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تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Example of methotrexate treatment protocols for tubal or interstitial ectopic pregnancy[1-3]

Example of methotrexate treatment protocols for tubal or interstitial ectopic pregnancy[1-3]
Pretreatment testing and instructions
  • hCG concentration
  • Transvaginal ultrasound
  • Blood group and RhD typing (with administration of anti-D immune globulin to RhD-negative patients), if indicated
  • Complete blood count
  • Liver and renal function tests
  • Discontinue folic acid supplements
  • Counsel patient to avoid nonsteroidal anti-inflammatory medications, recommend acetaminophen if an analgesic is needed
  • Advise patient to refrain from sexual intercourse and strenuous exercise
Treatment day Single-dose protocol* Two-dose protocol* Multiple-dose protocol
1
  • Measure hCG concentration
  • Give first dose methotrexate 50 mg/m2 BSA IM
  • Measure hCG concentration
  • Give first dose methotrexate 50 mg/m2 BSA IM
  • Measure hCG concentration
  • Give first dose methotrexate 1 mg/kg body weight IM or IV
2 – –
  • Leucovorin 0.1 mg/kg IM
3 – –
  • Measure hCG concentration
  • If <15% hCG decline from day 1 to 3, give second dose methotrexate 1 mg/kg IM or IV
  • If ≥15% decline from day 1 to 3, draw hCG concentration weekly until undetectable
4
  • Measure hCG concentrationΔ
  • Measure hCG concentrationΔ
  • Give second dose methotrexate 50 mg/m2 IM
  • Leucovorin 0.1 mg/kg IM
5 – –
  • Measure hCG concentration
  • If <15% decline from day 3 to 5, give third dose methotrexate 1 mg/kg IM or IV
  • If ≥15% decline from day 3 to 5, draw hCG concentration weekly until undetectable
6 – –
  • Leucovorin 0.1 mg/kg IM
7
  • Measure hCG concentration
  • If <15% hCG decline from day 4 to 7, give second dose of methotrexate 50 mg/m2 IM
  • If ≥15% hCG decline from day 4 to 7, draw hCG concentration weekly until hCG is undetectable
  • Measure hCG concentration
  • If <15% decline from day 4 to 7, give third dose methotrexate 50 mg/m2 IM
  • If ≥15% decline, draw hCG concentration weekly until undetectable
  • Measure hCG concentration
  • If <15% decline from day 5 to 7, give fourth dose methotrexate 1 mg/kg IM or IV
  • If ≥15% decline from day 5 to 7, draw hCG concentration weekly until undetectable
8 – –
  • Leucovorin 0.1 mg/kg IM
11 –
  • Measure hCG concentration
  • If <15% decline from day 7 to 11, give fourth dose methotrexate 50 mg/m2 IM
  • If ≥15% decline from day 7 to 11, draw hCG concentration weekly until undetectable
 –
14
  • Measure hCG concentration
  • If <15% hCG decline from day 7 to 14, give additional dose of methotrexate 50 mg/m2 IM◊
  • If ≥15% hCG decline from day 7 to 14, draw hCG concentration weekly until undetectable
  • Measure hCG concentration
  • If <15% hCG decline from day 11 to 14, consider surgical management
  • If ≥15% hCG decline from day 11 to 14, draw hCG concentration weekly until undetectable
  • Measure hCG concentration
  • If <15% hCG decline from day 7 to 14, give fifth dose of methotrexate 1 mg/kg IM or IV◊
  • If ≥15% hCG decline from day 7 to 14, draw hCG concentration weekly until undetectable
15 – –
  • Leucovorin 0.1 mg/kg IM
21
  • Measure hCG concentration
  • If three doses have been given and there is a <15% hCG decline from day 14 to 21, proceed with surgical management
 –
  • Measure hCG concentration
  • If 5 doses have been given and there is a <15% hCG decline from day 14 to 21, proceed with surgical management
Perform surgery if
  • Severe abdominal pain or an acute abdomen suggestive of tubal rupture
  • Ultrasonography findings are suggestive of hemoperitoneum

This table is an example; protocols may vary based on provider or institutional preference.

A calculator useful for determining BSA from patient height and body weight is available separately in UpToDate.

hCG: human chorionic gonadotropin beta-subunit; IM: intramuscularly; BSA: body surface area; IV: intravenously.

* Regimens named for the intended number of doses versus the actual number of doses given.

¶ Leucovorin is given only if methotrexate was given on the previous day. While leucovorin is typically administered IM for this indication, it can also be given orally. Leucovorin calcium is the preparation used for this indication.

Δ It is common to observe an increase in hCG levels from day 1 through day 4 due to continued hCG production by syncytiotrophoblasts despite cessation of production by cytotrophoblasts; this should not cause concern.

◊ Surgical management may be a reasonable option and depends on patient and provider preference.
References:
  1. Alur-Gupta S, Cooney LG, Senapati S. Two-dose versus single-dose methotrexate for treatment of ectopic pregnancy: a meta-analysis. Am J Obstet Gynecol 2019; 221:95.
  2. Barnhart KT. Clinical practice. Ectopic pregnancy. N Engl J Med 2009; 361:379.
  3. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins–Gynecology. ACOG Practice Bulletin No. 193: Tubal Ectopic Pregnancy. Obstet Gynecol 2018; 131:e91. Reaffirmed 2022.
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