Caesarean scar pregnancy (CSP)

You have been told that you have a caesarean scar pregnancy (CSP).

The information below has been provided with the aim to help you gain understanding and reach a well-informed decision with your medical team about how best to proceed in your specific case. We understand that this is unexpected news for you, you and your partner can contact Clinic 24 with any questions or concerns.

Caesarean scar pregnancy

This is a diagnosis which is made using ultrasound. It means that your pregnancy has implanted in or on the scar of your previous cesarean section.

Not all these type of pregnancies will have a foetus with a heartbeat. If you are having a non-viable pregnancy which is implanted in the scar we discuss and offer you treatment depending on the circumstances, including how clinically well you are. These will be discussed in more detail with you.

Treatment options include:

• Expectant management - allowing the pregnancy tissue and/or blood clots to pass naturally through the vagina, without any intervention. This will include weekly scans and blood tests in clinic 24.

Or

• Surgical management of miscarriage (SMM) - a procedure to remove pregnancy tissue and/or blood clots under general anaesthesia.

We are very sorry if this is the outcome for you. Please contact the team in Clinic 24 if you would like additional support.

If your pregnancy continues, there are some risks that are higher for you than in other pregnancies, including:

• Extensive vaginal bleeding
• Intra-abdominal bleeding
• Uterine rupture (the scar giving way)
• Need for blood transfusion(s)
• Hysterectomy (removal of womb)

Management

There is no proven ultrasound marker to predict who will suffer significant complications.

You will have a detailed discussion with your early pregnancy consultant about your specific case and your future fertility wishes.

You might together come to the conclusion that continuing the pregnancy entails too much risk for your own health and treatment to remove the pregnancy will be offered. This will be performed by one of our surgeons with expertise in this type of surgery.

If you decide to continue the pregnancy you will be classified as having a high risk pregnancy. This means you will be offered consultant led care throughout your pregnancy. Most CSP will develop into adherent placenta spectrum disorder. This is where the placenta will keep growing in the scar and can become very stuck to the womb or even growth into the surrounding organs.

Cambridge University Hospital is the regional centre for these types of pregnancy and we will provide all of your pregnancy care. If you were referred from another hospital, we will involve your local hospital in the agreed plan. Delivery will always be a planned cesarean section.

Research shows that the chance of a uterine rupture with CSP is 10%. This means that 90% will be able to make it to their planned cesarean birth. But when a rupture occurs this is an emergency which can end the life of both mother and child.

Until recently, it was thought too dangerous to continue with any CSP pregnancies, but there is now some research available showing that these pregnancies can sometimes progress to term. There hasn’t been enough research into CSP, so it can be difficult to give you clear statistic to support your decision making. The plan for your pregnancy will be individualised based on your obstetric history, the ultrasound findings, your beliefs and wishes and future fertility desire.

Future pregnancies

The chances of achieving a new pregnancy among women wishing to conceive after being treated for a CSP (whether managed expectantly or surgically) is 70-76% get pregnant.

The recurrence of CSP is around 20% (15-34%). Amongst the pregnant patients 82-83% have a pregnancy inside the uterine cavity. Of these 82-83% of pregnancies:

• 19% will miscarry
• 10% will have a preterm birth
• 4% will have a placenta accreta spectrum disorder
• 67% will have a livebirth at term

Contact information

• Clinic 24 (Emergency Gynaecology Unit/Early Pregnancy Unit): 01223 217636
  Monday to Friday, 08:00 – 20:00
  Weekends, 08:30 – 14:00
  Closed Bank holidays
• Daphne Ward (Inpatient Gynaecology Ward): 01223 257206
  At all other times

Further information

• The Ectopic Pregnancy Trust - Support For You And Your Loved Ones (opens in a new tab)
• The miscarriage association (opens in a new tab)
  Telephone: 01924 200799 (Monday - Friday, 09:00 – 16:00)
• Early miscarriage | RCOG (opens in a new tab)

References/sources of evidence

• Calì et al (2018) Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis Ultrasound Obstetric Gynaecology.51(2) 169-175
• Morlando et al (2020) Reproductive outcome after cesarean scar pregnancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2020 Oct;99(10):1278-1289
• Wu et al (2021) Outcomes of reproduction following cesarean scar pregnancy treatment: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2021 Jul;262:80-92
• Timor-Tritsch et al (2021) Recurrent Cesarean scar pregnancy: case series and literature review. Ultrasound Obstetric Gynecol. 2021 Jul;58(1):121-126