International Journal of Gynecology and Obstetrics 113 (2011) 178–182

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International Journal of Gynecology and Obstetrics

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CLINICAL ARTICLE

Transcatheter arterial chemoembolization versus systemic methotrexate for themanagement of cesarean scar pregnancy

Chunhai Li a, Caixia Li a, Danjun Feng b, Chunling Jia c, Bin Liu a, Xinfeng Zhan d,⁎a Department of Radiology, Qilu Hospital, Shandong University, Jinan, Chinab School of Nursing in Shandong University, Jinan, Chinac Department of Gynecology and Obstetrics, Qilu Hospital, Shandong University, Jinan, Chinad Department of Ultrasound, Qilu Hospital, Shandong University, Jinan, China

⁎ Corresponding author at: Department of UltrasoUniversity, Jinan, Shandong Province 250012, China. Tel.531 86927544.

E-mail address: zxf86335@163.com (X. Zhan).

0020-7292/$ – see front matter © 2011 International Fedoi:10.1016/j.ijgo.2010.11.027

a b s t r a c t

a r t i c l e i n f o

Article history:

Received 5 September 2010Received in revised form 29 November 2010Accepted 24 February 2011

Keywords:Cesarean scar pregnancyGelatin spongeMethotrexatePolyvinyl alcoholTranscatheter arterial chemoembolization

Objective: To evaluate the effectiveness/safety of systemicmethotrexate (MTX) treatment versus transcatheterarterial chemoembolization using different embolic agents for termination of cesarean scar pregnancy (CSP).Methods: Women with CSP were randomized to receive intravenous infusion of MTX (group 1, n=13),or chemoembolization with MTX and either gelatin sponge (GS; group 2, n=15) or polyvinyl alcohol(PVA; group 3, n=16) particles. Uterine suction curettage followed all procedures. Bleeding volume,time until resolution of serum β-hCG, and length of hospital stay were recorded as outcome endpoints.Results: Bleeding volume was smaller in groups 2 (mean ± SD, 73±20 mL) and 3 (63±22 mL) than ingroup 1 (952±471 mL) (Pb0.001). Time until resolution of β-hCGwas shorter in groups 2 (29±16 days) and3 (30±19 days) than in group 1 (57±25 days) (Pb0.01). Length of hospital stay was shorter in groups 2(13±4 days) and 3 (12±3 days) than in group 1 (36±8 days) (Pb0.01). Conclusion: Transcatheter

arterial chemoembolization was more effective than systemic MTX treatment for termination of CSP. Largecohort studies are warranted to compare effectiveness between PVA and GS particles.© 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

1. Introduction

Cesarean scar pregnancy (CSP), in which the pregnancy is located inthe scar of a previous cesarean delivery, is one of the rarest types ofectopic pregnancy and can lead to catastrophic complications, such asuterine rupture and potentially life-threatening hemorrhage. Therefore,accurate early diagnosis and effective treatment of the disorder arecrucial for preserving the uterus and future fertility.

In the past, the only treatment option for CSP was to perform anemergency laparotomy with the possible need for hysterectomy [1,2]to avoid maternal mortality. Recently, with the widespread use ofultrasound, the accuracy of early diagnosis of CSP has substantiallyincreased, providing the opportunity for conservative treatment. Theseoptions include systemic or local administration of methotrexate(MTX), uterine artery embolization, local resection of the ectopicgestational mass, operative hysteroscopy, and uterine suction curettage[3–6]. Most data on CSP, however, are case reports or small cohortseries, and there is no consensuson thepreferredmodeof treatment [7].

und, Qilu Hospital, Shandong:+86 531 82169396; fax:+86

deration of Gynecology and Obstetrics

Although MTX has been the drug of first choice for terminationof CSP, it takes time for MTX treatment both to normalize serumβ-human chorionic gonadotropin (β-hCG) (4–16 weeks) and to resolvethe CSPmass (severalmonths to a year) [2,7–10]. Transcatheter arterialchemoembolization combines transarterial infusion chemotherapywith arterial embolization. It has been used as an effective treatmentmodality for localized gestational trophoblastic disease and CSP[6,11,12]. Appropriate selection of the embolic agent has a key rolein chemoembolization. As the most commonly used and representativeembolic agents, gelatin sponge (GS) and polyvinyl alcohol (PVA)particles each have their own advantages and disadvantages.

