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Reproductive outcome after expectant management of ectopic pregnancy
ELSEVIER
European Journal of Obstetrics & Gynecology and ReproductiveBiology66 (1996) 1-2
GYNECI)WGY
Reproductive outcome after expectant management of ectopic pregnancy Efraim Zohav, Ofer Gemer*, Shmuel Segal Department of Obstetrics and Gynecology, Barzilai Medical Center1, 78306 Ashkelon, Israel
Received 20 September 1995; revision received 7 November 1995; accepted 29 November 1995
Abstract Objective: To study fertility rates following expectant management of clinically stable ectopic pregnancies. Study design: Twenty of 33 patients with laparoseopically confirmed aborting tubal pregnancies managed expectantly were followed for a period of 1-5 years (mean 2.7 years). Excluded were the patients not desiring pregnancy, and patients with known impediments to fertility, such as age >40 years and previous infertility, as well as patients lost to follow-up. Results: Successful pregnancies occurred in 16 patients (80%); one patient (5%) had a repeat ectopic pregnancy. Conclusions: Expectant management is associated with a favorable reproduction outcome. Keywords: Reproductive outcome; Ectopic pregnancy; Expectant management
1. Introduction
2. Patients and methods
The availability of sensitive diagnostic means and increased awareness has made early diagnosis of ectopic pregnancy possible, providing the impetus for nonsurgical management of this condition in clinically stable patients. Such an approach includes various medical and expectant management regimens [1]. Expectant management of ectopic pregnancy entails diagnosis and follow-up of clinically stable patients by serum/3-hCG determination and ultrasonography. When /~-hCG levels fall, surgery, as well as diagnostic laparo~opy, is generally avoided. Thus laparoscopy confirming the diagnosis has not been performed in most reported series. While reports on expectant management of tubal pregnancies have become numerous [2-4], reports on fertility rates following such management schemes of laparoscopically confirmed tubal pregnancies are few [5-7]. In this retrospective study, we set out to evaluate the long-term reproductive outcome in women with laparoscopically confirmed aborting tubal pregnancies who were managed expectantly.
The records of 33 patients admitted with ectopic pregnancy in a clinically stable condition and managed expectantly were reviewed. Initial diagnosis based on serial B-hCG levels and ultrasonography was confirmed by laparoscopy. These were patients with falling B-hCG levels, who at laparoscopy had signs of tubal abortion or a hematosalpinx <2 cm in diameter and hematoperitoneum of < 50 ml. The patients were managed expectantly, following their /3-hCG levels until they reached < 10 mlU/ml. Characteristics of the patients are summarized in Table 1. Subsequent reproductive outcome was assessed in 20 patients who desired pregnancy. Excluded were patients with impediments to fertility, such as those older than 40 years of age and patients with previous infertility, as well as patients who were lost for follow-up. The duration of follow-up varied from 1 to 5 years (mean 2.7 years).
* Correspondingauthor, Tel.: +972 7 745223; Fax: +972 7 736750. 1Affiliated to the Faculty of Health Sciences, Ben-Gurion Universityof the Negev, Beersheva, Israel.
3. Results
Of the 20 patients who desired pregnancy and were followed up, 16 (80%) delivered babies, one patient (5%) had a repeat ectopic pregnancy, and three patients (15%) were unable to conceive.
0301-2115/96/$15.00 © 1996ElsevierScienceIreland Ltd. All rights reserved SSD1 0301-2115(95)02370-M
2
E. Zohav et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 66 (1996) 1-2
Table I Previous fertility history of expectant therapy study group Factor
Expectant therapy group
Number of patients Mean age (years) Prior infertility Previous deliveries Mean of previous deliveries Previous abortions Previous ectopic pregnancy
33 (100%) 28.2 5 (15%) 22 (66.6%) 2.1 3 (9%) 3 (9%)
It may be concluded that in cases of aborting tubal pregnancies treated expectantly, a favorable reproductive outcome may be expected. There is future need for work to compare successful fertility per unit of time in which pregnancy is attempted, with non-parametric statistical comparison.
