Systematic review: What is the best first-line approach for cesarean section ectopic pregnancy?

Abstract

This systematic review aims to analyze the case reports, case series, or clinical studies describing the women with cesarean scar ectopic pregnancy (CSEP), and thus, to determine the efficacy and safety of different primary treatment modalities in the management of CSEP. A thorough search of electronic databases showed that 274 articles on CSEP were published between January 1978 and April 2014. Systemic methotrexate, uterine artery embolization, dilatation and curettage (D&C), hysterotomy, and hysteroscopy were the most frequently adopted first-line approaches. The success rates of systemic methotrexate, uterine artery embolization, hysteroscopy, D&C, and hysterotomy were 8.7%, 18.3%, 39.1%, 61.6%, and 92.1%, respectively. The hysterectomy rates were 3.6%, 1.1%, 0.0%, 7.3%, and 1.7% in CSEP cases that were treated by systemic methotrexate, uterine artery embolization, hysteroscopy, D&C, and hysterotomy, respectively. The ability to achieve a subsequent term pregnancy is related to successful systemic methotrexate treatment (p = 0.001) or hysterotomy (p = 0.009). Future term pregnancy was significantly more frequent in the hysterotomy group (p = 0.001). Hysteroscopy and laparoscopic hysterotomy are safe and efficient surgical procedures that can be adopted as primary treatment modalities for CSEP. Uterine artery embolization should be reserved for cases with significant bleeding and/or a high suspicion index for arteriovenous malformation. Systemic methotrexate and D&C are not recommended as first-line approaches for CSEP, as these procedures are associated with high complication and hysterectomy rates.

Retrospective study of patients with cesarean scar pregnancies treated by uterine artery chemoembolization and curettage

“…3,[8][9][10] Regarding recovery time, the mean hospitalization time was 5.7 days in the present study, whereas more than 10 days are necessary for spontaneous reabsorption of the CSP sac by systematic methotrexate treatment or UAE alone. In terms of treatment efficiency, the success rates of systemic methotrexate, UAE, hysteroscopy, and dilatation have been reported as 8.7%, 18.3%, 39.1%, and 61.6%, 8 respectively, which are all lower than the 99.0% success rate observed in the present study.…”

Ectopic Pregnancy in a Cesarean Section Scar: Successful Management Using Vacuum Aspiration under Laparoscopic Supervision—Mini Review of Current Literature

“…Further, patients presenting with an exogenously located CSEP are ideal candidates for laparoscopic intervention [7]. In a current literature review by Kanat-Pektas et al, 274 papers were evaluated with respect to different treatment modalities [13]. Methotrexate treatment was found to be the least effective method.…”

Cesarean Scar Pregnancy: Some Management Options

“…In a type II CSP, the progression is toward the bladder and the abdominal cavity, and thus it poses a greater threat than a type I CSP. Despite this study, conservative management in general is fraught with danger and the use of systemic MTX may not be as successful as in tubal ectopic pregnancies [7]. Sugawara et al [8] reported three cases of CSP that were successfully managed by UAE and direct injection of MTX to the gestational mass and surrounding myometrium.…”