The aim of the present study, therefore, was to compare the clinicaltherapeutic effectiveness and safety of systemic delivery of MTX versuschemoembolization using different particles for termination of CSP.

2. Materials and methods

The present prospective, controlled trial was conducted in QiluHospital, Jinan, China. Women attending the hospital for treatmentof CSP between January 1, 2002, and February 28, 2009, wereconsecutively enrolled in the study. CSP was diagnosed by patienthistory, clinical manifestations, serum β-hCG titer, and standardultrasonographic criteria. The treatment protocol was approved bythe ethics committee of Qilu hospital, and all women gave informed

. Published by Elsevier Ireland Ltd. All rights reserved.

179C. Li et al. / International Journal of Gynecology and Obstetrics 113 (2011) 178–182

consent, which included full information on the risks of ovarian failureand infertility, the possibility of rebleeding after chemoembolization,and other potential complications, benefits, and alternatives.

By using a randomization table, 44 women with CSP were dividedinto 3 groups to receive systemic MTX treatment (IV MTX group,n=13), chemoembolization with MTX and GS particles (IA MTX/GSgroup, n=15), or chemoembolizationwithMTX and PVA particles (IAMTX/PVA group, n=16). Before treatment, 40 women complainedof light or moderate vaginal bleeding, 2 had fetal cardiac motion,and 1 had cesarean scar twin pregnancy. In each group, treatmentwas followed by uterine suction curettage with transabdominalultrasound guidance.

Participants in the IV MTX groupwere given intravenously a singledose of MTX (50 mg per m2 of body surface area). On days 4, 7, and10, serum β-hCG measurement and transvaginal ultrasound wereperformed. A second course of IV MTX therapy was given if theultrasound revealed fetal cardiac activity on day 4. On day 7, if serumβ-hCG had decreased by less than 25% from the pre-therapy level,a third course was given. On day 10, if serum β-hCG had decreasedby less than 50%, a fourth course was given. When serum β-hCGdecreased to less than 50 mIU/mL, the uterocervical canal was dilatedto 7 mm by a cervical dilator, and the retained pregnancy mass wasaspirated and scraped with a slightly curved suction pipe attached toa vacuum extractor (negative pressure 400–600 mm Hg). If heavybleeding (500–1500 mL) occurred during suction curettage, iodoformgauze packing was placed in the vagina for 24–48 hours; if acutebleeding was more than 1500 mL, a life-saving emergency hysterec-tomy was performed.

Women in the IA MTX/GS and MTX/PVA groups underwentbilateral uterine artery chemoembolization. A right transfemoralapproach was used for artery access, and each uterine artery wassuperselectively catheterized with a 4-French glide Cobra catheter(Terumo, Tokyo, Japan). Chemoembolization of both uterine arterieswas performed with particles mixed with nonionic contrast medium(Omnipaqe; GE Healthcare (Shanghai), Shanghai, China) and 40 mgof MTX dissolved in 4 mL of physiological saline (particles 560–710 μm; Hangzhou Alicon Pharm and Tech, Linan, Zhejiang, China).Post-embolization angiography was performed to confirm completeocclusion of the vessels. After 24 hours, patients received uterinesuction curettage after confirmation of the absence of intralesionalblood flow by ultrasonography. Women who had active vaginalbleeding after uterine suction curettage were diagnosed as havingfailed blood loss control, and received iodoform gauze packing orrepeat embolization.

All patients remained in hospital and were observed for theduration of their therapy. Serum β-hCG level, estimated blood lossduring uterine suction curettage, frequency of hysterectomy, adverseeffects (including fever, nausea and vomiting, abdominal or pelvicpain, and abnormal liver or renal function), and length of hospitalstay were recorded and summarized. Serum β-hCG, renal and hepaticfunction, and routine blood tests were performed before intervention,on day 1 after uterine suction curettage, and then every 3 days untildischarge from hospital, every week for 3 months after discharge, andevery other week for another 3 months. The size of the heterogeneousmass was measured by transvaginal ultrasound, and clinical assess-ment was done at the same time. Successful treatment criteriawere a steady decline in serum β-hCG to normal levels and gradualdisappearance of the CSP mass, coupled with a lack of serious adverseeffects, avoidance of major complications (uterine scar rupture,recurrence of actively bleeding), and no requirement to repeatembolization or administer another treatment (laparoscopic surgery,laparotomy, or hysterectomy).

