Successful treatment of cesarean scar pregnancy by curettage after methotrexate therapy

Objective

In this study, we presented a case which was found to have cesarean scar pregnancy, applied suction curettage under ultrasonography when gestational material within cavity was not regressed after methotrexate administration, and treated without complication.

Case(s)

Twenty-seven-year-old G2P1A1 patient referred to our clinic with spotting complaint after 6 weeks of delayed menstruation. It was found in the transvaginal ultrasonography that there was an image consistent with the gestational sac with the size of 57x45 mm on isthmus level. It was observed that the gestational sac was localized in cesarean scar region and thinned down the myometrium in this region. Myometrial thickness was measured as 4.6 mm in the region adjacent to the bladder. The patient having bHCG value as 1670 was administered 1 mg/kg methotrexate intramuscularly. On the 21st day after methotrexate administration, suction curettage was applied under ultrasonography to the patient whose bHCG value dropped to 0 but no regression was observed in the mass within the cavity. After curettage, placental tissue in size of 24x22 mm with severe bleeding in scar area was observed. Due to possible uterine rupture and bleeding risk, the mass was not intervened again and methotrexate was applied for the second time. Two months after the treatment, it was seen that the mass was regressed completely, and the patient started to menstruate spontaneously.

Conclusion

If cesarean scar pregnancy is not diagnosed early and treated with an appropriate method, serious complications such as abundant bleeding, uterine rupture and bladder perforation may occur. There are two treatment options as medical and surgical methods. However, leading the treatment by considering the clinical presentation of patient, size of mass, distance from bladder and fertility request of patient is the most significant key to a successful treatment.

Keywords

Scar pregnancy, ultrasonography.