- Antimetabolite and antifolate drug which is an established, effective and safe treatment for unruptured ectopic pregnancy and treatment of PUL.
- Success rates are around 80-90%.
- Careful patient selection is paramount- consultant review is required.
- Avoid aspirin or anti inflammatory drugs for 1 week after administration.
- Avoid alcohol, vitamins containing folic acid, intercourse, and travel out with the local area until follow up is complete.
- The vast majority of patients who have methotrexate will go on to have a subsequent intra-uterine pregnancy.
[CG] Ectopic pregnancy, medical management
What's new / Latest updates
28/06/2021 Removal of Anti-D administration advice as per guideline update
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- Diagnosis of ectopic pregnancy or PUL confirmed according to EPAS guidelines.
- Patient clinically stable with minimal or no symptoms.
- No contra-indications to medical management.
- Patient fully counselled regarding treatment options and wishes medical management.
- Patient is able and willing to comply with follow up for several weeks - the average follow up time is 35 days.
- Patient agrees to avoid pregnancy until follow - up complete and three months after methotrexate.
- Fetal cardiac activity.
- Concurrent intrauterine pregnancy (heterotopic pregnancy).
- Significant free intraperitoneal fluid.
- Serum HCG≥ 5000 iu/l.
- Abnormal renal or hepatic function- discuss with consultant if deranged.
- Adnexal mass ≥ 4 cm.
- Hb ≤ 100g/l, WCC≤ 2 x 109/l , platelets ≤100 x 10 9/ l
- Patient currently breast feeding.
- Patient unwilling to avoid pregnancy for 3 months
Most side effects are usually mild:
- Nausea, diarrhoea, stomatitis.
More serious side effects are rare:
- Impaired liver function, bone marrow suppression- usually reversible.
Abdominal pain occurs in about 75% of patients 3-7 days after methotrexate. This “separation pain” can be difficult to distinguish from pain due to rupture. If patient presents with concerning symptoms, carry out ultrasound to look for free fluid +/or admit for observation and senior review.
There is a 7% risk of tubal rupture following methotrexate.
- Serum HCG
- FBC, U+E, LFTs, blood group
- Height and weight. Calculate Surface Area-copy and paste the following into a web browser:
(use the Dubois formula, weight in kg and height in centimetres)
- Offer Chlamydia screening.
- Pharmacy prescription to be completed by senior medical staff.
Day 1. Methotrexate administration day
- Ensure patient has had appropriate counselling and information sheet.
- Ensure consent form signed.
- Ensure patient contact details are clearly documented in notes.
- Ensure patient has EPAS contact numbers and gynaecology ward number for out- of -hours advice
- Inform GP of diagnosis and treatment- see GP information leaflet.
- Administer methotrexate 50 mg/m2 IM-see methotrexate prescription form for dose banding according to surface area.
Day 4. EPAS Review
- Check serum HCG
Day 7. EPAS Review
- Check serum HCG
- If HCG on day 7 has fallen by 15% or more from day 4 levels, check HCG weekly until < 5iu/l.
- If HCG has not fallen by at least 15%, discuss with senior medical staff. In carefully selected cases, it may be appropriate to repeat HCG levels on day 10.
- If HCG has risen, refer to senior medical staff to discuss option of laparoscopy or a second dose of methotrexate.
- Approximately 15% of women will require a second dose of methotrexate.
- Very rarely, a third dose may be appropriate- this must be a consultant decision.
Second Dose of Methotrexate
- Ensure treatment criteria still fulfilled and discuss case with Consultant
- Transvaginal scan.
- FBC, U+E, LFT.
- Check HCG levels weekly until <5iu/l
- If levels plateau or rise, discuss with senior medical staff
- Discharge patient when HCG < 5iu/l.
There are no absolute contra-indications to specific forms of contraception after an ectopic, other than usual cautions, but the use of a copper coil should be limited to patients for whom no other methods are suitable.
Advise to attend EPAS early in next pregnancy to confirm location.