The numerical data of baseline parameters were analyzed viaKruskal–Wallis test, and the categorical data were analyzed via χ2 test.For clinical outcome after treatment, Mann–Whitney test was used tocompare numerical data, and Fisher exact test was used to compare

categorical data among the groups. All data analyses were conductedwith SPSS version 17.0 (SPSS, Chicago, IL, USA). A value of P≤0.05was considered statistically significant for paired comparisons,and a value of Pb0.0167 was considered significant for multiplecomparisons after Bonferroni correction.

3. Results

There was no difference among the 3 groups in maternal age, timeof cesarean delivery, primary serum β-hCG level, and size of CSPmass,among other characteristics (PN0.05) (Table 1).

Among the IV MTX group, 3 of the 13 participants received 2courses of intravenous MTX therapy, 8 received 3 courses, and 2received 4 courses. In the 2 groups undergoing chemoembolization,all procedures were completed successfully (Fig. 1).

The clinical outcomes of the 3 groups are shown in Table 2 and Fig. 2.As expected, themean time for resolution of serumβ-hCGwas longer inthe IV MTX group than in either chemoembolization group (Pb0.01).Similarly, systemicMTX treatment resulted in a prolonged hospital stayas compared with chemoembolization treatment (Pb0.001).

We examined the incidence of complications among the 3 groups. Inthe IV MTX group, the preoperative laboratory test results of allparticipants were normal, but 3 women had massive acute uterinebleeding (N1500 mL) during the uterine suction curettage process andunderwent an emergency hysterectomy, and 4 women had heavybleeding (500–1500 mL) and were given tamponade with iodoformgauze. The mean bleeding volume in the curettage process wasconsiderably higher in the IVMTXgroup than in the chemoembolizationgroups (Pb0.001).

No patients required a hysterectomy in the 2 chemoembolizationgroups, but 5 women in the IA MTX/GS group had active vaginalrebleeding several days after uterine suction curettage. Establishmentof extensive collateral circulation and recanalization of embolizeduterine arteries were identified in these women by transvaginalultrasound or digital subtraction angiogram. Of these 5 patients,2 received tamponade with iodoform gauze treatment and 3 werereadmitted to undergo a second uterine artery embolization with PVAparticles for bleeding control. No vaginal rebleeding was observed inpatients in the IA MTX/PVA group; however, there was no significantdifference in the rate of successful treatment between the IA MTX/PVA and MTX/GS groups (P=0.018).

No serious adverse effects were observed in the IV MTX group: 2patients showed a mild increase in liver enzymes, but these levelsdecreased to normal 2 weeks after the fourth course of MTX therapy;and 1 patient had mild vomiting, which was alleviated with symptom-atic treatment. The adverse effects of chemoembolization treatmentwere alsominor: 2 patients in the IAMTX/GS groupand 3patients in theIA MTX/PVA group complained of moderate abdominal or pelvic pain;and 2 patients in both the IAMTX/GS and theMTX/PVA groups hadmildvomiting. These symptoms resolved after symptomatic treatment.

4. Discussion

The incidence of CSP is increasing, probably because more andmore deliveries are performed by cesarean. The baseline cesareandelivery rate is 15% worldwide but it accounts for approximately40%–60% of births in China, and possibly even more than 70% of birthsin some hospitals [13]. Another reason for the increase in CSP maybe due to the frequency of abortions that lead to endometrial andmyometrial trauma. Jurkovic et al. [2] estimated a prevalence of 1 CSPper 1800 pregnancies in an early pregnancy assessment unit inLondon, UK. The case series of Seow et al. [9] estimated an incidenceof CSP of 1 in 2226 pregnancies at a referral center in Taiwan, and afrequency of 0.15% in women with a previous CSP; in addition, theyestimated that CSP accounted for 6.1% of all ectopic pregnancies inwomen who had at least 1 cesarean delivery.

