Evolution of treatment approaches for cesarean scar pregnancy

BACKGROUND: Cesarean scar pregnancy is a relevant problem in modern obstetrics and gynecology. This condition may lead to life-threatening complications requiring urgent medical intervention. Hysteroscopic resection using the cold loop technique in combination with vacuum aspiration of the gestational sac is an effective and safe surgical method for the treatment of cesarean scar pregnancy.

AIM: This study aimed to evaluate treatment approaches for cesarean scar pregnancy and to determine optimal surgical strategies, as well as to analyze morphological findings in surgical specimens obtained from patients with cesarean scar pregnancy.

METHODS: The study was conducted at the Moscow Regional Research Institute of Obstetrics and Gynecology named after Academician V.I. Krasnopolsky. Between 2016 and 2025, surgical treatment was performed in 41 patients with cesarean scar pregnancy. Management strategies used in 2016–2019 were compared with those applied over the subsequent 5 years. Clinical characteristics, preoperative ultrasound findings, and surgical treatment methods were analyzed (including laparotomic metroplasty, vacuum aspiration of the gestational sac, hysteroscopic resection using a cold loop, and hysterectomy).

RESULTS: More than half of the examined women had a history of more than two cesarean deliveries performed with cervical dilation greater than 5 cm. Ultrasound examination demonstrated localization of the gestational sac within the scar area in all patients (COS-1 sign). Signs of chorionic invasion were identified in 22.7% of cases. Both organ-preserving and radical treatment approaches were applied. Over the past five years, a trend toward increased use of minimally invasive surgical techniques has been observed at the institute, resulting in reduced duration of hospitalization and postoperative rehabilitation. The complex of morphological features identified within scar niches containing ectopic pregnancies was characteristic of placenta accreta spectrum disorders (placenta creta); however, given the early gestational age and absence of a fully formed placenta, this condition may be referred to as chorionic invasion.

CONCLUSION: Cesarean scar pregnancy is a rare but extremely dangerous complication that may result in uterine rupture, massive hemorrhage, and maternal mortality. Minimally invasive organ-preserving techniques—vacuum aspiration and hysteroscopic resection using the cold loop technique—represent the optimal treatment strategy. In cases of pronounced destructive changes of the uterine wall, metroplasty is justified.