Research www. AJOG.

org

OBSTETRICS
The diagnosis, treatment, and follow-up
of cesarean scar pregnancy
Ilan E. Timor-Tritsch, MD; Ana Monteagudo, MD; Rosalba Santos, RDMS;
Tanya Tsymbal, RDMS; Grace Pineda, RDMS; Alan A. Arslan, MD

OBJECTIVE: The diagnosis and treatment of cesarean scar pregnancy RESULTS: The 19 treated pregnancies were followed for 24-177 days.
(CSP) is challenging. The objective of this study was to evaluate the di- No complications were observed. After the treatment, typically, there
agnostic method, treatments, and long-term follow-up of CSP. was an initial increase in the human chorionic gonadotropin serum con-
STUDY DESIGN: This is a retrospective case series of 26 patients be-
centrations as well as in the volume of the gestational sac and their vas-
tween 6-14 postmenstrual weeks suspected to have CSP who were re- cularization. After a variable time period mentioned elsewhere the val-
ferred for diagnosis and treatment. The diagnosis was confirmed with ues decreased, as expected.
transvaginal ultrasound. In 19 of the 26 patients the gestational sac was
injected with 50 mg of methotrexate: 25 mg into the area of the embryo/ CONCLUSION: Combined intramuscular and intragestational metho-
fetus and 25 mg into the placental area; and an additional 25 mg was trexate injection treatment was successful in treating these CSP.
administered intramuscularly. Serial serum human chorionic gonado-
tropin determinations were obtained. Gestational sac volumes and vas- Key words: accreta, cesarean section, cesarean section scar
cularization were assessed by 3-dimensional ultrasound and used to pregnancy, ectopic pregnancy, methotrexate, minimally invasive
monitor resolution of the injected site and outcome. procedure, placenta, pregnancy, punctures, ultrasound

Cite this article as: Timor-Tritsch IE, Monteagudo A, Santos R, et al. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol
2012;207:44.e1-13.

S ince 1996, the cesarean delivery

(CD) rate in the United States has
increased by approximately 40%, and in 12.6-20.6%) and a decline in vaginal de-
upon) since the bulk of the gestation in-
cluding the placenta are in the niche or in
the scar facing the uterine cavity and are
2007, the rate was 31.8%.1 This is largely liveries after CD (28-9.2%).1,2 The rate part of it.
attributed to a rise in primary CD (from of repeat CD is now about 91%.2 The The incidence of CSP has been esti-
trend toward an increasing rate of CD mated to range from 1/1800 –1/2500 of
has been reported in other countries.3,4 all CD performed.3,42,43,58 The diagnosis
From the Department of Obstetrics and A previous CD increases the risk for a is often difficult, and a false-negative
Gynecology, NYU School of Medicine, New pathologically adherent placenta (ac- diagnosis may result in major compli-
York, NY. creta, increta, and percreta) and the cations, including a hysterectomy. The
Received December 16, 2011; revised March magnitude of risk increases with each ad- diagnosis is based on finding a gesta-
16, 2012; accepted April 9, 2012.
ditional CD. Similar risks were reported tional sac at the site of the previous CD
The authors report no conflict of interest.
for cesarean scar pregnancy (CSP).3,5-11 in the presence of an empty uterine
Reprints: Ilan E. Timor-Tritsch, MD,
A particular complication of a preg- cavity and cervix, as well as a thin myo-
Department of Obstetrics and Gynecology,
NYU School of Medicine, 550 First Ave., NBV- nancy after CD is the implantation of the metrium adjacent to the bladder. Dif-
9N1, New York, NY 10016. gestational sac in the hysterotomy scar, ferent diagnostic, radiological imaging
[email protected]. known as a “cesarean scar pregnancy” methods, and management options have
0002-9378/free (CSP).10 This condition is referred to us- been proposed. However, the optimal
© 2012 Mosby, Inc. All rights reserved. ing several terms including “cesarean ec- management remains to be determined. If
http://dx.doi.org/10.1016/j.ajog.2012.04.018
topic pregnancy” or simply “cesarean the patient presents with a uterine rupture
For Editors’ Commentary, see scar ectopic.”3,12-30 Some other terms in- or major bleeding, surgery is unavoidable.
Contents clude the word “ectopic.” The term “ce- Management of diagnosed but stable pa-
sarean delivery scar pregnancy” has also tients represent a challenge (the reader is
See related article, page 14 been used.31,32 Since the majority of re- referred to a recent review for details).4 In
ports use “cesarean scar pregnancy,” this article, we describe the use of intrages-
Click Supplementary Content under (CSP)10,11,32-57 we will use this term in tational sac injection of methotrexate
VIDEO the title of this article in the the article. CSP are not ectopic gestations (MTX) as a simple and effective office-
online Table of Contents by definition (even though no official based treatment. The follow-up of the pa-
definition for them has been agreed tients is described.

