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

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.