Leaflet Details
| Title | Treating Ectopic Pregnancy with Methotrexate |
| Department | Early Pregnancy Unit / Gynaecology / Women’s Health |
| Author(s) | Miss Izuwah-Njoku, Dr Triveni Lall |
| Review Date | February 2023 |
| Next Review | February 2026 |
| Download | A5 Booklet PDF |
| Accessibility Options | Click on the Recite Me button to show our accessibility resources |
Patient Information
Introduction
Ectopic pregnancy can be a distressing and frightening experience. This leaflet aims to explain how ectopic pregnancy can be treated with a drug called methotrexate.
WHAT IS AN ECTOPIC PREGNANCY?
An ectopic pregnancy is one that develops outside of the womb and can pose significant risk to the mother’s life if it continues to grow. Between 1-2 in 100 pregnancies in the UK are ectopic. Please see the ectopic pregnancy leaflet for more information about ectopic pregnancy, causes and other treatment options.
WHY HAVE I BEEN OFFERED THIS TREATMENT?
Sometimes an ectopic pregnancy can be treated with a drug called methotrexate, this is termed ‘medical management’. This option can be offered to women if:
- They are well (with a normal blood pressure and heart rate and little to no pain)
- There is no evidence of a ruptured tube on ultrasound scan
- It is a small ectopic pregnancy with no heartbeat
- Their βhCG levels (pregnancy hormone) are relatively low
Very rarely, we may offer methotrexate for the treatment of pregnancy of unknown location (POUL) - please sees the POUL leaflet.
WHAT IS METHOTREXATE?
An ectopic pregnancy cannot develop into a normal pregnancy and is a serious condition which may be life threatening. Methotrexate is used to stop rapidly dividing cells from growing; in this situation these are pregnancy cells. Methotrexate works by blocking the enzymes that maintain the pregnancy. It stops the pregnancy from growing bigger and helps prevent the ectopic pregnancy from rupturing (bursting). The pregnancy tissue is then gradually reabsorbed by the body. Methotrexate can also be used for certain cancers, severe skin problems and rheumatoid arthritis.
It is given as an injection, either in the muscle e.g., buttock, or into the ectopic directly with a fine needle, under ultrasound guidance.
WHAT CAN I EXPECT?
When the ectopic pregnancy is confirmed on ultrasound the doctor will discuss the various treatment options suitable for you. If you agree to methotrexate treatment, an outpatient appointment will be booked for the injection to be administered.
This could be in Early pregnancy unit (EPU) at St Peter’s Hospital, or at the Haematology Day Unit at Ashford Hospital. You should be able to go home the same day.
You will have a blood test usually on the day before the injection, to check your pregnancy hormone levels. Following the injection, you will need regular blood tests in EPU to measure your pregnancy hormone levels and check they are falling. Blood tests are usually done at the start of treatment (before injection), days 4 and 7 after treatment. If based on these blood results the treatment is working, you will continue to have weekly blood tests thereafter until the hormone levels return to pre-pregnancy levels. This can take several weeks depending on the initial hormone level; however, these appointments are important to help ensure your safety.
If the pregnancy hormone levels are not dropping as expected or you have worsening pain or a repeat USS suggests significant internal bleeding or other worrying features or you change your mind, we will discuss suitable alternative treatment which may include surgery or repeat injection - see Ectopic pregnancy leaflet.
WHAT ARE THE SIDE EFFECTS?
You can expect some vaginal bleeding, but you do not need to contact us unless it is heavy, or you are concerned.
In some women the ectopic pregnancy can still rupture, this occurs in about 1 in 10 cases. This would present with increased abdominal pain, shoulder tip pain, feeling dizzy / unwell and we recommend you present to accident & emergency (A&E) immediately with any concerns around severe pain or if you feel unwell.
Some people experience some side effects after treatment with methotrexate. You may experience some, all or none of them.
