Treating ectopic pregnancy, pregnancy of unknown location or trophoblastic symptoms with methotrexate

When you have had an ectopic pregnancy or a pregnancy that we cannot tell the location of, you may receive an injection of a drug called methotrexate.

Methotrexate is a medicine that can be used to treat of a variety of conditions, including cancer and some rheumatoid and inflammatory conditions. In some cases, it can also be used to successfully treat an ectopic pregnancy without the need for surgery.

Methotrexate treatment for ectopic pregnancy has a very good success rate (more than 95 people in every 100) and, in small doses, is safe to use with few side effects. It also avoids the use of a general anaesthetic and the need for surgery.

Following methotrexate treatment you must return to either the gynaecology emergency room or early pregnancy assessment unit (EPAU), depending on where you are being treated, at regular intervals for close monitoring and observation. If this is not convenient for you, then treatment with methotrexate is not advisable and you should consider an alternative form of treatment.

Methotrexate will be offered if your ectopic pregnancy is small, your hormone levels are low, you are pain free (or minimal discomfort) and feeling well. Occasionally it is given after surgery if tests show your pregnancy hormone remains elevated.

Methotrexate works by stopping cells from dividing (growing). An ectopic pregnancy or pregnancy of unknown location cannot develop into a normal pregnancy and is a serious condition which may be life threatening.

Methotrexate works by blocking the enzymes in the body that maintain the pregnancy. It stops the tissue from growing bigger and stops it from rupturing (bursting). The pregnancy tissue is then gradually reabsorbed by the body.

When you come for your appointment we will check your height and weight to work out the right dose for you. We will inject the methotrexate into a muscle in your buttocks, which may be uncomfortable. Usually one dose will be enough but, very rarely, a second dose might be needed.

A few days after receiving methotrexate you will experience bleeding from your vagina. This is normal and is caused by your womb shedding its lining as the ectopic pregnancy falls away.

With this treatment:

• 5 in every 100 treatments do not work and need further treatment.
• In 15 out of 100 cases two doses may be necessary.
• 7 in 100 cases may end up needing an operation to remove the fallopian tube.

If methotrexate does not work, your ectopic pregnancy will still be there and could burst. If, after your treatment, you have stomach pain that does not go away or you feel generally unwell, you must call us to arrange an appointment (contact details at the end of the information).

If you have sudden pain, dizziness or nausea, go to A&E immediately.

There are generally very few side effects, though you can experience some. Methotrexate is an anti-cancer drug, but it is important to know you do not have cancer. We use much smaller doses of methotrexate than are used in cancer treatment, so the risk of side effects is quite small.

6 in 10 people get abdominal (tummy) pain in the first week after their injection (although this should not be very bad). This usually settles with pain killers.

Up to 15 people out of 100 may experience:

• nausea (feeling sick)
• vomiting (being sick)
• indigestion
• tiredness
• sensitivity to light
• skin rash
• temporary hair loss
• stomatitis (inflammation of the mouth; mouth ulcers)

Very rarely it may affect your liver or blood counts. If this happens it is usually mild and only lasts for a short time. We will check for this in your follow up blood tests.

You will need to come back to the hospital for blood tests to check your pregnancy hormone levels on day 4 and 7 after your injection of methotrexate. This information lets us know that the treatment is working. We will then take a blood test each week until all your hormone levels go back to normal.

On the 7th day after the methotrexate we will also check your full blood count and liver function to make sure they are unaffected by the treatment. If they are abnormal, it is usually short lasting but we need to repeat the tests to make sure they return to normal. Once your levels are back to normal, we will discharge you from our care.

Everyone is different regarding how soon after treatment they have their next period, however you would usually have a period within four to six weeks. Often this period may be different than usual (heavier or lighter). This is nothing to be concerned about, unless the bleeding is very heavy; in which case contact your GP, EPAU or ward B11.

You must not get pregnant for three months after having the last dose of methotrexate to allow it to completely clear from your body. Methotrexate can severely affect a developing embryo and cause abnormalities. You must use contraception during this time. During these months, do not take folic acid or non-steroidal anti-inflammatory drugs such as aspirin, ibuprofen, Nurofen® or Diclofenac. However, you can take paracetamol and codeine for pain relief.

After three months, any future pregnancies will not be affected by the methotrexate and it does not increase the risk of you having a miscarriage. However, following an ectopic pregnancy, you have a 10 -18 per cent chance of having another one. Therefore, it is very important to have an early ultrasound scan at about six weeks if you get pregnant again, to check that everything is normal. Please call your GP surgery and ask them to arrange this.

The following points are important:

• If you experience severe pain or heavy vaginal bleeding, immediately contact or attend the Early Pregnancy Assessment Unit (EPAU) on 01709 427072 or Ward B11 on 01709 424349
• Pregnancy should be avoided for 3 months after methotrexate has been given. We advise you to use a reliable barrier contraceptive or hormonal contraception. This applies for 6 months after more than one treatment.
• Avoid medications such as Ibuprofen or Aspirin for one week after treatment. Paracetamol is safe to use (up to two tablets, four times per day), but contact EPAU or Ward B11 if you need to take it for more than 3 days
• Avoid alcohol as drinking alcohol when taking methotrexate could cause damage to your liver.
• Avoid vitamin preparations containing folic acid until your blood levels (including liver functions) return to normal as having both together could affect how well methotrexate works.
• Avoid exposure to sunlight and do not use sunbeds as methotrexate may make skin more sensitive to sunburns and can lead to skin irritation.

You can ask questions at any point; do not hesitate to contact us for advice if you have any worries.

• The Ectopic Pregnancy Trust
• Miscarriage Association
• Association of Early Pregnancy Units

Early Pregnancy Assessment Unit (EPAU)

01709 427072

Ward B11

01709 424349

Unit Counsellor

01709 427636