Successful methotrexate treatment of a viable pregnancy within a thin uterine scar

Abstract

Case reportA 37 year old woman presented in her fourth pregnancy eight weeks of gestation with recurrent episodes of vaginal bleeding for seven days. Her first delivery was by a lower segment transverse caesarean section at 33 weeks of gestation due to pre-eclampsia. Her second and third pregnancies ended by a normal vaginal delivery. On admission her pulse and blood pressure were normal. Pelvic examination revealed moderate bleeding from the cervical canal; the cervix was long and closed. The size of the uterus was consistent with her dates. Transvaginal ultrasound demonstrated a live fetus with a crown-rump length of 19 mm equivalent to her menstrual dates. The gestational sac was 25 mm diameter which was located in the anterior wall of the uterus, just above the internal 0s. Only 4 mm thickness separated the sac from the urinary bladder, and the sac was located between two normal segments of the anterior uterine wall (Fig. 1). Based upon the ultrasound findings, a diagnosis of pregnancy in a very thin uterine scar was made. Following discussion, it was decided to terminate her pregnancy with methotrexate.A single dose of 80 mg (50 mg/m2) intramuscular methotrexate was given. Daily ultrasonography revealed loss of fetal heart beats three days following the injection. No adverse side effects were observed. Three days after the injection, the plasma level of the p subunit of human chorionic gonadotropin (p hCG) was 12,100 mIU/mL; it decreased to 1270, 107 and 20 mIU/mL after two, four and eight weeks, respectively.Despite the declining values of plasma p hCG levels, the patient had prolonged mild vaginal bloody discharge. Ultrasonography showed the same gestational sac containing amorphous tissue debris. Nine weeks after the methotrexate injection 10 ml of straw-like fluid was aspirated from the gestational sac by a transvaginal ultrasound guided needle, without any complications. Three months later transvaginal ultrasound showed complete disappearance of the gestational sac and normal uterine anatomy. Eight months after the

Embarazo Ectópico Ístmico-Cervical en Cicatriz De Cesárea Previa

“…Debido a la baja frecuencia de este tipo de embarazo ectópico no existen guías universales de tratamiento y no existe consenso en cuanto al tratamiento de elección, en reportes de casos se ha utilizado manejo médico, como lo es el metotrexato, KCl y solución glucosada hiperosmolar, tanto a nivel sistémico como local (3,(15)(16)(17). En cuanto al manejo quirúrgico se ha visto que está contraindicado el legrado uterino debido a que el tejido trofoblástico se encuentra fuera de la cavidad uterina expuesta y puede llevar a potencial ruptura de la cicatriz uterina y disrupción miometrial con hemorragia severa (18).…”

Cervico-isthmic pregnancy developing within the scar of a previous cesarean section: a case report

“…If the pregnant reported no clinical evidence of suffering, such us bleeding or abdominal pain, and the diagnosis is made at an early stage, we can consider a conservative management with systemic or local injection of methotrexate, potassium chloride, and hyperosmolar glucose [17,21,[27][28][29]. However, recent reports evidenced that the cases treated with local or systemic methotrexate, often required laparotomy due to massive hemorrhage [30].…”

Successful Conservative Treatment of a Cesarean Scar Pregnancy with Uterine Artery Embolization

“…Marked vaginal bleeding associated with scar pregnancy is frequently uncontrollable requiring hysterectomy (Herman et al 1995), although Valley et al (1998) reported that removal of trophoblastic tissue by hysterotomy was also complicated by massive bleeding. Conservative treatment of scar pregnancy with locally and/or systemically administered MTX has been reported recently (Lai et al 1995;Godin et al 1997;Ravhon et al 1997;Seow et al 2000). These conservative treatments avoid unnecessary laparotomy and preserve the patient's fertility.…”

“…Due to the severity of complications, it is important that early and accurate diagnosis of the disorder is obtained in order to preserve fertility. Recently, conservative treatment of scar pregnancy with locally and/or systemically administered methotrexate (MTX) has been reported (Lai et al 1995;Godin et al 1997;Ravhon et al 1997;Seow et al 2001). While these treatments avoid the need for unnecessary laparotomy, the control of profuse bleeding by conservative interventions has never been described precisely.…”