Treatment of Ectopic Pregnancy
Treatment depends on hemodynamic stability: unstable patients require immediate surgery, while stable patients with unruptured ectopic pregnancy can be managed with either methotrexate or surgery based on specific clinical criteria. 1, 2, 3
Ruptured Ectopic Pregnancy: Emergency Surgical Management
Any patient with hemodynamic instability, peritoneal signs, or significant hemoperitoneum on ultrasound requires immediate surgical intervention. 1, 2
- Hemodynamic resuscitation must occur simultaneously with preparation for emergency surgery 1
- Obtain complete blood count to assess degree of anemia from hemorrhage 1
- Methotrexate is absolutely contraindicated in ruptured ectopic pregnancy 1, 3
- Surgical options include laparoscopic salpingectomy or salpingostomy 3, 4
Post-operative Management
- Monitor serial β-hCG levels until undetectable to ensure complete removal of trophoblastic tissue 1
- Administer Rh immunoglobulin if patient is Rh-negative 1, 3
Unruptured Ectopic Pregnancy: Medical Management with Methotrexate
Methotrexate is the first-line medical treatment for hemodynamically stable patients who meet specific eligibility criteria. 3, 4
Eligibility Criteria for Methotrexate
Ideal candidates must meet ALL of the following: 3
- Hemodynamically stable with no peritoneal signs 3
- Ectopic mass ≤3.5 cm in greatest dimension 3
- β-hCG level preferably ≤5,000 mIU/mL 3
- No embryonic cardiac activity on ultrasound 3
- Able and willing to comply with close follow-up 3
Absolute Contraindications to Methotrexate
- Alcoholism or active liver disease
- Immunodeficiency
- Active peptic ulcer disease
- Active pulmonary, renal, or hematopoietic system disease
- Breastfeeding (must discontinue immediately and wait 3 months after last dose) 3
Pre-treatment Laboratory Requirements
- Complete blood count with differential and platelet count
- Hepatic enzyme levels
- Renal function tests
- Blood type and Rh status 2
Methotrexate Dosing Protocol
- Standard dose: 50 mg/m² intramuscular injection 3
- Alternative: 1 mg/kg intramuscularly 3
- Avoid folic acid supplements (counteracts methotrexate), aspirin, and NSAIDs (potentially lethal interactions) 3
Expected Outcomes and Success Rates
- Overall success rates: 71-96% with single dose 3
- Treatment failure occurs in 3-36% of cases, with 12% requiring a second dose 3
- Higher failure risk with β-hCG >5,000 mIU/mL, larger masses, and presence of cardiac activity 3
- Rupture rates: 0.5-19% across studies 3
Follow-up Monitoring Protocol
- Serial β-hCG measurements until clearly decreasing 3
- Second dose indicated if β-hCG fails to decrease appropriately or plateaus 3
- If β-hCG doesn't decrease by at least 15% between days 4-7, consider second dose 3
Critical Warning Signs Requiring Immediate Return
Patients must return immediately for: 3
- Severe abdominal pain (may represent rupture, not just expected treatment effect)
- Signs of hemodynamic instability
- Heavy vaginal bleeding
- Shoulder pain (indicates diaphragmatic irritation from blood)
Common pitfall: Gastrointestinal side effects from methotrexate (nausea, abdominal pain) can mimic acute rupture—rule out rupture before attributing symptoms to drug toxicity 3
Unruptured Ectopic Pregnancy: Surgical Management
Immediate surgical consultation is required for patients with: 2
- Fetal cardiac activity visualized on ultrasound
- Contraindications to methotrexate
- Patient preference for definitive treatment
- Inability to comply with close follow-up 3
Surgical Approach
- Laparoscopy is preferred over laparotomy 4, 5
- Salpingostomy (conservative) or salpingectomy (definitive) 3, 4
- Post-operative β-hCG monitoring until undetectable 1
Special Considerations
Rh-Negative Patients
- Administer anti-D immunoglobulin to all Rh-negative women with ectopic pregnancy due to risk of alloimmunization 3
Patients Initially Treated with Methotrexate Who Develop Rupture
- 38% of patients with ruptured ectopic pregnancy after methotrexate require surgical intervention 1
- Any patient on methotrexate who develops hemodynamic instability or peritoneal signs requires immediate surgery 1, 3