A 26-year-old woman with a history of left salpingectomy for ectopic pregnancy 2 years ago now presents with a positive pregnancy test. TVS shows a gestational sac with cardiac activity within the caesarean scar. This is a cesarean scar ectopic (CSE). The MOST appropriate primary management for a haemodynamically stable CSE at 7 weeks with cardiac activity is:
- A Systemic single-dose methotrexate (MTX) alone
- B Expectant management until spontaneous resolution
- C Combined approach: UAE or intrasac KCl/MTX injection, or systemic MTX with close monitoring — individualised decision with hysteroscopic or laparoscopic resection if primary treatment fails ✓
- D UAE (uterine artery embolisation) alone as definitive treatment
Explanation
Cesarean scar ectopic pregnancy is a life-threatening condition with risk of uterine rupture and massive haemorrhage, and its management is individualised and complex. For haemodynamically stable patients with cardiac activity (which worsens systemic MTX efficacy), options include: direct intrasac injection of KCl ± MTX (with or without UAE), UAE followed by surgical evacuation, or hysteroscopic resection. Systemic MTX alone has lower efficacy with cardiac activity (requires cardiac quiescence for best results). Expectant management is not appropriate with active cardiac activity due to rupture risk. There is no single universally agreed standard; combined/procedural approaches are preferred.
Reference: Williams Obstetrics, 26th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.