Singledose methotrexate

Methotrexate is most commonly given systemically according to a single-dose regimen (Table 10.1).5 In most units this involves giving a dose of 50 mg/m2 on the day of presentation or

Table 10.1. Protocol for the use of single

dose methotrexate in unruptured ectopic

pregnancy

Day

Management

0

Serum hCG, FBC, U&Es, LFTs, G&S

1

Serum hCG

Intramuscular methotrexate 50 mg/m2

4

Serum hCG

7

Serum hCG, FBC, LFT

2nd dose of methotrexate if hCG decrease

<15% days 4-7

If hCG decrease >15% repeat hCG weekly

until <12 IU/L

Table 10.2. Success rates for single dose methotrexate - a review of the literature. (Reproduced from2

Author and

Year

N =

Success

Overall

Additional

Mean hCG

Time to

reference

single dose

success

dose n =

(IU/L)

resolution

(days)

Stovall5

1993

120

91%

94.2%

3.3%

3950 ± 1193

35.5 ± 11.8

(109/120)

(113/120)

(4/120)

Glock8

1994

35

85.7%

85.7%

1388 ± 464

23.1 ± 2.9

(30/35)

(30/35)

Henry9

1994

61

59%

85%

26.2%

(36/61)

(52/61)

(16/61)

Ransom10

1994

21

67%

71%

4.8%

1575 ± 1350

(14/21)

(15/21)

(1/21)

Corsan11

1995

44

52%

75%

22.7%

2517 ± 3144

(23/44)

(33/44)

(10/44)

Gross12

1995

17

94.1%

3320

26.4

(16/17)

(158-12 420)

(12-55)

Stika13

1997

50

64%

78%

14%

1896.4 ± 2399

26.5 ± 17

(32/50)

(39/50)

(7/50)

Lecuru14

1998

37

83.7%

91.8%

8.1%

585

27.1

(31/37)

(34/37)

(3/37)

(50-5525)

(7-50)

Saraj15

1998

38

78.9%

94.7%

15.8%

3162 ± 772

27.2 ± 2.3

(30/38)

(36/38)

(6/38)

Gazvani16

1998

25

72%

88%

16%

(18/25)

(22/25)

(4/25)

Thoen17

1998

47

76.6%

91.5%

14.9%

803

25 ± 15

(36/47)

(43/47)

(7/47)

(45-49 473)

Elito18

1999

40

75%

85%

(30/40)

(34/40)

Tawfiq19

2000

60

73%

25.7 ± 8.8

(44/60)

Sowter20

2001

34

65%

26%

(22/34)

(9/34)

Lewis-Bliehall21

2001

119

70%

79%

9.2%

(83/119)

(94/119)

(11/19)

Olofsson22

2001

26

77%

24 ± 9

(20/26)

el-Lamie23

2002

35

71%

94.3%

22.9%

34.8

(25/35)

(33/35)

(8/35)

(15-70)

Gamzu24

2002

56

89.3%

2167 ± 220

(50/56)

Potter25

2003

81

85%

(69/81)

Alshimmiri26

2003

77

95%

2592 ± 3771

(73/77)

Erdem6

2004

34

65%

88%

26.6%

2490 ± 2912

(22/34)

(30/34)

(8/34)

Lipscomb27

2004

495

90.5%

(448/495)

© International Society of Ultrasound in Obstetrics and Gynecology, first published by John Wiley & Sons Ltd.)

Comments on Comments inclusion criteria

• Increase in hCG after uterine curettage

• 83% diagnosed after increase in hCG after uterine curettage

• No fetal cardiac activity

• Increase in hCG after uterine curettage

• No fetal cardiac activity

Diagnosis of ectopic pregnancy based on TVS, hCG and uterine curettage Serum hCG <15 000 IU/L No fetal cardiac activity

Serum hCG <5000 IU/L

100% success when hCG <3600 IU/L

Confirmed laparoscopically No fetal cardiac activity

USS diagnosis (haematosalpinx, tubal ring or live embryo) Ultrasound diagnosis in 70% Serum hCG <5000 IU/L

28% (13/47) visited emergency department because of pain

92.5% success hCG <4000 IU/L 35% success hCG >4000 IU/L

• Diagnosis on TVS and serial hCG quantification

• Fetal cardiac activity not an exclusion criteria

• Size of ectopic not related to success rate

• Presence of a yolk sac on TVS was a predictor of failure diagnosis (day 1). Serum hCG levels are then checked on days 4 and 7 post treatment. If the hCG level decreases by more than 15% between days 4 and 7, hCG levels are then checked on a weekly basis. If the hCG does not decrease by more than 15% a second dose can be given. In 3-27% of cases a second dose is needed.5,6 This protocol has been prospectively validated and been found to identify 90.9% of cases likely to have a successful outcome.7 Absolute contraindications to its use include significant pain, signs of an acute haemoperitoneum, and liver, kidney or bone marrow impairment. Relative contraindications include fetal cardiac activity, an ectopic mass greater than 3 cm in diameter and an initial hCG level greater than 5000 IU/L. As with expectant management, patient selection is extremely important. Women receiving methotrexate must be reliable and compliant and counselled appropriately before its administration. Although side effects from a single dose of methotrexate are rare, they include nausea, gastric disturbance, tiredness and abdominal pain. Women should be advised to avoid alcohol, folic acid and sexual intercourse during the period of treatment.

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