Successful Use of Myosure in the Management of Cesarean Scar Ectopic Pregnancy

Cesarean scar pregnancy (CSP) is a very serious complication of a prior cesarean delivery. The major risks associated with CSP are uncontrolled hemorrhage and uterine rupture, potentially leading to future infertility. Management of CSP remains a major obstetric challenge without a well-defined therapeutic procedure. Dilation & curettage is a commonly used procedure for the treatment of CSP. However, it can be ineffective and often leads to definite infertility. Therefore, we present a case of the successful use of an alternative procedure, Myosure® hysteroscopy, in the treatment of CSP. We herein report the case of a 32-year-old G5P3013 woman who presented with vaginal bleeding and past history of three cesarean sections. She was found to have a CSP with fetal pole and cardiac activity at 6 weeks 2 days. The patient was initially treated with a systemic methotrexate injection, but there was persistence of cardiac activity. A second course of methotrexate was administered into the gestational sac, which systemically led to successful fetal cardiac arrest and downtrend of beta-human chorionic gonadotropin (HCG) level. A dilation & curettage procedure was not successful in removing products of conception. A Myosure hysteroscopy procedure, however, was successful in removing products of conception. The patient was discharged after a negative ultrasound and beta-HCG level. In our review of the literature, we found that there is no general consensus on the management of cesarean scar ectopic pregnancies. To date, there is no literature cited about the use of Myosure for cesarean scar ectopic pregnancies. However, our case suggests that Myosure can be effective for CSP and this warrants a larger-scale controlled study to better evaluate this as a treatment for this condition.

Approaches in the Treatment of Cesarean Scar Pregnancy and Risk Factors for Intraoperative Hemorrhage: A Retrospective Study

Background: Cesarean scar pregnancy (CSP) involves a rare form of placental attachment that often leads to life-threatening conditions. The best treatment for CSP has been debated for decades. We aimed to evaluate the different treatments for CSP and analyzed the risk factors for intraoperative hemorrhage.

Methods: CSP patients treated at the Affiliated Hospital of Jiangnan University were reviewed retrospectively from January 2014 to 2020. CSP was classified into three types based on the location and shape of gestational tissue, blood flow features, and thickness of the myometrium at the incision site. The clinical characteristics, types, approaches of treatment, and clinical outcomes of CSP were analyzed.

Results: A total of 55 patients were included in this study, 29 (52.7%) of whom underwent transvaginal curettage after uterine artery embolization (UAE) and 22 (40%) of whom underwent transabdominal ultrasound-guided hysteroscopic curettage (USHC) in type I and II. Four patients (7.3%) classified as type III underwent laparoscopic cesarean scar resection (LCSR). Intraoperative blood loss, blood transfusion rate, and scar diverticulum were significantly higher in type II than in type I (P < 0.05). Even though USHC showed no differences in intraoperative blood loss, length of stay, and scar diverticulum compared with curettage after UAE (P > 0.05), superiority was found in surgical time and hospitalization cost (P < 0.05). Furthermore, the type of CSP (OR = 10.53, 95% CI: 1.69–65.57; P = 0.012) and diameter of the gestational sac (OR = 25.76, 95% CI: 2.67–248.20; P = 0.005) were found to be risk factors for intraoperative hemorrhage.

Conclusions: Transabdominal ultrasound-guided hysteroscopic curettage is an effective and relatively safe treatment option for patients with CSP. Type of CSP and diameter of the gestational sac were found to be associated with excessive intraoperative hemorrhage.

A Comparison of Transvaginal Removal and Repair of Uterine Defect for Type II Cesarean Scar Pregnancy and Uterine Artery Embolization Combined With Curettage

Background: There is no consensus on a standardized therapy for type II cesarean scar pregnancy (CSP II). The objective of the present study was to evaluate the efficacy and safety and compare costs associated with transvaginal removal and repair (TRR) of uterine defect for CSP II to those of uterine artery embolization (UAE) and curettage.

Methods: We conducted a retrospective study that included 87 patients diagnosed with CSP II and treated by performing UAE in combination with curettage and hysteroscopy (n = 53), or TRR (n = 34). Clinical data and outcomes were analyzed.

