Surgical treatment of cesarean scar pregnancy based on the three-category system: a retrospective analysis

Abstract

Background: Cesarean scar pregnancy (CSP), a distinct form of ectopic pregnancy, presents challenges in effective management. It is categorized into three subtypes according to the location of placental implantation and the thickness of the myometrium at the uterine scar. Nevertheless, the optimal choice of treatment modalities for these subtypes remains largely unexamined.

Methods: In this retrospective analysis, we investigated the cases of 130 patients diagnosed with CSP who underwent diverse treatment approaches, namely ultrasound-guided dilation and curettage (D&C), hysteroscopic surgery alone or in combination with laparoscopic surgery (HCoLC), or uterine artery embolization (UAE) followed by curettage. Clinical data were meticulously retrieved from medical records and follow-up data, and a comparative analysis of relevant indicators was carried out across the different CSP subtypes.

Results: From January 2017 to December 2021, 35 patients underwent D&C, 85 underwent HCoLC, and 10 received UAE as a pretreatment. In the D&C group, the success rates for Type I and Type II CSP were 64.29% (18/28) and 14.28% (1/7), respectively. Significant differences were observed between the success and failure groups in terms of gestational sac size and clinical classification. Compared to Type I CSP, Type II CSP exhibited significantly longer surgical durations and higher hospitalization costs (P < 0.05). Three patients classified as Type III underwent simultaneous hysteroscopic evacuation of cesarean scar pregnancy and laparoscopic repair of the cesarean scar defect, achieving a 100% success rate in their initial treatment. HCoLC showed no significant differences in surgical duration and hospitalization costs but had higher success rates and shorter hospital stays compared to the D&C and UAE groups (P < 0.05). The UAE group had significantly longer surgical durations, higher hospitalization costs, and a higher incidence of postoperative complications (P < 0.05). However, these factors did not result in improved surgical success rates.

Conclusion: The classification of CSP and the measurement of gestational sac are of crucial importance in determining the most appropriate surgical intervention strategy. For patients diagnosed with Type I CSP, D&C and hysteroscopy are reliable treatment choices. In cases with larger gestational sacs or Type II CSP, hysteroscopy, either alone or in combination with laparoscopy, is regarded as a reliable and effective treatment approach. In patients with type III CSP, lesion excision with uterine repair is the recommended treatment.

Keywords: Cesarean scar pregnancy; Hysteroscopy; Laparoscopy; Uterine artery embolization; Uterine scar repair.