Methotrexate/misoprostol embryopathy: Report of four cases resulting from failed medical abortion

Distal Tibial Hemimelia in Fetal Methotrexate Syndrome: A Case Study and Literature Review

Methotrexate (MTX), a folate antagonist, is used in various fields, including malignancies and rheumatoid or inflammatory autoimmune diseases. MTX is used for the non-surgical treatment of ectopic pregnancies and the elective termination of pregnancy. The teratogenic effects of MTX have been recognized since the 1960s. Fetal methotrexate syndrome (FMS) was established based on the study of congenital anomalies. Generally, there is a risk of FMS when MTX is used between four and six weeks after conception. Here, we reviewed the literature regarding MTX usage and described a case of FMS that was born with a rare anomaly, such as tibial hemimelia, in a mother who had received MTX 4 months before conception for the management of an ectopic pregnancy.

The role of teratogens in neural crest development

The neural crest (NC), discovered by Wilhelm His 150 years ago, gives rise to a multipotent migratory embryonic cell population that generates a remarkably diverse and important array of cell types during the development of the vertebrate embryo. These cells originate in the neural plate border (NPB), which is the ectoderm between the neural plate and the epidermis. They give rise to the neurons and glia of the peripheral nervous system, melanocytes, chondrocytes, smooth muscle cells, odontoblasts and neuroendocrine cells, among others. Neurocristopathies are a class of congenital diseases resulting from the abnormal induction, specification, migration, differentiation or death of NC cells (NCCs) during embryonic development and have an important medical and societal impact. In general, congenital defects affect an appreciable percentage of newborns worldwide. Some of these defects are caused by teratogens, which are agents that negatively impact the formation of tissues and organs during development. In this review, we will discuss the teratogens linked to the development of many birth defects, with a strong focus on those that specifically affect the development of the NC, thereby producing neurocristopathies. Although increasing attention is being paid to the effect of teratogens on embryonic development in general, there is a strong need to critically evaluate the specific role of these agents in NC development. Therefore, increased understanding of the role of these factors in NC development will contribute to the planning of strategies aimed at the prevention and treatment of human neurocristopathies, whose etiology was previously not considered.

Fetal methotrexate syndrome: A systematic review of case reports

Methotrexate is a folic acid antagonist known to be teratogenic in humans. Several cases of congenital malformations after fetal exposure to methotrexate have been published, resulting in the establishment of the 'fetal methotrexate syndrome'. However, it is unclear which congenital anomalies can truly be attributed to methotrexate exposure. The objective of this review is to delineate a consistent phenotype of the fetal methotrexate syndrome. We performed a systematic review that yielded 29 cases of (congenital) anomalies after in utero exposure to methotrexate and compared their malformation pattern to that of children and fetuses with congenital anomalies in general. Statistically significant higher proportions of microcephaly, craniosynostosis, tetralogy of Fallot, pulmonary valve atresia, limb reduction defects and syndactyly were found in the methotrexate group, indicating that these congenital anomalies are truly part of the fetal methotrexate syndrome. These results aid clinicians with diagnosing fetal methotrexate syndrome.

Improvements in Clinical Trials Information Will Improve the Reproductive Health and Fertility of Cancer Patients

There are a number of barriers that result in cancer patients not being referred for oncofertility care, which include knowledge about reproductive risks of antineoplastic agents. Without this information, clinicians do not always make recommendations for oncofertility care. The objective of this study was to describe the level of reproductive information and recommendations that clinicians have available in clinical trial protocols regarding oncofertility management and follow-up, and the information that patients may receive in clinical trials patient information sheets or consent forms. A literature review of the 71 antineoplastic drugs included in the 68 clinical trial protocols showed that 68% of the antineoplastic drugs had gonadotoxic animal data, 32% had gonadotoxic human data, 83% had teratogenic animal data, and 32% had teratogenic human data. When the clinical trial protocols were reviewed, only 22% of the protocols reported the teratogenic risks and 32% of the protocols reported the gonadotoxic risk. Only 56% of phase 3 protocols had gonadotoxic information and 13% of phase 3 protocols had teratogenic information. Nine percent of the protocols provided fertility preservation recommendations and 4% provided reproductive information in the follow-up and survivorship period. Twenty-six percent had a section in the clinical trials protocol, which identified oncofertility information easily. When gonadotoxic and teratogenic effects of treatment were known, they were not consistently included in the clinical trial protocols and the lack of data for new drugs was not reported. Very few protocols gave recommendations for oncofertility management and follow-up following the completion of cancer treatment. The research team proposes a number of recommendations that should be required for clinicians and pharmaceutical companies developing new trials.

