What is the treatment of choice of unruptured tubal pregnancy with serum p-hCG titre 2000 lU/ml
**Core Concept**
An ectopic pregnancy is a life-threatening condition where a fertilized ovum implants outside the uterine cavity, usually in the fallopian tube. In unruptured ectopic pregnancies, the goal is to preserve the fallopian tube and prevent rupture while eliminating the ectopic pregnancy. The choice of treatment depends on the size of the ectopic pregnancy, the level of serum beta-human chorionic gonadotropin (β-hCG) levels, and the patient's overall clinical condition.
**Why the Correct Answer is Right**
In cases of unruptured ectopic pregnancy with a serum β-hCG titre of 2000 IU/mL, the treatment of choice is usually medical management with methotrexate (MTX). MTX works by inhibiting the enzyme dihydrofolate reductase (DHFR), which is necessary for DNA synthesis and cell division. This leads to the death of rapidly dividing cells, such as those found in the ectopic pregnancy. MTX is most effective when the β-hCG levels are below 5000 IU/mL and the ectopic pregnancy is less than 4 cm in diameter.
**Why Each Wrong Option is Incorrect**
**Option A:** Surgical intervention is usually reserved for cases where medical management has failed, or there is a high suspicion of rupture or hemodynamic instability.
**Option B:** Expectant management may be considered in very early ectopic pregnancies with low β-hCG levels, but it is not the treatment of choice for an unruptured ectopic pregnancy with a β-hCG titre of 2000 IU/mL.
**Option C:** Hysterectomy is a definitive treatment for ectopic pregnancy but is usually reserved for cases where the patient is unstable or has a failed medical or surgical management.
**Clinical Pearl / High-Yield Fact**
The American College of Obstetricians and Gynecologists (ACOG) recommends that patients with ectopic pregnancies should have their β-hCG levels monitored every 2-3 days until they have fallen below 100 IU/mL, indicating resolution of the ectopic pregnancy.
**Correct Answer: A. Methotrexate**