Volume 73, Number 5

OBSTETRICAL AND GYNECOLOGICAL SURVEY

Copyright © 2018 Wolters Kluwer Health,
Inc. All rights reserved. CME REVIEW ARTICLE
CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of
13
36 AMA PRA Category 1 Credits™ can be earned in 2018. Instructions for how CME credits can be earned appear on the last page
of the Table of Contents.

Cesarean Scar Ectopic Pregnancy:

Current Management Strategies
Tanya L. Glenn, MD,*† James Bembry, MD,‡ Austin D. Findley, MD, MSCR,§¶
Jerome L. Yaklic, MD, MBA,|| Bala Bhagavath, MD,** Pascal Gagneux, PhD,††
and Steven R. Lindheim, MD, MMM‡‡
*Obstetrics and Gynecology Resident, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and
Gynecology, Boonshoft School of Medicine, Wright State University, Dayton, OH; †Obstetrics and Gynecology Resident, Department
of Obstetrics and Gynecology, Wright-Patterson Medical Center, Wright-Patterson Air Force Base; ‡Assistant Clinical Professor of
Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University,
Dayton, OH; §Assistant Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Boonshoft School of
Medicine, Wright State University, Dayton, OH; ¶Assistant Professor of Obstetrics and Gynecology, Department of Obstetrics and
Gynecology, Wright-Patterson Medical Center, Wright-Patterson Air Force Base; ||Chair, Associate Professor of Obstetrics and
Gynecology, and Associate Dean for Clinical Affairs, Department of Obstetrics and Gynecology, Boonshoft School of Medicine,
Wright State University, Dayton, OH; **Professor of Obstetrics and Gynecology, Division of Reproductive Endocrinology and
Infertility, Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester Medical Center,
Rochester, NY; ††Associate Professor, Department of Pathology, Department of Cellular and Molecular Medicine,
University of California San Diego, San Diego, CA; and ‡‡Professor of Obstetrics and Gynecology, and Director of the
Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology,
Boonshoft School of Medicine, Wright State University, Dayton, OH

Importance: Cesarean scar ectopic pregnancy (CSEP) has a high rate of morbidity with nonspecific signs and
symptoms making identification difficult. The criterion-standard treatment of CSEP has been subject to debate.
Objective: This review defines CSEP, discusses pathogenesis and diagnosis, and compares treatment op-
tions and outcomes.
Evidence Acquisition: A literature review was performed utilizing the term cesarean scar ectopic pregnancy
and subsequently selecting only meta-analyses and systematic reviews. Only articles published in English were
included. Relevant articles within the reviews were analyzed as necessary.
Results: Five basic pathways have been identified in treatment of CSEP: expectant management, medical
therapy, surgical intervention, uterine artery embolization, or a combination approach. Expectant management
has the highest probability of morbid outcomes, including hemorrhage, uterine rupture, and preterm delivery.
Medical management often requires further treatment with additional medication or surgery. Different surgical
methods have been explored including uterine artery embolization; dilation and curettage; surgical removal via
vaginal, laparoscopic, or laparotomic approach; and hysterectomy. Each method has various levels of success
and depends on surgeon skill and patient presentation.
Conclusions: Recent research supports any method that removes the pregnancy and scar to reduce morbid-
ity and promote future fertility. Laparoscopic and transvaginal approaches are options for CSEP treatment, al-
though continued research is required to identify the optimal approach.
Relevance: As cesarean delivery numbers rise, a subsequent increase in CSEPs can be anticipated. The ability
to accurately diagnose and treat this morbid condition is vital to the practice of any specialist in general obstetrics
and gynecology.

All authors, faculty, and staff in a position to control the content of
this CME activity and their spouses/life partners (if any) have
disclosed that they have no financial relationships with, or financial
interests in, any commercial organizations pertaining to this
educational activity.
Correspondence requests to: Steven R. Lindheim, MD, MMM,
Department of Obstetrics and Gynecology, Boonshoft School of
Medicine, Wright State University, Miami Valley Hospital, 128 Apple
St, Ste 3800 Weber CHE, Dayton, OH 45409. E-mail: Steven.
lindheim@wright.edu.

www.obgynsurvey.com | 293

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294 Obstetrical and Gynecological Survey

Target Audience: Obstetricians and gynecologists, family physicians.

Learning Objectives: After completing this activity, the learner should be better able to delineate the signs and
symptoms of cesarean scar ectopic pregnancy (CSEP), recall the ultrasound findings that are diagnostic for
CSEP, list common complications, and discuss the relative effectiveness management options for CSEP.

