Treatment standards are lacking, and several options are available. Expected management is an option, and live birth rates were 57 percent in one review (Maheux-Lacroix, 2017). However, hemorrhage, placenta accreta, and uterine rupture are risks. Thus, hysterectomy is an acceptable initial choice in those desiring sterilization. It is sometimes necessary with heavy uncontrolled bleeding. Fertility-preserving options include systemic or locally injected methotrexate, either alone or combined with conservative surgery (Birch Petersen, 2016; Cheung, 2015). Surgical procedures include visually guided suction curettage, hysteroscopic removal, or isthmic excision done abdominally or vaginally. hese are completed solely or with adjunctive MTX Qurkovic, 2016; Li, 2014a; Wang, 2014; Yang, 2009). Often uterine artery embolization (UE) is used preoperatively to minimize hemorrhage risk (Zhang, 2012; Zhuang, 2009). Foley balloon catheter placement can be another option for procedure-associated bleeding (TimorTritsch,i2015a).
Following conservative treatment, subsequent pregnancies have good outcomes, but placenta accreta and recurrent CSP are risks (Gao, 2016; Wang, 2015). Uterine arteriovenous malformations are a potential long-term complication (TimorTritsch,i2015b).
FIGURE 19-9 Cesarean scar pregnancy. A. Transvaginal sonogram of a uterus with a cesarean scar pregnancy (CSP) in a sagittal plane. An empty uterine cavity is identified by a bright hyperechoic endometrial stripe (long, white arrow). An empty cervical canal is similarly identified (short, white arrow). Last, an intrauterine mass is seen in the anterior part of the uterine isthmus (red arrows). Myometrium between the bladder and gestational sac is absent or thinned (1 to 3 mm). Photo contributor: Dr. Elysia Moschos.) B. Hysterectomy specimen containing a cesarean scar pregnancy. C. This same hysterectomy specimen is transversely sectioned at the level of the uterine isthmus and through the gestational sac. The uterine body lies to the left, and the cervix is on the right. A metal probe is placed through the endocervical canal to show the eccentric development of this gestation. Only a thin layer of myometrium overlies this pregnancy, which pushes anteriorly through the uterine wall. (Reproduced with permission from Gala RB: Ectopic pregnancy. In Hoffman BL, Schorge JO, Bradshaw KD, et al: Williams Gynecology, 3rd ed. New York, McGraw-Hili Education; 2016. Photo contributors: Drs. Sunil Balgobin, Manisha Sharma, and Rebecca Stone.) his rare ectopic pregnancy is defined by cervical glands noted histologically opposite the placental attachment site and by all or part of the placenta found below the entrance of the uterine vessels or below the peritoneal relection on the anterior uterus. In a typical case, the endocervix is eroded by trophoblast, and the pregnancy develops in the fibrous cervical wall. Predisposing risks include ART and prior uterine curettage (Ginsburg, 1994; Jeng, 2007).