Fig. 7.1
Methotrexate treatment protocol for tubal or interstitial ectopic pregnancy. (From Tulandi T: Methotrexate treatment of tubal and interstitial ectopic pregnancy. In: UpToDate (Eds. R.L. Barbieri and S.J. Falks))
After MTX injection, blood sampling is repeated either 4 or 7 days later. If the decrease in serum hCG level is less than 15 % from day 4 to day 7, a second dose of MTX is administered. It is common to see an increase in hCG levels in the first several days after MTX administration. A simpler protocol is to repeat the blood sampling on day 7 after the initial treatment, saving patient visit on day 4. A second dose of MTX is administered if the hCG level has not decreased by 25 % from day 1 level. Measurement of serum hCG level is repeated weekly until the level is undetectable (less than 10 mIU/mL).
Outcome
The patient received a single dose of MTX intramuscularly. Since she was Rh(D)-negative, she was also given Rhogam. She was instructed not to take folic acid (counteract with MTX), to avoid intercourse, and not to be exposed to sun to limit the risks of dermatitis. Serum hCG level 7 days after the injection was 2300 mIU/mL and she was given another dose of MTX. Two weeks later, the level was less than 10 mIU/mL. She spontaneously conceived 6 months after the MTX treatment. An ultrasound examination at 5 weeks gestation revealed an intrauterine pregnancy, and at 6 weeks, a single live fetus with cardiac activity.
Clinical Pearls/Pitfalls
The success rate of MTX treatment for ectopic pregnancy is close to 90 %.
The ideal candidates for MTX treatment of ectopic pregnancy are those who are hemodynamically stable, willing and able to comply with posttreatment follow-up, have a beta-subunit hCG concentration ≤ 5000 mIU/mL, and have no fetal cardiac activity
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