Local treatment with transvaginal ultrasound-guided injection of
methotrexate is an excellent option which also optimizes the chance for
fertility preservation [20].
Uterine curettage has been performed to treat caesarean scar
pregnancies, but this approach appears to have a high failure rate. Li
et al. [17] reported a failure in 12 of 17 women who underwent uterine
curettage as their initial treatment modality. Of note, removal of the
pregnancy by dilation and curettage is not recommended as severe
hemorrhage complicates a majority of cases so treated [21]. In this
decision process, pregnancy size, absence or presence of rupture,
ß-hCG levels, desire for future fertility and patient hemodynamic status
weigh heavily. Asymptomatic and hemodynamically stable patients are
candidates for medical management by methotrexate [22]. Regarding
the first case, the vaginal probe, which is considered the gold standard,
would have led to a wrong diagnosis. The gestational sac volume (Twin
pregnancy) and advanced gestational age limit our ability to explore
the whole of the uterus; in consequence we see only the gestational sac
that makes the diagnosis of caesarean scar twin pregnancy difficult or
impossible.
In control with abdominal probe, the diagnosis of the CSP was
evident. In the second case vacuum evacuation was immediately
complicated with haemorrhage controlled by balloon tamponade. The
third and fourth cases were treated successfully by a suction curettage.
All of the four cases had a three dimensional ultrasonography.
Transabdominal scan was performed with VOLUSON 730 pro
equipment using 3D transducer and colour Doppler imaging. All
volumes were stored and then processed off line.