Cesarean scar ectopic pregnancy (CSEP) is defined The hysterotomy was then repaired in 3 layers. At the
as a gestational sac that implants into the defect in the end of the procedure, a suction curettage was passed
myometrium at the hysterotomy site from a previous through the cervix to the fundus, and minimal blood
cesarean delivery.1 The diagnosis of CSEP is challeng- was noted. The total estimated blood loss was 30 mL,
ing as patient presentations vary considerably, with one and there were no other complications. The patient's
third of patients remaining asymptomatic at time of di- postoperative course was uncomplicated, and she was
agnosis.1 Because of this ambiguity, as many as 10% of sent home on the first postoperative day with a hemo-
CSEP cases are initially misdiagnosed.2 Although nu- globin of 11.2 g/dL and was followed with weekly se-
merous therapeutic interventions have been utilized, rum β-hCG level.
no clear treatment strategy has been established. Vari- The final pathology report indicated endometrium,
ous management options include expectant, medical, decidua, and immature chorionic villi. The patient
uterine artery embolization (UAE), surgical, or a com- followed up 1 week postoperatively and was noted to
bination approach. In this review, we present a clinical be doing well with a β-hCG of 7694 mIU/mL. Six
case and discuss the prevalence, diagnostic criteria, weeks postoperatively, the patient presented with a sig-
and current treatment options for CSEP. nificant vaginal bleed and a hemoglobin of 5.5 g/dL and
serum β-hCG of 163 mIU/mL. On admission to the
hospital, she was pale and mildly tachycardic and
CASE PRESENTATION complained of 2 syncopal episodes. The remainder of
her examination was unremarkable, including a trans-
A 34-year-old G4P1021 presented at 7 weeks' gesta-
vaginal ultrasound that revealed clots, but no retained
tion by her last menstrual cycle with painless vaginal
products of conception. She was admitted and given
bleeding. Her medical history was significant for 1 ce-
3 units of packed red blood cells. Her vital signs re-
sarean delivery for breech presentation, 2 spontaneous
mained stable after the transfusion, and she discharged
abortions, and a loop electrosurgical excision procedure
home the following day on oral contraceptive pills.
on her cervix. Her blood type was A+, initial hemoglo-
The assessment from the outside provider was that
bin was 13.2 g/dL, and quantitative β subunit of human
the hemorrhage episode was menstrual in origin as op-
chorionic gonadotropin (β-hCG) was not drawn. She
posed to bleeding from the hysterotomy site. However,
underwent a transvaginal ultrasound that was notable
considering her recent treatment for CSEP, persis-
for a retroflexed uterus with a live singleton pregnancy
tent trophoblastic tissue should not be ruled out. She
located within the previous hysterotomy site, approxi-
mately 2 cm from the external cervical os (Fig. 1). Ter-
mination was recommended because of the substantial
risk of rupture and hemorrhage. The patient voiced a
desire to maintain fertility. After extensive counseling
and review of options, a transvaginal colpotomy approach
was agreed upon.3 A repeat ultrasound on the day of sur-
gery confirmed an ongoing live CSEP. The patient was
placed under general anesthesia, and a transvaginal an-
terior colpotomy was achieved using electrosurgery af-
ter injection with vasopressin. Metzenbaum scissors
and blunt dissection were used to enter the vesico-
vaginal space approximately 2 to 3 cm from the ex-
ternal cervical os to the location of the suspected
ectopic pregnancy. A hysterotomy was created and
the ectopic pregnancy was easily identified and re-
moved via suction curettage through the colpotomy.
The uterine defect was palpated, apices were grasped, FIG. 1. Transvaginal ultrasound, sagittal view. 1 = Empty endocervical
and scarred edges removed with Metzenbaum scissors. canal, 2 = cesarean scar, 3 = gestational sac, 4 = empty uterine cavity.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

 Cesarean Scar Ectopic Pregnancy • CME Review Article 295

remained asymptomatic, and her β-hCG became unde-

tectable 13 weeks postoperatively.

