Leaflet: Medical Management of Ectopic Pregnancy

We are sorry that your doctor has informed you that you have an ectopic pregnancy.

It is an emotionally and physically difficult time and you will probably have some questions about your treatment and what is happening to you. There are different ways an ectopic pregnancy can be treated so, in this handout, we will cover only questions that relate to medical management of ectopic pregnancy.

What is medical management?

Medical management is where doctors use a drug called Methotrexate to treat your ectopic pregnancy.

What is Methotrexate?

Methotrexate is a powerful medication that works by interfering, in a temporary manner, with the way your body processes a vitamin called folate. Folate is needed to help rapidly dividing cells – such as those of a pregnancy. The drug stops the pregnancy developing any further and the pregnancy is gradually reabsorbed by the body leaving the Fallopian tube intact. Methotrexate is also used to try and control other unwanted rapidly dividing cells, such as those which cause the condition rheumatoid arthritis, psoriasis, and some specialised cancerous lesions.

When is treatment with Methotrexate most appropriate?

This method of treatment is more suitable for some women than others and doctors will suggest Methotrexate is the best treatment for you only if:

  • Your general health appears to be stable;
  • Your Fallopian tube has not ruptured;
  • Your hormone being made by the pregnancy (beta hCG) is low, usually below 5000 mlU/mL; and
  • An ultrasound scan shows there is no worrying bleeding.

Treatment of ectopic pregnancy with Methotrexate is not appropriate if you suffer from any of the following conditions:

  • Severe anaemia or shortage of other blood cells;
  • Kidney problems;
  • Liver problems;
  • An ongoing infection;
  • HIV/AIDS; or
  • Peptic ulcer or ulcerative colitis.

Why does my doctor want to treat me this way and not give me surgery?

This treatment has been developed to avoid surgery and The National Institute for Health and Care Excellence (NICE) recommend to doctors that they offer this as the first treatment option for women whose pregnancies will not resolve without medical intervention, whenever it is safe to do so. Doctors also prefer to use Methotrexate if it has a particular advantage over surgery. For example, if:

  • You have an ectopic pregnancy that is difficult to treat with surgery and has increased risk of bleeding;
  • You have adhesions in the abdomen or pelvis (as a result of previous surgery or infection); or
  • You have other medical problems that may increase the risks of a general anaesthetic.

You always have choice over your treatment so medical professionals will always be happy to discuss all treatment options with you. If you feel that medical management is not emotionally suitable for you, you should discuss with your doctors and be able to elect for surgical management.

Methotrexate is at least as good as surgery in terms of subsequent successful pregnancies. This may be due to the fact that medical treatment is non-invasive, whereas surgery may cause some scarring around the Fallopian tube.

How is the treatment given?

The treatment is given by means of an injection, usually given by a single dose into the muscle. If it needs to be administered by any other route, this will be discussed with you. The dose is calculated with reference to your height and weight. Before the injection, blood tests are done to check liver and kidney function and to ensure that you are not anaemic.

What happens after treatment?

Medical management requires careful monitoring and follow-up to make sure that your beta hCG hormone levels are decreasing. This means that you will have to attend the hospital every few days for blood tests until the tests are negative. This can take several weeks and will be explained by your doctor. Your hospital will make arrangements for you to have the hormone level checked.

Your doctor will usually test your hCG levels on the day the Methotrexate is given, again on day 4, and on day 7 after the injections. The hCG level often rises on day 4 but your doctors are looking to see a drop in your hCG value of at least 15% between days 4 and 7. Most women only need one injection but, if there has not been a 15% drop, doctors will consider a second dose of Methotrexate or surgery. Every 3-7 days, beta hCG levels will continue to be monitored to ensure that they are continuing to fall appropriately.

A few days after the injection, it is usual to begin to bleed and this can last between a few days and up to 6 weeks. It is usual to have some discomfort and pain initially. However, if the pain persists, or is not helped by taking paracetemol, or you feel faint, you will need to go to hospital immediately, as this may be a sign that the Fallopian tube has ruptured.

What are the side effects?

The most common side effects of Methotrexate are:

  • Cramping abdominal (tummy) pain usually occurs during the first 2 to 3 days of treatment – because abdominal pain is also a sign of a ruptured ectopic pregnancy, report any significant pain to your health professional;
  • Tiredness;
  • Vaginal bleeding or spotting;
  • Sickness and indigestion;
  • Light-headedness or dizziness – because this is also a sign of a ruptured ectopic pregnancy, please report it to your health professional; and
  • A numb or sore bottom from the injection.

