A Preliminary Study to Propose an Algorithm for Management of Cesarean Scar Pregnancy

Objectives: There is no consensus on the management of cesarean scar pregnancy (CSP). In this regard, this study proposed an algorithm for CSP management with consecutive outcomes. Materials and Methods: In this randomized clinical trial study, the data of 44 patients with CSP were collected, and the diagnosis was confirmed by transvaginal ultrasonography (TVS). Unstable patients underwent uterine artery embolization (UAE), and the fetal reduction was done for patients with the fetal heart rate (FHR). In addition, patients received systemic methotrexate (MTX) injections according to their beta-human chorionic gonadotropin (β-hCG) levels and then were followed on a predetermined schedule by β-hCG levels and TVS. Finally, prophylactic UAE was considered for patients with ongoing bleeding, placental hypervascularity, and the prospect of limited access to care. Results: Patients were within the age range of 33.9±4.9 years and the gestational age of 7.37±1.57 weeks. Twenty-two patients (50%) had vaginal bleeding, 3 of whom were unstable and underwent UAE. Five patients underwent a total abdominal hysterectomy, and fourteen patients with FHR underwent a fetal reduction. Based on β-hCG levels and changes, and placental vascularity, 4 patients received no treatment. In general, 11, 2, and 9 patients received single, double, and multiple MTX injections. A total of 10 patients underwent both multi-doses of MTX and prophylactic UAE. The median period to reach undetectable β-hCG levels was 7.3 weeks and the median interval to start menstruation was 2.8 weeks. In addition, the pregnancy remnant was resolved 3.6 months after the treatment. On the follow-up, no curettage or hysterectomy was needed and seven patients became pregnant (15.9%), 2 of whom presented recurrent CSP (28.6%). Conclusions: The proposed stepwise algorithm could be employed for CSP management with accountable outcomes, low hysterectomy rates, and fertility preservation.