Combined local and systemic methotrexate treatment of viable ectopic pregnancy: outcomes of 31 cases

Evaluation of Cesarean section scar using saline contrast sonohysterography in women with previous Cesarean scar pregnancy

OBJECTIVE

To evaluate Cesarean scar defects using saline contrast sonohysterography (SCSH) in women with a history of Cesarean scar pregnancy (CSP).

METHODS

A cohort of 38 non-pregnant women with a history of CSP treated with combined local and systemic methotrexate was investigated prospectively by SCSH. For the purpose of analysis, they were classified, according to the modified Delphi consensus criteria for CSP in early gestation, into three subgroups based on the depth of the gestational sac herniation in the midsagittal plane. Subgroup A included eight (21.1%) cases, in which the largest part of the gestational sac protruded towards the uterine cavity; Subgroup B included 20 (52.6%) cases, in which the largest part of the gestational sac was embedded in the myometrium; and Subgroup C included 10 (26.3%) cases, in which the gestational sac was located partially outside the outer contour of the cervix or uterus.

RESULTS

SCSH revealed that all women in Subgroup C had a uterine niche. The median niche length (P = 0.006) and depth (P = 0.015) were significantly greater in Subgroup C than in Subgroups A or B. The median residual myometrial thickness (RMT) was significantly lower in Subgroup C than in Subgroups A or B (P = 0.006).

CONCLUSIONS

Women with prior CSP who had a gestational sac protruding beyond the serosal line had a significantly greater niche length and depth, and lower RMT. This knowledge may guide individualized risk counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Outcomes of Cesarean Scar Pregnancies in Early Gestation According to the New Delphi Consensus Criteria

OBJECTIVES

Clinical evaluation of the new Delphi consensus definition of cesarean scar pregnancy (CSP) in early gestation.

METHODS

A retrospective cohort of 36 women diagnosed with CSP and treated with combined local and systemic methotrexate (MTX) between 2008 and 2021. The CSPs were classified according to the new Delphi consensus criteria into three subgroups based on the depth of the gestational sac herniation in the sagittal plane. Subgroup A included 8 (22.2%) cases in which the largest part of the gestational sac protruded toward the uterine cavity. Subgroup B included 22 (61.1%) cases in which the largest part of the gestational sac was embedded in the myometrium, and subgroup C included 6 (16.7%) cases in which the gestational was partially located outside the outer contour of the cervix or uterus.

RESULTS

The β-HCG level upon admission was significantly lower in subgroup A than in subgroups B or C (11,075 ± 7109, 18,787 ± 16,585, and 58,273 ± 55,267 mIU/mL, respectively, P = .01). All subgroup C patients had repeated courses of MTX and surgical interventions (laparotomy, uterine artery embolization, and operative hysteroscopy) at double the rate of subgroups A or B (100, 50, and 40.9%, respectively, P = .036). The duration of hospitalization was significantly shorter in subgroup A than in subgroups B or C (1.9 ± 1.5, 2.1 ± 1.1, and 5.4 ± 4.9 days, P = .01).

CONCLUSIONS

The outcome according to Delphi consensus criteria for defining CSP in early gestation has implications for clinical decision-making, patient care, and the follow-up of CSP.

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

INTRODUCTION

To evaluate subsequent reproductive among women with a prior cesarean scar pregnancy (CSP).

MATERIAL AND METHODS

MEDLINE, Embase and ClinicalTrials.gov databases were searched. Inclusion criteria were women with a prior CSP, defined as the gestational sac or trophoblast within the dehiscence/niche of the previous cesarean section scar or implanted on top of it. The primary outcome was the recurrence of CSP; secondary outcomes were the chance of achieving a pregnancy after CSP, miscarriage, preterm birth, uterine rupture and the occurrence of placenta accreta spectrum disorders. Subgroup analysis according to the management of CSP (surgical vs non-surgical) was also performed. Random effect meta-analyses of proportions were used to analyze the data.

