1. Methotrexate Management of an Ectopic Pregnancy in  Previous Cesarean Section Scar
Oudai ALI, Katja Christodoulou, Rafia Deader, Susanne Johnson
Southampton University Hospital, Southampton, UK
Discussion
This a case of none tubal ectopic. It implanted at the Caesarean section scar 4 months following the section. It presented confusion in the diagnosis and caused the patient to bleed profusely. She was managed non surgically by successful methotrexate treatment.
Non Tubal Ectopics
Historically, were only diagnosed at laparotomy after rupture, on histology of hysterectomy specimen. Difficult to assess true incidence.
Risk factors similar for all types: Previous ectopic, IUCD, and PID and they are on the rise ( better diagnosis and increased section rate).
Diagnostic and therapeutic challenge due to atypical location and lack of experience in management.
Management general; no routine treatment protocols due to small number of cases. Most treatments based on few cases or reviews.
Optimum treatment depends on many factors including; clinical status of patient, gestational, age, presence of fetal heart.
Management options C-section ectopic
Expectant (not recommended!),
ERPC (not recommended!)
Medical, Local injection methotrexate +/- KCl.
Systemic Methotrexate or Combined local and systemic
Surgical: Laparoscopic Resection/ Hysteroscopic resection
Interventional radiology: Selective Uterine artery embolisation
Initial scan at presentation to the gynaecology unit;’ a gestational sac of 14 x 11 x 10 mm with an embryo and fetal heart action present’. The diagnosis was stated as gestation sac implanted low , ? cervical ectopic.
Case Report
Clinical Presentation
This is a 28 year old woman, G5 P2+2 miscarriages, one emergency and one elective LSCS, the most recent section was only 4 months ago. She was seen initially in EPU with Left iliac fossa pain at approximately five week of unplanned gestation. The 48 hr β-hCG rise was from 780 to 2230 IU/L.. .
She was booked for USS but she cancelled it as she wanted scan at the CASH (family planning service) for likely termination. Two weeks later she presented to the AE with painless heavy PV bleeding. Patient reported that scan at CASH showed intrauterine pregnancy!
In the AE she was haemodynamically unstable at presentation, she was fluid resuscitated and transferred to the gynaecology unit. She was treated as “likely complete miscarriage”. The following day, PV bleeding started again. Departmental USS initially reported cervical ectopic but further USS by an experienced operator indicated “suspected Caesarean scar ectopic pregnancy’’ .
Next day on admission, she had more detailed TVUSS by a senior experienced sonographer. It was more detailed and indicated ectopic at the section scar.
The detailed TVUSS report; ‘gestation sac of 24 x 7 x 12 mm, containing a yolk sac and a fetal pole with fetal heart movements CRL measuring 5.8 mm (approximating 6W1D gestation)’
Case Report
Management
Patient continued to bleed, and was transfused 3 units of blood. The management discussed included balloon tamponade or treatment with systemic Methotrexate, and warned that she may require examination under anaesthesia with the possibility of hysterectomy. She was eventually treated with systemic Methotrexate and USS following day confirmed collapsing GS, no yolk sac or fetal pole seen.
Patient was self-discharged, but follow up was done in EPU clinic with β-hCG until normal.
Scan two after presentation showed a heterogeneous well defined small solid (no fetus) in the caesarean section scar, representing an old caesarean scar ectopic pregnancy not fully resorbed. She defaulted from further follow up scans.
One day after Methotrexate TUSS report; ‘the previously seen cervical gestation sac appears irregular and collapsed measuring 24 x 23 mm and containing low level echoes. No yolk sac or fetal pole seen’. This was reported as collapsing cervical ectopic.
References
Jurkovic D, Hillaby K, Woelfer B et al. First trimester diagnosis and management of pregnancies implanted in to the lower uterine segment Cesarean section scar. Ultrasound Obstetrics & Gynecology 2003; 21:
Chetty M & Elson. Treating non-tubal ectopic pregnancy. Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009)
Rotas M, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis and management. Obstetrics &Gynaecology 2006; 106 (6): 1373 – 1381
Gynaecological Ultrasound in Clinical Practice: Ultrasound Imaging in the Management of Gynaecological Conditions. Jurkovic D, Valentin L, Vyas S. Non-tubal ectopic pregnancies;
USS done two weeks following methotrexate treatment report; ‘there is heterogeneous well defined sold area with no fetus seen in the section scar measures 29 x 15 x 26 mm’. The impression is old Caesarean section scar ectopic, the products not fully resorbed.