Which treatment modalities have better efficacy and reduced complications among patients with Cesarean scar pregnancy?

The findings suggested that transvaginal resection (TVR), laparoscopy (Lap), hysteroscopic curettage (Hys), and high-intensity focused ultrasound combined with suction curettage (HIFU+SC) procedures exhibited superior efficacy with reduced complications.

The researchers recommended against utilizing methotrexate (both locally guided injection and systemic administration) as a standalone medical treatment.

Cesarean scar pregnancy may lead to various complications. There are many methods for it, but no unified or recognized treatment strategies exist. Therefore, Peiying Fu, Huazhong University of Science and Technology, Wuhan, PR China, and colleagues aimed to observe the safety and efficacy of treatment modalities for CSP patients by conducting a systematic review and network meta-analysis.

For this purpose, the researchers searched the online databases from their inception to January 31, 2024. Additionally, they manually searched for relevant reviews and meta-analyses for additional references.

The study incorporated head-to-head trials involving a minimum of ten women with CSP diagnosis through ultrasound imaging, or magnetic resonance imaging (MRI), encompassing a detailed depiction of any supplementary measures and primary interventions. Trials with a Newcastle-Ottawa Scale (NOS) score below four were excluded due to the low quality.

Following a predefined protocol, group-level data on treatment safety and efficacy, study design, reproductive outcomes, and demographic characteristics were extracted. The quality of the studies was assessed using the Newcastle‒Ottawa scale (NOS) for cohort studies and case series, and Cochrane risk-of-bias tools for randomized controlled trials (RCT).

The study's main outcomes were safety (complications) and efficacy (initial treatment success), of which summary odds ratios (ORs) and the surface under the cumulative ranking curve (SUCRA) using pairwise and network meta-analysis with random effects.

The researchers reported the following findings:

• The review included seventy-three trials (7 RCTs) assessing 738369 women and 17 treatment modalities.
• Network meta-analyses were rooted in data from 7373 trials that reported success rates and 55 trials that reported complications.
• Transvaginal resection, laparoscopy, hysteroscopic curettage, and High-intensity focused ultrasound combined with suction curettage demonstrated the highest cure rates, as evidenced by SUCRA rankings of 91.2, 88.2, 86.9, and 75.3, respectively.
• Compared to suction curettage (SC), the odds ratios of efficacy were 5.92 for TVR, 6.76 for Lap, 5.00 for Hys, and 3.27 for HIFU+SC.
• Complications were more likely to occur after receiving uterine artery chemoembolization (UACE), SC, MTX+Hys, and sMTX; Hys, HIFU+SC, and Lap were safer than the other options derived from finite evidence; and the confidence intervals of all the data were wide.

In conclusion, in the study focused on the efficacy and safety of various treatment modalities for cesarean scar pregnancy, the researchers found that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound with suction curettage emerged as the most effective interventions, with impressive success rates. Methotrexate, administered locally and systemically administered, was discouraged as a standalone medical treatment.

Reference:

Fu P, Sun H, Zhang L, Liu R. Efficacy and Safety of Treatment Modalities for Cesarean Scar Pregnancy: A Systematic Review and Network Meta-Analysis. Am J Obstet Gynecol MFM. 2024 Mar 12:101328. doi: 10.1016/j.ajogmf.2024.101328. Epub ahead of print. PMID: 38485053.