Abdominal Radiology (2023) 48:2672–2683

https://doi.org/10.1007/s00261-023-03953-7

REVIEW

Scarred for life: a review of cesarean section scar pregnancy

and potential pitfalls in diagnosis
Jennifer Huang1,2 · Catherine Phillips1 · Mariam Moshiri1

Received: 9 March 2023 / Revised: 3 May 2023 / Accepted: 4 May 2023 / Published online: 19 May 2023
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2023

Abstract
Cesarean section scar pregnancy (CSSP) is defined as abnormal implantation of a gestational sac on or in a previous cesar-
ean section scar. There is an increasing incidence of detection of CSSP, likely in part due to the growing rates of cesarean
deliveries and the improved rates of detection with advancing ultrasound technology. Diagnosis of CSSP is critical due to the
potentially life-threatening complications to the mother if left untreated. Pelvic ultrasound is the imaging modality of choice
in the initial evaluation of suspected CSSP, with MRI potentially useful if ultrasound findings are equivocal, or if confirma-
tion is requested prior to definitive intervention. Early and accurate diagnosis of CSSP allows for prompt management to
avoid severe complications and the potential to preserve the uterus and future fertility. A combination of medical and surgical
treatment strategies may be needed with specific therapy tailored to each patient. Follow-up after treatment should include
serial beta-hCG levels and possible repeat imaging if there is clinical concern for complications or treatment failure. This
article will provide a comprehensive review of this uncommon but important phenomenon, detailing the pathophysiology
and types of CSSP, imaging presentations, potential pitfalls in diagnosis, and management options.
Graphical abstract

Scarred for life: A review of cesarean secon scar pregnancy and

potenal pi alls in diagnosis
3
Suggested criteria for diagnosis
on ultrasound
1 • 1: empty uterine cavity
2
• 2: gestaonal sac in anterior
lower uterus

• 3: thin myometrium of
anterior lower uterus
Sagial US

Huang et al 2023

Keywords Cesarean section scar pregnancy · Cesarean section · Pelvic ultrasound · Abnormal implantation

Extended author information available on the last page of the article

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Abdominal Radiology (2023) 48:2672–2683 2673

Introduction (TVUS) is the imaging modality of choice in the initial

evaluation of suspected CSSP [8–10]. When ultrasound
Cesarean section scar pregnancy (CSSP), defined as findings are equivocal or confirmation is requested prior to
implantation of a gestational sac on or in previous Cesar- definitive intervention, the superior soft tissue resolution
ean section (CS) scar, is a rare form of ectopic pregnancy. of non-contrast magnetic resonance imaging (MRI) may
First described by Larsen and Solomon in 1978 [1], CSSP provide a useful problem-solving tool. Early and accurate
occurs with a reported frequency of approximately 1 in diagnosis is critical, as it can allow for prompt manage-
1800 to 1 in 2200 (0.05–0.04%) of all pregnancies [2, 3]. ment to avoid severe complications, thereby reducing risk
However, the incidence of detection of CSSP has contin- to maternal health and preserving uterus and future fertil-
ued to increase over the last several decades, now repre- ity [2, 11, 12].
senting approximately 6% of all ectopic pregnancies after This manuscript aims to provide a comprehensive review
cesarean deliveries [2]. This increase may be attributable of this important phenomenon, detailing the pathophysiol-
to growing rates of cesarean deliveries and the improved ogy and types of CSSP, variations of imaging presentations,
technology of transvaginal ultrasonography [4–6]. Accord- potential pitfalls in diagnosis, and management options.
ing to the World Health Organization, global CS rates have
risen from approximately 7% in 1990 to 21% in 2021, a
trend that is expected to continue to increase over the next Cesarean surgical techniques
decade [7].
Although an uncommon complication of CS, diagnosis CS are increasingly common, with a threefold increase in
of CSSP is critical due to the potentially life-threatening global CS rates over the last 30 years [7]. Depending on
complications to the mother if left untreated, such as uter- fetal lie, location of placenta, and future pregnancy plans,
ine rupture with severe hemorrhage, the need for emer- different uterine incision techniques may be utilized (Fig. 1),
gent hysterectomy (and loss of future fertility), and rarely which includes the low transverse incision, low vertical inci-
maternal death [6]. There are multiple risk factors asso- sion, and classical vertical incision. The generally preferred
ciated with an increased risk of CSSP, including history method for cesarean delivery is the low transverse incision
of multiple CS, increased gravidity and parity, advanced in the anterior lower uterine segment. The low vertical inci-
maternal age, and history of other invasive procedures sion is also in the noncontractile portion of the lower uterine
that can result in uterine scarring, including curettage and segment, with possible indications, including an obstructing
myomectomy. lesion, transverse fetal lie, anticipated intrauterine manipu-
The clinical presentation of CSSP is nonspecific, with lation, and large fetus. The classical vertical incision is in
the most common reported symptoms being vaginal bleed- the upper uterus/fundus (contractile portion) and is typically
ing and abdominal discomfort. Due to the often vague used in settings of difficulty accessing the lower uterus, pre-
clinical presentation, providers frequently rely on imag- term labor, fixed uterine abnormality, or transverse fetal lie.
ing for detection of CSSP. Transvaginal ultrasonography Although no studies have evaluated the incidence or mor-
bidity of CSSP in different types of uterine incision, the risk

