Importantly, 65 to 75 percent of women initially given MTX will have increasing pain beginning several days ater therapy. Thought to relect separation of the ectopic pregnancy from the tubal wall, this "separation pain" generally is mild and relieved by analgesics. In a series of 258 MTX-treated women by Lipscomb and colleagues (1999b), 20 percent had pain that merited evaluation in a clinic or emergency room. Dltimately, 10 of these 53 underwent surgical exploration. Said another way, 20 percent of women given single-dose MTX will have significant pain, and about 20 percent of these will require laparoscopy.
As shown in Table 19-1, monitoring single-dose therapy calls for serum 3-hCG determinations at days 4 and 7 following initial injection on day 1. After single-dose MTX, mean serum 3-hCG levels may rise or fall during the first 4 days and then gradually decline. If the level fails to drop more than 15 percent between days 4 and 7, then a second dose of MTX is required. This is necessary in 15 to 20 percent of women treated with single-dose therapy (Cohen, 2014a; Kirk, 2007).
With multi dose MTX, levels are measured at 48-hour intervals until they fall more than 15 percent. D p to four doses may be given to one patient if required (Stovall, 1991).
Once appropriately dropping levels are achieved in either regimen, serum 3-hCG determinations are then measured weekly until undetectable. Outpatient monitoring is preferred, but if patient safety or compliance is questioned, the woman is hospitalized during initial surveillance. Lipscomb and colleagues (1998) used single-dose MTX to successfully treat 287 women and reported that the average time to resolutiondeined as a serum 3-hCG level < 15 mID/mL, was 34 days. Importantly, the longest time was 109 days.
Failure is judged when the 3-hCG level plateaus or rises or the tube ruptures. Importantly, tubal rupture can occur even with declining 3-hCG levels. Lipscomb and associates (1998) described a 14-day mean time to rupture, but one woman had tubal rupture 32 days after single-dose MTX.
From one metaanalysis, the overall success rate for treatment with MX is 89 percent. The success for the multidose regiment is 92.7 percent, whereas that for single-dose is 88.1 percent (Barnhart, 2003a). Despite this diference, the single dose is more frequently used because of its simplicity and convenience.
Studies have compared laparotomy with laparoscopic surgery for ectopic pregnancy (Lundorf, 1991; Murphy, 1992; Vermesh, 1989). Overall, tubal patency and number of subsequent uterine pregnancies do not difer between these routes. hus, laparoscopy is the preferred surgical treatment for ectopic pregnancy unless a woman is hemodynamically unstable. As experience has accrued, cases previously managed by laparotomy-for example, ruptured tubal pregnancies with hemoperitoneum-can safely be managed laparoscopically by those with suitable expertise (Cohen, 2013; Sagiv, 2001). hat said, the lowered venous return and cardiac output associated with the pneumoperitoneum of laparoscopy must be factored into the decision to select mini mally invasive surgery for hypovolemic women.
Before surgery, future fertility desires are discussed. In women desiring permanent sterilization, the unafected tube can be ligated or removed concurrently with salpingectomy for the afected fallopian tube.