methotrexate vs. mifepri.

[peiyueng]

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Hi everyone . . . i have not done ob in years. I am in psychiatry. I have been brushing up using up-to-date on mifepristine.

I have a high functioning low IQ and developmentally delayed young girl who is now pregnant at 7.5 wks. Time is a factor.

I am her psychiatrist and also her general practiontioner for most things . . . (she has a PCM, but she sees me for most things). It is a relationship built over a long period of time. The family trusts me and she trusts me. We have a good therapeutic relationship.

In any case, as her GP/psychiatrist, I am now faced with getting my account set up with the mifepristine company and the distributor. It is a pain in the arse.

I know that methotrexate can be used in ectopics. My pt is not ectopically preg. But, is there any reason I couldn't use methotrexate at 1mg/kg oral? And the follow up with cytotec in 3-5 days?

Is there any particular reason I need to use mifepristone instead of methotrexate? I can write and fill methotrexate so much easier.

Please give pointers and help me out. I want to do this right. I have a delicate patient and a delicate situation here.

Thank you.

p.t.

Edit: ok I figured out her body surface area at 63 inches (5'3") and 110 pounds. Her BSA is 1.49 m sq. which means I need 75 mg of methotrexate IM. Single dose.

Does anyone have experience in this area of medical termination? Or do not many people perform these?

I need to do this before the 8-9th week. Is there any particular reason I should choose mifepristone over methotrexate?

thanks in advance.



cheers. thanx in advance

 

[anonperson]

Generally speaking, mifepristone along with misoprostol is considered superior to methotrexate and misoprostol in terms of quicker resolution of the pregnancy and less blood loss.

My concern with this situation is that it seems a bit poorly planned. Is there any way you can get a trained OB GYN involved?

What if she hemorrhages? What if the medical management is not satisfactory and she needs surgical management?

In addition, is the patient able to effectively understand some of the pain issues she might experience with a medical termination and would she be able to tolerate it effectively?

I understand that this is a sensitive issue concerning the patient's mental status, but the right thing is getting an OB GYN involved, at the very least peripherally.

 

[Global Disrobal]

I have to echo anonperson's concerns here. As a rule of thumb: if you can't handle the potential complications, do not perform the procedure.

Even though the psychosocial circumstances have placed you in a sensitive position, I'm positive that the family will understand and appreciate the fact that as a medical professional there are limits to our knowledge and skill sets. I would strongly recommend getting an OBGYN involved for co-management.

Good luck!

 

[sia_simba]

Ouch! I guess a bit late for reply. Can you please update us on what happened? which medication did you end up using?

I am not a strong fan of methotrexate for termination except for ectopic.

If you are going to go through the extreme, might as well use the RU486 along with cytotec. I have had excellent results with cytotec. They are a lot cheaper than methotrexate and you don't have to worry too much about the side effects. Plus, I use cytotec for post-partum hemorrhage. I have yet to perform D&C for patients after medical termination. My partner has done hundreds with cytotec and maybe 1-2 needed D&C.