A patient treated with single-agent methotrexate for low-risk GTN shows a rise in hCG of 10% over 3 consecutive weekly measurements. This is considered treatment failure. The next step in management is:

• A Increase methotrexate dose and continue monitoring
• B Immediate surgery (hysterectomy)
• C Recheck hCG in 4 weeks before changing treatment
• D Switch to single-agent actinomycin-D ✓

Explanation

When single-agent methotrexate fails in low-risk GTN (defined as hCG plateau for 3 weeks or 10% rise over 2 measurements), the standard salvage is switching to single-agent actinomycin-D, which achieves remission in approximately 70–90% of methotrexate-resistant low-risk GTN. If actinomycin-D also fails, then multi-agent EMA-CO is used. Increasing the methotrexate dose is not evidence-based for resistance. Hysterectomy may be considered in patients who have completed childbearing with uterine disease but is not the first step. Waiting 4 weeks would delay necessary treatment change in a potentially growing tumor.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.