European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 69–75

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Review

Individualisation of intervention for tubal ectopic pregnancy: historical

perspectives and the modern evidence based management of ectopic
pregnancy
Funlayo Odejinmi* , Keren O. Huff, Reeba Oliver
Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR, UK

A R T I C L E I N F O A B S T R A C T

Article history:
Received 16 September 2016 Historically, ectopic pregnancy was a life-threatening condition where diagnosis was possible only at
Accepted 21 October 2016 post mortem or laparotomy and maternal mortality was up to 90%. The evolution in the management of
ectopic pregnancy has meant that diagnosis can be made using non-invasive techniques with an aim to
Keywords: identify the ectopic gestation before tubal rupture. This enables health care professionals to offer
Ectopic pregnancy management options that consider not only maternal mortality, but morbidity and fertility outcomes as
Diagnosis well. In spite of this, diagnostic techniques and management options are not without limitations.
Management Research is currently focused on new tests with a single diagnostic capability, diagnostic and treatment
Salpingectomy
algorithms and safe methods of triaging patients. This article aims to review the current literature on the
Salpingotomy
diagnosis and management of ectopic pregnancy and to formulate a pathway to help individualise care
and achieve the best possible outcome.
© 2016 Elsevier Ireland Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Historical perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Diagnostic techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Inaccuracy in traditional methods of diagnosing ectopic pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Using clinical presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Using predictive risk factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Using ultrasound scan findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Using serum beta hCG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Using serum progesterone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Individualizing treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Patient categorisation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Triaging of patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Using a combination of beta hCG, ultrasound and symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Management options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Expectant management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Medical management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Surgical management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Conservative surgery: salpingotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Radical surgery: salpingectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Extraneous factors affecting choice of treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Fertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Cost and logistics of service delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Impact of treatments on quality of life and patient satisfaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

* Corresponding author at: Department of Gynaecology, Whipps Cross University

Hospital, Barts Health NHS Trust, London E11 1NR, UK. Fax: +44 2085356689.
E-mail addresses: jimi@doctors.org.uk, docjimi@me.com (F. Odejinmi).

http://dx.doi.org/10.1016/j.ejogrb.2016.10.037
0301-2115/© 2016 Elsevier Ireland Ltd. All rights reserved.
70 F. Odejinmi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 69–75

The utopic clinical situation ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Surgical treatment . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Conflicts of interest . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
References . . . . . . . . . . . . . .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

