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Federación Mexicana de Ginecología y Obstetricia, A.C.

2024, Number 01

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Ginecol Obstet Mex 2024; 92 (01)

Management of cesarean scar pregnancy with methotrexate. A case series of combined systemic and percutaneous therapy in a III level center in Colombia

Gómez-Bossa MA, Montaño-Mendoza AA, Lozada-Ríos A, Píneda-Marriaga JÁ

Language: Spanish
References: 33
Page: 27-40
PDF size: 957.59 Kb.


ABSTRACT

Objective: To report a scheme of non-surgical care in patients with cesarean scar pregnancy in the context of a health system with low resources. In addition, to describe the tolerance, monitoring, evolution and outcome of each of the patients treated with the proposed scheme.
Materials and Methods: Descriptive study of a case series of patients who, between May 2020 and March 2023, attended the emergency room of a tertiary care caviinstitution in Barranquilla, Colombia, because of obstetric symptoms or were referred to the institution with a diagnosis of cesarean scar pregnancy confirmed by ultrasound. Study parameters: measurement of sociodemographic, obstetric, clinical evolution and maternal complication variables. Descriptive analysis of data was performed.
Results: Eleven patients were documented, giving an incidence of 1.85 cases per 5000 pregnancies. Pelvic pain and bleeding were the most common symptoms. Five patients had two or more previous cesarean sections, the remainder had only one previous cesarean section, and five had a history of obstetric curettage. Nine of the 11 patients were treated at less than 8 weeks' gestation. The success rate was 100%, with a mean beta-hCG negativity of 38.7 days. There were no major complications and no surgical intervention was required.
Conclusions: We describe the implementation of a combined systemic and local regimen with methotrexate that was safe and effective, with preservation of fertility.


REFERENCES

  1. Miller R, Timor-Tritsch IE, Gyamfi-Bannerman C: Societyfor Maternal-Fetal Medicine (SMFM) Consult Series #49:cesarean scar pregnancy. Am J Obstet Gynecol 2020; 222:B2-B14. doi: 10.1016/j.ajog.2020.01.030

  2. Antoine C, Young BK. Cesarean section one hundred years1920-2020: the Good, the Bad and the Ugly. J Perinat Med2020; 49 (1): 5-16. doi: 10.1515/jpm-2020-0305

  3. Betran AP, Ye J, Moller AB, Souza JP, et al. Trends andprojections of caesarean section rates: global and regionalestimates. BMJ Glob Health 2021; 6 (6): e005671. doi:10.1136/bmjgh-2021-005671

  4. Timor-Tritsch IE, Monteagudo A, Calì G, D'Antonio F, etal. Cesarean scar pregnancy: diagnosis and pathogenesis.Obstet Gynecol Clin North Am 2019; 46 (4): 797-811. doi:10.1016/j.ogc.2019.07.009

  5. Timor-Tritsch IE, Monteagudo A, Cali G, Palacios-JaraquemadaJM, et al. Cesarean scar pregnancy and early placentaaccreta share common histology. Ultrasound Obstet Gynecol2014; 43 (4): 383-95. doi: 10.1002/uog.13282

  6. Pekar-Zlotin M, Melcer Y, Levinsohn-Tavor O, Tovbin J, et al.Cesarean Scar Pregnancy and Morbidly Adherent Placenta:Different or Similar? Isr Med Assoc J 2017; 19 (3): 168-71.PMID: 28457095

  7. Nijjar S, Jauniaux E, Jurkovic D. Definition and diagnosisof cesarean scar ectopic pregnancies. Best Pract Res ClinObstet Gynaecol 2023; 89: 102360. doi: 10.1016/j.bpobgyn.2023.102360

  8. Kaelin Agten A, Cali G, Monteagudo A, Oviedo J, Ramos J,et al. The clinical outcome of cesarean scar pregnanciesimplanted "on the scar" versus "in the niche". Am J ObstetGynecol 2017; 216 (5): 510.e1-510.e6. doi: 10.1016/j.ajog.2017.01.019

  9. Kulshrestha V, Agarwal N, Kachhawa G. Post-caesareanNiche (isthmocele) in uterine scar: an update. J ObstetGynaecol India 2020; 70 (6): 440-46. doi: 10.1007/s13224-020-01370-0

  10. Iannone P, Nencini G, Bonaccorsi G, Martinello R, et al. Isthmocele:from risk factors to management. Rev Bras GinecolObstet 2019; 41 (1): 44-52. doi: 10.1055/s-0038-1676109

  11. González N, Tulandi T. Cesarean Scar Pregnancy: A SystematicReview. J Minim Invasive Gynecol 2017; 24 (5): 731-38.doi: 10.1016/j.jmig.2017.02.020

  12. Liu D, Yang M, Wu Q. Application of ultrasonography inthe diagnosis and treatment of cesarean scar pregnancy.Clin Chim Acta 2018; 486: 291-97. doi: 10.1016/j.cca.2018.08.012

  13. Ravi Selvaraj L, Rose N, Ramachandran M. Pitfalls in UltrasoundDiagnosis of Cesarean Scar Pregnancy. J ObstetGynaecol India 2018; 68 (3): 164-72. doi: 10.1007/s13224-016-0956-1

  14. Glenn TL, Bembry J, Findley AD, Yaklic JL, et al. Cesareanscar ectopic pregnancy: current management strategies.Obstet Gynecol Surv 2018; 73 (5): 293-302. doi: 10.1097/OGX.0000000000000561

