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doi:10.1111/jog.12414
J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1700–1706, June 2014
Successful medical treatment of cesarean scar ectopic pregnancies with systemic multidose methotrexate: Single-center experience Mehmet Serdar Kutuk, Gulsum Uysal, Mehmet Dolanbay and Mahmut Tuncay Ozgun Department of Obstetrics and Gynecology, Erciyes University Faculty of Medicine, Kayseri, Turkey
Abstract Aim: The aim of this study was to investigate the efficacy, and the safety of systemic multidose methotrexate (MTX) for the treatment of cesarean scar pregnancy (CSP). Material and Methods: This retrospective cohort study was performed using records from the Department of Obstetrics and Gynecology, Erciyes University, between 2010 and 2012. The data were analyzed with respect to obstetric characteristic, course of treatment, clinical, and reproductive outcomes. Results: A total of 13 patients were evaluated. The median gestational age at diagnosis was 5 weeks 5 days (range: 4–9 weeks). The mean beta human chorionic gonadotrophin level was 11 240.31 ± 9812.68 IU/L (range: 2565–36 111 IU/L). All patients were successfully treated with systemic multidose MTX therapy. The average MTX dose was 5.7 (range: 2–9). The interval between the first MTX injection and the normalization of beta human chorionic gonadotrophin was 8 ± 2.27 weeks (range: 4–12 weeks). One patient showed mild leucopenia that reversed after the treatment. Three patients had successful uncomplicated intrauterine pregnancy after the treatment, which resulted in term infants. Conclusion: Systemic multidose MTX therapy is an effective and safe treatment method for CSP. However, further studies are needed to compare the safety, effectiveness and reproductive outcome of different treatment modalities in CSP. Key words: cesarean scar pregnancy, ectopic pregnancy, methotrexate, scar ectopic, systemic.
Introduction Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy resulting from implantation of an embryo on previous cesarean scar. Although little is known about the pathogenetic mechanism of CSP, the presence of previous uterine scar and/or injury is the sine qua non. With the increasing prevalence of cesarean section (CS) birth and the widespread use of ultrasonography in early gestation, the rate of CSP had been exponentially increased with a current rate of 1/1800– 2500.1–4 In view of its increasing prevalence and the
serious maternal complications associated with it, the diagnosis and treatment of CSP are of capital importance. However, the current treatment recommendations are largely based on small case groups, and expert opinions. As CSP is a condition of reproductive age, the conservation of fertility is the main concern for the patient and the gynecologist. Therefore, invasive and radical treatments, such as hysterectomy and hysterotomy, have recently been replaced by medical and minimally invasive therapies, and also some combinations of both.5 In this study, we aimed to present our experience
Received: August 10 2013. Accepted: January 25 2014. Reprint request to: Dr Mehmet Serdar Kutuk, Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Gevher Nesibe Hospital, 38039 Kayseri, Turkey. Email: [email protected]
1700
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Cesarean scar ectopic pregnancies
with 13 cases of CSP treated with systemic methotrexate (MTX) therapy with special emphasis on treatment outcome.
Methods This study was conducted in the Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University from 2010 to 2012. Thirteen cases of cesarean scar pregnancies were seen within a period of 24 months in our clinic. The medical records, sonographic images, and the follow-up data were assessed. Nine cases were primarily diagnosed by our clinic, and the rest were referred from local clinics with the diagnosis of CSP. All cases were evaluated with both transabdominal and transvaginal ultrasonography, the latter of which was the procedure of choice for final diagnosis. The diagnosis of CSP was based on the criteria postulated by Godin et al.6 and included: (i) well-formed gestational sac in the myometrium of the lower uterine segment; (ii) presence of an empty uterine and cervical cavity; and (iii) lack of continuity of myometrial image between bladder and gestational sac (Fig. 1). Patients were counseled about the risks of the condition and management alternatives, including potential benefits and risks. Patients signed a written informed consent for treatment. Baseline beta human chorionic gonadotrophin (β-hCG) levels were noted. Blood tests for liver function and complete blood count were requested. Gestational age was determined according to the last
(a)
(b)
(c)
(d)
Figure 1 Transvaginal sagittal view of cesarean scar pregnancies at (a) 4, (b) 5, (c) 5 and (d) 6 gestational weeks. Note the implantation of the gestational sacs on the cesarean scar and the empty endometrial cavities.
