Transvaginal ultrasound‐guided local methotrexate administration as the first‐line treatment for cesarean scar pregnancy: Follow‐up of 18 cases

Abstract

Cesarean scar pregnancy (CSP) is a rare type of ectopic pregnancy, which occurs in previous cesarean section scar tissue, with an incidence of 1 in 1800–3000 pregnancies. Transvaginal ultrasound‐guided local methotrexate (MTX) administration presents as a non‐systemic option with possible better penetration to the pregnancy site. We present the management of 18 patients with CSP solely by transvaginal ultrasound‐guided local MTX administration. All patients were treated with local MTX with a dose of 50 mg/m2. Eleven (61.1%) of the patients did not need any further intervention. Four patients (22.2%) were treated with additional single‐dose systemic MTX due to inadequate alteration in blood β‐human chorionic gonadotrophin levels. Three patients (16.7%) required hysteroscopy and/or laparotomy. We suggest that transvaginal ultrasound‐guided local MTX treatment may be considered as a first‐line treatment for CSP.

Local Methotrexate Injection as the First-line Treatment for Cesarean Scar Pregnancy: Review of the Literature

“…Eleven cases had failed methotrexate treatment and required surgical interventions, including dilatation and curettage or evacuation (3 cases), hysteroscopy (1), uterine artery embolization 6 dilatation and curettage (3), and laparotomy 6 hysteroscopy (4). Eight of 11 cases had intervention because of significant hemorrhage, which was described to be persistent because of injection in 2 cases [2], to occur at 14 and 102 days after injection in 2 cases [8,18], and because details were not reported in 4 cases [5,16]. Three cases had intervention because of persistent sonographic abnormalities (2 with persistent ectopic mass and 1 with evidence of incomplete abortion).…”

“…Fourteen cases achieved resolution after additional local or intramuscular methotrexate administration, giving an accumulated success rate of 88.5%. The reasons for additional doses of methotrexate given were re-elevation or inadequate decrease of hCG levels in all cases [4,5,7,14] and evidence of large venous sinuses seen around the gestational sac sonographically in 1 case [14]. Eleven cases had failed methotrexate treatment and required surgical interventions, including dilatation and curettage or evacuation (3 cases), hysteroscopy (1), uterine artery embolization 6 dilatation and curettage (3), and laparotomy 6 hysteroscopy (4).…”

“…Ninety-six cases from 95 women reported in 17 articles were reviewed [2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18]. Among these articles, 7 were retrospective reviews [2,[4][5][6][7]10,15], 5 case reports [11,13,14,17,18], 3 case series [3,8,16], 1 letter to the editor [12], and 1 short communication [9].…”

“…Among these articles, 7 were retrospective reviews [2,[4][5][6][7]10,15], 5 case reports [11,13,14,17,18], 3 case series [3,8,16], 1 letter to the editor [12], and 1 short communication [9]. Of the 3 articles in which only statistical data were provided [2,4,6], additional case information was obtained from the corresponding authors of 2 articles through e-mail requests [2,4].…”

Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes

“…10) Side effects may include nausea, diarrhea, leukopenia, hepatic dysfunction, arthralgias, and leg swelling [27,28]. Similar to systemic MTX therapy, there is no established guideline regarding the dose, site, and timing of MTX administration, although several case series have suggested protocols [29][30][31]. Additionally, even local administration has been shown to have a variable success rate with persistent gestational sacs, bleeding, need for additional MTX treatments, and even surgery [4,32,33] being reported.…”