Successful selective reduction of a heterotopic cesarean scar pregnancy in the second trimester: a case report and review of the literature

Background

Heterotopic cesarean scar pregnancy is a cesarean scar pregnancy combined with an intrauterine pregnancy that predisposes a woman to life-threatening complications such as uterine rupture and massive bleeding. Preservation of the intrauterine pregnancy in heterotopic cesarean scar pregnancy is a great challenge.

Case presentation

We report a case of a 33-year-old woman with heterotopic cesarean scar pregnancy after IVF-embryo transfer (ET). Expectant management was carried out with early diagnosis of heterotopic cesarean scar pregnancy (HCSP), and selective fetal reduction of cesarean scar pregnancy (CSP) was performed by ultrasound-guided intrathoracic injection of potassium chloride (KCl) at 16 + 4 weeks of gestation due to aggravation of CSP. Preservation of the intrauterine pregnancy was successful and a healthy baby was delivered by cesarean section at 37 + 6 weeks of gestation.

Conclusions

Heterotopic cesarean scar pregnancy is an extremely rare form of heterotopic pregnancy. Patients should be appropriately counseled regarding the different treatment options available. An ultrasound-guided injection of potassium chloride may constitute a safe, minimally invasive and reliable way to terminate the heterotopic gestation and preserve the intrauterine pregnancy. Intensive management should be performed during the ongoing pregnancy and cesarean section.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-016-1171-x) contains supplementary material, which is available to authorized users.

Effect of methotrexate exposure at middle gestation on the inner plate of the ocular cup and lens in the rat fetus

Pregnant rats were treated intraperitoneally with a single dose of methotrexate (MTX) 90 mg/kg on gestation day (GD) 13, and fetal eyeballs were examined time-dependently from GD 13.5 to 15.5. Throughout the experimental period, the inner plate of the ocular cup in the MTX group was significantly thinner than that in the control group. In the inner plate of the ocular cup on GD 15 and 15.5, whereas a developed ganglion cell layer was observed in the control group, the ganglion cell layer in the MTX group was undeveloped and indistinguishable. Disturbance of the arrangement of lens fiber cells, narrowing of the hyaloid cavity of the optic cup, and hypoplasia of optic nerve fibers were observed in the MTX group on GD 15 and 15.5. Increase of pyknosis and decrease of mitosis were induced in the optic cup and the lens epithelium of the MTX group. In the inner plate of the optic cup and the lens epithelium of the MTX group, the cleaved caspase-3- and TUNEL-positive rates increased significantly throughout the experimental period. The phospho-histone H3-positive rate in the inner plate of the optic cup decreased significantly from GD 13.5 to 14.5, and it recovered on GD 15. On the other hand, the phospho-histone H3-positive rate in the lens epithelium decreased significantly throughout the experimental period. These results suggested that optic tissue on GD 13 in rats was sensitive to MTX.

Safety of conventional systemic therapies for psoriasis on reproductive potential and outcomes

The effects of conventional systemic therapies for psoriasis on pregnancy outcomes, lactation, male fertility and mutagenicity are common concerns in the clinical setting. There is relatively little evidence to guide clinician and patient. In this study, we review the safety profile of the commonly used conventional systemic therapies used for psoriasis in individuals of reproductive potential. Safety data are derived from large-scale registries, adverse-event reporting databases, clinical trials and case reports. We assess the effect of each therapy on adverse pregnancy outcomes, including congenital malformations, and lactation with maternal administration. We also assess the effect of the therapies on male fertility and potential mutagenicity with paternal administration. We provide applicable guidance to inform clinician and patient before and after conception.