Fig. 1  Types of cesarean section

surgical incisions. Diagram
depicts several of the most com-
mon types of uterine surgical
incisions, including the gener-
ally preferred low transverse
incision, low vertical incision,
and classical vertical incision

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of uterine rupture is higher in the classical vertical incision The size of the scar niche may also be a risk factor for
(4 to 9%) compared to the other two incision methods (low CSSP, with larger scar defects presenting higher risk [20].
transverse incision 0.2 to 1.5%; low vertical incision 1 to Defect size can be characterized by residual myometrial
7%) [13, 14]. Additional early and late complications of CS thickness (RMT), which is defined as the distance between
are described in Table 1. the uterine serosal layer and the apex of the scar niche, with
a large scar defect having RMT less than 3 mm [21]. Report-
ing large scar niches on pelvic ultrasounds obtained for other
Pathogenesis of CSSP reasons may therefore be useful to help identify patients at
increased risk of developing CSSP.
CSSP represents a blastocyst that has implanted within a Several additional factors are associated with an increased
previous CS scar via a myometrial wedge defect or micro- risk of CSSP. Women who have undergone multiple cesar-
scopic dehiscent tract or fistula. Therefore, diagnosis of a ean deliveries are at higher risk of scar implantation due to
CSSP necessitates a previous history of cesarean delivery, increased scar surface area [22], with up to 72% of cases
which predisposes the patient to development of a morpho- occurring in women who have had two or more cesarean
logical myometrial scar abnormality or defect at the hyster- deliveries [23–25]. Other invasive procedures that can result
otomy site, termed a scar niche [15]. The scar niche reflects in uterine scarring, such as dilatation and curettage (D&C)
a focal area of discontinuity of the myometrium at the site and myomectomy, may also predispose women to develop-
of a previous cesarean section, and it is within this defect ment of CSSP. Advanced maternal age has also been pro-
that a CSSP may develop. The ectopically implanted ges- posed as a risk factor for CSSP, perhaps because of the effect
tational sac is thus outside of the endometrial cavity, either of age on endometrial healing [26, 27]. Additional reported
surrounded by myometrium or fibrous tissue of the scar [6]. risk factors include large niche/scar defect, increased gravid-
Niche formation in a CS scar occurs because of incom- ity and parity, and higher number of induced abortions [27].
plete healing. One hypothesis suggests that incomplete sur- There are two growth patterns of CSSP: type I (endo-
gical closure of the uterine wall may lead to a disrupted genic) and the more common type II (exogenic) [28, 29]
myometrium and subsequent niche development [15]. Many (Fig. 2). Because the endogenic type (type I) of CSSP results
studies, including the CAESAR and CORONIS trials, have in growth inward in the uterine cavity toward the cervico-
evaluated peri-operative outcomes following single-layer isthmic space, this subtype may result in a viable pregnancy
versus double-layer uterine closure; however, no significant but has a high risk of placenta accreta spectrum (PAS) [30]
difference in uterine rupture risk was identified [16, 17]. In (Table 2). The endogenic subtype is often more difficult
a meta-analysis of 1151 patients who received single-layer to diagnose on imaging, as it may be confused with low
or double-layer suturing, there was no significant difference implantation in the lower uterine segment. Type II/exogenic
in risk of uterine scar development; however, single-layer CSSP demonstrates deep invasion through the scar defect
closure resulted in a significantly thinner residual myome- toward the bladder and peritoneal cavity and therefore is
trial thickness [15]. Additionally, some studies comparing more prone to imminent uterine rupture. These two subtypes
locked versus unlocked sutures in uterine closure suggest may occasionally be difficult to differentiate, often becom-
that locked sutures in a single layer may be associated with ing easier to distinguish with further growth of the gesta-
increased tissue hypoxia and inadequate healing, with result- tional sac. Thickness of the lower uterine wall of greater
ant increased risk of uterine rupture [18, 19]. Therefore, than 3 mm has been proposed as a criterion to differentiate
double-layer uterine closure with non-locking sutures may the endogenic subtype [31].
allow for a thicker post-surgical myometrium and potential Increasing evidence suggests that CSSP may be a pre-
decreased risk of niche formation; however, further studies cursor to PAS. Timor-Tritsch et al. demonstrated 10 cases
are needed to confirm optimal closing technique. of early diagnosis of CSSP (before 10 weeks) that all had