PREVALENCE, PRESENTATION, AND

PATHOGENESIS
The first report of CSEP was a case report in 1978,
and from 1978 to 2001, only 19 additional cases were
reported.4,5 Overall, CSEPs are rare, occurring in ap-
proximately 1 in every 1800 to 2216 pregnancies and
accounting for 0.15% of all pregnancies.6 However,
since 2001, there has been a plethora of case reports,
meta-analyses, and systematic reviews regarding in-
dividual presentations and management practices.5
Although an increase in CSEPs can be anticipated
because of the rising rate of cesarean deliveries, better
awareness and diagnostic techniques may also contrib-
ute to the rising rate.5–9 The term cesarean scar ectopic
pregnancy is misleading as CSEPs can occur after any
myometrial trauma including myomectomy, manual
removal of placenta, dilation and curettage (D&C),
and even in vitro fertilization.6 It has been further esti-
mated that in individuals with at least 1 cesarean deliv-
ery, 6% of future ectopic pregnancies will be within the
cesarean scar.10
The most common presentations include no symp-
toms, painless vaginal bleeding, or generalized ab-
dominal pain1 (Table 1). Differentiating a CSEP from
an active miscarriage or cervical pregnancy is impor-
tant as management and outcomes differ. Vaginal
bleeding is usually heavier during a spontaneous mis-
carriage, and ultrasonography will demonstrate a ges-
tational sac within either the cervix or lower uterine
segment with no blood flow on Doppler examination,
indicating a detached gestational sac.5 A cervical preg-
nancy will have a bulbous region within the cervix,
blood flow surrounding the gestational sac, and a
layer of myometrium between the pregnancy and
the bladder.5 This contrasts with a CSEP, which will
have either limited or no myometrium between the
pregnancy and the bladder, and the cervical canal is
empty11 (Figs. 1 and 2).
Although the pathogenesis has not been delineated,
the prominent theory is that impaired wound healing af-
ter previous trauma creates a myometrial defect and
TABLE 1
Presentations of CSEP
Symptom Prevalence
Vaginal bleeding 39%
Asymptomatic 37%
Abdominal pain with or without bleeding 25%
1 5
Adapted from Rotas et al.
FIG. 2. Cesarean scar ectopic pregnancy type 1 versus type 2.
Type 1 CSEP (endogenic): gestational sac growing inward toward
cervicoisthmus space; type 2 CSEP (exogenic): gestational sac growing
outward toward bladder and abdominal wall.
subsequent scar at which the blastocyst implants. Im-
paired wound healing may be secondary to systemic
diseases that leads to poor blood flow such as diabetes,
poor tissue quality such as inadequate collagen forma-
tion, postoperative wound infections, short-interval preg-
nancy, or improper closure.2,6,7
MAKING THE DIAGNOSIS OF CSEP
The diagnostic criteria for CSEP include a trans-
vaginal ultrasound that demonstrates (1) an empty
uterus and cervical canal, (2) a gestational sac at the
hysterotomy site, (3) thin or absent myometrial tissue
between the bladder and the gestational sac, and (4) a
vascular area noted at the previous cesarean scar with
(5) a positive pregnancy test (Table 2).11 The diag-
nosis of CSEP can be difficult and easily overlooked,
especially considering the nonspecific or complete
lack of symptoms. In a systematic review by Gonzalez
and Tulandi,2 14.2% (107/751) of reported cases were
initially missed.
Two types of CSEPs have been described. Type 1
(endogenic) is where the gestational sac grows inward
toward the cervicoisthmus space, whereas type 2
TABLE 2
CSEP Diagnostic Criteria11
1 Empty uterus and cervical canal
2 Gestational sac within cesarean section scar
3 Thin or absent myometrial tissue between the bladder
and the gestational sac
4 Vascular area noted at the previous cesarean scar
Positive pregnancy test

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296 Obstetrical and Gynecological Survey

(exogenic) grows outward toward the bladder and ab-
dominal wall (Fig. 2). Determining the type may help
with counseling on expectant management or the opti-
mal medical/surgical approach for termination.12 More
than 30 different treatment modalities for CSEP have
been reported, which have been scaled down in this re-
view to those with the most evidence-based research
(Table 3).12 The success rate and associated morbidity
and mortality vary with each method and are dependent
on patient stability and desire for future fertility.
COUNSELING CONSIDERATIONS
Counseling patients with a CSEP poses significant
challenges due to associated morbidities, desire for future
fertility, and most importantly, by a lack of consensus on