Table 1Baseline parameters of patients at diagnosis in the 3 groups.

Characteristic Treatment groups χ2 P value

IV MTX (n=13) IA MTX/GS (n=15) IA MTX/PVA (n=16)

Age, years 33.2±4.5 (27–41) 34.2±5.5 (26–43) 34.1±5.5 (25–44) 0.270 0.874Gestational age, days 67.9±17.5 (38–99) 68.7±14.5 (48–100) 71.8±12.5 (50–102) 1.406 0.495Gravidity 4.7±1.3 (3–7) 5.2±1.7 (2–8) 4.8±1.4 (2–7) 1.019 0.601Parity 2.2±0.6 (1–3) 2.2±0.6 (1–3) 2.2±0.7 (1–3) 0.032 0.984No. of abortions 1.5±0.9 (0–3) 2.1±1.2 (0–4) 1.6±1.2 (0–4) 3.184 0.204No. of cesarean deliveries 1.5±0.5 (1–2) 1.7±0.5 (1–2) 1.6±0.5 (1–2) 1.131 0.568Interval time, months b 30.6±13.4 (11–51) 32.4±10.8 (14–54) 31.3±9.8 (12–49) 0.254 0.881Size of sac/mass, cm3 129.6±96.7 (4.5–318.0) 161.1±102.1 (2.0–339.3) 143.0±79.7 (23.9–281.7) 0.706 0.703Original serum β-hCG, mIU/mL 3653.7±3211.9 (629–10692) 5298.8±4271.9 (765–15490) 4404.8±4259.1 (538–14002) 1.123 0.570Cases with fetal cardiac motion 1 (7.69) 1 (6.67) 0 (0.0) 1.214 0.545Cases with vaginal bleeding 12 (92.31) 14 (93.3) 14 (87.5) 0.362 0.834

Abbreviations: β-hCG, β-human chorionic gonadotropin; IA MTX/GS, transcatheter arterial chemoembolization with MTX and gelatin sponge particles; IA MTX/PVA, transcatheterarterial chemoembolization with MTX and polyvinyl alcohol particles; IV MTX, systemic MTX treatment; MTX, methotrexate.a Values are given as mean±SD (range) or number (percentage) unless otherwise indicated.b The interval time was the time between the cesarean delivery and the current pregnancy.

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In general, termination of CSP in the first trimester is stronglyrecommended, and treatment objectives include performing feticidebefore rupture, removing the gestation sac, and retaining the futurefertility of the patient when desired [7]. During the past 7 years,chemoembolization with embolic agents mixed with chemothera-peutic agents such as MTX has been used in Qilu Hospital as anapproach to terminate CSP. The aim of combining chemotherapeuticdrugs with embolic material is to facilitate direct contact of the

Fig. 1. Digital subtraction angiograms of a patient with CSPwho received transcatheter arteriainternal iliac artery shows hypertrophied and tortuous left uterine artery (arrow), andsuperselective bilateral uterine arteriogram shows increased blood supply to enlarged uterusuterine artery (arrowheads in c). d,e After chemoembolization, selective bilateral internal ilia

chemotherapeutic agent with the embryo, in addition to targetingtissue ischemia. This approach can substantially increase the localconcentration of chemotherapeutic agent and extend its retention,while reducing systemic toxicity.

In the present study, patients treated by chemoembolization hadmuch less bleeding during uterine suction curettage, a shorter timeuntil serum β-hCG resolution, and a shorter stay in hospital than thosereceiving systemic MTX treatment. Moreover, chemoembolization

l chemoembolizationwith PVA particles. a Before chemoembolization, angiogram of leftanastomosis with right uterine artery (arrowhead). b,c Before chemoembolization,(arrowheads in b), and ascending segment and numerous intramural branches of rightc arteriogram shows absence of opacification in bilateral distal uterine arteries (arrows).

Table 2Comparison of clinical outcome after treatment among the 3 groups.

