Outcome and treatment of caesarean scar ectopic pregnancy under ultrasound-guided vacuum aspiration preceded by local methotrexate sac injection

Background: Scar ectopic pregnancy (SEP) is the rarest form of ectopic pregnancy and has been increasingly diagnosed all over the world. This is a life-threatening form of abnormal implantation of an embryo within the myometrium and fibrous tissues in a previous scar on the uterus, especially following caesarean section (C/S). Objective: To present cases of endogenic cesarean scar pregnancies (CSP) that were successfully treated with suction curettage under ultrasound (U/S) guide with local methotrexate (MTX) injection for viable pregnancy and its outcome. Patients and Methods: This retrospective case series study was done in a Sulaimani Maternity Teaching Hospital as a single-centre study on 17 hemodynamically stable patients in their first trimester diagnosed with endogenic CSP through transvaginal and abdominal U/S from May 2022 to April 2023. Among patients, 4 had viable fetuses with gestational sacs injected locally with MTX under the U/S guide, followed by vacuum aspiration under the U/S guide. At the same time, five patients need intracervical balloon insertion to stop bleeding without further treatment. Results: Most patients were aged 35 – 43 years old (52.9%) with a gestational age of 8 – 10 weeks (35.3%), resided in an urban area (58.8%), with three parities (47.1%), three previous C/S (41.2%), without last miscarriage (70.6%), missed period (58.8%), and dead fetus (76.5%). Patients with positive fetal heart (n=4) received local intrinsic MTX injection under the U/S guide, then suction curettage under the U/S guide. At the same time, those with negative fetal hearts (n=17) underwent only suction curettage under the U/S guide. Among treated women, 5 cases had an intrauterine balloon, following suction curettage to stop bleeding and only 3 instances needed blood transfusion due to the severe bleeding. Conclusions: SEP is a dangerous and complex disorder with increasing occurrence in recent years. Accurate early diagnosis and effective management are essential to reduce maternal mortality and mortality.