TABLE 3
Treatment Modalities for CSEP
Laparotomy Hysterectomy
Success Rate, % (n) Rate, % (n) Rate, % (n) Other, % (n)
Medical
Expectant management 33 (7)13 53.7 (22)12 29 (6)13 LBR: 57 (20)14
57 (17)12 41.5 (17)12 CH: 42.8 (15)14
63 (22)14 H: 12.2 (5)12
Systemic MTX 8.7 (49)10 2.9 (10)12 H: 7.4 (25),12 6 (12)14
41 (11)13 3 (6)14
56 (113)14 13.0 (44)12 3.6 (20)10
75.2 (255)12 11 (3)13
Local MTX 54 (27)13 012,13 H: 0,12 4 (5)14
60 (82)14 2.2 (3)14
64.9 (48)12 4.1 (3)12
73.9 (71)15
Local MTX + systemic MTX 74 (14)13 2.3 (1)12 013 H: 0,12 11 (12),14 11 (12)14
76.5 (26)12 2.9 (1)12
77 (82)14 3.8 (4)14
Surgical/procedural
Laparotomy + hysterotomy 96 (22)14 014 H: 4 (4)14
Laparoscopy + hysterotomy 97 (60)14 012 012,14 H: 012,14
97.1 (67)12
Hysteroscopy + resection 39.1 (37)10 1.1 (1)12 H: 0,12 3 (4)14
83.2 (79)12 3.2 (3)12 1.7 (2)14
88 (103)14
Transvaginal + hysterotomy 99.2 (117)12 0.9 (11)12 0.70 (1)14 H: 0,12 1 (2)14
99 (149)14 0.8 (1)12
Hysterectomy 100 (4)14 H: 25 (1)14
D&C 46 (40)13 21.0 (51)12
2.5 (16) 14
H: 15.2 (37),12 28 (181)14
48.1 (117)12 4.5 (11)12
61.6 (143)10 7 (17)10
76 (490)14 8 (9)13
D&C + UAE +/− hysteroscopy 93 (553)14 1.2 (1)12 1.2 (1)12,14 H: 0,12 4 (24)14
95.4 (81)12
UAE
UAE 013 3.4 (10)12 1.1 (4)10 H:1.4 (4),12 4.4 (5)14
18.3 (66)10 2 (6)12
81 (92)14 5 (6)14
93.6 (276)12 11 (213
Combination
Medical + D&C 80 (194)14 6.2 (15)14 H: 17 (41)14
UAE + local MTX 99.16 (237)2
UAE + systemic MTX 68.6 (293)12 2.8 (12)12 0.47 (2)12 H: 1.9 (8)12
UAE + D&C + MTX 98 (329)14 0.3 (1)14 H: 4 (14)14
MTX/KCl + needle aspiration 84.5 (125)12 13.5 (20)12 6.1 (9)12 H: 6.1 (128)12
Other
High-intensity focused US + suction 91 (84)14 012 012,14 H: 0,12 4 (4)14
D&C/high-intensity focused US ablation 100 (53)12
CH indicates cesarean hysterectomy; H, hemorrhage; LBR, live birth rate; US, ultrasound.

