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

Management of mid-term abdominal pregnancy: A rare case report and literature review

Abdominal pregnancy (AP) is a rare form of ectopic pregnancy. It is associated with significant maternal and fetal risks, including high rates of morbidity and mortality. The condition poses considerable therapeutic challenges, particularly in the mid to late stages of gestation. To date, there is no standardized treatment protocol for such cases. We describe a case of a 37-year-old woman, G2P1, who was diagnosed with a live 16-week AP. The patient underwent multidisciplinary treatment, including ultrasound-guided methotrexate injection into the fetal heart, lauromacrogol injection into the placenta, oral administration of mifepristone, and subsequent laparotomy to remove the fetus, placenta, and left fallopian tube. This approach successfully demised the fetus, reduced the placental blood supply, and created more favorable conditions for surgery. The patient recovered uneventfully post-surgery. This case illustrates the potential benefits of a combined therapeutic approach in successfully managing mid-term AP.

A prediction nomogram for residual after negative pressure aspiration for endogenic cesarean scar ectopic pregnancy: a retrospective study

BACKGROUND

We aimed to establish a predictive nomogram to evaluate the incidence of residual tissue in patients with endogenic cesarean scar ectopic pregnancy after negative pressure aspiration.

METHODS

This retrospective study included patients treated in the gynecology department of our institution from May 2017 to August 2023 who underwent negative pressure suction treatment, ultrasound examinations before and after treatment, and received telephone follow-up for at least 6 months. A total of 899 patients met the inclusion criteria and were divided into a training cohort (629 patients, 70%) and a validation cohort (270 patients, 30%). Independent predictive factors were established using multivariate logistic regression. The resulting nomogram was validated using 1,000 bootstrap resampling, and calibration curves were plotted. Receiver operating characteristic (ROC) analysis was performed to calculate the area under the curve, sensitivity, specificity, and other metrics to assess its discriminative performance. Clinical decision curves were constructed to evaluate clinical applicability and quantify the net benefit within a range of threshold probabilities. The model was externally validated in the validation cohort.

RESULTS

Predictive factors included in the nomogram included age (hazard ratio [HR]: 1.220, 95% confidence interval [CI]: 1.135-1.316), BMI (HR: 0.890, 95% CI: 0.796-0.986), intraoperative major hemorrhage (HR: 4.457, 95% CI: 1.610-12.292), maximum diameter of the gestational sac (HR: 1.572, 95% CI: 1.295, 1.914), and thickness of the remaining muscle layer of the lower uterine segment (HR: 1.572, 95% CI: 0.014, 0.430). The ROC curve of the resulting nomogram showed similar area under the curve values for the training (0.809, 95% CI: 0.751-0.867) and validation cohorts (0.814, 95% CI: 0.739, 0.888). The Hosmer-Lemeshow test indicated good model fit (P = 0.861), and the calibration curve was close to the ideal diagonal line. Decision curve analysis demonstrated good net benefit, and external validation confirmed its reliability.

CONCLUSIONS

The model may aid in individual clinical decision-making, allowing clinicians to perform immediate postoperative assessments for patients with endogenous ectopic pregnancy in cesarean section scars treated with negative pressure suction, identify high-risk subpopulations, and select appropriate supplementary treatment in advance, making it particularly suitable for low-income areas and resource-limited primary hospitals.

Local and systemic methotrexate in management of caesarean scar pregnancy

STUDY OBJECTIVE

The aim is to analyze the management of cesarean scar pregnancy (CSP) based on local and systemic Methotrexate, a protocol implemented in a referral center.

DESIGN

This is an observational, retrospective, monocentric, cohort study with a description of the local protocol, treatment results and tolerance profile. Design Classification III.

SETTING

Tertiary Referral center.

PATIENTS

All patients with CSP, confirmed by a reference ultrasound, without severity criteria requiring emergency surgery, between March 2015 to August 2022 were consecutively included.

INTERVENTIONS

All patients were treated by an Echo-guided trans-vaginal aspiration of the gestational sac followed by a local injection of Methotrexate 1 mg/kg under general anesthesia combined with Mifepristone and followed by an injection of 1 mg/kg within 2 days.

MEASUREMENT AND MAIN FINDING

We included 35 patients with a mean hCG level of 28 872 UI/l ± 38063 UI/l and a mean gestational age of 6.8 ± 1.6 weeks of gestation. All patients were managed effectively with a good reduction in hCG serum levels. The mean duration of hCG negativation was 66 ± 38 days after the start of management. Only one patient who had received the department's Methotrexate protocol required a second line of treatment. Among major complications, 2 patients experienced hemorrhagic shock which resolved without recourse to hemostasis hysterectomy. The success rate defined by the absence of recourse to secondary treatment was therefore 91.4 %. Among minor complications, the main complication was methotrexate-induced hepatic cytolysis in 7 patients (20 %). Nine women (26 %) required secondary hysteroscopic resection of trophoblastic retention. Twenty-one patients (60 %) had an ultrasound diagnosis of caesarean scar defect (CSD) after CSP management.

CONCLUSION

The combination of transvaginal ultrasound-guided local MTX, Mifepristone and systemic MTX appears to be an effective treatment protocol for patients with CSP.

Systematic evaluation of the efficacy of treatments for cesarean scar pregnancy

STUDY OBJECTIVE

Cesarean scar pregnancy (CSP) is a type of ectopic pregnancy associated with severe complications, including significant hemorrhage, the potential need for hysterectomy, and life-threatening risks. Currently, two classification methods exist for CSP: Vial (type Ia and IIa) and Chinese Expert's Consensus (type Ib, type IIb, and type IIIb). However, these methods have limitations in guiding the selection of appropriate treatment plans for CSP. The purpose of this study was to systematically evaluate the effectiveness of various treatments for CSP within our clinic.

