Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy

Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C). Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C). May 2020 (vol. 222, no. 5, page B2)American Journal of Obstetrics & GynecologyVol. 224Issue 1PreviewSociety for Maternal-Fetal Medicine, Miller M, Timor-Tritsch IE, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy. Am J Obstet Gynecol 2020;222:B2-14. Full-Text PDF Society for Maternal-Fetal Medicine Consult Series for cesarean scar pregnancy: each treatment option has its indicationsAmerican Journal of Obstetrics & GynecologyVol. 224Issue 1PreviewI read the Society for Maternal-Fetal Medicine Consult Series #49 by Miller et al1 regarding cesarean scar pregnancy (CSP) with great interest. As far as I know, this is the first authoritative recommendation on CSP. Many recommendations in this paper have a good guiding value for clinical work. However, there are still a few questions that need to be discussed. Full-Text PDF ReplyAmerican Journal of Obstetrics & GynecologyVol. 224Issue 1PreviewThe Society for Maternal-Fetal Medicine (SMFM) Publications Committee thanks Drs. OuYang, Wu, and Zhong for their letter regarding the recent “SMFM Consult Series #49: Cesarean scar pregnancy”. We appreciate their careful review of the paper. We acknowledge that there is some controversy regarding whether a cesarean scar pregnancy (CSP) represents a true “ectopic” pregnancy. Regardless of whether this terminology is applied, we agree that a CSP implants in a location that can be life threatening for the patient and therefore in which prompt intervention is required. Full-Text PDF