A)criteria for medical management include; patient should be haemodynamically stable ,had an ectopic sac less than 3 cm in diamter with no fetal cardiac pulsation, level of bHCG less than 3000 iu/L with no or minimal fluid collection in the pouch of Douglas by USS. she had been full counselled regarding benefits of medical management and accepted the possibilty of surgical intervention if it failed.
B) patient and her partner will be counselled regarding medical managment benefits and risks before obtaining written consent. Contact number of EPAU during 24 Hours peroid will be provided and informed to contact the hospital if any emergency arises like severe pain ,heavy bleedig . Intial blood sample for FBC,LFT,U/Es , Blood group and the pre- injection level of BhCG. Measuring her weight, height to calculate her body surface area. calculating dose of Methotrxate as 50 mg per square meter surface area to bo given deeply intramuscular.patient will be observed fo few hours after giving the injection before allowing her to go home with all contact numbers and details.
level of BhCG will be assessed D4 and D7 at EPAU unit along with information about any new symptoms. If level of BhCG dropped >15% between D4-D7 she will be followed up by weekly BhCG levels until less than 20 IU/l But if level plateued or rise discussion with Consultant regarding giving booster dose versus Laproscopic management.
Anti D 250 IU will be given if she is Rh negative,. If pain persist or increased ,or patient became haemodynamically unstable surgical treatment will be urgently requested.
She will need psychological support
contraception will be needed for 3 months after mehotrexate and she will be advised to be seen early in her next pregnancy for exclusion of another ectopic pregnancy by USS.
