In a study of 143 patients followed after undergoing laparoscopic procedures for ectopic pregnancy, the overall intrauterine pregnancy rates for laparoscopic salpingostomy (60%) and laparoscopic salpingectomy (54%) were not significantly different (188). If the patient had evidence of tubal damage, pregnancy rates (42%) were significantly lower than in those women who did not have tubal damage (79%). In another study, the reproductive outcome of 188 patients followed for a mean of 7.2 years (range 3–15 years) was reported after conservation by laparotomy for ectopic pregnancy (189). An intrauterine pregnancy occurred in 83 (70%) patients, with a recurrent ectopic pregnancy rate of 13%, suggesting that reproductive outcome after an ectopic pregnancy treated by laparotomy is similar to that of patients undergoing laparoscopic or medical management. A recent Cochrane review showed no difference in tubal patency rate, future intrauterine pregnancy rates, and recurrent ectopic pregnancy rates in those patients treated with salpingostomy by either laparoscopy or laparotomy approach (177).
Medical Treatment The drug most frequently used for medical management of ectopic pregnancy is methotrexate, although other agents were studied, including potassium chloride (KCl), hyperosmolar glucose, prostaglandins, and RU-486. These agents may be given systemically (intravenously, intramuscularly, or orally) or locally (laparoscopic direct injection, transvaginal ultrasonographically directed injection, or retrograde salpingography). Other agents besides methotrexate are not recommended for the treatment of ectopic pregnancy because their safety and efficacy are not well documented.
Table 20.2 Contraindications to Medical Therapy
Unable to comply with medical management follow-up
Alcoholism, alcoholic liver disease or chronic liver disease
Known sensitivity to methotrexate
Hepatic, renal, or hematologic disorder
Gestational sac larger than 3.5 cm
Adapted from ACOG Practice Bulletin Medical Management of Ectopic Pregnancy, 2008.
Methotrexate is a folic acid analogue that inhibits dehydrofolate reductase and thereby prevents synthesis of DNA. Methotrexate affects actively growing cells including trophoblastic tissues, malignant cells, bone marrow, intestinal mucosa, and respiratory epithelium (190). It is used extensively in the treatment of gestational trophoblastic disease (see Chapter 39). Initially, methotrexate was used for the treatment of trophoblastic tissue left in situ after exploration for an abdominal pregnancy (191). In 1982, Tanaka et al. treated an unruptured interstitial gestation with a 15-day course of intramuscular methotrexate (192). Multiple studies documented the safety and efficacy of methotrexate therapy for the management of ectopic pregnancies, and this is the first-line treatment for many providers. Approximately 35% of patients with ectopic pregnancies are candidates for primary therapy with methotrexate (193). Methotrexate is appropriate for primary treatment and may be given for the treatment of persistent ectopic pregnancies that failed surgical management.