Successful Methotrexate Therapy in Management Caesarean Scar, an

Ectopic Pregnancy: A Case Report

Putri Irmayani

Cut Meurah Yeni

Department Of Obstetrics & Gynecology, Dr.Zainoel Abidin, Hospital Banda Aceh, Indonesia

Feto Maternal Division, Department Of Obstetrics & Gynecology Syiah Kuala University – Dr.Zainoel Abidin Hospital

Banda Aceh, Indonesia

Keywords: Caesarean Scar, Pregnancy, Methotrexate, Management.

Abstract : An ectopic pregnancy developing in a Caesarean scar pregnancy (CSP) is a very rare case. We describe the

case of a-31 years old-women G4P2A1 6-7 weeks gestational age (wga), previous c-section 2 times, inter

delivery time (IDT) 2 years. She came with chief complaint amenorrrhoea for five weeks and was found to

have a positive urine pregnancy test. Transvaginal ultrasonography showed uterus was within normal limit

and there was a single intrauterine gestational sac positioned in the region lower segment caesarean section.

a local injection of NaCl 0,3 % into the amniotic sac under ultrasound guidance resulted embryonic demise.

Following the local injection, one doses of methotrexate were given intramuscular methotrexate 50 mg/m

The early diagnosis of caesarean scar ectopic pregnancy via transvaginal ultrasound is fundamental for a

successful conservative treatment.

1 INTRODUCTION

An ectopic pregnancy developing in a Caesarean

scar pregnancy (CSP) is a very rare case (Sapana et

al, 2014). Caesarean scar ectopic pregnancy occurs

where in the conceptus is implanted into the site of

previous caesarean section (Cunningham et al,

2014). Incidence of caesarean section is increasing

worldwide, therefore more cases are diagnosed and

reported (Srinivas et al, 2014). This type of ectopic

pregnancy carries with it a high risk of maternal

morbidity related to uterine rupture, miscarriage

with hemorrhage, placenta praevia with or without

accrete, and hysterectomy. Early diagnosis can offer

preservation woman’s fertility. Treatment options

CSP are medical management to surgical techniques,

which is medical use local/systemic methotrexate

(MTX) (Ross, 2016).

2 CASE REPORT

A-31 years old-women G4P2A1 6-7 weeks

gestational age (wga), previous c-section 2 times,

inter delivery time (IDT) 2 years. She came with

chief complaint amenorrrhoea for five weeks and

was found to have a positive urine pregnancy test.

Her first pregnancy was a spontaneous complete

abortion of four months pregnancy. Her second

pregnancy was an uneventful emergency caesarean

section pregnancy at 9 months due to severe

headache. She underwent elective caesarean section

in her third pregnancy due to previous c-section 1

time (IDT 16 months).

Transvaginal ultrasonography showed uterus was

within normal limit and there was a single

intrauterine gestational sac positioned in the region

lower segment caesarean section. CRL diameter

0,72 mm corresponding to 6-7 wga which is, fetal

pole was present, myometrium thickness 2 mm and

there was no free fluid in the pouch of Dauglas

(Figure 1-2).

She was in stable haemodinamic with a pulse

rate of 88/min and blood pressure of 120/70 mmHg.

Abdomen was large correspond to 6-7 wga.

Laboratory tests for complete blood count, ureum

and creatinine tests were within normal limit. Serum

HCG was 6625 IU/ml. Since the patient wished to

preserve her fertility, a conservative approach was

142

Irmayani, P. and Yeni, C.

Successful Methotrexate Therapy in Management Caesarean Scar, an Ectopic Pregnancy: A Case Report.

DOI: 10.5220/0008792501420144

In Proceedings of the 2nd Syiah Kuala International Conference on Medicine and Health Sciences (SKIC-MHS 2018), pages 142-144

ISBN: 978-989-758-438-1

implemented. Because of fetal cardiac activity was

still present, a local injection of NaCl 0,3 % into the

amniotic sac under ultrasound guidance resulted

embryonic demise. Following the local injection,

one doses of methotrexate were given intramuscular

methotrexate 50 mg/m

. Serial serum HCG values

were performed at weekly interval.