Results: UAE and TRR groups exhibited similar success rates. The TRR group had significantly lower complication rates (30.19 vs. 8.82%, P < 0.05) and lower total costs (13,765.89 ± 2,029.12 vs. 9,063.82 ± 954.67, P < 0.05) than the UAE group. The anterior myometrium of the lower uterine segment was relatively thicker after performing TRR, and no patient suffered from recurrent CSP II. The proportion of patients in the TRR group who had full-term delivery without uterine rupture was 88.24% (30/34), while four patients failed to pregnancy.

Conclusion: TRR is a safe and effective treatment method for patients with CSP II and presents a highly cost-effective outcome, especially for patients with future fertility desire.

The diagnostic value of 3.0T MRI in cesarean scar pregnancy

OBJECTIVE

The purpose was to evaluate the diagnostic value of 3.0T MRI in cesarean scar pregnancy (CSP).

METHODS

56 patients with suspected CSP treated in our hospital from August 2018 to July 2020 were recruited as the study cohort and diagnosed using ultrasound and 3.0T MRI. With the pathological examination results as the gold standard and the ultrasound examination results as a comparison, the diagnostic value of 3.0T MRI was evaluated according to the diagnostic accuracy, sensitivity, specificity, and positive and negative misdiagnosis rates, etc. Results: The pathological examination showed that 33 patients were positive for CSP but the other 23 were negative. The accuracy, sensitivity, and specificity of 3.0T MRI in the CSP diagnoses were significantly higher than the accuracy, sensitivity, and specificity of the ultrasound diagnoses (P<0.05), and the positive and negative misdiagnosis rates were significantly lower than the misdiagnosis rates of the ultrasound diagnosis (P<0.05). Moreover, the images from two patients showed that 3.0T MRI can provide clear images of the patients' lesion locations.

CONCLUSION

Compared with ultrasound diagnoses, 3.0TMRI has significant advantages in diagnosing CSP and has a high clinical value.

A Comparison of Ultrasound Guided Curettage With and Without Uterine Artery Embolization on Controlling Intraoperative Blood Loss for a Cesarean Scar Pregnancy Treatment: Study Protocol for a Randomized Clinical Trial

Introduction

Cesarean scar pregnancy affects 6% of all ectopic pregnancies in women with prior cesarean section, and there is currently no consensus on the optimal treatment. Options of surgical treatment have a risk of intraoperative blood loss; therefore, uterine artery embolization (UAE) has been considered as an option of reducing intraoperative blood loss. However, UAE may be overused in clinical practice, especially in China. We present this protocol for a randomized clinical trial investigating the necessity of performing UAE for cesarean scar pregnancy, in combination with surgical suction curettage, taking into account the different subtypes of cesarean scar pregnancy. We recently developed a risk-scoring system (QRS) to estimate intraoperative blood loss, with 93.8% sensitivity and 6.3% false negative. Through this randomized clinical trial, we will retrospectively validate the QRS score on predicting intraoperative blood loss.

Methods and Analysis

We propose undertaking a randomized clinical trial sequentially recruiting 200 patients. All the patients will randomly receive ultrasound guided curettage with or without UAE. Data on the subtypes of cesarean scar pregnancy (Types 1 and II and III) detected by ultrasound will be collected before operation. The score on estimating intraoperative blood loss assessed by our recently developed quantitative risk-scoring system (QRS) will be collected before the operation. We will primarily compare the duration of the operation, intraoperative blood loss, and complications between the two groups. We will also retrospectively analyze the association of subtypes of cesarean scar pregnancy and the options of treatment and validate the QRS score. Outcomes of subsequent pregnancy within the 2-year follow-up will be secondary outcomes.

Trial Registration Number

[website], identifier ChiCTR2100041654.

A New Modified Hysteroscopic-Laparoscopic Surgery for Cesarean Scar Pregnancy of Stable Type III

Objective

To introduce a modified hysteroscopic-laparoscopic operation for cesarean scar pregnancy (CSP) of stable type III.

