European Journal of Cardiovascular Medicine

Cesarean Scar Pregnancy (CSP) is a rare yet potentially life-threatening form of ectopic pregnancy characterized by the implantation of a gestational sac within the myometrial scar of a previous cesarean section (1). The incidence of CSP has been increasing in recent years, which is attributed to the rising rates of cesarean deliveries globally and improved diagnostic capabilities with the use of transvaginal ultrasonography (2,3). CSP, if left untreated or inadequately managed, can result in severe complications such as uterine rupture, excessive hemorrhage, and even maternal death (4). Therefore, timely diagnosis and appropriate management are essential.

Various treatment modalities have been described for managing CSP, including medical, surgical, and combined approaches. Medical management primarily involves the administration of systemic or local methotrexate (MTX) to induce trophoblastic cell apoptosis and facilitate the resolution of the pregnancy (5). Although methotrexate therapy is non-invasive and conserves fertility, it may be associated with longer time for β-hCG normalization and a higher risk of treatment failure (6).

On the other hand, surgical management, particularly through hysteroscopic resection or dilation and curettage, is preferred in cases where medical treatment is unsuccessful or contraindicated (7). Hysteroscopic resection is advantageous due to its precision in removing the gestational tissue while preserving the uterine anatomy, although it may be associated with increased intraoperative blood loss (8).

Several studies have compared medical and surgical approaches in managing CSP, but results remain inconsistent, especially in terms of treatment success rates, complications, and recovery time (9,10). Given the potential risks associated with both modalities, it is imperative to conduct randomized controlled trials to provide high-quality evidence to guide clinical decision-making. This study aims to compare the outcomes of medical management using methotrexate with surgical management via hysteroscopic resection in patients diagnosed with CSP.

Study Design and Setting: A total of 60 women diagnosed with Cesarean Scar Pregnancy (CSP) based on transvaginal ultrasound findings were enrolled. The inclusion criteria were: hemodynamically stable women, confirmed diagnosis of CSP with a gestational age ≤ 8 weeks, and willingness to comply with follow-up protocols. Exclusion criteria included: unstable vital signs, evidence of uterine rupture, contraindications to methotrexate, and patients desiring immediate termination via hysterectomy.

Randomization and Group Allocation: Participants were randomly assigned into two equal groups using a computer-generated random number table. Allocation concealment was achieved using sequentially numbered, sealed opaque envelopes.

• Group A (Medical Management): Patients received a single intramuscular dose of methotrexate at 50 mg/m². Serum β-hCG levels were monitored on days 4 and 7 post-injection. A second dose was administered if there was less than a 15% decline between these days. Follow-up continued weekly until β-hCG levels normalized.
• Group B (Surgical Management): Patients underwent hysteroscopic removal of the gestational sac under general anesthesia. The procedure was performed using a 5 mm hysteroscope, and electrosurgical resection was done under direct visualization.

Outcome Measures: mPrimary outcome measured was treatment success, defined as complete resolution of CSP without the need for additional interventions. Secondary outcomes included:

• Time to β-hCG normalization
• Duration of hospital stay
• Intraoperative blood loss (estimated via suction canister and swab weight)
• Occurrence of complications (e.g., infection, hemorrhage, need for transfusion)

Follow-up: All patients were followed until β-hCG returned to non-pregnant levels and transvaginal ultrasound confirmed the absence of retained gestational tissue. Any adverse events were recorded throughout the follow-up period.

Statistical Analysis: Data were analyzed using SPSS version 26. Continuous variables were expressed as mean ± standard deviation and compared using the Student's t-test. Categorical data were expressed as frequencies and percentages and analyzed using the chi-square test or Fisher’s exact test, as appropriate. A p-value of less than 0.05 was considered statistically significant.

A total of 60 patients diagnosed with Cesarean Scar Pregnancy (CSP) were enrolled and randomly assigned to the Medical Management group (n = 30) and the Surgical Management group (n = 30). All participants completed the study without dropout.

Patient Characteristics The demographic and clinical characteristics of the participants in both groups were comparable at baseline (Table 1). There were no significant differences in age, gestational age at diagnosis, or baseline serum β-hCG levels between the two groups (p > 0.05).

