A Complication of Methotrexate Use for Ectopic Pregnancy
Tuesday, September 11, 2007
Kenneth F. Trofatter, Jr., MD, PhD
At Thu Sep 06, 05:52:00 PM 2007, Anonymous said…
Hi. Thank you for answering all these questions. I also had a question regarding Methotrexate. I was injected with a dose of Methotrexate on the 25 of July, 07. I was told my 6 week pregnancy was ectopic and needed to be terminated. One week later I was still pregnant with rising hCG levels. I went to the hospital, had an ultrasound done, and was told I did not have an ectopic pregnancy. I was about 8 weeks along with a living fetus in my uterus. They showed me the fetus with a strong heart beat. Two days later, on Aug 3, I was given a D&C to end the pregnancy. My husband and I would like to try again. We have three boys, I had one miscarriage with my second pregnancy, but the others have been normal. I started my period on September 5. It's pretty heavy. I was wondering if the Methotrexate is out of my system now. Can we try again, or should we wait until after my next period in October? I'm having such a hard time thinking about waiting, but I do know it's important to be careful. I also read taking one baby aspirin a day until conceiving can help the uterus is this true. Thank you.
At Sun Sep 09, 06:21:00 PM 2007, Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Sept 6: Ever since methotrexate became popular for treating ectopic pregnancies, I have seen the unfortunate scenario reported by our reader above played out time and time again. Methotrexate (MTX) is an analog of folic acid. It binds tightly to an enzyme called dihydrofolate reductase and when it does so, interferes with the production of tetrahydrofolates. In the end, this interferes with the normal production and repair of DNA by limiting the production of a key nucleotide, thymidine. Other metabolic effects are also known, but the take home message is that MTX can result in lethal damage to cells that are replicating, particularly those that are replicating rapidly, like certain cancer cells.
In the mid-1950’s, Li and colleagues (Proc Exp Biol Med 1956;93:361) demonstrated efficacy of MTX against choriocarcinoma. Choriocarcinioma is a cancer derived from cells of trophoblastic (placental) origin. Although choriocarcinoma only comprises no more than 1% of all gynecologic malignancies, it affects young, reproductive age women and is deadly if not treated. Indeed, before adequate chemotherapy was available, more than 90% of women with metastatic choriocarcinoma died from their disease, usually very rapidly. Thanks to MTX, and other chemotherapeutic agents, most women now survive choriocarcinoma and once remission is achieved, have a very low risk for recurrent disease, ie., they are CURED.
Because of its documented efficacy in the treatment of malignant trophoblastic cells, MTX, in recent years, has been employed as an alternative to surgical therapy in selected cases of ectopic pregnancy (Lipscomb, et al. NEJM 2000;343:1325-29). Ectopic pregnancies, by definition, implant ‘outside the uterus’ with more than 95% occurring in the fallopian tubes and about 2.5% in the cornua of the uterus (where the fallopian tubes enter the uterus). For that reason, they are frequently referred to as ‘tubal pregnancies,’ although they can also occur in the cervix, ovary and intraabdominally. The fallopian tubes cannot restrict the growth of invasive placental tissues, as can the endometrium, and they certainly cannot accommodate a growing embryo beyond a certain point before they rupture and hemorrhage. Indeed, ectopic pregnancies can be quite deadly if not treated appropriately. They are still a major cause of maternal mortality, accounting for 10-15% of all maternal deaths, and they are the leading cause of death in pregnant women in the first trimester. A ruptured ectopic pregnancy is a true medical emergency.
Because of the rising incidence of ectopic pregnancy, the risk (maternal and medical-legal) of not identifying and treating an ectopic pregnancy in a timely fashion, and the widespread acceptance and success of MTX therapy as an alternative to surgical management of an ectopic pregnancy if caught early enough, there has been a coincident increase in the inadvertent use of MTX in unrecognized early intrauterine pregnancies. The usual scenario is one in which the pregnancy is not quite as far along as anticipated and the patient happens to present with complaints of abdominal pain or some spotting and no clear intrauterine pregnancy is identified by ultrasound. This situation can be especially confusing if the pregnancy hormone levels (hCG) appear to be low for the expected gestational age or if a woman has a tender adnexal mass because a hemorrhagic corpus luteum (intraovarian bleeding at the site from which the egg was ‘hatched’) or torsion of an adnexal mass might be very difficult to differentiate from an ectopic pregnancy.
