A 32-year-old woman with a previous ectopic pregnancy treated with right salpingectomy presents with 6 weeks amenorrhea and left-sided pelvic pain. Transvaginal ultrasound shows a 2.2 cm left tubal ectopic pregnancy with cardiac activity. Serum β-hCG is 4,500 mIU/mL. She is hemodynamically stable. What is the most appropriate management?
- A Single-dose methotrexate (50 mg/m² IM)
- B Left salpingostomy ✓
- C Two-dose methotrexate protocol
- D Left salpingectomy
Correct answer: B. Left salpingostomy
Explanation
The presence of cardiac activity in an ectopic pregnancy is a relative contraindication to methotrexate therapy, as failure rates are significantly higher. Surgical management is preferred. Between salpingostomy and salpingectomy, salpingostomy is preferred when the patient desires future fertility and the contralateral tube is absent or damaged (as here, with prior right salpingectomy). Salpingectomy would leave her with no fallopian tubes. Methotrexate has higher failure rates with cardiac activity and β-hCG >5,000 mIU/mL.
Reference: Bailey and Love's Short Practice of Surgery, 28th ed.
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Written and medically reviewed by the StethoPrep medical team.