• Reference Number: HEY-580/2022
• Departments: Gynaecology
• Last Updated: 1 May 2022

Introduction

This leaflet has been produced to give you general information about your treatment.  Most of your questions should be answered by this leaflet.  It is not intended to replace the discussion between you and your doctor but may act as a starting point for discussion.   If after reading it you have any concerns or require further explanation, please discuss this with a member of the healthcare team.

Why do I need medical management of an ectopic pregnancy or pregnancy of unknown location?

You have been diagnosed with an ectopic pregnancy or a pregnancy of unknown location (for more information on ectopic pregnancy please refer to the patient information leaflet entitled ‘Ectopic Pregnancy’)

In certain circumstances, an ectopic pregnancy, or pregnancy of unknown location (PUL), may be treated by medication (drug). The drug (methotrexate) prevents the pregnancy from developing and so the ectopic pregnancy gradually disappears. The drug is given as an injection. If your pregnancy is beyond the very early stages or the pregnancy hormone level is high, methotrexate is less likely to succeed. Many women experience some pain in the first few days, but this usually settles with paracetamol or similar pain relief medication

Please be advised that neither ectopic pregnancy or a pregnancy of unknown location lead to a viable, healthy pregnancy, but may pose a risk to your health and life.

What is methotrexate?

This is a potent drug that stops actively dividing cells from growing. The drug stops the pregnancy developing any further and the pregnancy is gradually reabsorbed.

What does the treatment involve?

The treatment is given to you by an injection into your muscle, usually in the buttock. Before you are given the injection, blood tests are completed to check liver and kidney function and to ensure that you are not anaemic.

This method avoids the need for surgery; however, it does require careful monitoring and follow-up. This means that you will have to attend the hospital regularly for blood tests until the tests are negative.

This can take several weeks and this will be explained by your doctor. Your hospital will make arrangements for you to have the hormone level checked. Your doctors will usually test your human chorionic gonadotropin (hCG) levels on the day the medicine is given, again on day four and on day seven after the injections

Can there be any complications or risks?

Some women may experience an increase in abdominal pain following the injection. This usually settles after a couple of days. However, if the pain persists and is getting worse rather than improving, and you are feeling generally unwell with dizziness and sickness, please contact the hospital for advice, by calling the number at the end of this information leaflet.

Minor side effects can include:

• Nausea and vomiting
•  Diarrhoea, flatulence
•  Sensitivity to sunlight and mild headache
•  Mouth ulcers
•  Some reversible hair thinning
•  Anaemia

Will I still need an operation?

The aim of this treatment is to resolve the ectopic pregnancy without an operation. However, this is not always possible. If you have any internal bleeding that occurs from the pregnancy, or it is increasing in size as seen on a scan or pregnancy hormone are failing to drop down then an operation may still be needed.

How do I prepare for having the medical treatment?

Please read the information leaflet.  Share the information it contains with your partner and family (if you wish) so that they can be of help and support.  There may be information they need to know, especially if they are taking care of you following this examination.

Do I need to take special precautions after having had the methotrexate injection?

Please follow the direction listed below:

• Do not have sexual intercourse during the treatment
• Avoid alcohol during and for the first week after treatment
• Avoid vitamin preparation until your treatment is complete
• Avoid non-steroid anti-inflammatory such as aspirin and ibuprofen
• Avoid strong or prolonged exposure to sunlight in the first 48 hours of treatment
• Once treatment is completed avoid pregnancy for three months if you have had only one injection
• We would also advise you to take an adequate fluid intake avoiding dehydration throughout this procedure

What will happen?

The injection is administered into the large muscle of the buttock.

Each patient’s dose is individually calculated and mixed by the medical staff and the Pharmacy Department.

Will I need to stay in hospital?

You will need to stay in hospital for half an hour after the injection and then it is important that you attend for regular check-ups. At each visit you will be asked about how you are feeling, a blood sample will be taken, and you will be given a time and date for your next appointment.

What happens afterwards?

For how long will I need to keep visiting the hospital?

The visits will be every three days during the first week. Once the first week is over, if the pregnancy hormone level is falling satisfactory, this is then reduced to once a week. We will continue to see you for between three and four weeks until the pregnancy hormone level falls completely. The higher the first level the longer it will take.

When should I return to hospital?

At each visit you will be told when to return next. The Nurse will telephone you with your blood results normally after 2 – 4 hours and confirm the date of your next appointment. You must telephone or attend the hospital if you are worried about severe or persistent lower abdominal pain, heavy vaginal bleeding or if you have any other concerns. (See telephone numbers provided at the end of the leaflet)

Will I experience any pain?

