A New Minimally Invasive Treatment for Cesarean Scar Pregnancy and Cervical Pregnancy

The occurrence of cesarean scar pregnancy and cervical pregnancy, unrelated forms of pathological pregnancies, present significant diagnostic and treatment challenges. A large number of treatments have been used with widely varying effectiveness and complication rates ranging from 10% to 62%. The incidence of cesarean scar pregnancy has been rising, paralleling the increasing rate of cesarean delivery in recent decades. Its incidence is unknown, but some investigators estimate it to occur from 1 in 1800 to 1 in 2500 cases of previous cesarean deliveries. There is a low likelihood of delivering a live neonate in women with these pregnancies and high risk of hysterectomy for a morbidly adherent placenta. Termination of cesarean scar pregnancies within the first 8 weeks is believed to be the only treatment option by the majority of obstetricians and gynecologists.When termination of the pregnancy is chosen, there are a large number of treatment options; however, most are slow to act or invasive or carry significant complications. The most severe complication is bleeding at or after the applied treatment. Lifesaving hysterectomy and uterine artery embolization may be required to treat complications. Health, Inc. All rights reserved. 22 Obstetrical and Gynecological Survey A previous study by the authors showed that use of a single-balloon tamponade after local injection of methotrexate in women with cesarean scar pregnancy and cervical pregnancy was effective in terminating the pregnancy. The results suggested that treating obstetric hemorrhage using balloon tamponade could prevent both hemostasis and cardiac activity. This study explored the feasibility and effectiveness of using a cervical ripening double-balloon catheter to terminate cesarean scar pregnancy and cervical pregnancy while avoiding invasive treatment. The ability of this office-based procedure to stop cardiac activity and at the same time prevent bleeding was evaluated. Data were obtained from a retrospective case series of patients with diagnosed cesarean scar pregnancy or cervical pregnancy between 6 and 8 weeks’ gestation. Inclusion criteria were gestational age between 6 and 8 weeks with demonstrable embryonic/fetal heart activity and a strong desire among patients for termination and for future fertility. For pain control, paracervical block with 1% lidocaine was administered to 3 patients. The catheter was inserted, and the upper balloon was inflated under transabdominal ultrasound guidance. The lower (pressure) balloon was inflated under transvaginal ultrasound guidance opposite the gestational sac. The patient was observed in the office for 1 hour, and the area of the sac was scanned. When there was no fetal heart activity and no bleeding, patients were discharged. The patient was told to return in 2 to 3 days for follow-up and possible removal of the catheter. Follow-up consisted of weekly serial ultrasound examinations and weekly serum human chorionic gonadotropin (until nonpregnant values were obtained). Seven patients with live cesarean scar pregnancy and 3 with live cervical pregnancy were successfully treated with the double-balloonmethod. At treatment, median gestational age was 6 weeks (range, 6 through 7 weeks). There was high acceptance among patients for the double-balloon treatment despite the initial low abdominal pressure felt when the balloons were inflated. Nine of the 10 patients noted vaginal spotting at the follow-up appointment, but only 1 experienced bleeding of dark blood. Balloons were kept in place for a median of 3 days (range, 1–5 days). Median time from treatment for the human chorionic gonadotropin values to return to nonpregnant values was 49 days (range, 28–97 days). These findings show that use of the double-balloon catheter is a novel, minimally invasive, and well-tolerated procedure for termination of cervical pregnancy and cesarean scar pregnancy. This procedure has several advantages: Embryonic cardiac activity is stopped, no significant bleeding occurs, no additional invasive treatments are needed, and the procedure is familiar to obstetricians-gynecologists who use the same cervical ripening balloon catheters for labor induction. Wider application of this method, however, must be validated using a larger patient population.