Patients and Methods

We retrospectively studied the case notes of 31 patients with stable type III cesarean scar pregnancy who underwent hysteroscopic-laparoscopic surgery in our hospital. Thirteen patients received the modified hysteroscopic-laparoscopic surgery (modified surgery group), and eighteen patients received traditional hysteroscopic-laparoscopic surgery (traditional surgery group).

Results

There was no significant difference in patients' age, gestational age, number of previous cesarean sections, the serum human chorionic gonadotropin (hCG) level before surgery, gestational sac diameter, myometrium thickness between the two groups. In the modified hysteroscopic-laparoscopic surgery, the mean surgical time was 50.45±24.45 mins, the mean length of stay in hospital was 4.50±0.50 days, which was significantly shorter than the traditional surgery group (84.75±33.28 mins and 5.50±0.75 days, respectively). And the intraoperative hemorrhage in the modified group was also less than that in the traditional group (40.50±12.25 mL vs 75.33±25.45mL). Whereas the time for hCG normalization, postoperative vaginal bleeding and menstrual recovery had no significant difference between the modified surgery group and the traditional surgery group. There was no recurrence of CSP in both groups.

Conclusion

The modified hysteroscopic-laparoscopic surgery had shorter operation time, less blood loss, and sooner recovery time after surgery compared to traditional hysteroscopic-laparoscopic surgery, which could be more beneficial to our patients and should be applied in clinics generally.

Outcomes of cesarean scar pregnancy treatment: Do we have options?

Objective:

To investigate the success and complications of medical and surgical modalities used in the treatment of cesarean scar pregnancies.

Materials and Methods:

Medical and surgical approaches that have been used to treat cesarean scar pregnancies were evaluated retrospectively, Local, systemic, and combined methotrexate treatments were grouped as the medical approach, and dilatation and evacuation, hysteroscopic resection, laparoscopic and laparotomic approaches were grouped as the surgical approach. Fifty-three patients were diagnosed as having cesarean scar pregnancy during the study period, 48 of whom were included in the final analysis. Eighteen patients were treated with medical interventions and 30 patients were treated surgically.

Results:

The success rate of surgical modalities was 96.6% and the medical treatment success was 33% (p<0.001). The complication rate was higher with medical approaches compared with surgical methods (66% vs 3.3%, respectively; p<0.001).

Conclusion:

Surgical intervention seems safer and more successful than medical treatment.

Contrast-enhanced ultrasound in uterine artery embolization treatment of cesarean scar pregnancy

Objective

The current study aimed to investigate the application of contrast-enhanced ultrasound (CEUS) in diagnosis and treatment of cesarean scar pregnancy (CSP).

Methods

A retrospective study was performed in 35 patients with clinically suspected CSP who requested termination of pregnancy and underwent contrast-enhanced ultrasound (CEUS). The patients were classified into two groups on the basis of whether they received uterine artery embolization (UAE). The CEUS characteristics of the two groups were reviewed.

Results

CEUS features of CSP were early enhancement of the cesarean scar and continuous infusion of contrast agent between the gestational sac and cesarean scar. Myometrial thickness in the cesarean scar was thinner in the UAE group than in the non-UAE group by CEUS and transvaginal ultrasound. Myometrial thickness measured by CEUS was thinner than that measured by transvaginal ultrasound in both groups. The parameters of the time-intensity curve in the UAE group were characterized by a faster arrival time, shorter time to peak, higher peak intensity, and greater enhancement rate compared with the non-UAE group.

Conclusions

CEUS may be a novel supplementary method to diagnose and assess CSP, and to help evaluate whether UAE is required.

Management for delayed diagnosis in cesarean scar pregnancy with hemorrhage intra- or postuterine dilation and curettage

Aim

This study aimed to examine the characteristics, management, and outcomes of delayed diagnosis of cesarean scar pregnancy (CSP) with hemorrhage intra‐ or postuterine curettage for early pregnancy termination.

Methods

The retrospective study, cases were identified from the interrogation of the hospital database and clinical data including the success rate of different treatments, vaginal bleeding time, abnormal beta‐human chorionic gonadotropin (β‐hCG) time, and menstrual recovery time, preservation of uterus were analyzed.

