286 Obstetrics and Gynecology Board Review •••
❍ What instructions should be given to patients receiving methotrexate?
Patients should be counseled to avoid folic acid supplements, NSAIDs, alcohol, and sunlight exposure. In addition,
they should refrain from sexual intercourse or vigorous physical activity.
❍ What is the risk of early ovarian failure with methotrexate use?
There does not appear to be an increased risk of ovarian failure with this chemotherapeutic agent.
❍ Single-dose methotrexate therapy (typically 50 mg/m^2 of body surface area) has what primary advantage
over multiple treatment regimens?
Fewer side effects are seen with single-dose treatment. The success rate is similar.
❍ What patients are reasonable candidates for medical treatment of an ectopic pregnancy?
Hemodynamically stable patients with a confirmed or highly suspicious unruptured ectopic pregnancy who agree
to comply with close follow-up care and do not have contraindications to methotrexate use.
❍ List the absolute and relative contraindications to methotrexate use.
Absolute:
(1) Breastfeeding.
(2) Overt or laboratory evidence of immunodeficiency.
(3) Alcoholism, alcoholic liver disease, or other chronic liver disease.
(4) Preexisting blood dyscrasias, such as bone marrow hypoplasia, leucopenia, thrombocytopenia, or significant
anemia.
(5) Known sensitivity to methotrexate.
(6) Active pulmonary disease.
(7) Hepatic, renal, or hematologic dysfunction.
Relative:
(1) Gestational sac larger than 3.5 cm.
(2) Embryonic cardiac motion.
❍ What lab values should be checked prior to giving methotrexate?
Baseline hCG levels, liver function tests, platelet count, and white blood cell count should be checked before and
after treatment. After treatment, hCG levels should be followed to zero.
❍ What criteria are used for assuring the success of methotrexate?
With a single-dose therapy, the hCG levels should fall by 15% between days 4 and 7 after therapy and continue to
fall weekly until undetectable.
❍ How common is pelvic pain following methotrexate therapy?
Up to 30% of women will experience pain within 2 weeks of treatment.
❍ Does pelvic pain after methotrexate require surgery?
Although these patients should be followed closely with ultrasound and CBCs, the pain often resolves without surgery.