Is local methotrexate therapy effective in the treatment of cesarean scar pregnancy? A retrospective cohort study

Treatments for cesarean scar pregnancy: a systematic review and meta-analysis

OBJECTIVE

To report the outcome of cesarean scar pregnancy (CSP) undergoing treatment.

METHODS

MEDLINE, Embase and CINAHL databases were searched. Inclusion criteria were women with CSP undergoing treatment. The primary outcome was successful treatment for CSP, defined as no need for additional medical or surgical strategies. Secondary outcomes were the type of additional treatment (surgical or medical), need for blood transfusion, emergency laparotomy, hysterectomy, post-treatment complications.All these outcomes were explored in women undergoing single and compound treatments for CSP. Furthermore, we performed a separate sub-group analysis only including studies which reported on the outcomes of elective treatments. Random effects meta-analyses were used to analyze the data and results reported as pooled proportions or odd ratio (OR).

RESULTS

176 studies (13431 women with CSP undergoing treatment) were included.Successful treatment after primary intervention was achieved in 86.2% (95% CI 82.3-89.7) of women with CSP undergoing treatment with ultrasound guided suction curettage, 72.4% (95% CI 64.8-79.3) with systemic MTX, 81.6% (95% CI 72.3-89.3) with local MTX, 83.9% (95% CI 66.7-95.6) with interventional radiology, 90.42% (95% CI 82.9-96.0) with hysteroscopy, 96.1% (95% CI (92.3-98.6) with laparoscopy and 92.6 with high intensity focused ultrasound (95% CI 78.2-99.6). Post-treatments complications were reported in 3.5% (95% CI 1.7-6.0) of women treated with systemic MTX, 5.9% (95% CI 0.8-15.1) with local MTX or KCl, 1.2% (95% CI 0.1-3.5) with interventional radiology, 1.4% (95% CI 0.4-2.9) with hysteroscopy, 5.5% (95% CI 0.4-25.7) with high intensity focused ultrasound and in none of the cases treated with ultrasound guided suction curettage.When considering compound treatments, successful resolution of CSP was achieved in 91.9% (95% CI 88.0-95.10) of women treated with interventional radiology followed by curettage, 83.3% (95% CI 68.8-93.8) with systemic MTX and curettage, 79.4% (95% CI 56.3-95.2) with local MTX and curettage, 96.2% (95% CI 92.3-98.7) with curettage followed by single or double balloon insertion in the uterine cavity, 98.3% (95% CI 95.9-99.7) with high intensity focused ultrasound followed by curettage, 91.1% (95% CI 3.4-97.0) with interventional radiology followed by removal of CSP with hysteroscopy, 64.3% (95% CI 13.8-99.2) with interventional radiology and systemic MTX and in 95.5% (95% CI 92.9-97.5) with curettage and hysteroscopy.When considering studies reporting a comparison between different treatments, there was no difference between systemic vs local MTX in the primary outcome. Curettage was associated with a higher chance of achieving a successful treatment.

CONCLUSIONS

A multitude of treatments for CSP have been reported in the published literature. All treatments described for CSP are apparently equally effective in treating this condition. The findings from this systematic review highlight the need for adopting a common definition and outcome reporting of CSP to better elucidate its natural history, estimate the magnitude of maternal complication after treatment and design appropriately powered RCT to elucidate the optimal treatment of CSP according to its ultrasound phenotype and gestational age at treatment, in terms of effective resolution of the condition and risk of post-intervention complications.

Treatment of Cesarean Scar and Cervical Pregnancies Using the Ovum Aspiration Set for Intrachorial Methotrexate Injection as a Conservative, Fertility-Preserving Procedure

Background and Objectives: Cesarean scar and cervical pregnancies are rare forms of ectopic pregnancies, occurring in 1 in 2000 and 1 in 9000 pregnancies, respectively. Both entities are medically challenging due to their high morbidity and mortality potential. Materials and Methods: In this retrospective study, we analyzed all cesarean scar and cervical pregnancies from 2010 to 2019 in the Department of Gynecology and Obstetrics of the University Hospital Freiburg, treated with both intrachorial (using the ovum aspiration set) and systemic methotrexate application. Results: We identified seven patients with a cesarean scar and four patients with cervical pregnancies. At diagnosis, the median gestational age was 7 + 1 (range: 5 + 5-9 + 5) weeks and the mean value of ß-hCG was 43,536 (range: 5132-87842) mlU/mL. On average, one dose of intrachorial and two doses of systemic methotrexate were administered per patient. The efficacy rate was 72.7% with three patients (27.3%) needing an additional surgical or interventional procedure. The uterus was preserved in 100% of the patients. Out of the eight patients with follow-up data, five reported subsequent pregnancies (62.5%) that resulted in six live births. None had recurrent cesarean scars or cervical pregnancies. In the subgroup analyses, when comparing cesarean scar pregnancies to cervical pregnancies, patient characteristics, treatment modality, and the outcome did not differ significantly, except for parity (2 versus 0, p = 0.02) and the duration since the last pregnancy (3 vs. 0.75 years, p = 0.048). When comparing cases with successful and failed methotrexate-only treatments, the maternal age was significantly higher in the successful group (34 vs. 27 years, p = 0.02). Localization of the gestation, gestational and maternal age, ß-hCG, and history of preceding pregnancies were non-predictive for the efficacy of the treatment. Conclusions: The combined application of intrachorial and systemic methotrexate for the treatment of cesarean scar and cervical pregnancies has been proven effective, well-tolerated, organ- and fertility-conserving with a low complication rate.

Efficacy of suction curettage as the first-line treatment of cesarean scar pregnancy: A retrospective study

OBJECTIVE

There is still no consensus on a safe and efficient treatment modality for cesarean scar pregnancy (CSP), which is known to cause severe complications, such as life-threatening hemorrhage. Suction curettage (SC) has been used as the first-line treatment for CSP with controversial outcomes. In this context, the objective of this study is to analyze the efficacy of SC in the treatment of CSP.

METHODS

The sample of this retrospective study consisted of 64 CSP patients treated using SC between 2012 and 2022. Patients' demographic and clinical variables, including the thickness of the myometrium at the lower uterine segment between the urinary bladder and cesarean scar, were obtained from their medical records. The study's primary outcome was determined as the success rate of SC. Accordingly, the patients were categorized into two groups: successful SC (Group 1) and unsuccessful SC (Group 2).

RESULTS

The success rate of SC was determined as 78.1%. The number of previous cesarean deliveries, gestational age, baseline beta-human chorionic gonadotropin (β-hCG) values, and endometrial thickness was significantly higher in Group 2 (p<0.05 for all), whereas the fetal cardiac activity and absence of an embryonic pole were significantly higher in Group 2 (p = 0.001 and p = 0.004, respectively). There was no significant difference between the groups in the thickness of the myometrium at the lower uterine segment (p = 0.890). The hemoglobin levels decreased significantly after SC in both Groups 1 and 2 (p<0.001 and p = 0.009, respectively). There was no significant difference between the groups in preoperative and postoperative hemoglobin values and the decrease in hemoglobin levels (p>0.05).

CONCLUSION

The study findings did not indicate any significant correlation between myometrial thickness at the lower uterine segment and the efficacy of SC in CSP patients. On the other hand, the number of cesarean deliveries, gestational age, baseline β-hCG values, endometrium thickness, fetal cardiac activity, and embryonic pole may be used to predict the outcome of SC in the treatment of CSP.