Methotrexate Treatment for Cesarean Scar Ectopic Pregnancy: Learning Lessons

Letter to the Editor Methotrexate Treatment for Cesarean Scar Ectopic Pregnancy: Learning Lessons To the Editor: We have read the review published by Cheung [1] on cesarean scar pregnancy (CSP) treatment by ultrasound-guided local methotrexate (MTX) with great interest. The author has concluded that except for women with a serum human chorionic gonadotropin level higher than 100,000 IU/L, ultrasound-guided local methotrexate injection could be considered as a first-line treatment modality for CSP. There is an urgent need to re-evaluate management strategies for CSP. We think that this review highlights several major limitations. First, there have never been data comparing MTX treatment (whether local or systemic) versus surgery in women with CSP. Second, CSPs are diagnosed at earlier gestations, and, consequently, women are more clinically stable at the time of ultrasound diagnosis. Collapse requiring emergency laparotomy is the exception rather than the rule [2]. However, several publications prove that hemodynamically stable women, often without the presence of fetal cardiac activity in the ectopic gestation, have been routinely subjected to surgery [3,4]. How many of these women actually had a failing CSP and therefore underwent unnecessary surgery or received unnecessary MTX? Current published data do not address this question. Third, within the clinically stable women and according to the trophoblastic activity, there are 2 other subgroups of women with CSP, those with an evolving CSP and those with a failing CSP. The presence of these subgroups of CSP patients has not been taken into consideration when designing clinical trials to date. These

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stable women should not be evaluated to either additional MTX (local vs systemic as reported by Peng et al [5]) or surgery, but instead an evaluation of trophoblastic activity (ongoing vs failing) needs to be made. This would ensure that stable women are not exposed to unnecessary MTX or even more invasive treatments, including surgery. Finally, published data have made little or no effort to determine which clinically stable CSP patients (without cardiac activity) do not need any intervention at all (i.e., either medical or surgery). Tarek Shokeir, MD Mansoura, Egypt References 1. Cheung VY. Local methotrexate injection as the first-line treatment for cesarean scar pregnancy: a review of the literature. J Minim Invasive Gynecol. 2015 [Epub ahead of print]. 2. Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol. 2004;23:247–253. 3. Cok T, Kalayci H, Ozdemir H, Haydardedeoglu B, Parlakgumus AH, Tarim E. Transvaginal ultrasound-guided local methotrexate administration as the first-line treatment for cesarean scar pregnancy: follow-up of 18 cases. J Obstet Gynaecol Res. 2015;41:803–808. 4. Siedhoff MT, Schiff LD, Moulder JK, Toubia T, Ivester T. Robotic-assisted laparoscopic removal of cesarean scar ectopic and hysterotomy revision. Am J Obstet Gynecol. 2015;212:681.e1–681.e4. 5. Peng P, Gui T, Liu X, Chen W, Liu Z. Comparative efficacy and safety of local and systemic methotrexate injection in cesarean scar pregnancy. Ther Clin Risk Manag. 2015;11:137–142. http://dx.doi.org/10.1016/j.jmig.2015.04.027