• Saeed Baradwan, Faryal Khan, and Dania Al-Jaroudi.
• Department of Obstetrics and Gynecology Reproductive Endocrine and Infertility Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia.
• Medicine (Baltimore). 2018 Sep 1; 97 (37): e12343.

RationaleCesarean scar twin pregnancy is exceedingly rare and it remains to be a life-threatening condition even in the early weeks of gestation. Because of its rare occurrence, there is no consensus on the treatment modality of cesarean ectopic pregnancy.Patient ConcernsA 41-year-old, woman, gravida 7, para 6, with a history of low transverse cesarean section 2 years back presented with an estimated 6 weeks gestational age and viable spontaneous twin, monochorionic diamniotic gestation. The patient presented to the Emergency Department with complaints of vaginal bleeding and mild lower abdominal pain for 5 days.DiagnosesAn ultrasound examination was performed demonstrating a single intrauterine gestational sac with 2 viable embryos (monochorionic diamniotic) implanted in the lower uterine segment at the level of the prior cesarean section scar. A diagnosis of viable cesarean scar twin pregnancy was made.InterventionsA 2 doses of 50 mg/m methotrexate (MTX) was given intramuscularly. The response to the treatment was monitored by serial beta-human chorionic gonadotropin (β-hCG) and ultrasound.OutcomesPatient was followed up with β-hCG weekly levels which became 0 after 68 days of treatment. During the follow-up, the patient was asymptomatic, no side effects of MTX were noticed.LessonsWe reported a rare case of viable monochorionic diamniotic twin pregnancy on a cesarean scar that was successfully treated with systemic MTX without any additional therapy. Additionally, the decline of β-hCG in twin ectopic cesarean scar pregnancy appears to be similar to a singleton ectopic pregnancy.

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