Novel Medical Therapy of Cesarean Scar Pregnancy With a Viable Embryo Combining Multidose Methotrexate and Mifepristone: A Case Report

Conservative treatment of cesarean scar pregnancy with the combination of methotrexate and mifepristone: A systematic review

BACKGROUND

Cesarean scar pregnancy (CSP) has become more frequent as a direct consequence of the increased number of cesarean deliveries and the advances in imaging. Although some cases are characterized by spontaneous resolution, unrecognized or mishandled CSP has the potential to cause both fetal and maternal morbidity and mortality. However, due to its infrequency, there is no agreement on the best management.

OBJECTIVE

The purpose of this study was to evaluate the safety, the risks and effectiveness of medical therapy with methotrexate and mifepristone to better understand its role in CSP therapy.

DESIGN

This study is a systematic review.

DATA SOURCES AND METHODS

The electronic databases PubMed, Medline, and Scopus were comprehensively searched until December 2023. Medical Subject Headings terms (Cesarean scar pregnancy) AND (Methotrexate) AND (Mifepristone) AND (Medical Therapy) were used to identify the relevant records. Due to the rarity of this pathology, the studies included are all case reports or case series. The methodological quality of the included studies was assessed using the JBI Critical Appraisal Checklist for case reports.

RESULTS

We included in our review a total of seven cases reported in five manuscripts at the end of the screening process. Our review suggests that this type of combination treatment can be considered. The success rate is 71.4%. Treatment seems to be most effective when beta human chorionic gonadotropin (B-hCG) is below 5,000 mUi/ml and when the gestational sac is less than 20 mm. The absence of fetal heartbeat seems to be a positive prognostic factor for a positive outcome.

CONCLUSION

Methotrexate and mifepristone administration can be considered as an alternative first-line effective treatment, especially in case of pregnancy with B-hCG <5,000 mUi/ml and when the gestational sac is less than 20 mm. It is important to individualize the management and treatment according to the clinical condition, the patient's age, number of previous cesarean deliveries, willingness to have other children, and the physicians' experience.

Analysis of risk factors for patients with cesarean scar pregnancy treated with methotrexate combined with suction curettage

PURPOSE

To analyze the predictive value of clinical and ultrasound parameters for treatment failure after administration of methotrexate (MTX) in combination with suction curettage (SC) in treatment of cesarean scar pregnancy (CSP) in the early first trimester.

METHODS

In this retrospective cohort study, electronic medical records of patients diagnosed with CSP and initially treated between 2015 and 2022 with MTX combined with SC were reviewed and outcome data were collected.

RESULTS

127 patients met inclusion criteria. 25 (19.69%) required additional treatment. Logistic regression analysis indicated that factors independently associated with the need for additional treatment included progesterone level > 25 mIU/mL (OR: 1.97; 95% CI: 0.98-2.87, P = 0.039), abundant blood flow (OR: 5.19; 95% CI: 2.44-16.31, P = 0.011), gestational sac size > 3 cm (OR: 2.54; 95% CI: 1.12-6.87, P = 0.029), and the myometrial thickness between the bladder and gestational sac < 2.5 mm (OR: 3.48; 95% CI: 1.91-6.98, P = 0.015).

CONCLUSIONS

Our study identified several factors which increase the need for additional treatment following the initial treatment of CSP with MTX and SC. Alternative therapy should be considered if these factors are present.

Treatment of Recurrent Cesarean Scar Pregnancy With Oral Mifepristone, Systemic Methotrexate, and Ultrasound-Guided Suction Dilation and Curettage

Cesarean scar pregnancy (CSP), or pregnancies with implantation in a prior cesarean section scar, are rare but may be becoming more common with an increase in cesarean section deliveries. History of prior CSP may also increase the risk for recurrent CSP. Several treatment options and combinations of treatment options for CSP have been described in the literature. Although the optimal treatment is unclear, the Society of Maternal-Fetal Medicine published recommendation guidelines, which include recommendations for the treatment/termination of CSP pregnancies. Treatment of CSP is recommended with operative resection, ultrasound-guided suction dilation and curettage (D&C), or intragestational methotrexate with or without treatment modalities. This is a case report of a patient with recurrent CSP. Her first CSP was incorrectly diagnosed as an incomplete abortion after unsuccessful treatment with misoprostol alone and ultimately was successfully treated with systemic methotrexate. Her second CSP is the basis of this case report and was successfully treated with oral mifepristone and systemic methotrexate (50 milligrams/meter²) before an ultrasound-guided suction D&C at 10 weeks 1 day gestational age. The combination of mifepristone, systemic methotrexate, and suction D&C under ultrasound guidance as a treatment for recurrent CSP has not previously been described in published literature.

Contrast-Enhanced Ultrasound Evaluation of Mifepristone for Treatment of Low-Risk Cesarean Scar Pregnancy

Purpose

The effect of mifepristone for treatment of low-risk cesarean scar pregnancy (CSP) was monitored by contrast-enhanced ultrasound (CEUS).

Methods

Data were collected from 23 CSP patients with a 10-point risk score <5 (low-risk CSP) and from 23 intrauterine pregnancy (IUP) patients with a scar from a previous cesarean delivery. All patients were prescribed 75 mg mifepristone daily for 2 days and underwent transvaginal CEUS before and after administration of mifepristone. On the third day, uterine curettage was performed after transvaginal CEUS. Arrival time (AT), peak intensity (PI), and area under the curve (AUC) around the gestational sac were monitored by CEUS before and after application of mifepristone, and the rate of effective treatment was compared between the two patient groups.

