Successful Conservative Management of 9 weeks Cesarean Scar Ectopic Pregnancy with Fetal Heart Activity
Lana Skrgatic (HR), Josko Lesin (HR), Magdalena Karadza (HR), Mihajlo Strelec (HR), Trpimir Goluza (HR), Dinka Baldani (HR)
[Skrgatic] Clinical Hospital Center Zagreb, University of Zagreb School of Medicine, [Lesin] Clinical Hospital Center Zagreb, University of Zagreb School of Medicine, [Karadza] Clinical Hospital Center Zagreb, University of Zagreb School of Medicine, [Strelec] Clinical Hospital Center Zagreb, University of Zagreb School of Medicine, [Goluza] Clinical Hospital Center Zagreb, University of Zagreb School of Medicine, [Baldani] Clinical Hospital Center Zagreb, University of Zagreb School of Medicine
Objective: Cesarean scar ectopic pregnancy (CSP) is a rare type of ectopic pregnancy with challenging diagnosis and treatment. A variety of interventions have been implemented to terminate the pregnancy and preserve the uterus. Combined intramuscular and intragestational methotrexate injection (MTX) treatment was proven successful in treating CSP. Very few cases with live embryo and high human chorionic gonadotropin (hCG) levels are described in the literature. Patient and intervention: A 31-year old patient was referred at 9-week gestation and was diagnosed with CSP with fetal heart rate activity and hCG serum levels of 79 503 IU/L. The diagnosis was confirmed with MRI and transvaginal ultrasound. She was treated with transvaginal ultrasound-guided gestational sac injection with 75 mg of MTX: 25 mg into the area of the embryo/fetus and 25 mg into the placental area; and an additional 25 mg was administered intramuscularly. Serial serum hCG determinations were obtained weekly for the first three weeks following monthly detection of hCG levels until negative serum levels were obtained. Transvaginal ultrasound was used to monitor resolution of the injected site. Results: Serum hCG values decreased slowly and became undetectable 60 days following MTX injection. The decrease in gestational volume was slow. The gestational volume of 169 cm3 was recorded 54 days following MTX and the volume recorded three months following MTX injection was 43.74 cm3. The area of involution was still visible 7 months’ post treatment. Conclusion: The optimal management of CSP continues to represent a therapeutic challenge. Combined intramuscular and intragestational MTX injection treatment represents a good conservative fertility preserving option for CSP treatment