A woman treated with methotrexate for an unruptured ectopic pregnancy (hCG 2800 IU/L, adnexal mass 2.8 cm, no fetal cardiac activity) presents on day 4 with worsening pelvic pain. hCG has risen to 3200 IU/L. What is the correct interpretation?

• A Treatment failure — hCG should fall ≥15% between days 4 and 7; refer for surgery
• B Indicates rupture — immediate laparoscopy is required
• C Resistance to methotrexate — give a second dose on day 4
• D Expected post-treatment rise — hCG commonly rises in the first 4 days due to trophoblast cell lysis ✓

Explanation

After single-dose methotrexate for ectopic pregnancy, hCG levels commonly rise or plateau in days 1–4 before declining; this is expected and does not indicate failure. The critical assessment point is days 4 to 7: if hCG does NOT fall by ≥15% between day 4 and day 7, that constitutes treatment failure and a second dose or surgery is considered. The day 4 pain (separation pain from trophoblast necrosis) is also expected. Immediate surgery is only warranted for hemodynamic instability, hemoperitoneum >300 mL, or progressive pain with tachycardia.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.