Abstract
Fetal methotrexate syndrome was first described several decades ago when this agent was being used as abortifacient. After this first trimester drug exposure was associated with fetal anomalies, this use as abortifacient became rare. Over the last several years the use of methotrexate for termination of pregnancy and medical management of ectopic pregnancies has again become more widespread. Case: A 23 year old G3 P2 female sought an abortion at 8 weeks of gestation. She was given an unknown dose of methotrexate. She had no follow-up until she presented at 10 weeks of gestation. At that time she was noted to have a viable intrauterine gestation. An ultrasound was done that showed a normal scan for 10 weeks of gestation. The patient had no prenatal care until she presented at 39 weeks of gestation. At that time she was noted to have severe preecalmpsia and HELLP syndrome. The fetus on ultrasound was symmetrically growth retarded with estimated fetal weight at less than the 5th percentile. Secondary to a breech presentation the infant was delivered by cesarean section. The infant was small for gestational age at 2050grams which is at the first percentile by the Lubcenco intrauterine growth standard. On physical exam the infant was hypotonic with the following anomalies: mild dolichocephaly, high forehead, prominent, broad nose, hypertelorism., small palpebral fissures, sacral crease, small mouth, clinodactaly, and hypoplastic toe nails. The infant's hospital course was complicated by temperature instability. A head CT and ultrasound were negative for any pathology. Chromosomes were normal. After a 7 day hospital course the infant was discharged home with a cardiac and respiratory monitor.
Discussion: Methotrexate have been extensively use in autoimmune disorder and as chemotherapy. Since their use is becoming more extensive as a abortifacient and for the medical management of ectopic pregnancies, we will see many cases of first trimester exposure of fetuses to this agent. This exposure should be considered when readily offered by the mother.
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Wheeler, M., Stanford, M. & Meara, P. Fetal methotrexate syndrome. Genet Med 2, 113 (2000). https://doi.org/10.1097/00125817-200001000-00227
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DOI: https://doi.org/10.1097/00125817-200001000-00227