A woman with a tubal ectopic pregnancy can be managed medically through the use of a single dose methotrexate regimen. This can be safe and successful provided it is carefully adhered to.


Initial dose: 50 mg per square meter of body surface area, given IM.


No leucovorin is given.


Contraindications to methotrexate therapy:

(1) thrombocytopenia

(2) leukopenia

(3) elevated serum liver function tests

(4) elevated serum creatinine


Serum monitoring of beta-HCG is done:

(1) on day 4

(2) on day 7

(3) weekly until serum beta-HCG is no longer detectable


A repeat dose is given if:

(1) the decline in serum beta-HCG between days 4 and 7 is < 15%, with the serum level on day 7 > 0.85 * (serum level on day 4)

(2) the serum level of beta HCG after day 7 plateaus or rises

(3) weekly serum measurements of beta-HCG fail to decline


NOTE: I assume that only a single repeat dose is given with this protocol.


Surgery is performed if:

(1) evidence of tubal rupture (clinical, ultrasonography, other)

(2) additional therapy required but the patient has a contraindication to further methotrexate therapy

(3) increasing pain


Patient instructions:

(1) avoid alcohol (because of potential liver injury)

(2) drink > 1,500 mL of liquid per day

(3) no sexual intercourse or pelvic examination until resolved

(4) pregnancy should be delayed for >= 3 months because of the teratogenic effect of methotrexate


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