title: Cesarean scar pregnancy: a systematic review of treatment studies.
abstract: OBJECTIVE
  To study treatment modalities for cesarean scar pregnancies (CSPs), focusing on efficacy and complications in relation to study quality.
  
  
  METHODS
  Systematic review.
  
  
  METHODS
  Not applicable.
  
  
  METHODS
  A total of 2,037 women with CSP.
  
  
  METHODS
  Review of MEDLINE, EMBASE, and Cochrane Library to find studies including five or more women. Data were extracted on primary treatment modality/efficacy, complications, and future fertility. The level of evidence was categorized according to Oxford Centre for Evidence-based Medicine guidelines. Quality was assessed using The Cochrane Collaboration's Risk of Bias Tools for Randomized Controlled Trials and the modified Delphi techniques for case series. Meta-analysis was impossible owing to multifarious treatments.
  
  
  METHODS
  Successful first-line treatment. Complications were hysterectomy, laparotomy, bleeding >1,000 mL, or blood transfusion.
  
  
  RESULTS
  Fifty-two studies were included: four randomized, controlled trials and 48 case series. Fifteen of the 52 analyzed studies were scored as high quality. Treatment modalities were condensed to 14 different approaches. Combining study quality, level of evidence, efficacy, and safety, five approaches for treating CSP are recommended, depending on availability, severity of patient symptoms, and surgical skills: [1] resection through a transvaginal approach, [2] laparoscopy, [3] uterine artery embolization in combination with dilatation and curettage and hysteroscopy, [4] uterine artery embolization in combination with dilatation and curettage, and [5] hysteroscopy.
  
  
  CONCLUSIONS
  This review recommends treatment options for CSP in clinical practice, based on efficacy and safety. The literature supports an interventional rather than medical approach. Present recommendations are primarily based on case series. Multicenter, well-designed studies are needed to draw definite conclusions on how to treat CSP.
authors.affiliation: Fertility Clinic 4071, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. Electronic address: kbirch@dadlnet.dk.
authors.forename: Kathrine
authors.initials: K
authors.lastname: Birch Petersen
authors.affiliation: Department of Obstetrics and Gynaecology, Copenhagen University Hospital, Roskilde Sygehus, Roskilde, Denmark.
authors.forename: Elise
authors.initials: E
authors.lastname: Hoffmann
authors.affiliation: Centre for Minimal Invasive and Robotic Surgery Research, Departments of Gynecology, General Surgery, and Urology, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark.
authors.forename: Christian
authors.initials: C
authors.lastname: Rifbjerg Larsen
authors.affiliation: Fertility Clinic 4071, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
authors.forename: Henriette
authors.initials: H
authors.lastname: Svarre Nielsen
mesh_terms: D002585:Cesarean Section / Q000009:adverse effects*; D002921:Cicatrix / Q000175:diagnosis* / Q000628:therapy*; D005260:Female; D006801:Humans; D011247:Pregnancy; D011271:Pregnancy, Ectopic / Q000175:diagnosis* / Q000628:therapy*; D016032:Randomized Controlled Trials as Topic / Q000379:methods
keywords: Cesarean scar pregnancy; early pregnancy complications; ectopic pregnancy; hysteroscopy methotrexate