Francesco Forlani, Ganesh Acharya, Alessandra Familiari, Ana Monteaugudo, Ilan E. Timor-Trisch, Danilo Buca, Francesco D'Antonio, Giovanni Scambia, Giuseppe Calì, Josè Palacios-Jaraquemada
Objective
To explore the outcome of women managed expectantly following a diagnosis of caesarean scar pregnancy (CSP).
Methods
The outcomes observed were: severe first trimester vaginal bleeding, clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment, uncomplicated miscarriage, complicated miscarriage requiring intervention, first or second trimester uterine rupture, first or second trimester hysterectomy, third trimester bleeding, third trimester uterine rupture, third trimester hysterectomy, maternal death, occurrence of abnormally invasive placenta (AIP), prevalence of placenta percreta, ultrasound signs suggestive of AIP, liveborn fetuses. Meta-analyses of proportions using random effect model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis.
Results
A total of 17 studies (69 cases of CSP managed expectantly, 52 with positive and 17 with negative embryonic/fetal heart beat) were included. In women with CSP with positive embryonic/fetal heart activity, 13.0% (95% CI 3.8-26.7; 4/39) experienced an uncomplicated miscarriage, while in 20.0% (95% CI 7.1-37.4; 8/39) intervention was required. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI 2.9-20.4; 3/39), while hysterectomy was required in 15.2% (95% CI 3.6-32.8; 6/39) of all cases. 76.8% (95% CI 65.4-86.5) women progressed to the third trimester of pregnancy and 29.6% (95% CI 13.7-50.2; 8/27) experienced severe bleeding. Finally, 75.0% (95% CI 58.8-87.3; 30/40) had surgical or pathological diagnosis of AIP at delivery and more than half (58.6%, 95% CI 38.9-76.5; 17/29) of them had placenta percreta.
In women affected by CSP with no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in (70.6%, 95% CI 44.0-89.7; 12/17) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 29.4% (95% CI 10.3-56.0; 4/17). Uterine rupture during the first trimester of pregnancy occurred in 5.89%(95% CI 0.1-28.7; 1/17), but hysterectomy was required in none.
Conclusion
CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidities including severe haemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of them may progress close or to term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome.
