Cesarean scar pregnancy: tertiary-centre experience

Abstract

The Cesarean delivery [CD] rate increased markedly in the past two decades. Its rate was doubled between 2000 and 2015 to reach almost 21% of all live births. This increase was noticed in 169 countries that reported 29.7 million deliveries by CD annually.1 This raise could be explained by the rise of primary [first] CD [from 12.620.6%] and a decline in vaginal births after CD [28-9.2%], so that the rate of repeat CD is now about 91%.2 The maternal morbidity prevalence is higher after CD than after normal vaginal birth. CD is associated with a higher incidence of ectopic pregnancy, abnormal placentation [placenta previa\accreta] and uterine rupture. Moreover, these risks increased in a dose–response manner.3 History of a past CD increased the risk of gestational sac implantation of the next pregnancy over the cesarean scar, creating the clinical condition defined as cesarean scar pregnancy [CSP] and as explained the magnitude of this risk raised with more repeated CD.4 Two types of CSP were recognized according to the extent of gestational sac invasion; Type 1: where superficial implantation on a scar progressing subsequently towards the cervico-isthmic space and/ or the uterine cavity, whereas Type 2: direct deep implantation into the myometrium±reaching up to inner surface of uterine visceral serosa.5 Since 2000, CSP incidence showed a significant increase, up to 6.1% of all ectopic pregnancies in women with past history of CD, which might be attributed to both increased number of CD and the improved diagnostic accuracy tools recognizing ectopic pregnancy.6 CSP carried the risk of major bleeding, fatal hemorrhage, and spontaneous uterine rupture up to hysterectomy to save the women’s lives.7 Although its clinical presentation vary between light painless vaginal bleeding and moderate abdominal pain, the accurate diagnosis remained difficult as the false negative results of multiple tests could lead to a life-threatening scenario.8 The ideal pathway of CSP management is widely controversial. However, it is universally agreed that surgery is the unavoidable 1st line of management of women presenting with uterine rupture or severe bleeding. On the other hand, the management of hemodynamically stable diagnosed with CSP might represent a challenge. There were almost 31 primary approaches published to treat CSPs but mostly sporadic and individual cases and their results seemed to be insufficient to conclude clearly which one was the most effective management protocol that leaded to the least adverse events. Thus, there is increased needs to develop a set of practice guidelines for health care professionals considering optimum management of CSP. The aim of this work was to describe the experience of a tertiary care hospital with the diagnosis and treatment of CSP and to explore patients’ complications related to this rare type of ectopic pregnancy.