Methotrexate for treatment of unruptured ectopic pregnancy

Clinical experience with and adverse effects of methotrexate for the treatment of unruptured ectopic pregnancy are described. Ectopic pregnancy is suspected in the presence of the following: positive results on pregnancy test (e.g., test for beta-human chorionic gonadotropin [beta-hCG]), lower abdominal pain, a normal or slightly enlarged uterus, and a mass on either side of the midline. When laparoscopy is required for diagnosis, surgical correction is done at the same time. However, use of serial beta-hCG titers, vaginal ultrasound examinations, serum progesterone concentrations, and dilation and curettage (when the pregnancy is confirmed to be nonviable) allows earlier detection of ectopic pregnancy without laparoscopy. If rupture has not occurred, i.v. or i.m. methotrexate is administered; usually, i.m. leucovorin is given, on alternate days, to prevent hematologic toxicity. Adverse effects of methotrexate include stomatitis, gastritis, and hepatic enzyme elevation. Use of a single-dose regimen of i.m. methotrexate without leucovorin has been associated with a lower frequency of toxicity. Selection criteria for patients are as follows: (1) an unruptured ectopic pregnancy less than or equal to 3.5 cm in greatest dimension on transvaginal ultrasound, (2) no active renal or hepatic disease, and (3) no evidence of leukopenia or thrombocytopenia. Intramuscular methotrexate therapy is a safe and effective alternative to surgery for the treatment of unruptured ectopic pregnancy.