First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry

Abstract

BackgroundCesarean scar pregnancy (CSP) is an iatrogenic consequence of a prior cesarean delivery (CD). The gestational sac implants into a niche created by the incision of the previous CD carrying a substantial risk for major maternal complications. The aim of this study is to report, analyze and compare effectiveness and safety of different treatments options of CSP managed in the first trimester through a registry. ObjectivesTo study the ultrasound findings, disease behavior, and management of first trimester CSP. Study designWe created an international registry of CSP to study the ultrasound findings, disease behavior, and management of CSP. The CSP-registry collects anonymized ultrasound and clinical data of individual CSP patients on a secure digital information platform. Cases were uploaded by 31 participating centers in 19 countries. In this study we only included live and failing CSP (with or without positive fetal heart beat) who received active treatment (medical or surgical) before 12+6 weeks’ gestation in order to evaluate effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of pregnancy without the need for any additional medical intervention. ResultsBetween 29 August 2018 and 28 February 2023, we recorded 460 patients with CSP (281 live, 179 failing CSP) who fulfilled the inclusion/exclusion and were registered. 270/460 (58.7%) patients were managed surgically, 123/460 (26.7%) underwent medical management, 46/460 (10%) underwent balloon management and 21/460 (4.6%) underwent other, less frequently used treatment options. Suction evacuation was very effective, with 202/221(91.5%, 95%CI 87.8-95.2) success rate whilst systemic methotrexate was least effective with only 38/64 (59.4%, 95% CI 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of CSP was successful in 236/258 (91.5%, 95% CI 88.4-94.5) and the complication rate was 24/258 (9.3%, 95% CI 6.6-11.9). ConclusionCSP in the first trimester of pregnancy can be managed effectively in more than 90% of cases with either suction evacuation, balloon treatment or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age CSP should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with KCl or methotrexate is less efficient in and has higher rates of complications compared to the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first line treatment.