Management of separation pain after single-dose methotrexate therapy for ectopic pregnancy.

Objective: To review the success of conservative management of moderate to severe abdominal/pelvic pain occurring after treatment of ectopic pregnancy with systemic methotrexate, to evaluate prognostic factors for success, and to determine if the overall resolution time was shorter in such patients.Methods: A retrospective chart review of all single-dose methotrexate patients treated from January 1, 1992 to January 1, 1997 who were admitted for observation or evaluated and subsequently discharged after an episode of increased abdominal/pelvic pain unrelieved within 1 hour by 800 mg oral ibuprofen. Before 1992, patients developing such pain generally underwent surgery. Candidates for conservative management were hemodynamically stable and had no more than moderate (confined to the pelvis) free fluid. Mild rebound was not an exclusion. Hospitalized patients had serial abdominal examinations, hematocrits, and hCG titers. Hematocrits, ultrasound findings, hCG levels, time for hCG levels to reach </=15 mIU/mL (resolution time), outcome at discharge, and final outcome were reviewed. Comparison between hospitalized and nonhospitalized patients and between those patients who did or did not ultimately require surgery was performed. Statistical analysis was performed using two-tailed Student t test and chi(2) or Fisher's Exact test. A P value <.05 was considered statistically significant.Results: Fifty-seven patients with 64 episodes of pain severe enough to meet criteria were identified from the 213 patients treated during the study interval. This resulted in 37 hospital admissions and 28 outpatient evaluations. All patients admitted and not requiring surgery were discharged within 24 hours. Eight of the 37 inpatient admissions underwent surgery during that hospitalization while 2 others ultimately required surgery at a later date. Only one outpatient ultimately underwent surgery. Four patients not candidates for conservative therapy also underwent surgery during the study interval. For all patients, the average time of onset of pain significant enough to require evaluation was 8.1 days with a mode of 3 days. When patients hospitalized were compared, there was no significant difference in final hematocrit, presence of free peritoneal cavity fluid, or hCG titers between those who underwent surgery and those who did not. There was a statistical difference in initial hematocrit (P =.04), and the presence of rebound approached significance (P =.04). The mean decline in hematocrit for patients not requiring surgery was 3.54 points +/- SD 2.47. Three of 8 patients underwent surgery for decreasing hematocrit, 2 for hemodynamic instability, 1 each for free fluid in the flanks on ultrasound, increasing abdominal pain, and the presence of a large complex hematoma. There was no difference between patients treated as an outpatient or hospitalized with regard to initial hematocrit, initial hCG, presence or amount of free fluid, or time for hCG to fall to <15 mIU/mL. Patients with rebound were more likely to be admitted (P =.01), and those with greater amounts of free fluid or rebound were more likely to undergo surgery (P =.04 and.02, respectively). There was also no difference in time of hCG resolution when the 28 inpatients in this study who did not require surgery were compared with 154 patients in our methotrexate database who were treated during the same time frame but did not have any significant pain (31.5 +/- SD 14.6 vs 33.1 +/- SD 17.2, P =.57).Conclusion: The data in this study indicate that with careful selection, the majority of patients with separation pain can be managed successfully without surgery either in the hospital with close observation, serial hematocrits and abdominal examinations for severe pain, or as an outpatient for patients with less severe pain.