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Altay MM, Mert SA, Gemici A, Kaplan M, Gelisen O. Successful technique of manual vacuum aspiration for treatment of type 2 cesarean scar pregnancies: evaluation of 40 cases. J Matern Fetal Neonatal Med 2019; 34:2693-2700. [PMID: 31575309 DOI: 10.1080/14767058.2019.1670807] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To demonstrate the effectiveness and safety of the defined manual vacuum aspiration (MVA) technique for treatment of type 2 cesarean scar pregnancies (CSPs). METHODS We treated 40 patients with CSP by MVA at the Early Pregnancy Clinic of our hospital between 1 January 2012 and 31 December 2014. The files of patients were reviewed and evaluated retrospectively. Eligibility criteria were hemodynamic stability and at least 2 mm myometrial thickness at the anterior part of the CSP. The key-point of successful MVA procedure is to keep away from entering the cesarean scar cavity directly; instead, CSP is displaced from the implantation site by applying vacuum, only while the cannula is passing near. RESULTS During the study period, the ratio of CSP to total pregnancies was 1/1000. The ratio of CSP to cesarean delivery (CD) was 1/372. In that time period, CSPs were constituted 4.41% of all ectopic pregnancies. Total of 40 patients were treated with dilatation and MVA. Complications such as excessive hemorrhage, persistence of CSP, and any need of extra intervention were not observed. The beta-hCG values of 21 patients (52.5%) decreased below 10 mIU/mL after the first 15 days, and the rest decreased below 10 mIU/mL after 3 weeks following MVA. CONCLUSIONS This MVA technique for treatment of CSP is easily applicable and effective method with high success and low complication rates. For appropriately selected patients, we think that this method can be considered as the first- line treatment.
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Affiliation(s)
- Mehmet Metin Altay
- Etlik Zubeyde Hanım Women's Health Education and Research Hospital, Ankara, Turkey
| | - Sule Atalay Mert
- Etlik Zubeyde Hanım Women's Health Education and Research Hospital, Ankara, Turkey
| | - Ali Gemici
- Obstetrics and Gynecology, Guven Hospital, Ankara, Turkey
| | - Metin Kaplan
- Etlik Zubeyde Hanım Women's Health Education and Research Hospital, Ankara, Turkey
| | - Orhan Gelisen
- Etlik Zubeyde Hanım Women's Health Education and Research Hospital, Ankara, Turkey
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Adkins JM, Thampy R, Thupili CR. Floating fetus: a rare complication of balloon tamponade treatment of caesarean scar ectopic pregnancy. BMJ Case Rep 2019; 12:12/1/e228500. [PMID: 30674501 DOI: 10.1136/bcr-2018-228500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Jake M Adkins
- Department of Diagnostic and Interventional Imaging, McGovern Medical School-UTHealth, Houston, Texas, USA
| | - Rajesh Thampy
- Department of Diagnostic and Interventional Imaging, McGovern Medical School-UTHealth, Houston, Texas, USA
| | - Chakradhar R Thupili
- Department of Diagnostic and Interventional Imaging, McGovern Medical School-UTHealth, Houston, Texas, USA
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Panaiotova J, Tokunaka M, Krajewska K, Zosmer N, Nicolaides KH. Screening for morbidly adherent placenta in early pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:101-106. [PMID: 30199114 DOI: 10.1002/uog.20104] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 08/10/2018] [Accepted: 08/12/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE To estimate the diagnostic accuracy of a two-stage strategy for early prediction of morbidly adherent placenta (MAP). In the first stage, at 11-13 weeks' gestation, women with low-lying placenta and history of uterine surgery are classified as being at high risk for MAP and, in the second stage, at 12-16 weeks, these high-risk pregnancies are assessed at a specialist MAP clinic. METHODS This was a prospective study in women having an ultrasound scan at 11-13 weeks' gestation as a part of routine pregnancy care. Women with low-lying placenta and a history of uterine surgery were followed up at a specialist MAP clinic at 12-16 weeks' gestation, 20-24 weeks and 28-34 weeks. At each visit to the MAP clinic, an ultrasound scan was carried out and the following features suggestive of MAP were recorded: non-visible Cesarean section scar; bladder wall interruption; thin retroplacental myometrium; presence of intraplacental lacunar spaces; presence of retroplacental arterial-trophoblastic blood flow; and irregular placental vascularization demonstrated by three-dimensional power Doppler. RESULTS Screening at 11-13 weeks was carried out in 22 604 singleton pregnancies, 1298 (6%) of which were considered to be at high risk of MAP because they had previous uterine surgery and low-lying placenta. At the MAP clinic at 12-16 weeks, the diagnosis of MAP was suspected in 14 cases and this was confirmed at delivery in 13. In the rest of the population, there were no cases of MAP. CONCLUSION Accurate prediction of MAP can be achieved by ultrasound examination at 12-16 weeks' gestation. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J Panaiotova
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - M Tokunaka
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K Krajewska
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - N Zosmer
