METHOTREXATE PROTOCOL FOR ECTOPIC PREGNANCY

(DRAFT)
DIAGNOSIS
BHCG >1500
Transvaginal ultrasound: no IUP (intrauterine pregnancy), adnexal mass
Abnormal uterine bleeding
Cervical os closed
Abdominal pain
INDICATIONS
ABSOLUTE
o Hemodynamically stable without active bleeding or signs of
hemoperitoneum(i.e. minimal free fluid in cul de sac on U/S)
o Patient desires future fertility
o General anesthesia poses significant risk
o Patient able to return for follow-up care
o Patient has no contraindications to methotrexate

RELATIVE
o Unruptured adnexal mass <3.5cm at greatest dimension
o No fetal cardiac motion detected
o BHCG that does not exceed 6,000-15,000mIU/mL

CONTRAINDICATIONS
ABSOLUTE
o Hepatic, renal or hematologic disease
o Active pulmonary disease
o Peptic ulcer disease
o Overt lab evidence of immunodeficiency
o Chronic liver disease, alcoholism, alcoholic liver disease
o Blood dyscrasia: thrombocytopenia, leucopenia, significant anemia, bone
marrow hypoplasia
o Breastfeeding

RELATIVE
o Gestational sac >3.5cm
o Embryonic cardiac motion

LABS TO BE CHECKED BEFORE MTX ADMINISTRATION

BHCG quant
CBC W/ DIFF
TYPE AND SCREEN

CHEM-7
HEPATIC FUNTION PANEL
COAGS: PT/INR, PTT

MTX ADMINISTRATION GUIDELINES/FOLLOW-UP

Dose: 50mg/m2 , single dose IM injection (to be ordered and administered by
GYN)
Follow-up:
o 1st BHCG check: Day 4 (BHCG level will peak)
o 2nd BHCG check : Day 7 (BHCH should decline by at least 15%)
Levels that do not decline appropriately indicate need for
additional dose of MTX or surgery
o Weekly thereafter until BHCG undetectable
PATIENT COUNSELLING
Patient may experience following side effects: at least one episode of increased
abdominal pain, vaginal bleeding, spotting or medication side effects (see below)
THERE IS A RISK OF RUPTURE OF ECTOPIC PREGNANCY WHICH CAN
LEAD TO INTERNAL BLEEDING. CALL PHYSICIAN IMMEDIATELY IF
ONE OF THE FOLLOWING EXPERIENCED: sudden severe abdominal pain,
heavy vaginal bleeding, lightheadedness, dizziness, fainting, heart palpitations
Avoid alcoholic beverages, vitamins containing folic acid, NSAIDS or sexual
intercourse until advised otherwise.
Importance of adherence to follow-up must be stressed
SIDE EFFECTS ASSOCIATED WITH METHOTREXATE
Drug side effects
o Nausea/vomiting
o Mouth sores
o Diarrhea/gastrointestinal upset
o Dizziness
o Severe neutropenia (rare)
o Reversible alopecia (rare)
o Pneumonitis
Treatment effects
o Increased abdominal pain (excluding severe pain, acute abdomen)
o Increased BHCG levels during days 1-3 after treatment
Signs of treatment failure/tubal rupture (rupture may occur despite declining
BHCG levels)
o Significantly worsening abdominal pain (regardless of change in BHCG)
o Hemodynamic instability
o BCG that does not decline by at least 15% between days 4-7 postinjection
o Increasing/plateauing BHCG levels after 1st week of treatment

Presbyterian Methotrexate Protocol

1. Once ectopic pregnancy is diagnosed or suspectedthe GYN attending on call
should be notified.
2. After full evaluation of the patient, the GYN attending or his/her representative
will decide if the patient is a candidate for MTX. All appropriate labs should be
ordered and all criteria/contraindications reviewed.
3. All risks and potential side effects of MTX will be discussed with the patient.
These will include but are not limited to- possible rupture of the fallopian tube,
massive hemorrhage, possible failure of MTX requiring re-treatment or surgery.
All risks should be documented on the chart and INFORMED CONSENT
OBTAINED in writing.
4. Dosage of MTX should be calculated, ordered and administered by the GYN
attending or his/her representative.
5. Appropriate follow-up should be arranged by the GYN attending/or his/her
representative and then documented on discharge instructions.