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

 Cesarean Scar Ectopic Pregnancy • CME Review Article
treatment approach.8 It is recommended that patients
terminate the CSEP soon after diagnosis to prevent
uterine rupture, placentation abnormalities, invasion
into surrounding organs, and hemorrhage associated
with continuing the pregnancy.6,10,16 Other significant
complications include disseminated intravascular co-
agulopathy, hypovolemic shock, and death.8
For those who desire to pursue expectant manage-
ment, there is a high likelihood of cesarean hysterec-
tomy, and an elective early cesarean hysterectomy
may be advised.6,16 Patients have to be chosen carefully
for this management option because compliance is crit-
ical as close surveillance is needed until complete reso-
lution of the pregnancy is confirmed.13
TREATMENT OPTIONS
Several treatment options have been utilized to treat
CSEP. These can be categorized as expectant, medical,
UAE, surgical, and combination.
EXPECTANT MANAGEMENT
Expectant management has been used as an option
when a patient desires to let nature take its course with
respect to the outcome of the pregnancy or when she
desires to continue the pregnancy. This has a high mor-
bidity rate and should be undertaken only with stable,
thoroughly counseled, and compliant patients.17 Ex-
pectant management requires a high degree of diligence
on the part of both the patient and the provider to be at-
tentive for any signs of decompensation or rupture of
the CSEP.17
For those desiring expectant management, basic
guidelines have been proposed including individuals
who are highly compliant and with a nonviable preg-
nancy, type 1 CSEP, minimal symptoms, and a declining
β-hCG.16,17 However, a high rate of morbidity with ex-
pectant management has been reported, with more than
50% of patients having complications including hyster-
ectomy, cesarean hysterectomy, preterm delivery, uterine
rupture, future infertility, and significant hemorrhage12–14
(Table 3). Better outcomes were seen when no fetal
cardiac activity was noted at time of diagnosis.14
Expectant management of CSEP should be under-
taken only in specific situations similar to those recom-
mended by the American College of Obstetricians and
Gynecologists (ACOG) for tubal ectopic pregnancies.
To be eligible for expectant management in tubal preg-
nancies, individuals should be asymptomatic, have de-
clining or plateauing hCG, and be fully counseled
about the risks including emergent surgery related to
fallopian tube rupture and subsequent hemoperitoneum.15
Although ruptured ectopic pregnancies as a group are
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
297
associated with 2.7% of maternal deaths, there are lim-
ited data concerning the exact rate of mortality with sub-
categories such as ruptured tubal ectopic pregnancies or
CSEP. For CSEP, published data support increased risk
of severe complications such as hysterectomy, uterine
rupture, and infertility.14,15,18
Overall, expectant management results in poor out-
comes, and it should not be recommended as first-line
treatment in most individuals with CSEP. Patients need
to be aware of the close surveillance and follow-up re-
quired by this option and the risk of subsequent morbid-
ity even if fetal cardiac activity is not noted initially.
MEDICAL TREATMENT
Medical management can be undertaken with local
(intragestational) or systemic (intramuscular) medica-
tions. Methotrexate (MTX) is most often utilized, as ob-
stetricians and gynecologists have the most experience
with this medication in the treatment of ectopic preg-
nancy. Other medical options have been used, including
potassium chloride, gefitinib, ethanol, hyperosmolar
glucose, vasopressin, mifepristone, and crystalline tri-
chosanthin; however, limited information is available
regarding their use.10,14,16 All of these agents have been
administered individually or in combination and with or
without ultrasound guidance. The use of medical treat-
ment as the first-line approach for CSEP is often asso-
ciated with a high failure rate (44%–91%), requiring
additional interventions such as surgery14 (Table 3).
Guidelines on choosing the best candidates for med-
ical treatment have been proposed. These include less
than 8 weeks of gestation, absent fetal cardiac activity,
hemodynamically stable patient, β-hCG of less than
5000 to 12,000 mIU/mL, and greater than 2-mm
thickness between the myometrium and bladder.2,14
However, high-quality studies, including randomized
controlled trials (RCTs), are lacking, making it difficult
to compare methods.2,14
Methotrexate
Methotrexate can be administered locally, systemi-
cally, or in combination with surgical management.
Additional surgical or medical management should
be considered if the CSEP does not resolve with the
initial MTX treatment.
Several investigators have reviewed the use of MTX
as first-line treatment for CSEP. Timor et al11 have
published multiple studies concerning the use of MTX
and in 2012 reported a retrospective case series in
26 patients in which MTX was administered within
the gestational sac, just outside the gestational sac,
and intramuscularly. Overall, they reported complete
298 Obstetrical and Gynecological Survey
eradication in the 19 patients who received treatment;
however, patients required between 22 and 177 days
for complete resolution.11 More recent systematic re-
views demonstrated that success for either local or sys-
temic MTX is similar (50%–66%) and increases
moderately when given in more than 1 dose.2,6,12,19
The simultaneous administration of MTX both locally
and systemically has not been shown to improve out-
comes compared with a multidose protocol.20 Compli-
cations range from significant hemorrhage, surgical
intervention, and hysterectomy2,14,19,20 (Table 3). The
