Management of Cesarean Scar Pregnancy: A Single-Institution Retrospective Review

Abstract

Objective Cesarean scar pregnancy (CSP) is a rare condition that occurs when the pregnancy implants in a cesarean scar. An early diagnosis and a proper management are fundamental to prevent maternal complications. We review and discuss the different treatment employed in our unit to reduce morbidity, preserve fertility, and predict possible complications. Methods The reported treatment has been expectant management, operative hysteroscopy approach, and intramuscular injection of 50 mg methotrexate (MTX), followed by cervical dilation and manual vacuum aspiration (D&S) with a Karman cannula under ultrasound guidance, uterine artery embolization (UAE), and manual vacuum aspiration under ultrasound guidance and uterine artery embolization before surgical laparotomic resection. Results Complications were more frequent in women with a history of three or more cesarean section deliveries and with a myometrial thickness thinner than 2 mm. MTX and D&S treatment appear to be most effective and safe at the early age of pregnancy, while UAE and D&S are related to the highest risk of complication in any age of pregnancy. Conclusion An appropriate preoperative diagnostic evaluation, the identification of cases at higher risk, and those eligible for a conservative treatment are fundamental to reduce complications.

Ectopic low-lying implantation pregnancy: analysis of outcomes depending on gestation age

“…Ectopic cesarean scar pregnancy needs to be differentiated from normal but low intrauterine pregnancy, abortion in progress, true cervical pregnancy [7,12,14,16]. There are lots of publications focused on early diagnostic criteria of cesarean scar pregnancy because treatment during first trimester in most cases allowed to preserve fertility [9,11,14,16,[18][19][20]27]. Unrecognized or misdiagnosed CSPs treated with inadequate procedures may lead to severe and sometime uncontrollable vaginal bleeding and hysterectomy.…”

“…Due to the relative rarity of the condition no universal treatment guidelines for management of CSP have been published up to now [9,18,20]. Fourteen women (54%) with CSP were managed conservatively, as there was evidence of a spontaneous resolution [20].…”

“…There are no standards for diagnostics and treatment of this pathology [5][6][7][8][9]. Management of non-tubal EP may involve expectancy, medical or surgical treatment, or their combination, minimally invasive radiological approaches depending on EP location and the patient's clinical stability [2,3,9].…”

“…The number of reported cases of Cesarean scar pregnancy (CSP) has increased in the last 10 years because of the increase in Cesarean sections number and the improvement in ultrasound detection in the first trimester [3,[10][11][12][13][14]. Cervico-isthmic implantation is also viewed as a variation of EP [9,[15][16][17]. Some authors associate this localization with CSP as pregnancy located below the internal os [15,17].…”

“…Some authors associate this localization with CSP as pregnancy located below the internal os [15,17]. Due to their relative rarity CSPs have proved difficult to study and there is still lack of agreement regarding the most appropriate diagnostic criteria and optimal strategies to treat this condition [9,10,12,[18][19][20]. Some specialists affiliate CSP, cervico-isthmic pregnancy (CIP) and cervical pregnancy into "pregnancy in an abnormal location" or "low-lying-implantation ectopic pregnancy" because the low segment is less capable of fibromuscular contraction to control bleeding [17,21].…”