Yes, you might have some lower pelvic pain or back ache at any time during the course of your treatment. If required, you can take paracetamol.

Whilst you are at home it is important to notify either Early Pregnancy Assessment Unit (EPAU) or Gynaecology Ward if:

• You experience any increase in pain
•  Pain somewhere you have not previously had it
• You feel faint or dizzy
•  Paracetamol is insufficient for any pain you are experiencing

Will I have any vaginal bleeding?

Yes. This can vary from dark brown spotting to heavier bright red loss. Use sanitary towels rather than tampons whilst you are bleeding, to reduce the risk of any infection.

If you are concerned that the bleeding is excessive (requiring you to change a sanitary pad every half an hour) please telephone either EPAU or the Gynaecology Ward, Ward 30.

Can I have a bath/shower during my treatment?

Avoid hot baths whilst you are bleeding heavily, as you may feel faint. Otherwise, it is safe for you to have a warm bath or shower.

Should I be off work during the treatment?

This is a very individual thing. However, it is stressful having treatment, also you are recovering from the loss of your baby which can be a very distressing event in a woman’s life. Many women feel that at least a few days off work may be necessary, especially during the first week when frequent trips to the hospital are required.

Is it possible to get pregnant immediately after the procedure?

The usual recommendation is that you wait three months after the treatment before trying for another baby. This ensures that the methotrexate has been cleared from your body. If you want any advice on contraception, please ask the nursing/medical staff and they will be happy to discuss this with you.

What is the chance of another ectopic pregnancy?

The overall chance of another ectopic pregnancy is between 7% and 10%.

Can the treatment harm any of my future babies?

There is no evidence to show that methotrexate causes any problems to subsequent babies. If you are planning on getting pregnant you should consider taking folic acid for three months before getting pregnant but after your treatment is complete.

Care in your next pregnancy

If you have had an ectopic pregnancy, you can refer yourself to EPAU for assessment when you are six weeks pregnant, please say when calling that you have had a previous ectopic pregnancy or PUL. This is so you can have an early pregnancy scan, at six weeks to check that the pregnancy is in the right place this time. If you have any pain or bleeding before six weeks then you can ring EPAU/Ward 30 for advice. They may advice for you to attend for a blood test or advice you to monitor your symptoms

Should you require further advice on the issues contained in this leaflet, please do not hesitate to contact the:

Early Pregnancy Assessment Unit, Women and Children’s Hospital – (01482) 608767 
Gynaecology Ward, Ward 30, Women and Children’s Hospital –  (01482) 604387 

Useful contacts and websites

The Ectopic pregnancy Trust
Phone Helpline 020 77332653
PO Box 485
Potters Bar
EN6 9FE
www.ectopic.org.uk

Miscarriage Association 
(Tel: 01924 200799 – Monday to Friday 9am to 4pm)
C/o Clayton Hospital, Northgate, Wakefield
West Yorkshire WF1 3JS
www.miscarriageassociation.org.uk

Information on Gynaecology Services at Hull University Teaching Hospitals NHS Trust can be found at: https://www.hey.nhs.uk/content/services/gynaecology

General Advice and Consent

Most of your questions should have been answered by this leaflet, but remember that this is only a starting point for discussion with the healthcare team.

Consent to treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. You should always ask them more questions if you do not understand or if you want more information.

The information you receive should be about your condition, the alternatives available to you, and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• you must be able to give your consent
• you must be given enough information to enable you to make a decision
• you must be acting under your own free will and not under the strong influence of another person

Information about you

We collect and use your information to provide you with care and treatment. As part of your care, information about you will be shared between members of a healthcare team, some of whom you may not meet. Your information may also be used to help train staff, to check the quality of our care, to manage and plan the health service, and to help with research. Wherever possible we use anonymous data.

We may pass on relevant information to other health organisations that provide you with care. All information is treated as strictly confidential and is not given to anyone who does not need it. If you have any concerns please ask your doctor, or the person caring for you.

Under the General Data Protection Regulation and the Data Protection Act 2018 we are responsible for maintaining the confidentiality of any information we hold about you. For further information visit the following page: Confidential Information about You.

If you or your carer needs information about your health and wellbeing and about your care and treatment in a different format, such as large print, braille or audio, due to disability, impairment or sensory loss, please advise a member of staff and this can be arranged.