A treated persistent PUL is defined as one managed medically (generally with methotrexate) without confirmation of the location of the pregnancy such as by ultrasound, laparoscopy or uterine evacuation. A resolved persistent PUL is defined as serum hCG reaching a non-pregnant value (generally less than 5 IU/L) after expectant management, or after uterine evacuation without evidence of chorionic villi on histopathological examination. In contrast, a relatively low and unresolving level of serum hCG indicates the possibility of an hCG-secreting tumour. Differential diagnosis
Other conditions that cause similar symptoms include: miscarriage, ovarian torsion, and acute appendicitis, ruptured ovarian cyst, kidney stone, and pelvic inflammatory disease, among others. Treatment
Expectant management
Most women with a PUL are followed up with serum hCG measurements and repeat TVS examinations until a final diagnosis is confirmed. Low-risk cases of PUL that appear to be failing pregnancies may be followed up with a urinary pregnancy test after two weeks and get subsequent telephone advice. Low-risk cases of PUL that are likely intrauterine pregnancies may have another TVS in two weeks to access viability. High-risk cases of PUL require further assessment, either with a TVS within 48 h or additional hCG measurement. Medical
Early treatment of an ectopic pregnancy with methotrexate is a viable alternative to surgical treatment which was developed in the 1980s. If administered early in the pregnancy, methotrexate terminates the growth of the developing embryo; this may cause an abortion, or the developing embryo may then be either resorbed by the womans body or pass with a menstrual period.
Contraindications include liver, kidney, or blood disease, as well as an ectopic embryonic mass > 3.5 cm. Also, it may lead to the inadvertent termination of an undetected intrauterine pregnancy, or severe abnormality in any surviving pregnancy. Therefore, it is recommended that methotrexate should only be administered when hCG has been serially monitored with a rise less than 35% over 48 hours, which practically excludes a viable intrauterine pregnancy.For nontubal ectopic pregnancy, evidence from randomised clinical trials in women with CSP is uncertain regarding treatment success, complications and side effects of methotrexate compared with surgery (uterine arterial embolization or uterine arterial chemoembolization).The United States uses a multi dose protocol of methotrexate (MTX) which involves four doses of intramuscular along with an intramuscular injection of folinic acid to protect cells from the effects of the drugs and to reduce side effects. In France, the single dose protocol is followed, but a single dose has a greater chance of failure. Surgery
If bleeding has already occurred, surgical intervention may be necessary. However, whether to pursue surgical intervention is an often difficult decision in a stable patient with minimal evidence of blood clot on ultrasound.Surgeons use laparoscopy or laparotomy to gain access to the pelvis and can either incise the affected Fallopian tube and remove only the pregnancy (salpingostomy) or remove the affected tube with the pregnancy (salpingectomy). The first successful surgery for an ectopic pregnancy was performed by Robert Lawson Tait in 1883.