Table 1  Complications Early Late

associated with CS [19,
20]. There are multiple Postpartum hemorrhage/hematoma Cesarean section scar pregnancy
complications associated with
Surgical site infection Cesarean scar retained products of conception
CS, which can be divided into
early and late time periods. Injury to adjacent structures (e.g., bladder, bowel) Abnormal placentation
There is increased risk for Venous thromboembolism Abdominal wall endometriosis
Cesarean section scar pregnancy Uterine dehiscence Adhesions and bowel obstruction
following CS due to formation
Uterine rupture Uterine rupture in subsequent pregnancy
of a niche
CS cesarean section

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Fig. 2  Types of CSSP growth patterns. The two CSSP growth pat- vico-isthmic space, whereas exogenic subtypes show deep invasion
terns include type I or endogenic and the more common, type II or through the scar defect toward the outer wall of the uterus. Exogenic
exogenic. Endogenic subtype results in inward growth toward the cer- CSSP is more prone to imminent uterine rupture

Ultrasound
Table 2  Types of CSSP: Endogenic vs Exogenic type. The type of
CSSP (endogenic vs exogenic) can influence the risk of uterine rup-
ture, as well as likelihood of viability of pregnancy Pelvic ultrasound (US), using a combined transabdominal
and transvaginal approach, is the first-line imaging modality
Direction of growth Type I/Endogenic Type II/Exogenic
for the evaluation of CSSP. In the case of CSSP, TVUS in
Toward endometrial Away from endo-
cavity metrial cavity the sagittal view along the long axis of the uterus can local-
ize a CSSP with a reported sensitivity of 86.4% [6]. The
Uterine rupture risk ↑ ↑↑ transabdominal scan provides a broader view of the pelvic
Likelihood of viable ↑↑ ↑ structures, including the uterus and its relationship to adja-
pregnancy
cent organs such as the bladder, which is particularly helpful
CSSP cesarean section scar pregnancy in later gestation.
On imaging, CSSP is attached to a previous CS scar in
the anterior lower uterine segment, either projecting above
placenta percreta on histopathological diagnosis after hys- the scar into the endometrial cavity (type I/endogenic) or
terectomy at the time of Cesarean delivery [32]. Therefore, projecting in/below the scar with a thin layer of overlying
CSSP may be considered a part of the spectrum of PAS, myometrium along the anterior aspect (type II/exogenic),
with indistinguishable histopathological features [33]. which may not be visible on imaging. Vial et al. proposed
three sonographic criteria for the diagnosis of CSSP: (i)
empty uterine cavity and cervical canal, (ii) gestational sac
in the anterior lower uterine segment, and (iii) absent or defi-
Imaging of CSSP cient myometrium between the gestational sac and the blad-
der wall [29] (Fig. 3). Depending on the stage and subtype
Clinical diagnosis of early CSSP can be difficult, and of CSSP, a yolk sac, embryo, and cardiac activity may be
delayed diagnosis can increase the risk of uterine rup- present. Cali et al. also described the crossover sign, which
ture and subsequent possible fatal maternal hemorrhage. describes the relationship between the GS, the CS scar, and
Therefore, imaging is often indicated for the diagnosis and the anterior uterine wall (Fig. 4) [34]. The crossover sign
evaluation of suspected CSSP. Serum beta human chori- may be a useful tool in discriminating groups of CSSP that
onic gonadotropin (beta-hCG) levels should be checked may have a poorer prognosis and therefore necessitate closer
in all patients with suspected CSSP, which can be used to management.
help interpret subsequent imaging findings in equivocal Color or power Doppler imaging may be used to differ-
cases. entiate between a viable CS pregnancy and a non-viable

