Medical management of ectopic pregnancy and pregnancy of unknown location (PUL) which is not resolving spontaneously

Information for women, birthing people, and their families

Sadly, your pregnancy is not progressing normally and is either ectopic (outside the womb) or a pregnancy of unknown location. In order to avoid surgery and treat the condition medically your doctor / nurse has suggested that you have treatment with a drug called Methotrexate. This leaflet will provide you with information about its use.

What is Methotrexate?

Methotrexate is a well-established drug used in a variety of conditions, for example rheumatoid arthritis, Crohn’s disease, psoriasis, and malignant disease (cancer). It is an antimetabolite drug which means it interferes with cell growth, and will prevent the pregnancy related tissue from growing. It can be used both as initial treatment for an ectopic pregnancy (or pregnancy of unknown location), or as additional treatment after surgery if the fallopian tube appeared healthy enough to remain.

Why have I been prescribed Methotrexate?

Your ultrasound scan, blood tests, and / or observations (pulse and blood pressure) show that you are well, with minimal signs and symptoms, so you are suitable for this non-surgical treatment. Although some ectopic pregnancies will miscarry naturally, others continue to grow, running the risk of becoming ruptured ectopic pregnancies needing emergency treatment like removal of a fallopian tube. Methotrexate has been prescribed with the aim to manage and resolve an ectopic pregnancy in the early stages.

How effective is it?

It is effective in about nine out of every 10 cases. Most women or birthing people need a single dose but in about 14 in every 100 cases a second dose is needed. You will need to have weekly hCG hormone level checks (blood tests) until they are negative, to be sure that the treatment has worked.

What if I decide not to have this treatment?

If left untreated, the ectopic pregnancy (or mass noted by ultrasound) may continue to grow causing a rupture, which results in internal bleeding.

Methotrexate cannot be offered to women or birthing people who have a mass or ectopic pregnancy greater than 3.5cm or with hCG hormone level greater than 5000 iu/L. Surgery would then be the only option.

How will I know if the treatment has worked?

You will be asked to return four days after your first dose of Methotrexate (or the closest working day if the fourth day falls when your local Early Pregnancy Assessment Unit is closed on a Saturday or Sunday) for a hCG hormone level check (blood test) to check your pregnancy hormone level. Your hormone level should be decreasing or slowing down by day five, and should have decreased by 15% by day seven. If so, you will be asked to come for weekly hormone blood tests until your level is less than 10, which usually takes four weeks or more.

If your hormone level fails to fall or becomes static after an initial fall, a second dose of Methotrexate can be given. The alternative treatment would be surgery.

How is Methotrexate given?

Methotrexate is given by intramuscular injection into your hip muscle by nurses in the Early Pregnancy Assessment Unit at Queen Elizabeth the Queen Mother (QEQM) Hospital Margate. These nurses are trained to administer chemotherapy.

Are there any side effects?

Methotrexate has been studied for this use in many patients and found to be safe and effective. Therefore, although the manufacturer’s licence for this drug does not specifically cover its use in ectopic pregnancy, your doctor is happy to recommend it.

There is often some lower abdominal pain after a few days as the treatment begins to work. You may also have some vaginal bleeding.

Most women or birthing people have no side effects from Methotrexate but occasionally report nausea (feeling sick) and vomiting, diarrhoea, sore mouth, conjunctivitis, indigestion, or tiredness. Please contact your GP or pharmacist if you are worried or need medication for any of the above. Alternatively you can discuss treatment and side effects with the nurse practitioner in the Early Pregnancy Assessment Unit (see the contact numbers at the end of this leaflet).

Will I have a follow-up appointment?

The treatment dose of Methotrexate is individually calculated, and your follow-up care is based on your pregnancy hormone level and can take at least three to four weeks to complete. It is extremely important that you comply with the follow-up care until your hormone level returns to normal.

When can I resume normal activities?

Do not have sex until your hormone level is less than 10 to reduce the risk of rupture. If you do decide to have sex during treatment, avoid using hormonal based contraceptives (for example the pill, implant, injection, and Mirena coil) until your hormone level is negative, as they could affect your blood results. Using condoms is a suitable method of contraception.

Avoid alcohol, vitamins containing folic acid, and direct sunlight, but drink plenty of fluids. Also avoid gas-producing foods like cabbage which can cause flatus (gas in your stomach or bowel) and abdominal distension (bloating) which can add to your discomfort.

Do not have any live vaccinations during your treatment.

When can I try to get pregnant again?

It is very important that you do not get pregnant again for at least three months after having the Methotrexate injection, as this medication could harm a baby that is conceived during this time.

What if I feel unwell or have concerns?

If in pain, do not use medication containing aspirin or ibuprofen for a week after treatment. Paracetamol can be taken; two tablets up to four times a day (ask your pharmacist if in doubt).

If you develop severe pain (not eased by paracetamol), have heavy vaginal bleeding, or start to feel light-headed and unwell get in touch with the Unit immediately or go to your nearest Emergency Department.

There is a small risk that the ectopic pregnancy can rupture, even with falling hormone levels, so it is advised that you stay with someone and within easy travelling distance of your local hospital.

We wish you the very best for the future and encourage you to have an early scan with us (at about six weeks) in any future pregnancies.

Please also feel free to contact the Early Pregnancy Assessment Unit any time for advice (see the contact numbers at the end of this leaflet).

Contact numbers

Support group / website information