Expectant management of tubal pregnancies with human chorionic gonadotropin up to 2000 mIU/mL

Nir Kugelman, Cohen B, Bracha Cohen, Yossef F, Fayrooz Yossef, Nadine Margieh, Margieh N, Noam Regev, Regev N, Shani U, Uria Shani, Yossi Bart, Bart Y
International Journal of Gynecology & Obstetrics · 2024 · vol. 164(3) , pp. 1094–1100 · doi:10.1002/ijgo.15162 · PMID:37776069
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This retrospective cohort study from two tertiary hospitals compared expectant management versus methotrexate in women with confirmed tubal pregnancies and pretreatment hCG <2000 mIU/mL, focusing on the eventual rate of surgical treatment. Among 545 eligible patients (201 expectant management, 344 methotrexate), all expectantly managed women had a declining hCG trend, while the methotrexate group had higher pretreatment hCG and more ultrasound findings of yolk sac or embryo presence. Eventual surgical treatment was lower with expectant management than methotrexate overall (4.5% vs 11.3%), and in subgroup analyses for hCG 1000–2000 mIU/mL, rates of eventual surgery, treatment failure, and tubal rupture were comparable; the paper’s caveat is its retrospective design and its exclusion of cases with unrecorded or unconfirmed diagnosis, limiting generalizability. Logistic regression showed eventual surgical treatment was independently associated with lower hCG (<1000 mIU/mL) and endometriosis (aOR 9.20). Relevance to endometriosis: endometriosis was identified as an independent predictor of eventual surgical treatment in this tubal pregnancy expectant-management versus methotrexate study, though the paper’s main focus is tubal pregnancy management.

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Abstract

OBJECTIVE: To describe outcomes of expectant management (EM) versus methotrexate (MTX) treatment in tubal pregnancies with pretreatment human chorionic gonadotropin (hCG) less than 2000 mIU/mL. METHODS: This retrospective cohort from two tertiary hospitals included women with confirmed tubal pregnancies and pretreatment hCG <2000 mIU/mL. Exclusion criteria were unrecorded pregnancy site, unconfirmed diagnosis, and surgical treatment upon diagnosis. The primary outcome was eventual rate of surgical treatment. RESULTS: Between December 2009 and June 2021, 545 of 2114 (25.8%) women diagnosed with a tubal pregnancy met our inclusion criteria. We compared women who underwent EM (N = 201) with women who received MTX (N = 344). All women in the EM group had a declining trend of hCG. The MTX group had higher pretreatment hCG and higher rates of yolk sac or embryo presence on ultrasound. Eventual surgical treatment rate was higher in the MTX group compared with the EM group (39 [11.3%] vs. 9 [4.5%], P = 0.006), with no difference in the treatment failure rate or tubal rupture rate. In a subgroup analysis of women with pretreatment hCG between 1000 and 2000 mIU/mL, eventual surgical treatment, treatment failure, and tubal rupture rates did not differ between groups. Logistic regression analysis revealed that eventual surgical treatment was independently associated with hCG levels less than 1000 mIU/mL (adjusted odds ratio [aOR] 0.28, 95% confidence interval [CI] 0.14-0.56) and endometriosis (aOR 9.20, 95% CI 3.55-23.81). CONCLUSION: Expectant management of tubal pregnancies with pretreatment hCG levels less than 2000 mIU/mL and even between 1000 and 2000 mIU/mL and with a declining trend of hCG demonstrated lower or comparable rates of eventual surgical treatment, when compared with MTX treatment.
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Abstract

Objective To describe outcomes of expectant management (EM) versus methotrexate (MTX) treatment in tubal pregnancies with pretreatment human chorionic gonadotropin (hCG) less than 2000 mIU/mL.

Methods

This retrospective cohort from two tertiary hospitals included women with confirmed tubal pregnancies and pretreatment hCG <2000 mIU/mL. Exclusion criteria were unrecorded pregnancy site, unconfirmed diagnosis, and surgical treatment upon diagnosis. The primary outcome was eventual rate of surgical treatment.

Results

Between December 2009 and June 2021, 545 of 2114 (25.8%) women diagnosed with a tubal pregnancy met our inclusion criteria. We compared women who underwent EM (N = 201) with women who received MTX (N = 344). All women in the EM group had a declining trend of hCG. The MTX group had higher pretreatment hCG and higher rates of yolk sac or embryo presence on ultrasound. Eventual surgical treatment rate was higher in the MTX group compared with the EM group (39 [11.3%] vs. 9 [4.5%], P = 0.006), with no difference in the treatment failure rate or tubal rupture rate. In a subgroup analysis of women with pretreatment hCG between 1000 and 2000 mIU/mL, eventual surgical treatment, treatment failure, and tubal rupture rates did not differ between groups. Logistic regression analysis revealed that eventual surgical treatment was independently associated with hCG levels less than 1000 mIU/mL (adjusted odds ratio [aOR] 0.28, 95% confidence interval [CI] 0.14–0.56) and endometriosis (aOR 9.20, 95% CI 3.55–23.81).

Conclusion

Expectant management of tubal pregnancies with pretreatment hCG levels less than 2000 mIU/mL and even between 1000 and 2000 mIU/mL and with a declining trend of hCG demonstrated lower or comparable rates of eventual surgical treatment, when compared with MTX treatment. CONFLICT OF INTEREST STATEMENT The authors have no conflicts of interest. DATA AVAILABILITY STATEMENT The data that support the findings of this study are available from the corresponding author, NK, upon reasonable request.

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Condition tags

endometriosis

MeSH descriptors

Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal Abortifacient Agents, Nonsteroidal

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