Publications

The objective of this systematic review is to assess the efficacy and safety of treatment options of cesarean scar pregnancies (CSP). We searched Medline, Embase, and Cochrane Library from inception to June 2016 as well as reference lists. We included English publications reporting treatment outcomes of at least 10 cases of CSP. Two authors screened for eligibility, extracted data and assessed the quality of included studies. Treatment was considered successful if no subsequent intervention was required following index treatment. Of the 1,257 citations identified, 63 studies were eligible. The overall success rate of systemic methotrexate (MTX) and/or local injection of MTX or potassium chloride was 62%. Dilation and curettage (D&C) was associated with a 28% risk of hemorrhage that dropped to 4% when combined with uterine artery embolization (UAE). Hysteroscopic resection of CSP was unsuccessful in 12% of cases and inadequate hCG decay was the primary indication for additional intervention. Laparoscopic, vaginal and open excision and repair of the defect were associated with high success rate (≥96%) and low risk of hemorrhage (≤4%). Expectant management resulted in a 57% live birth rate, but 63% of women required hysterectomy due to placental implantation abnormalities or second-trimester uterine rupture. Most studies were of low methodological quality and given the heterogeneity between studies and groups, statistical comparison of treatment options was deemed inappropriate. In conclusion, the decision to allow progression of CSP exposes women to a high risk of life-threatening hemorrhage and hysterectomy. Medical treatment options alone are often insufficient. D&C is a reasonable option in well-selected women or when combined with UAE. Potential benefits of excision and repair of scar defect on further pregnancy outcomes need to be further assessed.