RESULTS

Forty-four studies (3598 women with CSP) were included. CSP recurred in 17.6% of women. Miscarriage, preterm birth and placenta accreta spectrum disorders complicated 19.1% (65/341), 10.3% (25/243) and 4.0% of pregnancies, and 67.0% were uncomplicated. When stratifying the analysis according to the type of management, CSP recurred in 21% of women undergoing surgical and in 15.2% of those undergoing non-surgical management. Placenta accreta spectrum disorders complicated 4.0% and 12.0% of cases, respectively.

CONCLUSIONS

Women with a prior CSP are at high risk of recurrence, miscarriage, preterm birth and placenta accreta spectrum. There is still insufficient evidence to elucidate whether the type of management adopted (surgical vs non-surgical) can impact reproductive outcome after CSP. Further large, prospective studies sharing an objective protocol of prenatal management and long-term follow up are needed to establish the optimal management of CSP and to elucidate whether it may affect its risk of recurrence and pregnancy outcome in subsequent gestations.

Ultrasound-guided intrasacular injection of methotrexate in the management of ectopic pregnancies with embryo. A 12 year experience report in a tertiary hospital

OBJECTIVE

To evaluate the efficacy and safety of combined-therapy with ultrasound guided intrasacular injection of 50 mg of methotrexate (MTX) and a 50 mg/m² dose of systemic MTX in uncomplicated ectopic pregnancies with ultrasonographic evidence of embryonic structures in the gestational sac.

STUDY DESIGN

We designed a retrospective study including 60 patients to assess the efficacy of combined MTX treatment and to determine which clinical or ultrasonographic variables could be associated with successful medical treatment. Failed medical treatment was defined when surgery was needed. For statistical analysis, we developed a descriptive analysis and a univariate logistic regression study.

RESULTS

Medical approach was effective in 73.3 % of patients. MTX treatment was successful in 32 (68.1 %) out of 47 tubal pregnancies None of the 4 cervical or 2 abdominal pregnancies required surgery. Six (85.7 %) out of 7 cornual pregnancies were successfully treated. No statistically significant differences were found in the success rates according to clinical data, ultrasound or analytic characteristics of women.

CONCLUSION

Combined MTX therapy could be an effective and safe alternative in ectopic pregnancies with embryo in hemodynamically stable women. Clinical, ultrasound or analytic characteristics of patients should not entail a contraindication. In locations where surgery implies a technical difficulty, this option may decrease morbimortality rates frequently associated to a more invasive alternative.

Conservative treatment of abnormally located intrauterine pregnancies (cervical and cesarean scar pregnancies): a multicenter analysis (Polish series)

Objectives: To analyze the effectiveness and outcome of conservative treatment in cases of abnormally located intrauterine pregnancies (cervical and cesarean scar).Study design: A retrospective analysis was performed of 30 pregnant women hospitalized due to abnormally located intrauterine pregnancies. The analyzed group comprised 24 pregnant women with abnormally located pregnancies. The patients were divided into two groups: the first group consisted of patients treated systemically with methotrexate, while the second of those treated locally by administration of methotrexate (MTX) and/or potassium chloride (KCl) by gestational sac puncture.Results: The analyzed group comprised 24 pregnant women with abnormally located pregnancies. Eight patients were diagnosed with cervical pregnancy (CP) and 16 patients were diagnosed with cesarean scar pregnancy (CSP). Six patients were excluded from the study: two with spontaneous abortions, two heterotopic pregnancies, and two cornual pregnancies. Twelve analyzed patients underwent MTX systemic administration (five patients with CP, seven with CSP). In five patients, systemic treatment was ineffective; they were qualified for additional local therapy with gestational sac (GS) puncture and MTX or KCl administration to the sac and additional administration of MTX to the trophoblast area. In second group of 12 patients (three CP, nine CSP), local treatment (GS puncture with MTX or MTX + KCl) was used as the first line treatment. One patient underwent combined treatment (local + systemic).Conclusions: Conservative treatment should be the gold standard procedure in abnormally located intrauterine pregnancies. It is noticeable that MTX / KCl is more effective in a direct administration to the GS. In four cases, systemic MTX did not produce the desired effects. In these cases, the treatment was assisted by local administration of MTX or KCl, resulting in the termination of an abnormally located pregnancy.

