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Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

  1. Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26th September 3-4 pm on national and local contingency planning for future RDS outages.  Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

 

2.National  IV fluid prescribing  calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids  . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery.  It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

 

  1. New toolkits

The following toolkits are now live;

  1. Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

 

  1. Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit.  We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process.  The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

 

  1. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:
  • Thursday 5 September 1-2 pm
  • Wednesday 24 September 4-5 pm
  • Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

 

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

Ectopic Pregnancy Medical Management (116)

Please report any inaccuracies or issues with this guideline using our online form

Methotrexate

  1. Antimetabolite and antifolate drug which is an established, effective and safe treatment for unruptured ectopic pregnancy and treatment of PUL.
  2. Success rates are around 80-90%.
  3. Careful patient selection is paramount- consultant review is required.
  4. Avoid aspirin or anti inflammatory drugs for 1 week after administration.
  5. Avoid alcohol, vitamins containing folic acid, intercourse, and travel out with the local area until follow up is complete.
  6. The vast majority of patients who have methotrexate will go on to have a subsequent intra-uterine pregnancy.

Patient selection

  1. Diagnosis of ectopic pregnancy or PUL confirmed according to EPAS guidelines.
  2. Patient clinically stable with minimal or no symptoms.
  3. No contra-indications to medical management.
  4. Patient fully counselled regarding treatment options and wishes medical management.
  5. Patient is able and willing to comply with follow up for several weeks - the average follow up time is 35 days.
  6. Patient agrees to avoid pregnancy until follow - up complete and three months after methotrexate.

Contra-indications to medical management

  1. Fetal cardiac activity.
  2. Concurrent intrauterine pregnancy (heterotopic pregnancy).
  3. Significant free intraperitoneal fluid.
  4. Serum HCG≥ 5000 iu/l.
  5. Abnormal renal or hepatic function- discuss with consultant if deranged.
  6. Adnexal mass ≥ 4 cm.
  7. Hb ≤ 100g/l, WCC≤ 2 x 109/l , platelets ≤100 x 10 9/ l
  8. Immunodeficiency.
  9. Patient currently breast feeding.
  10. Patient unwilling to avoid pregnancy for 3 months

Adverse effects

Most side effects are usually mild:

  • Nausea, diarrhoea, stomatitis.

More serious side effects are rare:

  • Impaired liver function, bone marrow suppression- usually reversible.

Abdominal pain occurs in about 75% of patients 3-7 days after methotrexate. This “separation pain” can be difficult to distinguish from pain due to rupture. If patient presents with concerning symptoms, carry out ultrasound to look for free fluid +/or admit for observation and senior review.

There is a 7% risk of tubal rupture following methotrexate.

Pre- treatment Investigations

  1. Serum HCG
  2. FBC, U+E, LFTs, blood group
  3. Height and weight. Calculate Surface Area-copy and paste the following into a web browser:
    https://www.medicinescomplete.com/#/calculators?calcId=body-surface-area

    (use the Dubois formula, weight in kg and height in centimetres)

  4. Offer Chlamydia screening.
  5. Pharmacy prescription to be completed by senior medical staff.

Treatment Schedule

Day 1. Methotrexate administration day

  1. Ensure patient has had appropriate counselling and information sheet.
  2. Ensure consent form signed.
  3. Ensure patient contact details are clearly documented in notes.
  4. Ensure patient has EPAS contact numbers and gynaecology ward number for out- of -hours advice
  5. Inform GP of diagnosis and treatment- see GP information leaflet.
  6. Administer methotrexate 50 mg/m2  IM-see methotrexate prescription form for dose banding according to surface area.

Day 4. EPAS Review

  1. Check serum HCG

Day 7. EPAS Review

  1. Check serum HCG
  2. If HCG on day 7 has fallen by 15% or more from day 4 levels, check HCG weekly until < 5iu/l.
  3. If HCG has not fallen by at least 15%, discuss with senior medical staff. In carefully selected cases, it may be appropriate to repeat HCG levels on day 10.
  4. If HCG has risen, refer to senior medical staff to discuss option of laparoscopy or a second dose of methotrexate.
  5. Approximately 15% of women will require a second dose of methotrexate.
  6. Very rarely, a third dose may be appropriate- this must be a consultant decision.

Second Dose of Methotrexate

  1. Ensure treatment criteria still fulfilled and discuss case with Consultant
  2. Transvaginal scan.
  3. FBC, U+E, LFT.

Further Follow up

  1. Check HCG levels weekly until <5iu/l
  2. If levels plateau or rise, discuss with senior medical staff
  3. Discharge patient when HCG < 5iu/l.

Contraception

There are no absolute contra-indications to specific forms of contraception after an ectopic, other than usual cautions, but the use of a copper coil should be limited to patients for whom no other methods are suitable.

Subsequent pregnancies

Advise to attend EPAS early in next pregnancy to confirm location.

Appendix: Methotrexate for ectopic pregnancy

Methotrexate for ectopic pregnancy (pdf)

Editorial Information

Last reviewed: 23/07/2021

Next review date: 01/07/2024

Author(s): Lynne Thomson.

Version: 4

Approved By: Gynaecology Clinical Governance Group

Document Id: 116

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