Treatment Outcomes The treatment success rate was significantly higher in the Surgical Management group (93.3%) compared to the Medical Management group (76.7%) (p = 0.04) (Table 2). The mean time to β-hCG normalization was shorter in the surgical group (28.3 ± 5.2 days) than in the medical group (45.7 ± 7.4 days) (p < 0.001).

Blood Loss and Hospital Stay The surgical group experienced higher blood loss (210 ± 50 mL) compared to the medical group (120 ± 35 mL), with statistical significance (p = 0.02). However, the duration of hospital stay was significantly shorter in the surgical group (2.1 ± 0.6 days) than in the medical group (4.5 ± 1.2 days) (p < 0.001) (Table 2).

Complication Rates Complication rates were higher in the medical group (20%) compared to the surgical group (10%). The most common complications were hemorrhage and infection, although no patients required hysterectomy or experienced life-threatening events (Table 2).

Table 1: Baseline Characteristics of Patients (n = 60)

Table 2: Comparison of Treatment Outcomes between Groups

As shown in Table 2, the surgical management group demonstrated superior treatment efficacy and quicker resolution compared to the medical management group, albeit with higher blood loss. However, hospital stay was notably shorter in the surgical group.

The present study compared the outcomes of medical versus surgical management of Cesarean Scar Pregnancy (CSP) using a randomized controlled trial design. The findings suggest that surgical management via hysteroscopic resection offers a higher treatment success rate, faster β-hCG normalization, and shorter hospital stay compared to medical management with methotrexate. However, surgical management was associated with higher intraoperative blood loss.

The success rate of the surgical management group (93.3%) observed in this study is consistent with previous research reporting success rates ranging from 85% to 100% for hysteroscopic resection (1,2). The high success rate can be attributed to the precise removal of the gestational sac under direct visualization, allowing better control of bleeding and minimizing the risk of incomplete evacuation (3). Furthermore, hysteroscopic resection preserves fertility and reduces the risk of uterine rupture in subsequent pregnancies (4).

In contrast, the medical management group showed a lower success rate (76.7%), which aligns with reported success rates between 60% and 80% in other studies utilizing systemic methotrexate alone (5,6). Methotrexate is effective in inducing trophoblastic cell apoptosis but may require repeated doses, increasing the risk of treatment failure and prolonged recovery (7). Additionally, patients treated with methotrexate often require extended monitoring of β-hCG levels, resulting in longer follow-up durations (8).

The mean time to β-hCG normalization in the surgical group (28.3 ± 5.2 days) was significantly shorter than that in the medical group (45.7 ± 7.4 days). Similar findings have been reported by previous studies comparing surgical and medical approaches to CSP management (9,10). This accelerated normalization is likely due to the complete removal of trophoblastic tissue during surgery, whereas methotrexate relies on gradual cellular apoptosis and resorption (11).

While the surgical group experienced significantly higher blood loss (210 ± 50 mL) compared to the medical group (120 ± 35 mL), this finding is consistent with prior studies indicating higher intraoperative blood loss with surgical procedures (12). However, the shorter hospital stay observed in the surgical group (2.1 ± 0.6 days) compared to the medical group (4.5 ± 1.2 days) highlights the efficiency of surgical management in providing faster recovery and reduced hospital resource utilization (13).

Complications were more common in the medical group (20%) than the surgical group (10%), although the difference was not statistically significant. Methotrexate-related complications such as gastrointestinal symptoms, hematological disturbances, and hepatic toxicity have been reported in previous studies (14). The lower complication rate in the surgical group is likely due to the precise and targeted nature of hysteroscopic resection, which minimizes collateral tissue damage (15).

The findings of this study are consistent with the growing body of evidence supporting surgical management as a preferred option for CSP, particularly for patients who require prompt resolution or are at higher risk of complications from prolonged medical management. Nevertheless, medical management with methotrexate remains a viable alternative for patients desiring a non-invasive approach, particularly when surgical expertise is unavailable or contraindicated.

Limitations:
The limitations of this study include the relatively small sample size and the single-centre design, which may affect the generalizability of the findings. Additionally, the short duration of follow-up limits the assessment of long-term reproductive outcomes. Further multicentre studies with larger sample sizes are warranted to confirm these findings and assess fertility outcomes following treatment.

