A 28-year-old woman is treated with single-agent methotrexate for an ectopic pregnancy. She presents 4 days later with increased pelvic pain but is haemodynamically stable, with no free fluid on ultrasound, and serum hCG has decreased by 5% from day 1 to day 4. The most appropriate management is:

• A Emergency surgical intervention as increasing pain suggests rupture
• B Administer a second dose of methotrexate immediately
• C Discharge home with repeat hCG in 2 weeks
• D Reassurance that pain is normal (separation pain), repeat hCG on day 7 to assess response ✓

Explanation

In the first 4 days after methotrexate, it is expected and normal for hCG to rise or plateau (the drug induces cell death with initial hCG release) and for mild pelvic pain to occur ('separation pain' from haemorrhage into the tube). Response is assessed by comparing day 4 to day 7 hCG; a decrease of ≥15% indicates successful treatment. Only if the day 4–7 decline is <15% is a second dose given. Haemodynamic stability and absence of free fluid argue against rupture.

Reference: Williams Obstetrics, 26th ed.

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Written and medically reviewed by the StethoPrep medical team.