Since MTX is a category X drug, known to be teratogenic in humans, it is important to ascertain the presence of an ectopic pregnancy rather than simply to use it empirically. Unfortunately, its use in advertantly with an intrauterine pregnancy is most likely to occur during the time of neural tube and very early cardiac development, both of which rely on folate-dependent pathways. Various algorithms are in place that employ ultrasound imaging, quantitative hCG levels, and progesterone levels to differentiate abnormal from potentially normal pregnancies and these protocols can be useful in minimizing the chance of the inadvertent use of MTX and also in directing its use when appropriate for the management of an ectopic pregnancy. Perhaps the greatest risk of ectopic pregnancy is not suspecting that one could be present. Patients who are adequately counseled and followed closely are much less likely to end up in emergency situations.
Anyway, to finish the response to our reader’s questions, because the ‘half-life’ of MTX is measured in hours, and you received a very short course of the drug, you are probably 'safe' now to pursue another pregnancy from that standpoint. Whenever a D&C is perfomed, however, we often recommend waiting 3-4 months before attempting another pregnancy so that the inflammation in the uterus can die down and the endometrium fully reconstitute to improve the prospects for successful and normal implantation of another pregnancy. So, I would suggest waiting until after your next period and in the interim, starting supplemental folic acid 4 mg/day as well as a prenatal vitamin to reduce your risk even more. Before you start a baby aspirin, it is probably a good idea to discuss that with your doctor. Start all of this BEFORE you try to get pregnant and continue through the first trimester. Good luck next time and let me know how things turn out. Thanks again for reading and for a great question.
Dr T
Labels: Ectopic pregnancy, folate metabolism, methotrexate therapy
60 Comments:
At Wed Sep 12, 11:55:00 AM 2007,
A friend in need of advice! said…
Hello, I have a question. One of my best friend recently had a misscarriage. This is her second miscarriage this year, will she be able to have children? How long does she have to wait in order for her to get pregnant again? Do you know what cause them? She had both misscarriages when she was 5 months pregnant.
At Thu Sep 13, 04:40:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Sept 12: In her case, I do not think she should get pregnant again until she has seen a specialist who can evaluate the inside of the uterus properly by a sonohysterogram and/or hysteroscopy. The most common causes of recurrent pregnancy loss at 5 months are cervical incompetence and congenital abnormalities of the uterus (Mullerian defects) such as a bicornuate or septate uterus. I have written an entire series in this blog earlier this year on recurrent early pregnancy loss that you might want to check out. Thank you for reading! Dr T
At Mon Sep 24, 08:52:00 AM 2007,
Jennifer said…
hello i have had an ectopic preg ane i have had 2 doses and it has been a month since i have got the shots. my question was when am i going to start my period? and i also know it is wrong to have sex so soon, but is it possible to get pregnant after i have had my shots so soon?
At Thu Sep 27, 06:49:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Jennifer Sept 24: I would recommend waiting at least 3-6 months after an ectopic pregnancy treated with methotrexate. Having had one ectopic pregnancy, you are at much increased risk for having another. It is also VERY unpredictable when you will ovulate again. It is unusual to get pregnant within a month of treatment, but it COULD happen. Remember, you can get pregnant again as soon as you start ovulating, even if you have not had a period. I strongly recommend some form of reliable contraception for awhile before you tro to conceive and I would NOT recommend leaving things up to chance! Thanks for reading. Dr T
At Tue Oct 09, 07:58:00 AM 2007,
Anonymous said…
Hi Dr. T. I've been given conflicting answers by different gynecologists and rheumatologists in regards to methotrexate "wash out period" and pregnancy and frankly, I'm worried. Some say it's safe to get pregnant 3 months post methotrexate others say 4-6 months. Here's my scenario: I've been on methotrexate 25mg sc weekly dose, last dose being June 28, 07. LMP: sept 8, 07 and I just found out I was pregnant yesterday. Althought it's been almost 4 months since my last dose of methotrexate, I'm very concerned about my childs risk of teratogenicity. What are the chances of this happenning? What would the best course of action be? Also, would folinic acid help, in my case, to decrease the chances of birth defects? Thanks
At Wed Oct 10, 02:14:00 PM 2007,
Anonymous said…
Hello Dr. My question is regarding what is considered normal for betaHCG levels following MTX treatment for my ectopic pregnancy. On 02/10 I was admitted to the hospital with abdominal pain and slight bleeding for the two weeks prior (last period was Aug 24). Tested positive for pregnancy with betaHCG level at 960. Ultrasound + endovaginal showed nothing in the uterus. BetaHCG tested again on 5/10 was 1544 with u/s and endovaginal showing a small (1.1cm mass)in the right cornua (still nothing in the uterus). BetaHCG tested on 6/10 was 1797. Referred to OBGYN at ER for MTX treatment for ectopic, for which an injection of 50mg was given same day (my weight 49.8kg). BetaHCG tested on 10/10 was 2040 and I have not had the pain and abdominal cramping my Dr had prepared me for. My question is whether it is normal for the betaHCG level to continue rising 4 days after MTX injection? Shouldn't it be falling? Scheduled for another blood test on 13/10 but I was wondering when I should be worried that the MTX treatment is not working? I am 25 years old and would like to conceive in the next few years; thus, I would like to preserve both my tubes if possible and avoid surgery. Thank you kindly for your time and consideration.
