A meta-analysis on the safety of methotrexate in treating rheumatoid arthritis concluded that, for doses typical in this setting, data were lacking regarding the safety and risks of the drug during conception, pregnancy, and lactation.6 The review said that rheumatologists should discourage patients from continuing methotrexate if they wish to become pregnant, and that any continuing pregnancy should be closely monitored.6
The exact malformation rate after in utero exposure to methotrexate is unknown.7 Kozlowski et al reported 10 pregnancies in which the fetus was exposed to low-dose methotrexate (5 mg orally every week) for the treatment of rheumatoid arthritis.8 Five of the pregnancies were carried to term and the newborns exhibited no abnormalities, thus illustrating the drug’s variability for teratogenicity. The risk is real, however, and methotrexate can remain in human tissue for up to 8 months, thereby putting a fetus at risk for exposure even after a mother has discontinued the drug.2
The importance of primary care counsel
Incidental exposure. Inform any pregnant patient who has used methotrexate of the potential for congenital anomalies. The capacity to make educated decisions about elective termination of pregnancy requires a full disclosure of risks. In particular, ultrasound may not identify teratogenic effects from methotrexate exposure, and antenatal diagnosis of congenital anomalies is uncommon.9 Diagnosis is usually made at delivery. Thorough counseling on this point is imperative to prevent a false reassurance of having a normal fetus.
Did medical termination fail? Despite methotrexate’s widespread use for pregnancy termination, insufficient published data exist to guide the counseling of patients who have experienced a failed termination. Nevertheless, primary care physicians are often called on to counsel such patients.
Only about half of women who undergo a medical termination procedure attend follow-up visits with the abortion provider.10 One reason is the distance some patients travel and the associated costs. A 2000 report showed that 87% of counties in the United States lack even a single abortion provider, and that approximately 25% of women travel 50 miles or more for their abortions.11
Financial hardship leads some women to opt for continuing a pregnancy after a failed elective termination.1 That was the case with our patient. When she began experiencing pelvic pain after the termination procedure, she did not return to the abortion clinic, but instead sought guidance from her primary care physician at our medical center. After learning that she was 16 weeks pregnant, she opted to proceed with the pregnancy because she couldn’t afford a second elective termination.
Primary care involvement makes sense for other reasons as well. Protocols requiring in-person follow-up appointments after elective termination may not make the best use of the medical system.10 The high proportion of “no shows” can lead to scheduling difficulties and reduce a provider’s availability to perform abortions. This in turn would lead to a loss of income for the provider and could possibly increase the total cost of medical care.
One proposed solution has been to teach women how to recognize the signs and symptoms of a successful abortion or possible complications. However, a study of methotrexate-misoprostol abortion in the United States showed that women were often unable to assess whether they had successfully aborted.10 Of 50 women, 28 thought they had aborted by day 9, and 13 of those (46%) were still pregnant.10 A patient’s overestimation of her ability to make such judgments is thought to be another reason for the low follow-up rates post termination.
When termination is performed—regardless of the modality used—it is imperative to confirm that it was successful. Primary care providers, who are usually accessible and offer cost-effective care, can provide such confirmation. In addition, primary care physicians may need to address the psychological stress caused by elective termination.