METHOD

Our study included 906 patients with CSP from January 2013 to December 2018. The chi-squared test and logistic analysis were used to compare the clinical characteristics. The median and interquartile range (IQR) was calculated. We also analyzed whether preoperative application of methotrexate (MTX) could improve surgical outcomes and the relevant characteristics of misdiagnosed CSP patients.

RESULTS

There was a significant difference in gestational age, gestational sac diameter, gestational sac width, gestational sac area, remnant myometrial thickness, vaginal bleeding and preoperative hemoglobin levels (p < 0.001) but not in the incidence of residual tissue (p = 0.053). The other factors (intraoperative blood loss, hemoglobin decline, first hemoglobin after operation, total hospital stay, hospital stay after operation, transfusion and duration of catheter drain) were significantly different (p < 0.001). For type Ia and type Ib CSP, 39.3% and 40.2% of patients were treated with dilatation and curettage (D&E) under ultrasound, respectively. For type IIa and type IIIb CSP, 29.9% and 62.7% of patients were treated with laparotomy, respectively. There were no differences in surgical methods, residual tissue and reoperation between the MTX and non-MTX groups (p = 0.20), but liver damage, hospital stay and pain perception were more remarkable in the MTX group. It is noteworthy that 14% of the patients were misdiagnosed with an intrauterine pregnancy. The incidence of misdiagnosis in type IIa CSP patients was higher than that in type Ia CSP patients (p < 0.001).

CONCLUSION

For type I CSP patients, D&E under ultrasound or D&E under hysteroscopy should be recommended. For type IIIb CSP patients, operative resection should be used. It is currently difficult to choose the appropriate treatment methods for type IIa or type IIb CSP patients.

Laparoscopic Management of Cesarean Scar Pregnancy with Temporary Clipping of Anterior Trunk of Hypogastric Arteries: A Case Report

A cesarean scar ectopic pregnancy (CSP) represents an uncommon yet potentially life-threatening condition requiring immediate and efficient management. We present a case of a 32-year-old woman diagnosed with a scar pregnancy at 8 weeks of gestation. Laparoscopic surgical management was chosen due to its minimally invasive nature and potential for preserving fertility. During the procedure, temporary clipping of uterine arteries was employed to control intraoperative bleeding. The patient recovered well postoperatively with no complications. This case highlights the feasibility and effectiveness of laparoscopic intervention combined with temporary uterine artery clipping in the management of scar pregnancies, offering a valuable approach for clinicians faced with similar cases. Through this report, we aim to contribute to the existing literature on the optimal management of CSP and highlight the efficacy of laparoscopic surgery in this context.

Clinical efficacy and risk factors for suction curettage and hysteroscopy in patients with type I and II cesarean scar pregnancy

OBJECTIVE

To investigate the clinical efficacy and evaluate risk factors for suction curettage (SC) and hysteroscopy in the treatment of type I and II cesarean scar pregnancy (CSP).

METHODS

This was a retrospective study including 100 women diagnosed with type I/II CSP. Patients were treated with either ultrasound-guided SC (SC group) or hysteroscopy resection (surgery group). The success rates, mean operation time, hospitalization duration, hospitalization cost, risk factors, adverse events, and complications were analyzed.

RESULTS

The success rate of the SC and surgery groups were 85% and 100%, respectively, and the difference was statistically significant (P = 0.032). There was one case of type I CSP and eight cases of type II CSP that failed SC treatment. No failed cases were found in the surgery group. Analysis of the causes of treatment failure revealed that diameter of the gestational sac was a risk factor for SC failure (odds ratio, 19.66 [95% confidence interval {CI}, 1.70-227.72], P = 0.017). Comparing the clinical outcomes between the SC and surgery groups, although the mean operation time of the SC group was significantly shorter than the surgery group (15 [CI, 15-20] vs. 30 [CI, 27-40], P = 0.001), the cost and duration of hospitalization were significantly lower in the surgery group than that in the SC group. No significant differences were observed for adverse events and complications between the two groups (P > 0.05).

CONCLUSION

Hysteroscopy is an effective and economical method for treating type I/II CSP. Moreover, SC is not recommended for patients with type I/II CSP with a gestation age ≥8 weeks.

The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy

Cesarean scar pregnancy (CSP) is among the most severe complications of cesarean delivery. CSP refers to the abnormal implantation of the gestational sac in the area of the prior cesarean delivery (CD), potentially leading to severe hemorrhage, uterine rupture, or development of placenta accreta spectrum disorders (PAS). The management of women with CSP has not been standardized yet. In women who opted for termination, discussion about the treatments should consider maternal symptoms, gestational age at intervention, and the future reproductive risk. A multitude of treatments, either medical or surgical, for CSP has been reported in the published literature. The present review aims to provide up-to-date information on a recently introduced minimally invasive treatments for CSP, including the single and double balloon catheter. The methodology of using the single or double catheter is described in a step-by-step fashion illustrated by pictures as well as video recordings. Both catheters have their deserved place to be used as a primary method for terminating scar pregnancies as well as using them as adjuncts to other treatments. They were successfully used by multiple individual practitioners and institutions due to their simplicity and low complication rates. The rare, but possible post-procedure complications such as recurrent CSP and enhanced myometrial vascularity are also mentioned.

