Non-surgical management of caesarean scar ectopic pregnancy – a five-year experience

Abstract

The aim of this paper is to review the diagnosis and treatment of patients with a caesarean scar pregnancy (CSP), who have been managed at our unit, as well as to evaluate the effectiveness of the non-surgical treatment options. Twenty-six cases were identified over a period of 5 years and 4 months (January 2012 until April 2017). The main outcome measures were a number of previous caesarean births, a method of diagnosis of CSP, the mode of treatment and the outcome. The diagnostic criteria on the ultrasound were an empty uterine cavity and cervical canal, the presence of a gestational sac anterior to the isthmic portion of the uterus, an absent or thinned (<5 mm) myometrial thickness between the gestational sac and the bladder, with a peri-trophoblastic circulation around the gestational sac with the colour flow Doppler examination. The diagnosis was confirmed using ultrasound in 25 of the cases (96%) and by laparoscopy in one patient (4%). Fourteen women (54%) were managed conservatively, as there was evidence of a spontaneous resolution. A systemic methotrexate injection was used successfully to treat 11 (42%) patients. Only one patient (4%) needed an additional surgical treatment following an incomplete resolution. Impact Statement What is already known on this subject? A caesarean scar pregnancy is a life threatening condition whose incidence is increasing due to the global increase in the number of caesarean deliveries. Due to the relative rarity of the condition there is no consensus regarding the management of these cases. The management is mainly individualised, depending upon both the gestation and clinical symptoms. Surgical management or an intra-gestational sac injection of methotrexate with or without potassium chloride (KCl) dominates most of the published case reports and the systemic reviews. What the results of this study add? All of our patients in this case series were managed either conservatively with active monitoring, or were treated with an intramuscular methotrexate injection. Only one patient needed an additional minor surgical procedure due to an incomplete medical management. These results are very encouraging, and are attributed to the early diagnosis followed by a prompt treatment. An early detection requires a high index of suspicion, strict diagnostic criteria, and properly trained, experienced sonographers. A complete resolution was slow in some cases but the major high risk surgical procedures were avoided. What the implications are of these findings for clinical practice and/or further research? We wanted the sharing of our experience via this review to play a positive role in guiding the treatment of this rare but increasing subset of ectopic pregnancies.

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]. In over study the success rates of expectant management were 43% (9/21) [19].…”

“…Most studies focused on comparative evaluation of results of different methods of CSP treatment [9,19,20]. However, due to the rarity of this pathology statistical power of the majority of the studies is not sufficient for reliable results.…”

“…Taking into account the high risk of serious complications of LIP, including loss of reproductive function and potential growth of this pathology due to increase in uterus surgery among premenopausal women, we need to detect LIP earlier. An early diagnosis and a proper management are fundamental to prevent maternal complications [9,20].…”

“…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].…”