Management of Abnormal Placenta Implantation with Methotrexate: A Review of Published Data

Abstract

Abnormally invasive placenta is characterized by direct attachment of chorionic villi to the uterine wall. This adherent placenta traditionally has been managed by peripartum hysterectomy. Nowadays, there is a lot of interest toward gradual shift from traditional management of invasive placentation to conservative ones leaving the placenta in situ to avoid the surgical morbidity of hysterectomy and loss of future fertility. Administration of methotrexate (MTX), as an adjunctive antimetabolite drug, resulted in conflicting data during conservative management of abnormal placentation. This review assessed all published data on efficacy and safety of MTX therapy as conservative management of invasive placentation. Fifty-three articles including one prospective cohort study, 2 retrospective cohort studies, 10 case series and 40 case reports were identified. Conservative management has beneficial effects on the avoidance of major surgery with the consequent morbidity and the preservation of future fertility. Infection and vaginal bleeding were main complications of MTX therapy. Although MTX therapy may result in accelerated involution or expulsion of placenta and has some beneficial effects on hemorrhagic events, but there is not enough evidence on its efficacy and safety to recommend its routine uses in all cases of invasive placenta.

Conventional and conservative management of placenta accreta is two ends of a single continuum: A report of three cases and literature review

“…However, patients kept on passing small fragments of degenerated placenta for the first few weeks, and regular menstruation continued after a few months. The above results are also supported by Farasatinasab et al 18 in their retrospective review demonstrated the usage MTX as an adjuvant antimetabolite drug for the conservative management of PA to avoid any major surgery and for natural conception in the future. Another prospective study conducted by Lin et al 19 surface and complete placental expulsion commenced after 3-4 weeks.…”

Conservative management of placenta percreta

“…Notably, one maternal death related to the use of methotrexate during conservative management of PAS disorders had been reported in the literature 5. A previous study on methotrexate therapy for conservative management of PAS disorders showed some beneficial effects 12. The efficacy of methotrexate therapy, or complications arising from its use, was difficult to discern in the present study owing of the low numbers of patients in each group; however, no correlation was found between the route of administration and/or total dose of…”

A Case Report on Focal Placenta Accreta: Successful Conservative Management without Using Methotrexate

“…In a review that included 53 articles, all published data on efficacy and safety of MTX therapy was evaluated. 14 There wasn't enough evidence on its efficacy and safety to support its routine uses in all cases of invasive placenta. In addition, MTX may lead to several common toxicities including nausea, vomiting, diarrhea and mucosal ulcers and some serious side effects such as leukopenia, anemia, gastrointestinal ulcerations, nephrotoxicity, dose-related hepatotoxicity and a rare hypersensitivity like lung reaction.…”