menstrual period. Sac dimension and crown–rump length were used for determining gestational age in situations where patients could not remember last menstrual period, or where a discrepancy existed. In all cases, multidose MTX therapy was applied irrespective of the pre-treatment sonographic findings, gestational age and level of serum β-hCG. All patients were hospitalized at the beginning of the therapy. Multidose systemic MTX protocol included the administration of four doses of MTX alternating with leucovorin. Additional doses were given every other day when the β-hCG titers plateaued or did not decrease to 50% of baseline level (Table 1). For follow-up, serum β-hCG testing was performed every other day until the titers decreased to 50% of pretreatment levels and weekly thereafter, until the titers returned to normal levels (
doi:10.1111/jog.12414
J. Obstet. Gynaecol. Res. Vol. 40, No. 6: 1700–1706, June 2014
Successful medical treatment of cesarean scar ectopic pregnancies with systemic multidose methotrexate: Single-center experience Mehmet Serdar Kutuk, Gulsum Uysal, Mehmet Dolanbay and Mahmut Tuncay Ozgun Department of Obstetrics and Gynecology, Erciyes University Faculty of Medicine, Kayseri, Turkey
Abstract Aim: The aim of this study was to investigate the efficacy, and the safety of systemic multidose methotrexate (MTX) for the treatment of cesarean scar pregnancy (CSP). Material and Methods: This retrospective cohort study was performed using records from the Department of Obstetrics and Gynecology, Erciyes University, between 2010 and 2012. The data were analyzed with respect to obstetric characteristic, course of treatment, clinical, and reproductive outcomes. Results: A total of 13 patients were evaluated. The median gestational age at diagnosis was 5 weeks 5 days (range: 4–9 weeks). The mean beta human chorionic gonadotrophin level was 11 240.31 ± 9812.68 IU/L (range: 2565–36 111 IU/L). All patients were successfully treated with systemic multidose MTX therapy. The average MTX dose was 5.7 (range: 2–9). The interval between the first MTX injection and the normalization of beta human chorionic gonadotrophin was 8 ± 2.27 weeks (range: 4–12 weeks). One patient showed mild leucopenia that reversed after the treatment. Three patients had successful uncomplicated intrauterine pregnancy after the treatment, which resulted in term infants. Conclusion: Systemic multidose MTX therapy is an effective and safe treatment method for CSP. However, further studies are needed to compare the safety, effectiveness and reproductive outcome of different treatment modalities in CSP. Key words: cesarean scar pregnancy, ectopic pregnancy, methotrexate, scar ectopic, systemic.
Introduction Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy resulting from implantation of an embryo on previous cesarean scar. Although little is known about the pathogenetic mechanism of CSP, the presence of previous uterine scar and/or injury is the sine qua non. With the increasing prevalence of cesarean section (CS) birth and the widespread use of ultrasonography in early gestation, the rate of CSP had been exponentially increased with a current rate of 1/1800– 2500.1–4 In view of its increasing prevalence and the
serious maternal complications associated with it, the diagnosis and treatment of CSP are of capital importance. However, the current treatment recommendations are largely based on small case groups, and expert opinions. As CSP is a condition of reproductive age, the conservation of fertility is the main concern for the patient and the gynecologist. Therefore, invasive and radical treatments, such as hysterectomy and hysterotomy, have recently been replaced by medical and minimally invasive therapies, and also some combinations of both.5 In this study, we aimed to present our experience
Received: August 10 2013. Accepted: January 25 2014. Reprint request to: Dr Mehmet Serdar Kutuk, Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Gevher Nesibe Hospital, 38039 Kayseri, Turkey. Email: [email protected]
1700
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Cesarean scar ectopic pregnancies
with 13 cases of CSP treated with systemic methotrexate (MTX) therapy with special emphasis on treatment outcome.
Methods This study was conducted in the Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University from 2010 to 2012. Thirteen cases of cesarean scar pregnancies were seen within a period of 24 months in our clinic. The medical records, sonographic images, and the follow-up data were assessed. Nine cases were primarily diagnosed by our clinic, and the rest were referred from local clinics with the diagnosis of CSP. All cases were evaluated with both transabdominal and transvaginal ultrasonography, the latter of which was the procedure of choice for final diagnosis. The diagnosis of CSP was based on the criteria postulated by Godin et al.6 and included: (i) well-formed gestational sac in the myometrium of the lower uterine segment; (ii) presence of an empty uterine and cervical cavity; and (iii) lack of continuity of myometrial image between bladder and gestational sac (Fig. 1). Patients were counseled about the risks of the condition and management alternatives, including potential benefits and risks. Patients signed a written informed consent for treatment. Baseline beta human chorionic gonadotrophin (β-hCG) levels were noted. Blood tests for liver function and complete blood count were requested. Gestational age was determined according to the last
(a)
(b)
(c)
(d)
Figure 1 Transvaginal sagittal view of cesarean scar pregnancies at (a) 4, (b) 5, (c) 5 and (d) 6 gestational weeks. Note the implantation of the gestational sacs on the cesarean scar and the empty endometrial cavities.
menstrual period. Sac dimension and crown–rump length were used for determining gestational age in situations where patients could not remember last menstrual period, or where a discrepancy existed. In all cases, multidose MTX therapy was applied irrespective of the pre-treatment sonographic findings, gestational age and level of serum β-hCG. All patients were hospitalized at the beginning of the therapy. Multidose systemic MTX protocol included the administration of four doses of MTX alternating with leucovorin. Additional doses were given every other day when the β-hCG titers plateaued or did not decrease to 50% of baseline level (Table 1). For follow-up, serum β-hCG testing was performed every other day until the titers decreased to 50% of pretreatment levels and weekly thereafter, until the titers returned to normal levels (