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M ATERIALS AND M ETHODS area of a CD scar in the presence of a sac site did not show any more color
This is a retrospective case series of 26 positive pregnancy test (Figure 1, Doppler signals with a pulse repetition
patients between 6-14 weeks postmen- E-G). frequency as low as 0.3 kHz.
strual age referred to NYU Langone All these criteria had to be present to Patients were counseled about the
Medical Center over a period of 3 years diagnose CSP. Some of the above criteria risks of the condition and management
(2009 through 2011 and evaluated in were derived from the literature (items 1, alternatives, including potential benefits
2011) with diagnosed or suspected CSP. 4, and 5)59,60 or generated and modified and risks (known and unknown). The
The diagnosis, treatment, and follow-up by our group (items 2, 3, 6, and 7). need to adhere to a follow-up period was
of all patients were performed in the ul- Sonographic diagnosis and a baseline specified. Patients signed a written in-
trasound facility without anesthesia. serum human chorionic gonadotropin formed consent for treatment.
Twenty-two of the 26 patients had de- (hCG) concentration were determined. If interventional treatment was rec-
monstrable fetal heart activity at the time In addition, 3-dimensional (3D) ultra- ommended as an option, this consisted
of ultrasound examination in our insti- sound data sets using a 4- to 8-MHz of a real-time, transvaginal ultrasound-
tution. One patient was referred after she transvaginal probe (Voluson 730; Gen- guided puncture and MTX injection into
had undergone elective termination of a eral Electric Medical Systems, Milwau- the chorionic sac. An automated, spring-
7-week pregnancy. However, we subse- kee, WI) were obtained. Volume of the loaded device (Labotect Co, Göttingen,
quently diagnosed that the pregnancy chorionic sac site and power Doppler Germany) was attached to the transvag-
had not been located within the uterine was used serially after the injection of inal transducer (SL400; Siemens, Erlan-
cavity and was located in the hysterot- MTX and compared to baseline infor- gen, Germany). The procedure repre-
omy scar. One patient was referred be- mation obtained before the local injec- sented a slight modification of the
tion of MTX. Power Doppler settings puncture injection approach previously
cause of an arteriovenous (A-V) malfor-
were 0.9 kHz pulse repetition frequency reported by the authors.61-64 We used
mation in the scar of a CD. Two patients
and 200 MHz filter (standardized for all a 20-gauge needle. Under ultrasound
presented with CSP with embryos/fe-
examinations). Chorionic sac volume
tuses without heart activity. Two pa- guidance, the area of the embryonic/fetal
and vascularization were analyzed of-
tients were referred for a second opinion. heart was identified for the placement of
fline using a software system (4DView;
Twelve women had been treated with the tip of the needle.
General Electric Medical Systems). The
various doses (25-50 mg) of intramuscu- After confirming the placement of the
placenta/gestational sac complex vol-
lar MTX prior to referral to our institu- needle, 25 mg of MTX in 1 mL of solu-
ume (mL) was calculated using the man-
tion. Since MTX was not effective in tion was injected slowly. The intragesta-
ual segmentation procedure (Virtual Or-
causing cessation of fetal heart activity in tional sac dose administered was 25 mg,
gan Computer-aided Analysis [VOCAL]
these patients they were referred for ad- and an additional 25 mg was injected
4DView; General Electric Medical Sys-
ditional treatment. tems) (Figure 2, A). The outer boundar- outside the gestational sac as the needle
In the presence of a positive pregnancy ies of the segmentation, or in other was withdrawn, preferably the placental
test, a CSP was diagnosed by transvaginal words the perimeter of the gestational site if that area was in the needle tract.
ultrasound using the following criteria: sac, were followed to define the sac size. The patient underwent another sono-
1. Visualization of an empty uterine This area/volume also included the vas- graphic examination 60-90 minutes after
cavity as well as an empty endocervi- cular “ring.” Six rotational steps (60 de- the procedure to confirm cessation of fe-
cal canal (Figure 1, A and B). grees apart) were used to define sac vol- tal heart activity and to identify local
2. Detection of the placenta and/or a ume. The sensitivity for defining the bleeding. The patient also received an
gestational sac embedded in the hys- vascularization index (VI) was men- additional intramuscular injection of 25
terotomy scar (Figure 1, C). tioned above. The VI was calculated us- mg MTX (for a total, combined dose of
3. In early gestations (ⱕ8 weeks), a tri- ing the same software (Figure 2, B). The 75 mg) before discharge from our unit.
angular gestational sac that fills the VI is the number of color flow– contain- Patients were asked to return in 24-48
niche of the scar (Figure 1, D); at ⱖ8 ing voxels divided by the total number of hours for a follow-up scan. As for the
postmenstrual weeks this shape may voxels contained within the volume ex- number of CD before the CSP, of the 26
become rounded or even oval. pressed as a percent value (Figure 2, C). patients, 15 had 1, 9 had 2, and 2 had
4. A thin (1-3 mm) or absent myome- The mean VI for patients undergoing 3 CD.
trial layer between the gestational sac hysterectomies was compared to those One patient had 2 chorionic sacs (twin
and the bladder (Figure 1, C). who were not treated by hysterectomy. gestation) in the scar, but only 1 gesta-
5. A closed and empty cervical canal. Sonographic examinations were re- tional sac had detectable embryonic
6. The presence of embryonic/fetal pole peated for 3 weeks at weekly intervals at heart activity (an intragestational sac in-
and/or yolk sac with or without heart first, and subsequently, bimonthly, until jection was performed in the sac with
activity. the site of the sac was barely visible and cardiac activity) since the other sac did
7. The presence of a prominent and at the VI declined (usually ⬍3%). We also not contain viable embryo. One patient
times rich vascular pattern at or in the required that the area of the gestational had 3 consecutive CSP. All 3 were treated

