Medical Abortion: 3 to 9 Weeks with the use of Methotrexate

Medical abortions have become popular in the U.S. Since 2001 with the FDA approval of RU486 for pregnancy between 3 and 7 weeks. Prior to 2001, medical abortions were commonly carried out with methotrexate. Methtrexate was FDA approved in the late 1950's for treatment of certain cancers. Since then, it has been used to treat psoriasis and rheumatoid arthritis.

Methotrexate is known to cause miscarriages and severe fetal abnormalities in the first trimester of pregnancy (up to 12 weeks gestation). Patients diagnosed as being pregnant delay treatment for their particular disease until after delivery, or elect to undergo a termination of pregnancy especially if in the first trimester of pregnancy.

In the mid-80's, there was extensive documented research found in medical literaturethat discussed the treatment of tubal ectopic pregnancy (pregnancy outside of uterus). Methotrexate targets and destroys certain parts of the pregnancy tissue (trophoblasts) required for fetal growth. Without the trophoblastic tissue, pregnancy tissue reduces in size and disappears which prevents the need for surgery.

It has been observed in patients less than 6 weeks gestation that it takes 25 to 30 days after receiving methotrexate, for the uterus to begin to contract and expel the pregnancy tissue. In order to reduce the length it took to complete this abortion process, cytotec (misoprostol) was added. Cytotec is a prostaglandin known to cause uterine contractions. Changes also occur locally in the cervix (lower part of mother's womb) allowing the cervix to dilate (open) and become soft which causes the pregnancy tissue to be  expelled from the uterus. This process can take on average between 1 and 14 days to complete. In some patients it can take longer. On average, there is a 5 to 12% failure rate using the combination of methotrexate and cytotec to carry out this abortion procedure on patients between 3 and 9 weeks pregnant. Patients less than 6 weeks gestation have a  97 to 99% success rate. In essence, the earlier in gestation the medical abortion procedure is performed, the higher the success rate.

Abortions using methotrexate and cytotec are associated with very few complications. Given the small dosage of methotrexate used, there are minimal side effects. These inculde the possibility of diarrhea, cystitis (bladder irritation) a skin rash with excessive sun exposure. Hair loss and low blood cell counts have not been observed in our clinical practice. Other advantages of methotrexate is that it is not expensive to use, and can be given by injection or by mouth. For those patients who are not able to hold liquids or food down due to nausea and vomiting, giving methotrexate intramuscularly is an excellent choice.

Complications associated with the abortion procedure in general are retained (tissue remains behind in uterus) or failure of the procedure, continued or excessive bleeding, all of which require a surgical abortion procedure to be performed. In rare cases, blood transfusions have been required, and there have been reports of sporadic deaths due to a rare type of infection. There is no conclusion that these deaths are directly caused by the abortion procedure.

In conclusion, medical abortion with methotrexate and cytotec has been used for many years to terminate pregnancies up to 9 weeks gestation. Though it is not as effective as RU486 after 6 weeks gestation for terminating pregnancy, it has been found to be as effective in patients less than 6 weeks.. For patients who are allergic to the RU486 pill, unable to swallow pills, who are experiencing nausea and vomiting, or have other contraindications including adrenal insufficiency, the use of methotrexate is a viable alternative.