Ectopic Pregnancy



I'll do my best to describe the MCP protocol for methotrexate therapy in
ectopic pregnancy. The patient must have a beta HCG over 1200, with no
intrauterine pregnancy demonstrated by trans-vaginal U/S. This is the only
way they are comfortable ensuring they aren't aborting a viable pregnancy.

There should be no co-morbid disease.

There is a maximum size requirement, I think its 3 cm in largest dimension.
Anything larger is disqualified.

The patient returns in a set period of time (1 week I think, but it might
be sooner) and a repeat beta HCG is drawn. If it isn't dropping, the
patient gets a second shot of methotrexate. If it still fails to drop, they
go to surgery.

The protocol doesn't address ruptured or leaking ectopics, I would object
strenuously to non-surgical treatment of such a condition. To the best of
my knowledge, it has never been suggested.

The treatment is never given by the EM staff without OB-Gyn involvement,
after all, they gotta follow the patient.

The drug is given IM. Side effects (they tell me) are rare; most commonly
oral ulcers. I don't know the dose.

Aboout 14 months ago, an attending physician from the Gyn department came
to discuss the protocol, this after a renegade Gyn resident gave
methotrexate to a woman who had several of the exclusion criteria. He said
they had treated over 100 patients with this protocol, there were no
ruptures and only 2 subsequently went to surgery.

Howard Blumstein, MCP ED

Methotrexate has its limitations. Frequently the patients continue with
vaginal bleeding, lower abdominal cramping,  and has elevated B-HCG's often
in the 20-100 range, sometimes for several months. The condition is termed
chronic ectopic, and one could expect to see it after methotrexate
administration for ectopic pregnancy.

Barry Brenner, MD PHD FACEP
Vice-Chairman
Department of Emergency Medicine
The Brooklyn Hospital Center