Hysteroscopic removal of cesarean scar pregnancy after methotrexate treatment failure

A 35-year-old woman with persistent vaginal bleeding and a history of prior cesarean delivery was diagnosed with cesarean scar pregnancy (CSP) by transvaginal ultrasonography at 7 weeks of gestation. The patient was initially treated with a single dose of systemic methotrexate (MTX) injection. However, both follow-up β-hCG levels and transvaginal ultrasonography had shown evidence of ongoing pregnancy. Finally, she was treated with hysteroscopic resectoscope, by which the gestational tissue was removed completely. No intra-operative or post-operative complication occurred. Serum β-hCG level returned to normal limit four weeks after the surgery. In our experience, systemic MTX injection provides an alternative choice of treatment for carefully selected women with CSP, and hysteroscopic removal of CSP, which offers good prognosis, can serve both as the initial treatment and as the rescue management after a failed MTX treatment attempt.