Obstet Gynecol Sci.  2018 Jan;61(1):147-153. 10.5468/ogs.2018.61.1.147.

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

• Kim YR
• Moon MJ

• KMID: 2420164
• DOI: http://doi.org/10.5468/ogs.2018.61.1.147

Abstract

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.

Keyword

Cesarean scar pregnancy; Ultrasonography; Guideline; Methotrexate

MeSH Terms

Case-Control Studies
Chorionic Gonadotropin
Cicatrix*
Female
Follow-Up Studies
Gestational Age
Humans
Methods
Methotrexate*
Pregnancy*
Retrospective Studies
Ultrasonography
Chorionic Gonadotropin
Methotrexate

Figure

• 

  Fig. 1 Beta-human chorionic gonadotropin (β-hCG) levels (mIU/mL) after local methotrexate (MTX) injection.

• 

  Fig. 2 Beta-human chorionic gonadotropin (β-hCG) levels (mIU/mL) after systemic methotrexate (MTX) injection.

Reference

1. Clark EA, Silver RM. Long-term maternal morbidity associated with repeat cesarean delivery. Am J Obstet Gynecol. 2011; 205:S2–S10.

2. Seow KM, Cheng WC, Chuang J, Lee C, Tsai YL, Hwang JL. Methotrexate for cesarean scar pregnancy after in vitro fertilization and embryo transfer. A case report. J Reprod Med. 2000; 45:754–757.

3. Alammari R, Thibodeau R, Harmanli O. Vaginal hysterectomy for treatment of cervical ectopic pregnancy. Obstet Gynecol. 2017; 129:63–65.

4. Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. BJOG. 2007; 114:253–263.

5. Timor-Tritsch IE, Monteagudo A, Cali G, Palacios-Jaraquemada JM, Maymon R, Arslan AA, et al. Cesarean scar pregnancy and early placenta accreta share common histology. Ultrasound Obstet Gynecol. 2014; 43:383–395.

6. Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, Svarre Nielsen H. Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril. 2016; 105:958–967.

7. Seow KM, Wang PH, Huang LW, Hwang JL. Transvaginal sono-guided aspiration of gestational sac concurrent with a local methotrexate injection for the treatment of unruptured cesarean scar pregnancy. Arch Gynecol Obstet. 2013; 288:361–366.

8. Cheung VY. Local methotrexate injection as the first-line treatment for cesarean scar pregnancy: review of the literature. J Minim Invasive Gynecol. 2015; 22:753–758.

9. Hafner T, Aslam N, Ross JA, Zosmer N, Jurkovic D. The effectiveness of non-surgical management of early interstitial pregnancy: a report of ten cases and review of the literature. Ultrasound Obstet Gynecol. 1999; 13:131–136.

10. Uludag SZ, Kutuk MS, Ak M, Ozgun MT, Dolanbay M, Aygen EM, et al. Comparison of systemic and local methotrexate treatments in cesarean scar pregnancies: time to change conventional treatment and follow-up protocols. Eur J Obstet Gynecol Reprod Biol. 2016; 206:131–135.

11. Kutuk MS, Uysal G, Dolanbay M, Ozgun MT. Successful medical treatment of cesarean scar ectopic pregnancies with systemic multidose methotrexate: single-center experience. J Obstet Gynaecol Res. 2014; 40:1700–1706.

12. Kim HJ, Lee KS, Han MY, Lee EH, Choi WY. Conservative management of intramural pregnancy implanting in the cesarean section scar. Korean J Obstet Gynecol. 2004; 47:1743–1747.

13. Lian F, Wang Y, Chen W, Li J, Zhan Z, Ye Y, et al. Uterine artery embolization combined with local methotrexate and systemic methotrexate for treatment of cesarean scar pregnancy with different ultrasonographic pattern. Cardiovasc Intervent Radiol. 2012; 35:286–291.