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Management of Cesarean Scar Pregnancy

Author: Sara Whetstone, MD

Mentor: Meg Autry, MD
Editor: Sangini Sheth, MD

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Cesarean scar pregnancy (CSP), also referred to as cesarean scar ectopic pregnancy, was first reported in 1978. CSP is rare, occurring in 1 in 1800 to 2656 pregnancies, and it is, on average, diagnosed at 7.5 ± 2.5 weeks gestational age. More than 50% of CSPs occur in individuals with a single prior cesarean delivery. The clinical presentation of patients with CSP is variable, ranging from asymptomatic to painless vaginal bleeding to uterine rupture. The pathogenesis of CSP is incompletely understood but is hypothesized to result from blastocyst implantation in the dehiscence tract in the cesarean scar. In one case series, findings on histopathologic analysis of CSP were indistinguishable from those of placenta accreta spectrum.

Ultrasonography with color Doppler is the primary diagnostic modality. Diagnosis of CSP requires a positive pregnancy test along with key sonographic findings, including an empty uterine cavity and endocervix and implantation of the gestational sac in the cesarean scar. CSPs are described to be endogenic (“on the scar”), with the pregnancy growing within the uterine cavity, or exogenic (“in the niche”), with the pregnancy deeply implanted in the scar and growing towards the abdomen and bladder.  A number of other conditions can have similar ultrasonographic appearance including cervical ectopic pregnancies, spontaneous abortions, or low-lying intrauterine pregnancies. Referral to an experienced center is preferred to ongoing follow up evaluations that might delay prompt diagnosis.

Knowledge is limited about the natural history of CSPs. CSPs can result in live births; however, they are complicated by high rates (50%-100%) of hemorrhage, cesarean hysterectomy, and placenta accreta spectrum. Accordingly, expectant management of CSP is not recommended except in the case of nonviable CSP. Individuals who pursue expectant management should be counseled on the risk of significant obstetric complications, including death, preterm labor, and uterine rupture. Delivery should be planned for 34 0/7 to 35 6/7 weeks gestational age at a facility with the resources and expertise to manage massive hemorrhage and cesarean hysterectomy.

Treatment options for CSP include medical management, minimally invasive techniques, surgical management, and various combinations of treatments. Optimal treatment is uncertain given the lack of randomized controlled trials and direct comparisons, but should be guided by preserving maternal health with a secondary goal of preserving fertility if possible. Despite limited data, primary resection via transvaginal or laparoscopic techniques should be considered because the efficacy for either method exceeds 95% and complications are rarely reported. Minimally invasive operative resection also allows for scar revision. Systemic methotrexate should be avoided as a single treatment given a higher rate of complications (13%). Intragestational methotrexate is preferred and can be administered alone or in combination with other treatment. Uterine artery embolization with dilation and curettage can also be considered first-line treatment, as the success rate is higher than 93% and the complication rate is low. The addition of hysteroscopy to uterine artery embolization and dilation and curettage only slightly increases efficacy and decreases complications, but it is associated with increased cost. Small case series have reported high success of resolution (97%) and low complication rates (4%) with the use of a cervical ripening double balloon catheter that compresses the CSP blood supply. A gravid hysterectomy is an option for individuals who do not desire future fertility.

Given uncertainty regarding optimal management, the treatment options offered should be influenced by imaging findings, case complexity, patient preference, and provider/institutional capability. Patients with CSP should be counseled about the recurrence risk (5%-40%) and associated complications in subsequent pregnancies.

Further Reading:

Glenn TL, Bembry J, Findley AD, et al. Cesarean Scar Ectopic Pregnancy: Current Management Strategies. Obstet Gynecol Surv. 2018 May;73(5):293-302. doi: 10.1097/OGX.0000000000000561. PMID: 29850919.

Society for Maternal-Fetal Medicine (SMFM); Miller R, Timor-Tritsch IE, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #63: Cesarean scar ectopic pregnancy   Am J Obstet Gynecol. 2022;227(3):B9-B20.

Published February 2022.  Revised November 2023


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