Methotrexate is given weekly as an intramuscular injection of 15 to 25 mg. Side effects are rare and include leukopenia and hypersensitivity interstitial pneumonitis. Hepatic fibrosis is the most severe potential sequela of long-term therapy. Patients with concomitant alcohol abuse and/or morbid obesity are more likely to develop hepatic fibrosis and therefore should not be treated with methotrexate. It is prudent to obtain a baseline chest radiograph and to monitor complete blood count, liver function and renal function every two weeks until the patient is receiving oral therapy, and every one to three months thereafter. Before methotrexate therapy is initiated, the risks of treatment and the possible need for a liver biopsy should be discussed with the patient.
She needs help even to leave the house with four infants, limiting the things she can do during the day. Unlike other first-time moms, Justina couldn’t attend moms’ groups or early childhood classes with her four infants, or run to Target with her babies, or even walk around the block without another adult, because she can’t physically push two double strollers. (The Kopps decided to forgo the quad-stroller, “because of the spectacle aspect it would draw,” Justina said.) A recent trip to Boston for her brother’s wedding required serious logistical planning, with both strollers, four Pack-n-Plays, four car seats and 16 bottles.