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Cesarean scar pregnancy management: Different approach for different situation; A case series

The incidence of caesaean scar pregnancy (CSP) increases since the cesarean delivery rate had increased as well. Diagnosing of CSP was also a challenge to identify the type of CSP which important things for choosing the right management. The CSP could be classified into two types, which are endogenous and exogenous. While the management was dependent into the types, such as suction curettage, resection, and also hysterectomy. This paper showed cases of cesarean scar pregnancy in Cipto Mangunkusumo General Hospital, in one year.


Introduction
Cesarean scar pregnancy (CSP) is the implantation of gestational sac within the myometrium of prior cesarean surgery scar. The incidence of CSP is approximately 1 in 2.000 normal pregnancies. As cesarean delivery rate increases, the incidence of CSP has increased as well [1]. Diagnosis of CSP has become a challenge because of the lack of awareness about possibility of implantation in previous cesarean surgery scar. It could be a potential threat because CSP as it poses a great risk for maternal hemorrhage, placenta accreta spectrum, and uterine rupture [1,2,3]. Besides diagnosing of CSP, identifying the type of CSP was also important things for choosing the right management. This paper presented a Case series of cesarean scar pregnancy in Cipto Mangunkusumo General Hospital, since 2019 until 2020, with different types (endogenous and exogenous) and various management. This paper was also reported in line with SCARE criteria, and already registered on Research Registry UIN with number: researchregistry7099 [14]

Case presentation
This article presented 8 cases consists of 6 cases of endogenous type and 2 cases of exogenous type. All ultrasound examinations before procedure were described on Table 1. Different treatments were done for each cases based on the cases type and operator preference (all procedures were done by OBGYN), such as suction curettage, laparotomy exploration, laparoscopic mass resection, and many others. Three cases in this article were treated with suction curettage, with one of it was continued with exploratory laparotomy. Laparoscopic resection for mass evacuation was done for 1 Case, while other cases were treated with exploratory laparotomy. We had 3 from 8 cases that were done by subtotal hysterectomy, while other cases could be successfully conservated. The treatments were chosen by pre-intervention examinations that leading to chose whether needed surgery and what type of the interventions. Pre-operative we found no comorbidities background, however all patients were ended with good condition. All cases were summarized and each explained in Table 1.

Discussion
The first cesarean scar pregnancy (CSP) Case was reported in 1978 with the presence of gestational tissues found in the recess of cesarean scar. The more cesarean deliveries, the higher the risk of someone experiencing CSP [4,5]. Based on the pregnancy progression, CSP could be classified into two types. The first type is endogenous CSP where the gestational sac is implanted in the cesarean scar and grows toward the uterine cavity or cervico-isthmic, not the serosal lining. It gives a chance for live birth but a high risk of massive bleeding from the implantation site. Meanwhile, the second type is exogenous CSP where the gestational sac is implanted into the cesarean scar defect and further to the serosal lining then implanted up to the bladder or abdominal cavity. The exogenous CSP has a high risk of uterine rupture and hemorrhage [6,7].
The diagnosis of CSP has become a challenge for obstetricians [8]. The transvaginal ultrasound is the primary imaging modality to diagnose CSP with sensitivity of 86,4%. The differences between cervico-isthmic intrauterine pregnancy and CSP are so difficult to find sonographically. However the criteria for diagnosing cesarean scar pregnancy was defined in Table 2.
There are many options for CSP management. The expectant management where the pregnancy expected to resolve naturally without any intervention is very rarely used. If CSP lasts until the third trimester, it is more likely to cause morbidly adherent placenta and sometimes require cesarean hysterectomy. This approach could be used for endogenous Table 1 Comparison of Cases. CSP because it grows toward the uterine cavity even though the risk of uterine rupture, potentially life-threatening massive bleeding, and hysterectomy at any time should be discussed properly [9,10]. Thus, expectant management may not be a good fertility-preserving option. However, study reported the asymptomatic and nonviable CSP with declining hCG levels could successfully be resolved with the expectant management [7,11]. The other modality of CSP management is administration of methotrexate (MTX) systemically with dose 50 mg/m 2 body surface area (BSA). This modality is commonly used in haemodynamically stable patients [12]. If a medical approach does not work well, a surgical approach should be done. It is called sequential management [13]. While exogenous CPS, which has minimal myometrial thickness, is also better treated with administration of MTX prior to surgery than surgical treatment only [7]. All cases described in this article were compared and presented in Table 1.
The cases presented here showed that diagnosis of CSP is truly a challenge for obstetricians. Administration of MTX occurred in Case 5. Patient, G8P2A5 17 weeks of gestational age, had pregnancy termination in the other hospital. At that time, the conception came out but the placenta still remained. She already treated with MTX and evaluated every 2 weeks. The sequential management after that failed MTX treatment which consisted of laparotomy exploration, uterine resection, and conception remnant evacuation was performed.
The surgical approach that is commonly used is cervical dilatation and curettage. It is suitable for endogenous CSP with myometrial thickness at least 2 mm. However, the risk of bleeding and failure of complete gestational sac removal are also commonly found. Another surgical approach is surgical resection that could be performed abdominally or laparoscopically. This approach is more suitable for exogenous CSP with thin myometrium [7]. Surgical management commonly carries the risk of bleeding, especially D&C or hysteroscopic resection. The remaining cases of this Case series were treated with surgery, which were suction curettage (Case 1, 7), laparotomy exploration (Case 2, 4), and laparoscopic surgery (Case 3). From all the cases, only 2 out of 8 cases presented with exogenous CSP (Case 6 and 8) with different situation. Case 6 showed a patient that already informed regarding the CSP condition yet still chose continuing the pregnancy, unfortunately ended with uterine rupture. Meanwhile, the Case 8 was not identified as exogenous type of CSP and performed suction curettage which then converted to laparotomy and ended with subtotal hysterectomy. All of the patients in this cases were in good condition until being discharged.

Conclusion
Cesarean scar pregnancy (CSP) is a rare and potentially lifethreatening ectopic pregnancy. Diagnosis of CSP could be done by comprehensive history taking and examination. Ultrasound is the main modality to identify the type of CSP. Treatment of CSP is very individualized, either by surgical or medical approach. Early diagnosis and adequate treatment is very important to decrease morbidity and mortality of CSP. However further research regarding diagnostic methods or treatment guidelines for CSP could be considered.

Informed consent statement
All subjects here were already informed and gave consent.
Cesarean scar pregnancyultrasound diagnosis criteria Empty uterus with clearly visualized endometrium Empty cervical canal Gestational sac implanted in the lower uterine anterior segment at the presumed site of cesarean section incision scar Thin or absent myometrium between the gestational sac and the bladder (majority of cases have a myometrium thickness <5 milimeters)

Process guidelines
This paper had been in line with PROCESS criteria [14].

Provenance and peer review
Not commissioned, externally peer-reviewed .

Declaration of competing interest
None.