1. 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

2. 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

3. Cesarean Scar Pregnancy

4. 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.

5. 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

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

8. 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

9. 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%

10. 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

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

12. 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

13. Thank you…