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FIGURE 1
Transvaginal sonographic criteria for diagnosis of cesarean scar pregnancy
A B

C D

F G

A, Empty uterine cavity with gestational sac (arrow) between cavity and cervix (Cx). B, Power Doppler of blood vessels surrounding gestational sac. C,
Gestational sac embedded in scar. Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder. D, Triangular shape of sac (on sagittal plane)
assuming shape of niche. E-G, Prominent, richly vascular area in site of previous cesarean delivery scar highlighted by power Doppler in patient presenting
with bleeding and positive serum human chorionic gonadotropin test. Arrows point to vascular malformation.
Timor-Tritsch. Diagnosis and treatment of cesarean scar pregnancy. Am J Obstet Gynecol 2012.

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FIGURE 2
Evaluation of volume and vascular supply of cesarean scar pregnancy

Evaluation used 3-dimensional (3D) transvaginal ultrasound with Virtual Organ Computer-aided Analysis (VOCAL) software (General Electric Medical
Systems, Milwaukee, WI). A, 3D segmentation of sac perimeter drawn around outer boundaries of color ring resulting in sac volume. B, 3D angiographic
rendering of vascularization around gestational sac. C, 3D angiographic measurement of vascularization index representing percent blood flow containing
units (voxels) over outlined grayscale units.
Timor-Tritsch. Diagnosis and treatment of cesarean scar pregnancy. Am J Obstet Gynecol 2012.

according to the same protocol and ing them into an Excel spreadsheet (Mi- fuse bleeding at 15 and 17 weeks, respec-
counted as 3 separate cases. crosoft, Redmond, WA) on the day they tively, requiring massive blood transfu-
The protocol for follow-up included were obtained. These values were used to sions and hysterectomies.
evaluation of the outcome: (1) a weekly generate graphic representation, as a Patient 10 in Table 1 was scheduled to
serum hCG determination for 3 consec- function of the days following treatment. have intragestational sac MTX injection
utive weeks, and 1 determination bi- of a CSP at 6 weeks and 1 day, but slightly
monthly until this hormone was unde- R ESULTS bled prior to the scheduled procedure.
tectable; and (2) determination of the Clinical details of the patients are sum- The patient was treated by tamponade
gestational sac volume and the area vas- marized in Table 1. Of the 26 patients, 2 with a 5-mL balloon catheter inserted
cularization at the above intervals using of them (patients 4 and 15 in Table 1) into the cervix and inflated until bleed-
the previously described techniques. Pa- were referred to us for a second opinion. ing ceased. The next morning, there was
tients were asked not to have vaginal They each had 1 prior CD and presented absence of detectable fetal heart rate, and
intercourse until the resolution of the at 9 and 14 weeks, respectively. After the no additional treatment was given. Six
CSP. This was judged by sonographic diagnosis of CSP (Figure 3) and counsel- weeks later, involution of the scar site
examination. ing, both patients opted to continue their was noted.
Analysis of the data was as follows: val- pregnancies (after being informed of the On the day of referral, 2 patients (pa-
ues of the serum hCG, sac volume, and risk of a possible placenta accreta). Both tients 23 and 24 in Table 1) had detect-
VI were tabulated for each patient enter- patients had uterine rupture with pro- able embryonic/fetal cardiac activity and

