After surgery, 3-hCG levels usually fall quickly and approxi mate 10 percent of preoperative values by day 12 (Hajenius, 1995; Vermesh, 1988). Persistent trophoblast is rare following salpingectomy, but complicates 5 to 15 percent of salpingos tomies (Kayatas, 2014; Pouly, 1986; Seifer, 1993). Rates are lower for laparotomy versus laparoscopic procedures (Hajenius, 1995). Other risk factors are debatable but may include greater serum 3-hCG levels and smaller ectopic size (Rabischong, 2010; Seifer, 1997). Bleeding caused by retained trophoblast is the most serious complication.
Incomplete removal of trophoblast can be identiied by stable or rising 3-hCG levels. v1onitoring approaches are not codified. One scheme measures serum 3-hCG levels on postoperative day 1, and values dropping < 50 percent of the preoperative value relect risk for persistent trophoblast (Spandorfer, 1997). Another measures weekly levels (Mol, 2008). With stable or increasing 3-hCG levels, additional surgical or medical therapy is necessary. Without evidence for tubal rupture, standard therapy for this is single-dose MTX, 50 mg/m2 X body surface area (BSA). Rupture and bleeding require surgical intervention.
Several randomized trials have compared methotrexate treatment with laparoscopic surgery. One multicenter trial compared a multidose MTX protocol with laparoscopic salpingostomy and found no diferences for tubal preservation and primary treatment success (Hajenius, 1997). In this same study group, however, health-related quality-of-life factors such as pain, posttherapy depression, and decreased perception of health were significantly impaired after systemic MX compared with laparoscopic salpingostomy (Nieuwkerk, 1998). In their randomized controlled trial, Fernandez and coworkers (2013) compared multidose medical therapy against salpingostomy and found that medical and conservative surgery provided similar 2-year rates of attaining a uterine pregnancy.
Evidence is conlicting when single-dose MTX is compared with surgical intervention. In two separate studies, single-dose MTX was overall less successful in resolving pregnancy than laparoscopic salpingostomy, although tubal patency and subsequent uterine pregnancy rates were similar between both groups (Fernandez, 1998; Sowter, 2001). Women treated with MTX had significantly better physical functioning immediately following therapy, but there were no diferences in psychological functioning. Krag NIoeller and associates (2009) reported the results from their randomized trial that had a median surveillance period of 8.6 years during which future pregnancy rates were evaluated. Ectopic-resolution success rates were not significantly diferent between those managed surgically and those treated with MTX. Moreover, cumulative spontaneous uterine pregnancy rates were not diferent between the MTX group (73 percent) and the surgical group (62 percent).
Based on these studies, we conclude that women who are hemodynamically stable and in whom there is a small tubal diameter, no fetal cardiac activity, and serum �-hCG concentrations <5000 mIU/mL have similar outcomes with medicalior surgical management. Despite lower success rates with medical therapy for women with larger tubal size, higher serum �-hCG levels, and fetal cardiac activity, medical management can be ofered to the motivated woman who understands the risks.