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Fig. 3  Sonographic imaging features of CSSP. 40-year-old G5P3 gestational sac (white arrow) containing a yolk sac (white arrowhead)
woman with history of 3 C-sections presents with vaginal bleeding in the lower anterior uterus at the site of the cesarean section scar
and mild cramping. Her serum beta-HCG level was 1672 mIU/mL. defect. There is surrounding vascular flow on color Doppler imaging
Transvaginal a sagittal gray-scale and b sagittal color Doppler ultra- (black arrowhead) and thinning of the anterior myometrium of the
sound images of the midline uterus demonstrate a well-circumscribed uterus (black arrow)

pregnancy, which has potential implications in the choice MRI

of treatment. In cases of viable Cesarean scar pregnancy,
color or power Doppler imaging may demonstrate increased MRI can be a useful adjunct, particularly in cases where
flow around the gestational sac, with high velocity (peak diagnosis by US is indeterminate or difficult, such as in
systolic velocity > 20 cm/sec) and low resistance (pulsatility women with Mullerian anomalies, distorted anatomy from
index < 1) [2, 10, 35]. Dynamic imaging should be utilized large fibroids, high maternal body mass index, or in preg-
to evaluate for the “sliding sign” which is defined as the nancies at a later gestational age [5]. No specific diagnostic
gestational sac sliding against the endocervical canal occur- criteria have been developed for diagnosing CSSP using
ring when pressure is applied to the cervix using the ultra- MRI; however, the imaging findings are similar to those on
sound probe. The absence of the “sliding sign” favors CSSP US. MRI provides the added bonus of improved sensitivity
over miscarriage. Three-dimensional (3D) ultrasound can in detection of invasion of adjacent pelvic structures by the
enhance the diagnostic capability of ultrasound by showing early placenta due to its excellent soft tissue resolution and
CSSP in multiplanar views, while surface-rendered imag- multiplanar imaging capabilities [9].
ing allows better visualization of the gestational sac and its Transverse and sagittal T1- and T2-weighted imaging of
relationship to adjacent structures [6, 36]. the pelvis are the best views to image the CSSP. Intravenous
Contrast-enhanced ultrasound (CEUS) is not FDA gadolinium contrast is not routinely administered unless
approved for the diagnosis of CSSP but has been proposed in there is plan for termination. The typical appearance of the
several literature reports as a complementary tool to enhance CS scar is isointense to the myometrium on T1-weighted
imaging of the uterine microcirculation [37, 38]. Xiong et al. images and hypointense on T2-weighted images (Fig. 5).
compared conventional US and CEUS in women with sus- The T2-hyperintense gestational sac is eccentrically located
pected CSSP. The sensitivity of conventional ultrasound was in the anterior lower uterine segment with thinning of the
80.8% compared to 100% for CEUS, while specificity was overlying anterior myometrial wall.
87.5% and 95.0% for conventional US and CEUS, respec- Limitations of MRI include limitation of immediate
tively [37]. Additionally, Wu et al. demonstrated that CSSP access and the longer acquisition time, requiring a coopera-
demonstrates earlier enhancement and hyperenhancement tive and hemodynamically stable patient.
on CEUS compared to non-CSSP cases, which showed no
enhancement between the GS and the scar defect [38]. Thus,
CEUS may provide real-time perfusion imaging of the GS as Pitfalls
well as diagnostic information about the myometrial thick-
ness and integrity of the overlying serosa [38]. However, As stated previously, CSSP are particularly important to
its current utility in clinical practice is limited due to the identify and diagnose early due to their high risk of uterine
unknown fetal effects of the passage of microbubbles of the rupture and life-threatening bleeding. Some key differential
contrast agent through the placenta [38]. diagnoses include cervical ectopic pregnancy, interstitial