Results

Medical records of 80 confirmed CSP cases with dilation and curettage (D&C) as primary treatment were analyzed; among them, 22 were treated with uterine arterial embolization (UAE) + methotrexate (MTX); 32 with UAE + surgery; 26 with only surgery or resection and repair. Treatment with UAE had less intraoperative blood loss (p < 0.05). UAE + surgery treatment had the highest success rate (96.8%, p < 0.05), the least vaginal bleeding duration after treatment (11.9 ± 9.6 days, p < 0.05), and least β‐hCG normalization time (17.4 ±  7.8 days, p < 0.05).

Conclusion

UAE + surgery treatment is a favorable and effective option to control massive hemorrhage intra‐ or post‐uterine curettage for early CSP termination.

Pituitrin local injection versus uterine artery embolization in the management of cesarean scar pregnancy: A retrospective cohort study

AIM

To compare the effect of pituitrin local injection (PIT) and uterine artery embolization (UAE) as pretreatment before surgery during the management of cesarean scar pregnancy (CSP).

METHODS

Forty-nine CSP patients diagnosed in our department of Suzhou Ninth People's Hospital from October 2017 to October 2019. All patients underwent hysteroscopy and negative pressure aspiration (for type I CSP) or laparoscopic wedge-resection (for type II and III CSP) following one of the preoperative treatments: PIT group (n = 26) and UAE group (n = 23). The baseline clinical data, intraoperative blood loss, blood transfusion rate, postoperative hospital stay, hospitalization expenses, postoperative pain, postoperative fever, postoperative serum β-human chorionic gonadotropin (β-hCG) level, and pregnancy outcome were reviewed and analyzed.

RESULTS

There was no significant difference (p ≥ 0.05) between two groups in baseline characteristics including age, gravidity, previous cesarean section times, interval since last cesarean delivery, menolipsis time, maximum diameter of gestational sac or mass under ultrasound, fetal cardiac activity and preoperative β-hCG level. There was no significant difference in blood loss, transfusion rate, and postoperative β-hCG reduction percentage (p ≥ 0.05) either. The postoperative hospital stay, hospitalization expenses, postoperative pain, and postoperative fever rate in PIT group were significantly lower than those in UAE group (p < 0.05). Moreover, β-hCG level of all patients turned negative 1 month after surgery successfully.

CONCLUSIONS

PIT pretreatment seems to be a same effective, more economical, and with fewer side effects pretreatment method compared to traditional UAE pretreatment in the management of CSP.

Extreme enhanced myometrial vascularity following cesarean scar pregnancy: a new diagnostic entity

OBJECTIVE

To define, illustrate and to follow-up the diagnosis, pathophysiology and treatment of a subset of the known enhanced myometrial vascularity (EMV): its extreme form, associated with cesarean scar pregnancies (CSP) and with some cases pf placenta accreta spectrum being at increased risk of significant bleeding complications. We also aim to provide guidance to the management of such cases.

MATERIAL AND METHODS

This is an IRB-approved retrospective observational study of thirteen patients with an extreme form of EMV complicating CSPs. Patient's age, parity, number of cesarean deliveries, initial and time to negative serum hCG levels, primary and secondary diagnoses, blood flow peak systolic velocities, primary and secondary treatments, uterine artery embolization and outcomes were recorded.

RESULTS

Gestational ages ranged 6-11 weeks at initial presentation. Initial serum hCG was 20.0-102.48 mIU/L (mean 44.4 mIU/L). Diameter of EMV reached 20-75 mm (mean 46.8 mm). The mean peak systolic velocity (PSV) was 84.2 cm/s (range 46.7-118.0). Primary treatments were: systemic methotrexate (MTX) alone; D&C alone; MTX and D&C; local and systemic intra-gestational MTX injection; double cervical ripening balloon with systemic MTX; misoprostol and D&C; emergent UAE. UAE and hysterectomy were the two main secondary treatments in 10 women except 1 having a D&C after UAE, and in 1 the lesion regressed without secondary treatment. Mean time to nonpregnant hCG levels was 21-122 days (mean 67.2). Mean follow-up was 110.2 days (range 26-160). Ten women were treated with UAE, 6 had one, 3 had two embolizations. Two women had hysterectomies, one of these for persistent bleeding. Based upon the common denominators of the clinical and the US pictures, our definition of extreme EMV is sustained form of EMV associated with treated or untreated CSP, with peak systolic velocities of blood flow over 50 cm/s, slow return or plateauing serum hCG, with or without clinically significant vaginal bleeding, unresponsive to initial or secondary treatment requiring uterine artery embolization or hysterectomy.

