Symptoms Accompanying Methotrexate Therapy for Ectopic Pregnancy
Saturday, March 08, 2008
Kenneth F. Trofatter, Jr., MD, PhD
• At Wed Mar 05, 07:30:00 AM 2008, Anonymous said…
Hi, I had an 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 abdomen 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 mucousy-like. Is this something that will happen? This is my first pregnancy ever and well this whole thing is scary because I have gotten no definitive 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…
Many women who receive one or more doses of methotrexate for medical treatment of an ectopic pregnancy report cramping abdominal pain during the first 2 to 3 days (sometimes longer) of treatment. This is one of the most common side-effects of therapy. However, more severe and diffuse pain should be reported to your doctor because this can be a sign that the ectopic pregnancy has ruptured.
Vaginal bleeding and passage of mucous, such as you describe is also quite common. Progesterone produced by the corpus luteum (site of production of the egg that became the pregnancy) and the pregnancy hormones that are produced, even with an ectopic pregnancy, cause changes (decidualization) of the lining of the uterus in excess of that which occurs during a menstrual cycle. When the pregnancy is interrupted by the methotrexate, there is usually a heavy ‘withdrawal bleed’. In addition to the bleeding and ‘cramping’ (or “pressure” sensation associated with the distention of the fallopian tube or accompanying blood in the abdomen), occasionally, women will develop nausea, vomiting, indigestion, and feel tired, lightheaded and dizzy.
However, if you were selected by the recommended standard criteria for receiving medical therapy with methotrexate, there is a 70-95% chance that you will not require surgery. Selection criteria for methotrexate therapy include a patient who is hemodynamically stable, has no evidence of tubal rupture or significant amount of blood in the abdomen, has a tubal diameter of no more than 4 cm, understands the risks of the therapy, and is willing to return for follow-up. Resolution of the ectopic pregnancy using methotrexate results in tubal patency rates in the range of 80%, comparable to, if not higher than, those seen with surgery.
Remember that for whatever reason you had an ectopic 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. Recurrence rates overall are in the range of 20%. Conditions that increase the risk for recurrence include history of or evidence of previous pelvic inflammatory disease (PID), history of ruptured appendicitis, particularly if this was accompanied by rupture of the appendix, pregnancy after reconstructive tubal surgery or tubal ligation, pregnancy despite the presence of an intrauterine device, pregnancy with progestin-only oral contraceptives, and a history of infertility requiring ovulation induction. Interestingly, women who undergo in vitro fertilization have a risk for ectopic pregnancy in the range of 2-5% and this risk is even greater if they have had known ‘tubal factors’ and undergone reparative surgery for the same.
Incidentally, do not take any vitamin supplements that contain folic acid (like prenatal vitamins!) while you are undergoing treatment because the methotrexate works as a potent folic acid antagonist and you do not want to decrease its effectiveness. Report any unusual side-effects to your doctor and return for appropriate follow-up. 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
Labels: Ectopic pregnancy, methotrexate therapy
16 Comments:
At Sun Mar 09, 08:18:00 PM 2008,
miraclebaby said…
Dear Dr. T,
I didn't see an email address, but I have a few questions for you. I posted a while back asking about my miscarriage history and incompetent cervix. As I suspected, Kaiser will not refer me to a specialist until I have 3 early miscarriages in a row. Since my first one was late and I had a full-term pregnancy (by God's grace and an amazing perinatologist) with my daughter, they are only doing a few things at this point. Antibiotics for my husband and I at the beginning of the cycle that we try, progesterone supplements for me as soon as I find out I am pregnant, and chromosomal blood tests for husband and I. Mine came back normal. I am being seen by a regular OB. I hope this is a good plan at this point, but I am gun-shy to try without the help of a specialist. Does the current plan sound like a good one?
And off the topic, but on one you know much about:
I mentioned in my last comment about wanting to go into nursing. However, I have a secret dream about becoming an MD and specializing in Perinatology so I can help women who hare going through what I have. Most of the time I don't share this dream with anyone because I feel they would laugh me out of the room. Very few extended family members have finished college, and I would be the first in my immediate family to graduate (in the event that I do). Having been through the rigors of med-school and the demands of being a physician, would you mind sharing a blog entry on your journey through school? Is there any advice you could offer as to increasing my odds of getting into school as a non-traditional student? I am 27 and only in my 3rd term of college. So far I have a 4.0, but I am taking classes at community college. Portland State University is 70 minutes away in good traffic, and we are tight on finances (my husband didn't graduate from college, either). Will taking a good chunk of my pre-med requirements at community college hurt my chances even if my GPA remains strong? I hear that it would, but rumors fly around on the internet. What kinds of volunteer opportunities are out there for people who are interested in this particular area of medicine? Are there ways to find out more about it in a hands-on way so I can decide if I really want to go for it? And finally, is it impossible to get through med-school and residency as a mother of young children? People might think I'm crazy, but I'm losing sleep at night because I feel if I don't try I will always wonder what I could have accomplished if I had tried.
Sorry for all the questions! I probably have a million more, but I'll let you be:) Thanks in advance for your help.