need for further intervention is common when using
any of the MTX protocols.20
Some factors that appear to increase the chance of
success for local MTX include greater than 2-mm
myometrial thickness between pregnancy and the
bladder and a lower β-hCG level. The actual threshold
of β-hCG has not been determined, and a wide range
from less than 5000 to 100,000 mIU/mL has been
reported.6,20
Given that MTX has multiple mechanisms of action,
including inhibition of dihydrofolate reductase, nu-
merous adverse effects have been reported, such as al-
opecia, pneumonitis, bone marrow suppression, and
stomatitis.16,21 In severe cases, cirrhosis and hepatic fi-
brosis can occur because of accumulation of MTX by-
products in the liver, adipose tissue, and erythrocytes,
which can persist in tissues for weeks to months after
initial administration and needs to be part of patient
counseling and monitoring.21 However, the incidence
of these adverse effects is rare, and an article published
in 2012 demonstrated that a routine laboratory evalua-
tion of hepatic and renal function was unnecessary in
healthy women. Thus, a thorough history and physical
examination are an important aspect when counseling.22
Other Medications
Other medicinal options have included combined
systemic MTX with gefitinib, local administration of
ethanol, hyperosmolar glucose, vasopressin, mifepris-
tone, and crystalline trichosanthin.6,10,14,16 Because
there is scant information concerning the efficacy of
these methods for CSEP treatment, their application in
CSEP remains to be determined. In addition, most phy-
sicians do not have any experience administering these
medications.
UTERINE ARTERY EMBOLIZATION
Uterine artery embolization involves bilateral selec-
tive catheterization of the uterine arteries followed by
injection of polyvinyl alcohol or tris-acryl gelatin parti-
cles into the vessels with the goal of complete stasis of
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
blood flow to the uterus.23 Although pregnancy after
UAE is possible, it is often associated with complications,
including preterm labor, malpresentation, miscarriage,
and postpartum hemorrhage, and is not considered a
first-line option for patients who desire future fertility.23
Uterine artery embolization has a widely reported
range of success and complication rates, and it has been
suggested that UAE should be undertaken only in those
with arteriovenous malformations or when there is sig-
nificant bleeding10,13 (Table 3). As such, UAE alone
should not be used as first-line treatment for CSEP
outside research protocols because of the potential for
high failure and complication rates, and potential de-
trimental impact to future fertility.
Uterine artery embolization has been most often re-
ported in the treatment of symptomatic leiomyomas.
Although the procedure is generally safe, reported risks
include uterine infection, necrosis, ovarian failure, soft
tissue damage (if particles are injected into other arter-
ies), sexual dysfunction, and an uncertain effect on fu-
ture fertility.24
According to the American Society for Reproductive
Medicine, fertility rates after UAE have ranged from
12% to 100%, with a high rate of subsequent vaginal
deliveries.25 However, in a recent systematic review, el-
evated miscarriage rates were noted, although the pa-
tient population within this study was older, with an
inherent decline in fertility.26 Pregnancy after UAE
has also raised concerns regarding increased cesarean
delivery rates and postpartum hemorrhage.26 Until
further studies are performed to properly evaluate
the risk of pregnancy after UAE, patients need to be
counseled about the potential risks related to subse-
quent pregnancy.
SURGICAL
Numerous surgical methods have been described to
treat individuals with CSEP including D&C; direct ex-
cision of CSEP via abdominal, laparoscopic, hystero-
scopic, or vaginal approach; a combination approach;
and definitive management with hysterectomy. Many
have advocated any method that involves removal of
the cesarean scar with the pregnancy.14 However, skill
of the surgeon, patient presentation, and desire for
future fertility are important factors to consider in
choosing the method.2,10,12,14 Nonetheless, the lack
of high-quality studies makes it difficult to propose
evidence-based guidelines.
Arteriovenous malformation is a risk that may occur
after D&C, or even from the CSEP itself.11 Thus, care
must be taken before performing any procedures, and
patients with significant bleed should undergo further
 Cesarean Scar Ectopic Pregnancy • CME Review Article
imaging and have low threshold for treatment with con-
sideration for interventional radiology.11
Overall, minimally invasive surgery (MIS) has sig-
nificantly improved over the years, making the non-
invasive approaches safer. However, inherent risk of
surgery still needs to be discussed with patients includ-
ing infection, blood loss, thrombotic events, pain, anes-
thesia complications, and potential mortality.24
Hysteroscopy
Hysteroscopy has been utilized to remove CSEP ei-
ther alone or with adjuvant medical therapy. Many var-
iations of this method have been reviewed in several
studies, including hysteroscopic removal of tissue, aspi-
ration of gestational sac after medication, and injection
of MTX or ethanol into the gestational sac.2,10,12,14
Some suggest that hysteroscopic removal is best indi-
cated in individuals with type 1 CSEP.2 Unfortunately,
many of the systematic reviews failed to describe the
hysteroscopic technique that was utilized, making it dif-
ficult to provide best practice recommendations.
Hysteroscopic resection of the CSEP with or without
removal of the scar has had a variable rate of success,
and multiple reviews reported the requirement for addi-
tional procedures, including hysterectomy2,10,14 (Table 3).
