Therapeutic effect of methotrexate combined with hysteroscopy in the treatment of endogenous cesarean scar pregnancy_West China Medical Journal

Authors：

ZHENG Fengque ¹ , LIN Jiajing ¹ , WEI Lijin ¹ , FANG Shuang ¹ , HE Chunna ¹ ,  LI Jingjing ²

1. Gynecology Department, the Fourth Affiliated Hospital of Guangxi Medical University (Liuzhou Workers’ Hospital), Liuzhou, Guangxi 545005, P. R. China;
2. Gynecology Department, Liuzhou Maternity and Child Healthcare Hospital, Liuzhou, Guangxi 545001, P. R. China;

Corresponding author：

LI Jingjing, Email: 7407lijingjing@163.com

Keywords：

Cesarean scar pregnancy; Hysteroscope; Methotrexate; Clinical efficacy

DOI：

10.7507/1002-0179.201912263

Video：

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Objective To explore the clinical effect of intramuscular injection of methotrexate on hysteroscopic treatment of endogenous cesarean scar pregnancy (CSP). Methods A prospective analysis was conducted on 94 patients diagnosed with endogenous CSP who visited the Department of Gynecology in Liuzhou Workers’ Hospital between January 2013 and January 2018, and they were randomly divided into two groups, the intramuscular injection of methotrexate followed by hysteroscopic surgery group (the methotrexate group, n=39) and the direct hysteroscopic surgery group (the non-methotrexate group, n=55). The operation time, intraoperative blood loss, surgical complications, length of hospital stay, hospitalization expenses, the recovery time of blood human chorionic gonadotropin (HCG) and treatment outcomes of the two groups were compared. The normally distributed data were expressed as mean±standard deviation, and the non-normally distributed data were expressed as median (lower quartile, upper quartile). Results There was no statistically significant difference in age, gestational sac diameter, uterine scar thickness, number of cesarean sections, time from cesarean section to present, time of menopause, or preoperative blood HCG value between the two groups (P>0.05). There was no statistically significant difference in intraoperative blood loss [75 (35, 120) vs. 65 (35, 130) mL, P=0.821], incidence of complications (5.1% vs. 5.5%, P=1.000), postoperative blood HCG recovery time [(5.22±2.17) vs. (4.96±1.81) weeks, P=0.559] or the effective rate of treatment (94.9% vs. 90.9%, P=0.747) between the two groups. The methotrexate group had longer operation time [43 (34, 55) vs. 32 (28, 35) min, P=0.001], longer length of hospital stay [(10.89±1.42) vs. (5.82±1.47) d, P<0.001], and higher hospitalization cost [(8596.46±3336.59) vs. (7058.84±2638.49) yuan, P=0.014]. Conclusion For patients with endogenous CSP, intramuscular injection of methotrexate before hysteroscopic surgery is not necessary, for it has no significant impact on the treatment effect, instead, it may prolong the operation time and length of hospital stay, and increase the hospitalization cost.

Citation： ZHENG Fengque, LIN Jiajing, WEI Lijin, FANG Shuang, HE Chunna, LI Jingjing. Therapeutic effect of methotrexate combined with hysteroscopy in the treatment of endogenous cesarean scar pregnancy. West China Medical Journal, 2021, 36(9): 1216-1220. doi: 10.7507/1002-0179.201912263 Copy

1.	Liang J, Mu Y, Li X, et al. Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births. BMJ, 2018, 360: k817.
2.	Zhang Y, Gu Y, Wang JM, et al. Analysis of cases with cesarean scar pregnancy. J Obstet Gynaecol Res, 2013, 39(1): 195-202.
3.	Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol, 2000, 16(6): 592-593.
4.	Rozenberg P, Chevret S, Camus E, et al. Medical treatment of ectopic pregnancies: a randomized clinical trial comparing methotrexate-mifepristone and methotrexate-placebo. Hum Reprod, 2003, 18(9): 1802-1808.
5.	Long Y, Zhu H, Hu Y, et al. Interventions for non-tubal ectopic pregnancy. Cochrane Database Syst Rev, 2020, 7(7): CD011174.
6.	An X, Ming X, Li K, et al. The analysis of efficacy and failure factors of uterine artery methotrexate infusion and embolization in treatment of cesarean scar pregnancy. Sci World J, 2013, 2013: 213603.
7.	Peng P, Gui T, Liu X, et al. Comparative efficacy and safety of local and systemic methotrexate injection in cesarean scar pregnancy. Ther Clin Risk Manag, 2015, 11: 137-142.
8.	Chen YQ, Liu HS, Li WX, et al. Efficacy of transvaginal debridement and repair surgery for cesarean scar pregnancy: a cohort study compared with uterine artery embolism. Int J Clin Exp Med, 2015, 8(11): 21187-21193.
9.	Tang Q, Qin Y, Zhou Q, et al. Hysteroscopic treatment and reproductive outcomes in cesarean scar pregnancy: experience at a single institution. Fertil Steril, 2021: S0015-0282(21)00509-4.
10.	Sowter MC, Farquhar CM, Gudex G. An economic evaluation of single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured ectopic pregnancy. BJOG, 2001, 108(2): 204-212.
11.	Maheux-Lacroix S, Li F, Bujold E, et al. Cesarean scar pregnancies: a systematic review of treatment options. J Minim Invasive Gynecol, 2017, 24(6): 915-925.
12.	Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, et al. Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril, 2016, 105(4): 958-967.
13.	de Vaate AJ, Brölmann HA, van der Slikke JW, et al. Therapeutic options of caesarean scar pregnancy: case series and literature review. J Clin Ultrasound, 2010, 38(2): 75-84.
14.	Pan Y, Liu MB. The value of hysteroscopic management of cesarean scar pregnancy: a report of 44 cases. Taiwan J Obstet Gynecol, 2017, 56(2): 139-142.
15.	Uludag S, Kutuk M, Ak M, et al. Comparison of systemic and local methotrexate treatments in cesarean scar pregnancies: time to change conventional treatment and follow-up protocols. Eur J Obstet Gynecol Reprod Biol, 2016, 206: 131-135.
16.	Naeh A, Shrim A, Shalom-Paz E, et al. Cesarean scar pregnancy managed with local and systemic methotrexate: a single center case series. Eur J Obstet Gynecol Reprod Biol, 2019, 238: 138-142.
17.	Lou T, Gao Y, Feng Y, et al. Reproductive outcomes of cesarean scar pregnancies pretreated with methotrexate and uterine artery embolization prior to curettage. Taiwan J Obstet Gynecol, 2020, 59(3): 381-386.
18.	Wang S, Beejadhursing R, Ma X, et al. Management of caesarean scar pregnancy with or without methotrexate before curettage: human chorionic gonadotropin trends and patient outcomes. BMC Pregnancy Childbirth, 2018, 18(1): 289.
19.	Kim S, Yoon S, Kim M, et al. Cesarean scar pregnancy; diagnosis and management between 2003 and 2015 in a single center. Taiwan J Obstet Gynecol, 2018, 57(5): 688-691.
20.	Sun Y, Xi X, Yan Q, et al. Management of type II unruptured cesarean scar pregnancy: comparison of gestational mass excision and uterine artery embolization combined with methotrexate. Taiwan J Obstet Gynecol, 2015, 54(5): 489-484.

