Exclusive use of intrasac potassium chloride and methotrexate for treating cesarean scar pregnancy: effectiveness and subsequent fecundity

STUDY QUESTION: Is exclusive use of intragestational sac potassium chloride (KCI) and methotrexate (MTX) effective in the management of viable cesarean scar pregnancy (CSP)? SUMMARY ANSWER: Exclusive use of intragestational sac KCI and MTX was effective in the management of viable CSP. WHAT IS KNOWN ALREADY: Owing to a paucity of randomized studies on management of CSP, evidence-based management remains unclear. Intragestational sac KCI or MTX along with either systemic MTX or surgical intervention, such as uterine artery embolization or dilation and curettage, has proved to be effective in the management of CSP. Furthermore, there are limited data in the literature on the use of exclusive intragestational sac KCI and MTX for management of CSP and subsequent fecundity. STUDY DESIGN, SIZE, DURATION: A prospective cohort study was conducted from June 2017 to September 2019. We recruited nine CSP patients referred to our unit. There was no lost to follow-up noted. PARTICIPANTS/MATERIALS, SETTING, METHODS: Patients with an ultrasound diagnosis of CSP who fulfilled the inclusion criteria were recruited. The study was conducted in a tertiary care center. Clinical symptoms, pregnancy viability, gestational age and human chorionic gonadotrophin (HCG) values determined the management in each individual case. Accordingly, patients were grouped into the expectant management (Group I, n=3) and intragestational sac KCI with MTX (Group II, n 6) groups. Demographic details, clinical characteristics, ultrasound details at diagnosis, post-treatment HCG normalization time, menses resumption, mass resolution and subsequent fecundity were noted. Descriptive statistics were used for analyses. MAIN RESULTS AND THE ROLE OF CHANCE: Of the nine patients with CSP, six patients had viable CSP and required intervention. Out of these, four patients expressed a desire for future fertility. Mean gestational age at treatment among patients in Group II was 54.33 +/- 7.51 days (range 46-65). Mean HCG value at the time of diagnosis was 84 110 +/- 38 679.39 IU/l in Group II patients as compared with 2512 +/- 709.36 in Group I. HCG had decreased by 92.71 +/- 3.78% 2 weeks after intervention and normalized (<5 IU/l) by 53.5 +/- 14.97 days. No major complications occurred and additional treatment was not required in these patients. Menstruation had resumed by 26 +/- 6.6 days after treatment in Group II. On follow up, a small unresolved mass was present in two patients and the cesarean scar niche was visible in the remaining four patients. Out of the four patients desirous of future conception, three conceived naturally and one delivered a term baby via repeat lower segment cesarean section. LIMITATIONS, REASONS FOR CAUTION: The main limitation of our study was small sample size. All the patients were asymptomatic at presentation and hence we cannot comment on use of this method in those presenting with active vaginal bleeding. WIDER IMPLICATIONS OF THE FINDINGS: Intragestational sac KCI plus MTX may be a highly effective approach for the management of viable CSP despite high initial HCG values. There seems to be no need for any further intervention. It can be considered as the first line minimally invasive treatment option in patients desirous of future fertility. Nevertheless, accumulation of further cases is required to validate this treatment modality.