Second Dose Of Methotrexate Research Articles

Clinical and Pregnancy Outcome Following Ectopic Pregnancy; A Prospective Study Comparing Expectancy, Surgery and Systemic Methotrexate Treatment

As conservative management of ectopic pregnancy becomes more routine, attention is being paid to the long-term effects of treatment with either methotrexate (MTX) or surgery. This study describes the authors' experience with management of ectopic pregnancy in routine clinical practice and assesses pregnancy outcome after treatment. From 1995 through 1997, 107 patients with possible ectopic pregnancy were seen at Umea Hospital. After evaluation with a combination of transvaginal ultrasonography and serial measurement of β-human chorionic gonadotropin (β-hCG) levels. Spontaneous abortion was diagnosed in 18 women. The remaining 89 patients make up the study population. Patients in hemodynamic shock, in severe pain, with β-hCG levels greater than 7500 IU/liter, with ectopic pregnancy greater than 35 mm, with large intraabdominal bleeding, or who had other pelvic surgery planned were treated with open or laparoscopic surgery. If reabsorption of ectopic pregnancy was suspected because of declining β-hCG levels, the patient was managed expectantly, i. e., she was closely observed until her diagnosis was certain. Women who were hemodynamically stable, without severe pelvic pain, and with β-hCG levels less than 700 IU/liter were treated with MTX. They received a single intramuscular dose of 50 mg/m 2 MTX, followed by serial measurements of serum β-hCG levels taken on days 1, 2, 4, and 7. A second dose of 50 mg/m 2 was given if β-hCG levels declined less than 15% between days 4 and 7. Patients were followed weekly until their levels dropped below 10 IU/liter. The treatment regimen was converted to surgery if the patient developed severe, intractable pelvic pain associated with hemodynamic instability or peritoneal irritation. In all, 26 patients were treated with MTX, 46 underwent laparoscopy or laparotomy, and 17 were managed expectantly. Except for lower β-hCG levels, the women in the MTX group were similar in clinical and demographic characteristics to those in the surgical group. Twenty of the 26 MTX patients (77%) achieved successful remission of β-hCG levels with 2 requiring a second dose of MTX. There was no relationship seen between the pretreatment β-hCG levels and the length of time to resolution (mean 24 ′ 9 days). More than seven (7.4 ′ 1.8) clinic visits were needed for each MTX patient. The reasons for conversion to surgical treatment in the MTX group included persistent elevated β-hCG levels in one patient, intractable pain in two, ongoing intraabdominal bleeding in two, and delay of a second dose of MTX in one. There were no significant differences found between those treated successfully with MTX and those whose MTX treatment failed. Three of the 17 women who were managed expectantly required surgical treatment. In all, 55, of the 89 women (62%) underwent surgery for ectopic pregnancy. A total of 70 of the study subjects expressed a desire for another pregnancy. By August 2000, 64% of the eligible MTX patients, 51.4% of the eligible surgery patients, and 31% of the eligible patients treated expectantly had achieved an intrauterine pregnancy.

Oral methotrexate and vaginal misoprostol for early abortion

Intramuscular methotrexate followed by vaginal misoprostol has been shown to be effective for abortion at ≤49 days gestation. Oral dosing of the methotrexate may offer advantages over parenteral dosing. This pilot study was performed to evaluate if oral methotrexate would be effective when combined with vaginal misoprostol to effect abortion at ≤49 days gestation. Twenty pregnant women were randomized to receive methotrexate 25 mg or 50 mg followed 7 days later by misoprostol 800 μg vaginally. The misoprostol dose was repeated the next day if the abortion did not occur. Complete abortion occurred in all subjects in both groups within 20 days after the methotrexate. However, women in the 50 mg group passed the pregnancy within 24 hours of the first or second dose of methotrexate more often than women in the 25 mg group (80% vs. 50%, p = 0.35). Vaginal bleeding lasted 12.1 ± 3.1 days and 9.4 ± 4.5 days in immediate success and delayed success patients, respectively. Oral methotrexate may be an effective alternative to intramuscular methotrexate in treatment regimens for non-surgical abortion.