Fruit of the Womb
Fruit of the Womb

Symptoms Accompanying Methotrexate Therapy for Ectopic Pregnancy

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Below is a comment with questions from a reader who is undergoing methotrexate therapy for a tubal ectopic pregnancy. Ectopic pregnancy has been on the rise over the past 30-40 years and current rates are in the range of 1-2 per 1000 pregnancies. Fortunately, with early diagnosis, facilitated by rapid quantitative assays for hCG (human chorionic gonadotropin, the ‘pregnancy hormone’ measured in most pregnancy tests) and ultrasound, the death rate accompanying ectopic pregnancy has dropped dramatically during the same time period. A pregnancy should be visible within the uterus by transvaginal ultrasound by the time the hCG level reaches 2000 mIU/ml (5-6 weeks, or 1-2 weeks after the first missed menstrual period). The advantage of early diagnosis has been the option to consider ‘medical therapy’ with methotrexate prior to rupture of the ectopic that usually necessitates a surgical procedure. This option for therapy has gained well-deserved popularity in recent years, so there are many readers who may benefit from the comments below…

• 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
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