Conservative treatment of ectopic pregnancy in a cesarean section scar with methotrexate: a case report

Ectopic pregnancies sited in dehiscent cesarean section scars have a high risk of rupture and bleeding. Attempts at operative therapy frequently end in loss of the uterus. A connection with the cavum uteri justifies an attempt at dilatation and curettage. We describes a patient with combined systemic and local intra-amniotic methotrexate (MTX). The uterus was preserved.     

Isthmic pregnancy located in a previous caesarean section scar treated with methotrexate. A case report

We report a case of a patient who presented an isthmic pregnancy successfully treated with an intramuscular injection of methotrexate. The diagnosis of isthmic pregnancy was made clinically (cervical colour was normal, inferior segment soft and enlarged) and echographically (long cervix, foetal sack situated in the isthmus and the uterine body was empty). An isthmic full term pregnancy is possible but would carry major haemorrhagic risk. There are several therapeutic options if the pregnancy is interrupted: medical treatment of methotrexate, curettage, curettage with embolisation of the uterine arteries and as a last resort, hysterectomy. The success of conservative treatment seems to be related to the criteria known for the cervical pregnancy, which are cardiac activity, the level of HCG, gestational age and cranial-caudal length.     

Ectopic pregnancy in a cesarean section scar

A combination of systemic chemotherapy, feticide with intrachest and intra-abdominal injection with methotrexate, and hysteroscopy with dilation and curettage to remove the gestational tissue was successful in the treatment of a cesarean scar ectopic pregnancy. This case presents images of the ultrasound, magnetic resonance imaging, and pathologic features unique to a cesarean scar pregnancy.     

Cervico-isthmic pregnancy developing within the scar of a previous cesarean section: a case report

The cervico-isthmic pregnancy is a rare event occurring during pregnancy. In this current report, we describe a case of a woman with pregnancy developed within a previous cesarean section scar and successfully treated with conservative management.     

Ectopic pregnancy within a cesarean delivery scar: a case report

The implantation of a pregnancy within the scar of a previous cesarean delivery is the rarest of ectopic pregnancy locations. If it is diagnosed early, treatment options are capable of preserving the uterus and subsequent fertility. However, a delay in either diagnosis or treatment can lead to uterine rupture, hysterectomy, and significant maternal morbidity.     

Successful medical treatment of cesarean scar pregnancy: a case report

OBJECTIVE: Cesarean scar pregnancy is implantation of the pregnancy within the fibrous tissue of the cesarean scar which is completely surrounded by myometrium. METHOD AND RESULT: A 32-year-old woman, gravida 2, para 1 presented at our emergency department with mild lower abdominal pain and minimal vaginal bleeding. She was diagnosed with cesarean scar pregnancy. Conservative treatment with methotrexate 50 mg/m2 was administered IM on days 0 and 8. Her betaHCG value was zero at the 14th week after beginning of the treatment. CONCLUSION: Repeated methotrexate administration in the management of cesarean scar pregnancy should be attempted in informed patients who especially desire fertility and can be closely followed up.     

Methotrexate for cesarean scar pregnancy after in vitro fertilization and embryo transfer. A case report

BACKGROUND: Cesarean scar pregnancy is an exceedingly rare occurrence. We present the first case of cesarean scar pregnancy following in vitro fertilization-embryo transfer (IVF-ET). CASE: A 40-year-old woman with a history of a previous cesarean section presented with five years of unexplained infertility. The patient complained of abdominal pain 16 days after embryo transfer. Ultrasonography revealed a gestational sac with cardiac activity located outside the lower segment of the uterus. Dilatation and curettage was performed due to misdiagnosis of inevitable abortion. Two weeks later, repeated sonography demonstrated a sacculus, 4.07 x 4.07 cm, within the uterine isthmus with only 7.1 mm of thickness separating the sac from the urinary bladder. Normal cervical length without ballooning was noted. Cesarean scar pregnancy was diagnosed. Local injection of methotrexate (MTX) under ultrasound guidance was performed. Plasma beta-hCG levels declined from 23,328 to 8 mlU/mL within two months. CONCLUSION: For women with cesarean scar pregnancy who desire fertility, conservative treatment using MTX is an excellent choice.     

