Experience With Medical Treatment of Cesarean Scar Ectopic Pregnancy (CSEP) With Local Ultrasound-Guided Injection of Methotrexate

Abstract

Objective: Ectopic pregnancy within Cesarean section scars is a rare condition. Late diagnosis carries significant risk of bleeding with poor prognosis for survival. There is no consensus on the management of this type of pregnancy. Historically, our facility offered an intra-muscular injection of methotrexate that resulted in a significant failure rate and later need for surgery. We hypothesized that injecting methotrexate directly into the gestational sac would improve the success rate of the treatment.Patients and Methods: This retrospective, uni-centric study examined nine patients aged between 33 and 42 years (mean age = 36.5 years) with Cesarean scar ectopic pregnancy (CSEP) between 2010 and 2018. CSEP was diagnosed by transvaginal ultrasound at a mean gestational age of 8w0/7. CSEP was treated under general anesthetic by ultrasound-guided methotrexate injection directly into the gestational sac. HCG levels and subsequent childbearing were monitored post-treatment.Results: Half of the patients were asymptomatic at the time of diagnosis. All patients tolerated treatment well and all ectopic pregnancies were successfully removed. HCG levels returned to negative within 3 months without additional medical or surgical intervention. The post-treatment pregnancy rate was 50%. Discussions/Conclusions: Our findings indicate that local ultrasound-guided injection of methotrexate into the gestational sac is a safe and effective therapeutic approach when performed by a trained team on a hemodynamically stable patient in the early stages of CSEP.

Case report -Cesarean scar ectopic pregnancy

“…MRT is helpful in distinguishing cervical ectopic from scar ectopic pregnancy or consideration for expectant management of cesarean scar ectopic pregnancy. 6 Here, the case highlights the importance of early diagnosis and management of cesarean scar ectopic pregnancy. This patients presentation was similar to other case reports found in literature.…”

Local Methotrexate Injection Followed by Dilation and Curettage for Cesarean Scar Pregnancy: A Prospective Non-randomized Study

“…The advantages of local intragestational methotrexate to treat CSP has been previously described (19,20). However, the medical treatment alone of intragestational methotrexate remains controversial (13,21). A previous study reported that a local combined with systemic methotrexate without D&C has a success rate of 80.9% (22).…”

A review on management of caesarean scar pregnancy

“…The use of local ultrasound-guided injection of MTX into the gestational sac was considered as a well tolerated and effective therapeutic treatment for CSP, when performed by a trained team on a haemodynamically stable patient in the early stages of CSP. It was showed by a study of Gerday et al on a case series of nine patients [19].…”