An ectopic pregnancy is one that grows outside the uterus (womb). In the UK, 1 in 90 pregnancies (just over 1%) is an ectopic pregnancy. Women who have had a previous ectopic pregnancy are at higher risk. A pregnancy cannot survive in these situations and it can pose a serious risk to you.
Because an ectopic pregnancy cannot lead to the birth of a baby, all options will end the pregnancy in order to reduce the risks to your own health. Your options depend upon:
- How many weeks pregnant you are
- Your symptoms and clinical condition
- The level of βhCG (pregnancy hormone)
- Your scan result
- Your fertility status
- Your general health
- Your personal views and preferences – this should involve a discussion about your future pregnancy plans.
Methotrexate is the medication that is used to treat ectopic pregnancy, it has been introduced into the clinical practice to avoid surgery. It is a powerful drug that stops cells that are growing very rapidly, in this case, these are the cells in the ectopic pregnancy. It is given by injection usually in the leg.
Opting for the medication requires careful follow-up and may not be suitable for everyone.
The follow-up means attending for blood tests within the first week and thereafter once or twice weekly until the tests are negative. The doctor or nurse will explain the schedule of blood tests to you.
How successful is Methotrexate?
Success rates vary depending on the circumstances in which Methotrexate is given and studies report success rates of 65-95%. Success rates tend to be higher when women are treated with lower βhCG levels. Your doctor should be able to indicate to you the success rate of Methotrexate. If it is not successful we may have to reconsider surgical treatment. There may be the possibility of repeating the Methotrexate however this will need to be reviewed by one of our consultants
Methotrexate is also extensively used for a variety of other clinical conditions.
Advantages
This treatment can avoid the need to be admitted to the hospital and needing a general anaesthetic for a surgery.
Disadvantages
There is a 15% chance of the treatment not working as expected with the need for an additional injection or occasionally surgery.
The most common side effects of methotrexate are:
- Cramping abdominal (tummy) pain is the most common side effect, and it usually occurs during the first 2 to 3 days of treatment. Because abdominal pain is also a sign of a ruptured ectopic pregnancy, report any abdominal pain to your health professional;
- Fatigue – a number of women feel very tired and are shocked by the sheer exhaustion that they encounter during treatment;
- Vaginal bleeding or spotting;
- Nausea, vomiting, and indigestion;
- Light-headedness or dizziness – Again, because this is also a sign of a ruptured ectopic pregnancy, please report it to your health professional;
Other rarer side effects from methotrexate treatment for ectopic pregnancy, include:
- Skin sensitivity to sunlight
- Inflammation of the membrane covering the eye
- Sore mouth and throat
- Temporary hair loss
- Severe low blood counts (bone marrow suppression)
- Inflammation of the lung (pneumonitis)
Most women only need one injection of methotrexate for treatment. However, 15 in 100 women (15%) need to have a second injection of methotrexate. If your pregnancy is beyond the very early stages or the βhCG level is high, methotrexate is less likely to succeed. Seven in 100 women (7%) will need surgery even after medical treatment.
During treatment you should avoid:
- Strenuous activity
- Folic acid containing vitamins – as they may interfere with the treatment
- Sexual intercourse – as it may cause rupture of the ectopic pregnancy
- Alcohol
- Green leafy vegetables such as broccoli, leeks or cabbage
- Using tampons
Before the injection is given to you, you will have some blood tests to ensure you are suitable for the treatment. On day 4 and day 7 following the injection, these blood tests will be repeated.
The βhCG level often rises on the day four blood test because the action of methotrexate is not instantaneous, so the cells will have continued to divide for two or three days after the injection was given, and some cells release more βhCG when they start to disappear. Your doctors are looking to see a drop in your βhCG value of at least 15% between days four and seven. If there has not been a 15% drop, you may be considered for a second dose of Methotrexate.
The main worry with an ectopic pregnancy is that they may rupture and bleed. This risk exists while the pregnancy hormone persists in the blood. When all the placental tissue is dissolved the level of the hormone βhCG will return to normal.
It is very important, therefore, that you come for regular blood tests. If you develop any sharp pains or an increasing discomfort in your abdomen you should immediately phone the Early Pregnancy Assessment Unit or attend A&E. Contact details are given at the end of this information.
However, please remember that:
- If you have any change in your pain, i.e frequency or severity, we would ask you to call the EPAU so we can re assess you.
- As the pregnancy dissolves and the hormone levels fall you may get some vaginal bleeding like a period. This can last a few days or even up to 6 weeks.
Methotrexate is at least as good as surgery in terms of subsequent successful pregnancies. This may be due to the fact that medical treatment is non-invasive, whereas surgery may risk factors like some scarring around the Fallopian tube.
Aftercare
You should avoid pregnancy for three months after the completion of the treatment, use a reliable barrier or hormonal contraception.
You should:
- Remain in the local area until completion of treatment
- Attend all follow up appointments made for you by the Early Pregnancy Team
- Drink plenty of fluids
- Contact EPAU if you have any worries concerns or questions regarding your pain or bleeding
In your next pregnancy
The risk of a repeat ectopic pregnancy is 1 in 10. However, remember that you still have a much greater chance of having a normal healthy pregnancy, this is nearly the same after surgical treatment.
It is important that you have a scan at approximately 6 weeks in the Early Pregnancy Assessment Unit to confirm the location of your pregnancy. This can be organised by your GP or by contacting the Unit directly on the number provided at the end of this leaflet.
Your feelings
It is entirely normal to feel helpless, isolated and angry with yourself. Depression, guilt and self-blame are very common emotions after the loss of a baby. As time passes, you will be able to deal with your loss more positively. You may find that you are ready to get back to your normal routine quite quickly. If your symptoms continue, you should get in touch with your GP who will offer you the opportunity to see a counsellor who will be able to help you. Your well-being is the most important thing.
Your partner may find it difficult to express their feelings. They may well feel that they should be strong and protect you from any more distress. If this is the case, you will need to encourage them to talk to you about their feelings. Sharing feelings with each other can be very helpful.
Allow yourself time to recover physically and emotionally before trying for another baby.
We work closely with the hospital bereavement team and have a selection of items including contact details for charities providing support and information, memory making items such as memory boxes or bears. Please contact Early pregnancy Assessment Unit if you think this may be helpful to you.
If you need any further information or advice please speak to a member of the nursing team.
Contact information
Early Pregnancy Assessment Unit: 02476 865570
If out of hours please attend A&E
Further information
The Ectopic Pregnancy Trust Helpline: 020 77332653
References
The Ectopic Pregnancy Trust (2023) Medical Management of ectopic pregnancy with Methotrexate. Available at: https://
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