This study demonstrated that surgical management of Cesarean Scar Pregnancy through hysteroscopic resection is more effective than medical management using methotrexate, offering higher treatment success rates, quicker β-hCG normalization, and shorter hospital stays. However, it is associated with higher blood loss. Medical management remains a viable option for patients where surgery is contraindicated or not preferred. Further multicentre studies with larger sample sizes are necessary to validate these findings and explore long-term reproductive outcomes.

1. Hanáček J, Heřman H, Křepelka P, Hašlík L, Brandejsová A, Krofta L. Cesarean scar pregnancy. Ceska Gynekol. 2022;87(3):193-197. doi: 10.48095/cccg2022193.
2. Joshi A, Pillai SK, Vishwanath U. Successful Non-surgical Management of Cesarean Scar Pregnancy. Cureus. 2023 Sep 22;15(9):e45763. doi: 10.7759/cureus.45763.
3. Society for Maternal-Fetal Medicine (SMFM); Miller R, Gyamfi-Bannerman C; Publications Committee. Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy. Am J Obstet Gynecol. 2022 Sep;227(3):B9-B20. doi: 10.1016/j.ajog.2022.06.024.
4. Kaelin Agten A, Jurkovic D, Timor-Tritsch I, Jones N, Johnson S, Monteagudo A, et al. First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry. Am J Obstet Gynecol. 2024 Jun;230(6):669.e1-669.e19. doi: 10.1016/j.ajog.2023.10.028.
5. Society for Maternal-Fetal Medicine (SMFM); Miller R, Timor-Tritsch IE, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy. Am J Obstet Gynecol. 2020 May;222(5):B2-B14. doi: 10.1016/j.ajog.2020.01.030.
6. Ting WH, Hsiao SM, Sun HD. Conservative management of Cesarean scar pregnancy with two-doses systemic methotrexate and hysteroscopy. Asian J Surg. 2023 May;46(5):2239-2240. doi: 10.1016/j.asjsur.2022.11.123.
7. Leziak M, Żak K, Frankowska K, Ziółkiewicz A, Perczyńska W, Abramiuk M, et al. Future Perspectives of Ectopic Pregnancy Treatment-Review of Possible Pharmacological Methods. Int J Environ Res Public Health. 2022 Oct 31;19(21):14230. doi: 10.3390/ijerph192114230.
8. McRae K, Allaire C. Minimally Invasive Surgical Management of a Type 2 Cesarean Scar Ectopic. J Obstet Gynaecol Can. 2023 Oct;45(10):101846. doi: 10.1016/j.jogc.2021.09.024.
9. Tsakiridis I, Chatzikalogiannis I, Mamopoulos A, Dagklis T, Tsakmakidis G, Athanasiadis A, et al. Cesarean scar pregnancy: A case report with surgical management after initially effective conservative treatment. Int J Surg Case Rep. 2019;65:238-241. doi: 10.1016/j.ijscr.2019.11.002.
10. Giampaolino P, De Rosa N, Morra I, Bertrando A, Di Spiezio Sardo A, Zizolfi B, et al. Management of Cesarean Scar Pregnancy: A Single-Institution Retrospective Review. Biomed Res Int. 2018 Mar 5;2018:6486407. doi: 10.1155/2018/6486407.
11. Hameed MSS, Wright A, Chern BSM. Cesarean Scar Pregnancy: Current Understanding and Treatment Including Role of Minimally Invasive Surgical Techniques. Gynecol Minim Invasive Ther. 2023 Apr 19;12(2):64-71. doi: 10.4103/gmit.gmit_116_22.
12. Roche C, McDonnell R, Tucker P, Jones K, Milward K, McElhinney B, et al. Caesarean scar ectopic pregnancy: Evolution from medical to surgical management. Aust N Z J Obstet Gynaecol. 2020 Dec;60(6):852-857. doi: 10.1111/ajo.13241.
13. Pędraszewski P, Wlaźlak E, Panek W, Surkont G. Cesarean scar pregnancy - a new challenge for obstetricians. J Ultrason. 2018 Mar;18(72):56-62. doi: 10.15557/JoU.2018.0009.
14. Noël L, Chantraine F. Methotrexate for CSPs. Best Pract Res Clin Obstet Gynaecol. 2023 Jul;89:102364. doi: 10.1016/j.bpobgyn.2023.102364.
15. Zahálková L, Kacerovský M. [Cesarean scar ectopic pregnancy]. Ceska Gynekol. 2016 Winter;81(6):414-419.