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
| | - K H Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, UK
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Balalau OD, Corbu TA, Ples L, Dumitru VA, Stanescu AD. Cesarean scar defect- obstetric consequences. JOURNAL OF CLINICAL AND INVESTIGATIVE SURGERY 2018. [DOI: 10.25083/2559.5555/3.2/72.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Scope. This review aims to achieve a parallelism between literature studies on imaging diagnosis, the characteristics of cesarean scar defect and its evolution during pregnancy, and the obstetric consequences that can lead to increased maternal morbidity. Materials and Methods. There have been many literature studies published in recent years aimed to identify the methods of diagnosis for cesarean scar defect, the characteristics and the main changes of it during pregnancy, and the risks undertaken by pregnant women undergoing labor for vaginal delivery after a previous cesarean surgery. Results and Discussions. The most commonly used method for visualizing and evaluating uterine scar is transvaginal ultrasound in the first trimester of pregnancy, and abdominal ultrasonography in the II and III trimesters. The two areas characteristic of uterine scarring: "niche" and "thickness of the residual myometrium" undergo changes during the three trimesters of pregnancy. Some studies in the literature reported a higher incidence of uterine rupture, especially when the lower uterine segment fell below 2.3 mm, and a mean thickness of 3.2 mm, higher among multiparous women. A question that still does not have a generally valid answer refers to the hysterorrhaphy technique. There are different opinions among the authors, but most of them consider that after a double layer suture the thickness of the residual myometrium is higher. However, data from the literature show that the incidence of complications such as uterine rupture, dehiscence of the uterine trance are similar, regardless of the type of suture used. Another complication that occurs due to uterine scar is the pregnancy inserted at this level, which in the case of expectancy, leads to an increase in maternal and fetal morbidity. 50% of them evolve to spontaneous abortion in the first trimester, and almost all full-term pregnancies result in hysterectomy of necessity. Conclusions. Due to the many obstetrical and gynecological complications that occur on a uterine scar, an evaluation in dynamics is essential. There are no standardized protocols yet, but the identification and measurement of the uterine scar area in the third trimester may predict the chance of success of the labor test for vaginal delivery after cesarean surgery.
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Jauniaux E, Alfirevic Z, Bhide AG, Belfort MA, Burton GJ, Collins SL, Dornan S, Jurkovic D, Kayem G, Kingdom J, Silver R, Sentilhes L. Placenta Praevia and Placenta Accreta: Diagnosis and Management: Green-top Guideline No. 27a. BJOG 2018; 126:e1-e48. [PMID: 30260097 DOI: 10.1111/1471-0528.15306] [Citation(s) in RCA: 223] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Lin SY, Hsieh CJ, Tu YA, Li YP, Lee CN, Hsu WW, Shih JC. New ultrasound grading system for cesarean scar pregnancy and its implications for management strategies: An observational cohort study. PLoS One 2018; 13:e0202020. [PMID: 30092014 PMCID: PMC6084953 DOI: 10.1371/journal.pone.0202020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 07/26/2018] [Indexed: 12/05/2022] Open
Abstract
A cesarean section pregnancy (CSP) indicated the gestational sac (GS) implanted in the previous cesarean scar. The clinical manifestations of CSP present a wide range of variations, and the optimal management is yet to be defined. We retrospectively enrolled 109 patients with the diagnosis of CSP from our department and categorized them into four grades based on the ultrasound presentation. Grade I CSP indicated the GS embedded in less than one-half thickness of the lower anterior corpus; and grade II CSP represented the GS extended to more than one-half thickness of overlying myometrium. Grade III CSP implied the GS bulged out of the cesarean scar; and grade IV CSP denoted that GS became an amorphous tumor with rich vascularity at the cesarean scar. Seventy-eight women received surgery, and the complication rate was 14.1% (11/78). Linear regression analysis demonstrated a significant association between the invasiveness of the surgery and their ultrasound gradings. The mainstream operation for grade I CSP was transcervical resection, while the majority of grade III and IV patients required hysterotomy or hysterectomy. Another 31 women received chemotherapy with methotrexate as their initial treatment. The success rate for chemotherapy was 61.3%; the remaining patients required further surgery due to persistent CSP or heavy bleeding during or after chemotherapy. Fifteen patients (48.3%) receiving chemotherapy suffered from complications (mostly bleeding). Among them, 7 (22.6%) patients experienced bleeding of more than 1,000 mL, and 9 (29.0%) of these 31 patients required blood transfusions. Our novel ultrasound grading system for CSP may help to communicate between physicians, and determine the optimal surgical strategy. Chemotherapy with methotrexate for CSP is not satisfactory and is associated with a higher rate of complications.
