Interventions for tubal ectopic pregnancy

Abstract

Background

Treatment options for tubal ectopic pregnancy are; (1) surgery, e.g. salpingectomy or salpingo(s)tomy, either performed laparoscopically or by open surgery; (2) medical treatment, with a variety of drugs, that can be administered systemically and/or locally by various routes and (3) expectant management.

Objectives

To evaluate the effectiveness and safety of surgery, medical treatment and expectant management of tubal ectopic pregnancy in view of primary treatment success, tubal preservation and future fertility.

Search methods

We searched the Cochrane Menstrual Disorders and Subfertility Group's Specialised Register, Cochrane Controlled Trials Register (up to February 2006), Current Controlled Trials Register (up to October 2006), and MEDLINE (up to October 2006).

Selection criteria

Randomized controlled trials (RCTs) comparing treatments in women with tubal ectopic pregnancy.

Data collection and analysis

Two review authors independently extracted data and assessed quality. Differences were resolved by discussion with all review authors.

Main results

Thirty five studies have been analyzed on the treatment of tubal ectopic pregnancy, describing 25 different comparisons. 
 
 Surgery 
 Laparoscopic salpingostomy is significantly less successful than the open surgical approach in the elimination of tubal ectopic pregnancy (2 RCTs, n = 165, OR 0.28, 95% confidence interval (CI) 0.09 to 0.86) due to a significant higher persistent trophoblast rate in laparoscopic surgery (OR 3.5, 95% CI 1.1 to 11). However, the laparoscopic approach is significantly less costly than open surgery (P = 0.03). Long term follow up (n = 127) shows no evidence of a difference in intra uterine pregnancy rate (OR 1.2, 95% CI 0.59 to 2.5) but there is a non significant tendency to a lower repeat ectopic pregnancy rate (OR 0.47, 95% 0.15 to 1.5).

Medical treatment 
 Systemic methotrexate in a fixed multiple dose intramuscular regimen has a non significant tendency to a higher treatment success than laparoscopic salpingostomy (1 RCT, n = 100, OR 1.8, 95% CI 0.73 to 4.6). No significant differences are found in long term follow up (n=74): intra uterine pregnancy (OR 0.82, 95% CI 0.32 to 2.1) and repeat ectopic pregnancy (OR 0.87, 95% CI 0.19 to 4.1).

Expectant management 
 Expectant management is significantly less successful than prostaglandin therapy (1 RCT, n = 23, OR 0.08, 95% CI 0.02 to 0.39).

Authors' conclusions

In the surgical treatment of tubal ectopic pregnancy laparoscopic surgery is a cost effective treatment. An alternative non surgical treatment option in selected patients is medical treatment with systemic methotrexate. Expectant management can not be adequately evaluated yet.

Plain language summary

Interventions for tubal ectopic pregnancy

Approximately 1% of fertilized eggs implant outside the uterine cavity and develop into extra uterine pregnancies known as ectopic pregnancies. Ectopic pregnancies can occur anywhere along the reproductive tract with the most common site being the fallopian tube. 
 An ectopic pregnancy in the fallopian tube, if not treated, can cause tubal rupture and/or intra abdominal bleeding. Treatment options for tubal ectopic pregnancy are surgery, medical treatment, and expectant management. 
 This review of 35 randomised controlled trials found that laparoscopic surgery is feasible and less expensive than open surgery in the treatment of tubal ectopic pregnancy. In selected patients, non‐surgical treatment options can be used. Medical treatment with systemic methotrexate is an option for women with tubal ectopic pregnancy with no signs of bleeding whose pregnancy hormone blood levels are relatively low. An evaluation of expectant management of tubal ectopic pregnancy cannot be adequately made yet.