Abstract
Objective: A case of cesarean scar pregnancy (CSP) treated by a combination of systemic methotrexate (MTX) administration, selective uterine artery embolization (UAE), and hysteroscopic surgery is reported.
Case: A 37-year-old woman, with a history of two previous cesarean sections, presented with suspicion of a cervical pregnancy at 5 weeks' gestation. A diagnosis of CSP was made by ultrasonography when a gestational sac and viable embryo (without heart movement) were detected near the right cesarean scar. The findings were confirmed by magnetic resonance imaging. In addition, three-dimensional CT angiography showed that the gestational sac was perfused by only the right uterine artery. At first, single dose MTX (50 mg/body intramuscularly) was given. However, it failed, and serum hCG levels increased from 21995 mIU/ml to 38831 mIU/ml, and embryonic cardiac activity was detected. Therefore, the regimen was changed to a fixed multidose MTX regimen, which seemed effective because the serum hCG levels decreased gradually, and the fetal heartbeat was lost. At 9 weeks' gestation, the tissues of conception were removed by hysteroscopic surgery three days after selective right UAE. There were no complications such as heavy bleeding or uterine perforation.
Conclusion: When removing the gestational sac in CSP, hemorrhage may often be difficult to stop. However, there is no consensus about the optimal method for treating CSP. We consider that a combination of systemic MTX administration, selective UAE, and hysteroscopic surgery is a safe and useful treatment for CSP.
