Hysteroscopically-guided subchorionic methotrexate administration: A new technique for termination of cesarean scar pregnancy

Abstract

Introduction: cesarean scar pregnancy (csP) is a rare but life-threatening condition, due to the risk of uterine rupture or for the development of placenta previa/accreta. the mainstay of management to spare fertility is early diagnosis and pregnancy termination. Although several conservative treatments have been experienced, no consensus on the best therapeutic approach is currently shared. the medical therapy for csP termination is based on systemic or local Methotrexate (MtX) administration. Hysteroscopy allows the precise visualization of placental implantation and it can be used to drive MtX injection selectively within the intervillous placental spaces. this procedure increases drug concentration delivered to the target tissue, potentially improving its therapeutic index. case report: A 36-year-old female with a history of cesarean section was admitted to our department with a diagnosis of viable 7th weeks csP. the patient gave her consent to pregnancy termination by a hysteroscopically-guided MtX administration within the cervico-isthmic placental implantation site, followed by its resectoscopic removal. In an office setting, 80 mg of MtX were injected through a needle adaptable to the 5-Fr operative channel of hysteroscope, Giancarlo Garuti1, Stefania Calabrese1, Lorenzo Quirino1, Marco Di Mario1 Affiliations: 1MD, Obstetrics and Gynecology Department, Public Hospital of Lodi, Via Savoia 1, 26900-Lodi, Italy. Corresponding Author: Giancarlo Garuti (MD), Obstetrics and Gynecology Department, Lodi Hospital, via Savoia n° 1, 26900-Lodi, Italy; E-mail: giancarlo.garuti@tiscali.it Received: 03 October 2015 Accepted: 02 December 2015 Published: 27 February 2016 under the chorionic membrane of placental implantation site. the duration of the procedure took three minutes and it resulted easy, painless and uneventful. An early embryo demise was obtained; the human chorionic gonadotropinbeta subunit (beta-hcG) serum trend showed a rapid pregnancy termination and no patient complaints were recorded. After 28 days, a resectoscopic removal of the gestational sac and placenta was safely accomplished. conclusion: selective hysteroscopic administration of MtX within intervillous spaces of the ectopic placental implantation is effective and it can be considered for csP termination.