At Sat Oct 13, 02:26:00 PM 2007,
Anonymous said…
Just an update to my October 10th question...betaHCG is now at 2061. The OBGYN at the ER said that it should have fallen to 1600 by now and gave me the option of another MTX injection or surgery (which would likely result in the loss of the right tube and part of the uterus as the pregnancy is in the cornua). I choose another injection. My new question: What are the chances that this second injection will work? Are the chances of MTX treatment being successful the second time around greater, less than or the same as before? Are the risks that it will rupture greater the longer I put off surgery? I'm sorry, I know I should have asked these questions to the Dr at the ER who gave me the results but I was a bit stunned and upset at the time. Thanks again for any answers/advice you can provide.
At Mon Oct 15, 05:37:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous queries Oct 9 and Oct 10: I responded to your questions in my blog posted on October 15, 2007. I hope this helps. Best wishes to both of you and thanks for reading.
Dr T
At Mon Oct 15, 05:41:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous October 13: As noted in the blog I posted today in response to your initial query, you are probably just one of the 50% who have an increase in their hCG titers during the first 4 days. Presuming this really is an ectopic pregnancy, at your low titer, and with your lack of symptoms, I would be in NO rush to go to the operating room, especially for a cornual ectopic. Your greatest risk would have been not finding out early that you had the ectopic pregnancy in the first place. Again, good luck! Dr T
At Mon Oct 15, 07:17:00 PM 2007,
Anonymous said…
Thanks for your time and advice Dr T. I came across your site when googling for some answers and am really glad I did. I hope to have some good news by Thursday when I have another u/s and blood test scheduled. Many thanks, TC
At Wed Oct 17, 08:08:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To TC Oct 15: Thanks TC and hope things turn out well for you. Check back in under 'happier' circumstances, okay!?! Dr T
At Thu Oct 25, 06:02:00 PM 2007,
Anonymous said…
Hello,
I carry recipocal translocations invovling chromosomes 1 and 5 .
This doesnt mean that i wont be able to have kids does it? Also, would my baby have to carry the same tranlocation in order for me to have a successful pregenacy? Is it possible that i wouldn't experince any miscarriages?
At Fri Oct 26, 05:10:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Oct 25: With a balanced translocation you can have perfectly normal children, children who carry the same translocation (also 'normal'), and babies that end up with unbalanced chromosome complements that have a high likelihood of miscarriage. Very few of the aneuploid conceptuses resulting from that reciprocal translocation are likely to survive a pregnancy, but I strongly suggest that you sit down with a genetic conselor BEFORE you decide to get pregnant to discuss all of these issues and the evaluation that can be done during a pregnancy. Thanks for the questions and best of luck to you! Dr T
At Sun Nov 04, 11:03:00 PM 2007,
fryerfairy said…
I have endometriosis and had a cervical pregnancy I was in hospitalfor 3 weeks and I was treated with Methotrexate I think it was 3 shotsI had This was 6 months ago I was told that I might not be able to carry a baby full term, since having this 6 months on I am still in alot of pain and am losing big clots at each period I can no longer cope with the pain and the worry that I may never be a Mum I am only 23. Do you think I will go on to have a baby.
At Tue Nov 06, 12:18:00 PM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To fryerfairy: I wish I had my crystal ball for you. Let me ask a few questions: Did you have pain prior to the cervical pregnancy? Is this pain all the time or just at certain times of your menstrual cycle? Did they have to do any surgery in addition to the methotrexate? How do your doctors know that you have endometriosis? Have you had any treatment for your endometriosis to date? Are you having regular periods every month? Did you have any trouble conceiving the pregnancy that you lost? Do you have any other medical problems? Let me know and I will do the best to give you my thoughts. Dr T
At Tue Nov 06, 01:13:00 PM 2007,
fryerfairy said…
Hi,
I have had 2 laparoscopies in which the endometriosis was first diagnosed and burnt away the second one I had they checked my tubes and ovaries and removed a lot of endometriosis from my pelvis.
I had a miscarraige 6 months befor falling pregnant again which resulted in the cervical pregnancy.