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Affiliation(s)
- Shin-Yu Lin
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chia-Jung Hsieh
- Department of Public Health, Tzu Chi University, Hualien, Taiwan
| | - Yi-An Tu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-Ping Li
- Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Chien-Nan Lee
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Wen-Wei Hsu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jin-Chung Shih
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
- * E-mail:
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Liu J, Chai Y, Yu Y, Liu L. The value of 3-dimensional color Doppler in predicting intraoperative hemorrhage for cesarean scar pregnancy. Medicine (Baltimore) 2018; 97:e11969. [PMID: 30113503 PMCID: PMC6113015 DOI: 10.1097/md.0000000000011969] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 07/27/2018] [Indexed: 11/25/2022] Open
Abstract
The aim of this study is to evaluate the efficacy of 3-dimensional (3D) ultrasonography and 3D color power Doppler ultrasound in the management of cesarean scar pregnancy (CSP).A case-control study enrolled 190 CSP patients who underwent uterine artery embolization (UAE) in combination with dilatation and curettage (D&C). The maximum diameter of gestational sac or CSP mass, uterine scar thickness, and resistance index (RI) were measured by 2D ultrasound. The lesion volume, vascular index (VI), flow index (FI), blood vessels, and blood flow index (VFI) were assessed by 3D ultrasound. The changes of these parameters before and after UAE were analyzed. Then, the patients were divided into bleeding group and control group according to the intraoperative hemorrhage during D&C to access and compare the significance of 2D and 3D parameters in intraoperative hemorrhage.The mean VI and the mean VFI were significantly reduced after embolization (P < .01). In the bleeding group, the lesion volume and diameter of gestational sac or CSP mass were significantly larger, VI and VFI were significantly higher, the uterine scar thickness was thinner, and RI was lower (P < .05). The best indicator for prediction of massive intraoperative bleeding was the VI with an area under the curve of 0.870, the best cut-off value of VI was 7.500, and the sensitivity and specificity were 88.2% and 82.4%, respectively. In comparing the receiver operating characteristic curves among 2D and 3D ultrasound parameters, the diagnostic efficacy of lesion volume was significantly higher than maximum diameter (P < .001). The diagnostic efficacy of VI was significantly higher than maximum diameter (P = .020) and RI (P = .011).UAE reduces the number of vessels and the blood flow perfusion obviously; however, it does not reduce lesion size or increases myometrial thickness. Three-dimensional ultrasonography and power Doppler, especially VI, lesion volume may be helpful in predicting excessive bleeding during D&C after UAE.
