Beyond β-human chorionic gonadotropin: Caesarean scar pregnancy type, serum β-human chorionic gonadotropin levels, and primary treatment outcomes—a retrospective study

Background: Cesarean scar pregnancy (CSP) is a rare but potentially life-threatening form of ectopic pregnancy in which implantation occurs at the site of a previous cesarean section scar. Based on imaging characteristics, CSP is classified into Type I (endogenic) and Type II (exogenic), with important implications for management and outcomes. Although serum β-human chorionic gonadotropin (β-hCG) is commonly used to guide treatment decisions in ectopic pregnancy, its relationship with CSP type and treatment success remains unclear. Aims and Objective: The aim of the study was to evaluate the relationship between CSP type, serum β-hCG levels at diagnosis, and primary treatment outcomes. Materials and Methods: This retrospective observational study was conducted at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, from September 2022 to August 2025. Thirty women diagnosed with CSP on transvaginal ultrasound and/or magnetic resonance imaging were included. Cases were classified as Type I or Type II based on the direction of gestational sac growth and residual myometrial thickness. Clinical presentation, gestational age (GA), serum β-hCG levels at diagnosis, treatment modality, and primary treatment outcomes were analyzed. Results: Of the 30 women, 15 (50%) had Type I CSP and 15 (50%) had Type II CSP. The mean serum β-hCG level at diagnosis was 17,063 ± 15,706 mIU/mL and did not differ significantly between Type I and Type II CSP (P=0.16). Primary treatment was successful in 16 patients (53.3%), with comparable success rates between Type I (60%) and Type II CSP (46.7%; P=0.72). Serum β-hCG levels and GA at diagnosis were similar between women with successful and failed primary treatment (P>0.05). However, medical management was significantly more successful in Type I CSP compared with Type II CSP (75% vs. 0%, P=0.033). Conclusion: Serum β-hCG levels and GA at diagnosis do not reliably predict primary treatment success in CSP. Instead, CSP subtype plays a crucial role in determining the effectiveness of specific treatment modalities. Medical management appears suitable primarily for carefully selected Type I CSP, whereas Type II CSP is more effectively managed with early surgical intervention. These findings support an anatomy-based, individualized approach to the management of CSP.