I do suffer with a lot of pain and I can not remember the last time i was pain free, my doctor said that there is a lot of scarring and a lot of growths could this be the reason that the baby implanted in my cervix.
I was due to begin IVF treatment as my husband and I have been trying for over 3 years when i fell pregnant my cycles are regular but are odd and i do occasionlly get spotting throughout the month.
I dont have anyother medical problems. when i went to the hospital for an early scan they admitted me straight away but they did not know how to handle the situation due to it being so rare i felt like a guinea pig having tests done
At Wed Nov 07, 05:43:00 AM 2007,
Kenneth F. Trofatter, Jr., MD, PhD said…
To fryerfairy Nov 6: By your history and symptoms, it is highly likely that you have not only endometriosis, but ADENOMYOSIS as well. Adenomyosis is endometriosis in the muscle wall (myometrium)of the uterus itself. It can cause pain, anytime throughout your cycle, but especially with menstruation - if you can imagine bleeding into a muscle - by the irritation and inflammation that results. I am not an expert in Reproductive Endocrinology, but when very young women have severe endometriosis/adenomyosis they can have a great deal of difficulty conceiving and getting through first trimester and may have other underlying risk factors (autoimmune, hormonal, thrombophilic, and anatomical) that further increase their risk for recurrent early pregnancy loss. Some will have defects in the production of cell surface structures called 'integrins' as well. Integrins help the early embryo attach to and implant in the endometrium. Implanation defects seem to be a big problem in women with endometriosis who have recurrent early pregnancy losses. Treatment varies but, it is my understanding, the first step is to surgically ablate as much of the endometriosis as possible. Many REI doctors will then place their patients on a course of Lupron to suppress the hormonal production that supports the endometriosis. Then, controlled ovulation induction, the use of Femara, and even IVF may improve your chances for successful implantation and 'survival' through first trimester. We used to say that getting through a pregnancy is the best 'cure' for endometriosis. I don't know if that still holds, but I have had many women with a history of endometriosis return within a year of a successful pregnancy having then conceived again spontaneously! Good luck and thanks for reading. Dr T
At Wed Feb 13, 09:29:00 PM 2008,
Anonymous said…
Hello Dr. Trofatter,
I apologize in advance for my question being posted late and slightly off topic. I am an MSTP student and I arranged to take next year off before starting residency in part so that my husband and I could have a baby. We became pregnant in Nov. and I was dx with an ectopic in late Dec. I was tx with lap. salpingotomy and my betaHCG quickly returned to normal. My OB/GYN, who I highly respect, has told us to take at least 6 months before trying to conceive again. If we wait this long and were successful within the first few months, then the baby would be born at the same time that I start my internship, something I had hoped to avoid. In your opinion, is 6 months necessary after a lap. salpingotomy? I've done a literature search and can't find any scientific studies evaluating risk of ectopic recurrence in relation to post surgical recovery time. Thanks in advance, CNZ
At Fri Feb 15, 10:09:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To CNZ. the answer really depends on the extent of your surgery and the findings at the time of the operation. Your doctor is really in the best position to make recommendations on that point. I will say this, from many year's experience with residents...it is very difficult on both you and your feloow residents to be pregnant during your internship year. You might want to think about holding off on that for awhile in view of teh ectopic pregnancy. Remember, too, once you have had one ectopic, you are at greater risk for having another for whatever reasons the first one occurred! Best wishes and I hope you have a great time in residency! Dr T
At Wed Mar 05, 07:30:00 AM 2008,
Anonymous said…
Hi I had a ectopic pregnancy and I had gone through the methotrexate treatment just this past Sunday. How long roughly should my cramping and bleeding last? I also just started to have today pressure in my very lower abdoman region and also my bum region is this normal, its not extremely painful but is quite annoying? Also today I had a almost like a blood clot come out when I went to the washroom but it was more mucussy like, dont mean to be gross but ya it is. Is this something that will happen? This is my first pregnancy ever and well this whole thing is scary cause I have gotten no definative answers on anything. Basically what should I be going through while this drug does its thing? What is considered normal and how long does it last?
