The effectiveness of hysteroscopy for the treatment of cesarean scar pregnancy: a retrospective cohort study

Abstract

Background: Cesarean scar pregnancy (CSP) is a long-term complication of cesarean section characterized by the localization of a subsequent gestational sac within the scar area or niche developed as a result of a previous cesarean section. Its incidence has increased substantially because of the high global cesarean section rate in recent decades. Several surgical and drug treatments exist for this condition; however, there is currently no optimal treatment. This study compared the effectiveness of direct hysteroscopic removal of the gestational tissue and hysteroscopy combined with vacuum suction for the treatment of CSP.

Methods: From 2017 to 2023, 521 patients were diagnosed with CSP at our hospital. Of these patients, 45 underwent hysteroscopy. Among them, 28 underwent direct hysteroscopic removal (hysteroscopic removal group) and 17 underwent hysteroscopy combined with vacuum suction (hysteroscopic suction group). The clinical characteristics and outcomes of the hysteroscopic removal group and hysteroscopic suction group were analyzed.

Results: Among the 45 patients, the amount of bleeding and hospitalization cost were significantly higher in the hysteroscopic removal group than in the hysteroscopic suction group (33.8 mL vs. 9.9 mL, P < 0.001; and 8744.0 yuan vs. 5473.8 yuan, P < 0.001; respectively). The operation time and duration of hospitalization were significantly longer in the hysteroscopic removal group than in the hysteroscopic suction group (61.4 min vs. 28.2 min, P < 0.001; and 3.8 days vs. 2.4 days, P = 0.026; respectively). Three patients in the hysteroscopic removal group had uterine perforation and received laparoscopic repair during operation. No complications occurred in the hysteroscopic suction group. One patient in the hysteroscopic removal group received ultrasound-guided suction curettage due to postoperative moderate vaginal bleeding, and one patient in the hysteroscopic suction group received ultrasound-guided suction curettage due to postoperative gestational residue and elevated serum beta-human chorionic gonadotropin levels. Reproductive function was preserved in all patients.

Conclusions: Hysteroscopy is an effective method for treating CSP. Compared with direct hysteroscopic removal, hysteroscopy combined with vacuum suction is more suitable for CSP. However, multicenter prospective studies with large sample sizes are required for verification of these findings.

Keywords: Cesarean scar pregnancy; Direct gestational tissue removal; Hysteroscopy; Serum β-hCG; Vacuum suction.

Fig. 1

Flow diagram of data collection

Fig. 2

A, Hysteroscopic view of cesarean scar pregnancy before hysteroscopic removal. B and C, An electric loop was used to sweep the gestational tissue bluntly. D, Hysteroscopic views of the lower uterine segment confirming no remnants after hysteroscopic resection. CSS, cesarean section scar; GS, gestational sac; HIO, histological internal ostium

Fig. 3

Transvaginal ultrasound image of a cesarean scar pregnancy at 50 postmenstrual days. A, Image showing empty uterine cavity and cervical canal, with the gestational sac visible in the lower uterine segment. B, Color power Doppler image showing vascularity in the lower uterine segment. C and D, Image showing gestational residue in the lower uterine segment, with abundant blood flow signal 2 weeks after hysteroscopy. EN, endometrium; MYO, myoma; GS, gestational sac; CX, cervix; GT, gestational residue