Management of Cesarean Scar Pregnancy

Abstract

To evaluate the diagnosis and treatment and long term follow up of cesarean scar pregnancy. Methods: From January 2008 to December 2013, 12 cases of Cesarean scar pregnancy were diagnosed using transvaginal grey scale and color doppler ultrasound and managed by various approaches. Incidence, gestational age, ulrasound findings, serum beta-human chorionic gonadotropin ( beta-hCG) levels, flow profiles of transvaginal color doppler ultrasound, and different methods of treatment were recorded. Results: The incidence of cesarean scar pregnancy was 1:2051. Gestational age at diagnosis ranged from 5 weeks + 2days to 10weeks + 4 weeks. The time interval from the last cesarean section to the diagnosis of Cesarean scar pregnancy ranged from 5 months to 8 years. Patients were treated by different methods as follows: transvaginal ultrasound-guided injection of methotrexate(MTX) into the gestational sac (n = 1), systemic methotrexate administration alone (n = 2), dilatation and curettage (n = 3), or local resection of the gestation mass (n =6 ). After local or systemic MTX, high-velocity and low-impedance subtrophoblastic flow (resistance index (RI) = 0.35) persisted until beta-hCG returned to normal. One of 3 patients, treated by dilatation and curettage, underwent a hysterectomy because of uncontrolled profuse vaginal bleeding. The scar pregnancy mass took 2 months to 8 months for regression after treatment. None of the patient had uterine rupture. Conclusion: Sonography guided methotrexate injection and/or systemic methotrexate are the treatment of choice to manage cesarean scar pregnancy less than 6-8 week's gestation without fetal heart activity. Dilatation and curettage leads to profuse vaginal bleeding and not recommended for cesarean scar pregnancy due to high morbidity. Those patients having persistent pain and recurrent bleeding, surgical resection for removal of mass and repair of defective site should be recommended.