Cesarean Scar Ectopic Pregnancy—Case Series: Treatment Decision Algorithm and Success with Medical Treatment

Abstract

Background: Cesarean scar ectopic pregnancies are a rare form of extrauterine pregnancies, yet their incidence has increased along with the rise in the number of cesarean deliveries. As with other ectopic pregnancies, cesarean scar ectopic pregnancies pose a greater risk for maternal hemorrhage and ultimately maternal mortality. Case presentation: We present a series of clinical cases of cesarean scar ectopic pregnancy diagnosed by transvaginal ultrasonography. Each patient received an individualized treatment: the rate of success depended on the particular maternal condition in each case. Due to the low frequency of this entity, there are no clear protocols for its treatment and thus there are numerous options for treatment and follow-up: expectant management, medical therapy, surgical intervention, uterine artery embolization or a combined approach. Each method has different levels of success and is dependent on the surgeon’s skill and patient presentation. A transvaginal ultrasound is necessary to obtain the fine details of the gestation sac and its relation to the scar and must be followed by a meticulous abdominal scan with a full bladder. Conclusion: Herein, we present a rare pathological phenomenon whose frequency is on the rise, and for which transvaginal ultrasound and flow Doppler provide high diagnostic accuracy. Early diagnosis of cesarean scar ectopic pregnancies offers treatment options that may help avoid uterine rupture and bleeding, thus preserving the uterus and future fertility.

Conservative Management of Cesarean Scar Pregnancy: A Case Report and Literature Review

“…Conservative treatment with systemic MTX is considered the treatment of choice in clinically stable patients with a desire to preserve fertility [ 1 , 6 , 7 , 16 ].…”

“…In cases of positive embryocardium, as an alternative to the injection of 2 ml of KCl, the combined medical treatment with intrasaccular MTX + intramuscular MTX can be considered, since it is associated with an earlier negativization of β -HCG, the disappearance of the image of earlier ectopic gestation and a shorter hospitalization time [ 7 ].…”

“…In some selected cases of CSP, the surgical option may be considered [ 1 , 7 , 16 , 17 ]: Uterine curettage: Some authors [ 18 ] proposed performing aspiration curettage as the first therapeutic option in patients with superficial implantation who meet all the following diagnostic criteria: <8 weeks' gestation; a myometrial thickness between the bladder and gestational sac of >2 mm; and hemodynamic stability. In the case of suction curettage, it should be performed guided by transabdominal ultrasound, with a small cannula (4 or 6) and with a maximum suction pressure of 300 mmHg.…”

“…It can be performed simultaneously with the help of a Foley balloon [ 18 ]. Hysteroscopy: It is a therapeutic option with a low complication rate [ 19 , 20 ] that can be considered as an alternative to curettage in patients with the same criteria described for uterine curettage Surgical resection by laparoscopy or laparotomy [ 17 ]: It is an option in cases in which there is bladder infiltration [ 20 ], as well as in cases of suspected uterine rupture Hysterectomy may be indicated in cases of uncontrollable bleeding or the impossibility of conservative treatment [ 7 ]. …”

“…Methotrexate (MTX) is an antimetabolite drug that has been used in the treatment of molar and ectopic pregnancies, including CSP [ 6 , 7 ]. Although MTX is considered a safe and effective therapy, the optimal dose, route, and protocol for its use have yet to be determined for CSP [ 6 ].…”