Higher success with hysteroscopic removal appears to
be associated with lower gravidity/parity, fewer prior
cesarean deliveries, and earlier gestational age at time
of procedure.10
An American Society for Reproductive Medicine re-
view in 2016 on various methodologies for CSEP elim-
ination reported that hysteroscopy could be used to
remove the CSEP via direct visualization or ultrasound
assistance. They described a technique by careful dissec-
tion of the CSEP from the uterine wall using electrosur-
gery that had a high success rate and an extremely low
complication rate12 (Table 3). They suggested that the
method delineated in their review should be considered
a safe and effective method for CSEP termination.12
Although complications from hysteroscopy are rare,
they are more likely with any complex hysteroscopic
procedure including myomectomy and septum re-
moval.27 Complications include fluid overload, electro-
lyte imbalances, perforation, infection, and hospital
admission.27 Although reported to be uncommon, these
need to be addressed when counseling patients.
Laparotomy
There are very few data on laparotomy as a first choice
for the treatment of CSEP. Proponents suggest that an ab-
dominal, or open, technique enables direct visualization
of the lower uterine segment with the cesarean delivery
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
299
scar and implanted gestational sac.14 This approach
may be better when the myometrium between the
CSEP and the bladder is greater than 2 mm.14 The ab-
dominal approach can be utilized when performing
a myometrial wedge excision or complete hysterec-
tomy.13 Overall, this has a high success with a low com-
plication rate14 (Table 3).
Removal of the gestational sac via open technique, or
abdominal hysterectomy, generally is not deemed first-
line treatment because of the potential morbidity and in-
vasive nature of this method. The ACOG's Committee
Opinion states that an abdominal approach to gyneco-
logic surgery has a longer duration of hospital stay,
operating time, bladder/ureter injuries, intraoperative
blood loss, wound complications, and slower return to
normal activity.28 As such, MIS techniques should be
considered as a first line if the surgeon is adequately
trained, and an open approach should be avoided for
CSEP management if possible.
Colpotomy
A transvaginal approach to CSEP utilizes similar
technical aspects as a vaginal hysterectomy, where an
anterior colpotomy incision is made to access the CSEP
with subsequent removal and repair of the previous
scar.14 However, this approach appears to be utilized
the least when compared with hysterotomy via laparos-
copy or laparotomy.10
Overall, the morbidity associated with the trans-
vaginal approach has been demonstrated to be minimal
with success rates greater than 90%.10,12,14 A small
RCT also showed a faster resolution of β-hCG when
compared with UAE or hysteroscopic removal + MTX.9
Pooling data from many studies supports the use of a
transvaginal hysterotomy for stable patients who desire
future fertility12,14 (Table 3).
A transvaginal approach for CSEP has similar surgi-
cal risks to other approaches, including infection, bleed-
ing, and damage to surrounding structures. However,
there are minimal data comparing this vaginal approach
to laparoscopic or abdominal approaches for CSEP.
One concern that has been raised to this approach is in-
complete visualization of the CSEP and the previous
hysterotomy scar with the potential for persistent em-
bryonic tissue.
Laparoscopy
A laparoscopic hysterotomy with wedge resection of
the CSEP and previous scar has been reported in several
studies. It has been recommended by some that this ap-
proach was best suited in individuals with type 2 CSEP
(growing toward the bladder/abdominal wall).2
300 Obstetrical and Gynecological Survey
Two different systematic reviews reported a 97% suc-
cess rate with faster resolution of β-hCG and no com-
plications12,14 (Table 3). In addition, other long-term
outcomes, including a higher rate of subsequent preg-
nancies and a reduction of CSEP reoccurrence, have
been reported (data compiled for hysterotomies per-
formed via laparotomy, laparoscopy, or transvaginal ap-
proach).14 Other considerations should be given to
temporarily occluding blood supply to the uterus. This
has the potential to decrease blood loss, enable com-
plete resection of the CSEP, and prevent future compli-
cations such as pregnancy loss that can be seen with
UAE. As this approach allows for direct visualization
of the pregnancy and removal of the scar and is mini-
mally invasive, it has been encouraged as one of the pri-
mary approaches for CSEP management.12
Similar to the transvaginal approach, advanced skill
set in MIS with laparoscopy or robotic-assisted laparos-
copy is necessary for the laparoscopic removal of
CSEP.10,12 Other unique risks of laparoscopic surgery
are associated with initial entry into the abdomen includ-
ing perforation of vessels or intestines, trocar site infec-
tion or hernia, and changes in the hemodynamic status
from pneumoperitoneum or Trendelenburg position.29
As laparoscopic skills continue to improve, more MIS
physicians will invariably make this a primary option.
COMBINATION APPROACHES
Many studies report MTX administered in combina-
tion with other interventions including UAE, hystero-
scopic or laparoscopic removal of the ectopic, suction
curettage, and needle aspiration.2,12–14,30 This com-
bined approach appears to have greater success with
less morbid sequelae than MTX alone. The success
rates for MTX + UAE, MTX + hysteroscopic or laparo-
scopic excision, and MTX + needle aspiration are
greater than 80%.2,12,14 Complications, including hem-
orrhage, need for blood transfusion, hysterectomy, or
laparotomy, have been reported in all of these treatment
