Case Report

A Large Intrauterine Vascular Lesion

Developing After the Successful Treatment of
a Cesarean Scar Pregnancy with
Methotrexate Injection

Ji Won Song, MD,1 Da Hye Ju, MD,2 Sang Wook Yi, MD ,2 Joo Hee Lee, MD,1 Woo Seok Sohn, MD,2
Sang Soo Lee, MD2

1
Department of Obstetrics and Gynecology, Seoul Asan Hospital, University of Ulsan College of Medicine, Seoul,
Korea
2
Department of Obstetrics and Gynecology, Gangneung Asan Hospital, University of Ulsan College of Medicine,
Gangneung, Korea

Received 11 January 2017; accepted 22 March 2017

ABSTRACT: A cesarean scar pregnancy is a rare type
of ectopic pregnancy. Induced abortion by local meth-
otrexate (MTX) injection is an effective management
approach. We describe a case in which a large intra-
uterine vascular lesion appeared after the
sonographic-guided local injection of MTX, which
successfully induced the abortion of the cesarean
scar pregnancy. Although a cesarean scar pregnancy
may be safely treated with a local MTX injection,
close follow-up, including serum b-human chorionic
gonadotropin level measurement and Doppler sonog-
raphy, is needed because an intrauterine vascular
lesion could develop even after a successfully
induced abortion. VC 2017 Wiley Periodicals, Inc. J Clin
Ultrasound 00:000000, 2017; Published online in
Wiley Online Library (wileyonlinelibrary.com). DOI:
10.1002/jcu.22490
Keywords: cesarean scar pregnancy; obstetrics; local
methotrexate injection; ultrasound; uterus
INTRODUCTION
C esarean scar pregnancy is a rare type of
ectopic pregnancy with an incidence of
1:1,8001:2,216 among all pregnancies.1,2 It can
produce massive hemorrhage due to gestational
tissue implantation in the lower segment of the
uterus. Due to the risk of profuse
Correspondence to: S. W. Yi
C 2017 Wiley Periodicals, Inc.
V to our hospital for suspicion of a cervical
VOL. 00, NO. 00, MONTH 2017
hemorrhaging, many cesarean scar pregnancies
have been managed with medical therapy, such
as direct injection of methotrexate (MTX) into
the gestational sac (GS). Some authors have
suggested that transvaginal ultrasound (TVUS)-
guided sac aspiration and local MTX injection
should be considered the first-line treatment for
cesarean scar pregnancies.3,4
Several cases of uterine vascular lesions associ-
ated with pregnancy have been reported. Rare
cases of increase of intrauterine vascular lesions
have been reported after a successfully induced
abortion of a cesarean scar pregnancy. The patho-
genesis of uterine vascular lesions is unknown and
placental tissue invasion into the myometrium
and neovascular formation have been suggested.5
Because the amount of bleeding from the lesions
may be profuse, careful diagnosis and manage-
ment of such uterine vascular lesions are required.
We recently encountered a case involving a
large intrauterine vascular lesion that devel-
oped following the local MTX injection to induce
the abortion of a cesarean scar pregnancy. In
this case, an intrauterine vascular lesion was
formed despite the successful abortion.
CASE REPORT
A 35-year-old multiparous woman was referred
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 SONG ET AL

pregnancy and amenorrhea for 8 weeks. Her

history included one full-term vaginal delivery,
one cesarean section, followed by two vaginal
deliveries. TVUS examination performed with
an Accuvix A30 scanner equipped with a 49-
MHz endocavity transducer (Samsung Medison
Co. Ltd., Seoul, Korea) revealed a 3.6 3 2.1-cm
GS with a 0.95 cm crown-rump length and an
active fetal heartbeat near the cesarean scar
(Figure 1). The uterus was slightly enlarged
due to adenomyosis, and no pathologic findings
were observed in the bilateral adnexae. No oth-
er gestational tissues were observed in the
endometrial cavity or adnexa. The patients b-
human chorionic gonadotropin (b-hCG) serum
level was 17,926 mIU/ml.
After counseling regarding the risk of uterine
rupture, massive bleeding, and hysterectomy,
the patient underwent transvaginal aspiration
of the GS and an injection of MTX to preserve
her uterus. The procedure was performed under
transabdominal ultrasound (US) guidance, with
the patient in the lithotomy position, without
anesthesia. The GS was punctured and aspirat-
ed with an 18-gauge spinal needle. After aspira-
tion, 90 mg of MTX (50 mg/m2) was injected
slowly through the spinal needle. Serum b-hCG
testing was performed on days 1 and 5 and
then weekly to evaluate the success of the pro-
cedure. On the day after the procedure, the FIGURE 1. (A) Transvaginal sonogram revealed a 3.6 3 2.1-cm gesta-
patients b-hCG serum level was 16,572 mIU/ tional sac near the cesarean scar with a 0.95-cm crown-rump length.
ml, and no fetal heartbeat was detected. There- (B) Sonogram confirms an active fetal heartbeat.
fore, the patient was discharged and the need
for weekly follow-up to monitor her serum b- outpatient basis. Two weeks after the emboliza-
hCG levels was explained. tion, the patient experienced an episode of vagi-
The patients b-hCG serum levels after 5 days nal bleeding, which was treated conservatively.
and after 7 days were 20,490 mIU/ml and The serum b-hCG level normalized after 57
48,702 mIU/ml, respectively. TVUS with color days, and the patient had a regular menstrual
Doppler revealed a large vascular lesion in the period 2 months after the embolization. TVUS
uterus near the regressed GS without a fetal with color Doppler performed 124 days after the
heartbeat (Figure 2). The patient was admitted embolization showed the remnant tissue of the
to the hospital. CT angiography revealed an 8 3 cesarean scar pregnancy as a 0.9-cm avascular
4-cm vascular lesion on the right side of the echogenic mass (Figure 5). No additional inter-
uterine body with enlarged uterine arteries and vention or uterine curettage was performed.
ovarian veins (Figure 3). The vascular lesion
originated from the point where both uterine
arteries drained into the right side of the parau- DISCUSSION
terine venous plexus and gonadal vein (Figure
4). Bilateral uterine arterial embolization with Treatment modalities for cesarean scar preg-
a coil and gelfoam was performed following sys- nancy range from medical interventions to sur-
temic MTX chemotherapy. On the following day, gical procedures, uterine artery embolization,
the patients b-hCG serum level was 4,760 mIU/ chemoembolization, or a combination of them.
ml. The recovery period was uneventful. The Cok et al reported using TVUS-guided local
patient was discharged, and follow-up visits to MTX administration as the first-line treatment
monitor the serum b-hCG levels and undergo for cesarean scar pregnancy in 18 cases with
US examinations were performed on an follow-up.4 They reported that 11 of the 18
2 JOURNAL OF CLINICAL ULTRASOUND
 VASCULAR LESION AFTER CESAREAN SCAR PREGNANCY