References [1]
4. Discussion
In the past it was claimed that when observation was the only management of ectopic pregnancy, adhesions formed at the site of the ectopic pregnancy [8]. This has been refuted by others [4,7], who documented tubal patency by hysterosalpingography or laparoscopy in 72-92% of the patients treated expectantly. Apart from anecdotal reports [5,6], we are aware of only one study with substantial patient follow-up time, in which the pregnancy rates in laparoscopically confirmed ectopic pregnancies have been reported [7]. Fernandez et al. reported eight intrauterine pregnancies in nine women who desired pregnancy, achieved after a mean time of 16 months. Of note, the inclusion criteria for expectant management used by us and by Fernandez et al. were similar.
[2]
[3] [4]
[5]
[6]
[7]
[8]
PanskyM, Golan A, Bukovsky I, Caspi E. Non-surgical management of tubal preganancy, necessity in view of the changing clinical appearance. Am J Obstet Gynecol 1991: 164: 888-895. Ylostalo P, Cacciatore B, Koskimies Aet al. Conservative treatment of ectopic pregnancy. Ann NY Acad Sci 1991: 626: 516-523. Makinien JI, Kvigarvi AK, Fjala KM. Success of non-surgical management of ectopic pregnancy. Lancet 1990; 335: 1099. Sauer MV, Gorrill M J, Rodi IA et al. Non-surgical management of unruptured ectopic pregnancy: an extended clinical trial. Fertii Sterii 1987; 48: 752-755. Garcia A, Aubert J, Sama J, Josimivich JB. Expectant management of presumed ectopic pregnancies. Fertil Steril 1987; 48: 395-400. Carp HJ, Oelsner G, Scrr D, Mashiach S. Fertility after nonsurgical treatment of ectopic pregnancy. J Reprod Med 1986; 31: 119-122. Fernandez H, Lelaidier C, Baton C, Bourget P, Frydman R. Return of reproductive performance after expectant management and local treatment for ectopic pregnancy. Hum Reprod 1991; 6: 1474-1477. Cole T, Corlett RC. Chronic ectopic pregnancy. Obstet Gynecol 1982; 59; 63-68.
European Journal of Obstetrics & Gynecology and ReproductiveBiology66 (1996) 1-2
GYNECI)WGY
Reproductive outcome after expectant management of ectopic pregnancy Efraim Zohav, Ofer Gemer*, Shmuel Segal Department of Obstetrics and Gynecology, Barzilai Medical Center1, 78306 Ashkelon, Israel
Received 20 September 1995; revision received 7 November 1995; accepted 29 November 1995
Abstract Objective: To study fertility rates following expectant management of clinically stable ectopic pregnancies. Study design: Twenty of 33 patients with laparoseopically confirmed aborting tubal pregnancies managed expectantly were followed for a period of 1-5 years (mean 2.7 years). Excluded were the patients not desiring pregnancy, and patients with known impediments to fertility, such as age >40 years and previous infertility, as well as patients lost to follow-up. Results: Successful pregnancies occurred in 16 patients (80%); one patient (5%) had a repeat ectopic pregnancy. Conclusions: Expectant management is associated with a favorable reproduction outcome. Keywords: Reproductive outcome; Ectopic pregnancy; Expectant management
1. Introduction
2. Patients and methods
The availability of sensitive diagnostic means and increased awareness has made early diagnosis of ectopic pregnancy possible, providing the impetus for nonsurgical management of this condition in clinically stable patients. Such an approach includes various medical and expectant management regimens [1]. Expectant management of ectopic pregnancy entails diagnosis and follow-up of clinically stable patients by serum/3-hCG determination and ultrasonography. When /~-hCG levels fall, surgery, as well as diagnostic laparo~opy, is generally avoided. Thus laparoscopy confirming the diagnosis has not been performed in most reported series. While reports on expectant management of tubal pregnancies have become numerous [2-4], reports on fertility rates following such management schemes of laparoscopically confirmed tubal pregnancies are few [5-7]. In this retrospective study, we set out to evaluate the long-term reproductive outcome in women with laparoscopically confirmed aborting tubal pregnancies who were managed expectantly.
