title: Systematic review: What is the best first-line approach for cesarean section ectopic pregnancy?
abstract: This systematic review aims to analyze the case reports, case series, or clinical studies describing the women with cesarean scar ectopic pregnancy (CSEP), and thus, to determine the efficacy and safety of different primary treatment modalities in the management of CSEP. A thorough search of electronic databases showed that 274 articles on CSEP were published between January 1978 and April 2014. Systemic methotrexate, uterine artery embolization, dilatation and curettage (D&C), hysterotomy, and hysteroscopy were the most frequently adopted first-line approaches. The success rates of systemic methotrexate, uterine artery embolization, hysteroscopy, D&C, and hysterotomy were 8.7%, 18.3%, 39.1%, 61.6%, and 92.1%, respectively. The hysterectomy rates were 3.6%, 1.1%, 0.0%, 7.3%, and 1.7% in CSEP cases that were treated by systemic methotrexate, uterine artery embolization, hysteroscopy, D&C, and hysterotomy, respectively. The ability to achieve a subsequent term pregnancy is related to successful systemic methotrexate treatment (p = 0.001) or hysterotomy (p = 0.009). Future term pregnancy was significantly more frequent in the hysterotomy group (p = 0.001). Hysteroscopy and laparoscopic hysterotomy are safe and efficient surgical procedures that can be adopted as primary treatment modalities for CSEP. Uterine artery embolization should be reserved for cases with significant bleeding and/or a high suspicion index for arteriovenous malformation. Systemic methotrexate and D&C are not recommended as first-line approaches for CSEP, as these procedures are associated with high complication and hysterectomy rates.
authors.affiliation: Department of Obstetrics and Gynecology, Afyon Kocatepe University Medical Faculty Hospital, Afyonkarahisar, Turkey. Electronic address: minekanat@hotmail.com.
authors.forename: Mine
authors.initials: M
authors.lastname: Kanat-Pektas
authors.affiliation: Department of Obstetrics and Gynecology, Beytepe Military Hospital, Ankara, Turkey.
authors.forename: Serkan
authors.initials: S
authors.lastname: Bodur
authors.affiliation: Department of Obstetrics and Gynecology, Gulhane Military Academy of Medicine Haydarpasa Military Education Hospital, Istanbul, Turkey.
authors.forename: Ozgur
authors.initials: O
authors.lastname: Dundar
authors.affiliation: Department of Obstetrics and Gynecology, Haseki Education and Research Hospital, Istanbul, Turkey.
authors.forename: Vuslat Lale
authors.initials: VL
authors.lastname: Bakır
mesh_terms: D000020:Abortifacient Agents, Nonsteroidal / Q000627:therapeutic use; D002585:Cesarean Section / Q000009:adverse effects*; D002921:Cicatrix / Q000150:complications*; D004107:Dilatation and Curettage / Q000009:adverse effects; D005260:Female; D006801:Humans; D015907:Hysteroscopy / Q000009:adverse effects; D020883:Hysterotomy / Q000009:adverse effects; D008727:Methotrexate / Q000627:therapeutic use; D011247:Pregnancy; D011271:Pregnancy, Ectopic / Q000209:etiology / Q000628:therapy*; D055357:Uterine Artery Embolization / Q000009:adverse effects
chemical_list: D000020:Abortifacient Agents, Nonsteroidal; D008727:Methotrexate
keywords: cesarean scar ectopic pregnancy; ectopic pregnancy; treatment