Cesarean Scar Pregnancy Management: Minimally Invasive Suction of the Gestational Sac Content Combined With Local and Intramuscular Methotrexate Injection.

Background: Cesarean scar pregnancy is a rare, potentially life-threatening complication in patients with prior cesarean delivery. Vaginal bleeding is a common presenting symptom. Case Report: A 23-year-old female who presented with mild vaginal bleeding was diagnosed by transvaginal ultrasound with a viable cesarean scar pregnancy of 7 weeks' gestation. After the sac content was suctioned through a transvaginal approach under ultrasound guidance, the patient was injected with 50 mg local and 25 mg systemic methotrexate. One week later, a repeat systemic methotrexate dose of 50 mg was administered. The patient's beta human chorionic gonadotropin (hCG) levels were followed weekly until a negative beta hCG level was established. Conclusion: No management approach has been universally approved for cesarean scar pregnancy; the best option depends on case presentation, surgeon experience, and available facilities. We suggest that our minimally invasive treatment is an acceptable approach, especially if embryonic cardiac activity is present. We recommend the referral of such cases to tertiary centers to avoid complications.

Low-risk gestational trophoblastic neoplasia: A single-center experience from Saudi Arabia.

OBJECTIVE: To report our single-center experience in terms of patient clinical characteristics, treatment outcomes, and chemotherapy-related toxicities in patients with low-risk gestational trophoblastic neoplasia (GTN). MATERIALS AND METHODS: A retrospective cross-sectional study (2008-2013) was conducted at a tertiary health-care hospital in Saudi Arabia. Forty-four (n = 44) patients met the inclusion criteria for low-risk GTN. Methotrexate (MTX) was administered in a 5-day regimen: 0.3-0.5mg/kg intravenously (IV) daily for 5 days every 2 weeks (maximum 25mg per dose). Actinomycin D (ActD) was administered 1.25mg/m2 pulsed IV every 2 weeks. RESULTS: The majority of patients had molar pregnancy as the antecedent event (86%), developed GTN within the first 4 months after the initial evacuation (93.2%), had human chorionic gonadotropin levels between 1,000 and 10,000 mIU/dL (36.3%), and had the World Health Organization prognostic scores from 0 to 2 (48.7%). Only 38 patients accepted treatment with chemotherapy. A total of 37 patients received first-line MTX; 34 patients of them achieved complete remission (CR, 92%). The three patients who developed MTX resistance were salvaged with sequential ActD and all achieved CR of 100%. Only one patient received first-line ActD and achieved CR. The overall survival as well as cure rate for all patients with low-risk GTN was 100%. No patient developed MTX-related hepatic toxicity or ActD-related blister formation. No severe adverse effects occurred. CONCLUSION: Our 5-day IV MTX regimen was highly effective in treating patients with low-risk GTN, with CR rate of 92% and no severe toxicity. Primary and sequential ActD therapy appears to be very effective.