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MESH Headings
- Adult
- Area Under Curve
- Blood Loss, Surgical
- Case-Control Studies
- Cesarean Section/adverse effects
- Cicatrix/complications
- Dilatation and Curettage/adverse effects
- Female
- Humans
- Imaging, Three-Dimensional/methods
- Imaging, Three-Dimensional/statistics & numerical data
- Predictive Value of Tests
- Pregnancy
- Pregnancy, Ectopic/diagnostic imaging
- Pregnancy, Ectopic/etiology
- Pregnancy, Ectopic/surgery
- ROC Curve
- Reference Values
- Ultrasonography, Doppler, Color/methods
- Ultrasonography, Doppler, Color/statistics & numerical data
- Uterine Artery Embolization/adverse effects
- Young Adult
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Management of Caesarean scar pregnancy with or without methotrexate before curettage: human chorionic gonadotropin trends and patient outcomes. BMC Pregnancy Childbirth 2018; 18:289. [PMID: 29973177 PMCID: PMC6032533 DOI: 10.1186/s12884-018-1923-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 06/27/2018] [Indexed: 02/08/2023] Open
Abstract
Background To evaluate the effects of systemic methotrexate in cesarean scar pregnancy (CSP) patients treated with ultrasound-guided suction curettage. Methods A retrospective review of all women presenting with CSP treated with ultrasound-guided suction curettage at Tongji Hospital, Wuhan, China, between January 1, 2013 and December 31, 2015, was conducted. Patients were grouped into those not treated with methotrexate before curettage (group 1), treated with methotrexate by intramuscular injection (group 2) and treated with methotrexate by intravenous injection (group 3). The clinical characteristics and outcomes were analyzed. Results Among 107 patients, 47 patients were not treated with methotrexate before curettage, 46 patients had methotrexate administered by intramuscular injection and 14 patients had methotrexate injected intravenously. There were no significant differences among the groups in basic and clinical characteristics, such as age, gravity, parity, positive fetal heart beat and gestational age at diagnosis. Patients presented similar initial human chorionic gonadotropin (hCG) levels in all groups. After treatment with methotrexate or curettage, the percentage changes and varied ranges of the hCG levels were also similar in all groups. There were no significant differences in intraoperative blood loss and retained products of conception among the three groups. However group 1 had significantly shorter hospital stays than the two groups that were treated with methotrexate (p<0.001). Conclusion By grouping CSP patients who shared similar age, gravity, parity, fetal heart beat positive and gestational age at diagnosis, we found that the presence or absence of methotrexate treatment before curettage resulted in comparable outcomes and hCG levels, although patients who were not treated with methotrexate had significantly shorter stays in the hospital.
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Jabeen K, Karuppaswamy J. Non-surgical management of caesarean scar ectopic pregnancy – a five-year experience. J OBSTET GYNAECOL 2018; 38:1121-1127. [DOI: 10.1080/01443615.2018.1451986] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Kausar Jabeen
- The Obstetrics and Gynaecology Department, The Wigan and Leigh NHS Foundation Trust, Wigan, UK
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60
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Harb HM, Knight M, Bottomley C, Overton C, Tobias A, Gallos ID, Shehmar M, Farquharson R, Horne A, Latthe P, Edi-Osagie E, MacLean M, Marston E, Zamora J, Dawood F, Small R, Ross J, Bourne T, Coomarasamy A, Jurkovic D. Caesarean scar pregnancy in the UK: a national cohort study. BJOG 2018; 125:1663-1670. [PMID: 29697890 DOI: 10.1111/1471-0528.15255] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2018] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To estimate the incidence of caesarean scar pregnancy (CSP) and to describe the management outcomes associated with this condition. DESIGN A national cohort study using the UK Early Pregnancy Surveillance Service (UKEPSS). SETTING 86 participating Early Pregnancy Units. POPULATION All women diagnosed in the participating units with CSP between November 2013 and January 2015. METHODS Cohort study of women identified through the UKEPSS monthly mailing system. MAIN OUTCOME MEASURES Incidence, clinical outcomes and complications. RESULTS 102 cases of CSP were reported, with an estimated incidence of 1.5 per 10 000 (95% CI 1.1-1.9) maternities. Full outcome data were available for 92 women. Management was expectant in 21/92 (23%), medical in 15/92 (16%) and surgical in 56/92 (61%). The success rates of expectant, medical and surgical management were 43% (9/21), 46% (7/15) and 96% (54/56), respectively. The complication rates were 15/21 (71%) with expectant, 9/15 (60%) with medical and 20/56 (36%) with surgical management. Discharge from care (median number of days) was 82 (range 37-174) with expectant, 21 (range 10-31) with medical and 11 (range 4-49) with surgical management. CONCLUSIONS Surgical management appears to be associated with a high success rate, low complication rate and short post-treatment follow up. TWEETABLE ABSTRACT Surgery for CSP appears to be successful, with low complication rates and short post-treatment follow up.