Treatment of unruptured cornual pregnancies by local injections of methotrexate or potassium chloride under transvaginal ultrasonographic guidance

Objective

To demonstrate the outcome of intralesional management and show the safety of local treatment of cornual pregnancy.

Methods

Eight patients were treated with local methotrexate or potassium chloride injection. All patients underwent transvaginal ultrasound examination and were diagnosed by the criteria defined by Timor-Tritsch. In the case of fetal heart beat observation, potassium chloride was injected; and in the case of no heart beat detection, methotrexate was used. A follicle aspiration needle was inserted directly into the gestational sac under transvaginal guidance.

Results

Although it has been considered to be a risk factor, none of the patients in our study had previous ectopic pregnancy, history of infertility / in vitro fertilization, or cornual pregnancy. One of the patients had a medical history of abortion. In four cases, methotrexate was injected, and three patients received potassium chloride as a local treatment. None of the patients had any complication in the peri- or postoperative period.

Conclusion

Using a local approach, the treatment agent can reach the area of the cornual pregnancy in high concentrations. Based on this case series, a local approach seems to be an effective and fertility-sparing method for treating unruptured cornual pregnancies.

Treatment of Intramyometrial Pregnancy by In Situ Injection of Methotrexate

Intramyometrial ectopic pregnancies are rare, and various management modalities have been described. We report a patient with intramyometrial pregnancy who was successfully treated by in situ injection of methotrexate (MTX) after the failure of 2 intramuscular injections of MTX. We emphasize the difficult management of intramyometrial pregnancy and show that in situ MTX injection may be indicated for this particular type of ectopic pregnancy.

Catastrophic consequences of a caesarean scar pregnancy missed on ultrasound

Ectopic pregnancy that implants within the scar tissue of a previous caesarean scar is a situation that is seldom encountered and is almost invariably incompatible with a successful pregnancy. Caesarean scar ectopic pregnancies are fraught with life threatening complications such as scar rupture, significant haemorrhage, disseminated intravascular coagulation and the need for emergency life saving hysterectomy. The clinical diagnosis can be elusive, particularly in the early stages; therefore clinicians should be familiar with the condition's sonographic hallmarks. Early diagnosis and management is the key to preventing these complications. We describe a case of caesarean scar pregnancy which was initially misdiagnosed as “a spontaneous miscarriage in progress”, resulting in uncontrollable bleeding, necessitating an emergency abdominal hysterectomy. We also endeavour to review the literature with regards to the use of ultrasound in its management, treatment and follow up.

Transabdominal ultrasound-guided injection of methotrexate in the treatment of ectopic interstitial pregnancies

PURPOSE

In a retrospective observational study, we evaluated the feasibility and safety of medical therapy with transabdominal ultrasound-guided injection of methotrexate (MTX) into the gestational sac (GS) in patients with interstitial ectopic pregnancies.

METHODS

Fourteen interstitial ectopic pregnancies were treated with transabdominal ultrasound-guided injection of MTX (25 mg). All patients were hemodynamically stable. In all patients, the 10-cm distance between the GS and vaginal fornices was ≥10 cm, making transvaginal injection difficult. To evaluate feasibility and safety of the procedure, we assessed complications clinically and with imaging during a 1-year follow-up.

RESULTS

In all 14 patients, MTX injected locally into the GS successfully terminated the interstitial pregnancy, thereby avoiding surgery. There was no complications during follow-up.

CONCLUSIONS

The successful outcome in our patients suggests that the transabdominal route is feasible and safe as a nonsurgical option for terminating an ectopic interstitial pregnancy in patients in whom the transvaginal route is contraindicated or difficult, provided the patients are properly selected and operators have sufficient experience with the technique.

Uterine artery embolization combined with methotrexate in the treatment of cesarean scar pregnancy: results of a case series and review of the literature

PURPOSE

To explore the clinical value of uterine artery embolization (UAE) combined with methotrexate in the treatment of cesarean scar pregnancy (CSP) before and after uterine curettage.

