Methotrexate Ectopic Protocol

1. See Also
   1. Ectopic Pregnancy
   2. First Trimester Bleeding
2. Indications: Ectopic Pregnancy
   1. Quantitative bhCG < 5,000 mIU/ml
   2. Ectopic Pregnancy fully visualized on Ultrasound
      1. Embryo size under 3 cm
      2. Tubal serosa intact (no rupture
      3. No fetal heart activity)
   3. Normal lab testing (see screening below)
   4. No active bleeding
3. Advantages
   1. Allows for possible future fertility on affected side
4. Contraindications
   1. White Blood Cell Count <3000
   2. Platelet Count <100,000
   3. Liver disease or Elevated Aspartate Aminotransferase
   4. Renal Disease or elevated Serum Creatinine
   5. Poor compliance
   6. History Peptic Ulcer Disease
   7. Fetal cardiac activity noted on Ultrasound
5. Labs
   1. Chemistry Panel (chem8)
   2. Complete Blood Count with differential
   3. Liver enzymes
6. Protocol 1: Single Dose
   1. Contraception until bHCG returns to 5 mIU/ml or less
   2. Methotrexate 50 mg/m2 BSA IM for 1 dose (some protocols have used IV or PO)
   3. bHCG monitoring as below (days 4, 7 and then weekly)
      1. Repeat dose if bHCG does not drop 15% from days 4-7
      2. Consider surgery
   4. Consider Leucovorin rescue
   5. Outcomes
      1. Success rate: 88.1% (>1 dose needed in 14% of cases)
      2. Adverse effects: 31.3%
7. Protocol 2: Multiple Dose
   1. Contraception until bHCG returns to 5 mIU/ml or less
   2. bHCG monitoring as below
   3. Alternate agents up to 4 doses of each drug
      1. Methotrexate 1 mg/kg PO or IV on days 1, 3, 5, and 7
      2. Leucovorin 0.1 mg/kg on days 2, 4, 6, and 8
   4. Outcomes
      1. Success rate: 92.7%
      2. Adverse effects: 41.2%
8. Labs: Initial (See Contraindications)
   1. Complete Blood Count
   2. Aspartate Aminotransferase (AST)
   3. Quantitative bhCG
9. Monitoring
   1. Inadequate bHCG response requires intervention
      1. Methotrexate may be repeat dosed in Protocol 1
      2. Consult regarding possible surgical intervention
   2. Follow Quantitative bhCG
      1. First Week: Draw bHCG days 4 and 7
         1. Anticipate 15% bHCG decrease between days 4 and 7
      2. Subsequent Weeks: Draw bHCG weekly
         1. Anticipate drop to 5 mIU/ml by 3-4 weeks
   3. Serum Progesterone may also be followed
      1. Anticipate drop to 1.5 mg/ml by 2-3 weeks
10. Prognosis
    1. Recurrent Ectopic Pregnancy risk: 10-20%
    2. Chance of subsequent intrauterine pregnancy: 40-60%
11. References
    1. Barnhart (2003) Obstet Gynecol 101:778-84
    2. Lipscomb (1999) N Engl J Med 341:1974-8