Methotrexate use in ectopic pregnancy with baseline transaminase elevation

Ectopic pregnancy is a common complication in early pregnancy and remains a leading cause of first-trimester maternal morbidity (0.5 deaths per 100,000 live births). In hemodynamically stable patients, methotrexate is widely used as a fertility-preserving alternative to surgery. However, clinically significant hepatic disease is considered an absolute contraindication for methotrexate therapy. Current guidelines lack clarity concerning the management of patients with elevated liver enzymes, particularly those with metabolic risk factors such as polycystic ovary syndrome and nonalcoholic fatty liver disease, which are growing presentations in reproductive-aged women. We present a case of a tubal ectopic pregnancy managed with reduced-dose methotrexate in the setting of elevated liver enzymes, not seen previously in literature, followed by surgical intervention after medical management failure.