A 24-year-old woman underwent laparoscopic salpingotomy for a right ampullary ectopic pregnancy 7 days ago. Post-operative serial βhCG levels show a 15% decline by day 4 but a subsequent 8% rise by day 7. What is the most appropriate next management step?
- A Repeat serum βhCG in 48 hours and reassure as minor fluctuations are expected
- B Perform immediate laparoscopy for salpingectomy of the ipsilateral tube
- C Administer single-dose methotrexate 50 mg/m² intramuscularly — persistent ectopic ✓
- D Transvaginal ultrasound to localise residual trophoblast before deciding treatment
Explanation
Post-salpingotomy persistent ectopic pregnancy (residual trophoblastic tissue) occurs in approximately 8–15% of cases when salpingotomy is used instead of salpingectomy. Diagnosis is confirmed by failure of βhCG to decline by >15% on days 1 and 4 post-operatively, or a subsequent rise after initial decline. A rising βhCG at day 7 after an initial partial decline indicates persistent trophoblast. The standard management for haemodynamically stable persistent ectopic is single-dose systemic methotrexate 50 mg/m², which is highly effective (>90% success). Immediate surgery is reserved for haemodynamic instability or failed medical treatment.
Reference: Williams Obstetrics, 26th ed.
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Written and medically reviewed by the StethoPrep medical team.