Uterine curettage and hysteroscopy
We strongly caution against performing uterine curettage as first-line treatment for CSP. The pregnancy is often not in the uterine cavity so the products of conception may not be accessible, resulting in failure of the procedure. In addition, risk of uterine rupture and hemorrhage associated with the procedure is increased because of the thinness of the myometrial layer.10 Uterine curettage, however, can be considered after successful medical management, which is usually performed when Doppler ultrasound does not demonstrate active blood flow around the gestational sac.9
Hysteroscopy (HSC) can also be used to guide uterine curettage. Some providers have evaluated CSP with HSC and coagulated vasculature noted around the CSP.16 In a case series by Pan et al, HSC was used in conjunction with laparoscopy.16 If anterior myometrial thickness was < 3 mm on ultrasound, laparoscopy was performed prior to HSC to dissect bladder peritoneum from the lower uterine segment to attempt to remove the bladder from the site of surgical management and decrease risk of injury. In this case series, 44 patients were successfully treated with removal of products of conception.
Uterine artery embolization
Uterine artery embolization (UAE) has been chosen by providers as a first-line approach in managing CSP to theoretically decrease risk of hemorrhage before ultimate management with surgery.17 In the event that UAE is considered for treatment of a CSP, consideration should be given to a patient’s plans for future fertility because information is limited on fertility after the procedure.18
In a small case series, a double uterine balloon was presented as a minimally invasive option for managing CSP.19 This technique is novel and appears to have very high success rates overall. Briefly, a double balloon catheter was placed into the uterus under ultrasound guidance. Each balloon was inflated, with the lower uterine segment balloon placed to compress the CSP. The patient was then appropriately monitored and returned over the next few days for reevaluation with ultrasound. Once embryonic cardiac activity had ceased, the catheter was removed. With this procedure, treatment of CSP was successful and neither medication or dilation and curettage was needed in the published case series.19,20
Occasionally, patients fail to respond to all the above-mentioned procedures or they have severe abdominal pain (suspicious for uterine rupture) with bleeding. In these cases, hysterectomy should be considered (Figure 4).10,23
Fertility after CSP
Very little information exists with which to guide patients with CSP about future fertility. In a few case series, patients with CSP have undergone scar resection.21 The procedure has been performed with laparoscopic excision, CO2 laser, or ultrasound knife, with suture reapproximation of the myometrium afterwards in all cases.21 Data are limited regarding fertility after these procedures, but all patients who did achieve fecundity appeared to deliver via planned cesarean.
In a case series from Israel,22 eight of 18 patients with CSP treated with unclear methods went on to become pregnant again. Two of the eight ended up with a repeat CSP, for an incidence of 25%. The remaining six patients all had cesarean deliveries, four of which were uncomplicated and two emergent. The reasons for the emergent cesareans were placental abruption at 34 weeks’ gestation in one case and nonreassuring fetal status at 41 weeks in the other case.
Currently there is no evidence to indicate that a pregnancy has an affinity to locate in the cesarean delivery scar. Given the unpredictability of CSP, it is important to offer patients who have received treatment a very early ultrasound in their next pregnancy to ensure there is no recurrence. Outcomes of pregnancies in women previously treated for CSP are unclear.
The multiple challenges associated with managing a suspected CSP start with identification of the abnormal pregnancy. For best clinical outcomes, once a CSP is diagnosed, the following should be prioritized: (1) facilitating a multidisciplinary discussion to create an individualized treatment plan; (2) early gestational termination; and (3) disrupting trophoblastic invasion prior to surgical management. CSP is a complicated medical condition, but possible adverse outcomes can be avoided with a considerate approach to treatment.
The authors report no potential conflicts of interest with regard to this article.
- Rates of cesarean delivery-United States, 1993. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 1993;42:285-289.
- Hamilton BE, Martin JA, Osterman MJK, Driscoll AK, Rossen LM. Births: provisional data for 2017. Vital Statistics. 2018;Report No 004. 1-23.
- ACOG Practice Bulletin No. 205: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. 209 Feb;133(2):e110-e127.
- Boerma T, Ronsmans C, Melesse DY, et al. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392:1341-1348.
- Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar. Ultrasound Obstet Gynecol. 2003;21(3):220-227.
- Seow KM, Huang LW, Lin YH, Lin MY, Tsai Yl, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol. 2004: 23(3):247-253.
- Rotas M, Haberman S, Levgur M. Cesarean scar ectopic pregnanices: etiology, diagnosis, and management. Obstet Gynecol. June 2006;107(6):1373-1381.
- Cunningham F, Leveno KJ, Bloom SL, et al. Placentation, embryogenesis, and fetal development. Ectopic pregnancy. In: Williams Obstetrics. McGraw Hill Education. New York, NY; 2018:80-123.
- Roberts DJ, Benirschke K. Normal early development. In: Creasy and Resnik’s Maternal-Fetal Medicine: Principles and Practice. Elsevier. Philadelphia, PA: 2019:39-61
- Ash A, Smith A, Maxwell D. Cesarean scar pregnancy. BJOG. 2007 Mar;114(3):253-263.
- Soares MJ, Iqbal K, Kozai K. Hypoxia and placental Development. Birth Defects Res. 2017 Oct 16;109(17):1309–1329.
- Godin PA, Bassil S, Donnez J. An ectopic pregnancy developing in a previous caesarean section scar. Fertil Steril. 1997;67:398.
- Weimin W, Wenqing L. Effect of early pregnancy on a previous lower segment cesarean section scar. Int J Gynecol Obstet. 2002;77(3):201-207.
- Roberts H, Kohlenber C, Lanzarone DDU, Murray H. Ectopic pregnancy in lower segment uterine scar. Aust NZ J Obstet Gynecol. 1998;38(1)114.
- Shufaro Y, Nadjari M. Implantation of a gestational sac in a cesarean section scar. Fertil Steril. 2001;75(6):1217.
- Pan Y, Liu M. The value of hysteroscopic management of cesarean scar pregnancy: a report of 44 cases. Taiwanese J Obstet Gynecol. 2017;56(2):139-142.
- Xiao Z, Cheng D, Chen J, Yang J, Xu W, Xie Q. The effects of methotrexate and uterine arterial embolization in patients with cesarean scar pregnancy: A retrospective case-control study. Medicine. 2019;98(11):e14913.
- Mara, M, Kubinova K, Maskova J, Horak P, Belsan T, Kuzel D. Uterine artery embolization versus laparoscopic uterine artery occlusion: The outcomes of a prospective nonrandomized clinical trial. Cardiovasc Intervent Radiol.2012;35(5):1041-1052.
- Monteagudo A, Cali G, Rebarbar A, et al. Minimally invasive treatment of cesarean scar and cervical pregnancies using a cervical ripening double balloon catheter: Expanding the clinical series. J Ultrasound Med. 2018;28(3):785-793.
- Grechukhina O, Deshmukh U, Fan L, et al. Cesarean scar pregnancy, incidence, and recurrence: Five-year experience at a single tertiary care referral center. Obstet Gynecol. 2018;132(5):1285-95.
- Api M, Boza A, Gorgen H, Api O. Should Cesarean scar defect be treated laparoscopically? A case report and review of the literature. J Minim Invasive Gynecol 2015 Nov-Dec;22(7):1145-1152.
- Maymon R, Svirsky R, Smorgick N, et al. Fertility performance and obstetric outcomes among women with previous cesarean scar pregnancy. J Ultrasound Med. 2011;30(10):1444.
- Cali G, Timor-Tritsch I, Palacios-Jaraquemada J, et al. Outcome of cesarean scar pregnancy managed expectantly: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2018; 51: 169-175.