Methotrexate treatment of very high β-HCG ectopic pregnancy on previous cesarean scar: A case report

Abstract

Ectopic pregnancy in a previous caesarean scar is a rare, potentially life-threatening situation that can cause massive bleeding and uterine rupture. Clinical symptoms can range from vaginal bleeding with or without pain, to uterine rupture with hypovolemic shock. Early diagnosis is possible by ultrasound examination, and it is very important because it leads to prompt management, improving maternal morbidity and mortality as well as future fertility. The current case report refers to a G3P2 woman with a history of 2 previous caesarean deliveries, who was diagnosed with an ectopic pregnancy on the caesarean scar using ultrasonography. The patient was treated with methotrexate both systemic and into the sac, as well as with injection into the sac of 5mEq potassium chloride. The woman was followed up until measurements of serum β-Human Chorionic Gonadotropin were within nonpregnant levels. There is no clear-cut best way to handle cesarean scar pregnancy. Pregnancy with a cesarean scar should be identified and treated as soon as possible in order to avoid serious problems and preserve fertility. However, even more advanced cesarean scar pregnancies can be managed conservatively at first, when a highly expertized team in a tertiary hospital is available.

Keywords: Cesarean scar pregnancy; Conservative management; Ectopic pregnancy; Methotrexate treatment.

Fig. 1

Transvaginal ultrasound indicates the existence of an embryonic sac which had been implanted at the lower uterine segment. An embryo with fetal heart ratio of 115 bpm is found in the sac.

Fig. 2

The gestational sac appeared to be outside the uterine cavity, above the level of the internal os. At least two-third of the sac is within the anterior uterine wall.

Fig. 3

On the third day, an ultrasound guided gestational-sac injection of potassium chloride was administered, since cardiac activity was still present on ultrasound, followed by a single injection of 100 mg of methotrexate.

Fig. 4

Significant shrinkage of embryonic sac is observed on the day of discharge.