Medical Management of Ectopic Pregnancy

O0.0-2/O0.8-9

GENERAL MEASURES

Ruptured or suspected rupture of an ectopic pregnancy should be managed with urgent resuscitation and surgery.
There must be certainty that there is no viable intra-uterine pregnancy.
If the initial β-hCG level is below the discriminatory zone (<1500 IU/L) to diagnose a pregnancy on ultrasound, and transvaginal ultrasound cannot definitively identify an intrauterine or extra-uterine gestation, then serial β-hCG measurements are necessary to document either a growing, potentially viable, or a nonviable pregnancy.
Repeat the β-hCG in 48 hours. If the level has dropped, conservative management may be appropriate.
The minimum rise in β-hCG for a potentially viable pregnancy in women who present with symptoms of pain and/or vaginal bleeding is 53% every 2 days.
If the level has increased by >50% or is now above the discriminatory zone, do a repeat scan to exclude an intra-uterine pregnancy before methotrexate is administered.

LoEIII [36]

MEDICINE TREATMENT

Methotrexate should be the first-line management for women who are able to return for follow-up and who have the following characteristics:

  • haemodynamic stability and no significant pain
  • an unruptured ectopic pregnancy with a mass <35 mm with no visible heartbeat
  • low serum β-hCG, ideally less than 1500 IU/L but can be up to 5000 IU/L
  • certainty that there is no intrauterine pregnancy
  • willingness to attend for follow-up

There are single dose or multiple dose methotrexate protocols available. The single dose protocol is less expensive, requires less intensive monitoring and does not require folinic acid rescue. The single dose protocol is recommended for the medical management of ectopic pregnancy.

LoEI [37]


Protocol:

Day 1: Do urea, creatinine, AST and FBC to exclude abnormalities.

  • Methotrexate, IM, 50 mg/m2 of body surface area (BSA).
    • BSA may be calculated based upon height and weight on the day of treatment using the formula BSA = square root ([cm X kg]/3600)

Day 4: Repeat β-hCG.

Day 7: Repeat β-hCG.

If the decrease from day 4 to day 7 is ≥15%:

  • Continue with weekly β -hCG until undetectable.

If decrease <15% and patient still fulfil the criteria for medical management:

  • Methotrexate, IM, 50 mg/m2 BSA.

LoEIII [38]

Day 14: Repeat β-hCG.



REFERRAL

After two doses of methotrexate, if the decline in β-hCG is still <15% on day 14, refer for specialist care.