Stepwise minimally invasive management of cesarean scar pregnancy: retrospective clinical and fertility outcomes

Aim: To evaluate the effectiveness and safety of the intra-arterial infusion of methotrexate (MTX) followed by uterine arteries embolization (UAE) in women with cesarean scar pregnancy (CSP) in which serum β-HCG levels remained elevated and the gestational sac showed no significant reduction 2 weeks after systemic administration of MTX. Material and methods: Twenty-one patients with CSP were enrolled in the study. Technical success, clinical success and complication rates were assessed. Technical success was defined as complete bilateral intra-arterial MTX infusion and successful UAE. Primary clinical outcomes included reduction of gestational sac size, absence of active vaginal re-bleeding, and normalization or steady decline of β-HCG values. Secondary clinical outcomes comprised pregnancy termination, gestational sac expulsion, and reduced or absent bleeding during suction curettage of the uterine cavity. Additionally, the need for uterine cavity revision, time to menstruation recovery, and outcome of subsequent pregnancies were evaluated. Results: Technical success, primary clinical outcome, and pregnancy termination were achieved in all cases (100%). Spontaneous expulsion of the gestational sac occurred in five patients (23.9%), while the remaining patients underwent ultrasound-guided suction curettage of the uterine cavity. Two patients (9.5%) required additional hysteroscopy. No major complications were registered. Pain was effectively managed in all patients within 24 h. Menstrual function resumed within 3 months in all women. Among the 12 patients (91.6%) who wished to conceive again, 11 (91.6%) achieved a successful pregnancy. Conclusion: Intra-arterial MTX and UAE, following systemic MTX, appear to be a safe and effective treatment for CSP.