At Wed Mar 12, 09:49:00 PM 2008,
Anonymous said…
Dear Dr.my name is natasha and i had an ectopic pregancy where i lost my tube as a result,later i had two healty boys with one tube,after the baby was born i underwent a ligasation,now at age 33 i would like to have another baby,however i was told that i don't stand a chance as reviseing the ligasation could result in my tube being severler damaged and since i only have one i am a bit scared,i am willing to go for tests and do whatever it takes to have a healty baby.please help me if you can i am desparete
At Sun Mar 16, 06:14:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Natasha Mar 12: There are specialists in Reproductive Endocrinology and Infertility who can counsel you regarding the feasibility of a tubal reanastamosis (reversing the tubal ligation) vs simply undergoing in vitro fertilization (harvesting eggs from your ovaries using ultrasound guidance, fertilizing them in the laboratory with your partner's sperm, and then putting the embryos back into your uterus). At your age, the latter may be your better option, but it is expensive. Best of luck and thanks for reading. Dr T
At Sun Mar 16, 08:54:00 PM 2008,
JaneDoe said…
I was treated on Thursday with Methotrexate for a cornual ectopic and my Dr told me that I have none of the "risk factors" for an ectopic and she would not have expected this would happen and that I was very unlucky this time as cornual ectopics are very rare as well. This is my first pregnancy and I have no idea how to assess my risks going forward. Does the 20% chance of having another extopic apply to me if there are no risk factors such as prior PID etc? Also is my age a factor? I have just turned 38. My husband and I got pregnant in the first month we tried without any intervention.
At Fri Mar 21, 07:08:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Jane Doe: Yes, once you have had an ectopic pregnancy, the risk of another is in the range of 20% even in the absence of identifiable risk factors. Good luck to you! Dr T
At Tue Apr 22, 06:07:00 PM 2008,
Missy Impatient said…
I had only one metho treatment on march 3/08 and I was only approx 4 weeks at the time of finding out, my hcg was only 295 and went to 5 by the 13th so really within the next days it was zero, I have had a period now on Apr/4/08 and it was as normal as the others. I have been back on 1mg of folic for over a month and also the other pre-natels as well, what is your thoughts on trying to conceive now, I took a Ovulation test on the 18th and it came back positive for the LH, could I attempt to try again this time around. I dont want to be irresponsible but not one doctor from the time this happened to now has given me a normal answer instead I have had a bunch of different answers. Please give me your thoughts.
At Sat Apr 26, 03:46:00 PM 2008,
Anonymous said…
Any idea how long it takes after the methotrexate shot before I will start bleeding, etc? I had my shot 2 days ago, when my hcg was 5,000 with a cornual pregnancy
At Wed Apr 30, 05:55:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To anonymous Apr 26: It can take 7-10 days before you start bleeding (sometimes longer). Hopefully, the hCG will start to drop dramatically soon in anticipation of that. Good luck. The MTX takes awhile to work. Dr T
At Sun May 04, 12:08:00 AM 2008,
Anonymous said…
Dear Dr. T
I had a ectopic pregnancy diagonised on feb 18 2008 my HCg was 9000 then i was given the methotrexate shot one time and one the 2nd HCG read at around 4000 my level continued to drop dramatically, for the first month the doctor said everythings seems fine. YET now it is April and my levels are dropping slower and are in the 70's i have ask the doctor questions regarding this but he says not to worry as long as the levels are going down. Im considering getting a second opinion from another doctor or should is this normal almost 3 months later and my HCG is still not 0.
thank-you,
WORRIED
At Tue May 06, 04:37:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To worried: That is a low level, so I doubt this represents choriocarcinoma - more likely a 'chronic ectopic'. If the level increases at all, I would recommend consultation and/or ruling out another perganncy and if the levels persist and are low, considering a second course of methotrexate with VERY careful follow-up afterwards. Dr T
At Wed May 07, 07:26:00 PM 2008,
Kassie said…
Hi Dr. T,
I have had two periods since my methotrexate therapy on 2/7/08 but they were only 2 weeks apart, 3/13 and 3/29. Since then some spotting 4/16 4/17 and now nothing. According to my calculations I am late over a week for my period. Is it possible that the spotting was a period? If not, is it normal for my body to be so inconstant after the methotrexate?
thanks for your help.
At Thu May 08, 05:05:00 PM 2008,
Anonymous said…
Dr. T, I really appreciate you getting back to me . I will go in Friday to get another Beta check to see if the levels are continuing to drop. In the mean time I wondering what is the difference between a chronic ectopic pregnancy and a ectopic pregnancy I briefly researched online and Im wondering if it is a chronic ectopic will i have to go through surgery; or is methotrexate still used in those cases.
Thanks Again,
worried
At Fri May 09, 08:14:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To Kassie May 7: Are you pregnant again? MTX does not cause irergular periods, but lots of other things can, including stress. Let us know what happens. Dr T
At Fri May 09, 08:15:00 PM 2008,
Kenneth F. Trofatter, Jr., MD, PhD said…
To worried again: At that low level of hCG, methotrexate should work. Dr T
At Sat May 10, 08:46:00 AM 2008,
Kassie said…
Hi Dr. T,
Thanks for getting back to me so quickly. I have take two tests both showing up negative so I do not think I am pregnant. However, I have had quite a bit of discharge, light cramping. Not sure what that is about? I have been a bit stressed, sad actually over all this so maybe that is it. Should I take another pregnancy test? Do I just wait? Any thoughts?
At Mon May 12, 06:31:00 AM 2008,
Anonymous said…
Question: I had the methotrexate shot back in February - since I have had two periods, but no symptoms of ovulation, breast tenderness or swelling which prior to the shot I have always had. Can the shot affect my hormones? Should I see a doctor regarding this?
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