MATERIALS AND METHODS

From August 2009 to April 2012, 15 patients with CSP treated with UAE (before or after uterine curettage) were analyzed retrospectively. Eleven subjects with a definite diagnosis of CSP were offered preventive UAE combined with methotrexate before uterine curettage. The other four patients, who were misdiagnosed as having an intrauterine pregnancy, were treated with emergency UAE for uncontrollable massive hemorrhage after uterine curettage. Clinical data, treatment sequence, and outcome were analyzed, and a brief review of the published literature summarizing UAE in the treatment of CSP was performed.

RESULTS

Eleven patients with definite CSP received preventive UAE combined with methotrexate followed by uterine curettage, and CSP was resolved successfully without hysterectomy. In the four misdiagnosed patients, three were treated successfully with emergency UAE. The other patient underwent uterine curettage and emergency UAE followed by repeat curettage, but hysterectomy was performed because of continued severe hemorrhage.

CONCLUSIONS

Based on a small number of patients, it appears that UAE may be an effective means of treating CSP, including treatment in an emergency setting. Further study is required before the safety and effectiveness of UAE can be confirmed.

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.

Video laparoscopic intervention for an interstitial pregnancy after failure of clinical treatment

CONTEXT

Interstitial pregnancy is a rare form of ectopic pregnancy for which the best therapeutic course of action has yet to be determined. Surgical intervention entails a high risk of hemorrhage due to the great vascularization of the cornual region of the uterus. Case descriptions facilitate the analysis of results and aid clinicians in determining the most appropriate course of action in these situations.

CASE REPORT

In a patient with an ultrasound diagnosis of interstitial pregnancy, clinical treatment using methotrexate was chosen. However, after one week, there was a marked decline in the serum level of the β subunit of chorionic gonadotropin hormone, although an ultrasound examination revealed embryonic cardiac activity. A second dose of the chemotherapy was administered. Embryonic cardiac activity persisted 48 hours later. Video laparoscopy was performed to achieve right-side cornual resection, which resulted in satisfactory resolution of the case.

Fertility performance and obstetric outcomes among women with previous cesarean scar pregnancy

OBJECTIVES

The purpose of this study was to assess fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy.

METHODS

We conducted a retrospective study in a large tertiary hospital in Israel. The study included 18 women with a diagnosis of cesarean scar pregnancy between 2000 and 2009.

RESULTS

The incidence of cesarean scar pregnancy among our parturient patients was 1 per 3000 for the general obstetric population and 1 per 531 among those with at least 1 cesarean delivery. Sixteen were treated primarily with methotrexate. Two were treated primarily by surgery, and 2 more were treated by surgery after failed methotrexate treatment. After cesarean scar pregnancy treatment, 7 women conceived spontaneously, and 1 conceived by in vitro fertilization-intracytoplasmic sperm injection. The remaining 10 (55%) did not wish to conceive again. Two of the women who became pregnant (25%) had recurrent cesarean scar pregnancy.

CONCLUSIONS

This study shows encouraging results for fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy. Nevertheless, the risk of recurrent cesarean scar pregnancy is not negligible.

Sonographic diagnosis and successful medical management of an intramural ectopic pregnancy

We report a case of posterior wall intramural pregnancy in a 36-year-old primigravida at 6 weeks gestation. Sonographic examination showed a viable intramural pregnancy distorting the contour of the uterus. The pregnancy was terminated by intrafetal injection of potassium chloride followed by intra-amniotic methotrexate injection.

Therapeutic options of caesarean scar pregnancy: case series and literature review

We describe our experience with the treatment of 4 caesarean scar pregnancies and provide an overview of current literature. Four women diagnosed with a caesarean scar pregnancy in our hospital between 1996 and 2007 were treated with local or systemic methotrexate and had a steady decline of the serum beta-hCG level. The uterus was preserved in all women and 3 of them had an uneventful subsequent pregnancy and delivery. We suggest that transcervical needle aspiration of amniotic fluid followed by intra-amniotic injection of methotrexate should be the treatment of choice, followed by surgical treatment only if methotrexate fails.