FIGURE 2. (A) Transvaginal gray-scale sonogram shows an anechoic lesion in the uterus near the regressed gestational sac (white arrow). (B) Col-
or Doppler confirms the blood flow in the vascular lesion.

FIGURE 3. CT scan shows an enhanced vascular lesion (white arrow) around the gestational sac (black arrow) in the cesarean section scar
pregnancy.

patients (61.1%) did not require further inter-
vention. Four patients (22.2%) were treated
with an additional single dose of systemic MTX,
and three patients required a hysteroscopy and/
or laparotomy. Yamaguchi et al retrospectively
reviewed eight cases of cesarean scar pregnancy
treated with a local MTX injection under TVUS
guidance.6 They concluded that a transvaginal
MTX injection was effective and safe as the sole
treatment for cesarean scar pregnancy, although
the course after treatment tended to be long. In
a retrospective clinical study of 131 cesarean
VOL. 00, NO. 00, MONTH 2017
scar pregnancies, both uterine arterial emboli-
zation and MTX conservative treatment
achieved the expected therapeutic effect, and
the recovery time in the dilatation and curet-
tage subgroup was significantly shorter than in
the noncurettage group.7 Considering these
reports, we treated our patient with a transva-
ginal local MTX injection under transabdominal
US guidance. After the local MTX injection, the
fetal heartbeat ceased, and the serum -hCG
level decreased. Generally, after a local MTX
injection, a decline in the serum -hCG level
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 SONG ET AL

FIGURE 4. CT angiography with reconstruction. There is an 8 3 4-cm vascular lesion in the right side of the uterine body with enlarged uterine
arteries and ovarian veins.

FIGURE 5. Transvaginal sonogram obtained 124 days after the embolization shows the 0.9-cm echogenic remnant tissue of the cesarean scar
pregnancy (arrow). Calipers showed longitudinal diameter and anterioposterior diameter of the uterus.

indicates regression of the conception tissue. In one case series, a small (<3 cm) intrauter-
However, the placental tissue can be activated ine vascular lesion was observed following a
despite the induction of an abortion. successfully induced abortion using a local MTX
4 JOURNAL OF CLINICAL ULTRASOUND
 VASCULAR LESION AFTER CESAREAN SCAR PREGNANCY
injection. The pathogenesis of intrauterine vas-
cular lesions is unclear. Some authors have sug-
gested that trophoblasts such as the retained
placenta might play a role as a precursor of the
lesion. The placental tissue may have been
involved in vascular disruption and neovascula-
rization.5 One case of a cesarean scar pregnancy
associated with a uterine artery pseudoaneur-
ysm has been reported.8 This case involved a
uterine arterial pseudoaneurysm and a cesare-
an scar pregnancy without a fetal heartbeat. In
our case, a large intrauterine vascular lesion
was observed following a successful abortion,
producing a sudden increase in the serum -
hCG level. Because intrauterine vascular
lesions greater than 3 cm in size with increas-
ing serum -hCG levels tend to continue to
increase or persist, interventional management
is needed.5 Therefore, careful monitoring of the
serum -hCG level and Doppler sonography
after a local MTX injection for a cesarean scar
pregnancy are required.
The treatment options for intrauterine vascu-
lar lesions include hysterectomy, uterine arteri-
al embolization, chemotherapy with MTX, and
conservative management.5 Due to the possibili-
ty of profuse vaginal bleeding, patients should
be referred to a center with an interventional
radiology unit. Curettage can cause heavy and
life-threatening bleeding if the diagnosis of vas-
cular abnormalities is not made prior to the
intervention. Tan et al described a case of a
cesarean section pregnancy associated with a
uterine artery pseudoaneurysm.8 They per-
formed uterine arterial embolization followed by
curettage under sonographic guidance 1 week
later.
A cesarean scar pregnancy may be safely
treated with a local MTX injection. However,
close follow-up, including serum -hCG level
VOL. 00, NO. 00, MONTH 2017
measurement and color Doppler US, is needed
because an intrauterine vascular lesion could
occur even after a successfully induced abortion.
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