A 21 year old female presents to the ED with vaginal bleeding. She reports that a home pregnancy test was positive this morning. A beta hcg quant level is drawn and pending. On ultrasound you identify an extrauterine gestational sac without an IUP. The patient is hemodynamically stable and you discuss treatment options with her. All of the following would make this patient an optimal candidate for methotrexate except:

A. Beta hCG < 5,000

B. No fetal cardiac activity

C. Ectopic Mass <4 cm

D. Trace free fluid on US

Answer: D. This patient has an ectopic pregnancy. Any free fluid is considered a contraindication to treatment with methotrexate. The other answer choices represent features of an optimal candidate for methotrexate therapy of a stable confirmed ectopic pregnancy. Ultimately, the patient’s treatment plan will be made in consultation with your OBGYN colleagues. However, it is important to be aware of other contraindications to methotrexate: immunodeficiency, active pulmonary or peptic ulcer disease, coexistent viable IUP, breastfeeding, and poor access to post-therapeutic follow up.

Barnhart KT. Clinical practice. Ectopic pregnancy. N Engl J Med. 2009 Jul 23;361(4):379-87. doi: 10.1056/NEJMcp0810384. PMID: 19625718.