Efficacy and Safety of Treatment Modalities for Cesarean Scar Pregnancy: A Systematic Review and Network Meta-Analysis.

OBJECTIVE: Cesarean scar pregnancy (CSP) may lead to varying degrees of complications. There are many treatment methods for it, but there is no unified or recognized treatment strategies. The study of systematic review and network meta-analysis is to observe the efficacy and safety of treatment modalities for patients with CSP.

DATA SOURCES: MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from their inception to January 31, 2024. Additionally, relevant reviews and meta-analyses were manually searched for additional references.

STUDY ELIGIBILITY CRITERIA: Our study incorporated head-to-head trials involving a minimum of ten women diagnosed with CSP through ultrasound imaging or magnetic resonance imaging (MRI), encompassing a detailed depiction of primary interventions and any supplementary measures. Trials with a Newcastle-Ottawa Scale (NOS) score below 4 were excluded due to their low quality.

STUDY APPRAISAL AND SYNTHESIS METHODS: We conducted a random-effects network meta-analysis and review for cesarean scar pregnancy. Group-level data on treatment efficacy and safety, reproductive outcomes, study design and demographic characteristics were extracted following a predefined protocol. Studies' quality was assessed using the Cochrane risk-of-bias tools for randomized controlled trials (RCT) and the Newcastle‒Ottawa scale (NOS) for cohort studies and case series. The main outcomes were efficacy (initial treatment success) and safety (complications), of which summary odds ratios (ORs) and the surface under the cumulative ranking curve (SUCRA) using pairwise and network meta-analysis with random effects.

RESULTS: Seventy-three trials (7 RCTs) assessing a total of 738369 women and 17 treatment modalities were included. Network meta-analyses were rooted in data from 7373 trials that reported success rates and 55 trials that reported complications. The findings indicate that laparoscopy (Lap), transvaginal resection (TVR), hysteroscopic curettage (Hys) and High-intensity focused ultrasound combined with suction curettage (HIFU+SC) demonstrated the highest cure rates, as evidenced by SUCRA rankings of 91.2, 88.2, 86.9 and 75.3, respectively. When compared to suction curettage (SC), the odds ratios of efficacy were 6.76 (1.99, 23.01) for Lap, 5.92 (1.47, 23.78) for TVR, 5.00 (1.99, 23.78) for Hys and 3.27 (1.08, 9.89) 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.

CONCLUSION: Our findings indicate that Lap, TVR, Hys and HIFU+SC procedures exhibit superior efficacy with reduced complications. The utilization of methotrexate (both locally guided injection and systemic administration) as a standalone medical treatment is not recommended.