Characteristic Treatment groups a Z P value

IV MTX (n=13) IA MTX/GS (n=15) IA MTX/PVA (n=16)

Time till resolution of serum β-hCG, days 57±25 (28–102) 29±16 (16–70) 30±19 (15–83) Gp 1 vs Gp 2: –3.388 0. 001Gp 1 vs Gp 3: –2.962 0. 003Gp 2 vs Gp 3: –0.396 0. 692

Length of hospital stay, days 36±8 (23–50) 13±4 (8–20) 12±3 (7–17) Gp 1 vs Gp 2: –4.494 b0. 001Gp 1 vs Gp 3: –4.570 b0. 001Gp 2 vs Gp 3: –1.133 0. 257

Bleeding, mL b 952±471 (400–1700) 73±20 (40–110) 63±22 (35–105) Gp 1 vs Gp 2: – 4.500 b0. 001Gp 1 vs Gp 3: –4.568 b0. 001Gp 2 vs Gp 3: –1.372 0. 170

Patients with adverse effects c 3 (23.1) 4 (26.7) 5 (31.2) Gp 1 vs Gp 2: — N0.99Gp 1 vs Gp 3: — 0. 697Gp 2 vs Gp 3: — N0.99

Patients with hysterectomy 3 (23.1) 0 (0.0) 0 (0.0) Gp 1 vs Gp 2: — 0. 087Gp 1 vs Gp 3: — 0. 078Gp 2 vs Gp 3: — —

Successful cases 10 (76.9) 10 (66.7) 16 (100.0) Gp 1 vs Gp 2: — 0. 686Gp 1 vs Gp 3: — 0. 078Gp 2 vs Gp 3: — 0.018

Abbreviations: β-hCG, β-human chorionic gonadotropin; Gp 1, IV MTX group; Gp 2, IA MTX/GS group; Gp 3, IA MTX/PVA group; IA MTX/GS, transcatheter arterialchemoembolization with MTX and gelatin sponge particles; IA MTX/PVA, transcatheter arterial chemoembolization with MTX and polyvinyl alcohol particles; IV MTX, systemicMTX treatment; MTX, methotrexate.

a Values are given as or mean ± SD (range) or number (percentage) unless otherwise indicated.b Estimated blood loss during suction curettage.c Adverse effects included vomiting, fever, abdominal or pelvic pain, and abnormal liver or renal function.

181C. Li et al. / International Journal of Gynecology and Obstetrics 113 (2011) 178–182

followed by uterine suction curettage was not associated with ahigher incidence of complications as compared with MTX treatment.Although controlled randomized trials of a larger cohort will berequired to validate these observations, the present study indicatesthat chemoembolization—in particular, when PVA is used as theembolic agent—followed by uterine suction curettage represents aneffective and safe treatment alternative for CSP.

Recently, Zhuang and Huang [14] demonstrated that uterineartery embolization alone, followed by uterine suction curettage, wasmore effective than systemic MTX treatment for CSP. However,if arterial embolization alone does not cause complete necrosis ofthe placental villous tissue, the retained placental tissue may berevascularized through recanalization of feeding vessels and/orcollateral neovascularization. As a result, the treatment fails andsecondary hemorrhage occurs that may require repeat embolization.

Fig. 2. Flow chart and clinical outcome after treatment for CSP among the 3 groups. Adversefunction. Abbreviations: IV MTX, systemic MTX treatment; IA MTX/GS, transcatheterchemoembolization with MTX and polyvinyl alcohol particles.

The approach used in the present study went a step further bycombining a chemotherapeutic agent with an embolic agent, bothdelivered locally. In chemoembolization, an embolic agent is usedto block or retard blood flow to the region of the embryo, resultingin a locally increased concentration of chemotherapeutic agent.This results in termination of the embryo in a more timely mannerand rapid loss of trophoblastic activity, thereby avoiding uterinebleeding. In our experience, the procedure of chemoembolization isno more complicated than embolization alone, and we believe thatchemoembolization is more advantageous than embolization alone.

