall TG, Huff G, Portera SG, Ling FW. Predictors of success of methotrexate treatment in women with tubal ectopic pregnancies. N Engl J Med. 1999;341(26):1974-8.
Barnhart KT, Rinaudo P, Hummel A, Pena J, Sammel MD, Chittams J. Acute and chronic presentation of ectopic pregnancy may be two clinical entities. Fertil Steril. 2003; 80(6):1345-51.
Atri M, Chow CM, Kintzen G, et al. Expectant treatment of ectopic pregnancies: clinical and sonographic predictors. AJR Am J Roentgenol. 2001;176(1):123-7.
Fernandez H, Bourget P. Medical treatment of ectopic preg- nancy. Contracept Fertil Sex. 1992;20:511-9.
Atri M, Bret PM, Tulandi T. Spontaneous resolution of ectopic pregnancy: initial appearance and evolution at transvaginal US. Radiology. 1993;186(1):83-6.
Brown DL, Felker RE, Stovall TG, Emerson DS, Ling FW. Serial endovaginal sonography of ectopic pregnancies treated with methotrexate. Obstet Gynecol. 1991;77(3):406-9.
Van Thiel DH, Ross GT, Lipsett MB. Pregnancies after chemotherapy of trophoblastic neoplasms. Science. 1970; 169(952):1326-7.
Walden PA, Bagshawe KD. Reproductive performance of women successfully treated for gestational trophoblastic tumors. Am J Obstet Gynecol. 1976;125(8):1108-14.
Rustin GJ, Rustin F, Dent J, Booth M, Salt S, Bagshawe KD. No increase in second tumors after cytotoxic chemo- therapy for gestational trophoblastic tumors. N Engl J Med. 1983;308(9):473-6.
Tulandi T, Hemmings R, Khalifa F. Rupture of ectopic pregnancy in women with low and declining serum beta-human chorionic gonadotropin concentrations. Fertil Steril. 1991;56(4):786-7.