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Fig. 4  Crossover sign. The endometrial line (yellow line) is drawn as the SID of the GS is above the endometrial line, toward the anterior
a straight line connecting the internal cervical os and the uterine fun- uterus. In Crossover sign 2, the GS is implanted in the c-section scar
dus through the endometrium on a sagittal view of the uterus. A per- but less than two-thirds of the SID of the GS is above the endometrial
pendicular line measuring the superior-inferior diameter (SID) of the line. Note that there is intersection of the SID and endometrial line in
gestational sac is then drawn (green line). Crossover sign 1 indicates COS2 +, but not in COS2-
that a GS is implanted in the c-section scar and at least two-thirds of

ectopic pregnancy, miscarriage in progress, PAS, and preg- CSSP may demonstrate an empty uterine cavity; however,
nancies with low implantation [39]. At times, these entities CEPs are located within the cervix below the level of the
may have similar imaging appearances and can sometimes internal os, whereas CSSPs are implanted superior to the
be difficult to differentiate on imaging. A literature review internal os [40] (Fig. 6). The position of the GS in CEP
by Timor–Tritsch and Monteagudo showed that 13.6% of may be lateral or posterior compared to CSSP which must
cases of CSSP were originally misdiagnosed [4]. In such be anterior due to the location of the CS scar. Management
instances of uncertainty, follow-up imaging and/or serial strategies are similar, although it is helpful to distinguish
clinical examinations may be warranted if the mother is these two entities for surgical planning [41].
hemodynamically stable.
Miscarriage in progress
Cervical ectopic pregnancy
A miscarriage in progress may present with similar clinical
Cervical ectopic pregnancy (CEP) is defined as implanta- features to CSSP including vaginal bleeding with or with-
tion of the GS within the endocervical canal. Both CEP and out pain. A GS that is in the process of passing from the

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Fig. 5  MR imaging features of CSSP. 35-year-old G5P3 woman with with placental tissue along the inferior margin of the GS. Marked
history of 3 prior C-sections presents with intermittent vaginal bleed- thinning of the anterior myometrium (white arrowhead) is noted
ing and cramping. Her serum beta-HCG level as 116,550 mIU/mL. a along the lower uterine segment at the site of the cesarean section
Sagittal T2-weighted and b sagittal BFFE MR images of the pelvis scar (black arrowhead). Obscured fat plane (dotted arrow) between
demonstrate an ovoid T2-hyperintense gestational sac (white arrow) the uterus and bladder dome raises concern for PAS with placental
in the lower uterine segment containing an embryo (black arrow) extension to the bladder serosa

Fig. 6  Cervical ectopic pregnancy. 30-year-old G1P0 woman pre- cervix, below the level of the internal cervical os (white arrowhead).
sents with vaginal bleeding. Her serum beta-HCG level was 26,738 Yolk sac (black arrowhead) and fetal cardiac motion were present
mIU/mL. Gray-scale a transvaginal sagittal image of the uterus and b (not shown). Cine clip (not shown) with application of pressure using
transvaginal sagittal image of the cervix demonstrate an empty endo- the transducer shows no movement of the gestational sac with the
metrial canal (white arrow), with gestational sac (black arrow) in the uterus (absence of “sliding sign”)