Congenital bladder exstrophy associated with Duogynon hormonal pregnancy tests-signal for teratogenicity or consumer report bias?

A combination of ethinylestradiol and 10mg norethisterone under the brand names of Duogynon (Germany) or Primodos (UK) was used as a pregnancy test until the 1970s. Until very recently there was continuing public concern about the safety of these drugs and legal proceedings were instituted against the medicinal authorization holder. Given the lack of epidemiological studies focusing on Duogynon/Primodos, the present study evaluates 296 consumer reports of the German Duogynon database and compares the reported birth defects with data from a population based birth registry. The most striking result is an increase of bladder exstrophy (OR=37.27; 95%-CI 14.56-95.28). Neural tube defects (OR=2.99; 95%-CI 1.85-4.84) and renal agenesis (OR=2.53; 95%-CI 1.17-5.45) were also significantly increased. Bladder exstrophy may be a yet undetected teratogenic effect of Duogynon, but may also represent a reporting bias. The present study highlights the difficulties of evaluating consumer reports which may be influenced by public media.

Teratogen update: methotrexate

Methotrexate and aminopterin are folic acid antagonists that inhibit dihydrofolate reductase, resulting in a block in the synthesis of thymidine and inhibition of DNA synthesis. Methotrexate has been used for the treatment of malignancy, rheumatic disorders, and psoriasis and termination of intrauterine pregnancy. Recently, methotrexate has become a standard treatment for ectopic pregnancy. The misdiagnosis of an intrauterine pregnancy as an ectopic pregnancy can result in exposure of a continuing pregnancy to dose levels of methotrexate of 50 mg/m(2) (maternal body surface area). Experimental animal studies have associated methotrexate therapy with embryo death in mice, rats, rabbits, and monkeys. Structural malformations have been most consistently produced in rabbits at a maternal dose level of 19.2 mg/kg. Abnormalities in rabbits include hydrocephalus, microphthalmia, cleft lip and palate, micrognathia, dysplastic sacral and caudal vertebrate, phocomelia, hemimelia, syndactyly, and ectrodactyly. Based on human case reports of methotrexate exposure during pregnancy, a methotrexate embryopathy has been described that includes growth deficiency, microcephaly, hypoplasia of skull bones, wide fontanels, coronal or lambdoidal craniosynostosis, upswept frontal scalp hair, broad nasal bridge, shallow supraorbital ridges, prominent eyes, low-set ears, maxillary hypoplasia, epicanthal folds, short limbs, talipes, hypodactyly, and syndactyly. This syndrome may be associated with exposures between 6 and 8 weeks after conception and dose levels of 10 mg/week or greater. More recent case reports of methotrexate exposure for the misdiagnosis of ectopic pregnancy involve treatment before 6 weeks after conception and have raised the suggestion of a distinct syndrome due to such early exposures. Tetralogy of Fallot and perhaps other neural crest cell-related abnormalities may be features of this early syndrome. A disproportionality analysis of methotrexate and aminopterin case reports and series provides support for pulmonary atresia, craniosynostosis, and limb deficiencies as reported more often than expected in methotrexate-exposed children. Denominator-based data will be welcome to better define elements of a methotrexate embryopathy and possibly to distinguish an early exposure syndrome from anomalies traditionally associated with methotrexate exposure.

