**Question:** Management of tubal ectopic pregnancy of 2.5 x 3 cm is -

A. Medical management with methotrexate
B. Surgical management with salpingectomy
C. Observation and expectant management
D. Medical management with methotrexate followed by surgical intervention if necessary

**Correct Answer:** D. Medical management with methotrexate followed by surgical intervention if necessary

**Core Concept:**
Ectopic pregnancy is a condition where the fertilized egg implants outside the uterine cavity, most commonly in the fallopian tube. Tubal ectopic pregnancies account for approximately 95% of all ectopic pregnancies. The management options for tubal ectopic pregnancies depend on the size, location, and stability of the pregnancy, as well as the patient's preference and overall health status.

**Why the Correct Answer is Right:**
For tubal ectopic pregnancies with a size less than 5 cm, medical management with methotrexate is a viable option in certain cases. Methotrexate is an anti-folate drug that interferes with DNA synthesis and cell proliferation, leading to fetal demise. In this context, methotrexate is administered intramuscularly, and the patient is monitored for fetal heart rate loss and hemodynamic stability. If the pregnancy does not respond to methotrexate or is unstable, surgical intervention is required.

**Why Each Wrong Option is Incorrect:**

A. Medical management with methotrexate is contraindicated for larger pregnancies (>5 cm) as it may lead to uterine rupture and severe complications.
B. Salpingectomy (surgical removal of the fallopian tube) is not the first-line management for tubal pregnancies, as it results in sterility and may lead to increased risk of ectopic pregnancies in the future.
C. Observation and expectant management is not a suitable choice for tubal pregnancies as it may lead to uterine rupture, severe hemorrhage, and life-threatening complications.

**Clinical Pearl:**
In cases where medical management with methotrexate is chosen, the patient should be closely monitored and prepared for surgical intervention if the pregnancy does not respond to methotrexate or is unstable. This approach ensures a lower risk of severe complications and preserves the patient's fertility potential.