Outcomes of primary surgical evacuation during the first trimester in different types of implantation in women with cesarean scar pregnancy

Objective: To assess the efficacy and safety of primary surgical evacuation therapy for cesarean scar pregnancy (CSP) of the first trimester, and to evaluate its possible prognostic factors. Design: Retrospective consecutive cohort study. Setting: Tertiary care university hospital. Subject(s): A cohort of patients with CSP and clear ultrasound images who underwent primary surgical evacuation from January 2000 to December 2012. Intervention(s): Patients fulfilling the ultrasound criteria of CSP were further classified into superficial and deep groups according to their implantation locations and extents. The final decision on the method of treatment, including methotrexate chemotherapy, surgical evacuation, and others, was made by the patients after consultation with the physician. Pretreatment patient characteristics were compared in the patients with superficial and deep implantation, as were the results after primary surgical evacuation. Main Outcome Measure(s): Rates of successful treatment by primary surgical evacuation of CSP and the need for salvage intervention in the patients with deep and superficial implantation. Result(s): Forty-eight CSP patients who had sufficient data and imaging for analysis were enrolled. Of these 48 cases, 26 in the superficial group and 14 in the deep group were willing to undergo primary surgical evacuation. Blood loss and need for salvage intervention were significantly lower in the patients with superficial implantation. Surgical evacuation was successful in 23 of 26 patients (88.5%) with superficial implantation and in 8 of 14 patients (57.1%) with deep implantation. Patients who failed primary surgical evacuation showed complete recovery, with uterus preservation, after salvage interventions, including laparoscopic surgery, angioembolization, and laparotomy. Conclusion(s): Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment. Primary single-step surgical evacuation was successful in most patients with superficial implantation, but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation. (C) 2014 by American Society for Reproductive Medicine.