Successful Pregnancy Outcome Immediately after Methotrexate Treatment for Cesarean Section Scar Pregnancy.

A 27-year-old cesarean section scar pregnancy (CSSP) case diagnosed by the vaginal ultrasound which showed gestational sac located in the lower uterine anterior quadrant close to the site of the previous scars (with yolk sac inside) with β-hCG 15,373 mIU/ml in September 2017 was managed by intramuscular (IM) multidose methotrexate (MTX). The studied woman discharged home when the β-hCG decreased to 11,630 mIU/ml on the 1st week after the first MTX dose. On the 5th week after the first dose of IM-MTX, the β-hCG dropped to zero and the gestational sac completely disappeared. She was counseled about the risk of pregnancy in the first 6 months after the MTX and the possibility of the CSSP recurrence. She presented on December 16, 2018, with preterm delivery at 35 weeks' gestation. After delivery, her neonate admitted to the neonatal intensive care unit (NICU) due to mild respiratory distress and discharged from the NICU on the 4th day in good condition. Multi-dose MTX regimen for the treatment of CSSP supported by many authors with follow-up by β-hCG and vaginal ultrasound. This report highlights the successful outcome immediately after the proper management of CSSP cases. Copyright:

INTRODUCTION

Cesarean section scar pregnancy (CSSP) is an intrauterine pregnancy that occurs following implantation of the gestational sac over the previous uterine scars.[1]

Previous uterine scar is the only risk factor for CSSP. The true incidence of CSSP estimated as 1/1800–1/2500 of all cesarean deliveries,[1] and the incidence of CSSP increased due to increased rate of cesarean deliveries and improved imaging tools.[2]

The CSSP is often misdiagnosed as inevitable miscarriage or ectopic pregnancy.[3]

This report highlights the successful outcome immediately after the proper management of CSSP cases.

CASE REPORT

A 27-year-old CSSP case diagnosed by the vaginal ultrasound which showed gestational sac located in the lower uterine anterior quadrant close to the site of the previous scars (with yolk sac inside) with β-hCG 15373 mIU/ml in September 2017 was managed by intramuscular (IM) multi-dose methotrexate (MTX). IM-MTX injection was alternating with leucovorin (active form of folic acid). She was followed up by the β-hCG, vaginal ultrasound, and hematological parameters.

The studied woman discharged home when the β-hCG decreased to 11,630 on the 1st week after the first MTX dose.

On the 5th week after the first dose of IM-MTX, the β-hCG dropped to zero and the gestational sac completely disappeared. She was counseled about the risk of pregnancy in the first 6 months after the MTX and the possibility of the CSSP recurrence.

She presented at December 16, 2018, with preterm delivery at 35 weeks' gestation (the last dose of MTX was taken on October 5, 2017, and her 1st day of the LMP was April 14, 2018). After delivery, her neonate admitted to the neonatal intensive care unit (NICU) due to mild respiratory distress and discharged from the NICU in the 4th day in good condition.

Written consent was taken from the studied woman and approval from the local ethical committee of the obstetrics and gynecology department to use the patient's medical records and data for publication and medical education.

DISCUSSION

CSSP was diagnosed in women with previous uterine scar (s) based on positive pregnancy test and the following ultrasound findings:[34] (1) empty uterus, (2) gestational sac located in the lower uterine anterior quadrant close to the site of the uterine scar with closed cervix(s) [Figure 1] ± yolk sac [Figure 2] ± fetal pole and/or heart-beats; (3) thin layer of myometrial muscles between the gestational sac and the bladder wall, and (4) multiple vessels around the gestational sac indicating the placental implantation site.

Figure 1

Transvaginal ultrasound showing cesarean section scar pregnancy

Figure 2

Transvaginal ultrasound shows cesarean section scar pregnancy with yolk sac inside

The CSSP without fetal cardiac activity and no yolk sac and/or fetal echo can be managed by the ultrasound and β-hCG follow-up ± IM-MTX.[3]

The CSSP with fetal cardiac activity can be managed either termination or continuation of the pregnancy. The continuation of pregnancy increases the risk of hemorrhage and emergency hysterectomy.[3]

The risk of CSSP recurrence is 1% and the treatment of CSSP should be individualized based on the patient's age and future fertility.[4]

The suggested treatments for CSSP are (1) surgical excision with subsequent uterine repair, (2) suction aspiration followed by balloon compression or hysterectomy (3). MTX (local and/or systemic).[5678]

MTX is the most common treatment option for CSSP including (1) systemic single-dose IM-MTX regimen of 1 mg/kg of body weight,[5] (2) systemic multi-dose IM-MTX regimen,[7] (3) local MTX injection inside the gestation sac (ultrasound guided) is the most effective treatment for CSSP between 6–8 weeks' gestation (it stopped fetal cardiac activity and considered if future fertility desired).[5]

Embolization of the uterine artery with intra-gestational MTX treatment or ultrasound-guided local and systemic MTX treatment was similarly effective in treating CSSP and both treatment likely to fail for CSSP with gestational sac >5 cm.[9]

The studied CSSP case managed according to the protocol by systemic multi-dose IM-MTX with follow-up by β-hCG, vaginal ultrasound, and blood picture. On the 5th week after the first dose of IM-MTX, the β-hCG dropped to zero and the gestational sac completely disappeared.

Multi-dose IM-MTX regimen for CSSP with ultrasound and biochemical (β-hCG) follow-up was recommended by many authors.[3]

The β-hCG returned to nonpregnant level 6 weeks after the multi-dose MTX regimen for the treatment of CSSP.[10]

Uludag et al. compared the use of systemic and local MTX in the treatment of CSSP, and they found that the mean times for β-hCG normalization and the uterine-mass disappearance were significantly shorter in local MTX group than in systemic MTX group.[10]

However, oral ulcers[10] with decreased hematological parameters recorded as side effects of multi-dose IM-MTX treatment for CSSP.[10]

The studied woman did not develop any complication or side effects following the multi-dose IM-MTX regimen. This report represents the first case of successful pregnancy outcome immediately after multi-dose IM-MTX treatment for CSSP to highlight the successful outcome immediately after the proper management of CSSP cases.

CONCLUSION

There is no single best treatment to terminate the CSSP and the procedure with the least complications should be selected. Multi-dose MTX regimen for the treatment of CSSP was supported by many authors with follow-up by β-hCG and vaginal ultrasound.

This report highlights the successful outcome immediately after the proper management of CSSP cases.

Ethical approval

The local Obstetrics and Gynecology Department Ethical Committee of Ahmadi hospital has approved this study. The Institutional Review Board Project (approval number) OBGYN_REC_18.12.20 obtained on 20th December in 2018.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.