Patients who are treated with methotrexate or salpingostomy should be followed
up with β-hCG titers to ensure there has been complete destruction of the ectopic
trophoblastic villi.
Methotrexate. This folate antagonist attacks rapidly proliferating
tissues including trophoblastic villi. Criteria for methotrexate include
pregnancy mass <3.5 cm diameter, absence of fetal heart motion, β-hCG
level <6,000 mIU, and no history of folic supplementation. Single dose 1
mg/kg is 90% successful. Patients with an ectopic pregnancy should be
advised of the somewhat increased incidence of recurrent ectopic
pregnancies. Follow-up with serial β-hCG levels is crucial to ensure
pregnancy resolution. Rh-negative women should be administered
RhoGAM.
Laparoscopy. If criteria for methotrexate are not met, surgical
evaluation is performed through a laparoscopy or through a laparotomy
incision. The preferred procedure for an unruptured ampullary tubal
pregnancy is a salpingostomy, in which the trophoblastic villi are
dissected free preserving the oviduct. Isthmic tubal pregnancies are
managed with a segmental resection, in which the tubal segment
containing the pregnancy is resected.
Salpingectomy is reserved for the patient with a ruptured ectopic
pregnancy or those with no desire for further fertility. After a
salpingostomy, β-hCG titers should be obtained on a weekly basis to make
sure there is resolution of the pregnancy. Rh-negative women should be
administered RhoGAM.