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Medical management of ectopic pregnancy — MCCQE Part 1 MCQ

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HardPregnancyMedical management of ectopic pregnancyMCCQE Part 1

A stable patient with an unruptured tubal ectopic pregnancy receives single-dose methotrexate. Her beta-hCG is 3,200 IU/L on day 4 and 2,900 IU/L on day 7. She has mild resolving pain and no haemoperitoneum. What is the most appropriate interpretation and next step?

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Correct answer: E — The fall is below 15%; reassess for repeat methotrexate or surgery

The fall exceeds 15%; continue weekly beta-hCG monitoring to resolution: A subthreshold fall cannot be accepted as adequate treatment response and needs more than routine delayed testing. The fall is below 15%; reassess for repeat methotrexate or surgery: The calculated decline is 300 divided by 3,200, or 9.4% after rounding, below the 15% response criterion and therefore not reassuring. The fall exceeds 15%; discontinue follow-up after one additional measurement: Follow-up continues to an undetectable concentration because rupture remains possible even while beta-hCG falls. The fall is excessive; give folinic acid and stop biochemical surveillance: Folinic acid is not given simply because beta-hCG has fallen; it would counteract intended methotrexate treatment. The fall establishes rupture; proceed to laparoscopic salpingectomy this evening: Inadequate biochemical response does not prove rupture when the patient is stable and imaging shows no haemoperitoneum; management remains individualized.

Reference: https://www.cmaj.ca/content/193/29/E1137