The use of misoprostol in termination of second-trimester pregnancy

Misoprostol, a synthetic prostaglandin E1 analog, is initially used to prevent peptic ulcer. The initial US Food and Drug Administration-approved indication in the product labeling is the treatment and prevention of intestinal ulcer disease resulting from nonsteroidal anti-inflammatory drugs use. In recent two decades, misoprostol has approved to be an effective agent for termination of pregnancy in various gestation, cervical ripening, labor induction in term pregnancy, and possible management of postpartum hemorrhage. For the termination of second-trimester pregnancy using the combination of mifepristone and misoprostol seems to have the highest efficacy and the shortest time interval of abortion. When mifepristone is not available, misoprostol alone is a good alternative. Misoprostol, 400 μg given vaginally every 3-6 hours, is probably the optimal regimen for second-trimester abortion. More than 800 μg of misoprostol is likely to have more side effects, especially diarrhea. Although misoprostol can be used in women with scarred uterus for termination of second-trimester pregnancy, it is recommended that women with a scarred uterus should receive lower doses and do not double the dose if there is no initial response. It is also important for us to recognize the associated teratogenic effects of misoprostol and thorough consultation before prescribing this medication to patients regarding these risks, especially when failure of abortion occurs, is needed.

Outcome following high-dose methotrexate in pregnancies misdiagnosed as ectopic

OBJECTIVE

The objective of this study was to report the outcomes of intrauterine pregnancies misdiagnosed as ectopic and exposed to methotrexate, a major teratogen.

STUDY DESIGN

We report the outcomes of all subjects who sought consultation after exposure to high-dose methotrexate to induce abortion in presumed ectopic pregnancies, which were later identified as viable intrauterine pregnancies by 3 North American Teratology Information Services between 2002 and 2010.

RESULTS

Eight women with normal, desired pregnancies were administered high-dose methotrexate in the first trimester because of presumed, misdiagnosed ectopic pregnancies. All pregnancies resulted in catastrophic outcomes. Two pregnancies resulted in severely malformed newborns with methotrexate embryopathy; 3 women miscarried shortly after exposure, and in 3 the erroneous diagnosis led the physicians to advise and perform surgical termination.

CONCLUSION

Erroneous diagnosis of intrauterine pregnancies as ectopic with subsequent first-trimester exposure to methotrexate may result in the birth of severely malformed babies or fetal demise.

Teratogenic exposures

A consideration of teratogenic exposures includes not only an agent (chemical, radiation, biologic) but an exposure level and timing of exposure. There are criteria by which exposures are evaluated for a causal connection with an abnormal outcome. We here review some teratogenic exposures and discuss how they were initially described and confirmed. We have limited our discussion to some of the exposures for which a connection to structural malformations has been accepted in some quarters, and we indicate some exposures for which a causal association awaits confirmation. We recommend that counselors find a reliable and updatable source of information on exposures during pregnancy.

Importance of timing of gestational exposure to methotrexate for its teratogenic effects when used in setting of misdiagnosis of ectopic pregnancy

OBJECTIVE

To report a case of embryopathy due to misadministration of methotrexate in the setting of suspected ectopic pregnancy that resulted in a different pattern of malformations than is typically seen with methotrexate.

DESIGN

Case report.

SETTING

Community hospital.

PATIENT(S)

A 30-year-old primigravida women exposed to methotrexate (50 mg/m(2)) at 5 6/7 weeks' gestation.

INTERVENTION(S)

The patient underwent amniocentesis because of abnormal results at the first-trimester genetic screening (low levels of pregnancy associated plasma protein A and hCG) and fetal echocardiogram because of single umbilical artery.

MAIN OUTCOME MEASURE(S)

Fetal anomalies.

RESULT(S)

The fetus was found to have a single umbilical artery, tetralogy of Fallot, and a "horseshoe lung," despite administration of high doses of folic acid. The pregnancy ultimately ended with fetal demise at 30 weeks.

CONCLUSION(S)

As medical management of ectopic pregnancy becomes more common, practitioners should be cautious about the potential teratogenic effects in unrecognized intrauterine pregnancies and be able to diagnose the myriad defects, including cardiac anomalies, that could result from such exposure.

Rheumatology drugs and pregnancy

Medication exposure during pregnancy, especially in the first trimester, is a common event that causes considerable concern among patients and healthcare professionals alike. Once the pregnancy is known, the response often consists in stopping or substantially diminishing the use of medications. Some medications are teratogenic and/or fetotoxic, requiring effective birth control and prior information of women of childbearing potential. Nevertheless, limiting the use of medications out of a sense of caution is warranted only if no major adverse impact on the mother is expected throughout the 9 months of the pregnancy. Treatment decisions during pregnancy should rest on a careful reappraisal of treatment practices and on an in-depth evaluation of the risk/benefit ratio of each medication. Here, we will discuss the main rheumatology drug classes whose use during pregnancy is most likely to cause concern.