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TABLE 1
Cesarean scar pregnancies with and without
intragestational MTX injections
Pretreatment Days to resolution
Patient GA, wks hCG, mIU/mL Sac volume, mL VI, % hCG Sac volume VI Treatment Observations
With MTX
................................................................................................................................................................................................................................................................................................................................................................................
1 7 2/7 46,300 14.1 7.3 88 133 133 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
2 10 3/7 101,000 119.9 25.5 63 150 150 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
3 6 1/7 37,200 10.6 34.6 125 125 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
5 7 0/7 2640 6.6 24.5 68 57 57 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
6 8 1/7 100,010 44.9 27.5 64 177 177 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
7 7 3/7 7600 8.3 37.1 95 140 140 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
8 8 2/7 2950 21.1 6.4 63 93 93 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
11 7 0/7 43,341 11.4 12.2 35 44 44 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
12 6 1/7 13,076 3.6 23.1 98 133 133 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
13 6 6/7 1976 28.7 24.1 89 110 110 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
14 6 2/7 8518 2.9 4.5 60 60 60 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
16 8 0/7 2717 14.3 9.3 24 76 72 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
17 6 2/7 5469 4.1 7.9 33 109 109 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
18 6 2/7 4673 17.0 43.0 63 22 63 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
19 6 4/7 2870 1.3 4.7 61 62 48 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
20 6 1/7 1340 2.1 6.1 63 63 63 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
21 7 2/7 2100 3.1 16.4 41 41 41 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
22 7 6/7 12,657 1.7 15.2 54 61 61 L⫹S MTX
.......................................................................................................................................................................................................................................................................................................................................................................
25 5 6/7 8550 3.2 3.9 26 26 26 L⫹S MTX Clots from cavity
aspirated on d 26
................................................................................................................................................................................................................................................................................................................................................................................
Without MTX
.......................................................................................................................................................................................................................................................................................................................................................................
4 9 1/7 Unavailable 59.9 39.7 — — — Declined Bled at 15 wk, TAH
.......................................................................................................................................................................................................................................................................................................................................................................
9 7 6/7 55 53.6 71 — — — UA embolization A-V malformation; TAH
(Table 2)
.......................................................................................................................................................................................................................................................................................................................................................................
10 6 0/7 59 2.6 7.8 39 39 39 Bleed: balloon catheter Resolved
.......................................................................................................................................................................................................................................................................................................................................................................
15 14 0/7 Unavailable 35.0 48.5 — — — Declined Rupture at 18 wk, TAH
.......................................................................................................................................................................................................................................................................................................................................................................
23 6 0/7 6081 3.1 4.1 58 65 65 No FHR Resolved
.......................................................................................................................................................................................................................................................................................................................................................................
24 6 4/7 8868 4.0 4.0 42 42 42 No FHR Resolved
.......................................................................................................................................................................................................................................................................................................................................................................
26 Unavailable 0 — 65.0 — — — Embolization A-V malformation
................................................................................................................................................................................................................................................................................................................................................................................
A-V, arteriovenous; FHR, fetal heart rate; GA, gestational age; hCG, human chorionic gonadotropin; L, local; MTX, methotrexate; S, systemic; TAH, total abdominal hysterectomy; UA, uterine artery;
VI, vascularization index.
Timor-Tritsch. Diagnosis and treatment of cesarean scar pregnancy. Am J Obstet Gynecol 2012.

were scheduled for treatment, but the lowed up according to the protocol de- tion of pregnancy at 7 weeks of gestation
following day (when the procedure was scribed above. at another institution (the pathology re-
scheduled), fetal cardiac activity had Patient 9 in Table 1 had a complex port described the presence of chorionic
ceased. No treatment was administered. clinical course. This 33-year-old patient villi). The patient had 2 previous CD and
Patient 23 received intramuscular MTX had 6 pregnancies, 4 deliveries, and 1 2 normal vaginal deliveries at term. At
prior to referral, while for patient 24, the abortion, and presented to the emer- presentation, the serum hCG was 55
fetal cardiac activity ceased without MTX gency room with vaginal bleeding 67 mIU/mL, and sonographic examination
administration. These patients were fol- days after an attempted elective termina- at our center revealed an empty uterine

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FIGURE 3
Two untreated CSPs with subsequent uterine rupture and hysterectomy
A B

A, 3-Dimensional power Doppler angiogram at 9 weeks of patient 4 in Table 1. B, 2-Dimensional color Doppler ultrasound image at 14 postmenstrual
weeks of patient 15 in Table 1.
CSP, cesarean scar pregnancy cases.
Timor-Tritsch. Diagnosis and treatment of cesarean scar pregnancy. Am J Obstet Gynecol 2012.

