Comparison of different treatment strategies in the management of endogenic caesarean scar pregnancy: a multicentre retrospective study

Abstract

Background The aim of this study was to evaluate the effectiveness and safety of different treatment strategies for endogenic caesarean scar pregnancy (CSP) patients. Methods According to Vial’s standard, we defined endogenic-type CSP as (1) the gestational sac growing towards the uterine cavity and (2) a greater than 0.3 cm thickness of myometrial tissue at the caesarean scar. A total of 447 endogenic CSP patients out of 527 patients from 4 medical centres in China were enrolled in this study. A total of 120 patients were treated with methotrexate (MTX) followed by surgery, 106 received ultrasound-guided curettage directly and 221 received curettage combined with hysteroscopy. The clinical information and clinical outcomes of these patients were reviewed. Successful treatment was defined as (1) no additional treatment needed, (2) no retained mass of conception and (3) serum β subunit of human chorionic gonadotropin (β-hCG) level returning to a normal level within 4 weeks. The success rate was analysed based on these factors. Result Among 447 patients, no significant difference was observed in baseline characteristics between groups except for foetal heartbeat. The success rate was significantly different (p<0.001) among the three groups. The highest success rate of 95.9% was noted in the hysteroscopy group, and the lowest success rate of 84.0% was noted in the curettage group. In addition, the MTX group reported the longest hospital stay and highest expenses, but the curettage group showed the shortest and lowest expenses, respectively. Nevertheless, no difference in blood loss was observed between the groups. Conclusion The combination of curettage and hysteroscopy represents the most effective strategy. Pretreatment with MTX did not result in better clinical outcomes. Ultrasound-guided curettage directly should not be considered a first-line treatment choice for endogenic CSP patients.

Cesarean Scar Ectopic Pregnancy Clinical Classification System With Recommended Surgical Strategy

“…Recently, the implementation and potential benefits of hysteroscopic removal of first-trimester cesarean scar ectopic pregnancy were reported, which were consistent with our result because the cesarean scar ectopic pregnancy type referred to in their study could be classified as type I in our classification system. 20 , 21 …”

“…Recently, the implementation and potential benefits of hysteroscopic removal of first-trimester cesarean scar ectopic pregnancy were reported, which were consistent with our result because the cesarean scar ectopic pregnancy type referred to in their study could be classified as type I in our classification system. 20,21 Patients with cesarean scar ectopic pregnancy type IIIb may have the highest risk of intraoperative hemorrhage, so laparoscopic excision after uterine artery embolization or laparotomy directly was recommended. In keeping with this result, one study implied that for type II of the Vial et al 8 classification, laparotomy could be an effective and reasonable treatment for deep-implantation cesarean scar ectopic pregnancy.…”

Outcomes of Cesarean Scar Pregnancies in Early Gestation According to the New Delphi Consensus Criteria

“…This has been fueled by inconsistencies in the few systematic overviews on CSP, which make it difficult to determine the most appropriate treatment modality that takes both the procedural success and risks into account. 10 The literature reports a number of cases of misdiagnosis of CSP as cervical ectopic pregnancy, an ongoing miscarriage, or a malignant tumor. These errors led to massive blood loss and/or emergency hysterectomies.…”

“…[6][7][8][9] Although the international literature has discussed CSP management in terms of surgery, medical treatment, or minimally invasive therapies, questions still remain as to what constitutes the best treatment. 10 There are no figures on the actual rate of CSP. Virtually all publications cite estimates that range from 1/1800 to 1/2500 of all cesarean deliveries.…”

An update and review of nontubal ectopic pregnancy management

“…Several methods for resection of the CSEP have been described in the literature. Hysteroscopic resection has been found to have a high success rate (88% in two meta-analysis), with a low risk of complication [16,23,24 ▪ ,25]. Hysteroscopic resection of residual avascular trophoblastic tissue after treatment with methotrexate and follow-up has also been reported to produce good results [26].…”