Introduction A recent meta-analysis identified that the examination

findings of cervical motion tenderness resulted in a positive
The diagnosis and treatment of ectopic pregnancy has had a likelihood ratio (LR) of 4.9 [95% CI, 1.7–14], presence of an
long chequered history, from a life threatening condition with no adnexal mass LR of 2.4 [95% CI, 1.6–3.7], and elicitation of adnexal
treatment before the 18th century to diagnosis and treatment by tenderness LR of 1.9, [95% CI, 1.0–3.5], all increasing the
laparotomy in few to non-invasive diagnosis and management in likelihood of an ectopic pregnancy. But all components of the
the 21st century. Despite the advances in technology and patient history had a positive LR less than 1.5 [11]. Conversely, a
treatment modalities, the outcome is not universally successful prospective observational study of 1320 women found that the
or free of morbidity. This review aims to summarise the current presence of pelvic pain and >3 episodes of diarrhoea in 24 h
methods, assess the newer developments and give a consensus caused a relative risk of ectopic pregnancy (RR) of 2.4 and
opinion on the best way forward based on current available 2.2 respectively. The only other symptom of significance was
evidence. duration of bleeding, with each day of bleeding increasing the
risk of ectopic pregnancy by 20% [12]. Thus history and
Historical perspective examination are important factors, but the evidence suggests
that they would be inadequate to make the diagnosis of ectopic
Before the 20th century, the majority of ectopic pregnancies pregnancy alone.
presented ruptured with low expectation of maternal survival [1].
Thus the main achievement in the modern management of Using predictive risk factors
ectopic pregnancy is the decrease in mortality rate: from 72–90% It is well known that several risk factors increase a woman’s
in 1880 to 0.14% in 1990 [1]. Currently, ectopic pregnancy occurs risk of developing an extra uterine implantation. Barnhart et al.
in 1–2% of pregnancies worldwide, and is responsible for 54% of showed that previous ectopic pregnancy was a significant risk
deaths in early pregnancy and 4–6% of pregnancy related deaths factor with an odds ratio (OR) of 2.98 [95% CI, 1.88–4.73] for one
[2]. prior EP and 16.04 [5.39–47.72] for 2 or more. History of pelvic
With the evolution of ultrasound and bHCG, ectopic pregnan- inflammatory disease had an OR of 1.5 [1.11–2.05] [13]. Bouyer
cies are now diagnosed earlier, affording options that can consider et al. reviewed 803 cases of ectopic pregnancy. The main risk
not only survival but also quality of life during treatment and factors were pelvic inflammatory disease with an OR of 3.4 [95%
fertility outcomes. From the health care provider’s perspective, the CI, 2.4 = 5.0] smoking with an OR of 3.9 [95% CI, 2.6–5.9], age,
endpoint should be provision of the highest quality and cost- previous miscarriages, history of infertility, intrauterine device
effective care available affording optimal patient satisfaction. and previous medical termination of pregnancy (TOP) with an OR
of 2.8 [95% CI, 1.1–7.2] [14]. Most studies concur that using risk
Diagnostic techniques factors alone would result in suboptimal diagnosis of ectopic
pregnancy.
The “Achilles heel” in the management of an ectopic pregnancy
is that there is no single diagnostic test. Currently diagnosis is Using ultrasound scan findings
achieved by a combined assessment of clinical presentation, Currently the emphasis of diagnosis using ultrasound scanning
ultrasonography and serum beta human chorionic gonadotrophin is the identification of an extra-uterine pregnancy rather than
(bhCG) with or without progesterone levels. These tests vary in relying on the absence of an intrauterine pregnancy (IUP). 87–99%
sensitivity and specificity which contributes to suboptimal of tubal pregnancies can be diagnosed using transvaginal
treatment outcomes. Currently 8–31% of women presenting with ultrasound with a sensitivity of 74% (95% CI: 65.1–81.6) and a
symptoms suggestive of an ectopic pregnancy and a positive specificity of 99.9% (95% CI: 99.8–100) [9]. About two-thirds of
pregnancy test are diagnosed as pregnancy of unknown location ectopic pregnancies are seen as inhomogeneous masses, the so
(PUL) [3–6]. Almost 20% will be subsequently diagnosed with an called “blob sign” [15]. 20% appear as a hyperechoic ring the “bagel
ectopic pregnancy [7–9]. It has been shown that 74% of ectopic sign” whilst 13% will have a gestational sac with a fetal pole, with or
pregnancies in early pregnancy units can be diagnosed at first without fetal cardiac activity [16]. At present, this is the gold
presentation [9]. These suboptimal figures reflect the fact that standard for diagnosis of ectopic pregnancy.
there is no single pathognomonic sign or symptom for ectopic
pregnancy, nor has any single discriminatory biochemical or Using serum beta hCG
ultrasound test been developed with adequate sensitivity and Although serum bhCG is universally used as an adjunct to
specificity. ultrasound findings, it has several pitfalls. Whilst serial serum
bhCG levels can distinguish an active from a failing pregnancy, it
Inaccuracy in traditional methods of diagnosing ectopic pregnancy cannot distinguish the location of the pregnancy [17–20]. Serum
bhCG levels are based on the doubling time or 66% rise in 48 h in
Using clinical presentation healthy pregnancies. However, 15% of healthy IUPs do not increase
