Ectopic Pregnancy and Methotrexate

Author: Michelle Lin, MD
Updated: 11/11/2011

Methotrexate for Ectopic Pregnancy

Methotrexate (MTX)


  • Dihydrofolate reductase inhibitor
  • Overall success rate for treating ectopic pregnancy = 71-94%
  • Success rate of single-dose MTX for beta-hCG >5,000 mIU/mL = 85.7%

Side Effects

  • Abdominal pain
  • Nausea/vomiting
  • Stomatitis

Eligibility / Contraindications for MTX in Ectopic Pregnancy

Eligibility Criteria: (Need to fulfill all criteria)

  • High clinical suspicion or confirmed ectopic pregnancy
  • Hemodynamically stable
  • Unruptured mass
  • Able to comply with close follow-up
  • Normal creatinine, liver transaminases, WBC, hematocrit, and platelet counts


  • Breastfeeding
  • Overt or lab evidence of immunodeficiency
  • Alcoholism, alcoholic or chronic liver disease
  • Preexisting blood dyscrasias or significant anemia
  • Known sensitivity to MTX
  • Active pulmonary disease
  • Peptic ulcer disease
  • Hepatic, renal, or hematologic dysfunction
  • Gestational sac >3.5 cm on U/S (relative contraindication)
  • Embryonic cardiac motion on U/S (relative contraindication)

Single-Dose Regimen

  • Day 1: Methotrexate 50 mg/m2 IM

Follow up with obstetrician:

  • Days 4 and 7: Measure beta-hCG
  • Between Days 4 and 7: Check for 15% beta-hCG decrease
  • Measure beta-hCG weekly until non-pregnant level
  • If beta-hCG dose not decrease by >15% as expected, re-dose 50 mg/m2 IM and repeat B-hCG on days 4 and 7 after 2nd dose.

Alternative Regimens

  • Two-Dose and Fixed Multidose regimens available as proposed by ACOG guidelines - Consider for beta-hCG level >5,000 mIU/mL


  • ACOG Practice Bulletin No. 94:Medical management of ectopic pregnancy. Obstet Gynecology. 2008; 111(6):1479-85. [PubMed]