Minimally invasive procedure for type II canal defect caesarean scar pregnancy with cardiac activity and high hCG titres at 8+2 weeks of gestation

Type II caesarean scar pregnancy (CSP) not only poses important maternal hazards, such as severe bleeding, uterine rupture, disseminated intravascular coagulation and maternal death due to its abnormal location and invasive characteristics, but its surgical management may lead to operative complications and even loss of fertility. The sonographic and Doppler findings of a “canal defect CSP” that has previously been hypothesised, but not illustrated, are presented here. A minimally invasive approach was performed in the presence of a 38.3 mm gestational sac (GS) with a crown rump length of 11.3 mm embryo (8+2 weeks of gestation) and cardiac activity with high (118,839.2 mIU/mL) human chorionic gonadotropin (hCG) levels. A transabdominal intragestational sac injection of potassium chloride to stop cardiac activity, and consecutively, methotrexate (MTX) was given before systemic MTX therapy. Embryonic cardiac activity stopped. Systemic methotrexate was repeated 8 days after the procedure. While vaginal bleeding ceased in 3 weeks with gradual shrinkage of the GS, hCG fell to non-pregnant levels within 112 days (16 weeks); complete resolution of the ectopic mass required 8 months. This is the first report presenting the success of a minimally invasive procedure at a hCG level of 118,839.2 mIU/mL with embryonic cardiac activity in type II CSP.