Systemic methotrexate is a safe and effective method in the management of cesarean scar pregnancy; a case series Kazibe Koyuncu, Emre Şükür, Batuhan Turgay, Salih Taşkın, Cem Atabekoğlu, Ruşen Aytaç, Esra Çetinkaya

Cesarean Scar Pregnancy The frequency of cesarean section (CS) is increasing, 1 in 2,000 pregnancy and accounts for 6% of ectopic pregnancies The pregnancy is located in the scar, surrounded by myometrium and connective tissue. Reported risk factors for CSP; Adenomyosis, In vitro fertilization, Previous dilation and curettage, Anual removal of the placenta

Cesarean Scar Pregnancy

Cesarean Scar Pregnancy Here in, we report four women with different clinical presentations who were diagnosed with CSP between January 2014 and January 2016 and their management.

Clinical characteristics of the patients Age 38 41 39 Parity/ Previous CS (n) 4/2 2/1 2/2 3/3 Presentation Bleeding (spotting) Pelvic discomfort Asymptomatic Moderate bleeding, pelvic pain, uterine tenderness Ultrasonography findings GS: 30x34x55 mm, YS (+), CRL: 5.7 mm, HB (-) GS: 27x23x17 mm, YS (+), CRL: 5.1 mm, HB (-) GS: 32x25x18 mm, YS (+), CRL: 5.8 mm, HB (-) GS: 21x18x15 mm, YS (+) Estimated GA (weeks) 8 7 βhCG level on admission (mIU/mL) 51.740 23.054 38.057 1.170 Systemic methotrexate Single dose Second dose Duration of βhCG to become negative (days) 35 22 27 28

Discussion The complication rates increase with the increasing prevalence of cesarean section Symptoms may occur later when compared to tubal ectopic pregnancies

Discussion Treatment modalities for CSP; Include systemic or local methotrexate administration, Local potassium chloride injection Surgical resection of CSP Dilatation and curettage with or without hysteroscopy Uterine artery embolization Laparoscopy Bilateral uterine artery chemoembolization

Discussion Most women diagnosed with CSP are in their reproductive ages and preserving fertility is one of the main issues during the management. Medical treatment appears to be the most appropriate first line treatment and has been adopted in our clinic as the primary treatment for CSP. The success rate of systemic methotrexate was reported between 71 to 80%, with a hysterectomy rate of only 6%

Discussion The time needed for βhCG levels to become undetectable were 5 weeks at most The majority of patients get pregnant spontaneously following uterine-conservative treatment of CSPs. The conception rate is 87.5% A one-year interval is suggested before conception after a CSP that the scar may heal

Discussion In our study systemic methotrexate treatment was succesfull in all cases, despite the wide range of βhCG levels

Conclusion CSP is a rare type of ectopic pregnancy and may refer with several presentations from asymptomatic to bleeding and pain Although the patients generally present with high βhCG levels, CSP can be successfully managed with systemic methotrexate therapy Although there is no consensus on treatment method for CSP, systemic methotrexate seems to be safe as a first line approach in clinically stable patients

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