Introduction: Caesarean scar pregnancies (CSPs) are on the rise parallel to increasing caesarean section rates. Management of CSP lacks consensus. We report here our experience of treating nine CSPs in a single unit with medical management followed by suction evacuation.
Materials and Methods: All cases of CSPs had pre-treatment serum beta human chorionic gonadotropin (βhCG). If embryonic cardiac activity was present, Potassium Chloride (KCl) 0.3 to 0.5 ml was injected intracardiac under ultrasound guidance transvaginally. This was followed by intramuscular methotrexate alternating with follinic acid (methotrexate day 1,3,5,7 and follinic acid day 2,4,6,8). If embryonic cardiac activity was absent, only methotreaxate along with follinic acid was used in the same manner. Serum βhCG was measured on day 5,7,14 and thereafter fortnightly. At fall of 15% of previous level, methotrexate was stopped. At βhCG level of ≤200 mIU/ ml suction evacuation was done. Note was made of hemorrhage requiring blood transfusion/tamponade/surgical management. Complete cure was defined as successful suction evacuation, or spontaneous resolution of mass and no complications.
Results: Mean gestational age of entire cohort was53.44 days (r43-70).Mean βhCG level was 63484.2mIU/ml (r 12275-91970 mIU/ml). Embryonic cardiac activity was present in six out of nine cases. Four doses of methotrexate were required in two patients, three doses in five, two doses in two patients.
By day 14, all patients had a significant fall in βhCG level (p=0.008). By day 60th, all patients had βhCG level of ≤ 200 mIU/ml. Regarding outcome, suction evacuation was required in 7 patients, one had spontaneous resolution. One case had significant hemorrhage at suction evacuation which was successfully managed with balloon tamponade. One case required emergency hysterectomy. Both these cases required blood transfusion. No patient experienced any adverse effects of methotrexate.
Overall success rate was 77.78% (7 out of 9 cases) and the complication rate of 22.22% (2 out of 9 cases).
Conclusion: Medical management followed by suction evacuation is a reasonable option for treating CSPs.