At Wed Mar 05, 10:32:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Mar 5: Many women who receive one or more doses of methotrexat for medical treatment of an ectopic pregnany report cramping abdominal pain during the first 2 to 3 days (sometimes longer) of treatment. This is one of the most common side effect of therapy. However, more severe and diffuse pain should be reported to your doctor because this can be asign of abdominal pain is also a sign that the ectopic pregnancy has ruptured. pain to your health professional. Vaginal bleeding such as you describe is also quite common and occasionally women will develop nausea, vomiting, indigestion, and feel tired, lightheaded and dizzy. However, if you were selected by standard criteria for receiving medical therapy with methotrexate, there is a 90-95% chance that you will not require surgery. Do not take any vitamin supplements that contain folic acid while you are undergoing treatment because the methotrexate works as a folate antagonist and you do not want to decrease its effectiveness. Report any unusual side-effects to your doctor and return for appropriate follw-up. Remember, that for whatever reason you had an ectopiv pregnancy this time, you are at increased risk for another one with a future pregnancy, so always seek out early prenatal care when you think you might be pregnant and inform your provider that you had an ectopic pregnancy in the past. The greatest risk of an ectopic pregnancy is not being aware that you might have one and ignoring the typical signs and symptoms that usually accompany it. Best of luck to you. You will probably feel much better within the next 7-10 days. Dr T
At Tue Mar 11, 06:05:00 AM 2008,
Anonymous said…
hello,
i am 26 yr old. just had ectopic pregnancy on my first pregnancy. 2nd dose of methotrexate starting to work. hcg levels dropping.
I had no suspected causes / reasons that normally are associated with why ectopic pregnancy occur.. just wondering why it happended? will i beable to have a normal pregnancy?
At Fri Mar 14, 03:15:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Mar 11: Some ectopic pregnancies occur by vhance alone and there is never any explanation. Others occur because there has been previous damage to the tube as the result of an infection, such as chlamydia that can be totally asymptomatic, or even endometriosis. For whatever reason you had the first ectopic, you are at increased risk for another one, but the odds are in your favor that someday you will have a "normal" pregnancy. Thanks for reading and let us know how things turn out in the future!
Dr T
At Mon Mar 17, 01:41:00 PM 2008,
Anonymous said…
I am 45 years old and was recently diagnosed as having a cervical pregnancy although not definitively (no sac etc after a weekend of heavy bleeding). Beta HCG levels have declined although not as fast as my doctor expected and she is now recommending a shot of methotrexate. I am concerned about the relative risks of having the drug and not.
At Wed Mar 19, 06:55:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Anonymous Mar 17: A single dose (or even two) of methotrexate places you at VERY low risk for complications. The half life is also short and should not affect another attempt at pregnancy in the near future if that is something you want to try, but please discuss this with your doctor first. Dr T
At Thu Mar 20, 11:01:00 PM 2008,
Anonymous said…
Hi Dr.,
I had an ectopic pregnancy in Nov, 2007. I have been given 3 shots of Methotrexate till date and my hcg level has recently dropped as follows since the third shot: 17, 9, 5, 8, 8. So, it has plateaued at 8 over two successive weeks of tests. My OBGYN has referred me to GYN-ONCOLOGY. Is this situation a cause for concern? Or can this happen? How will this be managed henceforth? I am very scared at the moment.
Thanks,
bunch_o
At Fri Mar 21, 06:26:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To bunch_o: The hCG levels are not very high, more consistent with a chronic ectopic pregnancy, or perhaps an ovarian neoplasm that is (producing hCG or something that cross-reacts with it), rather than choriocarcinoma, but I definitely agree with the plans to have you see a GYN Oncologist. Sit tight until you talk with him/her and please let us know what you find out. Best wishes and thanks for eading! Dr T
At Thu Mar 27, 01:05:00 PM 2008,
Anonymous said…
Hi Dr.,
I am diagnosed with PCOS and my RE started a clomid treatment with 50mg dose which did not work. So it was increased to 100mg. It helped me in conceiving.
Initially the HCG level started quite low (28). Later it increased to 70 -> 145 -> 836 -> 1333. By the end of 6th week it reached 1700. RE did u/s scans in 6th week and found that my uterus is tipped backward. RE didn't see any sac in uterus. There was no sign of any swelling / bleeding inside my abdomen. I did not experience any abdominal pain / bleeding. After repeating scans and blood work, RE concluded that it's an ectopic pregnancy. Not sure if this diagnosis was correct.
1. If we do not see any sac in the uterus by end of 6th week and if the HCG levels are around 1700, is this a valid ectopic case?
Then to end the ectopic pregnancy, RE gave me 81mg Methotrexate dose on 3/24. Again I am not experiencing any pain / bleeding. Based on internet reading, most of the women reported these symptoms. I am worried if I will have to go for surgery.
