Pretreatment testing and instructions |
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- Blood group and RhD typing (with administration of anti-D immune globulin to RhD-negative patients), if indicated
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- Liver and renal function tests
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- Discontinue folic acid supplements
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- Counsel patient to avoid nonsteroidal anti-inflammatory medications, recommend acetaminophen if an analgesic is needed
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- Advise patient to refrain from sexual intercourse and strenuous exercise
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Treatment day | Single-dose protocol* | Two-dose protocol* | Multiple-dose protocol |
1 | - Measure hCG concentration
- Give first dose methotrexate 50 mg/m2 BSA IM
| - Measure hCG concentration
- Give first dose methotrexate 50 mg/m2 BSA IM
| - Measure hCG concentration
- Give first dose methotrexate 1 mg/kg body weight IM or IV
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2 | – | – | |
3 | – | – | - Measure hCG concentration
- If <15% hCG decline from day 1 to 3, give second dose methotrexate 1 mg/kg IM or IV
- If ≥15% decline from day 1 to 3, draw hCG concentration weekly until undetectable
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4 | - Measure hCG concentrationΔ
| - Measure hCG concentrationΔ
- Give second dose methotrexate 50 mg/m2 IM
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5 | – | – | - Measure hCG concentration
- If <15% decline from day 3 to 5, give third dose methotrexate 1 mg/kg IM or IV
- If ≥15% decline from day 3 to 5, draw hCG concentration weekly until undetectable
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6 | – | – | |
7 | - Measure hCG concentration
- If <15% hCG decline from day 4 to 7, give second dose of methotrexate 50 mg/m2 IM
- If ≥15% hCG decline from day 4 to 7, draw hCG concentration weekly until hCG is undetectable
| - Measure hCG concentration
- If <15% decline from day 4 to 7, give third dose methotrexate 50 mg/m2 IM
- If ≥15% decline, draw hCG concentration weekly until undetectable
| - Measure hCG concentration
- If <15% decline from day 5 to 7, give fourth dose methotrexate 1 mg/kg IM or IV
- If ≥15% decline from day 5 to 7, draw hCG concentration weekly until undetectable
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8 | – | – | |
11 | – | - Measure hCG concentration
- If <15% decline from day 7 to 11, give fourth dose methotrexate 50 mg/m2 IM
- If ≥15% decline from day 7 to 11, draw hCG concentration weekly until undetectable
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14 | - Measure hCG concentration
- If <15% hCG decline from day 7 to 14, give additional dose of methotrexate 50 mg/m2 IM◊
- If ≥15% hCG decline from day 7 to 14, draw hCG concentration weekly until undetectable
| - Measure hCG concentration
- If <15% hCG decline from day 11 to 14, consider surgical management
- If ≥15% hCG decline from day 11 to 14, draw hCG concentration weekly until undetectable
| - Measure hCG concentration
- If <15% hCG decline from day 7 to 14, give fifth dose of methotrexate 1 mg/kg IM or IV◊
- If ≥15% hCG decline from day 7 to 14, draw hCG concentration weekly until undetectable
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15 | – | – | |
21 | - Measure hCG concentration
- If three doses have been given and there is a <15% hCG decline from day 14 to 21, proceed with surgical management
| – | - Measure hCG concentration
- If 5 doses have been given and there is a <15% hCG decline from day 14 to 21, proceed with surgical management
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Perform surgery if |
- Severe abdominal pain or an acute abdomen suggestive of tubal rupture
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- Ultrasonography findings are suggestive of hemoperitoneum
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