40 Multidose methotrexate treatment of tubal ectopic pregnancies with high initial β-human chorionic gonadotropin over 5,000 mIU/mL

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Introduction and aims of the study: To investigate the success, fertilization and side effect rates of individualized multidose methotrexate (MTX) regimen in patients with high initial serum hCG (>5000mIU/mL). Methods: 90 patients with tubal pregnancies were included to this prospective case-control study that consists of three groups: Single-dose (n=40), double-dose (n=10) and multi-dose (n=40) regimens. Patients were followed between 2014-2020 in a dedicated referral center for management ectopic pregnancies. Patients with serum βhCG>5,000 mIU/mL received individualized multiple doses of Mtx (1mg/kg) with tailored folinic acid rescue taking the patient's clinical course into consideration. Results: The success rate of single-, double- and multi-dose MTX regimens were 90%, 80% and 82.5%, respectively. Mean BhCG level was found as 11631.3±7577.3 mIU/mL (range:5042-31114). The changes in before and after MTX injections can be seen in Figure-1. Twelve patients were conceived after the multidose regimen; 10 of those have delivered healthy babies and remaining 2 have ongoing pregnancy. There was no recurrent ectopic pregnancy observed. In multidose protocol,10 patients (25%) had ectopic mass size larger than 30mm with mean size of 35.1±2.77mm and success rate of 80% (n=8/10; failures had 35 and 40 mm). Fetal pole was seen in 13 patients (32.5%) and success rate was 69.2% in patients with visible fetal pole. Free intraperitoneal fluid was observed in 17 patients (42.5%, mean: 28.59±14.45mm). Among those, the success rate was 82.35% (n=3). Side effects in multidose protocol were observed in 23 of 40 (57.5%); 20(50%) of them exhibited mild symptoms and all resolved spontaneously, whereas 3 patients (7.5%) had a severe symptom, where all were resolved under appropriate medical treatment. A second dose of MTX was needed in 12.5% of patients who underwent to single-dose protocol. Conclusions: Multiple-dose Mtx treatment for ectopic pregnancies with high initial hCG is safe and effective alternative to elective surgery.