This document outlines the medical management of ectopic pregnancies. It describes the criteria for using medical management, including gestational sac size and beta HCG levels. The main drug used is methotrexate, which works by depleting folate cofactors and inhibiting trophoblast growth. Methotrexate can be given as a single intramuscular dose or multiple doses over days, monitoring beta HCG levels. Other drugs like potassium chloride, prostaglandins, and hyperosmolar glucose can also be locally injected under ultrasound guidance to terminate the ectopic pregnancy. Contraindications for methotrexate are also listed.
2. Criteria for medical management
• No hemodynamic instability
• No tubal rupture
• Fertility desired
• Gestational sac < 3.5cm
• Beta HCG level < 5000mIu/ml
• No cardiac motion on USG
• Ability and willingness to comply with follow
up.
3. Drugs commonly used are:
• Methotrexate (drug of choice)
• Potassium chloride
• Prostaglandin(PGF₂α)
• Hyperosmolar glucose
4. Methotrexate
mechanism of action & regimens
• MOA: methotrexate depletes tetrahydrofolate cofactors for DNA & RNA synthesis
and inhibits rapidly growing trpohoblast of EP.
• Regimens:
1)Single dose- methotrexate i.m 50mg/m² of body surface area.
o β-HCG level on D₄ and D₇ is measured, minimum difference of > 15 percent should
be there
o Dose to be repeated - if difference is < 15 percent b/w D₄ and D₇ .
OR
o fetal cardiac activity is present on D₇.
o β-HCG level is repeated weekly until undetectable.
2)Multiple dose- methotrexate 1mg/kg i.m on D₁,D₃,D₅,D₇ & lecuovorin
0 .1mg/kg i.m on D₂,D₄,D₆,D₈
o β-HCG level is measured every alternate day, Until decreased upto 15 percent in 2
consecutive days
o Then weekly β-HCG level estimation is done until undetectable.
5. Contraindication of methotrexate
• Hemoperitoneum
• Breast feeding
• Immunodeficiency
• EP > 4cm
• Alcoholism
• Hepatic/Renal disease
• Blood disorder
6. Local injection
• 20 percent potassium chloride 0.5 ml under
USG guidance – causes asystole & resolution
of ectopic
• Hyperosmolar glucose 1 to 3 ml injected into
the sac.
• PGF₂α when injected causes contraction and
vasoconstriction thus resolution of pregnancy.
