SUCCESSFUL MANAGEMENT OF CESAREAN SCAR PREGNANCY

WITH COMBINATION OF METHOTREXATE AND NACL 3%

: CASE REPORT
Defarendy sulaiman1 Cut Meurah Yeni2
1
Residen Departemen Obstetri dan Ginekologi Fakultas Kedokteran Universitas Syiah Kuala/ Rumah Sakit Umum
Zainoel Abidin, Banda Aceh
2
Staff Departemen Obstetri dan Ginekologi Fakultas Kedokteran Universitas Syiah Kuala/ Rumah Sakit Umum
Zainoel Abidin, Banda Aceh

Abstract
Objective : Cesarean scar pregnancy is extremely rare type of ectopic pregnancy. Early diagnosis
and treatment can prevent maternal morbidity and mortality.
Case : A 34 year old woman (2 gravida, 1 para) with vaginal bleeding and elevated beta human
chorionic gonadotrophin (β-hcg) level diagnosed with cesarean scar pregnancy. Treated by
systemic and local multiple dose of methotrexate (MTX) and local injection of Natrium Chloride
guided by ultrasound.
Conclusion :Cesarean scar pregnancy can be treated with local injection of natrium chloride
combined with systemic methotrexate.
INTRODUCTION
Caesarean Scar Pregnancy (CSP) is defined as a pregnancy implanted in a cesarean surgical wound
due to a history of previous cesarean section. In CSP implantation into the myometrial defect
resulting from previous intra-uterine surgery.(1) The average age of cases of CSP ranges from 27
to 39 years and the average gestational age of these cases ranges from 5 to 10 weeks. The incidence
of CSP ranges from 1: 1800 to 1: 2216 pregnancies and contribute 6.1% of total ectopic
pregnancies with a history of cesarean section. An increase in CSP incidence occurs due to an
increase in the number of caesarean deliveries. Some cases have reported an increase in CSP
incidence of 50-72% in patients who have undergone caesarean section 2 or more times.(2)(3) The
mechanism that can best explain the implantation of a cesarean surgical wound is the presence of
myometrial invasion via a microtubular "pathway" between a cesarean section wound and the
endometrial canal. This "pathway" can also be formed from other trauma to the uterus such as
curettage, myomectomy, hysteroscopy and even manual placenta.(4) Uterine rupture and massive
bleeding, which is a life-threatening situation that can threaten the mother, and also cause high
morbidity in CSP patients.(5)(6) Injection of methotrexate (MTX) is a standard treatment in ectopic
pregnancies and can be given systemically (intravenous / intramuscular / oral) or locally. The
success rate with MTX therapy was 75% and according to controlled trials conducted to compare
MTX injection locally and systemically no differences were found.(7)

CASE REPORT
A multiparous woman (Gravida 2 Para 1) 34 years old with 7 weeks gestational age, comes with
vaginal discharge occurs since 1 week before admitted to hospital with a history of cesarean section
6 years ago due to dystosia active phase of labor. On general physical examination no
abnormalities were found, testpack indicates a positive pregnancy and from inspeculo findings,
the ostium uteri external is closed with no active bleeding. Transvaginal ultrasound found a
retroflexi uterus, a gestational sac in the myometrial at the scar of previous cesarean section, a
positive fetal pole (Picture 1A). Early laboratory results showed anemia and an increase in β-hCG
levels (Chart 1).
We decided to use 2 cc normal saline NaCl 3% using a 20mm spinal needle with ultrasound
guidance on the gestational sac under local analgesia, followed by 50 mg local methotrexate
(MTX) intravaginally and 25 mg intramuscularly. The same therapy was carried out 1 week later,
followed by 50 mg intramuscular MTX administration at the third and fourth weeks. Regular
monitoring is carried out every week.

1A 1B
1A

1D
1C

Picture 1A-1D: Gestational sac in the myometrium on the previous caesarean scar with a positive fetal pole (Picture
1A). Positive fetal pole with no fetal heart rate, positive gestational sac at fourth week of therapy Picture 1B). Fetal
pole cannot be assessed, gestation sac is still visible at fifth week (Picture 1C). Gestational sac with irregular shape
at sixth week (Picture 1D)
 (β-hCG) LEVEL
60000

48721
50000

38789.9
40000
β-hCG Level

30000

20000

10000 4313.1
2070.5 1450.5 327.7 2.13
0
1 2 3 4 5 6 7
Week

DISCUSSION
There is no definitive algorithm in the management of CSP. However, termination in the first
trimester is recommended to avoid risks, such as the uterine rupture and severe bleeding. Under
ultrasound guidance, MTX can be injected locally into the yolk sac via transabdominal or via the
transvaginal route. Intramuscular methotrexate is given as a single dose calculated from the
patient's body surface area (50 mg / m2).(6) (8) KCL injection can also be given directly to the fetus
were found. So that local MTX injection is recommended compared to systemic administration. (2)
(11) (13)
Medically, CSP can heal within 3-9 months. Post-therapy evaluation are highly
recommended which include weekly measurements of β-hCG, evaluation of endovaginal
intracardiac to make fetal heart asystole.(7) (9) (10) The combination of intramuscular MTX and local
injection of KCl in the gestational sac is effective for CSP therapy. This therapy is very useful for
obstetrician to terminate the pregnancy in early trismester to reduce the risk of massive bleeding
and hypovolemic shock in patients.(9) (11) (12)
This patient was given therapy with local and systemic intramuscular MTX and injection of 3%
NaCl which was a substitution of KCL as an embrioside. The success rate of MTX therapy was
75% and according to a controlled trial conducted to compare local injection MTX and systemic
no differences ultrasound, and then followed by monthly evaluation until no product of conception
is detected. (4)
CONCLUSION
Accurate initial diagnosis of CSP performed at the earliest possible gestational age (5-10 weeks)
is very important to reduce the risk of morbidity and mortality. The use of ultrasonography has
high sensitivity and specificity as the main diagnostic tool for CSP detection. Treatment method
in this case is using a combination of local and intramuscular methotrexate and injection of 3%
NaCl locally. Periodic checks are needed to assess the effectiveness of the treatment carried out.
Although there is no standard management protocol for nontubal ectopic pregnancy. It is
recommended to assess clinical manifestation, gestational age, initial β-hCG levels, and the
presence or absence of cardiac activity to determine the use of clinical modalities in managing
CSP
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