Cesarean scar ectopic pregnancy: nuances in diagnosis and treatment

A cesarean scar ectopic pregnancy (CSEP) occurs when the embryo implants on the scar of a previous cesarean delivery. The number of births delivered by cesarean section has climbed by 50% over the last decade, from a nadir of 20.7% in 1996 to 32.1% in 2021. As a result, the incidence of CSEP has also increased. Because CSEP may cause serious morbidity such as life-threatening hemorrhage, uterine rupture, placental accreta spectrum, hysterectomy, and even mortality, accurate diagnosis and appropriate management of this condition are essential. This review focuses on the etiology, incidence, clinical diagnosis, and management of CSEPs.

Nontubal ectopic pregnancies: overview of diagnosis and treatment

Nontubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal ectopic pregnancies. Diagnostic and management options may be limited, especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for nontubal ectopic pregnancies.

Methotrexate for CSPs

Expectant management of a cesarean scar pregnancy (CSP) is associated with a high risk of severe maternal morbidity. Therefore, most experts recommend immediate termination after the diagnosis of a CSP. However, there is no consensus about the optimal management of a CSP in terms of efficacy, safety, and preservation of future fertility. Methotrexate (MTX) is a folic acid antagonist that has been largely used to treat tubal ectopic pregnancies. This review summarizes the current knowledge and uncertainties about the administration of MTX as a medical or non-invasive option to terminate a CSP; the preferred injection route (systemic or local/intragestational), the comparison with other treatment modalities, and the prognostic factors for MTX success will be discussed, as well as the recommendations from scientific societies.

Is local methotrexate therapy effective in the treatment of cesarean scar pregnancy? A retrospective cohort study

AIM

To evaluate the success of local methotrexate (MTX) treatment, the side-effect profile and its fertility effect in patients diagnosed with cesarean scar pregnancy.

MATERIALS

This retrospective cohort study included 56 cesarean scar pregnancy patients who applied to Erciyes University Faculty of Medicine, Department of Obstetrics and Gynecology between January 2012 and January 2022 and were treated with ultrasound-guided local MTX. The results of 56 patients with cesarean scar pregnancy who underwent transvaginal ultrasound-guided single-dose local MTX treatment were evaluated. First, the contents of the sac were aspirated, and then 50 mg of MTX was injected into the gestational sac.

RESULTS

The median gestational age at diagnosis was 7 weeks 2 days. The mean beta human chorionic gonadotrophin level was 31 345 ± 37 838 (range: 113-233 835 mIU/mL). Fifty-four patients were successfully treated with local MTX therapy. The interval between the first MTX injection and the normalization of beta human chorionic gonadotrophin was 55.2 ± 41.0 days. None of our patients required surgical treatment. Beta human chorionic gonadotrophin values did not decrease in one patient and she was treated with systemic MTX. Local MTX therapy could not be applied to one patient for technical reasons. Only one patient needed blood transfusion after local MTX. Thirteen patients become pregnant after treatment (76%). No systemic side effects related to MTX were observed in any of the patients.

CONCLUSION

Transvaginal ultrasound-guided single-dose local MTX treatment is an effective, safe, and fertility-preserving treatment method for cesarean scar pregnancy.

Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy

Cesarean scar ectopic pregnancy is a complication in which an early pregnancy implants in the scar from a previous cesarean delivery. This condition presents a substantial risk for severe maternal morbidity and mortality because of challenges in securing a prompt diagnosis. Ultrasound is the primary imaging modality for cesarean scar ectopic pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar ectopic pregnancy management, but the optimal treatment is unknown. Patients who decline treatment of a cesarean scar ectopic pregnancy should be counseled regarding the risk for severe morbidity. The following are the Society for Maternal-Fetal Medicine recommendations: we recommend against expectant management of cesarean scar ectopic pregnancy (GRADE 1B); we suggest that operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided uterine aspiration be considered for the surgical management of cesarean scar ectopic pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for the medical treatment of cesarean scar ectopic pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar ectopic pregnancy (GRADE 1C); in patients who choose expectant management and continuation of a cesarean scar ectopic pregnancy, we recommend repeated cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that patients with a cesarean scar ectopic pregnancy be advised on the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).

The management of caesarean scar pregnancy with or without a combination of methods prior to hysteroscopy: ovarian reserve trends and patient outcomes

STUDY OBJECTIVE

This study compared the efficacy and safety of a combination of uterine artery embolization or methotrexate before hysteroscopy in the treatment of cesarean scar pregnancy.

METHODS

We divided 276 cesarean scar pregnancy patients into three groups. Group A underwent direct hysteroscopy; Group B received uterine artery embolization plus hysteroscopy; Group C received the systemic administration of methotrexate prior to hysteroscopy.

RESULTS

The patients in Group A lost significantly more blood than those in Groups B (P < 0.05). There were no significant differences between the three groups with regards to massive hemorrhage and transfusion (P > 0.05). None of the patients required hysterectomy. Group A was also associated with a significantly shorter period of hospitalization, reduced medical costs, and fewer adverse events than either Group B or C (P < 0.05). Moreover, among women of advanced age (≥35y), the levels of serum anti-Mullerian hormone in Group B were significantly lower than those of the baseline group (P<0.05), which were significantly lower than those in Group A after surgery (4.22 ± 2.35 vs 2.78± 1.89 ng/ml, P < 0.05).

CONCLUSION

Direct hysteroscopy is a reliable treatment option for most early type I cesarean scar pregnancy patients with a gestational sac. A combination of methotrexate and uterine artery embolization before hysteroscopy in these patients has limited remedial effects. uterine artery embolization may reduce ovarian reserve in patients aged ≥35y.

