“In Situ” Methotrexate Injection Followed by Hysteroscopic Resection for Caesarean Scar Pregnancy: A Single-Center Experience

Abstract

Background: We evaluated the efficacy of local methotrexate (MTX) treatment followed by hysteroscopic resection for caesarean scar pregnancy and its impact on future fertility. Methods: Monocentric, prospective, observational study performed in the Haykel Hospital between June 2016 and December 2020. Twenty-one women with caesarean scar pregnancy underwent a transcutaneous ultrasound-guided direct injection of MTX into the gestational sac in an outpatient setting. Hysteroscopic resection of residual trophoblastic retention was then performed according to perisaccular blood flow. Main results: Two patients had complete spontaneous trophoblast expulsion after MTX injection, and hysteroscopy was performed in 19 patients for residual trophoblastic retention 1 to 12 weeks after MTX injection. Successful preservation of a healthy uterus with the combined procedure was obtained in 94.8% of patients. Hemostatic hysterectomy was required in one patient. Mean hospitalization duration was 1.5 days. Three patients had spontaneous pregnancy after the procedure. Conclusion: Direct MTX injection into the gestational sac for caesarean scar pregnancy followed by hysteroscopic resection was an effective technique with a short hospitalization, fertility preservation and a low major complication rate compared with other modalities of treatment reported in the literature. Further larger prospective comparative studies are needed to confirm the efficacy of this procedure.

Scar Pregnancy: A Rare, but Challenging, Obstetric Condition

“…Scar pregnancy poses unique management considerations due to the increased risk of complications associated with the previous uterine scar. Several treatment options exist, including medical management with methotrexate [ 4 ], surgical interventions [ 5 ], such as dilation and curettage, or a combination of both. The choice of management depends on factors, such as the patient’s hemodynamic stability, gestational age, and desire for future fertility [ 6 , 7 , 8 ].…”