- Colicky abdominal pain occurs in up to 3 in 4 women
- Sickness and occasionally vomiting
- Skin rash and mouth and lip ulcers
- Diarrhoea
- Short term effect on liver function and blood count
- Sensitivity to light or tiredness
FOLLOWING THE INJECTION, YOU SHOULD
All the precautions below are required until the treatment is complete, and the ectopic pregnancy resolved.
- Not get pregnant for three months after the injection. Methotrexate can cause foetal abnormalities in early pregnancy; you will require effective contraception during this time. Please request the contraception leaflet or ask your GP or practice nurse for advice.
- Remain in the local area so there is easy access to your medical notes.
- Avoid strenuous exercise to reduce risk of rupture.
- Not use tampons and avoid sexual intercourse or internal examinations - as above.
- Not take Aspirin or ibuprofen for pain relief (may increase risk of bleeding), but you may take paracetamol or codeine containing pain killers.
- Not take any alcohol until discharged from follow up, as it may affect your liver.
- Not take folic acid (this counteracts the way methotrexate works).
- Attend for regular follow up blood tests as directed.
- Keep well hydrated.
- Contact EPU or attend A & E with a copy of your scan report (if available) if you experience severe pain. Please be aware you may require to be admitted.
Planning for the future
After three months, any future pregnancies will not be affected by methotrexate and it does not increase the risk of you having a miscarriage in the future. After an ectopic pregnancy, you have an increased chance of another ectopic pregnancy and this is about 5-18% compared to 1-2% if you have not had an ectopic pregnancy.
Due to your history of a previous ectopic pregnancy, you can self-refer to the EPU at St Peter’s hospital or other early pregnancy unit. Please contact us 01932 722662 to arrange an ultrasound scan between five to six weeks to check if the pregnancy is within the womb.
If you develop pain or vaginal bleeding before this time, please contact EPU or attend A & E for an urgent assessment.
Post-ectopic Clinic
After having an ectopic pregnancy, we offer an appointment in our post-ectopic clinic. Please contact our secretary on 01932 723536 or 07355021429 six to eight weeks after discharge to book an appointment if you have not received an appointment.
ADVANTAGES AND DISADVANTAGES OF METHOTREXATE?
| Advantages | Disadvantages |
| Mainly outpatient based and avoids the need to be admitted | Treatment failure rate of about 10% - those would require repeat injection or surgery |
| May avoid the risks of surgery and general anaesthetic | Follow up could be for several months until blood tests shows normal hormone levels |
| Able to eat and drink prior to injection | Must avoid pregnancy for 3 months following injection and requires effective contraception |
PROCEDURE FLOW CHART
- When the decision has been made to use methotrexate to manage your ectopic pregnancy, a blood sample will be taken to measure your pregnancy hormone levels, kidney and liver function before the injection.
- We will also check your weight and height and gain written consent. We will inform you of the date and time of your injection. This will either be in EPU at St Peter’s or at Ashford hospital.
- On the day you attend your appointment, we will administer the injection. You can eat and drink normally beforehand. You should be able to return home on the same day.
- You will be followed up with a blood test in EPU on the 4th and 7th day (excluding weekend / bank holiday) following the injection. If these dates fall on a bank holiday or weekend, a suitable alternative date will be arranged for you to have the blood test. This change should not affect the success of treatment.
- You will require weekly blood tests to measure the hormone levels until they are <100 and then 2 weekly until they are in the non-pregnant range. At this stage you will be discharged.
WHO DO I CONTACT FOR MORE INFORMATION?
Staff in the EPU will be able to answer any further questions you may have: EPU number - 01932 722662, (Monday - Friday 09.00 - 17.00).
If you have increased pain at any time, you should contact either EPU during our working hours or attend the Accident and Emergency as soon as possible.
Out of hours / Weekends / Bank holidays - Please attend Accident and Emergency department for review by the on-call Gynaecology team.
USEFUL CONTACTS
The Ectopic Pregnancy Trust
Telephone: 020 7733 2653
https://ectopic.org.uk
Miscarriage UK
Telephone: 01924 200799
https://www.miscarriageuk.org
The Royal College of Obstetricians and Gynaecologists
Telephone: 020 7772 6200
https://www.rcog.org.uk
