Is liver function testing necessary prior to methotrexate treatment for ectopic pregnancy?

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Study objectives: Methotrexate is used extensively for the nonsurgical management of ectopic pregnancy. Hepatic function testing, specifically aminotransferase testing, was part of the initial methotrexate safety profile and continues to be routinely required before treatment with methotrexate. We seek to determine the incidence of abnormal aminotransferase values among emergency department (ED) patients with ectopic pregnancy. We examine risk factors for liver disease (eg, history of hepatitis, alcohol abuse) among patients with abnormal aminotransferase values and the time spent waiting for aminotransferase testing before methotrexate treatment. Methods: ED medical records were examined over a 4-year period for all patients with an International Classification of Diseases, Ninth Revision diagnosis of ectopic pregnancy. Patients with ectopic pregnancy were included if aminotransferase testing was performed during the ED visit. The medical record was reviewed for risk factors for liver disease if aminotransferase values were elevated. If a patient was treated with methotrexate, the time between orders for aminotransferase and methotrexate was recorded. Results: Over a 4-year period, 205 patients were diagnosed with ectopic pregnancy. Of these patients, the study group consisted of 121 patients who also had serum aminotransferase testing. In the study group, 42 patients were treated with methotrexate, and 79 were treated surgically. Two of the 121 (1.2%) patients had abnormal aminotransferase values. One patient had a normal aspartate aminotransferase (AST) level and an alanine aminotransferase (ALT) level of 43 U/L (reference range 15 to 40 U/L). This patient had a history of hepatitis C. The second patient had a normal ALT level and an AST level of 81 U/L (reference range 15 to 65 U/L). This patient had a history of alcohol abuse. Of the 42 patients treated with methotrexate, the mean time between orders for aminotransferase testing and methotrexate administration was 102 minutes (95% confidence interval 94 to 109 minutes). Conclusion: Among patients with ectopic pregnancy being considered for methotrexate treatment, the incidence of aminotransferase abnormalities is low. Aminotransferase testing significantly prolonged ED treatment time among patients receiving methotrexate. Further prospective study may identify a majority of patients who may be treated with methotrexate without previous aminotransferase testing.