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Case Reports and Images in Obstetrics and Gynecology

 
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Case Report
 
Hysteroscopically-guided subchorionic methotrexate administration: A new technique for termination of cesarean scar pregnancy
Giancarlo Garuti1, Stefania Calabrese1, Lorenzo Quirino1, Marco Di Mario1
1MD, Obstetrics and Gynecology Department, Public Hospital of Lodi, Via Savoia 1, 26900-Lodi, Italy.

Article ID: 100008Z08GG2016
doi:10.5348/Z08-2016-8-CR-1

Address correspondence to:
Giancarlo Garuti
(MD), Obstetrics and Gynecology Department
Lodi Hospital, via Savoia n° 1
26900-Lodi
Italy

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How to cite this article:
Garuti G, Calabrese S, Quirino L, Mario MD. Hysteroscopically-guided subchorionic methotrexate administration: A new technique for termination of cesarean scar pregnancy. J Case Rep Images Gynecol Obstet 2016;2:1–6.


Abstract
Introduction: Cesarean scar pregnancy (CSP) is a rare but life-threatening condition, due to the risk of uterine rupture or for the development of placenta previa/accreta. The mainstay of management to spare fertility is early diagnosis and pregnancy termination. Although several conservative treatments have been experienced, no consensus on the best therapeutic approach is currently shared. The medical therapy for CSP termination is based on systemic or local Methotrexate (MTX) administration. Hysteroscopy allows the precise visualization of placental implantation and it can be used to drive MTX injection selectively within the intervillous placental spaces. This procedure increases drug concentration delivered to the target tissue, potentially improving its therapeutic index.
Case Report: A 36-year-old female with a history of cesarean section was admitted to our department with a diagnosis of viable 7th weeks CSP. The patient gave her consent to pregnancy termination by a hysteroscopically-guided MTX administration within the cervico-isthmic placental implantation site, followed by its resectoscopic removal. In an office setting, 80 mg of MTX were injected through a needle adaptable to the 5-Fr operative channel of hysteroscope, under the chorionic membrane of placental implantation site. The duration of the procedure took three minutes and it resulted easy, painless and uneventful. An early embryo demise was obtained; the human chorionic gonadotropin-beta subunit (beta-hCG) serum trend showed a rapid pregnancy termination and no patient complaints were recorded. After 28 days, a resectoscopic removal of the gestational sac and placenta was safely accomplished.
Conclusion: Selective hysteroscopic administration of MTX within intervillous spaces of the ectopic placental implantation is effective and it can be considered for CSP termination.

Keywords: Cesarean scar pregnancy, Ectopic pregnancy, Hysteroscopy, Methotrexate, Office hysteroscopy, Resectoscopy


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Author Contributions
Giancarlo Garuti – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Stefania Calabrese – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Lorenzo Quirino – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Marco Di Mario – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2016 Giancarlo Garutid et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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