Fetal methotrexate/aminopterin syndrome in an adult: a likely case with ectodermal abnormalities

Exposure to folic acid antagonists during the first trimester of pregnancy may lead to fetal death or to a recognized pattern of malformations in liveborn infants. Few reports of affected adult individuals have been observed. In this report, the clinical findings of a likely affected 45-year-old woman are described and compared with reported cases. New ectodermal abnormalities are also described.

A role for Drosophila in understanding drug-induced cytotoxicity and teratogenesis

Drosophila research has been and continues to be an essential tool for many aspects of biological scientific research and has provided insight into numerous genetic, biochemical, and behavioral processes. As well, due to the remarkable conservation of gene function between Drosophila and humans, and the easy ability to manipulate these genes in a whole organism, Drosophila research has proven critical for studying human disease and the physiological response to chemical reagents. Methotrexate, a widely prescribed pharmaceutical which inhibits dihydrofolate reductase and therefore folate metabolism, is known to cause teratogenic effects in human fetuses. Recently, there has been resurgence in the use of methotrexate for inflammatory diseases and ectopic or unwanted pregnancies thus, increasing the need to fully understand the cytotoxicity of this pharmaceutical. Concerns have been raised over the ethics of studying teratogenic drugs like methotrexate in mammalian systems and thus, we have proposed a Drosophila model. We have shown that exposure of female Drosophila to methotrexate results in progeny with developmental abnormalities. We have also shown that methotrexate exposure changes the abundance of many fundamental cellular transcripts. Expression of a dihydrofolate reductase with a reduced affinity for methotrexate can not only prevent much of the abnormal transcript profile but the teratogenesis seen after drug treatment. In the future, such studies may generate useful tools for mammalian antifolate "rescue" therapies.

Anomalies Associated With Failed Methotrexate and Misoprostol Termination

BACKGROUND

Methotrexate and misoprostol are frequently used in combination for medical termination of pregnancy. Despite their frequent use, published information about low-dose exposures to these known teratogens is sparse and neonatal follow-up data are limited. We present neonatal outcomes in three infants from two different women who had failed medical terminations with methotrexate and misoprostol.

CASES

A young gravida 1, para 0, presented with intrauterine pregnancy complicated by first-trimester exposure to oral methotrexate and vaginal misoprostol. Ultrasonography determined that the fetus had intrauterine growth restriction and ventriculomegaly. The infant had growth and developmental delays. A young gravida 4, para 3-0-0-3, also presented after first trimester exposure to methotrexate and misoprostol, and was found to have a twin gestation. The infants were noted to have multiple congenital anomalies, growth restriction, and developmental delay.

CONCLUSION

Even single doses of methotrexate and misoprostol used in medical termination of pregnancy can be associated with multiple congenital anomalies.

A de novo, apparently balanced reciprocal translocation in a child with developmental delay whose mother was being treated with low-dose methotrexate at the time of conception

BACKGROUND

Methotrexate is a proven teratogen and its use periconceptually is strongly advised against. Concerns about possible chromosomal effects in the offspring of women treated with this agent have been raised, but they have not been reported. In vivo and in vitro studies have supported this possibility, however.

CASE

A 32-year-old primigravida was treated with low-dose methotrexate for rheumatoid arthritis from prior to conception until six weeks postconception. Her child was born without congenital malformations but subsequently developed seizures and was diagnosed with developmental delay. He was found to have a de novo, apparently balanced, reciprocal translocation between chromosomes 5 and 20 (46,XY,t(5:20)(q15;p12)). Other investigations failed to reveal another cause for his developmental delay.

CONCLUSIONS

The possible association between maternal methotrexate exposure and a de novo chromosomal anomaly in an offspring supports the recommendation that women should be advised to cease taking this drug for at least six months prior to conception.