Treatment of left tubal pregnancy with foetal cardiac activity using a two-dose methotrexate regimen

The incidence of ectopic pregnancy (EP) is about 1.3–2.4%. Approximately 6% of maternal deaths in the first trimester occur following ruptured EP. A 35-year-old lady, G4, P3, pregnant 7 weeks + 2 days, presented with left iliac pain, after positive pregnancy test, and β-human chorionic gonadotropin (β-hCG) 3614 mIU/ml. The transvaginal sonography showed an empty uterus, with a well-defined left adnexal echogenic structure measuring 38×32 mm (left adnexal gestational sac – GS) with foetal pole (bagel sign). The colour Doppler examination showed foetal cardiac activity with circumferential Doppler flow around the GS (ring of fire). She was diagnosed as left undisturbed tubal pregnancy with foetal cardiac activity. She refused the option of laparoscopic surgery. Therefore, she was counselled for medical treatment using methotrexate (MTX). She was also informed that the MTX treatment may fail due to the presence of foetal cardiac activity, and she may need more than one MTX dose. She received the first MTX dose at an initial β-hCG 3614 mIU/ml. The fourth day β-hCG after the first MTX dose was 5421 mIU/ml, while the seventh day β-hCG was 5055 mIU/ml [< 15% decrease of β-hCG (6.75%)]; therefore, she was given a second MTX dose. The fourth day β-hCG after the second MTX dose was 3851 mIU/ml, while the seventh day β-hCG was 2218 mIU/ml [> 15% decrease of β-hCG (42.4%)]; therefore, she was discharged home for follow-up in the outpatient department. This report represents the treatment of left undisturbed tubal pregnancy with foetal cardiac activity using a two-dose MTX regimen.