A Milestone in Fertility-Preserving Management of Cesarean Scar Pregnancy at UNICO Hospital

A Milestone in Fertility-Preserving Management of Cesarean Scar Pregnancy at UNICO Hospital

A successful multidisciplinary management of a cesarean scar pregnancy using ultrasound-guided local methotrexate injection

Cesarean Scar Pregnancy (CSP) is a rare but potentially life-threatening form of ectopic pregnancy in which the pregnancy implants within the scar of a previous cesarean section. If left untreated, it may lead to catastrophic hemorrhage, uterine rupture, massive blood loss, hysterectomy, and even maternal death. Early diagnosis and timely intervention are therefore essential, not only to save the woman's life but also to preserve her future fertility.

Introduction

Cesarean scar pregnancy (CSP) is a rare but potentially life-threatening form of ectopic pregnancy in which the gestational sac implants within the myometrial scar of a previous cesarean section. If left untreated, CSP may result in catastrophic complications including massive hemorrhage, uterine rupture, disseminated intravascular coagulation, hysterectomy, loss of fertility, and even maternal death. Therefore, early diagnosis and timely intervention are essential not only to prevent maternal morbidity and mortality but also to preserve future reproductive potential.

The optimal management of CSP remains is a big issue. Conventional surgical evacuation carries a substantial risk of severe hemorrhage due to the rich vascularity surrounding the implantation site within the scar tissue.  Consequently, many clinicians delay uterine evacuation until the pregnancy becomes less vascular following medical treatment with methotrexate.

Traditionally, methotrexate has been administered intramuscularly as a systemic therapy. However, systemic administration exposes the entire body to the drug while delivering only a fraction of the dose to the scar implantation site. Clinical evidence suggests that systemic methotrexate alone is associated with slower resolution, lower treatment success in selected CSP cases, prolonged follow-up, and a greater likelihood of requiring additional interventions. In contrast, ultrasound-guided local methotrexate injection directly into the gestational sac or trophoblastic tissue achieves a high local drug concentration with minimal systemic exposure. This targeted approach facilitates rapid devascularization of the pregnancy, enhances treatment efficacy in appropriately selected patients, reduces systemic adverse effects, and may allow earlier and safer surgical evacuation when required.

For these reasons, ultrasound-guided local methotrexate injection has emerged as an internationally recognized, minimally invasive, fertility-preserving treatment option for carefully selected women with cesarean scar pregnancy, either as a standalone therapy or as part of a combined management strategy with subsequent suction evacuation or hysteroscopic removal.

Unfortunately, despite its tremendous potential, this procedure remains available in only a limited number of clinical setups in Bangladesh.

On 27 June 2026, a 33-year-old woman (Para 2, both delivered by lower segment cesarean section) presented to UNICO Hospital as a known case of 7-week cesarean scar pregnancy. Serial transvaginal ultrasonography demonstrated a gestational sac implanted within the previous cesarean scar without a fetal pole, although her serum β-hCG continued to rise.

The patient had initially consulted a gynecologist on 19 June 2026. Following a β-hCG level of 16,840 mIU/mL, she received a single intramuscular ampoule of methotrexate. However, repeat β-hCG performed on 25 June increased further to 21,338 mIU/mL. She was then advised to take medical abortion tablets (MM Kit) for uterine evacuation. Fortunately, her husband carefully reviewed reliable medical information and learned that such medication is contraindicated in ectopic pregnancy. They therefore decided not to proceed with that treatment and searched extensively for further expert opinion. The family eventually found our team online. Notably, the patient's first baby had also been delivered by one of our team member seven years earlier by cesarean section for fetal distress, which further strengthened their confidence in seeking care at UNICO Hospital.

Before proceeding, the patient and her husband received comprehensive counseling regarding the diagnosis, treatment options, expected course, and possible complications. They were informed that management of cesarean scar pregnancy is not a single-step procedure but a carefully planned treatment process requiring close follow-up. We explained that the initial step would be an ultrasound-guided local methotrexate injection into the gestational sac, followed by serial serum β-hCG measurements and transvaginal ultrasonography to monitor treatment response. Depending on the progress, vacuum aspiration of the products of conception might subsequently be required. They were also counseled that, in the event of scar dehiscence, heavy bleeding, or other complications, surgical repair of the cesarean scar could become necessary, either by laparoscopy or laparotomy, to ensure the patient's safety.

After listening carefully to the entire treatment plan, the patient's husband responded with remarkable confidence and trust, saying, "Madam, please proceed with whatever you believe is the best treatment. We have complete faith in your judgment and your team's care." This mutual trust, built upon transparent communication and shared decision-making, gave our team the confidence to undertake this challenging fertility-preserving procedure.

A multidisciplinary team was immediately organized, comprising Dr. Fatema Ashraf (Team Lead), Dr. Razia Parvin (Senior Consultant, Gynecology), Dr. Sanjida Rahman (Senior Consultant, Gynecology), Dr. LutfunNahar (Ultrasonography Specialist), Floor In-charge Nurses Shathi and Tashifa, together with OPD Staff Nurse Nusrat Jahan and Turzaun Mohona.

The ultrasound-guided local methotrexate injection was successfully performed under deep sedation as a day-care procedure. The intervention was completed smoothly with only minimal bleeding and no immediate complications. The patient recovered well after the procedure and entered the planned follow-up phase with serial β-hCG estimation and transvaginal ultrasonography to evaluate treatment response and determine the need for any subsequent intervention.

The successful completion of this case at UNICO Hospital demonstrates that, with early diagnosis, meticulous planning, multidisciplinary collaboration, and patient-centered care, advanced fertility-preserving management can be safely offered in our country.

This achievement reflects UNICO Hospital's commitment to delivering evidence-based, minimally invasive women's healthcare while placing patient safety, informed decision-making, and preservation of future fertility at the heart of clinical practice. It also reinforces a principle we deeply believe in - when medical expertise is combined with compassionate counseling, multidisciplinary teamwork, and patients' trust, even the most challenging clinical situations can be transformed into stories of hope.