Surgical Management Algorithm for Caesarean Scar Pregnancy

Abstract

Objectives: To report our experience with the management of Caesarean scar pregnancy (CSP) in the first trimester and to develop a unique treatment algorithm allowing physicians to customize their management based on clinical patient characteristics.

Methods: A retrospective review of 12 patients diagnosed with CSP between December 2012 and June 2016 was conducted in a tertiary care hospital in Toronto. All patients were diagnosed with CSP by transvaginal ultrasound using radiologic criteria. Patients were initially treated with an ultrasound-guided embryocidal injection when fetal heart activity was present. Next, patients underwent medical management with systemic multidose methotrexate (MTX) or surgical management using a laparoscopic or transcervical approach depending on CSP characteristics.

Results: The mean age at diagnosis was 35.6 years. The median number of previous CSs was one. The mean serum human chorionic gonadotropin level was 59 938 IU/L. The mean GA at presentation was 8+1 weeks. Two-thirds of patients received medical management with systemic multidose methotrexate. Of these, 50% required additional surgical treatment for the resolution of their CSP. One-third of patients underwent primary surgical treatment, resulting in complete resolution of CSP with no complications. Given the improved outcomes of surgical management in our series, we suggest a treatment algorithm that tailors the surgical approach, either laparoscopic or transcervical, to the characteristics of the CSP.

Conclusion: This constitutes the largest case series of CSP in Canada. Based on our results, CSP can be safely and effectively managed using the suggested surgical algorithm, which accounts for individual patient characteristics.

Keywords: Caesarean scar pregnancy; algorithm; surgical management; type 1 Caesarean scar pregnancy; type 2 Caesarean scar pregnancy.