Expectant management
The term expectant management is usually defined as watchful waiting or close monitoring by a physician instead of immediate treatment.
Increasingly doctors use expectant management for ectopic pregnancy. More than half of all ectopic pregnancies will end naturally without the need for medical or surgical treatment. Research has shown that in patients who are properly assessed, where their pregnancy hormone level (hCG) is dropping, up to 50% of these pregnancies will end naturally and there will be no need for an operation or a drug to treat the condition.
Your hospital should have given you a number to contact for health advice if you feel that anything is changing, or you will have been told to report to the accident and emergency department. If you have not been told what to do and need to speak to someone ring the hospital department which is treating you or NHS Direct on 0845 46 47.
When is expectant management most appropriate?
Expectant management is the best treatment when:
- The hormone being made by the pregnancy (beta hCG) is low
- General health appears to be stable
- Pain levels are considered to be acceptable
- An ultrasound scan shows a small ectopic pregnancy with no worrying bleeding into the abdomen.
Why does my doctor want to treat me this way and not give me medication or surgery?
Doctors always consider the least invasive form of treatment or management first where they can. Research-based evidence has shown that in properly selected patients, a proportion with a diagnosed or suspected ectopic pregnancy will need no active treatment and it will resolve on its own if we watch and wait. Although this can feel quite frightening and as though no one is doing anything, if the pregnancy does resolve on its own, avoiding surgery or powerful drug treatments, your recovery will be faster.
How successful is expectant management?
In properly selected patients, expectant management is very successful, with almost three-quarters of the women managed this way needing no further treatment.
What are the risks of being managed like this?
The main risk associated with expectant management is that the cells of the ectopic pregnancy might continue to divide, which could result in there still being a need for medical treatment or surgery after a period of expectant management. Around 25% of women who are expectantly managed initially, go to on to need medical or surgical treatment. Doctors can tell if the specialised cells of a pregnancy that produce the hCG hormone are dividing because the hCG level will rise and not fall. Occasionally an ectopic pregnancy can rupture despite low hCG levels. If you are concerned about your level of pain, please contact your hospital.
How will I know if there is a problem and I need a different treatment?
Your doctors will be able to tell if your pregnancy is not resolving, as this will be shown in the results of the regular blood tests. If this is the case, they will suggest other forms of treatment for you. The signs of a deteriorating ectopic pregnancy, which include severely increased pain levels; vaginal bleeding; shortness of breath; and pain in the tip of the shoulder among others may become noticable. More information on a deteriorating ectopic pregnancy can be found here. If you suffer any of these symptoms you will need to be reassessed. Your hospital should have given you a number to contact for health advice if you feel that anything is changing, or you will have been told to report to the accident and emergency department. If you have not been told what to do and need to speak to someone ring the hospital department which is treating you or NHS Direct on 0845 46 47. If you need further treatment If medical treatment with methotrexate is considered suitable it will be discussed with you. alternatively, you may be transferred to surgery to resolve the pregnancy. More information on the management of ectopic pregnancy with surgery can be found here.
What can I do to help this kind of management work for me?
It is important that you do not undertake any strenuous exercise or lift heavy weights while the hCG levels are dropping. You should also avoid sexual intercourse until your doctor is confident that the pregnancy is resolving. You should stop taking your folic acid supplements and avoid any other vitamin and/or mineral supplements until the hCG levels confirm that the ectopic pregnancy has ended. It is important to take things gently in the first few days after your diagnosis, until it can be established that the hCG levels are dropping on their own.
How will I be monitored?
Your doctors have arrived at a diagnosis after a series of clinical tests and assessments, including blood tests, ultrasound scan(s) and an assessment of your general health. Your doctors will want to test your blood to ensure that your hCG levels are dropping, usually twice in the first week and then weekly thereafter, until the levels have dropped to below 5<mIU/ml. It is not usually necessary to do another ultrasound scan unless you present with other symptoms, in which case your doctors will undertake a reassessment.
How long will I have to be monitored by the hospital?
This will depend upon how long it takes for your hCG levels to drop to below 5<mIU/mL and this can vary quite considerably from woman to woman. As a general rule, as long as your hCG levels are dropping between blood tests, your doctors will continue to monitor you and manage you expectantly. It can take anything between 2 weeks and 3 months, for your hCG levels to fall back to a non-pregnant level. But for most women, hCG levels have reached a non-pregnant state within around 4 weeks.
If you are at all worried at any point while you are being expectantly managed, you should report to the accident and emergency department.
Your emotions
Being managed expectantly can be a worrying time for any woman, and until your hCG levels drop, you may still ‘feel’ pregnant. Being worried about whether the pregnancy is resolving is quite normal and that is why your doctors are checking your hCG levels. However, women often say they feel guilty that they want the pregnancy to be over when they are also grieving for the loss of their baby. It is important you remember that the ectopic pregnancy was not your fault and that there was nothing you could have done to prevent it happening.
