Methotrexate Consent Methotrexate (MTX) is a chemotherapeutic medication used to treat some ectopic pregnancies or early miscarriages. It has FDA approval for use in treating tumors, psoriasis and arthritis. It works by preventing the cells or an early pregnancy to multiply, causing these cells to die. Though it is widely used in the treatment of ectopic pregnancies, it does not yet have FDA approval for this indication. Successful treatment with Methotrexate can reduce the need for surgery due to an abnormal pregnancy. More than 95% of patients treated with Methotrexate are able to avoid surgery. The risks and side effects of MTX include nausea, vomiting and diarrhea. If these symptoms occur, they usually resolve within 3 days. Occasionally mouth sores or a sore throat may develop. Very rare side effects include fatigue, liver inflammation, low platelets or white cell count, or anemia. If the MTX does not work, you may need emergency surgery, which may include removing your fallopian tube or requiring a blood transfusion. Alternatives to MTX use include observation, dilation and curettage (surgically remove the uterine lining), laparoscopy(looking inside the abdomen with a periscope) or laparotomy (incision and exploration of the abdomen). After the injection: It is normal to feel some abdominal or pelvic pain for up to two weeks. If you have severe pain, become dizzy, have shoulder pain or "don’t feel right", you should call your physician immediately as your fallopian tube may be rupturing. Avoid intercourse or strenuous activity until cleared by your physician. Avoid aspirin, ibuprofen, naprosyn, folic acid and prenatal vitamins until cleared by your physician. Use birth control for at least 2 months after your last blood test. I understand that conditions may arise which are unforeseen at this time that may require a change in the treatment plan. I authorize and consent for Methotrexate injection in an effort to treat my abnormal pregnancy. I understand that my physician cannot guarantee or give assurance of a successful result and that additional treatment may be necessary which includes the possibility of elective or emergency surgery. I understand the risks, possible complications and alternatives to Methotrexate treatment. All my questions have been answered. Date: _____________ Signature: ____________________________________________ Height __________ = ________inches. Weight: _________lbs. Blood type:________ Surface area 2 (calculated by MD) ____________ Dose (50mg/M squared):___________ LABS DATE Hct. Platelets SGOT QHCG Day 0           Day 3           Day 7           If HCG levels decline by 15% or more in the first 4-7 days, repeat HCG weekly until less than 5 mIU/ml. Repeat MTX if levels do not decline by at least 15% by 4-7 days.