The classical triad of lower abdominal pain, amenorrhea, and by 66%, 13% of ectopic pregnancies have a 66% rise in bhCG levels
vaginal bleeding was first described by Italian anatomist Giovanni and 64% of very early ectopic pregnancies may have doubling bhCG
Domenico Santorini (1681–1737) [10]. Unfortunately, diagnostic levels [21].
accuracy using this triad is poor as only 50% of patients present Furthermore, bhCG levels cannot always be correlated with
typically. ultrasound findings, for example multiple gestations [22].
 F. Odejinmi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 69–75
Using serum progesterone
Serum progesterone has been used as an adjunct to bhCG
levels and ultrasound, but difficulties in interpretation and
correlation with clinical findings limit its usage. Several authors
have proposed different cut-offs with varying sensitivity and
specificity [23–25]. A meta-analysis showed that a single
measurement of progesterone (cut-off values from 3.2 to 6 ng/
ml) predicted a non-viable pregnancy (sensitivity of 74.6% (95%
CI, 50.6–89.4), specificity of 98.4% (95% CI, 90.9–99.7) [25].
However, this did not distinguish between a failing intrauterine
pregnancy and an ectopic pregnancy. Additionally, in women who
have in vitro fertilisation, progesterone levels are unreliable [26].
Thus to date, the usefulness of serum progesterone has been
limited to a single level and only used as an adjunct in ectopic
pregnancy diagnosis.
Individualizing treatment
Ectopic pregnancies are managed either non-surgically or by
surgery. The modality used and success depends on the accurate
triage of patients.
Patient categorisation
Women can be categorised into 2 main groups:
1. Those that present acutely with haemodynamic compromise.
2. Those that present without haemodynamic instability.
Thus triaging should be driven by careful analyses of the
following factors:
1. Symptoms and clinical presentation.
2. bhCG levels.
3. Ultrasound scan findings.
Barnhart et al. [5] in a consensus statement suggested that
ectopic pregnancies should be categorized as:
a) Definite ectopic pregnancy: where an embryo is seen outside
the uterine cavity with or without cardiac activity.
b) Probable ectopic pregnancy: where an inhomogeneous mass or
non-cystic structure is seen outside the uterine cavity.
For haemodynamically stable women, the ectopic pregnancy
then needs to be categorised as either a progressing ectopic
pregnancy or one that has the potential to resolve. This can be
determined by the pregnancies “level of activity”. However, what
constitutes ‘activity’ is still an issue of debate [27]. This can mostly
be determined by ultrasound findings and bhCG levels.
Triaging of patients
Using a combination of beta hCG, ultrasound and symptoms
Capmas et al. propose that a “less active ectopic pregnancy” is
one in which
1. Serum HCG estimations are less than 5000 IU.
2. Patient is asymptomatic.
3. Patient is haemodynamically stable.
4. There is no fetal cardiac activity.
5. Haematosalpinx measures less than 3.5 cm.
The inclusion of ultrasound characteristics in algorithms
further aids in the safe triage of patients. Characteristics taken
into consideration include:
71
1. Yolk sac.
2. The presence of a tubal ring.
3. The presence of an embryo and cardiac activity.
Fernandez et al. [28] in their scoring system used six criteria
evaluated on a scale from 1 to 3:
1. Gestational age.
2. Human chorionic gonadotrophin (bhCG) level.
3. Progesterone level.
4. Abdominal pain.
5. Haemoperitoneum volume.
6. Haematosalpinx diameter.
With a score of less than 12 the success rate of expectant/
medical management was 82%, compared with 50% success rate
when the score was greater than 12.
Management options
Non-surgical management of ectopic pregnancy affords women
choice, however careful selection and counselling is imperative as
the conservative approach still exposes the women to the risk of
tubal rupture. Non surgical management can be expectant or
medical.
Expectant management
This management modality is based on the natural history of
evolution of an ectopic pregnancy and has been shown to be safe in
women who:
1. Are haemodynamically stable.
2. Have been adequately counselled.
3. Are compliant with the treatment pathway.
4. Have no barriers to accessing healthcare.
5. Have ectopic pregnancies of low activity.
The recent METEX trial included 73 women over a 5-year
period. 60% of women showed complete resolution with
expectant management and there was no difference in the
resolution on comparison with the methotrexate group [29]. The
trial suggested that methotrexate should be used only as a second
line therapy in less active ectopic pregnancies. Levin et al.
retrospectively reviewed 401 patients eligible for non-surgical
management. Less active pregnancies were managed expectantly
(46%) and more active pregnancies were managed medically
(53.6%) after 24 h. In the expectant management group there was
a success rate of 88% and 93 women avoided unnecessary
methotrexate [30].
Despite the above evidence the National Institute for Clinical
Excellence (NICE) guidance on ectopic pregnancy management
does not recommend expectant management for clinically stable
patients irrespective of ultrasound features or bhCG levels as
markers of low ectopic ‘activity’ [31]. Guidance from the Royal
College of Obstetricians and Gynaecologists, however, does
recommend that expectant management is an option for stable
patients with a falling bhCG with an initial value of <1000 IU/l [32].
Despite the NICE guidance, expectant management has been