2. Is it normal not to experience pain/ bleeding after MTX shot? Does this mean MTX is not working?
Thanks,
Aai
At Thu Mar 27, 06:14:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Aai Mar 27: You either have an ectopic pregnancy or you have a nonviable intrauterine pregnancy based on what you have told me. I doubt you will need surgery. Sometimes it takes several days and more than one dose of methotrexate, but your doctor will simply follow your hCG levels to ensure that they continue to fall. Sorry for your loss and let us know what happens. Dr T
At Fri Mar 28, 12:11:00 PM 2008,
Anonymous said…
Hi Dr.T,
Thank you very much for your prompt response.
After MTX shot, I got blood work done today (28-Mar-08). The HCG level increased from 2104 to 3484. RE had mentioned that the level normally increases by 15% but mine increased by around 65%. I am little worried now.
I have 7th day blood work scheduled on Monday. I will write back again on Monday.
Kind Regards,
Aai
At Sun Mar 30, 07:52:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Aai: I hope this wasn't an intrauterine pregnancy that just wasn't as far along as expected. Your doctor may want to repeat the ultrasound. Best wishes and do let us know what is found out.
Dr T
At Mon Mar 31, 03:11:00 PM 2008,
Anonymous said…
Hi Dr.T,
Today I got my 7th day HCG levels tested. Instead of decreasing, the levels increased from 3484 to 3531. Since yesterday I am experiencing very light occasional bleeding.
The RE has advised to repeat the blood test tomorrow. After checking tomorrow's levels, they will give the second (and probably higher) MTX shot.
Doctor has not yet mentioned about u/s scan. Will that help? In my case is there any way to find out the root cause (whether it is ectopic / nonviable intrauterine)? Will that help us in planning or taking some precautions the next time?
Thanks for your support.
Regards,
Aai
At Tue Apr 01, 01:21:00 PM 2008,
Anonymous said…
Hi Dr. T,
After the MTX shot, my HCG levels came as follows:
4th Day - 3484
7th Day - 3531
8th Day - 3243
As you had correctly guessed, my RE has scheduled a u/s scan tomorrow. He mentioned that they will give second shot of MTX after the scan. I am experiencing very light bleeding, weakness and body ache.
I am quite scared with the way things are turning out. Is there any way to confirm if this is an ectopic pregnancy or an intrauterine?
Thanks and Regards,
Aai
At Fri Apr 04, 07:23:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Aai: At that hCG level, if there is an intrauterine pregnancy, they should be able to see evidence of that by ultrasound. regardless, the hCGs are now beginning to fall, so hopefully, you will not need an operative procedure. Good luck again and let us know how things turn out. Dr T
At Mon Apr 07, 02:07:00 PM 2008,
Anonymous said…
Thank you for responding to my post of about 2 weeks ago. I am the 45 year old woman whose doctor thought she had a cervical pregnancy and was inquiring about methotrexate.
I have a follow on question. I never got the shot of methotrexate and my Beta HCG levels have since declined to 17 and then to 3. My last ultrasound which was the 3rd I had since the miscarriage no longer showed any suspicious area in my cervix which was the source of the concern that it was a cervical pregnancy. The ultrasound person indicated that this seemed to rule out an ectopic pregnancy although my doctor seemed to think that it still could have been cervical but resolved itself naturally. Does one or the other seem more likely? Does it matter to know for sure?
Thanks again for responding.
At Mon Apr 07, 05:14:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 7: Sorry, but I really can't tell from what you have told me, but in the end, it probably doesn't matter. Everything appears to have resolved spontaneously and now you don't have to worry about the potential effects of the methotrexate. Thanks for letting us know how things turned out and best of luck to you. Dr T
At Fri Apr 18, 08:18:00 AM 2008,
Anonymous said…
Hi,
I had a heterotopic pregancy and my BETAhcg levels went back down to zero on 26th March. I have just found out that I'm pregnant again (would have been conceived around the week of 22nd March) and I've read that there's a much higher risk of me having another ectopic. Please can you tell me what the percentages are? I know that there would usually be about a 10/15% chance of having an ectopic again if I waited for three months, but I've heard that the risk is increased again as I got pregnant so soon after the last one. Is this correct? Thanks for your help
At Sun Apr 20, 06:36:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 18: Your risk may depend on which tube picked up the egg this time. You will be at higher risk if it is in the tube that recently had the ectopic, but rememeber, conditions that increase risk for ectopic pregnancies often affect BOTH tubes. Hopefully, that is not your case! Best wishes and let us know how things turn out! Dr T
At Mon May 12, 09:27:00 PM 2008,
Anonymous said…
Hello Dr. Trofatter. I have read your comments on ectopic pregnancies...thank you for your wealth of knowledge on this subject. I had an ectopic (first pregnancy) a couple months back & was adminstered 2 methotrexate injections. In one of your comments, you mention waiting until 1 cycle to try again is sufficient, however, in another post, you told a woman to wait 3-6 months after she received the drug. Am I reading this wrong? How long should one wait after 2 shots of methotrexate to try to coneive again?
