Hysteroscopic resection outdoes ultrasound-guided D&E for caesarean scar ectopic pregnancy

Treatment success of caesarean scar ectopic pregnancy (CSP) appears to be higher with hysteroscopic resection than with ultrasound-guided dilation and evacuation (D&E), according to a study.

This nonblinded, randomized clinical trial was conducted at a single centre in Italy and included 54 women with singleton gestations of less than 8 weeks and 6 days and a diagnosis of CSP. All women had positive embryonic heart activity and opted for termination of pregnancy. Prior caesarean delivery ranged from one to three in this sample.

The women were randomly assigned to undergo either hysteroscopic resection (intervention group; n=27) or ultrasound guided D&E (control group; n=27). All women groups received 50 mg/m² of methotrexate, administered intramuscularly, at the time of randomization and another dose at day 3. A third dose of MTX was planned in case of persistence of positive foetal heart activity at day 5. The procedure was performed from 1–5 days after the last dose of MTX.

The primary outcome of success of the treatment protocol was defined as no further treatment required until the complete resolution of the CSP. CSP resolution was assessed based on a decline in Beta-hCG and absence of residual gestational material in the endometrial cavity. Women who required further treatment until the complete resolution of the CSP were deemed to have treatment failure.

Overall, 10 women received a third dose of MTX, including seven (25.9 percent) in the intervention group and three (11.1 percent) in the control group. All women in the intervention group achieved treatment success, while only 81.5 percent in the control group did (relative risk, 1.22, 95 percent confidence interval [CI], 1.01–1.48). Five women in the control group required additional procedures, including three hysterectomies, one laparotomic uterine segmental resection, and one hysteroscopic resection.

The mean duration of hospital stay was 9.0 days in the intervention group and 10.0 days in the control group (mean difference, –1.0 day, 95 percent CI, –2.71 to 0.71). None of the women died or were admitted to intensive care unit.