Criteria for medical management• No hemodynamic instability• No tubal rupture• Fertility desired• Gestational sac < 3.5cm• Beta HCG level < 5000mIu/ml• No cardiac motion on USG• Ability and willingness to comply with follow up.
Drugs commonly used are:• Methotrexate (drug of choice)• Potassium chloride• Prostaglandin(PGF₂α)• Hyperosmolar glucose
Methotrexate mechanism of action & regimens• MOA: methotrexate depletes tetrahydrofolate cofactors for DNA & RNA synthesis and inhibits rapidly growing trpohoblast of EP.• Regimens:1)Single dose- methotrexate i.m 50mg/m² of body surface area.o β-HCG level on D₄ and D₇ is measured, minimum difference of > 15 percent should be thereo Dose to be repeated - if difference is < 15 percent b/w D₄ and D₇ . ORo fetal cardiac activity is present on D₇.o β-HCG level is repeated weekly until undetectable.2)Multiple dose- methotrexate 1mg/kg i.m on D₁,D₃,D₅,D₇ & lecuovorin0 .1mg/kg i.m on D₂,D₄,D₆,D₈o β-HCG level is measured every alternate day, Until decreased upto 15 percent in 2 consecutive dayso Then weekly β-HCG level estimation is done until undetectable.
Contraindication of methotrexate• Hemoperitoneum• Breast feeding• Immunodeficiency• EP > 4cm• Alcoholism• Hepatic/Renal disease• Blood disorder
Local injection• 20 percent potassium chloride 0.5 ml under USG guidance – causes asystole & resolution of ectopic• Hyperosmolar glucose 1 to 3 ml injected into the sac.• PGF₂α when injected causes contraction and vasoconstriction thus resolution of pregnancy.