Surgical evacuation with adjuvant uterine artery embolization: a fertility preserving treatment for advanced live caesarean scar ectopic pregnancies

Abstract Study question Can advanced caesarean scar ectopic pregnancies be managed safely surgically whilst preserving future fertility? Summary answer With the available support of uterine artery embolization, suction and curettage can be an effective treatment for live advanced caesarean scar ectopic pregnancies, avoiding hysterectomy. What is known already Caesarean scar ectopic pregnancies (CSEPs) are associated with significant maternal morbidity and termination of pregnancy is often offered to patients to protect their health and fertility. Treatment of early first trimester CSEPs is usually effective and safe, but the management of more advanced cases is more challenging, and hysterectomy has been considered the treatment of choice for second trimester CSEPs. Study design, size, duration This was a retrospective cohort study in a tertiary referral centre between 2008-2023. Of 371 women diagnosed with CSEP, 22 (6%) had live advanced CSEPs. 17/22 (77%) patients opted for surgery, whilst the remaining five opted to continue with their pregnancies. CSEP was defined by implantation of the pregnancy into a myometrial defect caused by dehiscence of a lower uterine segment caesarean scar. Advanced CSEP was defined as crown rump length (CRL) of ≥ 40mm. Participants/materials, setting, methods A preoperative ultrasound was performed in each patient. All women underwent surgical evacuation under ultrasound guidance and insertion of modified Shirodkar cervical suture as a primary haemostatic measure. Additional haemostatic measures included uterine artery embolization (UAE). Our primary outcome was the rate of blood transfusion. Secondary outcomes were estimated intraoperative blood loss (BL), UAE, and admission to intensive care unit (ICU) and fertility preservation. Descriptive statistics were used to describe these variables. Main results and the role of chance For the 17 cases included, median CRL was 54.1 mm (range 40.0 - 85.7) and median gestational sac diameter was 52.7mm (range 41.0 – 82.7). Median gestational age based on CRL was 12 + 2 weeks (range 10 + 6 weeks and 15 + 2 weeks). Two (12%) women had a recurrent CSEP and 1 woman had a heterotropic pregnancy. On pre-operative ultrasound placental lacunae were recorded in 13 (76%) cases and colour Doppler score was ≥3 in 10 (59%) cases. A Shirodkar cervical suture was used in all cases, as per our protocol. It was successful in achieving haemostasis by tamponade in 13/17 (76%) cases. In the remaining 4 (24%) tamponade failed to achieve a complete haemostasis and UAE was required to control persistent arterial bleeding into the uterine cavity. Median BL at the time of surgery was 800 ml (range 250-2500) and 7/17 (41%) patients had a BL of > 1000 ml with 6/17 (35%) requiring blood transfusion. All four women who had UAE required admission to ICU. Three cases had a two-stage procedure with interval UAE to control the bleeding. All patients made a good postoperative recovery and no emergency hysterectomy was required. Three patients fell pregnant again and all pregnancies were normally sited. Limitations, reasons for caution Although this is the largest series of advanced CSEPs one limitation is its retrospective design and the relatively small number of cases. A second limitation is no women ≥ 16 weeks were included. Lastly, this study was conducted in a tertiary referral centre and results may not be widely replicable. Wider implications of the findings Surgical evacuation with a Shirodkar cervical suture and selective UAE is an effective treatment for advanced CSEPs and should be available to women who want to retain their fertility and avoid a hysterectomy. Pre-surgical planning and collaboration between gynaecologists and interventional radiologists is key in managing these high-risk women. Trial registration number not applicable