cavity, a clearly imaged hysterotomy scar ence of an A-V malformation (Video Clips teen patients (6-9 weeks of gestation)
niche (Figure 4, A), and a richly vascu- 1 and 2). Vaginal bleeding persisted, and underwent successful local injection of
larized anterior uterine wall (which was on the 155th day bilateral uterine artery 50 mg of MTX and all showed evidence
double in thickness compared to the embolization was performed. Vaginal of embryonic/fetal cardiac activity. One
posterior wall) (Figure 4, B). We consid- bleeding decreased, but there was persis- patient had 3 prior CD. Typically, pa-
ered that the images were consistent with tence of the prominent vessel in the lower tients had prolonged, intermittent vagi-
the diagnosis of placenta accreta or per- anterior uterine wall (Figure 4, C). The nal spotting for 2-3 weeks following the
creta that was left untouched during the peak systolic velocity within the vascular procedure. During the follow-up period,
termination procedure. The pregnancy structure was 45.3 cm/s, consistent with an most women resumed menses before
was in close proximity to the hysterot- A-V vascular malformation (Figure 4, D). resolution of the gestational sac volume
omy scar. We managed this condition by Five days later, the patient underwent a and vascularization. No side effects were
administering intramuscular MTX (80 hysterectomy with an uneventful recovery. seen related to the MTX treatments.
mg) on day 81 after her initial dilatation The sequence of events is illustrated in Of interest, 1 patient with 2 previous CD
and curettage (D&C) on the first day un- Table 2. underwent intragestational sac MTX in-
der our care. This injection was admin- Patient 26 in Table 1 was referred to us jection of 50 mg at 7 postmenstrual weeks
istered with the suspicion that the pa- for vaginal bleeding and a positive preg- for a CSP, and subsequently returned 10
tient may have had residual gestational nancy test. On transvaginal ultrasound weeks later with a second CSP at 6 post-
trophoblastic disease. On follow-up the an A-V malformation was seen at the site menstrual weeks. She underwent again in-
hCG serum concentration became non- of her previous CD scar (Figure 1, E-G). tragestational sac MTX injection. It is
detectable 2 weeks (on the 100th day) This patient did not have any surgical in- noteworthy that the first CSP was a dicho-
from the time of the initial surgical inter- tervention for this pregnancy and was rionic twin gestation with 1 empty sac
vention. The VI and placental volume promptly treated by emergency uterine (blighted ovum?), and an additional gesta-
showed a decrease in magnitude on the artery embolization to stop the bleeding. tional sac containing an embryo. This
105th day. However, the patient devel- Two other patients had no demonstrable same patient returned again, 4 months af-
oped severe vaginal bleeding. A hysterec- embryonic/fetal cardiac activity on the ter her second CSP similarly treated with a
tomy and uterine artery embolization day of their scheduled MTX injection third CSP at 5 postmenstrual weeks and 6
were offered, but declined by the patient. thus were not treated at all. days. She was treated again as per our de-
A repeat sonographic examination dem- In only 1 patient (patient 3 in Table 1) scribed protocol with good outcome.
onstrated an increase in the VI. The ultra- was the CSP the result of in vitro fertil- A small number of clots from the uter-
sound image was suspicious for the pres- ization and transfer of 2 embryos. Nine- ine cavity were aspirated on day 26 in

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patient 25 after continuous spotting was