3 DISCUSSIONS

Ectopic pregnancy in a Caesarean scar was first

reported in 1978 by Larson and Solomon (Persadie

et al, 2005). The incidence of CSP has been

estimated to range from 1/1800–1/2216 and it

constitutes 6.1% of all ectopic pregnancies in

women with history of caesarean deliveries. The

pathophysiology is the invasion of the blastocyst in

the myometrium through minimal communication

between the previous cesarean scar and the

endometrial cavity (Vora and Bansal, 2017).

Risk factors include number of two or more

previous cesarean sections, previous dilatation and

curettage, other uterine surgery such as hysterotomy,

hysteroscopy and myomectomy, abnormal

placentation, previous manual removal of placenta,

short time interval between the cesarean delivery

and the current pregnancy and retroversion of the

uterus which may lead to greater cesarean scar

dehiscence, increasing the chance of implantation of

the gestational sac in this region (Persadie et al,

2005). In this patient we found that she had history

two or more previous cesarean sections.

The diagnosis of cesarean scar pregnancy was

confirmed if all of the following sonographic using

the following criteria (Vora and Bansal, 2017):

(1) The uterus was empty, with clearly demonstrated

endometrium;

(2) The cervical canal was empty, without

gestational sac or ballooning at the early

diagnosis;

(3) Presence of the gestation sac with or without a

fetal pole, with or without fetal cardiac activity

(depending on the gestation age) in the anterior

part of the isthmic portion of the uterus; and an

absence of normal myometrium between the

urinary bladder wall and the gestational sac.

(4) Color Doppler shows high velocity with low

impedance peri-trophoblastic vascular flow

clearly surrounding the sac.

(5) In early gestations (≤8 weeks), a triangular

gestational sac that fills the niche of the scar

and at ≥8 postmenstrual weeks this shape may

become rounded or even oval

(6) A thin (1-3 mm) or absent myometrial layer

between the gestational sac and the bladder

The exact etiology of cesarean scar pregnancy is

unknown. There are several hypotheses, proposed by

different authors. There was two different type of

cesarean scar pregnancy. First type of cesarean scar

pregnancy is an implantation of conceptus on prior

cesarean scar and it grows towards the

cervicoisthmic space or the uterine cavity. Second

type of cesarean scar pregnancy is a deep

implantation into a cesarean scar defect, and it grows

towards the urinary bladder and abdominal cavity.

Transvaginal ultrasonography with color Doppler is

very useful for diagnosis of cesarean scar

pregnancies. It must be distinguished from other

Figure 2. Transvaginal ultrasonography showe

gestation sac in the lower uterine segment and empt

uterine cavity and cervical canal.

Figure 2 Transvaginal ultrasonography showed fetaL

heart rate of the fetus.

Successful Methotrexate Therapy in Management Caesarean Scar, an Ectopic Pregnancy: A Case Report

143

types of abnormally implanted pregnancies,

including cervical, cervicoisthmic, and

cervicoisthmic corporeal pregnancies, as outcome

and treatment may differ in each (Sapana et al,

2014).

CSP has showed to respond well to it (dose of 50

mg/m2), especially in those with b-hCG levels <

5000 miu/ml. Conservative medical treatment is

appropriate for a woman who is pain free and

haemodynamically stable with an unruptured CSP of

<8 weeks of gestation and a myometrial thickness <

2mm between the CSP and the bladder (Ash et al,

2007). In this case we use MTX. MTX resulted in

resolution of cesarean scar pregnancy without

surgical intervention (Jain, 2014).

Till now no well defined guidelines are available

in literature regarding management of CSP.

Ultrasound guided intra amniotic Methotrexate

injection has been proposed as a method of choice

after treatment of 12 cases in a 6 year period (Jain,

2014).

4 CONCLUSSIONS

The early diagnosis of caesarean scar ectopic

pregnancy via transvaginal ultrasound is

fundamental for a successful conservative treatment.

Owing to their rarity, there is no consensus on

treatment regimens. The options are medical,

surgical or a combination of both methods.

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