Cleft Palate and Toe Malformations in a Child With Fetal Methotrexate Exposure Jay W. Granzow, MD, MPH, Seth R. Thaller, MD, DMD, FACS, FAAP, and Zubin Panthaki, MD, FRCSC Miami, Florida Methotrexate, a commonly administered chemo- therapeutic agent, is a well-known human terato- gen. Exposure of a fetus between 6 and 8 weeks of gestation is postulated to cause birth defects. How- ever, fetal exposure to this drug after this critical period is thought to have little to no effect on even- tual fetal development and growth. The authors re- port a case of an infant whose mother was exposed to methotrexate during pregnancy. The infant was evaluated at their clinic for an incomplete cleft pal- ate and associated asymmetric deformities of the toes on both feet. CASE REPORT A 38-day-old infant presented to the cleft/cranio- facial clinic for evaluation of an incomplete cleft palate and associated bilateral deformities of the toes. The baby’s mother had taken methotrexate for the management of a molar pregnancy at approxi- mately the eighth week of gestation. The infant presented with a cleft of the soft pal- ate. The remainder of the head and neck examination and examination of both upper extremities were normal. The right foot revealed an agenesis of the fifth toe with a foreshortened second toe. The remainder of the foot was apparently normal on physical ex- amination. Examination of the left foot revealed fu- sion of the third, fourth, and fifth toes with clinodac- tyly of the second toe. The remainder of the left foot and lower extremity was also normal on physical examination. DISCUSSION M ethotrexate is a medication commonly admin- istered as part of cancer chemotherapy proto- cols and for the management of rheumatoid arthritis. From the Division of Plastic Surgery, DeWitt Daughtry Depart- ment of Surgery, University of Miami/Jackson Memorial Hospi- tal, Miami, Florida, U.S.A. Address correspondence and reprint requests to Seth R. Thaller, MD, DMD, Division of Plastic Surgery, University of Miami/Jack- son Memorial Hospital, 1611 NW 12th Avenue, East Tower #3019, Miami, FL 33136, U.S.A. Fig 1 Fig 2 747