Caesarean Scar Pregnancy: A Case Report and a Literature Review

Background and Objectives: Caesarean scar pregnancy (CSP) refers to placental implantation on or in the scar of a previous caesarean section and represents a potentially life-threatening condition. CSP is considered a diagnostic challenge in obstetrics, with the diagnosis relying mainly on transvaginal ultrasound (TVS) and the management depending upon case presentation and available healthcare infrastructures. Case Presentation: We present a case of 34-year-old G3P2 with a history of two-previous caesarean sections referred to the outpatient gynaecology clinic of our Department at the 7th week (7/40) of gestation with abnormal early pregnancy TVS findings, illustrating the gestational sac attached to the caesarean scar and a foetal pole with evidence of foetal cardiac activity. We discuss the outcome of an alternative combined medical and surgical approach we followed as well as an updated review of the current literature. Conclusions: The ideal management of CSP requires tertiary centers, equipment availability and experienced healthcare professionals capable of dealing with any possible complication, as well as individualized treatment based on each case presentation.

Comparison of different treatment strategies in the management of endogenic caesarean scar pregnancy: a multicentre retrospective study

Background

The aim of this study was to evaluate the effectiveness and safety of different treatment strategies for endogenic caesarean scar pregnancy (CSP) patients.

Methods

According to Vial’s standard, we defined endogenic-type CSP as (1) the gestational sac growing towards the uterine cavity and (2) a greater than 0.3 cm thickness of myometrial tissue at the caesarean scar. A total of 447 endogenic CSP patients out of 527 patients from 4 medical centres in China were enrolled in this study. A total of 120 patients were treated with methotrexate (MTX) followed by surgery, 106 received ultrasound-guided curettage directly and 221 received curettage combined with hysteroscopy. The clinical information and clinical outcomes of these patients were reviewed. Successful treatment was defined as (1) no additional treatment needed, (2) no retained mass of conception and (3) serum β subunit of human chorionic gonadotropin (β-hCG) level returning to a normal level within 4 weeks. The success rate was analysed based on these factors.

Result

Among 447 patients, no significant difference was observed in baseline characteristics between groups except for foetal heartbeat. The success rate was significantly different (p<0.001) among the three groups. The highest success rate of 95.9% was noted in the hysteroscopy group, and the lowest success rate of 84.0% was noted in the curettage group. In addition, the MTX group reported the longest hospital stay and highest expenses, but the curettage group showed the shortest and lowest expenses, respectively. Nevertheless, no difference in blood loss was observed between the groups.

Conclusion

The combination of curettage and hysteroscopy represents the most effective strategy. Pretreatment with MTX did not result in better clinical outcomes. Ultrasound-guided curettage directly should not be considered a first-line treatment choice for endogenic CSP patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04633-y.

A laparoscopic approach to cesarean scar ectopic pregnancy

Cesarean scar pregnancies confer serious risk and severe morbidity. Appropriate management is the key to preventing complications. Although expectant management is usually contraindicated, the ideal combination of medical or surgical treatments is unclear and must be tailored to the patient's preferences and stability, provider skill, and the available resources. In this article, we present a combined medical and surgical approach that was successfully employed for the termination and excision of a cesarean scar pregnancy at 12 weeks' gestation in a patient desiring uterine preservation. A video is included, demonstrating the surgical steps of a laparoscopic approach used to safely resect the pregnancy and cesarean delivery scar with minimal blood loss. The management technique described can be utilized to effectively resolve cesarean scar pregnancy, to possibly decrease the risk of recurrence, and preserve future fertility with a minimally invasive outpatient surgery.

The Efficacy and Health Economics of Different Treatments for Type 1 Cesarean Scar Pregnancy

Objectives: To evaluate the efficacy and health economics of four treatments for type 1 cesarean scar pregnancy (CSP).

Methods: From January 2009 to December 2018, 326 patients diagnosed with type 1 CSP were examined, among whom 31 received ultrasound-guided local injection of methotrexate (local injection group), 160 patients received uterine artery embolization combined with suction aspiration (UAE group), 25 patients received ultrasound-guided suction aspiration (aspiration group) and 90 received ultrasound-guided local injection of lauromacrogol combined with suction aspiration (lauromacrogol group). Clinical data and outcomes were analyzed. The decision tree model was used to compare the economics of four treatments.

Results: The success rate of the local injection group was 71.0% (22/31), which was significantly different from 98.8% (158/160) of the UAE group and 100.0% (90/90) of the lauromacrogol group. The success rate of the aspiration group was 92.0% (23/25), which was significantly lower than that of the lauromacrogol group. The cost-effectiveness ratio was 1,876.53 yuan for the aspiration group, 2,164.63 yuan for the lauromacrogol group, 4,383.56 yuan for the local injection group, and 7,850.81 yuan for the UAE group. The Incremental cost effectiveness ratio (ICER) of the lauromacrogol group to the aspiration group was 5,477.75 yuan, indicating that if the willing to pay of patients was higher than 5,477.75 yuan, the lauromacrogol group had a cost-effectiveness advantage in treating type 1 CSP, compared to aspiration group. On the contrary, aspiration group has a higher cost-effectiveness advantage. The ICER of the lauromacrogol group to the local injection group or the UAE group were both less than 0, indicating that local injection group and UAE group was not cost-effective in the treatment of type 1 CSP.

Conclusion: For type 1 CSP, the ultrasound-guided local injection of lauromacrogol combined with suction aspiration and ultrasound-guided suction aspiration, are effective and economical, and the choice between the two can be based on the patient’s willing to pay.

