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Ectopic methotrexate eligibility — USMLE Step 3 MCQ

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HardOB/GYN (prenatal care, contraception, screening)Ectopic methotrexate eligibilityUSMLE Step 3

A stable 31-year-old woman with a 2.4-cm unruptured tubal ectopic pregnancy received single-dose methotrexate. She has no fetal cardiac activity and can return reliably. Beta-hCG was 2,600 mIU/mL on day 4 and 2,450 mIU/mL on day 7. She has mild pelvic discomfort, no peritoneal signs, and normal hemoglobin, creatinine, and aminotransferases. Which management is most appropriate?

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Correct answer: B — Repeat methotrexate or perform laparoscopic treatment after shared decision-making

The best answer is “Repeat methotrexate or perform laparoscopic treatment after shared decision-making”. A successful single-dose protocol requires at least a 15% beta-hCG decline from day 4 to day 7; this decline is only about 6%. A stable patient without rupture can receive another methotrexate dose or choose laparoscopic management after counseling. Continued weekly hCG surveillance is mandatory until resolution. Mild pain alone can occur, whereas hemodynamic instability or peritoneal findings would mandate surgery.

Reference: ACOG Practice Bulletin: Tubal Ectopic Pregnancy: https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2018/03/tubal-ectopic-pregnancy