FIGURE 4
reported.
Placenta percreta in case no. 9 from Table 1
The following observations were noted
regarding the hCG serum concentrations, B
the gestational sac volume, and the VI:
1. Serum hCG: in 13 of the 19 injected A
cases after an initial plateau or a small
temporary increase in the serum hCG
concentrations, the values decreased
slowly and became nondetectable
(cutoff was ⬍3 mIU/L) 41-100 days
following MTX injection (Figure 5).
2. Gestational sac volume: in 12 of the
cases the gestational sac volume in- C
creased or plateaued after MTX injec-
tion, and this was followed by a slow D
decrease in volumes (Figure 6). How-
ever, the area of involution was visible
even ⬎5 months’ posttreatment.
3. VI: in 14 of the cases after an initial in-
crease or brief plateau in the VI, a slow
but steady decline was observed to what
was considered to be minimal values A, Sagittal section of uterus. Anatomy is outlined by dotted lines and annotations indicate placental
(⬍3%). Color Doppler did not demon- location, cesarean section (C/S) niche, empty uterine cavity, and cervical canal. B, 3-Dimensional
strate vascularization 30-140 days from power Doppler image of vascularization. C, After 140-144 days large dilated blood vessel is seen.
the MTX injection (Figure 7). Inlay represents color flow of vessel. D, Peak systolic velocity of 45.3 cm/s was measured in vessel.
Timor-Tritsch. Diagnosis and treatment of cesarean scar pregnancy. Am J Obstet Gynecol 2012.
The interquartile ranges for the serum
hCG concentrations, the sac volumes,
and VI are presented in Table 3. The clinical challenge of a cesarean a uterine rupture–in both, emergency
section pregnancy surgery or uterine artery embolization
This pregnancy complication can pres- by interventional radiology are re-
C OMMENT ent broadly in 2 ways: (1) as an acute quired36,65-68; and (2) at sonography in a
Principal findings of this study emergency in which the patient has patient with a history of CD, who under-
First, an early diagnosis of CSP is possi- bleeding, or an acute abdomen due to goes an ultrasound examination.
ble using the criteria proposed in this ar-
ticle. Second, treatment is possible using
a combination of systemic and intrages- TABLE 2
tational sac injection with MTX. Third, Clinical and laboratory data of patient 9 from Table 1
the local injection of MTX into the ges- Events Date Days post D&C Volume, mL VI, % hCG, mIU/mL MTX, mg
tational sac is simple to perform under
1 10/17/09 0 Unavailable Unavailable Unavailable —
ultrasound guidance using a needle ..............................................................................................................................................................................................................................................

guide, and in this report, was done trans- 2 01/04/10 81 48 66 16 100

..............................................................................................................................................................................................................................................

vaginally. Lastly, the natural history of 3 02/03/10 100 53.6 71 ⬍2 —

..............................................................................................................................................................................................................................................
hCG serum concentrations, gestational 4 02/05/10 102 60 42 ⬍2 —
..............................................................................................................................................................................................................................................
sac volume, and the VI after systemic and 5 02/08/10 105 25 15.1 ⬍2 —
..............................................................................................................................................................................................................................................
local MTX treatment is described. An in-
6 02/24/10 121 34.4 52.6 Bleeding
crease in both serum hCG and gesta- ..............................................................................................................................................................................................................................................

tional sac volume was consistently ob- 7 03/15/10 140 35 76.7 — —

..............................................................................................................................................................................................................................................
served immediately after treatment, and 8 03/19/10 144 Bleeds again
..............................................................................................................................................................................................................................................
was followed by a progressive decline un- 9 03/26/10 155 Embolization
..............................................................................................................................................................................................................................................
til hCG became nondetectable and the 10 04/02/10 160 Hysterectomy
gestational sac involuted. The optimal ..............................................................................................................................................................................................................................................
D&C, dilatation and curettage; hCG, human chorionic gonadotropin; MTX, methotrexate; VI, vascularization index.
management of CSP continues to repre- Timor-Tritsch. Diagnosis and treatment of cesarean scar pregnancy. Am J Obstet Gynecol 2012.
sent a challenge.4

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In general, these procedures can be

FIGURE 5
performed by obstetricians and gynecol-
Graph of serum hCG as function of days post injection ogists with expertise in ultrasound. Some
procedures require involvement of the
radiology department.

Diagnosis of CSP
A recent literature search4 identified 751
cases of CSP. Of interest is that 13.6%
(107/751) had been misdiagnosed as cer-
vical pregnancies, spontaneous abor-
tions in progress (on its way to expul-
sion), or low intrauterine pregnancies.
Given the potential serious complica-
tions of a CSP, reliable diagnostic criteria
are required for the differential diag-
nosis. The primary scanning route used
was transvaginal using frequencies of
5-12 MHz. Transabdominal probes may
also be used. However, due to the lower
After initial increase most levels dropped to undetectable levels by day 40-60.
hCG, human chorionic gonadotropin.
resolution ability of transabdominal
Timor-Tritsch. Diagnosis and treatment of cesarean scar pregnancy. Am J Obstet Gynecol 2012. probes, fine details of placental implan-
tation site, definition of embryonic/fetal
as well as extraembryonic structures are
The optimal treatment of the patient a. Curettage4,10,11,13-15,22,24,25,31,32,36,37,39,43, seen better using the transvaginal ultra-
in the first trimester of pregnancy with a 45,48,49,53,68-83
sound probes. Another reason for using
transvaginal probes was that the viewing
sonographic diagnosis of suspected CSP b. Hysteroscopy12,17,24,54,55,84-86
point and viewing angle of the probe was
remains uncertain. The list of proposed c. Systemic MTX alone10,14,17,18,21,26-28,32,
identical both at the diagnosis as well as
treatment modalities is long and in- 33,35,40,41,47,50,52,56,69,76,87-98
at the time of the injection. The diagnos-
volves among other one main treatment d. Laparotomy21,51,77,84,86,99-102
tic criteria used in this study included
alone or its combination with other e. Uterine artery embolization34,38,44,56,57,
were mentioned in the “Materials and
treatment modalities: 86,93,96,103,104
Methods” section.
While the presence of embryonic/fetal
FIGURE 6 cardiac activity facilitates the diagnosis
Graph of gestational sac volumes as a function of days post injection of CSP, its absence does not exclude the
diagnosis, since in many cases there may
be cessation of cardiac activity, and this
does not eliminate the complications de-
rived from CSP. Another consideration
is that patients may have been previously
treated with intramuscular MTX and
come to the attention of the ultrasound
unit after fetal demise has already oc-
curred. Since the exact time and amounts
as well as, in certain cases, the intervals be-
tween multiple administrations were un-
reliable and inaccurate, we can only say
that these data could not be analyzed in a
meaningful way. The precise sensitivity,
specificity, and predictive values of these
criteria would need to be tested prospec-
tively. However, we have proposed these
criteria after considerable experience in
Timor-Tritsch. Diagnosis and treatment of cesarean scar pregnancy. Am J Obstet Gynecol 2012. our unit and welcome evaluation of their
clinical utility.