widely adopted given the above evidence that it is a safe option in
selected patients.
Medical management
This modality of treatment should be offered as part of
protocols for the management of stable women with ectopic
72 F. Odejinmi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 69–75
pregnancy. Triage again is most important in this group of women
to avoid inadvertent embryopathy.
Indicators for medical management include:
1. Less active ectopic pregnancies.
2. Patient choice for suitable cases.
3. Failure of conservative management.
The most commonly used drug for medical management is
methotrexate, which is an antimetabolite that acts on actively
proliferating cells. Regimens include: a single dose injection, two
dose injection or multi dose protocols of four injections [33,34].
Methotrexate can be administered by intra-lesional injection into
the ectopic gestation under ultrasound guidance or intramuscu-
larly [33–38]. Other substances used have included prostaglandin-
F2 alpha and hyperosmolar glucose [39–41].
As for expectant management, patients need to be counselled
appropriately and pre-treatment blood tests to ensure normal liver
and renal function tests are required. The reported success rates
vary widely (63–96.7%) [38,42–44]. Cohen et al. retrospectively
evaluated 1083 ectopic pregnancies in those with stable or
increasing bhCG levels. 13% required surgical intervention, the
success rate in women with bhCG between 2500 and 3500 IU was
75% and above 4500 IU was 65% [45]. Studies have varied in their
inclusion criteria, pretreatment bhCG levels, treatment protocols
and definitions of treatment failure and thus it is difficult to draw a
consensus opinion on the efficacy of treatment.
The inclusion of methotrexate in treatment protocols helps to
decrease the rate of surgical intervention. Mavrelos et al. evaluated
a protocol which only included expectant and surgical manage-
ment. Their success rate was 71% with 29% of women ultimately
needing surgical intervention [46]. This demonstrates a potentially
high surgical intervention rate without the option of medical
management in protocols.
Surgical management
Surgery remains the mainstay of treatment for up to 70% of
women who have ectopic pregnancy. Operative laparoscopy is
considered the gold standard for the therapeutic management of
women with ectopic pregnancy irrespective of haemodynamic
status and location of the pregnancy [47]. Even in haemodynami-
cally unstable patients, once resuscitation is effected hemostasis
can be achieved within minutes of entry into the abdomen and the
procedure completed just any other surgery for ectopic pregnancy
[48] however, this is dependent on the facilities available and the
surgeon’s expertise.
Indicators for surgical management:
1. Women with definitive ultrasound diagnosis of ectopic preg-
nancy and who are unsuitable for expectant or medical
management.
2. Women with definitive ultrasound diagnosis of ectopic preg-
nancy and who decline conservative interventions.
3. Women in whom conservative management has failed.
4. Women who are haemodynamically unstable.
For women who are about to have surgery, treatment of the
ectopic pregnancy should be guided by adequate patient counsel-
ling and this should be based on:
1. Haemodynamic status.
2. Location of the ectopic pregnancy.
3. Anticipated or known condition of the contralateral tube.
4. The condition of the tube that has the ectopic pregnancy.
5. The presence or absence of perihepatic adhesions.
Conservative surgery: salpingotomy
Salpingotomy is usually performed where the contralateral
tube is damaged or absent and preservation of fertility is
desirable. The success rate depends on the skill of the surgeon
and thus reported rates of persistent trophoblast vary widely
from 6.6% to 17.5% [49,50]. This failure rate can be reduced with a
post-operative dose of methotrexate. Although this has been
shown to be cost effective, the risk of side effects has led the
recommendations against its systemic use in a Cochrane review
[51]. The DEMETER multicenter trial showed a low failure rate of
0.6% and other studies have reiterated similar findings of
statistically significant decrease in persistent trophoblastic
disease [42,52,50].
After salpingotomy, strict protocols must be in place to monitor
for persistent trophoblastic tissue and to avoid tubal rupture.
Persistent trophoblastic disease does not appear to have an effect
on future fertility [53].
Radical surgery: salpingectomy
Salpingectomy is preferable as the success rate should be
100%, although there have been reports of persistent trophoblast
after salpingectomy where the whole of the tube has not been
removed [54]. It is usually performed where the contralateral
tube “appears” normal, where haemostasis is difficult to achieve
during salpingotomy, where future fertility is not an issue or
where the tube is ruptured and normal anatomy cannot be
restored.
Extraneous factors affecting choice of treatment
Fertility
Fertility potential is one of the end-points of management of
ectopic pregnancy. Randomised trials addressing this issue have
found no difference between salpingectomy and salpingotomy
[42,55]. The DEMETER trial showed no difference in subsequent 2-
year fertility between salpingotomy and salpingectomy: 70% vs.
64% for intrauterine pregnancy (IUP), respectively, hazard ratio
1.06 (0.69–1.63; p = 0.78) [42]. The Auvergne registry data
however, when subjected to univariate analysis, found reduced
