OC08.04: Maternal and fetal outcomes in expectant management of live Caesarean scar pregnancies

With Caesarean scar pregnancy (CSP) recognised as a potential precursor to placenta accreta spectrum (PAS), we evaluated the outcomes of patients opting for expectant management of live CSP. A retrospective study of patients diagnosed with live CSP in the first trimester who chose expectant management post-counselling, at a New York City tertiary academic institution between 2010-2023. Patients with a non-viable CSP were excluded. Data on maternal demographics, sonographic findings, gestation, and delivery were extracted from medical records. Outcomes assessed included hysterectomy necessity, first trimester interventions, pregnancy loss, live birth rate, uterine rupture, PAS occurrence, delivery timing, and surgical complications. Among 110 CSP diagnoses, 70 were viable, with 19 (27.1%) electing for expectant management. The average gestational age at diagnosis was 9.2 ± 0.7 weeks. Early pregnancy loss occurred in one case (5.3%). Two patients (10.5%) underwent successful transvaginal ultrasound-guided feticide due to sac protrusion into the bladder seen on a subsequent ultrasound. Of the remaining 16, hysterectomy rates were 73.7% by intention-to-treat and 87.5% for ongoing pregnancies. Two patients (10.5%) required a gravid hysterectomy in the first trimester, one for hemorrhage requiring massive transfusion and the second for sepsis. The remaining 14 patients reached the third trimester resulting in a live birth, for an overall live birth rate of 73.7% with 12 (85.7%) undergoing Caesarean hysterectomy due to placenta increta or percreta between 29 and 35 weeks. Uterine conservation was achieved in two cases of focal accreta. A urologic injury occurred in one delivery (7.1%). Expectant management in live CSP presents considerable maternal risk, predominantly necessitating hysterectomy. However, three-quarters of patients achieved a live birth, all preterm, emphasising the need for rigorous clinical decision-making and patient education regarding associated risks.