The clinical significance of Cesarean scar pregnancy (CSP) has escalated in tandem with the increasing global rate of primary and repeat cesarean sections. CSP carries an immense risk of placenta accreta spectrum (PAS) disorders, uterine rupture, and maternal exsanguination if mismanaged or diagnosed late. Currently, a lack of universal consensus on the 'best' management strategy leads to significant variation in clinical practice, often resulting in avoidable hysterectomies in young women. By providing a comparative analysis of surgical and medical interventions, this research addresses a critical gap in reproductive emergency medicine. Focusing on diagnostic precision via ultrasound and the integration of minimally invasive radiological techniques (UAE) allows for fertility-sparing treatments. This study is highly relevant to obstetricians and radiologists, offering evidence-based insights to improve maternal safety and long-term reproductive outcomes in a growing demographic of high-risk pregnancies.
To assess the diagnostic accuracy of standardized sonographic criteria for Cesarean scar pregnancy and to compare the safety and efficacy of UAE-combined surgical evacuation versus systemic methotrexate therapy.
A retrospective cohort study was conducted on 142 patients diagnosed with CSP at a tertiary referral center over a five-year period. Diagnostic accuracy was evaluated against surgical findings or MRI confirmation. Patients were categorized into two treatment arms: Group A (n=78) received UAE followed by ultrasound-guided suction curettage within 24–48 hours; Group B (n=64) received systemic multi-dose MTX (1mg/kg). Diagnostic criteria included the absence of an intrauterine pregnancy, a vacant cervical canal, and presence of the gestational sac in the anterior lower uterine segment with myometrial thinning (<3mm). Primary outcomes were defined as successful resolution (normalization of β-hCG <5 mIU/mL without secondary intervention) and complication rates. Data were analyzed using Chi-square tests and independent t-tests, with significance set at p<0.05. Odds ratios (OR) with 95% confidence intervals (CI) were calculated to compare management efficacy.
TVUS demonstrated a sensitivity of 92.4% and a specificity of 88.6% for CSP detection. In the management cohort, the successful resolution rate was significantly higher in Group A (UAE+UGSC) compared to Group B (MTX) (94.9% vs. 71.8%; p<0.001; OR: 6.8, 95% CI: 2.1–21.5). The mean time for β-hCG normalization was 28.4 ± 6.2 days in Group A versus 44.1 ± 11.5 days in Group B (p<0.05). Intraoperative blood loss was significantly lower in the UAE group (mean 45 mL vs. 110 mL in MTX-failure cases requiring rescue surgery). Complications, including heavy vaginal bleeding requiring emergency transfusion, occurred in 3.8% of Group A versus 18.7% of Group B (p=0.007). Myometrial thickness <2mm at diagnosis was a significant predictor of treatment failure in the medical management group (p=0.012). No cases in the UAE group required a hysterectomy, whereas 2 patients in the MTX group underwent hysterectomy due to refractory bleeding.
Early diagnosis of CSP using standardized TVUS criteria is essential to prevent catastrophic uterine rupture. Our data conclude that UAE followed by ultrasound-guided suction curettage is significantly more effective than systemic MTX for Type II CSP, offering higher primary success rates, reduced blood loss, and shorter recovery times. The high rate of secondary interventions in the MTX group suggests that medical management should be reserved for highly stable, early-gestation cases with low initial hCG levels. Future clinical guidelines should prioritize interventional radiology-assisted surgical evacuation as a primary management strategy to optimize maternal reproductive health outcomes and preserve fertility in this high-risk population.