Results

No patients experienced side effects from either the CEUS procedure or the mifepristone treatment. Changes in AT, PI, and AUC index from before vs. after mifepristone treatment did not differ significantly between the two groups (all p values >0.05). There was also no significant difference in the rate of effective treatment between the two groups (95.65% in the CSP group vs. 100% in the IUP group; p > 0.05).

Conclusions

Based on monitoring by CEUS, the effect of mifepristone in low-risk CSP was comparable to that in IUP.

Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series

Background

There is no clear consensus on the management of caesarean scar pregnancy (CSP), a complex and life-threatening condition. The objective of this study was to present a novel approach to management of CSP that combines medical therapy of multidose methotrexate and mifepristone with active surgical management by uterine curettage and consecutive local haemostasis.

Case presentation

We report on a prospective case series of six women with first trimester pregnancy, in whom the diagnosis of CSP was confirmed by 2D and color Doppler transvaginal ultrasound and serial hormone chorionic gonadotropin (hCG) testing. Women were between 23 and 36 years old and had at least one previous delivery by caesarean. At admission, gestational age ranged between 6 to 14 weeks, and serum hCG levels between 397 and 23,000 mUI/ml. Upon decision of pregnancy termination, medical management was undertaken in all cases and 1 mg/kg systemic Methotrexate was administered between 1 and 5 daily doses. Mifepristone was part of the treatment in cases with live pregnancy. Surgical management was employed for the cases were an embryo was seen by ultrasound, being prompted by inadequate response to Methotrexate and/or signs of miscarriage with vaginal bleeding. Curettage combined with local isthmic balloon or vaginal pack tamponade prevented further complications. High treatment rates with preservation of fertility was achieved in all patients except one who underwent hysterectomy for invasive placentation. Ultrasound and hCG levels surveillance ensured that the resolution of pregnancy was achieved.

Conclusion

Women with history of delivery by caesarean section should be carefully monitored in future pregnancies for prompt diagnosis of CSP. Early diagnosis of CSP allows selection of successful conservative therapy. Through this case series we contribute with our experience to the body of knowledge about the management of this serious complication of early pregnancy.

Therapeutic approach for the cesarean scar pregnancy

The aim of this study was to explore the pros and cons of different treatments of cesarean scar pregnancy (CSP).We retrospectively studied 205 cases of CSP that were treated in our hospital from June 2013 to June 2014, 189 of which had surgical operation.The average age of the patients was (32.98 ± 4.56) years. Data from those 189 cases were analyzed.Two hundred five patients from Beijing Obstetrics and Gynecology Hospital.One hundred eighty-nine cases who had operative treatment, 111 of which received curettage under hysteroscopy, 70 of which received curettage under ultrasonography, 8 of which received laparoscopic Cesarean scar resection.Management of 189 ectopic Cesarean scar pregnancy cases discussed in this article was usage of methotrexate (MTX) via the utility of uterine arterial chemotherapy embolization (UACE).All of 189 patients were cured without hysterectomy. Hysteroscopy provides a clear view for us, making it easy to identify the range of affected tissues, and clean the pregnancy tissue. Curettage under ultrasonography is relatively simple and inexpensive. Laparoscopic surgery is more suitable for exogenous CSP patients that can reduce the operation risk and prevent uterine perforation. However, laparoscopic surgery costs much more than those 2 and needs longer time of hospitalization.Treatment options should be personalized according to different situations. Minimal invasion, thorough treatment, quick recovery, low risk of hysterectomy, preserved fertility function, and improved life quality are the principles we have been pursuing for.

Clinical classification and treatment of cesarean scar pregnancy

AIM

Embryo implantation in a cesarean scar resulting in a cesarean scar pregnancy (CSP) is a special form of ectopic pregnancy. The aim of this article is to present our clinical classification and therapeutic strategy for CSP and to assess the efficacy, safety, and social benefits.

METHODS

We categorized CSP as either risky or stable. Risky CSP have a high risk of severe hemorrhage and should be treated immediately, while stable CSP patients have neither obvious vaginal bleeding nor significantly elevated serum β-human chorionic gonadotrophin (β-hCG). According to the thickness of the myometrial wall between the sac and the bladder and the location of the gestational sac, risky CSP were classified into three types and the thinner myometrial wall type (type I) was divided into three subtypes. Four treatment categories were applied to the corresponding types and subtypes of CSP. A total of 331 patients with CSP in our hospital were studied. The study group (n = 81) was treated based on our classification and optimized treatment system, while the control group (n = 250) underwent the conventional methods. We assessed the efficacy, safety, and social benefits of our classification and optimized treatment system.

RESULTS

The values of intraoperative blood loss, operative time, hospital stay, and hospital cost in the study group were significantly lower than those in the control group (P < 0.05). Suction curettage was more frequently used in the study group (P < 0.005).

CONCLUSION

Our clinical classification system and therapeutic strategy provide an effective and safe way to treat CSP patients resulting in reduced intraoperative bleeding, operative time, hospital days, and hospital cost.