The records of 33 patients admitted with ectopic pregnancy in a clinically stable condition and managed expectantly were reviewed. Initial diagnosis based on serial B-hCG levels and ultrasonography was confirmed by laparoscopy. These were patients with falling B-hCG levels, who at laparoscopy had signs of tubal abortion or a hematosalpinx <2 cm in diameter and hematoperitoneum of < 50 ml. The patients were managed expectantly, following their /3-hCG levels until they reached < 10 mlU/ml. Characteristics of the patients are summarized in Table 1. Subsequent reproductive outcome was assessed in 20 patients who desired pregnancy. Excluded were patients with impediments to fertility, such as those older than 40 years of age and patients with previous infertility, as well as patients who were lost for follow-up. The duration of follow-up varied from 1 to 5 years (mean 2.7 years).
* Correspondingauthor, Tel.: +972 7 745223; Fax: +972 7 736750. 1Affiliated to the Faculty of Health Sciences, Ben-Gurion Universityof the Negev, Beersheva, Israel.
3. Results
Of the 20 patients who desired pregnancy and were followed up, 16 (80%) delivered babies, one patient (5%) had a repeat ectopic pregnancy, and three patients (15%) were unable to conceive.
0301-2115/96/$15.00 © 1996ElsevierScienceIreland Ltd. All rights reserved SSD1 0301-2115(95)02370-M
2
E. Zohav et al./European Journal of Obstetrics & Gynecology and Reproductive Biology 66 (1996) 1-2
Table I Previous fertility history of expectant therapy study group Factor
Expectant therapy group
Number of patients Mean age (years) Prior infertility Previous deliveries Mean of previous deliveries Previous abortions Previous ectopic pregnancy
33 (100%) 28.2 5 (15%) 22 (66.6%) 2.1 3 (9%) 3 (9%)
It may be concluded that in cases of aborting tubal pregnancies treated expectantly, a favorable reproductive outcome may be expected. There is future need for work to compare successful fertility per unit of time in which pregnancy is attempted, with non-parametric statistical comparison.
References [1]
4. Discussion
In the past it was claimed that when observation was the only management of ectopic pregnancy, adhesions formed at the site of the ectopic pregnancy [8]. This has been refuted by others [4,7], who documented tubal patency by hysterosalpingography or laparoscopy in 72-92% of the patients treated expectantly. Apart from anecdotal reports [5,6], we are aware of only one study with substantial patient follow-up time, in which the pregnancy rates in laparoscopically confirmed ectopic pregnancies have been reported [7]. Fernandez et al. reported eight intrauterine pregnancies in nine women who desired pregnancy, achieved after a mean time of 16 months. Of note, the inclusion criteria for expectant management used by us and by Fernandez et al. were similar.
[2]
[3] [4]
[5]
[6]
[7]
[8]
PanskyM, Golan A, Bukovsky I, Caspi E. Non-surgical management of tubal preganancy, necessity in view of the changing clinical appearance. Am J Obstet Gynecol 1991: 164: 888-895. Ylostalo P, Cacciatore B, Koskimies Aet al. Conservative treatment of ectopic pregnancy. Ann NY Acad Sci 1991: 626: 516-523. Makinien JI, Kvigarvi AK, Fjala KM. Success of non-surgical management of ectopic pregnancy. Lancet 1990; 335: 1099. Sauer MV, Gorrill M J, Rodi IA et al. Non-surgical management of unruptured ectopic pregnancy: an extended clinical trial. Fertii Sterii 1987; 48: 752-755. Garcia A, Aubert J, Sama J, Josimivich JB. Expectant management of presumed ectopic pregnancies. Fertil Steril 1987; 48: 395-400. Carp HJ, Oelsner G, Scrr D, Mashiach S. Fertility after nonsurgical treatment of ectopic pregnancy. J Reprod Med 1986; 31: 119-122. Fernandez H, Lelaidier C, Baton C, Bourget P, Frydman R. Return of reproductive performance after expectant management and local treatment for ectopic pregnancy. Hum Reprod 1991; 6: 1474-1477. Cole T, Corlett RC. Chronic ectopic pregnancy. Obstet Gynecol 1982; 59; 63-68.