Exclusive use of intrasac potassium chloride and methotrexate for treating cesarean scar pregnancy: effectiveness and subsequent fecundity

Abstract

STUDY QUESTION Is exclusive use of intragestational sac potassium chloride (KCl) and methotrexate (MTX) effective in the management of viable cesarean scar pregnancy (CSP)? SUMMARY ANSWER Exclusive use of intragestational sac KCl and MTX was effective in the management of viable CSP. WHAT IS KNOWN ALREADY Owing to a paucity of randomized studies on management of CSP, evidence-based management remains unclear. Intragestational sac KCl or MTX along with either systemic MTX or surgical intervention, such as uterine artery embolization or dilation and curettage, has proved to be effective in the management of CSP. Furthermore, there are limited data in the literature on the use of exclusive intragestational sac KCl and MTX for management of CSP and subsequent fecundity. STUDY DESIGN, SIZE, DURATION A prospective cohort study was conducted from June 2017 to September 2019. We recruited nine CSP patients referred to our unit. There was no lost to follow-up noted. PARTICIPANTS/MATERIALS, SETTING, METHODS Patients with an ultrasound diagnosis of CSP who fulfilled the inclusion criteria were recruited. The study was conducted in a tertiary care center. Clinical symptoms, pregnancy viability, gestational age and human chorionic gonadotrophin (HCG) values determined the management in each individual case. Accordingly, patients were grouped into the expectant management (Group I, n = 3) and intragestational sac KCl with MTX (Group II, n = 6) groups. Demographic details, clinical characteristics, ultrasound details at diagnosis, post-treatment HCG normalization time, menses resumption, mass resolution and subsequent fecundity were noted. Descriptive statistics were used for analyses. MAIN RESULTS AND THE ROLE OF CHANCE Of the nine patients with CSP, six patients had viable CSP and required intervention. Out of these, four patients expressed a desire for future fertility. Mean gestational age at treatment among patients in Group II was 54.33 ± 7.51 days (range 46–65). Mean HCG value at the time of diagnosis was 84 110 ± 38 679.39 IU/l in Group II patients as compared with 2512 ± 709.36 in Group I. HCG had decreased by 92.7 ± 3.78% 2 weeks after intervention and normalized (<5 IU/l) by 53.5 ± 14.97 days. No major complications occurred and additional treatment was not required in these patients. Menstruation had resumed by 26 ± 6.6 days after treatment in Group II. On follow up, a small unresolved mass was present in two patients and the cesarean scar niche was visible in the remaining four patients. Out of the four patients desirous of future conception, three conceived naturally and one delivered a term baby via repeat lower segment cesarean section. LIMITATIONS, REASONS FOR CAUTION The main limitation of our study was small sample size. All the patients were asymptomatic at presentation and hence we cannot comment on use of this method in those presenting with active vaginal bleeding. WIDER IMPLICATIONS OF THE FINDINGS Intragestational sac KCl plus MTX may be a highly effective approach for the management of viable CSP despite high initial HCG values. There seems to be no need for any further intervention. It can be considered as the first line minimally invasive treatment option in patients desirous of future fertility. Nevertheless, accumulation of further cases is required to validate this treatment modality. STUDY FUNDING/COMPETING INTERESTS No specific funding was received to undertake this study. The authors report no conflict of interest. TRIAL REGISTRATION NUMBER N/A

Efficacy of Treatment of Cesarean Scar Ectopic Pregnancies with Alcohol Injection to the Gestational Sac and Dilatation Curettage with or without Systemic Methotrexate: A Case-Control Study

“…Qian et al, 29 24h after UAE, compared D&S (n=33) and operative hysteroscopy (n=33) in the treatment of CSP , and they didn't find a significant difference in the intrauterine pregnancies after surgeries between the two groups (p=1.000) in the 12 months following. According to a report by Gundewar et al, 30 three of four patients who desired to conceive were able to do so naturally after undergoing intra-sac KCl and MTX treatment. Likewise, in a study, among 13 cases treated with systemic MTX, three out of four patients who wanted to conceive were able to have a successful pregnancy.…”

Outcome and treatment of caesarean scar ectopic pregnancy under ultrasound-guided vacuum aspiration preceded by local methotrexate sac injection

“…Shen et al also mentioned that most patients (70.4%) had been managed by transcervical aspiration of the gestational sac, and open surgeries had been used to manage 22.2% of the patients, while the remainder had been managed either by transcervical aspiration of the gestational sac and MTX (14.8%) or MTX alone (7.4%) 11 . There is no uniform guideline for managing CSEP, and previous studies mentioned different approaches, such as elective cesarean hysterectomy 12 , aspiration of the CSEP aspiration of the CSEP, intragestational injection of MTX with or without KCL 20 , and systemic MTX 21 . Therefore, different, less invasive, and patient-tailored methods were used in the current study, and the risk of CSEP increases when the frequency of gravidity increases.…”

Scar Ectopic Pregnancy as an Uncommon Site of Ectopic Pregnancy: A Case Report and Literature Review

“…It can be administered intramuscularly-systemically, locally, or in a combination of both. Methotrexate, potassium chloride (KCL), hyperosmolar glucose, or crystalline trichosanthin have all been injected once under ultrasound guidance [53]. Systemic regimens for cesarean scar pregnancy have produced reassuring outcomes, both with and without intrasac medication injections.…”