Medical treatment of cesarean scar pregnancy.

摘要

We read the interesting article by Qing Yang et al [1] on the treatment of cesarean scar pregnancy (CSP). The authors describe the hysteroscopic removal of the trophoblastic tissue in 39 patients under ultrasonographic guidance. Two patients (5%) experienced excessive bleeding and required additional hysteroscopy. No follow-up on further fertility was available.The authors conclude in the discussion section that they "consider hysteroscopic surgery to be the first-line therapy of CSP." However, we believe that the current case series cannot give rise to this conclusion because other treatment options were not studied and medical treatment was not discussed. Future fertility should lead the choice of therapy. For several years, ultrasound-guided transcervical aspiration of the gestational sac, followed by intraamniotic injection of methotrexate (MTX: 1 mg/kg body weight) has been performed successfully in our hospital. In a consecutive series of 4 patients with a CSP who were treated accordingly, the uterus was preserved. Three patients who had wanted to retain their fertility had an uneventful pregnancy and delivery. No complications or significant side effects occurred with MTX treatment. Because we consider local MTX after amniotic sac aspiration substantially less invasive than hysteroscopic surgery, we suggest that this management should be the preferred treatment, followed by surgical treatment (hysteroscopy or laparoscopy depending on the myometrial invasion) only if MTX fails.