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Treatment of an early
FIGURE 7
diagnosis of CSP
VI as function of time after intragestational
Treatment of CSP carried a significant
sac injection of methotrexate
complication rate. Of the 751 cases, 331
(44.1%) ended up with complications.
As a result, 36 hysterectomies, 40 lapa-
rotomies, and 21 uterine artery emboliza-
tions were performed as emergency mea-
sures to treat complications. Treatments,
such as systemic MTX, D&C, and uterine
artery embolization carried the highest
number of complications (62.1%, 61.9%,
and 46.9%, respectively).4
Mean vascularity indices for the 3 pa-
tients undergoing hysterectomy in our
series was 63.1% while for the 16 patients
without hysterectomy the mean VI was
17.8% (P ⬍ .05). The lowest complica-
tion rates were achieved by using local
intragestational injection of MTX or ka-
lium chloride as well as hysteroscopy
VI increased after injection and steadily dropped thereafter.
(9.6% and 18.4%, respectively).4 In
VI, vascularization index.
treating our patients with local intrages- Timor-Tritsch. Diagnosis and treatment of cesarean scar pregnancy. Am J Obstet Gynecol 2012.
tational MTX injection we applied the
lessons learned from reviewing the entire
available literature on CSP. In all but one not fully effective leading to hysterec- vaginal ultrasound probe.61-64 The tech-
of the referred patients intramuscular tomy.4 It is important to mention that nique we used is not the only one to be
MTX injections by the primary provid- the patient who presented with heavy used for such a treatment. The fact is, al-
ers failed to stop the heart activity. All of bleeding to our emergency department most all manufacturers enable a needle
our injected cases were successfully (patient 26 in Table 1) was promptly di- guide to be attached to their transvaginal
treated (ie, the heartbeats were stopped) agnosed with an A-V malformation probe. They also feature an electronic on-
and yielded the expected results (ie, no within the CD and in this case the pa- screen needle path with depth markings.
complications were noted). CSP compli- thologies were successfully treated by Given the above, the technique of trans-
cation can present in 2 ways: (1) as an emergency embolization of the uterine vaginal (or for that matter, transabdomi-
acute emergency in which the patient is artery. nal) ultrasound-guided puncture and in-
bleeding, or has an acute abdomen due to Since real-time transvaginal (or transab- jection is widely available. Oocyte retrieval
uterine rupture–in both, emergency sur- dominal) ultrasound-guided intragesta- relies on similar needle insertion tech-
gery or uterine artery embolization by in- tional sac injections can be performed in niques for years.106,107 A considerable ad-
terventional radiology are required; and an outpatient office setting, no anesthesia vantage of ultrasound-guided intragesta-
(2) at sonography in a patient with a his- is required. None of our 19 patients had tional sac injection is that it can be
tory of CD, who undergoes ultrasound anesthesia. To perform the intragesta- performed as an office procedure. This is
examination. tional sac injection we used an automated, in contrast to most surgical treatment ap-
Our expectations of the treatment spring-loaded device mated to the trans- proaches, which are performed under an-
were based upon our previously re-
ported results of injecting various ecto- TABLE 3
pic pregnancies61-64 as well as the first in- Mean, SE, and interquartile range for serum hCG,
tragestational sac injection cases by volume of gestational sac, and VI
Godin et al.105 In the advanced case (pa-
tient 9 in Table 2) where D&C was used, Measure Mean SE 25-75% range
not only did the procedure fail to provide hCG, mIU/mL 4334.6 1114.1 9.0–4677.0
..............................................................................................................................................................................................................................................
the expected and final treatment, but it Volume, mL 18.1 3.1 2.4–24.6
..............................................................................................................................................................................................................................................
may have led to the development of an VI 18.9 2.1 7.0–26.4
A-V malformation. In the same case, as ..............................................................................................................................................................................................................................................
hCG, human chorionic gonadotropin; VI, vascularization index.
in some cases reported in the literature, Timor-Tritsch. Diagnosis and treatment of cesarean scar pregnancy. Am J Obstet Gynecol 2012.
embolization of the uterine artery was