CONCLUSION

The EMV developing in the background of retained placental tissue associated with CSP differs following the normal regression of the physiologically re-modelled, dilated vascular bed from the faulty "disrepair" of the vessel wall in in treated or untreated CSPs. The "threatening" appearance of the above EMVs warranted the term "extreme", creating their separate new sub-category." Extreme forms of CSP-related EMV pose significant diagnostic and management challenges. Prompt recognition and intervention, the proactive use of UAE, can maximize the outcome of women affected by this "extreme" form of EMV enabling to preserve reproductive potential. Obstetricians, gynecologists and interventional radiologists should be aware of this form of severe vascular complication.

Cesarean scar ectopic pregnancy: A cause of failed first trimester surgical termination of pregnancy (case report)

Cesarean scar (ectopic) pregnancy is due to blastocyst implantation on a Caesarean scar. The current case presented by vaginal bleeding after a failed surgical termination of pregnancy. The ultrasound scan revealed a cesarean scar ectopic pregnancy managed by surgical removal. The possibility of cesarean scar ectopic pregnancy should be considered in any case presenting with a low-lying gestational sac.

Clinical Assessment of Ultrasound-Guided Local Lauromacrogol Injection Combined With Curettage and Hysteroscopy for Cesarean Scar Pregnancy

Background: To evaluate the efficacy, safeness and cost of ultrasound-guided local lauromacrogol injection (USG-LLI) combined with curettage and hysteroscopy for cesarean scar pregnancy (CSP).

Methods: This was a retrospective study included 151 CSP patients diagnosed with CSP from June 2017 to December 2019, and treated by USG-LLI (n = 86) or uterine artery embolization (UAE) (n = 65) combined with curettage and hysteroscopy. Clinical data and outcome were analyzed.

Results: There were no significant differences in basic clinical characteristics in the two groups. Two groups showed the similar success rates. USG-LLI group, compared with UAE group had significantly lower complication rates (9.30 vs. 44.62%), lower total costs (both medical and non-medication cost) (p < 0.05).

Conclusions: USG-LLI combined with curettage and hysteroscopy is a feasible method to treat CSP with minimal invasion and high efficacy. Moreover, compared with curettage after UAE, USG-LLI exhibited lower complication rate and required fewer expenses.

A comparison between laparoscopy and hysteroscopy approach in treatment of cesarean scar pregnancy

The aim of the study was to compare the efficacy of laparoscopy and hysteroscopy for the treatment of cesarean scar pregnancy (CSP) and analyze the clinical factors associated with successful selection for hysteroscopic or laparoscopic treatment of CSP.We retrospectively studied 112 cases of CSP that were treated by laparoscopy and/or hysteroscopy in our hospital from December 2014 to December 2017. In total, 72 of these patients underwent ultrasound-guided curettage and hysteroscopic resection without uterine scar defect repair. Fourty of these patients underwent laparoscopic resection and repair of the uterine scar defect. We analyzed the different clinical variables between the 2 groups and identified the clinical factors which could predict the need for the laparoscopic repair of uterine scar defect. Results showed that laparoscopy and hysteroscopy were safe ways to treat CSP, and no patient underwent hysterectomy. The β-hCG level in both of the 2 groups decreased to normal 4 to 8 weeks after surgery. There were significant differences between the hysteroscopy group and laparoscopy uterine scar repair group in terms of days of amenorrhea, gestational sac diameter, myometrial thickness, operation time, intraoperative blood loss, and hospitalization duration (P < .05). Logistic regression analysis showed that the days of amenorrhea, gestational sac diameter and myometrial thickness were independent risk factors for CSP treated by minimally invasive surgery, which were also shown by ROC curve analysis to be predictors of the need for the repair of the uterine scar defect, with optimal cutoffs of 52.50 days, 3.25 cm, and 2.05 mm, respectively; and the areas under their corresponding ROC were 0.721, 0.851, and 0.927, respectively.We conclude that laparoscopy and hysteroscopy are safe and efficient minimally invasive procedures for the treatment of CSP. The days of amenorrhea, gestational sac diameter and myometrial thickness may be key factors associated with successful selection for hysteroscopic or laparoscopic treatment of CSP.

