RAMB Março/Abril 2016

ocal

management

with

methotrexate

cesarean

scar

ectopic

pregnancy

with

live

embryo

guided

transvaginal

ultrasound

: A

case

report

ssoc

ras

2016; 62(2):184-187

185

than 5,000 mIU/mL, and a single dose if less than 5,000

mIU/mL; drug treatment with local injection of metho-

trexate guided by transvaginal ultrasound if the embryo

is alive, with an association made with the protocol for

multiple dose of systemic methotrexate if the

-hCG val-

ue exceeds 5,000 mIU/mL. In the last treatment option,

methotrexate is given at a dose of 1 mg/kg, initially with

local injection, followed by 3 intramuscular doses on al-

ternate days. In the days between these doses, folinic acid

was administered at a dose of 0.1 mg/kg and control tests

for possible methotrexate toxicity (hepatic and renal func-

tion), and

-hCG dosage are measured.

In this case report the patient presented a cesarean

scar ectopic pregnancy with live embryo and

-hCG of

18,716 mIU/mL. As such, local treatment with transvag-

inal ultrasound-guided injection of methotrexate was in-

dicated, complemented with the protocol of multiple sys-

temic doses of methotrexate.

Post treatment follow-up was done with weekly dos-

ing of

-hCG up to a value of less than 5,000 mIU/mL

and realization of transvaginal ultrasound until the ab-

sence of the Doppler flow.

ase

report

The 30-year old pregnant patient, weighing 68 kg,

secundi-

gravida

, with previous cesarean delivery 12 years before, was

6 weeks late on her period although presenting a small

amount of vaginal bleeding for 1 day. On physical exami-

nation the patient was hemodynamically stable; in the spec-

ulum examination there was the presence of vaginal bleed-

ing collected in small quantities; and in the touch

examination the cervix was impervious, with an increased

uterus for 6 weeks, and palpable attachments without chang-

es. The laboratory tests were:

-hCG of 18,716, mIU/mL,

blood test with hemoglobin (Hb) of 12.8 g/dL, hematocrin

(Ht) of 38.5%, leukocytes of 7,450/uL, platelets of 209,000/

uL, positive O Rh blood typing, 0.57 mg/dL of creatinine,

urea of 18 mg/dL, SGOT of 26 U/L and SGPT of 28 U/L.

Transvaginal ultrasound performed on this day showed

a 6 mm crown to rump length (CRL), corresponding to

gestational age of 6 weeks and 4 days, a gestational sac of

16 x 14 x 9.6 mm located at the site of the previous cesare-

an section scar with a live embryo (126 bpm fetal heart

rate), an empty uterine cavity and attachments without

changes. The gestational sac was located approximately 22

mm from the external orifice of the cervix (Figure 1).

Due to the presence of the live embryo, the patient

was submitted to transvaginal ultrasound-guided punc-

ture and injection of methotrexate inside the gestation-

al sac at 68 mg (1 mg/kg). A 17 Gauge Cook

Medical

needle was used, guided by the Aloka 500

ultrasound

apparatus.

In addition to the local dose, three 68 mg intramus-

cular doses of methotrexate (1 mg/kg) interspersed with

4 intramuscular doses of folinic acid at 6.8 mg (0.1 mg/

kg) were given.

The patient remained in hospital until the last dose

of folinic acid without clinical complications after the

procedure, showing only slight abdominal colic treated

with analgesia, receiving a discharge with weekly follow-

up at the outpatient clinic specializing in ectopic preg-

nancy at Hospital São Paulo (Unifesp).

It is important to note that blood test, hepatic and

renal function examinations remained normal from ad-

mission to discharge from hospital.

Seven days after discharge, the patient sought the

Gynecology and Obstetrics emergency service of the Hos-

pital São Paulo complaining of vaginal bleeding. In the

physical examination the patient was found to be hemo-

dynamically stable, the abdominal examination showed

no changes, the specular examination showed the pres-

ence of a discrete amount of blood collected, painless vag-

inal touch with impervious cervix, and intrapelvic uter-

us and attachments normal to the touch. The laboratory

examinations on this occasion were still normal (blood,

hepatic and renal function), showing that there was no

methotrexate toxicity, with Hb of 12 g/dL and

-hCG of

6,129 mIU/mL. Another ultrasound examination was per-

formed with uterine volume of 200 cm³ and presence of

a cystic image on the anterior uterine wall with anecho-

ic content and irregular walls, measuring 1.3 x 1.2 x 0.5 cm,

without characterization of an embryo, endometrial echo

of 1.2 cm and unchanged attachments.

FIGURE 1

Ultrasonography showing the anatomical relationship

between bladder, cervix, uterine body and gestational sac in the

topography of the cesarean scar, with an empty uterine cavity.