Management of Cesarean Section Uterine Scar Ectopic Pregnancy Type 2 Using Methotrexate: Insights from a Case Report

BACKGROUND Cesarean section uterine scar ectopic pregnancies (CSEP) are rare occurrences in which an embryo implants along uterine scar tissue from previous hysterotomies. These cases carry high morbidity and mortality, including risk of significant hemorrhage and uterine rupture. Society for Maternal-Fetal Medicine guidelines suggest either medical or surgical termination of these pregnancies; however, there are no current definitive recommendations for the management of these cases. Here, we present the case of a 36-year-old patient with a first-trimester CSEP who was managed with local intra-gestational methotrexate (MTX) and 6-month follow-up with beta-human chorionic gonadotropin (ß-hCG) monitoring. CASE REPORT We describe the case of a stable, asymptomatic 36-year-old patient with 2 previous low transverse cesarean sections, presenting in the early first trimester with a visualized CSEP on ultrasound. The patient was presented with medical and surgical options for management. After extensive counseling, she opted for a medical abortion with an intra-gestational MTX injection. She was monitored with serial quantitative ß-hCG measurements for 6 months before complete resolution of the terminated pregnancy, an interval significantly longer than typically observed in similar cases. She did not require additional medication doses or surgical intervention. CONCLUSIONS After a prolonged surveillance, this patient safely reached undetectable ß-hCG levels. There is great variability in the presentation, treatment, and long-term outcome of CSEPs, and management requires extensive provider-patient communication. Medical management with intra-gestational MTX, followed by close monitoring, is a viable option for treating stable, type 2 CSEP in patients who have access to reliable follow-up care.