Successful conservative treatment of a caesarean scar twin pregnancy with systemically administered methotrexate and subsequent uterine artery embolization: a rare case report


  • Shanthi K. Elango Department of Obstetrics & Gynaecology, Government RSRM Lying in Hospital, Chennai, Tamil Nadu, India
  • K. Nevetha Department of Obstetrics & Gynaecology, Government RSRM Lying in Hospital, Chennai, Tamil Nadu, India
  • Aruna . Department of Obstetrics & Gynaecology, Government RSRM Lying in Hospital, Chennai, Tamil Nadu, India



Caesarean scar pregnancy, Methotrexate, Uterine artery embolism


Caesarean scar pregnancy is a very rare form of ectopic pregnancy. It complicates approximately 1 in 2200 pregnancies. However, it is becoming increasingly more frequent with the increasing number of caesarean sections performed each year. The recommended approach to treatment is therapeutic termination of pregnancy at the time of recognition. In this article, we present a case of caesarean scar pregnancy managed expectantly with Methotrexate and uterine Artery Embolization. We reported a case of 30 years old female, gravida 5, para1, live 1, abortion 3 with a previous history of caesarean section with GA of 8w5d/DCDA twin was admitted in view of low implantation of gestational sacs in lower uterine corpus. Trans vaginal ultrasound done and diagnosis of caesarean scar twin pregnancy was made. She was treated with Methotrexate 50 mg intramuscularly along with uterine artery embolization and follow up with beta HCG levels. Post embolization sac size was reduced and falling level of beta HCG values. Patient was discharged and follow-up with beta HCG level weekly. It is important for obstetrician and radiologist managing women with risk factor for a scar ectopic pregnancy to maintain a high index of suspicion during follow up. Failure to diagnose and initiate prompt management may lead to uterine rupture, massive Haemorrhage and maternal death.


Herman Z, Weinraub O, Avrech R, Maymon R, Ron-El Y. Bukovsky, Follow up and outcome of isthmic pregnancy located in a previous caesarean section scar. British Journal of Obstetrics and Gynaecology.1995;102(10):839-41.

Seow KM, Cheng C, Chuang J, Lee C, Tsai YL, Hwang JL. Methotrexate for cesarean scar pregnancy after invitro fertilization and embryo transfer: a case report. Journal of Reproductive Medicine for the Obstetrician and Gynecologist. 2000;45(9):754-7.

Godin PA, Bassil S, Donnez J. An ectopic pregnancy developing in a previous caesarian section scar. Fertility and Sterility.1997;67(2):398-400.

Persadie RJ, Fortier A, Stopps RG. Ectopic pregnancy in a caesarean scar: a case report. 2005;27(12):398-400.

Sugawara J, Senoo M, Chisaka H, Yaegashi N, Okamura K. Successful conservative treatment of a Cesarean scar pregnancy with uterine artery embolization. Tohoku Journal of Experimental Medicine. 2005;206(3):261-5.

Yang MJ, Jeng MH. Combination of transarterial embolization of uterine arteries and conservative surgical treatment for pregnancy in a cesarean section scar: a report of 3 cases. Journal of Reproductive Medicine for the Obstetrician and Gynecologist. 200348(3):213-6.

Yan CM. A report of four cases of caesarean scar pregnancy in a period of 12 months,Hong KongMedical Journal. 2007;13(2):141-3.

Larsen JV, Solomon MH. Pregnancy in a uterine scar sacculus: an unusual cause of postabortal haemorrhage. A case report, South African Medical Journal. 1978;53(4):142-3.

Seow KM, Hwang JL, Tsai YL, Huang LW, Lin YH, Hsieh BC, Subsequent pregnancy outcome after conservative treatment of a previous cesarean scar pregnancy. Acta Obstetricia et Gynecologica Scandinavica. 2004;83(12):1167-72.

Hamilton CJCM, Legarth J, Jaroudi KA. Intramural pregnancy after in vitro fertilization and embryo transfer, Fertility and Sterility.1992;57(1):215-7.

Al-Nazer A, Omar L, Wahba M, Abbas T, Abdulkarim M. Ectopic intramural pregnancy developing at the site of a cesarean section scar: a case report, Cases Journal. 2009;2(12):art.9404.

Fylstra DL, Pound-Chang T, Miller MG, Cooper A, Miller KM. Ectopic pregnancy within a cesarean delivery scar: a case report. American Journal of Obstetrics and Gynaecology. 2002;187(2):302-4.

Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar. Ultrasound in Obstetrics and Gynecology. 2003;21(3):220-7.

Tulpin L, Morel O, Malartic C, Barranger E. Conservative management of a Cesarean scar ectopic pregnancy: a case report. Cases Journal. 2009;2(8):7794.

Arslan M, Pata O, Dilek TUK, Aktas A, Aban M, Dilek S. Treatment of viable cesarean scar ectopic pregnancy with suction curettage. International Journal of Gynecology and Obstetrics. 2005;89(2):163-6.

Kung FT, Huang CW, Chen CW, Cheng YF. Cesarean scar ectopic pregnancy. Fertility and Sterility. 2006;85(5):1508-9.

Shufaro Y, Nadjari M. Implantation of a gestational sac in a cesarean section scar. Fertility and Sterility. 2001;75(6):1217.

Nagi JB, Helmy S, Ofili-Yebovi D, Yazbek, Sawyer E, Jurkovic D, Reproductive outcomes of women with a previous history of Caesarean scar ectopic pregnancies. Human Reproduction. 2007;22(7):2012-5.

Doubilet PM, Benson CB, Frates MC, Ginsburg E. Sonographically guided minimally invasive treatment of unusual ectopic pregnancies. Journal of Ultrasound in Medicine. 2004;23(3):359-70.

Hasegawa J, Ichizuka K, Matsuoka R, Otsuki K, Sekizawa A, Okai T. Limitations of conservative treatment for repeat Cesarean scar pregnancy. Ultrasound in Obstetrics and Gynecology. 2005;25(3):310-1.






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