EMedHome's Clinical Pearl
Women diagnosed with ectopic pregnancy and treated with methotrexate in the ED found high rates of return ED visits. (CJEM 2018. doi: 10.1017/cem.2018.440.) Patients for whom methotrexate treatment failed had on average 1.7 return visits to the ED. Twenty-seven (17.8%) of the 152 patients treated with methotrexate went on to require surgical management, with 17 (11.2%) documented as having rupture.
Twenty (13.1%) patients had at least one relative contraindication to methotrexate (pretreatment bHCG levels of >5,000 mIU/mL, the presence of fetal cardiac activity, or an ectopic pregnancy size of >4 cm). Five of these patients (25%) had an ectopic rupture, and three (15%) required nonurgent surgical management.
This study was conducted in a Canadian academic tertiary care institution with a high-acuity obstetrics program, suggesting a high level of expertise with ectopic pregnancy. Just because your obstetrical consultant ordered the methotrexate for your ED patient does not mean that contraindications were properly evaluated.
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Michael Winters, MD: Post-Arrest Care: http://bit.ly/EMN-EMedHomeVideos. Dr. Winters is an associate professor of emergency medicine and the co-director of the Combined EM/IM/Critical Care Program at University of Maryland School of Medicine.
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Amal Mattu, MD, and Colleagues: Post-Cardiac Arrest Care, One-Pill Killers in Pediatrics, and Abrupt Headaches: http://bit.ly/MattuEMN. Dr. Mattu is one of the premier speakers in emergency medicine, and a professor of emergency medicine and the vice chair of emergency medicine at the University of Maryland School of Medicine in Baltimore.