Search

Objective: To retrospectively investigate cesarean scar pregnancy (CSP) patients who received systemic methotrexate (MTX) and to clarify the criteria for administering systemic MTX to CSP patients., Materials and Methods: Fifteen CSP patients who were initially treated with systemic MTX (50 mg/m 2 /week) were included. Nine patients, who needed a uterine artery embolization (UAE) or a laparotomy, including a transabdominal hysterectomy (TAH), were defined as the unsuccessful MTX group. Six patients who did not require UAE or a laparotomy were defined as the successful MTX group. Furthermore, the hCG cut-off value and the GS cut-off size at the time of CSP diagnosis, which differentiated successful and unsuccessful patients, were defined. MTX success rates were investigated by combining the hCG and gestational sac (GS) size cut-off values., Results: The hCG cut-off value was 17757.0 mIU/mL, and the GS cut-off size was 10.4 mm. In patients with hCG values less than 17757.0 mIU/mL, the MTX success rate was 75.0%. Fewer patients needed UAE or a laparotomy compared to patients with hCG values higher than 17757.0 mIU/mL (P = 0.007). In patients with a GS size less than 10.4 mm, the MTX success rate was 80.0%. Fewer patients among them needed UAE or a laparotomy compared to those among patients with a GS size greater than 10.4 mm (P = 0.089). In patients with hCG values and GS sizes lower than the cut-off values, the MTX success rate was 80.0%. Fewer patients among them needed UAE or a laparotomy compared to those among patients with hCG values and/or GS sizes higher than the cut-off values, respectively (P = 0.010)., Conclusion: Patients with hCG values less than 17757.0 mIU/mL and GS sizes less than 10.4 mm may have a greater chance of successful systemic MTX treatment when it is used as the first line of treatment for CSP., Competing Interests: Declaration of competing interest None., (Copyright © 2021. Published by Elsevier B.V.)

Rationale: Cesarean scar twin pregnancy is exceedingly rare and it remains to be a life-threatening condition even in the early weeks of gestation. Because of its rare occurrence, there is no consensus on the treatment modality of cesarean ectopic pregnancy., Patient Concerns: A 41-year-old, woman, gravida 7, para 6, with a history of low transverse cesarean section 2 years back presented with an estimated 6 weeks gestational age and viable spontaneous twin, monochorionic diamniotic gestation. The patient presented to the Emergency Department with complaints of vaginal bleeding and mild lower abdominal pain for 5 days., Diagnoses: An ultrasound examination was performed demonstrating a single intrauterine gestational sac with 2 viable embryos (monochorionic diamniotic) implanted in the lower uterine segment at the level of the prior cesarean section scar. A diagnosis of viable cesarean scar twin pregnancy was made., Interventions: A 2 doses of 50 mg/m methotrexate (MTX) was given intramuscularly. The response to the treatment was monitored by serial beta-human chorionic gonadotropin (β-hCG) and ultrasound., Outcomes: Patient was followed up with β-hCG weekly levels which became 0 after 68 days of treatment. During the follow-up, the patient was asymptomatic, no side effects of MTX were noticed., Lessons: We reported a rare case of viable monochorionic diamniotic twin pregnancy on a cesarean scar that was successfully treated with systemic MTX without any additional therapy. Additionally, the decline of β-hCG in twin ectopic cesarean scar pregnancy appears to be similar to a singleton ectopic pregnancy.

Heterotopic pregnancy is a well-established complication of assisted reproductive technology. We report a case of intrauterine pregnancy combined with abdominal pregnancy diagnosed at 12 weeks in a 37-year-old nulliparous woman. Following surgical resection of the ectopic, implantation of hemorrhagic ectopic trophoblastic tissue onto bowel serosa, mesentery and omentum persisted. Due to the high risk of additional bleeding, systemic methotrexate was administered to the patient. The intrauterine pregnancy progressed well and a live infant was born at 27(+3) weeks. In such difficult cases, systemic methotrexate appears to have therapeutically helpful effects at low dosing regimens without immediate fetal toxicity., (© 2011 The Authors Acta Obstetricia et Gynecologica Scandinavica© 2011 Nordic Federation of Societies of Obstetrics and Gynecology.)