A patient with low-risk GTN (FIGO score 4) is started on single-agent methotrexate. After 3 cycles, beta-hCG levels have risen by 20% above the nadir. What is the MOST appropriate next step?

• A Continue methotrexate for 2 more cycles before changing
• B Escalate to EMA-CO regimen
• C Switch to single-agent actinomycin-D ✓
• D Administer high-dose methotrexate with folinic acid rescue

Explanation

In low-risk GTN, resistance to first-line single-agent methotrexate (defined as rising beta-hCG or failure to reach normal levels) is managed by switching to the alternative single agent — actinomycin-D — rather than escalating to multi-agent EMA-CO, which is reserved for high-risk GTN or low-risk GTN resistant to both single agents. This strategy maintains cure rates while avoiding unnecessary toxicity.

Reference: Williams Obstetrics, 26th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.