Where the Pendulum of Expectant Management of Ectopic Pregnancy Should Rest?

Samuel Lurie, MD, Department of Obstetrics and Gynecology, Kaplan Hospital, IL-76100 Rehovot (Israel) Dear Sir, By reporting successful surgical treatment of tubal pregnancy in the British Medical Journal in 1884, Robert Lawson Tait (1845-1899) [1] made a revolutionary statement recommending the adoption of extirpative treatment of ectopic pregnancy. Enormous progress has been made during the twentieth century in the management of ectopic pregnancy. Preservation of future fertility became possible with the introduction of conservative surgical procedures, expectant management, and the use of methotrex-ate [2]. However, in spite of the progress, the optimal treatment of ectopic pregnancies remains far from satisfactory. The question of expectant management is a difficult one, especially because there is a recent trend to treat tubal pregnancies more conservatively. It is usually accepted that if the patient with a presumptive ectopic pregnancy and declining ß-subunit of human chorionic gonado-tropin (ßhCG) is asymptomatic or has only mild discomfort, surgery is unnecessary and expectant management is warranted [3]. However, tubal rupture could occur with declining and low ßhCG levels [4] and with any initial level [5]. Therefore, the distinction between patients with unruptured ectopic pregnancis that will undergo spontaneous resolution or are destined to rupture is a primary goal in the management of ectopic pregnancy. Recently, some attempts were made towards resolution of this quandary. One study suggested that expectant management could be offered in declining ßhCG levels only with an initial ßhCG of < 2,000 mlU/ml [6]. Another study has shown that expectant management is more successful in patients with an initial ßhCG of < l, O0OmΓU/ml[7]. Since 1990, a conservative treatment protocol [8] has been used in our department. Between January 1, 1990 and October 31, 1993, 173 patients were treated in accordance with our protocol. Briefly, symptomatic patients were treated surgically; patients with declining ßhCG, irrespective of the initial level, entered expectant management, and patients with rising levels of ßhCG were treated surgically when the ßhCG level rose above 2,500 mlU/ml (2nd International Standard). The cutoff point for ßhCG of 2,500 mlU/ml was set based upon our previous retrospective analysis of 134 consecutive patients with tubal pregnancies [5]. We had 60 patients with declining ßhCG, spontaneous resolution occurred in 37 (61.6%) and 23 (38.3%) failed to escape surgical treatment. The initial level of ßhCG in patients with spontaneous resolution was 1,758.8 ± 1,528.3 mlU/ml (range 210-6,000), while in the failure group it was 7,620.0 ± 6,300.9 mlU/ml (range 2,500-18,600).