Methotrexate and misoprostol for abortion

Examples

Generic Name	Brand Name
methotrexate	MTX
misoprostol	Cytotec

How It Works

Methotrexate and misoprostol use is a two-step method.

• First, methotrexate tablets are taken by mouth or an injection of methotrexate is given by your health professional. Methotrexate interferes with the growth of the placenta, which allows it to separate from the endometrium. This is an unlabeled use of methotrexate. For reference, see an illustration of the reproductive organs.
• Second, tablets of misoprostol are taken by mouth or inserted vaginally, usually 5 to 7 days later. This medicine causes uterine contractions so that your body passes the uterine contents. The pregnancy usually ends at home within a day or two when the tissue from the uterus is passed.

Note: Many doctors are only giving misoprostol by mouth. This is because of recent reports of a very rare, fatal infection that has affected a few women after using vaginal misoprostol.¹

A medical abortion usually requires three visits to your health professional over several weeks. Medicines are given at the first and second visits. The third visit is a follow-up appointment and is usually scheduled within 20 days after the second visit to make sure the abortion is complete and no complications are present. If a medical abortion is unsuccessful, a surgical abortion must be done to complete the process. (A fetus may not develop normally after exposure to methotrexate or misoprostol.)

You may also take pain medicine by mouth for this procedure.

Why It Is Used

A medical abortion with methotrexate is most effective when performed within the first 7 weeks of pregnancy.² This offers women an early-pregnancy abortion option that doesn't involve surgery.

Methotrexate is also used for treatment of an ectopic pregnancy.

How Well It Works

A medical abortion with methotrexate and misoprostol is effective over 90% of the time. When completed before 7 weeks of pregnancy, injected methotrexate is effective in 95% to 99% of cases.²

Some studies show that injected methotrexate and vaginal misoprostol work more quickly, with fewer side effects, than when both medicines are taken by mouth.³ But many doctors are only giving misoprostol by mouth. This is because of recent reports of a very rare, fatal infection that has affected a few women after using vaginal misoprostol.¹

Over 60% of pregnancies will end within the first 24 hours after taking misoprostol (a second dose of misoprostol can be used). However, methotrexate and misoprostol can take up to 3 weeks to be effective, which is longer than other abortion methods.²

Side Effects

This method of abortion causes symptoms similar to a miscarriage (such as severe cramping and vaginal bleeding) as tissue and clots pass from the uterus.

• Nausea.
• Vomiting.
• Diarrhea.
• Headache.
• Dizziness.
• Chills or hot flushes (sweating and feeling overly hot).
• Shivering.
• Fatigue.

Signs of complications

Less than 1% of all women who have an abortion have serious problems afterward.⁴

Call your health professional immediately if you have any of these symptoms after an abortion:

• Severe bleeding. Both medical and surgical abortions usually cause bleeding that is different from a normal menstrual period. Severe bleeding can mean:
  • Passing clots that are bigger than a golf ball, lasting 2 or more hours.
  • Soaking more than 2 large sanitary pads in an hour, for 2 hours in a row.
  • Bleeding heavily for 12 hours in a row.
• Signs of infection in your whole body, such as headache, muscle aches, dizziness, or a general feeling of illness. Severe infection is possible without fever.
• Severe pain in the abdomen that is not relieved by pain medicine, rest, or heat
• Hot flushes or a fever of 100.4°F (38°C) or higher that lasts longer than 4 hours
• Vomiting lasting more than 4 to 6 hours
• Sudden abdominal swelling or rapid heart rate
• Vaginal discharge that has increased in amount or smells bad
• Pain, swelling, or redness in the genital area

Call your health professional for an appointment if you have had any of these symptoms after a recent abortion:

• Bleeding (not spotting) for longer than 2 weeks
• New, unexplained symptoms that may be caused by medicines used in your treatment
• No menstrual period within 6 weeks after the procedure
• Signs and symptoms of depression. Hormonal changes after a pregnancy can cause postpartum depression that requires treatment.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Choosing a medical or surgical procedure for an abortion will depend on your medical history, how many weeks pregnant you are, what options are available where you live, and your personal preferences.

Methotrexate for medical abortions has not been evaluated in women with the following medical conditions:

• Anemia
• Human immunodeficiency virus (HIV)
• Alcoholism
• Bone marrow diseases
• Blood clotting disorders
• Low white blood cell count (leukopenia)
• Thrombocytopenia
• Liver or kidney disease
• Uncontrolled seizure disorder
• Acute inflammatory bowel disease (IBD)
• Allergy to methotrexate
• Intrauterine device (IUD) in place

Avoid alcohol and aspirin while using methotrexate and misoprostol for a medical abortion.

Avoid folic acid supplements—folic acid (folate) can interfere with the action of methotrexate during a medical abortion.

Methotrexate can be used by women with asthma.

A medical abortion does not require surgery but methotrexate must be used in the first 7 weeks of pregnancy to be most effective. If methotrexate fails, a vacuum aspiration must be done as follow-up. If the abortion is not completed, complications can include abnormal development of the fetus.

After a medical abortion

Expect that you may experience different emotional reactions after an abortion.

Postpartum depression can be triggered by changing pregnancy hormones after an abortion. If you have more than 2 weeks of postpartum depression symptoms, such as fatigue, sleep or appetite change, or feelings of sadness, emptiness, anxiety, or irritability, see your health professional about treatment. Keep track of your symptoms with a postpartum depression checklist(What is a PDF document?).

Do not have sexual intercourse for at least 1 week, or longer, as advised by your health professional.

When you start having intercourse again, use birth control, and use condoms to prevent infection. For immediately effective birth control, you can use a barrier method (such as a diaphragm, cervical cap, or condom). An intrauterine device (IUD) is effective immediately after it is placed in the uterus. If you start hormone birth control pills, patches, or injections right after the procedure, be sure to use a backup method until the hormone medicine becomes effective. For more information, see the topic Birth Control.

Your next regular period may come at any time within 6 weeks after the abortion. Be sure to contact your health professional if you do not have a period in 6 weeks.

Complete the new medication information form (PDF)(What is a PDF document?) to help you understand this medication.

Author:	Healthwise Medical Writer	Last Updated: October 6, 2006
Medical Review:	Joy Melnikow, MD, MPH - Family Medicine Lori A. Boardman, MD, ScM - Obstetrics and Gynecology
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