Could we treat more unruptured ectopic pregnancies with intramuscular methotrexate

The main reason for the restricted use of methotrexate in the treatment of ectopic pregnancy (EP) obviously is the fear of tubal rupture in patients w ith lower abdominal pain after the administration of methotrexate. Therefor e, we wanted to find out if patient characteristics at first presentation, such as age, pretreatment beta-hCG level, adnexal mass as visualized by tra nsvaginal ultrasonography, or history of prior EP, would identify patients at risk for tubal rupture if they were hemodynamically stable and showed no signs of peritoneal irritation. We examined whether more patients could ha ve been treated medically with methotrexate, because tubal rupture was unfo reseeable at first presentation and inclusion criteria for methotrexate tre atment were fulfilled. From January 1996 to August 1998, 122 patients diagn osed as having EP were treated at the Gynecologic Department of the Univers ity Hospital of Vienna. Inclusion criteria for medical treatment with intra muscular methotrexate (50 mg/m(2) body surface area) were (1) hemodynamic s tability, (2) an unruptured ectopic mass less than or equal to 5 cm at the greatest dimension demonstrated at transvaginal ultrasonography; (3) beta-h CG level less than or equal to 5,000 mlU/ml; (4) no cardiac activity of the extrauterine embryo; (5) wish of future fertility, and (6) informed consen t. Patients with hemodynamic instability, severe abdominal pain, an ectopic mass less than or equal to 5 cm at the greatest dimension, beta-hCG levels greater than or equal to 5,000 mlU/ ml, cardiac activity of the extrauteri ne embryo, and no wish of future fertility, or disagreement with methotrexa te treatment, primarily underwent surgery. Despite the fact that none of th e above patient characteristics at first presentation identified patients a t risk for tubal rupture, only 60/122 patients (49%) actually underwent med ical treatment whereas our inclusion criteria would have granted medical tr eatment in 101/122 patients (83%). We determined the actual and maximal pos sible percentages of patients with unruptured EP eligible for medical treat ment of EP with intramuscular single-dose methotrexate 50 mg/m(2) body surf ace area. Our data show that tubal rupture in hemodynamically stable patien ts is not foreseeable and should not lead to a restricted use of medical tr eatment in patients preferring methotrexate. Copyright (C) 2000 S. Karger A G, Basel.