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.

Figure 1

Flow chart of patients: class risk, treatment modality, and postoperative complications. According to ultrasound findings that focused on myometrial thickness and presence of a vascular pattern of the cesarean section scar, we stratified patients into tree risk classes: class 1: myometrial thickness ≤ 2 and high vascular pattern; class 2: myometrial thickness > 2 and high vascular pattern; class 3: myometrial thickness > 2 and normal vascular pattern. W: weeks of gestation at diagnosis; UAE: uterine artery embolization; D&S: dilatation and suction; MTX ii: methotrexate intramuscular injection; HSC: hysteroscopic resection; EM: Expectant Management; Surg: surgery (laparotomic edge excision or hysterectomy).

Figure 2

Receiver operating characteristic (ROC) curve analysis of risk factors for treatment complications. (a) The AUCs for number of cesarean deliveries (CDs) and treatment modalities; (b) myometrial thickness; (c) risk class.

Figure 3

Receiver operating characteristic (ROC) curve analysis of risk factors for primary treatment complications. (a) For number of cesarean deliveries, a cutoff of 3 was the preferable indicator. (b) A 2 mm cutoff was the preferable myometrial thickness indicator. (c) The UAE + D&S was the major indicator of treatment complication occurrence. (d) Considering risk class the cutoff value was risk class = 1. (e) When the four cutoff variables were also compared the UAE & DS was the risk factor with the higher AUC.