Successful Management of Caesarean Scar Ectopic Pregnancies: A Report of Five Cases

Background:

Cesarean section scar ectopic pregnancy (CSEP) is a rare and potentially life-threatening condition. A standardized management protocol is yet to be established owing to limited data available.

Case Presentation:

In this paper, five cases of CSEP over a period of 18 months at a tertiary referral hospital, managed medically with methotrexate administered both systemically and into the gestational sac at the time of feticide with potassium chloride (KCL) are presented. Surgical management was the second line therapy when medical treatment failed.

Conclusion:

With rising trends in cesarean deliveries, CSEP may be a challenge which requires close investigation regarding its diagnosis and treatment on the merits of case studies and available healthcare facilities.

Safety and efficacy of a single local methotrexate injection for cesarean scar pregnancy

OBJECTIVE

To investigate the safety and efficacy of a single local methotrexate (MTX) injection for the treatment of cesarean scar pregnancy (CSP), assess reproductive outcomes after treatment, and confirm clinical outcomes after the treatment of CSP patients according to the presence of fetal cardiac activity or serum human chorionic gonadotropin (hCG) levels.

DESIGN

Retrospective cohort study SETTING: University hospital PATIENTS: Women with CSP INTERVENTIONS: Single local MTX injection under transvaginal ultrasound guidance MEASUREMENTS AND MAIN RESULTS: Forty-five CSP cases were identified; the mean (SD, range) estimated gestational age was 7.7 (1.7, 5.4-12.5) weeks and the mean serum hCG level was 51,801 (40,761, 2,307-187,898) mIU/mL. Three cases required additional treatment with MTX, and none of the cases needed uterine artery embolization or hysterectomy. The success rate for a single dose was 93.3%, and it was 100% if additional treatments with MTX were included. The mean time required for hCG normalization in those with fetal cardiac activity or with an initial level of hCG greater than 100,000 mIU/mL was not significantly longer than that in the controls (93.4 vs. 77.1 days, p=0.12; 113.7 days vs. 83.6 days, p=0.10). Of the 23 women who desired a subsequent pregnancy, 13 delivered 14 healthy newborns after treatment, three had an ongoing pregnancy, and three experienced recurrent CSP.

CONCLUSIONS

A single local MTX injection is safe and effective for the treatment of CSP despite the presence of fetal cardiac activity or any initial level of hCG and may allow the possibility of a subsequent uneventful pregnancy.

Efficacy of In Situ Methotrexate Injection in the Treatment of Nontubal Ectopic Pregnancies: A Retrospective Multicenter Study

STUDY OBJECTIVE

Evaluation of the efficacy of different injection sites of methotrexate in the treatment of nontubal ectopic pregnancies.

DESIGN

Retrospective multicenter study.

SETTING

Multicenter, including 3 teaching hospitals, an intercommunal hospital, and a clinic.

PATIENTS

A total of 106 patients with nontubal ectopic pregnancies, including 59 interstitial, 39 cesarean scar, and 8 cervical or isthmic.

INTERVENTIONS

Overall, 58 patients received methotrexate via intramuscular injection (IM group), 35 received methotrexate via in situ injection (IS group), and 13 received a combination of both in situ and intramuscular injections of methotrexate (IS + IM group).

MEASUREMENTS AND MAIN RESULTS

The main end point of this study was measured via the primary success rate (defined as a negative β-human chorionic gonadotropin level without recourse to any additional treatment) of treatment with methotrexate according to injection site. The primary success rate was 46.55% in the IM group, 60% in the IS group, and 61.54% in the IS + IM group, respectively. In the multivariate analysis, the primary success rate of treatment was significantly correlated to the in situ injection of methotrexate, either solely or in conjunction with an intramuscular injection of methotrexate administered the following day, (odds ratio = 2.7; 95% confidence interval, 1.03-7.14).

CONCLUSION

Solely an intramuscular injection of methotrexate is a less efficient first-line treatment strategy for the conservative management of nontubular ectopic pregnancy. The use of an in situ injection of methotrexate should therefore be preferred.

An updated guide to the diagnosis and management of cesarean scar pregnancies

PURPOSE OF REVIEW

To review the current literature on the diagnosis and management of cesarean scar pregnancies RECENT FINDINGS: The incidence of cesarean scar pregnancies (CSPs) is increasing as a result of the increasing cesarean section rate, improved diagnostic capabilities, and a growing awareness. CSPs are associated with significant morbidity and early diagnosis is key. Diagnosis is best achieved with transvaginal ultrasound. Sonographic diagnostic criteria have been developed over decades and recently endorsed by the Society for Maternal-Fetal Medicine and other professional societies. The current categorization system differentiates CSPs that are endogenic or 'on the scar' from those that are exogenic or 'in the niche'. Following diagnosis, the challenge remains in determining the optimal management as multiple modalities can be considered. Studies have demonstrated the favorable outcomes with combined local and systemic methotrexate, surgical excision through multiple routes, and adjunctive therapies, such as uterine artery embolization or uterine balloons. The current evidence is insufficient to identify a single best treatment course and a combined approach to treatment is often required.

SUMMARY

Successful outcomes while minimizing complications can be achieved with a multidisciplinary, collaborative effort. Guidelines for cesarean scar pregnancies will continue to evolve as the published reports grow.

Approaches in the Treatment of Cesarean Scar Pregnancy and Risk Factors for Intraoperative Hemorrhage: A Retrospective Study

Background: Cesarean scar pregnancy (CSP) involves a rare form of placental attachment that often leads to life-threatening conditions. The best treatment for CSP has been debated for decades. We aimed to evaluate the different treatments for CSP and analyzed the risk factors for intraoperative hemorrhage.

