Methotrexate

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We are sorry for your pregnancy loss. You have decided to manage your pregnancy loss medically with the use of Methotrexate. This leaflet will hopefully answer most questions you might have concerning Methotrexate.

What is methotrexate?

Methotrexate is a powerful drug which works by interfering with the processing in the body of an essential vitamin called folate. This is temporary. Folate is needed to help rapidly dividing cells, such as those of a pregnancy. The drug stops the pregnancy developing any further and the pregnancy is gradually reabsorbed. Methotrexate is also used to try and control other unwanted rapidly dividing cells (cancer cells).

When is treatment with methotrexate most appropriate?

This method of treatment is more suitable for some women than others and is more likely to be successful if, you are in good health, your tube has not ruptured and your pregnancy hormone level is low (HCG). You are also not experiencing significant abdominal bleeding / pain.

Treatment of ectopic pregnancy with methotrexate is a decision undertaken by a consultants at the Royal Sussex County Hospital or Princess Royal Hospital.

How is the treatment given?

The treatment is given by means of a single intramuscular injection. The dose is calculated according to your height and weight. Before the injection, blood tests are done to check liver and kidney function and to ensure that you are not anaemic. Bhcg or pregnancy hormone levels will be monitored to ensure that they are falling appropriately. Most women only need one injection. A further injection may be required if blood hormone levels are not decreasing, this is a consultant based decision.

What happens after treatment?

This method requires careful monitoring and follow-up. We will test your hormone levels on the day the methotrexate is given and again on day 4, day 7 and day 10 after the injection. Further tests may be required until your levels are negative. The action of methotrexate is not instantaneous, it takes a few days for the cells of the pregnancy to stop dividing.

The pregnancy hormone level often rises on day 4; we then hope to see a drop in your levels. A few days after the injection, it is usual to begin to bleed and this bleeding can last between a few days and up to 6 weeks. It is usual to have some discomfort and pain initially but as long as this is not severe. If your pain is severe, please come into hospital immediately.

The way Methotrexate works is to deplete the body of the essential vitamin it needs to replicate cells. Our bodies are replicating cells all the time. The action of Methotrexate is short-acting and depletes the body of folate so it is common for our bodies to try to work very hard to recover from this. On or around day 4 following treatment, it is very normal to feel some exhaustion because the drug interferes with essential amino acids that give us energy as a side effect.

What can I do to help the treatment work?

Some medicines interfere with the effects of Methotrexate. It is particularly important that you do not take any folic acid supplements. Stop taking any vitamins, minerals or other medicines unless you have discussed it with our doctor.

You should not do any heavy lifting however gentle exercise acceptable.

You should avoid sexual intercourse until your levels are negative.

The preferred painkiller is paracetamol if you require stronger pain relief please discuss with the doctor in the Unit. You should refrain from drinking alcohol until the levels have fallen to a non-pregnant state because Methotrexate is metabolized in the liver in a similar way to alcohol and this can result in liver problems.

What are the risks of being managed like this?

The main risk associated with treating you medically is that the medication will not work and the cells of the ectopic pregnancy might continue to divide, which could result in there still being a need for surgery. Some women who are treated with Methotrexate initially go on to need further medical or surgical treatment. Doctors can tell if the specialized cells of a pregnancy that produce the hCG hormone are dividing because the hCG level will rise and not fall. Occasionally an ectopic pregnancy can rupture despite low hCG levels. If you are concerned about your level of pain, please contact the Early Pregnancy Clinic / Gynae ward.

What are the side effects?

Sometimes you may notice some mild to moderate abdominal pain. This tends to occur on day 3 or 4 after treatment. Many people feel very tired and are shocked by the sheer exhaustion that they encounter. Other occasional side effects (affecting up to 15% of patients) include nausea, indigestion, diarrhoea and sore mouth, fatigue, vaginal bleeding. Very occasionally, changes in the blood count, liver and kidney function may occur, but these are usually temporary. Rare side effects include skin sensitivity to sunlight, inflammation of the membrane covering the eye, sore mouth and throat. Cramping abdominal pain is the most common side effect, and it usually occurs during the first 2 to 3 days of treatment. Because abdominal pain is also a sign of a ruptured ectopic pregnancy, report any abdominal pain to the unit / ward.

How successful is it?

The time taken to resolve an ectopic pregnancy and the chance of you falling pregnant again in the future, is likely to be the same whether you choose to ‘watch and wait’ or have methotrexate.

How will I know if there’s a problem and I need a different treatment?

We will be able to tell if your pregnancy isn’t resolving, as this will be shown in the results of the regular blood tests. If this is the case we will ensure that your case is reviewed by the lead consultants who will decide the best course of action. A description of the signs of a deteriorating ectopic pregnancy, which include severely increased pain levels, vaginal bleeding, shortness of breath and pain in the tip of the shoulder, among others, which will alert you to the fact that you need to contact us.

Please contact us on:

01273 696955 Extension 64402
Early Pregnancy Assessment Clinic: Extension 4013 or 4022
Level 11 Gynae ward if you feel that anything is changing, or report to the accident and emergency department in case of an emergency.

What precautions must I take for the future?

Avoid becoming pregnant; we advise using effective contraception for about three to six months. If you fall pregnant prior to recommended time this could result in a greater chance of the baby having a neural tube defect such as hare lip, cleft palate, or even spina bifida or other NT defects. The drug is metabolized quickly but can affect the quality of your cells, including those of your eggs and the quality of your blood for up to 3 or 4 months after it has been given. The medicine can also affect the way your liver works and so you need to give your body time to recover properly before a new pregnancy is considered.

Your emotions

Grieving the loss of your pregnancy can be an incredibly difficult and painful time. Choosing to medically manage this can be worrying for any woman and until your hormone levels drop safely, you may still feel pregnant. It is important you remember that the ectopic pregnancy was not your fault and that there was nothing you could have done to prevent it happening. Alternatives are a local charity that provides emotional support to woman and their partners who have experienced a pregnancy loss and attend our Early Pregnancy Unit.

If you have bleeding and /or pain you can get medical help and advice from:

• Your GP or midwife who may advise you to go to hospital.
• Your nearest Early Pregnancy Unit
• Referral into the Early Pregnancy Unit is based on assessment by a health professional.

NHS CHOICES 111 when you need medical help fast but it’s not a 999 emergency. The service is available 24 hours a day, 365 days a year. Calls are free from landlines and mobile phones.

The Miscarriage association
c/o Clayton Hospital, Northgate, Wakefield, West Yorkshire WF1 3JS
Telephone: 01924 200799 or e-mail: [email protected]

This is an organisation through which you may find information and support that you need to help you through if you have been affected by miscarriage.

References:

• BSUH NHS TRUST(2011) GP001 Early Pregnancy Unit Clinical Guidelines.
• Patient UK Information leaflets Women’s Health Category.
• Royal College of Obstetricians and Gynaecologists
• National institute for Heath and Clinical Excellence

The information in this leaflet is part based on information by the Ectopic Pregnancy Trust Foundation and produced by Samantha Nair. (EPAC –L11 Gynaecology Department)