by Adi Dayan-Schwartz, Suzan Abd Elgani, Tamam Abdul-Ghani, Liron Kogan, Ari Reiss, Alon Tal
International Journal of Obstetrics & Gynecology,15 April 2024, pp. 1330-1336 (Open access)
https://doi.org/10.1002/ijgo.15511
Visual of an ectopic pregnancy, from
From the Introduction
Tubal pregnancy may be managed pharmacologically, surgically or by expectant management. The pharmacological treatment of choice is methotrexate (MTX), a folic acid antagonist, and is used in selected cases, to avoid hospitalization and surgery, thus preserving fertility and reducing the treatment cost. The first single-dose MTX protocol was developed by Stovall et al., with a successful treatment defined as >15% decline in β-hCG levels from days 4–7. The initial success rate according to this protocol was 96.7%. Two years later, using the same protocol, Stovall and Ling repeated their trial in an expanded prospective clinical trial including 120 women and reported a success rate of 94.2% (113/120).
Since 1991 the literature depicts several studies evaluating alternative follow-up protocols: day 1 to 7 β-hCG levels and day 1 to 4 β-hCG levels as predictors for successful treatment, with conflicting results.
According to the American College of Obstetricians and Gynecologists the traditional protocol of day 4 to 7 β-hCG levels is still the recommended follow up protocol. The few studies that have compared the cost of laparoscopic treatment to methotrexate treatment for ectopic pregnancy have shown a reduction of 46%–70% with methotrexate usage. The main factor influencing the cost reduction was decreased hospital stay.
In addition to the financial costs, hospitalization has a significant impact on patients’ emotional and psychological well-being that could exacerbate their emotions and increase feelings of depression and anxiety.
Omitting one of the follow up days of β-hCG measurement may save time and costs for both patient and the healthcare system.
The aim of the present study was to compare the clinical safety of β-hCG measurement protocols: (1) day 1 to 7 β-hCG levels, (2) day 1 to 4 β-hCG levels and (3) day 4 to 7 β-hCG levels.
A retrospective study was conducted at a single university teaching hospital between January 2001 and May 2021. Once ectopic pregnancy was diagnosed, all patients were offered the choice of treatment. Patients without contraindication to methotrexate treatment were given a choice of a single dose of methotrexate or surgical (salpingectomy) treatment. The study group included patients diagnosed with ectopic pregnancy who were initially treated with a single dose intramuscular injection protocol of methotrexate (1 mg/kg).
Successful methotrexate treatment was defined as no surgical intervention.
From the results
A total of 229 women were included in our final analysis as shown in Figure 1. Over the study period our department had 88 338 births and 1044 ectopic pregnancies, an average of 4309 births annually and a rate of 1.1% ectopic pregnancies from all births. Overall, 184 (80.3%) patients were treated successfully with a single dose of methotrexate, and 160 (69.8%) of those had adequate 4 to 7 day β-hCG decline, while another 24 (10.4%) had inadequate 4 to 7 day β-hCG decline, but completed a successful expectant management as they refused either surgery or a second methotrexate dose. A total of 45 patients (19.6%) were treated surgically; of those 20 (8.7%) were asymptomatic on day 7 but had inadequate day 4 to 7 β-hCG decline and the additional 25 (10.9%) patients were treated due to pain after day 7 β-hCG measurement.
From the conclusion
Patients treated with methotrexate for ectopic pregnancy, measurement of day 1–7 β-hCG levels has cost minimization advantage with no decline in safety or accuracy.
[Note: The text of this research report was very dense and clinical. I have tried to excerpt and slightly reword the most important points, and avoided the many abbreviations so as to try to make it more understandable, including for myself. Editor]