Contrast-enhanced ultrasound enhancement-pattern classification for procedure selection and perioperative outcomes in...

To develop a pragmatic contrast-enhanced ultrasound (CEUS) enhancement-pattern classification for cesarean scar pregnancy (CSP) and evaluate its association with procedure selection and perioperative outcomes.

We retrospectively analyzed consecutive CSP patients who underwent pre-procedural CEUS at The People's Hospital of Yingshang (Yingshang County, Anhui, China) between August 2021 and January 2026. In our center, once outpatient two-dimensional ultrasound raised suspicion for CSP and the patient was admitted, CEUS was routinely performed as part of the preoperative assessment to evaluate the relationship between the scar lesion and contrast enhancement morphology. CSP severity was recorded using the 2016 transvaginal ultrasound (TVS) Type I-III system. CEUS patterns were classified into five predefined subtypes (ICSPF, ICSPB, CCSPF, CCSPB, and MA) according to early wash-in distribution, extent of enhancement, and vascular architecture, and then linked to a three-tier procedure recommendation. Two experienced ultrasound physicians reviewed representative cases after standardized training, showing substantial interobserver agreement for the TVS classification (κ = 0.775) and the CEUS enhancement-pattern classification (κ = 0.800). Concordance between CEUS-based recommendation and definitive procedure was assessed using Cohen's kappa. Perioperative outcomes included operative time, estimated blood loss (EBL), length of stay, and adverse events. Incremental value beyond TVS was assessed using logistic regression for predicting lesion resection plus scar repair.

Among 131 patients, CEUS patterns were strongly associated with conventional ultrasound severity markers, including TVS type, residual myometrial thickness, and scar thickness. CEUS-based recommendations showed 90.1% concordance with definitive management (κ = 0.82). Perioperative outcomes differed by procedure, with lesion resection plus scar repair associated with greater procedural burden. Adding a CEUS high-risk pattern (CCSPB) improved prediction of cases managed with scar repair compared with a TVS-based model.

CEUS enhancement-pattern classification aligns with established ultrasound severity indicators and supports real-world procedure selection in CSP. The CCSPB pattern may provide incremental value beyond selected TVS parameters for identifying patients who ultimately require scar repair, although this finding should be interpreted cautiously. Prospective multicenter validation is warranted.