endometrial canal may be transiently identified in the lower present in CSSP and absent in miscarriage in progress. If the
uterine segment or in the cervical canal (Fig. 7). Compared patient is hemodynamically stable, follow-up imaging and/
to CSSP, a miscarriage in progress is associated with stable or serial beta-HCG levels may be useful in distinguishing
or decreasing serum beta-hCG levels and an open internal os these two entities in equivocal cases.
[39]. The GS in miscarriage in progress tends to be flattened,
mobile, and avascular [42]. The sliding sac sign, which Low implantation of an intrauterine pregnancy
refers to movement of the GS within the endocervical canal
with gentle probe pressure, may be seen [43]. Additionally, Low intrauterine pregnancy (IUP) refers to a pregnancy
pressure on the cervical region with the ultrasound probe located toward to lower uterine segment of the endometrial
may deform the GS. Thinning or absence of the myome- canal. Low IUPs represent a normal spectrum of pregnancy
trial wall is another useful distinguishing feature, which is implantation and will eventually decompress into upper

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Fig. 7  Miscarriage in progress. 34-year-old G5P3 woman presents in shape, from convex outward margins to angular margins (black
with vaginal bleeding. Her serum beta-HCG level was 7336 mIU/mL. arrow). Note the normal thickness of the overlying myometrium
Transvaginal gray-scale a sagittal image of the uterus and b sagit- (black arrowhead). Within the GS, there is expanded amnion and
tal image of the cervix demonstrate a mobile intrauterine gestational small embryo (dotted arrow). These imaging findings are diagnostic
sac (white arrow) that is seen to move from the central endometrial of a miscarriage in progress
canal (a) toward the cervix (b) (white arrowhead). The sac changes

portion of the endometrial canal. Sonographic features to effective in terminating CSSP depending on multiple patient
help differentiate low IUPs from CSSP include more central factors [45].
location of the low IUP and normal thickness of the overly-
ing myometrial wall [44] (Fig. 8). Expectant management

With expectant management, it is proposed that the sac and

its contents will be reabsorbed or expelled by itself. The
Treatment available data on expectant management suggests that it
is rarely successful, with Rotas et al. showing that uterine
There are multiple treatment options for CSSP, including rupture with severe hemorrhage occurred in half of women
expectant, medical, and surgical management. A combina- managed expectantly without treatment [46]. Indeed, the
tion of different techniques is generally preferred as the most Society for Maternal–Fetal Medicine (SMFM) recommends

Fig. 8  Low intrauterine pregnancy. 19-year-old G2P0 woman pre- overlying myometrium is normal in thickness (black arrow). b Fol-
sents with vaginal bleeding and an initial serum beta-HCG level of low-up transvaginal gray-scale image of the uterus performed 14 days
744 mIU/mL, with the serum levels subsequently rising to beta-HCG later shows a well-defined GS (white arrowhead) containing yolk sac
13,313 mIU/mL. a Initial transvaginal gray-scale sagittal image of the (black arrowhead) and embryo (not pictured) more cranially located
uterus demonstrates a small intrauterine GS (white arrow) with a tiny within the endometrial canal. The pregnancy proceeded without com-
yolk sac, which is slightly low lying in the endometrial canal. The plication and resulted in an uncomplicated vaginal delivery

