Level B recommendations. (1) Arrange outpatient follow-up for patients who receive methotrexate therapy in the ED for a confirmed or suspected ectopic pregnancy. (2) Strongly consider ruptured ectopic pregnancy in the differential diagnosis of patients who have received methotrexate and present with concerning signs or symptoms.

Level C recommendations. None specified.

Methotrexate, administered as a single intramuscular or intravenous dose in the ED, is an alternative to surgical treatment for known or suspected early ectopic pregnancy. Because a single dose of methotrexate is often ineffective, patients may require repeated doses until their b-hCG levels are clearly decreasing. Treatment failure leading to rupture of the ectopic pregnancy is one of the most serious complications of methotrexate therapy; in several cohort studies, more than 20% of patients receiving methotrexate required surgery. Nineteen Class I, II, and III studies were included for discussion. Taken together, these data support a Level B recommendation to arrange outpatient follow-up and to strongly consider ruptured ectopic pregnancy in patients who develop increasing pain and/or signs of hemodynamic instability after methotrexate therapy.

Conclusion

The definitive diagnosis of ectopic pregnancy in the first trimester remains a clinical challenge. There is growing evidence that clinicians should not rely upon a discriminatory threshold to decide which patients to perform an ultrasound on, nor use the b-hCG to try to predict which patients with an indeterminate ultrasound have an ectopic pregnancy. Despite the clinician’s best efforts, a significant minority of patients will not have a definitive diagnosis after their ED workup, and the management and disposition will need to take into account the patient’s clinical picture as well as other contributing factors, including availability of outpatient follow up.

This clinical policy can also be found on ACEP’s Web site www.acep.org and has been submitted for abstraction on the National Guideline Clearinghouse Web site, www.guidelines.gov.

Dr. Bernstein is a senior resident in emergency medicine at Yale-New Haven Hospital, and is the 2011-2013 EMRA Representative to the ACEP Clinical Policies Committee.

Dr. Hahn is an assistant professor in emergency medicine at the Mount Sinai School of Medicine in New York, and is a member of the ACEP Clinical Policies Committee.