Methods: CSP patients treated at the Affiliated Hospital of Jiangnan University were reviewed retrospectively from January 2014 to 2020. CSP was classified into three types based on the location and shape of gestational tissue, blood flow features, and thickness of the myometrium at the incision site. The clinical characteristics, types, approaches of treatment, and clinical outcomes of CSP were analyzed.

Results: A total of 55 patients were included in this study, 29 (52.7%) of whom underwent transvaginal curettage after uterine artery embolization (UAE) and 22 (40%) of whom underwent transabdominal ultrasound-guided hysteroscopic curettage (USHC) in type I and II. Four patients (7.3%) classified as type III underwent laparoscopic cesarean scar resection (LCSR). Intraoperative blood loss, blood transfusion rate, and scar diverticulum were significantly higher in type II than in type I (P < 0.05). Even though USHC showed no differences in intraoperative blood loss, length of stay, and scar diverticulum compared with curettage after UAE (P > 0.05), superiority was found in surgical time and hospitalization cost (P < 0.05). Furthermore, the type of CSP (OR = 10.53, 95% CI: 1.69–65.57; P = 0.012) and diameter of the gestational sac (OR = 25.76, 95% CI: 2.67–248.20; P = 0.005) were found to be risk factors for intraoperative hemorrhage.

Conclusions: Transabdominal ultrasound-guided hysteroscopic curettage is an effective and relatively safe treatment option for patients with CSP. Type of CSP and diameter of the gestational sac were found to be associated with excessive intraoperative hemorrhage.

Single- versus multiple-dose methotrexate in cesarean scar pregnancies management: treatment and reproductive outcomes

PURPOSE

We aim to assess the outcome of the treatment of cesarean scar pregnancy (CSP) with single-dose methotrexate (MTX) versus multiple-dose MTX protocols.

METHODS

A retrospective cohort study including two tertiary medical centers was conducted. All women diagnosed with CSPs between the years 2011 and 2019 that were initially managed with systemic MTX were included. Single-dose MTX practiced in one medical center was compared to multiple-dose MTX, practiced in the other medical center.

RESULTS

The study cohort included 31 women in the single dose and 32 women in the multiple-dose MTX groups. Baseline characteristics did not differ between groups. The primary outcome occurred in 12 (38.7%) of the cases in the single-dose group and in 6 (18.8%) in the multiple-dose group (p = 0.083). The rate of conversion to surgical treatment was similar in both groups (4 vs. 5 in the single vs. multiple-dose groups, respectively, p = 0.758). There was no significant difference between the single- and the multiple-dose groups in the administration of blood products (16.1% vs. 3.1%, respectively, p = 0.104), total days of admission (18 ± 9.3 vs. 17 ± 12.8 days, respectively, p = 0.850), and readmission rate (32.3% vs. 21.9%, respectively, p = 0.353). Data regarding sequential pregnancies were available for 11 women in the single and 13 women in the multiple-dose MTX groups. There were no differences between the groups in rates of term deliveries, CSP recurrence, and abortions.

CONCLUSION

Both single- and multiple-dose MTX treatment protocols offer high success rate with a relatively low complication rate in the treatment of CSP.

Experience With Medical Treatment of Cesarean Scar Ectopic Pregnancy (CSEP) With Local Ultrasound-Guided Injection of Methotrexate

Objective: Ectopic pregnancy within Cesarean section scars is a rare condition. Late diagnosis carries significant risk of bleeding with poor prognosis for survival. There is no consensus on the management of this type of pregnancy. Historically, our facility offered an intra-muscular injection of methotrexate that resulted in a significant failure rate and later need for surgery. We hypothesized that injecting methotrexate directly into the gestational sac would improve the success rate of the treatment.

Patients and Methods: This retrospective, uni-centric study examined nine patients aged between 33 and 42 years (mean age = 36.5 years) with Cesarean scar ectopic pregnancy (CSEP) between 2010 and 2018. CSEP was diagnosed by transvaginal ultrasound at a mean gestational age of 8w0/7. CSEP was treated under general anesthetic by ultrasound-guided methotrexate injection directly into the gestational sac. HCG levels and subsequent childbearing were monitored post-treatment.

Results: Half of the patients were asymptomatic at the time of diagnosis. All patients tolerated treatment well and all ectopic pregnancies were successfully removed. HCG levels returned to negative within 3 months without additional medical or surgical intervention. The post-treatment pregnancy rate was 50%.

Discussions/Conclusions: Our findings indicate that local ultrasound-guided injection of methotrexate into the gestational sac is a safe and effective therapeutic approach when performed by a trained team on a hemodynamically stable patient in the early stages of CSEP.

Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy

Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).

Effectiveness of conservative medical treatment for non-tubal ectopic pregnancies: a multicenter study

OBJECTIVE

To assess the effectiveness of conservative treatment for the management of non-tubal ectopic pregnancies (NTEP) METHODS: Retrospective cohort study in three centers (two referral centers) of patients managed for NTEP diagnosed by 2D or 3D ultrasonograhy. Patients underwent one of the following: expectant management, systemic methotrexate (MTX) injection, local MTX injection, combined MTX injection (local and systemic), local injection of hyperosmolar glucose, or misoprostol administration. The primary endpoint was final success defined by resolution of hCG level without need for emergency surgical treatment. Sixty-four patients diagnosed with NTEP were included: 37 (57%) had an interstitial pregnancy, 23 (35.9%) a cesarean scar pregnancy, two (3.1%) a cervical pregnancy and two (3.1%) an ovarian pregnancy.

