“Ultrasound guided suction curettage of caesarean scar pregnancies is effective and generally associated with minimal blood loss. Conservative management is a safe alternative for non viable caesarean scar pregnancies”

 

INTRODUCTION Caesarean scar pregnancies (CSP) are rare, affecting 1/2000 pregnancies. Approximately 30% miscarry in the first trimester. Those that progress into the 3 rd trimester are likely to be complicated by placenta praevia or accreta. Early intervention is therefore justified to prevent a potentially life threatening condition. There is, however, a lack of consensus on the optimal management of CSP

 

METHOD Retrospective review of all CSP diagnosed on first trimester TVUS between 2018-2022 Pregnancies classified as viable, non viable and early (defined as mean sac diameter <25mm or CRL <7mm and no heart activity yet detected) Management of the pregnancy was compared. This included conservative, medical and surgical management. Complications, blood loss and length of follow up were analysed.

RESULTS ▪ 28 caesarean scar pregnancies were diagnosed (CSP rate 0.8/1000). ▪ 18/28 (64%) were managed surgically, 9/28 (32%) conservatively and 1 patient medically ▪ Viable pregnancies were more likely to be managed surgically (83%) whereas 50% of non viable and early pregnancies were managed conservatively SURGICAL MANAGEMENT ▪ 17/18 were by US guided suction curettage. ▪ 4/18 required insertion of a foley catheter into the lower uterine cavity for haemostasis. ▪ A larger CRL was associated with the need for foley catheter. ▪ Median blood loss was 50 ml (30-2000ml) ▪ 83% had a blood loss of less than 200ml ▪ There were no significant complications

CONSERVATIVE MANAGEMENT ▪ Serial serum hCG +/- TVUS ▪ 100% of early and non viable pregnancies managed conservatively resolved within 3 months with no additional intervention

 

CONCLUSION Conservative management of non viable and early CSP is safe and effective. US guided suction evacuation of viable CSP is associated with low median blood loss and complications Consider insertion of a foley catheter during suction evacuation for those with a larger CRL