Cesarean scar pregnancy: should surgery be the preferred treatment approach?

Purpose: To compare the characteristics and outcomes of non-surgical and surgical treatments for Cesarean scar pregnancy (CSP).

Methods: A retrospective study conducted at a tertiary university affiliated medical center, including all women diagnosed with Cesarean scar pregnancy between 2019 and 2023. Women treated non-surgically (including: methotrexate, uterine artery embolization and balloon catheter) were compared to women treated surgically (including: hysterectomy, hysteroscopy and excision of the pregnancy with or without uterine niche repair). Demographic information, medical history, obstetric and gynecological characteristics, presenting symptoms, imaging findings, management details, surgical characteristics, and follow-up data were collected from the women's electronic medical records. Primary outcome was defined as the β-hCG levels on follow-up visit at 2 weeks following treatment.

Results: 42 women were diagnosed with Cesarean scar pregnancy during the study period, of them 9 (21%) were treated non-surgically and 33 (79%) were treated surgically. Median age was 33 (30-36) year old and median BMI was 31 (27-35) kg/m², with no statistical differences in-between the groups. Most of the women had previous two Cesarean sections (n = 12, 28%). 63% of the women were asymptomatic at the time of diagnosis. On transvaginal ultrasound examination, embryo was demonstrated in 66.7% and cardiac activity was observed in 75%. The median gestational age at diagnosis and β-hCG levels were comparable between the non-surgical and surgical treatment groups (p = 0.22, p = 0.61, respectively). In the surgical arm, the most common surgical procedure was excision of the pregnancy with uterine niche repair, that was performed in 14/42 (33%) of the women. Median hospitalization length was 3 (1-4) and 2 (1-3) days, for the non-surgical and surgical treatment groups, respectively (p = 0.51). The hemoglobin level before discharge was similar between the groups (p = 0.20). Only one woman in each group visited the emergency room before the follow-up visit (p = 0.31). β-hCG levels on follow-up were significantly lower in the surgical group compared to the non-surgical (p = 0.02).

Conclusions: Cesarean scar pregnancy can be asymptomatic and should be suspected to enable early diagnosis. Both non-surgical and surgical treatments are viable options, with comparable hospitalization lengths; however, the surgical intervention group is expected to show a significantly faster decrease in β-hCG levels.