RESULTS

Six patients (9.4%) underwent expectant management, 24 (37.5%) a systemic MTX injection, 28 (43.8%) a local injection of MTX, three (4.7%) a combined MTX injection, one (1.6%) a local injection of hyperosmolar glucose (1.6%), and two (3.1%) were administered misoprostol. The median age was 32 years (22-45) and mean follow-up was 41 months. The final success rate overall was 92.2%: 100% for expectant management, 87.5% for systemic MTX, 96.4% for local MTX, 100% for combined injection of MTX, 100% for local injection of hyperosmolar glucose, and 50% for misoprostol. No patient required a hysterectomy. Nine (14.1%) patients required surgery, including five (7.8% (5/64)) following a rupture of the NTEP.

CONCLUSIONS

Our results suggest that conservative medical management of NTEP is effective and safe and should be the first-line treatment for pauci-symptomatic patients with an NTEP.

Cesarean Scar Ectopic Pregnancy: Current Management Strategies

Importance

Cesarean scar ectopic pregnancy (CSEP) has a high rate of morbidity with nonspecific signs and symptoms making identification difficult. The criterion-standard treatment of CSEP has been subject to debate.

Objective

This review defines CSEP, discusses pathogenesis and diagnosis, and compares treatment options and outcomes.

Evidence Acquisition

A literature review was performed utilizing the term cesarean scar ectopic pregnancy and subsequently selecting only meta-analyses and systematic reviews. Only articles published in English were included. Relevant articles within the reviews were analyzed as necessary.

Results

Five basic pathways have been identified in treatment of CSEP: expectant management, medical therapy, surgical intervention, uterine artery embolization, or a combination approach. Expectant management has the highest probability of morbid outcomes, including hemorrhage, uterine rupture, and preterm delivery. Medical management often requires further treatment with additional medication or surgery. Different surgical methods have been explored including uterine artery embolization; dilation and curettage; surgical removal via vaginal, laparoscopic, or laparotomic approach; and hysterectomy. Each method has various levels of success and depends on surgeon skill and patient presentation.

Conclusions

Recent research supports any method that removes the pregnancy and scar to reduce morbidity and promote future fertility. Laparoscopic and transvaginal approaches are options for CSEP treatment, although continued research is required to identify the optimal approach.

Relevance

As cesarean delivery numbers rise, a subsequent increase in CSEPs can be anticipated. The ability to accurately diagnose and treat this morbid condition is vital to the practice of any specialist in general obstetrics and gynecology.

New ultrasound grading system for cesarean scar pregnancy and its implications for management strategies: An observational cohort study

A cesarean section pregnancy (CSP) indicated the gestational sac (GS) implanted in the previous cesarean scar. The clinical manifestations of CSP present a wide range of variations, and the optimal management is yet to be defined. We retrospectively enrolled 109 patients with the diagnosis of CSP from our department and categorized them into four grades based on the ultrasound presentation. Grade I CSP indicated the GS embedded in less than one-half thickness of the lower anterior corpus; and grade II CSP represented the GS extended to more than one-half thickness of overlying myometrium. Grade III CSP implied the GS bulged out of the cesarean scar; and grade IV CSP denoted that GS became an amorphous tumor with rich vascularity at the cesarean scar. Seventy-eight women received surgery, and the complication rate was 14.1% (11/78). Linear regression analysis demonstrated a significant association between the invasiveness of the surgery and their ultrasound gradings. The mainstream operation for grade I CSP was transcervical resection, while the majority of grade III and IV patients required hysterotomy or hysterectomy. Another 31 women received chemotherapy with methotrexate as their initial treatment. The success rate for chemotherapy was 61.3%; the remaining patients required further surgery due to persistent CSP or heavy bleeding during or after chemotherapy. Fifteen patients (48.3%) receiving chemotherapy suffered from complications (mostly bleeding). Among them, 7 (22.6%) patients experienced bleeding of more than 1,000 mL, and 9 (29.0%) of these 31 patients required blood transfusions. Our novel ultrasound grading system for CSP may help to communicate between physicians, and determine the optimal surgical strategy. Chemotherapy with methotrexate for CSP is not satisfactory and is associated with a higher rate of complications.

Ultrasound-guided local injection of methotrexate and systemic intramuscular methotrexate in the treatment of cesarean scar pregnancy

Objective

To assess the efficacy and safety of ultrasound-guided intragestational injection of methotrexate (MTX) and systemic intramuscular MTX in the management of cesarean scar pregnancies.

Methods

This was a retrospective case-control study that included women diagnosed with cesarean scar pregnancy at CHA Bundang Medical Center unit between 2009 and 2015. The 26 cases were managed with local injection of MTX under ultrasound guidance and 15 cases were treated with systemic intramuscular of MTX. After the procedure, serial follow-up sonographic examination and serum beta-human chorionic gonadotropin (β-hCG) measurement were performed.

Results

The mean initial β-hCG level was 20,610.73 mIU/mL and ranged from 263.00-71,316.50 mIU/mL. Mean gestational age was 6.3 weeks and ranged from 4.8 to 8.5 weeks. The majority of ectopic cases were treated successfully and follow-up β-hCG level declined abruptly following the first dose of MTX. The rate of success of local MTX treatment was significantly higher than that of systemic MTX treatment. It was 93.75% vs. 73.33%, respectively (P<0.05).

Conclusion

Ultrasound-guided intragestational injection of MTX is an effective method for the management of cesarean scar pregnancies and is associated with minimal side effects and high treatment success.

