Transrectal ultrasound-guided surgical evacuation of Cesarean scar ectopic pregnancy

Objectives To describe a new technique for the management of Cesarean scar ectopic pregnancy (CSEP): transrectal ultrasound (TRS)-guided surgical evacuation. Methods All women who presented at our early pregnancy units (EPU) from November 2006 to July 2008 underwent transvaginal sonography. CSEP was diagnosed if all of the following criteria were met: absence of an intrauterine pregnancy; empty endocervical canal; presence of a gestational sac implanted within the lower anterior segment of the uterine corpus, with or without evidence of myometrial thinning. Women were offered TRS-guided surgical evacuation under general anesthesia. Successful treatment was defined as complete primary evacuation of the CSEP. The need to perform additional interventions (emergency cervical cerclage, insertion of Foley's balloon catheter, blood transfusions) was recorded. Results Of 1195 consecutive women who presented at the EPUs, seven (0.59%) were diagnosed with CSEP. Three (43%) of these were viable at the time of diagnosis. Two (29%) of the seven pregnancies followed in-vitro fertilization; six (86%) women had previously had a single Cesarean section and one had had two. One of these women had a previous tubal ectopic pregnancy, and one a previous CSEP. Three (43%) of the women were asymptomatic. Five (71%) women were treated with TRS-guided surgical evacuation as the primary treatment, whilst two (29%) were given systemic methotrexate, one of whom subsequently underwent TRS-guided aspiration because of failure of conservative management. There were no major complications. Conclusions The best treatment for CSEP has yet to be established. TRS-guided surgical evacuation is a novel and potentially alternative treatment modality. However, in the absence of further studies we cannot draw any conclusions, and the management of such women should be individualized. Copyright (C) 2010 ISUOG. Published by John Wiley & Sons, Ltd.