1. Liang J, Mu Y, Li X, et al. Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births. BMJ, 2018, 360: k817.
2. Zhang Y, Gu Y, Wang JM, et al. Analysis of cases with cesarean scar pregnancy. J Obstet Gynaecol Res, 2013, 39(1): 195-202.
3. Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol, 2000, 16(6): 592-593.
4. Rozenberg P, Chevret S, Camus E, et al. Medical treatment of ectopic pregnancies: a randomized clinical trial comparing methotrexate-mifepristone and methotrexate-placebo. Hum Reprod, 2003, 18(9): 1802-1808.
5. Long Y, Zhu H, Hu Y, et al. Interventions for non-tubal ectopic pregnancy. Cochrane Database Syst Rev, 2020, 7(7): CD011174.
6. An X, Ming X, Li K, et al. The analysis of efficacy and failure factors of uterine artery methotrexate infusion and embolization in treatment of cesarean scar pregnancy. Sci World J, 2013, 2013: 213603.
7. Peng P, Gui T, Liu X, et al. Comparative efficacy and safety of local and systemic methotrexate injection in cesarean scar pregnancy. Ther Clin Risk Manag, 2015, 11: 137-142.
8. Chen YQ, Liu HS, Li WX, et al. Efficacy of transvaginal debridement and repair surgery for cesarean scar pregnancy: a cohort study compared with uterine artery embolism. Int J Clin Exp Med, 2015, 8(11): 21187-21193.
9. Tang Q, Qin Y, Zhou Q, et al. Hysteroscopic treatment and reproductive outcomes in cesarean scar pregnancy: experience at a single institution. Fertil Steril, 2021: S0015-0282(21)00509-4.
10. Sowter MC, Farquhar CM, Gudex G. An economic evaluation of single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured ectopic pregnancy. BJOG, 2001, 108(2): 204-212.
11. Maheux-Lacroix S, Li F, Bujold E, et al. Cesarean scar pregnancies: a systematic review of treatment options. J Minim Invasive Gynecol, 2017, 24(6): 915-925.
12. Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, et al. Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril, 2016, 105(4): 958-967.
13. de Vaate AJ, Brölmann HA, van der Slikke JW, et al. Therapeutic options of caesarean scar pregnancy: case series and literature review. J Clin Ultrasound, 2010, 38(2): 75-84.
14. Pan Y, Liu MB. The value of hysteroscopic management of cesarean scar pregnancy: a report of 44 cases. Taiwan J Obstet Gynecol, 2017, 56(2): 139-142.
15. Uludag S, Kutuk M, Ak M, et al. Comparison of systemic and local methotrexate treatments in cesarean scar pregnancies: time to change conventional treatment and follow-up protocols. Eur J Obstet Gynecol Reprod Biol, 2016, 206: 131-135.
16. Naeh A, Shrim A, Shalom-Paz E, et al. Cesarean scar pregnancy managed with local and systemic methotrexate: a single center case series. Eur J Obstet Gynecol Reprod Biol, 2019, 238: 138-142.
17. Lou T, Gao Y, Feng Y, et al. Reproductive outcomes of cesarean scar pregnancies pretreated with methotrexate and uterine artery embolization prior to curettage. Taiwan J Obstet Gynecol, 2020, 59(3): 381-386.
18. Wang S, Beejadhursing R, Ma X, et al. Management of caesarean scar pregnancy with or without methotrexate before curettage: human chorionic gonadotropin trends and patient outcomes. BMC Pregnancy Childbirth, 2018, 18(1): 289.
19. Kim S, Yoon S, Kim M, et al. Cesarean scar pregnancy; diagnosis and management between 2003 and 2015 in a single center. Taiwan J Obstet Gynecol, 2018, 57(5): 688-691.
20. Sun Y, Xi X, Yan Q, et al. Management of type II unruptured cesarean scar pregnancy: comparison of gestational mass excision and uterine artery embolization combined with methotrexate. Taiwan J Obstet Gynecol, 2015, 54(5): 489-484.

West China Medical Journal

Therapeutic effect of methotrexate combined with hysteroscopy in the treatment of endogenous cesarean scar pregnancy

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