Also, is it standard medical protocol to perform an HSG test after having 1 ectopic or is that not always necessary? Thank you in advance.
At Thu May 15, 06:51:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 12: From the standpoint of MTX toxicity, the half-life of the drug is such that it should not affect a baby conceived a month or so after 1-2 injections, HOWEVER, I really do believe it is better to wait awhile longer to give time for the inflammation to die down and the tube to heal. This might reduce your risk for another ectopic although the risk is still significant that you could have one anyway. Not everyone recommends that you have an HSG, but if that is your doctor's standard of practice, it is not an unreasonable thing to do. Dr T
At Fri May 16, 05:28:00 AM 2008,
Anonymous said…
Hi Dr T,
I posted a comment a while ago about my previous heterotopic pregnancy. I'm pregnant again and although it's been confirmed it's the right place I'm still worried about how the previous pregnancy will affect this one. Basically they left the last one for conservative management, so i miscarried the normal pregnancy but the ectopic (cornual) one is still there and shows up on the scans although it isn't active. I'm still waiting to see a consultant but am worried as i'm bleeding again. Could the old pregnancy affect this one?
At Fri May 16, 05:45:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 16: I doubt it unless there is still some inflammation associated with it. The spotting might have nothing to do with that other pregnancy. Best of luck. Dr T
At Thu May 29, 04:10:00 PM 2008,
Anonymous said…
Hello Dr. I had an ectopic pregnancy in March and had two doses of methotrexate...the second one being March 17, 2008. This past Tuesday my HCG was 5 (negative?) and this past Sat. I had my period. I just started taking my prenatal vit and an extra 400 mg of folic acid. should I be okay TTC after my next period? thank you! ( I did not have to have any surgery)
At Thu May 29, 05:50:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous May 29: You should be okay from the standpoint of the methotrexate being out of your body. You are and will always be at increased risk for another ectopic pregnancy for whatever reasons set you up for the first one. So, be sure to let your doctor know as soon as you are pregnant again. Best wishes! Dr T
At Mon Jun 09, 09:33:00 AM 2008,
jenn78 said…
I had an ectopic pregnancy in the left tube removed surgicaly on May 22. The tube was removed but I still have my right tube. What are my chances of getting pregnant again and when can I start trying again. Thank you
At Tue Jun 10, 07:30:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Jenn78: Your chances arevery good unless there has been damage to the other tube by whatever conditions might have led to the ectopic pregnancy. I usually tell my patients to wait 2-3 months before trying to conceive again to give some time for all of the involutional changes and inflammation to die down after the ectopic pregnancy. Remembre, you are still at risk for an ectopic pregnancy in the remaining tube. Best wishes! Dr T
At Fri Jun 20, 11:46:00 AM 2008,
Bargon said…
Hello, I have a question. I had an ectopic pregnancy diagnosed at 4weeks, how long should I keep off foods with folic acid after treatment with methotrexate?
Thanks, Barbara G
At Sat Jun 21, 02:24:00 AM 2008,
Bargon said…
Dear Dr.T I had a question earlier on, but below is some background information to assist me to get the proper advice.
I have undergone ART procedure in form of an IUI on 12th May,2008. I underwent IUI on a stimulated cycle using FS.The pregnancy test performed on 26th May, 2008 confirmed pregancy. The scan performed on 10th June, 2008 indicated there was no evidence of a gestational in the uterus, despite the fact that the BHCG levels are in excess of 2000mul/ml. My doctor suspected it could be a leaking ectopic pregnancy. My HB is 13.5g/dl
MY husnabd and I were counselled thoroughly regarding the treatment options being;
1.Laparoscopic treatment
2.Medical treatment in form of methotrexate.
we opted for methotrexate treatment and I was given an Intranuscular Injection of 50mg(my weight was 60kg. Iwas advised to return after every 5 days to check my BHCG levels.
At 4 weeks what are the chances that I might return for laparoscopy? I had stomach cramping for 4 days and light bleeding.I sometimes have pain in my legs, right from the hip level down to the ankles.
I wonder how long I should keep away from foods with folic acid? Could you please also advise on which foods are not so rich or are completely free of folic acid, I have been searching for the same and am not quite clear.
Thanks Dr.