Prospective First-Trimester Ultrasound Imaging of Low Implantation and Placenta Accreta Spectrum

OBJECTIVES

To prospectively evaluate low implantation of the gestational sac and other first-trimester ultrasound (US) parameters for prediction of placenta accreta spectrum (PAS).

METHODS

Women with a diagnosis of low implantation on clinically indicated first-trimester US underwent a transvaginal US examination at 10 to 13 weeks' gestation to assess the trophoblast location, anechoic areas, bridging vessels, and smallest myometrial thickness (SMT). The placental location was evaluated in the second trimester, and serial US examinations were performed in cases of low placentation. Placenta accreta spectrum was based on clinical findings and confirmed by histologic results.

RESULTS

Of 68 women, 40 (59%) had prior cesarean delivery (CD). Hysterectomy was performed in 8, all with prior CD. Of these, 7 (88%) had US suspicion of PAS. In 16 with prior CD and basalis overlying the internal os, 9 (56%) had second-trimester placenta previa, and 7 of 9 (78%) underwent hysterectomy with pathologic confirmation of PAS. Of 28 without prior CD, there were no cases of persistent low placentation in the third trimester regardless of the trophoblast location. Ultrasound parameters associated with PAS were a smaller distance from the inferior trophoblastic border to the external os, disruption of the bladder-serosal interface, bridging vessels, anechoic areas, and the SMT. In women with prior CD, use of the SMT in the sagittal plane yielded an area under the receiver operating characteristic curve of 0.96 (95% confidence interval, 0.91-1.00).

CONCLUSIONS

First-trimester low implantation increases the risk of persistent placenta previa and PAS in women with prior CD. All parameters were associated with PAS, the most predictive being the SMT.

Late-diagnosed cesarean scar pregnancy resulting in unexpected placenta accreta spectrum necessitating hysterectomy

Cesarean scar pregnancy (CSP) is a rare complication involving the implantation of the gestational sac in a cesarean delivery scar. The authors report a case of unexpected placenta accreta spectrum (PAS) caused by late diagnosed CSP, necessitating emergent hysterectomy. A 28-year-old Japanese woman with two previous cesarean deliveries presented to our hospital at 11 weeks of gestation with abnormal transvaginal ultrasound findings obtained at another hospital;however, transabdominal ultrasound revealed that the fetus was already present in the uterine cavity at this time. At 28 weeks, there was no evidence of placenta previa. The woman developed preeclampsia at 29 weeks, and a cesarean section was conducted. Intraoperative findings confirmed PAS, and hysterectomy was conducted immediately.

Clinical characteristics and treatment of different types of cesarean scar pregnancy

OBJECTIVES

The purpose of this study was to evaluate the clinical characteristics and compare the treatment efficacy of different types of cesarean scar pregnancy (CSP).

MATERIAL AND METHODS

We performed a retrospective chart review of 66 women (69 cases) with CSP who received treatment with mifepristone/methotrexate (MTX) plus curettage, uterine artery embolization (UAE) plus curettage, additional MTX, or laparotomy, and compared the clinical characteristics, treatment efficacy, and occurrence of complications among 3 types of CSP (partial, complete, and mass type).

RESULTS

Review of the 69 cases revealed a considerable increase of gestational duration(p < 0.001), sac/lesion size(p < 0.001) and vaginal bleeding (p < 0.05) in patients with mass-type CSP compared to that of other types. All CSP cases were successfully treated, 4 cases of mass-type received laparotomy and none of the cases required a hysterectomy. Severe bleeding was observed in 2 cases of partial-type and complete-type, respectively, and 3 cases for mass-type. Moreover, bleeding occurred during initial treatment with mifepristone plus curettage in partial-type cases, but not with UAE plus curettage.