protocols2 (Table 3).
Methotrexate with or without D&C or suction curet-
tage appears to have the most conflicting results when
compared with MTX alone. Some research has failed
to show any differences between the two.2 However,
an RCT revealed that UAE + curettage had fewer ad-
verse events compared with those who had MTX + cu-
rettage, including blood loss (−343.24 mL; 95%
confidence interval [CI], −432.95 to −253.54 mL;
P < 0.001), hospitalization (−15.05 days; 95% CI,
−25.42 to −4.67 days; P = .004), and resolution of
β-hCG (−16.76 days; 95% CI, −24.60 to −8.92 days;
P < 0.001).30 Overall, given the likely need for additional
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
intervention and potential for adverse events, MTX with
or without surgical intervention should not be considered
as a primary method of CSEP termination.
Many studies have reported the use of UAE in com-
bination with other surgical methods. Compiling results
from 2 different studies, it was reported that UAE + cu-
rettage has a 93.6% success rate, fewer days to β-hCG
resolution, and fewer complications compared with
MTX + curettage for primary treatment of CSEP.12,30
Reports suggest that success was further enhanced with
the use of hysteroscopy12 (Table 3). Although these
studies had several limitations, including lack of ran-
domization, an isolated patient population, and failure
to assess future fertility, UAE in combination with other
surgical methods has been advocated strongly in indi-
viduals who do not desire future fertility.12
Hysteroscopic resection in combination with other
methods has been described including UAE, D&C, and
adjuvant MTX with variable levels of success to acceler-
ate the resolution of the gestational sac. The combination
of UAE, D&C, and hysteroscopy has a higher success
and lower complication rate compared with hysteroscopy
alone.12 However, the addition of MTX did not seem to
increase success overall but did have a marginally
higher hemorrhage rate.14 Although the combination
of hysteroscopy with another surgical method has a bet-
ter outcome than hysteroscopy alone, these methods
should be compared by an RCT in order to determine
their overall effectiveness and safety profile.14
CASE REPORT DISCUSSION
In our patient, given her desire to preserve future fertil-
ity, we elected to perform a transvaginal hysterotomy with
removal of the abnormal implantation followed by repair
of defect in the myometrial tissue. Although there were no
initial complications, our patient had a slow resolution of
β-hCG and a hospital admission for hemorrhage; both
may have been secondary to incomplete removal of the
gestational sac. Reviewing this case, we could have con-
sidered the addition of MTX to expedite resolution of
any remaining decidual tissue. However, recent system-
atic reviews demonstrated that the addition of MTX to
surgical management added little to the overall success
rates.14 Therefore, other considerations should include
laparoscopic resection, which enables the surgeon to
clearly visualize the CSEP and irrigate the wound bed to
remove gestational tissue remnants.
SUMMARY
There are numerous strategies to treat CSEP, and
currently level I evidence is not available to propose
specific evidence-based guidelines. Recent level II
 Cesarean Scar Ectopic Pregnancy • CME Review Article
evidence suggests that any method that removes the CSEP
and previous scar (via transvaginal, laparoscopy, or laparot-
omy) is best practice. This has the lowest morbidity with
respect to hemorrhage, hysterectomy, and further sequelae
and is associated with a higher rate of preserved fertility.
Neither ACOG nor the American Association of Gyne-
cologic Laparoscopists has specific recommendations or
opinions related to CSEP treatment. The American Soci-
ety for Reproductive Medicine recommends, based on
level III evidence, that multiple different mechanisms can
be utilized, such as D&C, laparoscopy/laparotomy exci-
sion, or local or systemic MTX.31 Overall, primary medical
management has a high failure and complication rate, thus
not recommended as first-line approach to CSEP.14
In conclusion, although current consensus does not
exist for the most ideal treatment method, it is generally
accepted that the treatment should fit the patient's cur-
rent hemodynamic status, location of the pregnancy
based on ultrasound, gestational age, desire for future
fertility, level of patient compliance, and surgeon exper-
tise. Level II evidence currently supports any minimally
invasive method that removes the pregnancy and scar
at once, such as a transvaginal or laparoscopic hyster-
otomy. These methods have a high success rate with
minimal complications. However, because of lack of
adequate RCTs, continued research is needed to sup-
port these recommendations.
PRACTICE PEARLS
(1) Cesarean scar ectopic pregnancy can occur after
any myometrial trauma associated with cesarean
deliveries, D&C, myomectomy, and IVF.
(2) CSEP is often asymptomatic but can also present
with vaginal bleeding and abdominal pain.
(3) CSEP is diagnosed by specific ultrasound criteria.
(4) Expectant management of CSEP is appropriate in
patients who understand the substantial risk of
rupture, hemorrhage, and potential hysterectomy
and who have stable vital signs/examination with
close follow-up.
(5) Medical management of CSEP often requires ad-
ditional medication or surgical management.
(6) Optimal surgical management of CSEP removes
the previous scar and the pregnancy. The method
of doing this should be as least invasive as possi-
ble, pending surgeon ability and patient stability.
(7) Further research is required to delineate algo-
rithms for best practice management of CSEP.
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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.