Study on influencing factors and related clinical issues in cesarean scar pregnancy

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Objective: This study aims to investigate the etiological and bleeding risk factors of cesarean scar pregnancy (CSP) and attempts to determine the clinical value of uterine artery embolization (UAE) combined with curettage, methotrexate (MTX) chemotherapy combined with curettage, and uterine curettage alone in terminating CSP. Materials and methods: A total of 154 patients with CSP and 155 patients with cicatricial uterus termination of pregnancy in the same period who were hospitalized in the Department of Obstetrics and Gynecology, Second Affiliated Hospital of Nanchang University from January 2013 to March 2020 were enrolled in this study. The clinical characteristics of the two groups were statistically analyzed, and CSP patients were divided into the UAE + uterine curettage group (n = 49), MTX + uterine curettage group (n = 33) and uterine curettage alone group (n = 72) according to different treatment methods. The scar thickness, intraoperative blood loss, time to resumption of menstruation and other indicators were compared and analyzed among the three groups. Results: The proportion of CSP patients with cesarean section time < 24 months and ≥ 60 months was significantly higher than that of pregnant women with scar uterus. In the MTX + curettage group, 2 cases had intraoperative blood loss of more than 200 mL where the gestational age was more than 10 weeks, in which they were given Foley’s catheter balloon compression hemostasis. In patients with simple uterine curettage, 6 cases had intraoperative blood loss of more than 200 mL with a gestational age of more than 8 weeks. Two cases were given emergency interventional treatment, while four underwent Foley catheter balloon compression hemostasis. The recovery time of β-hCG in the UAE + curettage group was shortest, which was found to be statistically significant. Furthermore, menopause time, blood β-hCG level and gestational sac diameter were found to be positively correlated with the amount of bleeding, while the thickness of the uterine scar was negatively correlated with the amount of bleeding. Conclusions: Gestational age, blood β-hCG level before treatment, gestational sac diameter and scar thickness were early warning indicators to evaluate the amount of bleeding in the treatment of CSP. UAE OR MTX pretreatment before cesarean section in CSP patients can significantly reduce intraoperative blood loss, and MTX + curettage is safe and effective for patients with abundant blood flow around the gestational sac with a gestational age of 8–10 weeks. However, in regard to CSP patients with a gestational age greater than 10 weeks and rich blood flow around the gestational sac, UAE pretreatment followed by termination of pregnancy is preferred. In case of hemorrhage during uterine curettage, the emergency intrauterine balloon compression can achieves adequate hemostasis.