Laparoscopic management of an ectopic pregnancy in a lower segment cesarean section scar: a review and case report

Implantation of a pregnancy within the scar of a previous cesarean delivery is the rarest of ectopic pregnancy locations, with only 32 cases reported in the English-language medical literature. A 28-year-old woman was admitted to our institution with a suspected ectopic pregnancy located in the scar from a previous cesarean section. Ultrasound revealed a well-encapsulated, bulging mass with a gestational sac within the anterior uterine isthmus in the site of an old cesarean delivery scar. Laparoscopy was performed to confirm the diagnosis, and the gestational products also were removed laparoscopically. The defect in the uterus was then repaired by suturing. Total operative time was 120 minutes, blood loss was limited, and no transfusion was needed. Laparoscopy may be a reasonable alternative to laparotomy for an unruptured ectopic pregnancy in a cesarean scar.     

Elective cesarean section in case of threatened twin pregnancy: a case report

The authors present the use of computer-aided monitoring of pregnancy in case of twin. In our case one twin was threatened of intrauterine death. The frequency of antepartum death of one twin varies from 0.5%-6.8% of all twin deliveries. The underlying causes for antepartum death are multiple. It suggests that fetal growth retardation is due to competition for uteroplacental circulation and nourishment. In this case, the smaller twin was threatened of intrauterine death, because of intrauterine growth retardation, so the pregnancy was delivered on 32. week of gestational age by cesarean section.     

High-grade endometrial stromal sarcoma in cesarean section scar isthmocele - case report

ObjectiveCesarean section scar defect isthmocele, the pouchlike defect in the anterior uterine wall of the prior cesarean site. No previous report of malignant neoplasm in the isthmocele have been published. We reported a case of High-grade endometrial stromal sarcoma in isthmocele.Case reportA 45-year-old patient with gravida 4, parity 2, two previous cesarean section presents of recurrent heavy vaginal bleeding. Curettage and hormone therapy were unsuccessful. She underwent hysteroscopic isthmoplasty. The pathology revealed high-grade sarcoma. Patient was referred to a tertiary medical center and she underwent total hysterectomy with bilateral salpingo-oophorectomy, aortic & pelvic LNs dissection. The final diagnosis was High-grade endometrial stromal sarcoma (HG-ESS) stage IA (pT1a N0) involving isthmocele.ConclusionThe presence of this rare tumor in the isthmocele is very interested. We stress the necessity for a high degree of suspicion to diagnose the malignancy in perimenopausal women with isthmocele and persisted abnormal uterine bleeding.     

Low-dose methotrexate treatment for interstitial pregnancy. A case report

BACKGROUND: Only a small number of case reports have described medical treatment of interstitial ectopic pregnancies. Almost all of the reported patients were treated with repeated high doses (1 mg/kg) of methotrexate. CASE: At 6 weeks of gestation, a 31-year-old woman, gravida 5, para 4, was diagnosed with a 0.96 x 1.36-cm right cornual pregnancy. As the patient desired future fertility, she received 100 mg of intramuscular methotrexate (50 mg/m2). She was then followed on an outpatient basis, with serum human chorionic gonadotropin values appropriately declining. Serial ultrasound also showed decreasing size of the gestational sac. Twenty-one days after the methotrexate dose, the patient experienced rupture of the right posterior cornu, necessitating exploratory laparotomy. CONCLUSION: Extreme caution should be used when treating interstitial gestations with single-dose methotrexate. All patients should be extensively counseled regarding the significantly increased risk of failure, possibility of rupture and need for emergency surgery.     

Hysteroscopic management of cesarean scar pregnancy after unsuccessful methotrexate treatment

Current management of cesarean scar pregnancy is conservative and consists of medical treatment with methotrexate (MTX). We present a report on a woman with this type of pregnancy who had continuous vaginal bleeding and persistent serum levels of beta human chorionic gonadotropin after undergoing curettage and MTX. Eventually, the remaining ectopic gestational tissue was removed by operative hysteroscopy.     

Effect of early pregnancy on a previous lower segment cesarean section scar.