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against expectant management for the treatment of CSSP SMFM Consult series recommends strongly against expectant
[8]. management or systemic MTX alone [8]. Many authors favor
a combination of 2–3 treatment modalities with individual-
Medical management ized consideration of each patient depending on her clinical
presentation, gestational age, and desire for future pregnancies.
Medical management may include systemic or local admin- Regardless of the treatment approach, there is a high risk of
istration of methotrexate (MTX), potassium chloride, or a excessive hemorrhage, particularly with increasing gestational
combination of the two [47]. Systemic administration most age and increasing size of GS. Blind curettage alone has the
often involves a single intramuscular dose of 50 mg/m2 of highest rate of treatment failure and severe bleeding risk [4, 6,
MTX. Alternatively, MTX can be injected directly into the 9]. Preservation of future fertility is also an important consid-
GS using US or laparoscopic guidance. Multiple doses or a eration, although in life-threatening situations, hysterectomy
combined treatment approach may be needed [48]. The like- may be needed [63].
lihood of success with MTX is greatest when serum beta-
hCG levels are less than 5000 mIU/mL, gestational age is Follow‑up
less than 6–8 weeks, and/or when there is no fetal cardiac
activity [4, 27]. Post-treatment serum beta-hCG levels may initially rise, par-
There is some debate regarding whether systemic MTX ticularly after imaging-guided local MTX administration, pos-
is considered the standard of care due to the impaired vas- sibly due to the disruption of the chorionic sac by the needle
cularization of the fibrous CS tissue [49], which may lead with resultant cytotoxic lysis of the trophoblast [65]. However,
to poor penetration into the GS [50]. Further, Petersen et al. with expectant therapy, steady decline of beta-hCG levels is
showed that nearly 20% of women treated with systemic anticipated with a goal of 15% or more drop by day 4–7 [66].
MTX experienced a major complication and almost all Close follow-up with serial quantitative beta-HCG levels is
women required additional surgery with D&C [51]. Due to recommended until the level falls to less than 15 mIU/mL.
these risks, SMFM recommends against the use of systemic Women undergoing medical management do not typically
MTX alone for the treatment of CSSP, and local laparo- warrant follow-up imaging if they are asymptomatic. How-
scopic or US-guided administration into the GS may be an ever, if there is clinical concern for complications or treatment
alternative [8]. Multiple studies comparing the efficacy and failure, transvaginal US can be performed with the main goal
safety of local versus systemic MTX have demonstrated of determining the next therapeutic step. When post-treat-
conflicting results. Several have shown similar treatment ment US following medical management is performed, serial
success and reproductive outcomes, but a more favorable examinations should show initial increase in size of the treated
profile for local MTX with regards to recovery time, side CSSP remnant with gradual decrease in size accompanied by
effects, and treatment costs [4, 9, 52, 53]. However, these decreasing vascular flow [66]. The GS may appear more elon-
results are complicated by the wide variability in adjuvant gated or tubular in shape, more heterogeneous in appearance
or subsequent therapies and the definitions of treatment suc- and may develop surrounding fluid or hematoma, particularly
cess [54–59]. after local therapy.
New detection of cardiac activity or growth of a fetal pole
Surgical management following treatment indicates treatment failure and further sur-
gical treatment strategy may be warranted. Clinically, patients
In cases of failed medical treatment, surgical options such who have undergone successful treatment may experience
as uterine artery embolization, laparoscopy, hysteroscopy, mild abdominal discomfort. Treatment success is reached
and D&C should be considered [3, 60, 61]. Many of these when no remaining tissue is seen at the site of previous CSSP
are minimally invasive and demonstrate high success rates, is found on TVUS, and maternal serum beta-HCG levels are
often with preservation of fertility. Some surgical treatment undetectable. Regardless of management strategy, the recur-
strategies such as hysteroscopy also allow for concomitant rence risk may be as high as 20–35%, therefore Timor-Tritsch
scar revision with multilayer closure, potentially decreasing et al. suggested that in patients with previously treated CSSP,
risk of uterine rupture or recurrent CSSP [62]. early first-trimester TVUS may be warranted to determine the
Other novel treatment approaches, including resection of location of the GS [67].
CSSP through a transvaginal approach and repeated high-
intensity focused ultrasound, have also been suggested, but
the published literature is not yet sufficient to be recom-
mended for daily clinical practice [63, 64].
There is no widely accepted consensus on the best man-
agement pathway and treatment for CSSP, although the 2020

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Abdominal Radiology (2023) 48:2672–2683 2681

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Abdominal Radiology (2023) 48:2672–2683 2683

Authors and Affiliations

Jennifer Huang1,2 · Catherine Phillips1 · Mariam Moshiri1

1
* Jennifer Huang Department of Radiology, Vanderbilt University Medical
[email protected] Center, 1161 21st Avenue South, Nashville, TN, USA
2
Catherine Phillips PGY‑5 Chief Resident, Diagnostic Radiology Residency,
[email protected] Vanderbilt University Medical Center, 1161 21st Ave South,
Nashville, TN 37232, USA
Mariam Moshiri
[email protected]

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