Ectopic pregnancy accounts for approximately 2% of all reported pregnancies. Ectopic pregnancy can be a life-threatening condition and requires timely diagnosis, management and treatment. When shared decision making can be used to decide a treatment plan, discussion includes both medical management with the use of methotrexate and surgical management.¹ Treatment considerations for lactating individuals include time away from their infant for surgery as well as medication side effects and impact on lactation.

Surgical considerations may include plans for pumping while separated from the infant to prevent lactation complications such as engorgement, plugged ducts and changes to milk production. Anesthesia does not generally require pumping and dumping. For more information, see the section on Anesthesia.

While the American College of Obstetricians and Gynecologists (ACOG) lists breastfeeding as an absolute contraindication to methotrexate therapy,¹ this may be more nuanced in the context of ectopic pregnancy treatment which generally requires single or few low dose treatments as compared to dosing required for chemotherapy use. Methotrexate regimens for treatment of ectopic pregnancy include single-dose, two-dose (2 doses 4 days apart), and fixed multiple-dose regimens (4 doses every other day for 1 week).

Methotrexate is found in low levels in breast milk. In one study of a single dose regimen of methotrexate used for ectopic pregnancy treatment, methotrexate was undetectable in all milk samples.² In a lactating person, a single-dose regimen may be preferred as this would result in the lowest possible levels of methotrexate exposure to the infant.

Methotrexate use for ectopic pregnancy treatment is considered low risk and probably compatible by e-lactancia while other sources are more cautious regarding the use of any methotrexate during lactation. After a single low dose, pumping and dumping breastmilk for the first 24 hours may decrease the relative infant dose (RID) by 40% and further reduce the risk to the breastfeeding infant.

For a single low dose of methotrexate for the management of ectopic pregnancies, lactating individuals should be engaged in shared decision making about pumping and dumping for 24 hours.  If a lactating parent requires more than a single low dose of methotrexate, pumping and dumping milk for at least 1 week after the last dose is suggested.