Cesarean scar pregnancy management: Medical or surgical? When and which? A literature review

Abstract

Aim: The aim of this study was to compare the effectiveness of treatment methods and to highlight treatment debates of cesarean scar pregnancy in the light of the current literature. Materials and methods: A total of 55 cesarean scar pregnancy patients from 39 English, free full-text available case reports published between year 2010 and 2020 were analyzed. The patients were treated with various treatment methods. The most commonly used methods, complications, and treatment failures were evaluated. Cases with uterine dehiscence, rupture, acute abdomen, placental abnormalities, trophoblastic diseases, heterotopic pregnancies, twin pregnancies, and emergency surgeries were excluded from the analysis. Results: Overall, 55 patients from 39 case reports were included in the analysis. Of these cases, 24 were treated with methotrexate (14 patients systemically, 9 systemically methotrexate plus local potassium chloride, 1 methotrexate plus mifepristone). Surgical management was performed in 31 patients, and involved: dilatation and suction curettage, laparoscopy, uterine artery embolization, laparotomy, hysteroscopy, high intensity focused ultrasound, bilateral uterine artery balloon catheter insertion, obliteration of the feeding artery with fibrin sealant, and cesarean section. Two of the cesarean scar pregnancies were continued and cesarean section plus hysterectomy was performed at 35 weeks gestation. Limitations of the study: Dependence of the analysis on anecdotal case reports and series is the main limitation of this study. Therefore, there is a need for larger prospective series comparing treatment options and outcomes. Another limitation that precludes us from definitive conclusions is the heterogeneity in the methods of laboratory measurements, the quality of ultrasonography equipment, and the experience of surgeons. Conclusion: In conclusion, although there has been no established consensus on the management of scar line pregnancies in the literature, current literature indicates that one size does not fit and that it is reasonable to plan the treatment according to the patients’ characteristics. Ultrasonography is valuable in diagnosis and choosing a treatment modality. It is also crucial to determine the type of scar line pregnancy before planning the treatment.