At Sat Jun 21, 07:46:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Barbara: Just avoid EXTRA folic acid in vitamin supplements for the week or so after the injection. Wait til the hCG levels have begun to fall significantly. Dr T
At Sun Jun 22, 05:59:00 AM 2008,
Jacqueline said…
I have a question. I had a shot of Methotrexate on April 18, 2008 for an almost 5 week ectopic pregnancy in the left tube near the ovary. I had a normal menstrual cycle on May 16th. I found out on June 19th that I am pregnant and my beta HCG was 7818. My question is the methotrexate out of my system and if not, could it cause a birth defect? Thanks...
At Sun Jun 22, 04:55:00 PM 2008,
Arabee72 said…
Dr T, I had a Mirena IUD and found out I was pregnant with an ectopic. I underwent MTX injection on June 1/08 and had my IUD out on June 3rd (hubby and I were planning to try in Aug/Sep). Levels have continued to fall, but other than to make sure we us contraception, when is it safe to start having sex again. I am still having some spotting/bleeding, but it is darker. Is there a reason for the pelvic rest? Does sex add to inflammation? I don't see the Dr. for 2 more weeks (july 4) but am getting weekly HCG readings. As well, when I'm able to supplement with folic acid again,is there any contraindication to Folic acid injections. I've had mouth ulcers as well as a hemmoragic beula in the left cheek that has recently come up. I'm guessing this is from the methotrexate. Sorry for the long post
At Fri Jul 04, 09:19:00 AM 2008,
Bargon said…
Dear Dr T, I sent a question about the methotrexate injection for stopping ectopic pregnancy.Below are my BHCG readings,
10/06/2008 2328
14/06/2008 4974
17/06/2008 2793
24/06/2008 2087
01/07/2008 718
I got bleeding on 2nd July to date and stomach cramping, and terible backache, does this mean the pregnancy has dissolved? Now can I resume foods with folic acid?
Thanks Dr.
At Fri Jul 04, 09:26:00 AM 2008,
Bargon said…
Dear Dr T, I sent a question about the methotrexate injection for stopping ectopic pregnancy.Below are my BHCG readings,
10/06/2008 2328
14/06/2008 4974
17/06/2008 2793
24/06/2008 2087
01/07/2008 718
I got heavy bleeding with thick brownish clots on 2nd July to date and stomach cramping, and terible backache, does this mean the pregnancy has dissolved? Now can I resume foods with folic acid?
Thanks Dr.
At Tue Jul 08, 10:26:00 AM 2008,
Kirsty5 said…
Hi Dr T, I was diagnosed with an ectopic pregnancy 3/52 ago following 6/52 bleeding. My betahcg was 990 & 48hrs later was 900. Methotrexate was given & next betahcg was 1100 & then 1500, another dose of methotrexate has been given, levels have fallen to 1100 & finally 1060. According to consultant i either require a 3rd dose of methotrexate or surgery. Can i ask from your experience which you recommend as my consultant has never given a 3rd dose before & is apprehensive. Thanks
At Sat Jul 12, 05:05:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Kirsty5: As long as the hCG levels are falling (at least not rising) and you are not symptomatic, I would suggest not giving the third dose of methotrexate or operating and just waiting things out. Dr T
At Sat Jul 12, 08:09:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To arabee72: Sorry, for some reason I did not get your comment until now. Intercourse may increase your risk for infection, especially while you are having bleeding. There is also a small chance that intercouse could cause the ectopic pregnancy to rupture before it has regressed and the tube has had a chance to heal. Hold off on the extra folic acid until yor hCG levels are undetectable. Dr T
At Sat Jul 12, 08:12:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To bargon: You can resume foods with folic acid, but just don't use extra folic acid in a vitamin supplement. Your hCG levels are falling, but they still have a way to go and there is still a possibility you will need a second dose of the methotrexate. Dr T
At Sat Jul 12, 10:18:00 PM 2008,
Bargon said…
Dear Dr T, thanks for the advice, You wrote back that I might need another dose of methotrexate, can this one more reading of BHCG taken on 8th July,08 determine something? Thanks Dr.
Date Levels
10/06/2008 2328
14/06/2008 4974
17/06/2008 2793
24/06/2008 2087
01/07/2008 718
08/07/2008 67
At Sat Jul 12, 10:19:00 PM 2008,
Bargon said…
Dear Dr T, thanks for the advice, You wrote back that I might need another dose of methotrexate, can this one more reading of BHCG taken on 8th July,08 determine something? Thanks Dr.
Date Levels
10/06/2008 2328
14/06/2008 4974
17/06/2008 2793
24/06/2008 2087
01/07/2008 718
08/07/2008 67
At Tue Jul 15, 10:21:00 AM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Bargon: I doubt you will need another dose of methotrexate
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