Ans. is c, i.e. Presence of fetal heart activityRef Dutta Obs. 7/e, p 186; Leon Speroff 7/e, p 1287, 1288; Novak 14/e, p 624; Williams Gynae 7/e, p 166Methotrexate: It is a folic acid analogue which inhibits dehydrofolate reductaseQ and prevents synthesis of DNA.QCandidates for methotrexate (Williams 24/e, p 384, Table 19.2): --Leon Speroff 7/e, p 1290Absolute requirementsHemodynamic stabilityQNo evidence of acute intra-abdominal bleedingQReliable commitment to comply with required follow-up careQNo contraindications to treatment viz woman should not be breast feeding/renal/hepatic dysfunction.Preferable requirementsAbsent or mild painSerum beta hCG level less than 5,000IU/L (best results seen with HCG<2000IU/L)Q It is the single best prognostic indicator of treatment success.Absent embryonic heart activityQEctopic gestational mass less than 4 cm in diameter without cardiac activity and < 3.5 cm with cardiac activityQFriends, there is no doubt on this issue that presence of cardiac activity is a relative contraindication according to books like Williams Obs 23/e, Williams Gynae 1/ed and Leon Speroff 7/ed."Fetal cardiac activity - Although this is a relative contraindication to medical therapy; the admention is based on limited evidence." --William Obs. 23/e, p 247"The presence of embryonic heart activity is not an absolute contraindication for medical management but the likelihood of failure and the risk of tubal rupture are substantially increased (therefore it is a relative contraindication)." --Leon Speroff 7/e, p 1287As far as fluid in cul-de-sac is concerned: Earlier, it was also considered a relative contraindication to medical treatment, but studies have shown that free peritoneal fluid can be seen in almost 40% of women with early unruptured ectopic pregnancy and so it's presence and absence does not accurately predict the success or failure of medical treatment.Contraindications to methotrexate treatment: (Williams 24/e, p 384, Table 19.2)Breast feedingQ Immunodeficiency statesQAlcoholism or evidence of chronic liver disease (elevated transaminases) QRenal disease (elevated serum creatinine) QHematological abnormalities (severe anemia, leukopenia or thrombocytopenia) QKnown sensitivity to methotrexateQActive pulmonary diseaseQPeptic ulcer disease. QEvidence of tubal rupture