ECTOPIC PREGNANCY TREATMENT — An ectopic pregnancy must be treated to stop its growth; observation or "watch and wait" treatment is never recommended because the life of the woman is at risk if treatment is delayed. Treatment is started as soon as a diagnosis of ectopic pregnancy is confirmed, and includes either medication or surgery.
Medical management — the majority of women with unruptured ectopic pregnancies are treated with methotrexate, which stops the growth of the embryo. It is given as an intramuscular injection.
After the injection, there are some side effects that may be experienced. The most common side effect is fatigue. Many women experience abdominal pain or cramps; this usually occurs approximately 10-14 days after the injection. This pain is an indication that the medication is working. The pain is due to the ectopic pregnancy beginning to detach from the wall of the fallopian tube. When this occurs, a small amount of blood can leak from the end of the tube into the pelvic cavity, causing discomfort or pain.
This pain can usually be controlled with acetaminophen (Tylenol®).
Nonsteroidal anti-inflammatory drugs (e.g., ibuprofen/Advil®/Motrin® or naprosyn/Naproxen®/Anaprox®) should be avoided due to the risk of an interaction between NSAIDs and methotrexate. There are other important restrictions which you should follow while being treated with Methotrexate. It is important to stop your prenatal vitamins, or any folic acid supplementation, as this interferes with the mechanism of action of Methotrexate. You should also avoid sexual intercourse, any aerobic exercise, heavy lifting, or any strenuous activity. These activities potentially could increase pressure in the pelvis, which could cause the ectopic pregnancy to rupture.
The effectiveness of the treatment is monitored by with blood tests to monitor serum HCG levels HCG is the hormone produced by the pregnancy, and it is important to follow the level of HCG until it is no longer detectable in the blood. The HCG level is checked the same day that Methotrexate is administered. This is considered day one. On day 4 and day 7 (after Methotrexate), HCG levels are checked by blood tests. Typically the day 4 level will be greater than the day 1 level. For the treatment to be considered successful, the day 7 level should be 15% lower than the day 4 level. Assuming that there is a 15% decline, the HCG levels are monitored 2X/week until the HCG level is negative.
In 20 – 30 percent of women, a second dose of methotrexate is necessary. There are several instances which would require the administration of a second HCG injection. One such circumstance would be if the day 7 HCG level has not fallen by at least 15 percent from the day 4 HCG level. Other circumstances requiring additional HCG injections include any plateauing or rise of serum HCG levels during the time your levels are being monitored. Occasionally, it is necessary to administer multiple doses of methotrexate
Methotrexate is most successful in women who have an ectopic pregnancy without symptoms (e.g., pain), and whose HCG level and ultrasound findings meet specific criteria. When used in appropriate situations, treatment with methotrexate is successful up to 98 percent of the time. If treatment with methotrexate is unsuccessful, tubal rupture can occur. This complication is avoided in the majority of cases with close monitoring. Surgical intervention if required should the fallopian tube rupture.
There are many advantages to Methotrexate over surgery. The most obvious advantage is that this is an injection, as opposed to a surgical procedure under general anesthesia. There have been studies which have shown that the integrity of the fallopian tube is maintained in a greater percentage of women when an ectopic pregnancy is treated with Methotrexate as opposed to surgery.