CONCLUSIONS

UAE plus curettage is a more effective treatment option for partial- and complete-type of CSP than mifepristone plus curettage. The cases of mass-type often need surgery and are prone to have longer gestational duration, larger lesions, and more vaginal bleeding.

Prediction of Delivery Complications by First-Trimester Ultrasound Measurement of the Gestational Sac's Distance From a Previous Cesarean Section Scar

OBJECTIVES

This study was designed to investigate the clinical relationship between labor complications in the second and third trimesters and the distance from the gestational sac to a previous cesarean section (CS) scar.

METHODS

We conducted a retrospective review of the electronic medical records and included all 7- to 9-week transvaginal ultrasound examination reports from pregnancies with a history of a single cesarean delivery in our hospital between January 2015 and December 2017. Women were divided into 6 groups according to the distance of the gestational sac to the CS scar (groups A-F). A composite of pregnancy outcomes (gestational age at birth, delivery mode, placental abnormality, blood loss, uterine rupture, and hysterectomy) and other maternal and neonatal outcomes were assessed.

RESULTS

A total of 699 cases were included in our study. The median gestational age was 39.0 (range, 38.1-39.9) weeks. The median intrapartum blood loss volume was 400 (range, 300-500) mL. The results showed no statistically significant difference in blood loss (P = .297) or birth weight of the neonate (P = .318) among the distance subgroups. Overall, the fetuses were stillborn in 9 of 699 cases (1.29%). There was a statistically significant difference in a morbidly adherent placenta, placenta previa, and preterm labor, and their incidence increased with decreasing distance (P < .001; P for trend < .05). There was no statistically significant difference in uterine rupture (P = .597) or the delivery mode (P = .187) among the subgroups.

CONCLUSIONS

The relative positions of a CS scar and the gestational sac in the first trimester are associated with the incidence of placental abnormalities. As the distance decreases, the extent of a morbidly adherent placenta increases.

Cesarean scar pregnancy combined with arteriovenous malformation successfully treated with transvaginal fertility-sparing surgery: A case report and literature review

INTRODUCTION

A cesarean scar pregnancy (CSP), when combined with an arteriovenous malformation (AVM), is a rare, but potentially life-threatening condition that may be associated with uncontrolled hemorrhage. Hysterectomy is indicated when conservative treatment fails. Preservation of fertility is challenging.

PATIENT CONCERNS

We reported a 33-year-old woman with a CSP combined with an AVM who failed methotrexate administration as conservative treatment.

DIAGNOSES

A CSP combined with an AVM was diagnosed via three-dimensional color Doppler angiogram and magnetic resonance imaging.

INTERVENTIONS

Transvaginal removal of the ectopic gestation and repair of the uterine defect was performed without incident.

OUTCOMES

The fertility of the patient was preserved and hysterectomy was avoided.

CONCLUSION

Transvaginal fertility-sparing surgery may be successfully performed to prevent hysterectomy when conservative treatment fails in patients with a CSP combined with an AVM.

Reproductive outcome after cesarean scar pregnancy: A systematic review and meta-analysis

INTRODUCTION

To evaluate subsequent reproductive among women with a prior cesarean scar pregnancy (CSP).

MATERIAL AND METHODS

MEDLINE, Embase and ClinicalTrials.gov databases were searched. Inclusion criteria were women with a prior CSP, defined as the gestational sac or trophoblast within the dehiscence/niche of the previous cesarean section scar or implanted on top of it. The primary outcome was the recurrence of CSP; secondary outcomes were the chance of achieving a pregnancy after CSP, miscarriage, preterm birth, uterine rupture and the occurrence of placenta accreta spectrum disorders. Subgroup analysis according to the management of CSP (surgical vs non-surgical) was also performed. Random effect meta-analyses of proportions were used to analyze the data.