OBJECTIVE: To summarize the manifestation, diagnosis, and early management of early pregnancy on a previous cesarean section scar. METHOD: Fifteen cases of early pregnancies implanted on previous cesarean section scars were diagnosed and treated in two obstetrical centers. RESULTS: The 15 patients had light, painless vaginal bleeding and their serum beta-subunit human chorionic gonadotropin (beta-HCG) was elevated. The interval between cesarean section and admission ranged from 6 months to 12 years (7.1+/-3.6 years). Doppler and real-time ultrasonic examinations demonstrated an enlargement of the previous cesarean section scar in the lower segment, a gestational sac or a mixed mass attached to the cicatrix, and a very thin myometrium between the gestational sac and the bladder wall. Serum beta-HCG dropped to normal in 12 of the 15 patients following treatment with crystalline trichosanthin injected into the cervix followed by oral mifepristone, intramuscular injections of methotrexate, or other appropriate treatment. Two patients underwent total hysterectomy due to massive vaginal bleeding. The remaining patient was misdiagnosed with choriocarcinoma and also had total hysterectomy. CONCLUSION: Pregnancy on a previous lower segment cesarean section scar is rare but very dangerous. Early diagnosis and effective conservative drug treatment may be instrumental in decreasing the occurrence of uterine rupture.     

Oral methotrexate for persistent ectopic pregnancy. A case report.

Persistent ectopic pregnancy complicates a significant percentage of conservative tubal pregnancy procedures. The optimal treatment of persistent trophoblast has yet to be determined. Most reported cases have been treated by reoperation and removal of the affected tube. Use of methotrexate may avoid the need for reoperation and permit tubal salvage. We report on a case of persistent ectopic pregnancy treated successfully using an oral methotrexate regimen originally described for treating nonmetastatic gestational trophoblastic neoplasia. Oral methotrexate provides a simple, convenient, outpatient treatment option for cases of persistent ectopic pregnancy diagnosed by a rise or plateau in human chorionic gonadotropin levels following conservative surgery.     

Recurrence of carcinoma cervix in the scar of previous cesarean section: a case report

Although rare, reports of carcinoma cervix recurring in abdominal incision, episiotomy scars, laparoscopic port sites, and drain sites are available. However, recurrence in the scar of a previous cesarean section (CS) is unreported. A 49-year-old female with a diagnosis of keratinizing squamous cell carcinoma (SCC) of cervix, stage IIB, was treated by radical radiotherapy. She had undergone CS, through midline abdominal incision, for three previous deliveries. Twenty months later, she presented with a nodule of size 2.5 x 2 cm(2) on the 26-year-old abdominal CS scar. Infiltration of the skin and extension into the deeper structures of the abdominal wall was present in an area of 5 x 4 cm(2). There was no evidence of disease on the cervix. A fine-needle aspiration cytologic examination from the nodule revealed keratinizing SCC. Ultrasonography and computerized tomography scan revealed a mass lesion along the abdominal CS scar with subcutaneous nodule and peritoneal extension. Multiple metastatic lesions were present in the liver. She was treated with chemotherapy and radiotherapy. The patient has lived for more than 12.5 months. The first report of recurrence of carcinoma cervix in a CS scar is presented. Literature on surgical scar recurrence in carcinoma cervix is reviewed.     

Symptomatic cesarean scar diverticulum: a case report

BACKGROUND: Extrauterine lesions of intermediate trophoblast have occurred in and around fallopian tubes and ovaries and are thought to result from an exaggerated trophoblastic response to the implantation site of a previous ectopic pregnancy. Additionally, cesarean scar defects have recently been identified as a source of persistent, irregular vaginal bleeding in women and can be identified by pelvic ultrasound. CASE: A 35-year-old woman presented with irregular vaginal bleeding in association with an anterior extrauterine cystic mass detected by pelvic ultrasound and thought to represent a cesarean scar defect. Subsequent histology revealed an endometrial diverticulum lined with chorionic-type intermediate trophoblast, a subpopulation of trophoblast that composes placental site nodules. CONCLUSION: This was the first case of a lesion of intermediate trophoblast occurring in a cesarean scar diverticulum.