Diagnosis and management of low segment Cesarean section scar pregnancies

Abstract

Background: Rising Cesarean section rates have led to an increasing number of pregnancies implanted into postoperative uterine scars. We report a large series of Cesarean scar pregnancies treated in a single tertiary referral center. Methods: The diagnosis of Cesarean scar pregnancy was made on ultrasound scan when trophoblast was seen covering the lower segment uterine scar. Pregnancies <14 weeks size were treated either medically (local injection of methotrexate ± KCl) or with conservative surgery (dilatation and curettage ± insertion of Foley catheter). Surgical treatment was used for smaller, non‐viable pregnancies and in cases complicated by heavy bleeding or infection. Clinically stable patients with larger, viable pregnancies were treated medically. A single viable pregnancy >14 weeks required total abdominal hysterectomy. Results: In a 4‐year period, 14 Cesarean section scar pregnancies were diagnosed. Out of 13 women who were <14 weeks pregnant, seven were treated surgically (54%), five medically (38%) and one expectantly (8%). Surgery was successful in all cases. Three women (43%) required insertion of Foley catheter into the cervix to arrest the bleeding and one (14%) required blood transfusion. Three out of five (60%) women who received medical treatment were cured. Two women required surgery because of prolonged and heavy bleeding, one of them was transfused (20%). A case managed expectantly resolved spontaneously without any intervention. Five women tried to conceive again after treatment. All three women who succeeded (60%) had normal singleton intrauterine pregnancies. Conclusion: Early Cesarean scar pregnancies can be safely treated both medically and by conservative surgery. Although surgical treatment was more effective, this may be due to the selection criteria, which favored use of surgery in cases of smaller, non‐viable pregnancies.