fertility rates after salpingectomy in women over the age of 35 with
a history of infertility or tubal disease [56].
Based on current evidence we conclude that in the absence of
infertility in women under the age of 35, salpingectomy should be
advised over salpingotomy as there is no fertility advantage at
2 year follow up.
Cost and logistics of service delivery
Choosing between treatment modalities can be difficult, as
the success rates and risks seem to be similar. Hence increasingly,
the choices are dictated by cost effectiveness. Mol et al., in
2008 in a meta-analysis of literature from 1966 to 2008 compar-
ing expectant, medical and surgical management of ectopic
pregnancy, found laparoscopic surgery more cost effective than
other managements in the treatment of ectopic pregnancy [57].
In New Zealand, Sowter et al. undertook a cost minimisation
study evaluating single dose systemic methotrexate and laparos-
copy for the treatment of unruptured ectopic pregnancy [58].
Mean direct and indirect costs were significantly lower in the
methotrexate group.
Ebner et al. reviewed six studies evaluating cost effectiveness
[58–64]. 40–60% of the total cost was due to the inpatient stay
 F. Odejinmi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 69–75
andsurgically treated patients are hospitalised longer (1.3–2.7 vs.
0–1.1 days) than medically treated patients. In medically
managed patients, direct costs were caused by the repeated
laboratory tests, ultrasound examinations and consultant
reviews. They concluded that the management of small ectopic
pregnancies with bhCG <1500 IU medically was more cost
effective than surgery. At bhCG levels between 1500–3000 IU the
costs were similar and with bhCG >5000 IU, surgical management
was more cost effective.
Impact of treatments on quality of life and patient satisfaction
With the availability of different modalities of management of
ectopic pregnancy, as part of informed consent, quality of life
issues need to be considered. Van Mello et al. assessed the impact
on the quality of life (QOL) by expectant management vs
methotrexate [65] and found that the mode of management had
no impact on the QOL. Van Mello also found that women preferred
a salpingectomy over salpingotomy as it avoided a repeat ectopic
pregnancy. This preference was held even though there was a
perceived decreased chance of a spontaneous intrauterine
pregnancy [66].
Nieuwkerk et al. performed a randomised controlled trial
comparing the QOL after laparoscopic salpingectomy vs. systemic
methotrexate. They found that overall quality of life was more
impaired following medical management with patients feeling
more depressed with limitations on both physical and social
function [67].
Deepa et al. identified factors that influence the woman’s
satisfaction during the process of treatment of ectopic pregnan-
cies. The amount of haemoperitoneum and need for blood
transfusion had a significant influence on the overall satisfaction
rates (blood loss <200 ml – 94% satisfied, 200–800 ml – 81% and
>800 ml – 72%, p = 0.001). Good communication pre-operatively
(87% satisfaction with good communication vs. 30% without,
p < 0.001), provision of post-operative leaflets prior to discharge
(90% vs. 68%, p = 0.001) and adequate pain relief (89% vs.
64%, p = 0.001) resulted in good patient experience [68]. Thus
in the modern management of ectopic pregnancies, taking
patient satisfaction into account is imperative to achieve holistic
care.
Fig. 1. Pathway for management of tubal ectopic pregnancy.
73
The utopic clinical situation
The care of women with ectopic pregnancy has evolved from a
life-saving event to an ambulatory treatment for most women.
The utopic patient would be one with the following character-
istics:
 Asymptomatic.
 No risk factors for an ectopic pregnancy.
 A low activity ectopic pregnancy found on ultrasound scan.
 bhCG level of 1000 IU or less at presentation.
 A decline in bhCG levels 48 h later.
In such a scenario, after discussion expectant management
would be the best course of action.
Where the bhCG is between 1000–3000 IU and the patient is
asymptomatic, expectant management may not be successful thus
medical management would be ideal and would be cost effective.
Above this level cost effectiveness is lost and the patient may be
best served by operative laparoscopy.
Surgical treatment
 For patients who require surgery, laparoscopic surgery is the gold
standard irrespective of haemodynamic status, provided local
health care delivery systems can provide safe care, with the level
of expertise required. This should be the objective of all centres
that care for women with ectopic pregnancy.
 If the contralateral tube is normal on the basis of current
evidence, a laparoscopic salpingectomy should be performed.
Alternatively, if the contralateral tube is abnormal or the patient
is aged over 35 with a history of infertility or tubal damage,
laparoscopic salpingotomy would be the best option.
A proposed pathway for the management of patients with an
ectopic pregnancy based on the above conclusion is outlined in
Fig. 1.
It should be remembered that each patient should be
considered on an individual basis and care provided in a
compassionate and holistic manner taking into consideration
the patient’s presentation and her expectations.
74 F. Odejinmi et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 210 (2017) 69–75
Conflicts of interest
There are no disclosures of funding or conflicts of interest.
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