Any location of pregnancy other than the uterus is dangerous for the woman. We also assess the severity of the problem based on serum HCG levels. Any level more than 5 mIU/ml is considered positive. When the HCG level is 1000 million units per ml but we do not find a pregnancy sac in the scan, there we might ask for a repeat HCG test at the end of 48 hours to 78 hours, wherein we check the doubling of that HCG value. When it is a pregnancy of an unknown location, the doubling may or may not happen. Even if some amount of doubling happens, there we repeat ultrasound.
If we find a pregnancy sac and the location is outside the uterus then we have three treatment options. One is the surgical option. 2nd is the medical option and in a few selected situations only observation & close monitoring. The observation and close monitoring is done when the HCG levels are relatively low where we serially do a scan and repeat blood test to see that we are not missing out on anything. This is generally done when the HCG levels are less than 500 and the level of doubling is too slow. we monitor you at closer intervals and once the levels fall, you get menstrual bleeding. This opportunity is only for a few because most of the values will be between 1000 to 2000 million units per ml.
Why I am specifically saying this is, some reports come in litres. Then you should look at whether it is international units per litre or million units per ml. That is where sometimes mistakes happen. If the ultrasound shows a pregnancy measuring up to 3cm in the fallopian tube or it shows foetal heartbeat in the fallopian tube or if there is a mass in the tube with HCG levels above 2000. Some may take above 5000 and in that situation a key whole surgery or otherwise known as laparoscopy is done and then the damaged fallopian tube is removed. In a few instances when it is feasible we try to remove ectopic and repair the tube by a process called salpingostomy which involves just a cut on the tube.
This is to preserve the tube but it doesn’t mean another ectopic pregnancy will not come in that tube. When the damage is significantly more or in a case of ruptured ectopic, that fallopian tube is removed. This is called salpingectomy. The 3rd option we have is medical management. That means stopping the growth medically. Methotrexate injection is given and then serial monitoring is done till HCG level drops significantly. There are advantages and disadvantages to medical treatment. If we start medical management when HCG is below 2000 to 3000 million units per ml the success rate is close to 95%, the other 5 people might need laparoscopy or surgery.
If we are taking a value for medical management of around 5000 million units per ml, then the success rate is 66 percent only. 30 percent of the time you will need a laparoscopy at later date. so, you should be in close vicinity under observation. This risk-benefit ratio should be decided by the couple and the doctor in joint consultation. In my personal opinion, the decision should be left to the doctor who is a better judge at that critical point. You will be informed pros and cons.