Different treatment modalities for cesarean scar pregnancies: a single-center experience and literature review

Cesarean scar pregnancy (CSP) remains a sporadic form of ectopic pregnancy associated with a severe life-threatening condition. There is no consensus on the treatment modality or a generally accepted guideline in CSP. This study aims to evaluate the outcomes of the different treatment modalities used in CSP treatment at a single center, as well as a literature review.

This is a retrospective case series study that was conducted; all women who diagnosed with CSP between January 2013 and November 2019 at Women's Specialized Hospital, King Fahad Medical City. The clinical characteristics, diagnosis, different treatment modalities, and clinical outcomes were analyzed.

Twenty-seven cases of CSP identified during the study period. The median maternal age was 38 years (range 23-47 years). The gestational age at diagnosis ranged between 5 weeks and 5 days to 13 weeks and 6 days. All diagnoses were made by ultrasound. The absence of embryonic cardiac activity was seen in 10 cases (37.03%). The most commonly used method for first-line treatment was medical treatment. A total of 14 patients (51.85%) were treated with systemic methotrexate (MTX), three (11.1%) intra-sac and systemic MTX, and two (7.4%) intra-cardiac potassium chloride (KCl) along with systemic MTX, five (18.51%) cases had expectant management, one case initially treated with Laparotomy Wedge resection, and one case treated with uterine artery embolization (UAE) and systemic MTX. A total of 20 (74.07%) patients were treated successfully with first-line treatment. Seven (25.92%) patients needed additional second-line treatment. Among them, only one case had surgical intervention. None of the women in the medical treatment group experienced any side effects. Based on ANOVA results, there is no considerable relationship between the mean time of resolution of β-hCG and four treatment modalities for CSP (p = 0.2406). There was no statistical significance when the fetal viability at the time of diagnosis was compared to the need for second-line treatment of CSP (p = 0.58).

The treatment of CSP should be individualized based on risk factors. Diagnosis and management of CSP need expertise and a multidisciplinary approach to prevent complications. Early diagnosis and management of cesarean scar ectopic pregnancy remains the mainstay for a successful outcome.