Uterine Artery Embolization and Methotrexate Infusion as Sole Management for Caesarean Scar and Cervical Ectopic Pregnancies: A Single-Center Experience and Literature Review

Abstract

Introduction The incidence of caesarean scar pregnancy (CSP) and cervical pregnancy (CP) has increased significantly in recent years. The related hemorrhage can be lethal and often needs hysterectomy. This study aims to assess the technical and clinical results of uterine artery embolization (UAE) combined with intra-arterial methotrexate (MTX) infusion for CSP and CP. Methods A retrospective study was conducted for 11 patients (age range from 25–40 years, mean; 31.8 y) with CSP (7/11) and CP (4/11). The diagnosis was confirmed by elevated b-hCG levels (mean 31.245 mIU/mL) with sonography and/or magnetic resonance imaging. They were treated with UAE using particulate embolic material. In all patients, the infusion of MTX (50 mg/m2) was performed before UAE. Follow-up periods after UAE ranged between 6-24 months included weekly sonography and b-hCG level assessment. A literature review was performed using standard online search tools. Results In 10 patients, UAE controlled active vaginal bleeding and reduced post-procedural b-hCG levels significantly by the second week. One patient presented with persistent elevated b-hCG level and vaginal rebleeding. The rebleeding was successfully controlled by second UAE procedure. The ectopic pregnancies were resolved, and the uterus was preserved in all patients. No major complications were detected. Normal menses resumed within 2 months after UAE. Two patients had subsequent natural successful intrauterine pregnancies. Conclusion UAE combined with intra-arterial MTX infusion resulted in resolution of ectopic pregnancies with control of hemorrhage and without hysterectomy in this small group of patients.

Ectopic Cervical Pregnancy: Treatment Route

“…Currently no therapeutic protocols have yet been established worldwide because CP management experiences are based mainly on case series studies due to the rarity of the condition [ 8 ]. The choice of treatment depends on GA, initial serum βhCG level, fetal heartbeat presence, vaginal bleeding and desire to preserve fertility.…”

“…Some authors have considered UAE to be the only alternative to hysterectomy for bleeding control in case of CP. It plays an important role in the conservative management of some gynecological hemorrhage by causing an extensive blockage of the uterine vascularity [ 8 ]. Anyway, re-bleeding or delayed bleeding can occur after UAE, because the extensive collateral circulation to the cervix will be established within hours [ 11 ].…”

Reproductive outcome after cesarean scar pregnancy: A systematic review and meta‐analysis

“…A total of 358 articles were identified; 122 were assessed with respect to their eligibility for inclusion and 44 studies were included in the systematic review (Table 1, Figure 1). 9,10,21‐61 These studies included 3598 women with a prior CSP; of these, information on subsequent pregnancy was available for 592 women.…”

The Effect of Prophylactic Uterine Artery Embolisation On Reproductive Outcomes In Caesarean Scar Pregnancy Patients: A Propensity Score-Matched Study

“…Before the operation, UAE with or without MTX is provided either locally or systematically. The successful treatment of CSP and cervical pregnancy using UAE and MTX alone has also been reported [17]. However, a study by Ou j et al…”