Uterine suction curettage can remove most of the CSP mass;however, when used alone as a primary therapy to terminate CSP,it carries the risk of serious intraoperative hemorrhage [7,9]. Uterinesuction curettage has been shown to be unsuccessful or causecomplications requiring secondary referrals or surgical treatment,

effects included vomiting, fever, abdominal or pelvic pain, and abnormal liver or renalarterial chemoembolization with MTX and gelatin sponge particles; IA MTX/PVA,

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with a failure rate as high as 70% [4,15]. In the present study, weperformed uterine suction curettage either when serum β-hCG levelsdecreased to less than50 mIU/mL for the IVMTXgroupor24 hours afterthe chemoembolization procedure. As a result, 3 patients in the IVMTXgroup required hysterectomy owing to massive hemorrhage, whereasno one in either chemoembolization group required hysterectomy.Although the numbers were too small to allow a meaningful statisticalanalysis, therewas a risk of hysterectomywith systemicMTX treatment.Therefore, chemoembolization followed by uterine suction curettagemay be the treatment of choice for patients with CSP who wish topreserve their uterus.

The choice of embolic agent is important in determining the extentof arterial occlusion achieved during embolization. As a temporaryembolic agent, GS particles alone have been used for embolization inCSP [6,16,17]. Because the embolized vessel reopens after absorptionof the GS particles 2–3 weeks after embolization, this approach isparticularly suitable for women who want to preserve fertility [16].However, studies have shown that most CSP masses require severalmonths to a year to achieve complete resolution [9,10]. Therefore, the2–3-week duration of occlusion with absorbable GS particles mightbe too short to achieve complete resolution of the CSP mass. In thepresent study, among the 15 patients undergoing chemoembolizationwith GS particles, 5 experienced active vaginal bleeding, and 3required additional embolization. Similar data have been reportedelsewhere [14,17].

By contrast, PVA particles, as a permanent embolic agent, may besuperior to GS particles in achieving complete and long-lastingvascular embolization. On the one hand, in the present study, single-dose embolization with PVA particles resulted in a success rate of100%, the shortest hospital stay, minimal blood loss, and no incidenceof hysterectomy or active vaginal bleeding after chemoembolization.Although these results are encouraging, we cannot draw firmconclusions because of the small number of patients; nevertheless,the risk of vaginal rebleeding after chemoembolization with GSparticles should be recognized. On the other hand, it remains to bedetermined how uterine artery embolization with PVA particlesaffects fertility and ovarian function. For example, the AmericanCollege of Obstetrics and Gynecology and other treatment centershave advised against the use of this treatmentmodality inwomenwhowant to preserve their fertility [18,19]; by contrast, several studieshave reported that the risk of ovarian failure is almost negligible(b1%) in patients who are younger than 40 years, and fertility can bepreserved after uterine artery embolization using either PVA or GSparticles [20–23]. We believe that caution needs to be taken withthe use of PVA inwomenwho desire fertility, and further investigationis warranted to find an optimal temporary embolic agent for thetreatment of CSP.

In conclusion, transcatheter arterial chemoembolization followedby uterine suction curettage seemed to be advantageous over systemicMTX treatment for CSP. The permanent embolic agent PVA particlesmight have superior effectiveness to temporary embolic agent GSparticles; however, it is necessary to carry out further studies witha large study sample. The main limitation of the present study wasthe short follow-up period. Following up the long-term effects willestablishwhether chemoembolizationwith PVAparticles can be safelyused for women who desire fertility.

Conflict of interest

The authors have no conflicts of interest.

References

[1] Fylstra DL. Ectopic pregnancy within a cesarean scar: a review. Obstet GynecolSurv 2002;57(8):537–43.

[2] Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimesterdiagnosis and management of pregnancies implanted into the lower uterinesegment cesarean section scar. Ultrasound Obstet Gynecol 2003;21(3):220–7.

[3] Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology,diagnosis, and management. Obstet Gynecol 2006;107(6):1373–81.

[4] ArslanM, PataO,Dilek TU, AktasA, AbanM,Dilek S. Treatment of viable cesarean scarectopic pregnancy with uterine suction curettage. Int J Gynecol Obstet 2005;89(2):163–6.

[5] Ravhon A, Ben-Chetrit A, Rabinowitz R, Neuman M, Beller U. Successfulmethotrexate treatment of a viable pregnancy within a thin uterine scar. Br JObstet Gynaecol 1997;104(5):628–9.

