What is the recommended management for a Cesarean Scar Pregnancy (CSP)?

Management of Cesarean Scar Pregnancy

Cesarean scar pregnancy (CSP) should be terminated upon diagnosis, with expectant management strongly discouraged due to the high risk of uterine rupture and life-threatening hemorrhage. 1, 2

Immediate Diagnostic Confirmation

• Transvaginal ultrasound is the primary diagnostic tool, identifying a gestational sac embedded in the uterine window at the cesarean scar site, with an empty uterine cavity and cervical canal, and a thin or absent myometrial layer between the gestational sac and bladder. 3
• MRI should be obtained when ultrasound findings are inconclusive, demonstrating dark intraplacental bands on T2-weighted imaging and disruption of the uterine-placental interface. 3
• Referral to centers with expertise in CSP imaging and management is essential, as diagnostic accuracy depends heavily on examiner experience. 3

Treatment Algorithm Based on Fertility Desires

For Patients Desiring Future Fertility

Ultrasound-guided intragestational methotrexate injection emerges as the preferred treatment, either alone or combined with other modalities. 4, 2

• Operative resection via transvaginal or laparoscopic approaches, or ultrasound-guided vacuum aspiration are recommended surgical options. 2
• Sharp curettage alone must be avoided due to high risk of profuse bleeding requiring hysterectomy. 4, 2
• Systemic methotrexate alone should not be used as it has insufficient efficacy for CSP treatment. 2
• Local methotrexate injection (transvaginal or transabdominal ultrasound-guided) into the gestational sac or embryo provides direct treatment with fertility preservation in most cases. 4

For Patients Not Desiring Future Fertility

• Hysterectomy is definitive management and eliminates all risks of hemorrhage and uterine rupture. 5
• This approach is particularly appropriate for patients with multiple prior cesarean deliveries or other risk factors for placenta accreta spectrum. 5

Critical Management Principles

• Hemorrhage management protocols must be established before any procedure, with blood products immediately available and multidisciplinary team mobilization planned. 6
• Thromboprophylaxis should be considered during hospitalization, especially if the patient is immobilized or undergoes surgical intervention. 6
• High-velocity, low-impedance subtrophoblastic flow on color Doppler ultrasound (resistance index ~0.38) persists until beta-hCG normalizes, which can take 2 months to 1 year after treatment. 4

If Patient Refuses Treatment

For patients who decline termination and choose expectant management despite counseling:

• Planned cesarean delivery between 34 0/7 and 35 6/7 weeks gestation is mandatory. 2
• Counsel that 79% will develop morbidly adherent placenta (approaching 100% risk), 55% will require hysterectomy, and 40% will experience severe bleeding. 3, 7
• While 78% of expectantly managed cases result in live births at or near term, the maternal morbidity burden is substantial. 7
• Uterine rupture can occur during subsequent pregnancies, even at term gestational ages. 4

Counseling for Future Pregnancies

• All patients must be counseled about increased risks in future pregnancies, including recurrent CSP, placenta accreta spectrum, and uterine rupture. 6, 8
• Detailed transvaginal ultrasound evaluation in early pregnancy is essential to confirm proper implantation site in any subsequent conception. 6, 8
• Long-acting reversible contraception or permanent contraception should be discussed given the severity of risks with future pregnancies. 2

Common Pitfalls to Avoid

• Do not misdiagnose CSP as cervical ectopic pregnancy or spontaneous abortion in progress—maintain high clinical suspicion in any patient with prior cesarean delivery presenting with early pregnancy symptoms or abnormal bleeding. 3
• Do not perform sharp curettage alone—this carries the highest risk of catastrophic hemorrhage requiring emergency hysterectomy. 4, 2
• Do not use systemic methotrexate as monotherapy—it has inadequate efficacy for CSP and delays definitive treatment. 2
• Do not offer expectant management as a routine option—this should only occur after extensive counseling about the near-certain development of placenta accreta spectrum and high likelihood of hysterectomy. 2, 7