Subsequent pregnancy outcomes and recurrence in women with previous Cesarean scar pregnancy: a 3-year follow-up study in a tertiary hospital.

Abstract

Subsequent pregnancy outcomes in women with a history of Cesarean scar pregnancy (CSP) have not been well described. In addition, there is currently no agreement on the optimal management of CSP, although five treatment options are recommended. In this study of women with a history of CSP, we analyzed the outcomes of their subsequent intrauterine pregnancy, the recurrence of CSP and whether the recurrence was associated with previous treatment. During a 3-year period, 158 women with a history of CSP (clinical characteristics are shown in Table S1) were followed up, and 24 women had a subsequent spontaneous pregnancy (Figure 1). Twenty (83.3%) women had an intrauterine pregnancy, two (8.3%) developed recurrent CSP (for one of them, it was the third recurrent CSP) and two (8.3%) developed an ectopic pregnancy. Clinical characteristics at diagnosis of CSP in women with a subsequent spontaneous pregnancy, according to the location of the gestation, are summarized in Table 1. Of the 20 women with intrauterine pregnancy, 14 delivered a healthy infant (mean birth weight, 3553 g) at term (mean gestational age, 39 + 3 (SD, 3.5) weeks) and one woman delivered a large-for-gestational-age infant (mean birth weight, 3850 g) at 35 + 1 weeks. Four women with an intrauterine pregnancy underwent termination of pregnancy for personal reasons. One woman experienced a missed miscarriage at 10 weeks. Of women with live birth (n = 15), three (20.0%) developed gestational diabetes mellitus (GDM). To date, the exact recurrence rate of CSP is unknown, although a rate of 5–40% has been reported1-5. The large variation between the studies could be due to relatively small sample sizes of women with subsequent pregnancies and how the recurrence rate was calculated. A recent study reported a recurrence rate of 40%, however, three recurrent CSPs were from the same patient3, while in all other studies, the recurrence rate of CSP was calculated taking into account only one subsequent pregnancy. Here, we report a recurrence rate of 8.3% in 24 individual subsequent pregnancies, which is similar to that cited in other studies, suggesting that the risk of developing recurrent CSP is low4. We also found that 8.3% of women with a history of CSP subsequently developed an ectopic pregnancy, which is lower than the rate of 13% reported in a similar population in another study5. However, the rate of ectopic pregnancy in our study is higher compared with the general incidence of ectopic pregnancy in developed countries (about 2%). Interestingly, in our study, we also found that 20% of women with live birth developed GDM in their subsequent pregnancy, which is higher than the incidence of GDM in the Chinese population (15%). None of these women developed any complications in their first pregnancy and their body mass index (BMI) was within the normal range (BMI < 24 kg/m2). We acknowledge that the small number of women with a subsequent pregnancy in our study did not allow us to examine the association between complications (ectopic pregnancy and GDM) and history of CSP. The type of treatment of CSP appears to be associated with recurrence of CSP or other complications in subsequent pregnancy. High-intensity focused ultrasound followed by ultrasound-guided dilatation and curettage treatment in previous CSP has been shown to be associated with a lower risk of recurrent CSP and other complications in subsequent pregnancies5. However, other studies did not find such an association, suggesting that the recurrence of CSP is unlikely to be related to the option of previous treatment. In our hospital, hysteroscopy is the most common treatment for CSP, although non-surgical management is more common in Western countries. Furthermore, we found that serum levels of β-human chorionic gonadotropin, the size of the gestational sac and gestational age at diagnosis of previous CSP are unlikely to be associated with the risk of developing recurrent CSP. Despite the risk of catastrophic consequences after a CSP, the cases in this study had good outcome, with a live birth in 62.5% of subsequent pregnancies and an 8.3% recurrence rate of CSP. The risk for developing other complications in a subsequent pregnancy needs to be investigated in future studies. Data will be available on reasonable request. Table S1 Clinical characteristics of 158 patients with Cesarean scar pregnancy Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.