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L
ocal
management
with
methotrexate
of
cesarean
scar
ectopic
pregnancy
with
live
embryo
guided
by
transvaginal
ultrasound
: A
case
report
R
ev
A
ssoc
M
ed
B
ras
2016; 62(2):184-187
187
peated when
β
-hCG reaches a negative value or after 3
months of drug treatment. This should only be brought
forward if there are new episodes of bleeding.
In our case, a surgical approach was not required,
using merely drug treatment with a local dose plus three
local doses of systemic methotrexate. However, a slow re-
gression of
β
-hCG values was observed to the initially
high values, taking 58 days to reach negative values. An
Australian article about 13 cases of cesarean scar ecto-
pic pregnancy suggests that the association of local drug
treatment with systemic doses can reduce the time in-
terval for
β
-hCG to become negative and that local meth-
otrexate seems to be more effective than systemic treat-
ment alone due to the presence of fibrotic tissue in the
region of the scar, limiting the access of systemic medi-
cation.
14
After 3 to 6 months of disappearance of the image of
the ectopic pregnancy, our recommendation is to per-
form hysterosalpingography and hysteroscopy for better
assessment of the uterine cavity, as well as adequate re-
productive planning for these patients.
C
onclusion
The early diagnosis of cesarean scar ectopic pregnancy is
performed via transvaginal ultrasound and is fundamen-
tal for the indication of suitable conservative treatment.
Drug treatment with a local dose of ultrasound-guided
methotrexate in the presence of a live embryo, associat-
ed with a protocol of multiple doses of systemic metho-
trexate when
β
-hCG exceeds 5,000 mIU/mL has been
found effective, preventing mutilating surgeries and spar-
ing fertility in these patients.
R
esumo
Tratamento local com metotrexato guiado por ultrasso-
nografia transvaginal de gravidez ectópica em cicatriz de
cesárea com embrião vivo: relato de caso
A gravidez ectópica na cicatriz de cesárea é uma forma rara
de gestação ectópica com elevada morbimortalidade. O em-
prego de condutas conservadoras, como o tratamento me-
dicamentoso commetotrexato, tem evitado cirurgias muti-
ladoras, como a histerectomia, e preservado o futuro
reprodutivo da mulher. Relatamos um caso de paciente de
30 anos, com gravidez ectópica em cicatriz de cesárea, com
embrião vivo, tratada com injeção local de metotrexato guia-
da por ultrassonografia transvaginal, complementada com
tratamento sistêmico commúltiplas doses de metotrexato.
Palavras-chave:
gravidez ectópica, metotrexato, cicatriz,
cesárea.
R
eferences
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FIGURE 3
Transvaginal ultrasonography after 3 months of drug
treatment with local and systemic methotrexate for cesarean scar
ectopic pregnancy.