From the Guidelines
Medical management of ectopic pregnancy primarily involves methotrexate, a medication that stops cell growth and dissolves existing cells, and is recommended for patients who are hemodynamically stable, have no contraindications to methotrexate, have a tubal mass less than 3.5 cm, no fetal cardiac activity, and hCG levels typically below 5,000 mIU/mL.
Key Considerations
- A single-dose regimen of 50 mg/m² of methotrexate intramuscularly is typically recommended, followed by monitoring hCG levels on days 4 and 7 post-injection 1.
- If hCG levels don't decrease by at least 15% between days 4 and 7, a second dose may be administered 1.
- Some cases may require a multi-dose regimen of 1 mg/kg on days 1,3,5, and 7, alternating with leucovorin 0.1 mg/kg on days 2,4,6, and 8 1.
- Patients should avoid folic acid supplements, non-steroidal anti-inflammatory drugs, alcohol, and sun exposure during treatment, and abstain from sexual intercourse until hCG levels are undetectable 1.
Indications for Surgical Intervention
- Surgical intervention is necessary for patients who are hemodynamically unstable, have a ruptured ectopic pregnancy, or when medical management fails 1.
Importance of Monitoring
- Close monitoring of hCG levels and patient symptoms is crucial to ensure the effectiveness of medical management and to promptly identify any potential complications 1.
From the Research
Medical Management of Ectopic Pregnancy
The medical management of ectopic pregnancy involves the use of methotrexate, a folic acid antagonist, as an alternative to surgical therapy 2. The most commonly used protocol consists of methotrexate 50 mg/m of actual body weight, with assessment of human chorionic gonadotropin (hCG) levels repeated on days 4 and 7 2.
Selection Criteria for Medical Management
Selection criteria for patients include:
- An unruptured ectopic pregnancy less than or equal to 3.5 cm in greatest dimension on transvaginal ultrasound 3
- No active renal or hepatic disease 3
- No evidence of leukopenia or thrombocytopenia 3
- Low titers of beta-hCG and masses with a small diameter 4
Efficacy of Methotrexate Treatment
The efficacy of methotrexate treatment can be predicted by:
- A decrease in beta-hCG levels between days 0 and 4 after treatment 5
- A decline of ≥15% in beta-hCG levels on days 4 and 7 after dose administration 5, 2
- A success rate of above 90% is achievable with methotrexate treatment 2
Monitoring and Follow-up
Patients undergoing methotrexate treatment should be closely monitored, with regular assessment of beta-hCG levels and transvaginal ultrasound examinations 3, 6. Adverse effects of methotrexate include stomatitis, gastritis, and hepatic enzyme elevation, which can be prevented with the use of leucovorin 3.
Special Considerations
In cases of high-beta-hCG ectopic pregnancy, methotrexate treatment may still be effective, but requires close monitoring and a multidisciplinary approach 6. The choice of medical management ultimately depends on the experience of the medical team and the woman's reproductive desire 4.