Management of caesarean scar pregnancy with high dose intravenous methotrexate infusion therapy: 10-year experience at a single tertiary centre

Abstract

Objective: Incidence of caesarean scar pregnancy (CSP) is increasing due to rising caesarean section rate and advanced imaging modalities. At present, there is no consensus to recommend any specific intervention. In our centre, we have adopted the high dose intravenous methotrexate therapy followed by folinic acid for the management of CSP. In this retrospective study, we report the success rate and safety of this regimen.

Study design: This was a 10-year retrospective study of women with CSP who received high dose methotrexate therapy with folinic acid at a tertiary centre from 1 st January 2008 to 31 st December 2017. Treatment regimen consisted of a bolus dose of intravenous methotrexate followed by methotrexate infusion over 12 h. Oral folinic acid rescues were given post treatment. Successful treatment was confirmed with either resolution of serum beta-human chorionic gonadotropin or subsequent intrauterine pregnancy.

Results: Of 28 women with CSP who were treated with the regimen, 24 women (85.7%) were treated successfully with methotrexate alone. 3 women (10.7%) required suction evacuation following initial treatment with methotrexate and folinic acid. There was no serious side effect from methotrexate. Advanced gestational age, higher serum β-hCG, larger gestational sac diameter and crown-rump length, and the presence of embryonic cardiac activity were associated with methotrexate failure or need for additional therapy.

Conclusions: Our high dose intravenous methotrexate infusion therapy with folinic acid is effective and well tolerated. Caution is needed with factors associated with failure. Ensuring follow up ultrasound for live CSP and follow up β-hCG for all women with CSP is essential.

Keywords: Caesarean scar pregnancy; Ectopic pregnancy; Medical management; Methotrexate.