When a cesarean section scar is more than an innocent bystander in a subsequent pregnancy: Ultrasound to the rescue

Over the years, cesarean section has played a pivotal role in reducing maternal and perinatal morbidity and mortality. With the rising trend of this surgery, a substantial number of pregnant women have a cesarean section scar. The scar can serve as the abode of grave conditions in subsequent pregnancies, namely cesarean scar pregnancy, morbidly adherent placenta, and scar dehiscence. Sonography has emerged as a robust tool for the diagnosis of these potentially life-threatening conditions. This review highlights the key sonographic features of various complications that can occur at the cesarean scar site in subsequent pregnancies. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:319-327, 2017.

Comparison of management regimens following ultrasound diagnosis of nontubal ectopic pregnancies: a retrospective cohort study

OBJECTIVE

To review management options for nontubal ectopic pregnancies.

DESIGN

Retrospective cohort study.

SETTING

Tertiary hospital in Melbourne, Australia.

POPULATION

A total of 100 nontubal pregnancies: 1 abdominal, 32 caesarean scar, 14 cervical, 41 cornual-interstitial, 12 ovarian.

METHODS

Cases were classified according to ectopic site. Management categories were medical, surgical, combination or expectant. Use of minimally invasive approaches (ultrasound-guided intra-sac injections or selective surgical techniques) was identified. Primary management was considered to be successful if no further unplanned interventions were required.

MAIN OUTCOME MEASURES

Success of primary management and frequency of unplanned interventions.

RESULTS

A high rate of success (82%) was demonstrated for all management regimens, with minimal morbidity and no deaths occurring. A high success rate was shown when the primary management regimen was systemic methotrexate or ultrasound-guided intra-sac injection (88%). The success rate for primary surgical management was 57%. High success rates were reported for both primary management with ultrasound-guided injections or in combination with systemic methotrexate (94%) and for primary management with systemic methotrexate alone (81%). Seventy-five per cent of women managed with minimally invasive surgical approaches avoided the need for more extensive surgery, but required longer follow up and additional interventions.

CONCLUSION

Minimally invasive approaches were found to be safe and effective treatment for women desiring to conserve fertility. Ultrasound-guided intra-sac injection and laparoscopic ectopic removal procedures aimed at preserving reproductive organs should be included as minimally invasive primary management tools in addition to the well-recognised option of systemic methotrexate.

TWEETABLE ABSTRACT

Nontubal ectopics: minimally invasive procedures a safe alternative to surgery in selected cases.

Safety and Efficacy of Uterine Artery Embolization in Ectopic Pregnancies Refractory to Systemic Methotrexate Treatment: A Single-Center Study

BACKGROUND

To investigate the use of uterine artery embolization (UAE) to manage ectopic pregnancies that are refractory to systemic methotrexate (MTX) therapy and plagued by persistently high serum β-human chorionic gonadotrophin (hCG) levels and vaginal bleeding. The safety and efficacy of UAE were addressed.

MATERIALS AND METHODS

A retrospective review was conducted for thirteen patients (mean age 35.2 years; range 28-41 years), who were treated between December 2006 and June 2016. Each was subjected to UAE due to persistently high serum β-hCG levels and vaginal bleeding after systemic MTX therapy for ectopic pregnancy. Embolic agents used were non-spherical polyvinyl alcohol or gelatin sponge particles. Post-treatment follow-up was performed by monitoring for clinical signs of vaginal bleeding, serum β-hCG testing, and transvaginal US. Outcomes were technical success, clinical success, and complications.

RESULTS

Median follow-up period was 172.5 days (range 30-600 days). Technical success was achieved in all 13 patients (100%). In 10 patients, vaginal bleeding resolved after one UAE attempt (clinical success 76.0%). Rebleeding in other three (23.1%) was controlled through repeat UAE. Seven patients (53.8%) had additional dilatation and curettage to remove gestational sac remnants. All ectopic pregnancies were successfully treated by UAE, with normalization of serum β-hCG levels during follow-up monitoring (P = 0.01). Uterine preservation was achieved in all 13 patients, without major procedural complications.

CONCLUSION

UAE appears safe and effective as treatment of ectopic pregnancies marked by persistently high serum β-hCG levels and vaginal bleeding after systemic MTX treatment.

Risk factors associated with failure of treatment for cesarean scar pregnancy

OBJECTIVE

To identify risk factors associated with treatment failure among women with cesarean scar pregnancy (CSP).

METHODS

In a retrospective study, the medical records of patients with CSP treated at National Taiwan University Hospital, Taipei, Taiwan, from 1994 to 2015 were reviewed. The women were managed primarily with hysterotomy, evacuation, or methotrexate. Receiver operating characteristic (ROC) curve analysis and logistic regression analysis were used to evaluate the factors associated with treatment failure.

RESULTS

Among 90 patients, 44 underwent hysterotomy, 18 underwent evacuation, and 28 received methotrexate. The success rates were 100% (44/44) for hysterotomy, 83% (15/18) for evacuation, and 57% (16/28) for methotrexate (P<0.001). ROC curve analysis indicated that a pregnancy length of 8 weeks and a mean sac diameter (MSD) of 4 cm were both predictive of failure of treatment by primary evacuation and methotrexate. In multivariate logistic regression analysis, an MSD of 4 cm or more was the only independent risk factor for treatment failure (odds ratio 68.99, 95% confidence interval 6.27-759.60; P=0.001).

CONCLUSION

Primary hysterotomy was suitable for treatment of CSP of any size. Failure of primary evacuation or methotrexate usually occurred when the MSD was larger than 4 cm.