Therapeutic curettage as a safe and effective first-line approach in cesarean scar pregnancy: A single-center comparative analysis with the literature

Objective: Cesarean scar pregnancy (CSP) is a rare ectopic pregnancy implanted in a previous cesarean scar and is associated with risks of hemorrhage, uterine rupture, and infertility. Rising cesarean rates have increased its incidence, accounting for up to 6% of ectopic pregnancies. Diagnosis is made by transvaginal ultrasound, which typically shows an empty uterine cavity and a gestational sac at the anterior isthmus with thin myometrium. Treatment options include methotrexate, uterine artery embolization, hysteroscopic or laparoscopic excision, and curettage. No consensus standard exists; management should be individualized. Material and Methods: We retrospectively analyzed 129 CSP patients treated between 2015 and 2025 at Zeynep Kamil Hospital, Istanbul. Inclusion required an ultrasound-confirmed diagnosis and complete hematologic data. Patients managed conservatively or with incomplete records were excluded. Treatment included primary curettage, methotrexate plus curettage, or laparoscopic repair. Curettage was ultrasound-guided using a Karman cannula. Hemoglobin and hematocrit levels were compared pre-and postoperatively, and transfusion needs were documented. Results: Of the 129 patients, 123 (95.4%) underwent curettage, 3 underwent methotrexate plus curettage, and 3 underwent laparoscopic repair. The mean hemoglobin drop was 0.8 g/dL (p<0.001), and the mean hematocrit decrease was 2.2% (p<0.001). Only 3 patients (2.3%) required transfusion. Subgroup analysis showed greater hemoglobin decline in patients with a gestational age ≥8 weeks and fetal cardiac activity. Compared with the literature reporting larger declines and higher transfusion rates, our outcomes were favorable. Conclusion: Ultrasound-guided therapeutic curettage is a safe, effective, and fertility-preserving first-line treatment for CSP. It achieved low blood loss and minimal transfusion requirements compared with prior reports. Despite the retrospective design and lack of long-term follow-up, our results support curettage as a reliable option in appropriately selected patients.