Effective Management of Cesarean Scar Ectopic Pregnancy with Local Methotrexate Injection and Balloon Catheter Compression: A Detailed Case Report

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What are the key imaging findings on transvaginal ultrasound suggestive of Cesarean Scar Ectopic Pregnancy (CSEP)?

Understanding Cesarean Scar Ectopic Pregnancy (CSEP)

Cesarean scar ectopic pregnancy (CSEP),a rare but life-threatening complication of prior cesarean delivery,occurs when a gestational sac implants within the scar tissue of the uterine wall. The incidence of CSEP is rising, correlating with increasing rates of cesarean sections globally. Early diagnosis is crucial, as rupture can lead to catastrophic hemorrhage and maternal morbidity. Key risk factors include multiple cesarean deliveries, a history of myomectomy, and assisted reproductive technologies (ART). Accurate diagnosis relies heavily on transvaginal ultrasound (TVUS) and serum beta-hCG monitoring.differentiating CSEP from a pseudo-gestational sac is paramount.

Diagnostic Challenges & Imaging Modalities

Diagnosing CSEP can be challenging due to its rarity and often subtle presentation. Symptoms can mimic those of a normal early pregnancy or a threatened miscarriage, including vaginal bleeding, abdominal pain, and a positive pregnancy test.

* Transvaginal Ultrasound (TVUS): The primary imaging modality. Findings suggestive of CSEP include a gestational sac located within the lower uterine segment at the site of a previous cesarean scar, a thin myometrial layer surrounding the sac, and absent or minimal blood flow within the sac.

* serum Beta-hCG: Serial monitoring of beta-hCG levels can aid in diagnosis. In a viable intrauterine pregnancy, beta-hCG typically doubles every 48-72 hours. In CSEP, the rise may be slower or plateau.

* MRI: Magnetic Resonance Imaging (MRI) can be helpful in cases where TVUS findings are inconclusive, providing a more detailed visualization of the uterine scar and gestational sac.

Medical Management: Local Methotrexate Injection

Systemic methotrexate (MTX) has traditionally been the mainstay of medical management for CSEP.However, systemic MTX carries potential side effects, including myelosuppression and liver toxicity. Local methotrexate injection, guided by ultrasound, offers a targeted approach with potentially fewer systemic complications.

* Injection Technique: Under ultrasound guidance, a small dose of MTX (typically 50mg/mL) is directly injected into the gestational sac.

* Monitoring: Post-injection, patients require close monitoring of serum beta-hCG levels. A decline of at least 15% every 48-72 hours is considered a positive response.

* Success Rates: Local MTX injection has demonstrated promising success rates, ranging from 70-90% in carefully selected patients.

Balloon Catheter Compression: An Adjunctive Technique

Balloon catheter compression (BCC) is increasingly being utilized as an adjunctive technique to enhance the efficacy of local MTX injection, particularly in cases of persistent or slow-responding CSEP. The principle behind BCC is to achieve hemostasis by compressing the feeding vessels to the ectopic pregnancy.

* Procedure: Following local MTX injection,a foley catheter balloon is inserted into the gestational sac and inflated with saline under ultrasound guidance.

* Compression Duration: The balloon is typically left in place for 24-72 hours, depending on the clinical response.

* Benefits: BCC can reduce the risk of tubal rupture and the need for surgical intervention. It also aids in achieving complete resolution of the ectopic pregnancy.

Case Report: Prosperous Management of CSEP

A 32-year-old patient, G2P1, with a history of one prior cesarean delivery, presented with vaginal bleeding and lower abdominal pain at 6 weeks gestation. TVUS revealed a gestational sac implanted within the lower uterine segment at the site of the previous cesarean scar, consistent with CSEP. Serum beta-hCG was 1200 mIU/mL.

The patient was deemed a suitable candidate for local MTX injection and BCC. Under ultrasound guidance, 50mg of MTX was injected directly into the gestational sac, followed by insertion of a 12 French Foley catheter balloon inflated with 5mL of saline.The balloon was left in place for 48 hours.

Serial beta-hCG levels demonstrated a notable decline: 800 mIU/mL after 48 hours, and undetectable levels after 7 days. Follow-up TVUS confirmed complete resolution of the gestational sac. The patient remained stable throughout the treatment and was discharged home with close follow-up.

Patient Selection Criteria for Combined Therapy

Careful patient selection is crucial for optimizing the success of combined local MTX injection and BCC. Ideal candidates include:

1. Hemodynamically stable patients.
2. No evidence of rupture or significant bleeding.
3. Beta-hCG levels < 5000 mIU/mL. (Though this is a guideline, individual cases should be assessed.)
4. Absence of contraindications to MTX (e.g., liver disease, renal failure, bone marrow suppression).
5. Willingness to adhere to close follow-up.

Potential Complications & Management Strategies

While local MTX injection and BCC are generally safe, potential complications can occur.

* MTX Side Effects: Although less common with local injection, systemic side effects such as nausea, stomatitis