Case Series: Medical Versus Surgical Management of Cesarean Scar Pregnancy [ID 2683419

Abstract

INTRODUCTION: Although cesarean scar pregnancy (CSP) is rare, it is a potentially fatal condition, and the incidence is rising. Treatment of CSP may consist of medical management with methotrexate or surgical management; however, a consensus regarding optimal treatment has not been well defined. This series reports our experience with management of CSP. METHODS: Our series included a chart review that identified 10 cases of CSP from 2020 to 2023 at a high-volume, community-based, academic hospital that serves as a surgical referral center in a metropolitan area. We obtained IRB exemption. RESULTS: At diagnosis of CSP, gestational age by ultrasound ranged from 5 6/7 weeks to 11 4/7 weeks. None of the pregnancies had ruptured. Eight cases reported symptoms including bleeding or abdominal pain. Six underwent surgical management: one dilation and evacuation (D&E), one D&E converted to laparotomy, two combined D&Es with robotic-assisted laparoscopic excisions, and two laparotomies with excision. Four received methotrexate: one intragestational, two dual-dose intramuscular, and one single-dose intramuscular. All surgical cases resulted in definitive resolution. Of those treated with methotrexate, three of four cases required additional methotrexate treatment. Time from initial dose of methotrexate to resolution ranged from 29 to 95 days. CONCLUSION: In our experience, the advancement of gynecologic surgical modalities has broadened options for CSP treatment to allow for definitive and timely management. Methotrexate remains a viable option; however, treatment failures occur and may prolong a potentially life-threatening condition. Our findings strengthen the recommendation for surgical management, consistent with SMFM guidelines. Furthermore, there is an opportunity to provide surgical training to better equip gynecologists with the ability to treat this challenging condition.