[6] Hois EL, Hibbeln JF, Alonzo MJ, Chen ME, Freimanis MG. Ectopic pregnancy in acesarean section scar treated with intramuscular methotrexate and bilateraluterine artery embolization. J Clin Ultrasound 2008;36(2):123–7.

[7] Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. Br J Obstet Gynaecol2007;114(3):253–63.

[8] Maymon R, Halperin R, Mendlovic S, Schneider D, Vaknin Z, Herman A, et al.Ectopic pregnancies in caesarean section scars: the 8 year experience of onemedical centre. Hum Reprod 2004;19(2):278–84.

[9] Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy:issues in management. Ultrasound Obstet Gynecol 2004;23(3):247–53.

[10] Wang CJ, Yuen LT, Chao AS, Lee CL, Yen CF, Soong YK. Caesarean scar pregnancysuccessfully treated by operative hysteroscopy and suction curettage. Br J ObstetGynaecol 2005;112(6):839–40.

[11] Lang EK. Reduced systemic toxicity from superselective chemoembolizationcompared with systemic chemotherapy in patients with high-risk metastaticgestational trophoblastic disease. Cardiovasc Intervent Radiol 1997;20(4):280–4.

[12] Maroulis GB, Hammond CB, Johnsrude IS, Weed Jr JC, Parker RT. Arteriographyand infusional chemotherapy in localized trophoblastic disease. Obstet Gynecol1975;45(4):397–406.

[13] ZhangW. Abuse of cesarean section. China Economic Weekly 2010;18(548):11–7.[14] Zhuang Y, Huang L. Uterine artery embolization compared with methotrexate

for the management of pregnancy implanted within a cesarean scar. Am J ObstetGynecol 2009;201(2) 152.e1–3.

[15] Wang YL, Su TH, Chen HS. Operative laparoscopy for unruptured ectopicpregnancy in a caesarean scar. Br J Obstet Gynaecol 2006;113(9):1035–8.

[16] Chua GC, Wilsher M, Young MP, Manyonda I, Morgan R, Belli AM. Comparison ofparticle penetration with non-spherical polyvinyl alcohol versus trisacryl gelatinmicrospheres in women undergoing premyomectomy uterine artery embolization.Clin Radiol 2005;60(1):116–22.

[17] ChouMM,Hwang JI, Tseng JJ, HuangYF, HoES. Cesarean scar pregnancy: quantitativeassessment of uterine neovascularization with 3-dimensional color power Dopplerimaging and successful treatment with uterine artery embolization. Am J ObstetGynecol 2004;190(3):866–8.

[18] Pelage JP, Le Dref O, Soyer P, KardacheM, Dahan H, Abitbol M, et al. Fibroid-relatedmenorrhagia: treatment with superselective embolization of the uterine arteriesand midterm follow-up. Radiology 2000;215(2):428–31.

[19] Committee on Gynecologic Practice, American College of Obstetricians andGynecologists. ACOG Committee Opinion. Uterine artery embolization. ObstetGynecol 2004;103(2):403–4.

[20] Ryu RK, Siddiqi A, Omary RA, Chrisman HB, Nemcek Jr AA, Sichlau MJ, et al.Sonography of delayed effects of uterine artery embolization on ovarian arterialperfusion and function. Am J Roentgenol 2003;181(1):89–92.

[21] Tropeano G, Di Stasi C, Litwicka K, Romano D, Draisci G, Mancuso S. Uterine arteryembolization for fibroids does not have adverse effects on ovarian reserve inregularly cycling women younger than 40 years. Fertil Steril 2004;81(4):1055–61.

[22] Carpenter TT, Walker WJ. Pregnancy following uterine artery embolisation forsymptomatic fibroids: a series of 26 completed pregnancies. Br J Obstet Gynaecol2005;112(3):321–5.

[23] Kim MD, Kim NK, Kim HJ, Lee MH. Pregnancy following uterine arteryembolization with polyvinyl alcohol particles for patients with uterine fibroidor adenomyosis. Cardiovasc Intervent Radiol 2005;28(5):611–5.