How successful is medical management?

Success rates do vary depending on the circumstances in which Methotrexate is given and studies report success rates of 65-95%. Success rates tend to be higher when women are treated with lower beta hCG levels. Your doctor should be able to tell you the success rate of Methotrexate in their hospital.

How will I know if there is a problem and I need a different treatment?

Your doctors will be able to tell if your ectopic pregnancy is not resolving, as this will be shown in the results of your regular hCG blood tests. If this is the case, they will usually suggest surgery for you.

Symptoms of a deteriorating ectopic pregnancy include increased pain levels; vaginal bleeding; shortness of breath; feeling faint and/or pain in the tip of the shoulder among others. If you suffer any of these symptoms you will need to be reassessed. Your hospital will have given you a number to contact for health advice if you feel that anything is changing or you will have been told to report to the Accident and Emergency (A&E) department. If you have not been told what to do and need to speak to someone, ring the hospital department which is treating you or the NHS 111 service by dialling 111.

What are the risks of being managed like this?

Approximately 15% of women treated with Methotrexate go on to need surgery. Doctors can use the blood tests to tell whether the Methotrexate is working or whether the specialised cells of pregnancy are continuing to divide depending on whether the beta hCG level is rising or falling fast enough.

Occasionally, an ectopic pregnancy can rupture despite low hCG levels. If you are worried about any symptoms any point while you are being medically managed, you should report to the hospital’s Accident and Emergency (A&E) department.

What can I do to help the treatment work?

  • You should stop taking any vitamins, minerals or other medicines unless you have been told by the doctors treating you to continue with them, as some medicines interfere with the effects of Methotrexate.
  • It is particularly important that you do not take any folic acid supplements until your doctors are sure that the drug has worked.
  • You should not do any heavy lifting or housework until the hCG levels are dropping consistently and should only undertake gentle exercise, such as walking, until the hCG is at non-pregnant level.
  • You should avoid sexual intercourse until your hCG is down to non-pregnant level.
  • Most people take time off from work initially and do not return to work for at least two weeks while the treatment begins to work. Your hospital can give you a certificate to refrain from work for your employers or the Department of Social Security, so you can claim sickness benefit if you are entitled to it.
  • In the first week, it is important to avoid pain killers which fall into the NSAID group such as ibuprofen. The preferred painkiller is paracetamol and you should refrain from drinking alcohol until the levels have fallen to a non-pregnant level.

What precautions must I take for the future?

If you have had either one or two injections of Methotrexate you must wait until your hCG levels have fallen to below 5mIU/mL (your doctor will advise you when this is through blood tests) and then take a folic acid supplement for 12 weeks before you try to conceive. This is because the Methotrexate may have reduced the level of folate in your body which is needed to ensure a baby develops healthily. For example, it could result in the baby having a neural tube defect such as cleft lip, cleft palate or spina bifida. The drug is metabolised quickly but can affect the quality of your cells, including those of your eggs, and the quality of your blood for up to 3 or 4 months after it has been given. The drug can also affect the way your liver works and so you need to give your body time to recover properly before a new pregnancy is considered.

Your emotions

Undergoing treatment for an ectopic pregnancy is a stressful and scary experience. As well as the physical strain of treatment, you may also find it challenging to come to terms emotionally with what has happened. It can be difficult to process and for emotions to surface properly. Women often feel a complex mix of emotions and this is understandable and normal. Do give yourself time and space to recover physically, psychologically and emotionally. It is important to remember that the ectopic pregnancy was not your fault and that there was nothing you could have done to prevent it happening.

Your partner’s emotions

Partners can sometimes find it difficult to understand your feelings and you may feel your partner is not supporting you in the way in which you would like. Partners can feel confused, scared and isolated too but typically express their emotions in a different way and often do not share how they feel. Your partner’s focus may be on you and your wellbeing rather than the pregnancy and this can be difficult to accept. It is important to keep communication open and to speak to your partner about your feelings and theirs.

How The Ectopic Pregnancy Trust can provide support

The Ectopic Pregnancy Trust provides information and support to women and their families experiencing early pregnancy complications and loss, such as ectopic pregnancy or miscarriage. Our website has medically-overseen content and includes moderated message boards where you can share your experiences with others who understand what you are going through and ask questions. The message boards provide an arena for mutual support in a safe, supportive environment: go to ectopic.org.uk/talk. If you think we can help you, please visit our website, email or call.

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