  15. Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, SvarreNielsen H. Cesarean scar pregnancy: a systematic reviewof treatment studies. Fertil Steril 2016; 105 (4): 958-67.doi: 10.1016/j.fertnstert.2015.12.130

  16. Timor-Tritsch IE, Monteagudo A, Calì G, D'Antonio F, et al.Cesarean scar pregnancy: patient counseling and management.Obstet Gynecol Clin North Am 2019; 46 (4): 813-28.doi: 10.1016/j.ogc.2019.07.010

  17. Osborn DA, Williams TR, Craig BM. Cesarean scar pregnancy:sonographic and magnetic resonance imaging findings,complications, and treatment. J Ultrasound Med 2012; 31(9): 1449-56. doi: 10.7863/jum.2012.31.9.1449

  18. Cheung VY. Local Methotrexate Injection as the First-lineTreatment for Cesarean Scar Pregnancy: Review of theLiterature. J Minim Invasive Gynecol 2015; 22 (5): 753-8.doi: 10.1016/j.jmig.2015.04.008

  19. Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, et al.The diagnosis, treatment, and follow-up of cesarean scarpregnancy. Am J Obstet Gynecol 2012; 207 (1): 44.e1-13.doi: 10.1016/j.ajog.2012.04.018

  20. Gulino FA, Ettore C, Ettore G. A review on management ofcaesarean scar pregnancy. Curr Opin Obstet Gynecol 2021;33 (5): 400-404. doi: 10.1097/GCO.0000000000000734

  21. Al-Jaroudi D, Aboudi S, Baradwan S. Different treatmentmodalities for cesarean scar pregnancies: a single-centerexperience and literature review. Arch Gynecol Obstet2021; 303 (5): 1143-51. doi: 10.1007/s00404-020-05831-9

  22. Timor-Tritsch IE, Monteagudo A. Unforeseen consequencesof the increasing rate of cesarean deliveries: early placentaaccreta and cesarean scar pregnancy. A review. Am J ObstetGynecol 2012; 207: 14-29. doi: 10.1016/j.ajog.2012.03.007

  23. Gulino FA, Pappalardo E, Ettore C, Laganà AS, et al.Caesarean scar pregnancy: descriptive paper of threedifferent types of management on a series of clinical cases.Prz Menopauzalny 2020; 19 (2): 61-65. doi: 10.5114/pm.2020.97836

  24. Yin XH, Yang SZ, Wang ZQ, et al. Injection of MTX forthe treatment of cesarean scar pregnancy: comparisonbetween different methods. Int J Clin Exp Med 2014; 7:1867-72. PMID: 25126192.

  25. Yamaguchi M, Honda R, Uchino K, et al. Transvaginalmethotrexate injection for the treatment of cesareanscar pregnancy: efficacy and subsequent fecundity. JMinim Invasive Gynecol 2014; 21: 877-83. doi: 10.1016/j.jmig.2014.03.024

  26. Glenn TL, Bembry J, Findley A, Yaklic JL, et al. Cesareanscar ectopic pregnancy: Current management strategies.Obstet Gynecol Survey 2018; 73 (5): 293-302. doi: 10.1097/OGX.0000000000000561

  27. Pedraszewski P, Wlazlak E, Panek W, Surkont G. Cesareanscar pregnancy a new challenge for obstetricians. J Ultrason2018; 18: 56-62. doi: 10.15557/JoU.2018.0009

  28. Grechukhina O, Deshmukh U, Fan L, Kohari K, et al. Cesareanscar pregnancy, incidence, and recurrence: fiveyearexperience at a single tertiary care referral center.Obstet Gynecol 2018; 132 (5): 1285-95. doi: 10.1097/AOG.0000000000002940

  29. Noël L, Chantraine F. Methotrexate for embarazoen cicatriz de cesáreas. Best Pract Res Clin ObstetGynaecol 2023; 89: 102364. doi: 10.1016/j.bpobgyn.2023.102364 Noël L, Chantraine F. Methotrexatefor CSPs. Best Practice & research. Clinical Obstetrics& Gynaecology. 2023 Jul;89:102364. DOI: 10.1016/j.bpobgyn.2023.102364.

  30. Yang H, Li S, Ma Z, et al. Therapeutic effects of uterine arteryembolisation (UAE) and methotrexate (MTX) conservativetherapy used in treatment of cesarean scar pregnancy.Arch Gynecol Obstet 2016; 293: 819e23. doi: 10.1007/s00404-015-3881-0.

  31. Gromnica-Ihle E, Kr€uger K. Use of methotrexate in youngpatients with respect to the reproductive system. Clin ExpRheumatol 2010; 28: S80e4. PMID: 21044438

  32. Calì G, Timor-Tritsch IE, Palacios-Jaraquemada J, MonteaugudoA, et al. Outcome of Cesarean scar pregnancy managedexpectantly: systematic review and meta-analysis.Ultrasound Obstet Gynecol 2018; 51 (2): 169-75. doi:10.1002/uog.17568.

  33. Levin G, Zigron R, Dior UP, Gilad R, et al. Conservativemanagement of Caesarean scar pregnancies with systemicmultidose methotrexate: predictors of treatment failureand reproductive outcomes. Reprod Biomed Online 2019;39 (5): 827-34. doi: 10.1016/j.rbmo.2019.05.015.




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