RESULTS

Forty-four studies (3598 women with CSP) were included. CSP recurred in 17.6% of women. Miscarriage, preterm birth and placenta accreta spectrum disorders complicated 19.1% (65/341), 10.3% (25/243) and 4.0% of pregnancies, and 67.0% were uncomplicated. When stratifying the analysis according to the type of management, CSP recurred in 21% of women undergoing surgical and in 15.2% of those undergoing non-surgical management. Placenta accreta spectrum disorders complicated 4.0% and 12.0% of cases, respectively.

CONCLUSIONS

Women with a prior CSP are at high risk of recurrence, miscarriage, preterm birth and placenta accreta spectrum. There is still insufficient evidence to elucidate whether the type of management adopted (surgical vs non-surgical) can impact reproductive outcome after CSP. Further large, prospective studies sharing an objective protocol of prenatal management and long-term follow up are needed to establish the optimal management of CSP and to elucidate whether it may affect its risk of recurrence and pregnancy outcome in subsequent gestations.

Cesarean scar pregnancy - case resports and literature review

The current increase in the percentage of cesarean sections is accompanied by a significant growth in the incidence of cesarean scar pregnancies (CSP) located in the lower uterine segment, while the advancements in diagnostic ultrasound techniques have led to an increased number of CSP diagnoses. A misdiagnosed cesarean scar pregnancy, or one that is diagnosed too late, is a threat to the pregnant patient's life, and predisposes her to such complications as hemorrhage or uterine rupture, which often necessitate hysterectomy and therefore result in irreversible fertility loss. In this paper 4 cases of ectopic pregnancies located within the cesarean scar in women hospitalized at the university clinical center, within a short span of merely three months in 2018, are presented. The purpose of this paper is to indicate to doctors and gynecology and obstetric societies that there is a very urgent need for drawing up guidelines for CSP management. To this effect, information about individual cases should be gathered and analyzed thoroughly, latest reports followed, and knowledge skills and experience shared in order to be able to work out a procedure that is both effective and as safe as possible.

Validation of a 10-Point Scoring System for Treatment of Cesarean Scar Pregnancy

Purpose

To validate a 10-point scoring system for the prediction of successful treatment modality in patients with cesarean scar pregnancy (CSP).

Patients and Methods

Data were collected from women seen between April 1, 2018, and June 30, 2019, at the Second Affiliated Hospital of Army Medical University of China who were diagnosed with CSP and underwent evacuation, followed by uterine artery embolization (UAE) and successive laparoscopic local resection as salvage treatment if necessary. A score was computed based on clinical and ultrasonographic parameters included in a previously developed scoring system. Treatment indicated by the scoring system was compared with actual treatment received. Receiver operating characteristic (ROC) curves were used to identify cut-off scores for salvage treatment.

Results

Of 183 women, 108 were successfully treated by evacuation, 57 required UAE, and 18 eventually underwent laparoscopic surgery. Among 97 women scoring 0–4, 89 (91.8%) were treated by evacuation only. Of 69 women scoring between 5 and 7, 44 (63.8%) needed UAE following evacuation. Of 17 women scoring 8–10, 10 women (58.8%) underwent laparoscopic surgery. A cut-off of 4.145 was obtained by ROC curve for prediction of any salvage treatment; this was comparable to the scale’s conventional cut-off of 4. The cut-off score for women requiring laparoscopic surgery was 6.580, which was lower than 8 obtained in the scale’s initial validation.

Conclusion

The overall performance of the 10-point scoring system was moderate for predicting successful treatment modalities of women with CSP, but the scale showed good predictive ability in recognizing women needing only evacuation before recovery.

Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use:

https://youtu.be/tsQjjM4rS6Y

First-trimester treatment of cesarean scar pregnancy using a cervical ripening-double-balloon catheter: A case report

Cesarean scar pregnancies are relatively rare. In the first trimester, if the decision is made to terminate the pregnancy, it should be done as soon as possible to avoid complications. We report a successful termination of a live, 6 weeks and 4 days cesarean scar pregnancy using a double-balloon cervical ripening catheter in a patient with two previous cesarean deliveries.

Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy

Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).