44.e9 American Journal of Obstetrics & Gynecology JULY 2012

www.AJOG.org Obstetrics Research

esthesia, therefore, one has to also consider trophoblast viability. Serum concentrations served, we recommend expectant man-
this as an additional source of risk, mini- of hCG are used to follow up patients with agement, which has been successful in
mal as it may be. All our locally injected ectopic pregnancies treated with MTX, and the cases presented in this series.
cases provided adequate final treatment also, gestational trophoblastic disease. The We have used 3D ultrasound to
with no resulting complications. finding of a nondetectable hCG concentra- monitor the effect of treatment on
We have to address the issue of treat- tion in serum is widely accepted as evidence CSP. The rationale for this is that the
ment with MTX by the referring site that no trophoblast is viable. This is a reason- VOCAL software allows calculation of
prior to our intervention. To our knowl- able indication that treatment of MTX injec- the volume of the mass, and that the VI
edge, patients were injected with low tionoftheintragestationalsacwassuccessful. is an index of the degree of vasculariza-
doses of MTX (25-50 mg) and were re- However, we (and others) have observed tion based upon power angiography
ferred to our care 7-10 days later when complications of ectopic pregnancy in pa- with 3D ultrasound. Whether these
the serum hCG levels failed to drop and tients with a nondetectable hCG.111 Such modalities are superior to 2-dimen-
the heart activity was still present. We complications often result from the detach- sional ultrasound and simple color and
suggest that waiting in excess of 3-4 days mentofthegestationalsacfromthematernal power Doppler remains to be deter-
for the trophoblast to cease its function tissues.111 For this reason, we incorporated mined. A comparison of the 2 was not
and result in declining hCG production the other 2 sonographic parameters: volume the purpose of this study. Subjective
causing the heart activity to stop endan- estimation of the gestational sac and the de- observation and follow-up of vessel
gers the patient. During this period of gree of vascularization. The expectation density in the injected area should
waiting for results, the gestation is grow- would be that successful treatment would re- guide those who do not use the 3D ul-
ing and its vascularization is increasing, sultinareductioninthesizeofthegestational trasound angiographic techniques.
presenting a more challenging manage- sac and decrease of the VI.
ment problem. Our approach treating A fact is worth mentioning: the mean VI Conclusion
pregnancies by injecting MTX is that this in the 3 patients treated by hysterectomy CSP represents a diagnostic and thera-
should be done as early as possible for the was higher than the 23 patients who did peutic challenge. Its frequency is increas-
aforementioned reasons. not have their uteri removed (68.1% vs ing as more CD are performed. We have
17.8%). This may imply that a high VI at used a set of diagnostic criteria as well as
Follow-up and resolution presentation may be a predictor of compli- a management and follow-up program
As to the resolution of the CSP after its cations. Even though patient 26 with an for the minimally invasive treatment of
local treatment, it should be clear that A-V malformation did not undergo surgi- this complication of pregnancy. The
this is a long process measured in many cal treatment her VI was high (65%) and combination of systemic and intragesta-
weeks or months. The mean time of res- she had uterine artery embolization. tional sac administration of MTX is rel-
olution of the 22 patients who did not An interesting observation of our atively simple, can be performed as an
have hysterectomy or embolization was study is that, after the treatment regimen office procedure, and has been highly
88.6 days (range, 26 –177). The literature was instituted, hCG concentrations ini- successful in the treatment of CSP in this
acknowledges this as well as the initial tially increased, the volume of the gesta- case series. Recent articles suggest that
increase of the serum hCG, the sac vol- tional sac went up, and the VI also rose. transvaginal ultrasound can be used
ume, and its vascularity before their Similar observations have been made by to examine the first-trimester uterine
slow resolution.10,18,32,48,52,89,96,108-110 others.10,32,48,52,89,96,108-110 One possible scar112 and the likelihood of placenta ac-
The reasons for the initial increase of the explanation for this is that, after MTX creta in the first trimester.113 f
serum hCG are unclear. More impor- administration, trophoblast cells un-
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