CONSERVATIVE MANAGEMENT OF CESAREAN SCAR PREGNANCY WITH METHOTREXATE: A CASE REPORT

Abstract

Cesarean scar pregnancy is a rare form of ectopic pregnancy associated with potentially severe complications, including hemorrhage, uterine rupture, and the need for emergency surgical intervention. This case describes a 39-year-old G5P3L3A1 woman at approximately 5+1 weeks of gestation with a history of three previous lower-segment cesarean sections who presented with vaginal bleeding. Transvaginal ultrasonography demonstrated a low anterior gestational sac related to the previous cesarean scar with associated vascularity, while pelvic magnetic resonance imaging further supported implantation at the scar site. Conservative treatment was initiated with ultrasound-guided transvaginal intrasac methotrexate using a 20-gauge Chiba needle, with 50 mg methotrexate in 2 mL instilled directly into the gestational sac. Serial serum beta-human chorionic gonadotropin (beta-hCG) levels decreased from 904 mIU/mL on 20 July 2026 to 742 mIU/mL on 24 July 2026 and further to 122.2 mIU/mL on 4 August 2026, representing an overall decline of approximately 86.5% from baseline. Follow-up ultrasonography demonstrated regression and collapse of the gestational sac with reduced vascularity, supporting a marked biochemical and sonographic response to treatment. Additional methotrexate-based therapy was subsequently documented. Despite the favorable initial response, recurrent vaginal bleeding later required referral for further management. This case highlights the potential role of conservative methotrexate-based management in carefully selected, hemodynamically stable patients with early cesarean scar pregnancy and emphasizes the importance of serial beta-hCG monitoring, repeat ultrasonography, and readiness for treatment escalation.