Subsequent pregnancy outcomes of excisional surgery vs conservative surgery for cesarean scar pregnancy.

Background: Recurrent cesarean scar pregnancy (CSP) presents a significant clinical challenge for gynecologists. A thinner residual myometrium is an independent risk factor for CSP recurrence. There is limited evidence regarding which treatment modalities effectively reduce the risk of CSP recurrence.

Objective: This study compared subsequent pregnancy outcomes between excisional and conservative surgical treatments in CSP patients with a thin residual myometrium.

Study design: This was a multicenter retrospective observational cohort study of CSP patients hospitalized in China. The participants were recruited from January 1, 2019, to December 31, 2021, and data on pregnancy outcomes were collected up to January 31, 2025. Data were collected from CSP patients with a residual myometrium thickness ≤3 mm who underwent surgical management through either excisional surgery (ES) (CSP excision and hysterotomy closure) or conservative surgery (CS) (vacuum aspiration and surgical hysteroscopy). Patients with a residual myometrium >3 mm, those with a gestational age greater than 12 weeks, those with incomplete medical records or follow-up data, those who did not undergo surgical management, and those without fertility requirements were excluded. Data were obtained from the health system's electronic health records and telephone follow-up. The primary outcome was the subsequent pregnancy outcome of CSP. Survival analysis was performed to evaluate the risk of CSP recurrence.

Results: Among the 464 CSP patients (median [interquartile range] age, 34.0 [31.0-37.0] years), 32 (6.9%) underwent ES, and 432 (93.1%) underwent CS. The pregnancy rate in the excisional group was significantly greater than that in the conservative group (20 [62.5%, 95% confidence interval (95% CI): 45.7%-79.3%] vs 130 [30.1%, 95% CI: 25.8%-34.4%], P<.001). The CSP recurrence rate in the excisional group was significantly lower than that in the conservative group (1 [5.0%, 95% CI: 0%-14.6%] vs 41 [31.5%, 95% CI: 23.6%-39.5%], P=.014). After the postsurgical pregnancy interval were considered, the CSP recurrence rate in the excisional group was lower than that in the conservative group according to time-dependent Cox regression analysis (hazard ratio, 0.34; 95% CI: 0.14-0.82; P=.01).

Conclusion: For CSP patients with a thinner residual myometrium, ES improves the pregnancy rate while effectively reducing the risk of CSP recurrence.