Cesarean Scar Pregnancy (CSP) · Management

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

Full pathway

1. [Decision] Hemodynamics + growth direction + fertility wish
   Hemodynamics/rupture? Toward the cavity (endogenic) vs deep toward bladder/serosa (exogenic)? Fertility wish? (Early diagnosis by TVUS (Timor-Tritsch criteria); histology is the same as placenta accreta spectrum (PAS); early termination is strongly advised to avoid progression to morbidly adherent/accreta.)
   • Hemodynamically unstable/uterine rupture/heavy bleeding → Unstable/rupture → emergency surgery
   • Stable, growing toward the cavity (endogenic), reasonable residual myometrium → Toward cavity → multimodal minimally invasive
   • Stable, deep toward bladder/serosa (exogenic), thin myometrium, high rupture risk → Deep implant/thin myometrium → scar excision + niche repair
   • Rare cases insisting on continuing the pregnancy after counselling → Insists on continuing → PAS center follow-up
2. [End] Unstable/rupture → emergency surgery
   Hemodynamically unstable/rupture/heavy bleeding → emergency surgery for hemostasis: laparoscopic/open scar pregnancy excision + repair, uterine artery ligation/embolization if needed; uncontrollable or no fertility wish → hysterectomy; concurrent resuscitation and transfusion.
3. [End] Toward cavity → multimodal minimally invasive
   Stable, growing toward the cavity → multimodal minimally invasive: after UAE or local/systemic MTX to reduce blood supply, ultrasound/hysteroscopic-guided evacuation or hysteroscopic resection; have intrauterine balloon tamponade ready; avoid blind curettage (high bleeding risk).
4. [End] Deep implant/thin myometrium → scar excision + niche repair
   Deep toward bladder/serosa, thin myometrium, high rupture risk → surgical excision of the scar pregnancy (transvaginal/laparoscopic) with niche (isthmocele) repair — simultaneously corrects the scar defect and lowers recurrence; preoperative UAE/MTX may reduce bleeding.
5. [End] Insists on continuing → PAS center follow-up
   Rare cases insisting on continuing after counselling → must be fully informed of morbidly adherent placenta, massive hemorrhage, uterine rupture, hysterectomy and even death risk; refer to a center with PAS capability for multidisciplinary close follow-up.

Source guidelines & references

• Cesarean scar pregnancy management (SMFM Consult Series #63 2022/2023; related to placenta accreta spectrum PAS)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

Other pathways