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Affiliation(s)
- H M Harb
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - M Knight
- National Perinatal Epidemiology Unit, Oxford, UK
| | - C Bottomley
- Chelsea and Westminster Hospital, London, UK
| | | | - A Tobias
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - I D Gallos
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - M Shehmar
- Birmingham Women's Hospital, Edgbaston, UK
| | | | - A Horne
- The Queen's Medical Research Institute, University of Edinburgh and Royal Infirmary of Edinburgh, Edinburgh, UK
| | - P Latthe
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - E Edi-Osagie
- Central Manchester University Hospitals, Saint Mary's Hospital, Manchester, UK
| | - M MacLean
- NHS Ayrshire and Arran, Crosshouse Hospital, Kilmarnock, Ayrshire, UK
| | - E Marston
- College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - J Zamora
- Hospital Ramon y Cajal, Madrid, Spain
| | - F Dawood
- Liverpool Women's Hospital, Liverpool, UK
| | - R Small
- Heart of England NHS Foundation Trust, Heartlands Hospital, Bordesley Green East, UK
| | - J Ross
- King's College Hospital, London, UK
| | - T Bourne
- Tommy's National Centre for Miscarriage, Research, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - A Coomarasamy
- Tommy's National Centre for Miscarriage Research, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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Fu LP. Therapeutic approach for the cesarean scar pregnancy. Medicine (Baltimore) 2018; 97:e0476. [PMID: 29718837 PMCID: PMC6392718 DOI: 10.1097/md.0000000000010476] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 03/21/2018] [Accepted: 03/27/2018] [Indexed: 02/06/2023] Open
Abstract
The aim of this study was to explore the pros and cons of different treatments of cesarean scar pregnancy (CSP).We retrospectively studied 205 cases of CSP that were treated in our hospital from June 2013 to June 2014, 189 of which had surgical operation.The average age of the patients was (32.98 ± 4.56) years. Data from those 189 cases were analyzed.Two hundred five patients from Beijing Obstetrics and Gynecology Hospital.One hundred eighty-nine cases who had operative treatment, 111 of which received curettage under hysteroscopy, 70 of which received curettage under ultrasonography, 8 of which received laparoscopic Cesarean scar resection.Management of 189 ectopic Cesarean scar pregnancy cases discussed in this article was usage of methotrexate (MTX) via the utility of uterine arterial chemotherapy embolization (UACE).All of 189 patients were cured without hysterectomy. Hysteroscopy provides a clear view for us, making it easy to identify the range of affected tissues, and clean the pregnancy tissue. Curettage under ultrasonography is relatively simple and inexpensive. Laparoscopic surgery is more suitable for exogenous CSP patients that can reduce the operation risk and prevent uterine perforation. However, laparoscopic surgery costs much more than those 2 and needs longer time of hospitalization.Treatment options should be personalized according to different situations. Minimal invasion, thorough treatment, quick recovery, low risk of hysterectomy, preserved fertility function, and improved life quality are the principles we have been pursuing for.
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Hitzerd E, Bogers H, Kianmanesh Rad NA, Duvekot JJ. A viable caesarean scar pregnancy in a woman using a levonorgestrel-releasing intrauterine device: a case report. EUR J CONTRACEP REPR 2018; 23:161-163. [PMID: 29583023 DOI: 10.1080/13625187.2018.1447663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Although the levonorgestrel-releasing intrauterine device (LNG-IUD) is one of the most reliable methods of contraception, it is associated with an increased risk of ectopic pregnancy in case of unintended pregnancy. A rare form of ectopic pregnancy is the caesarean scar pregnancy (CSP), with a high risk of serious maternal morbidity, such as uterine rupture, massive haemorrhage and resulting infertility. This report describes the first case of a viable CSP at 13 weeks of gestation in association with the use of a LNG-IUD. Case-presentation: A 36-year-old Caucasian woman was referred to our outpatient clinic because of suspicion of a CSP. The pregnancy was unintended and was diagnosed during replacement of the LNG-IUD after five years. The patient had undergone two caesarean sections in the past. Ultrasound investigation showed an intact pregnancy of approximately 13 weeks of gestation located in the uterine scar. Because of the size of the gestational sac, a laparotomy was performed under general anaesthesia using a Joel-Cohen incision. The procedure was complicated by a total blood loss of 1500 mL, mostly caused by diffuse bleeding from the placental bed. CONCLUSION Unintended pregnancies in women using a LNG-IUD are frequently ectopic pregnancies with a preponderance to nidate outside the fallopian tube. Therefore, early diagnosis and location of the pregnancy in women using a LNG-IUD is essential.
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Affiliation(s)
- Emilie Hitzerd
- a Department of Obstetrics and Gynaecology , Erasmus MC University Medical Center , Rotterdam , The Netherlands
| | - Hein Bogers
- a Department of Obstetrics and Gynaecology , Erasmus MC University Medical Center , Rotterdam , The Netherlands
| | - Noush A Kianmanesh Rad
- b Department of Obstetrics and Gynaecology , IJsselland Hospital , Capelle aan den IJssel , The Netherlands
| | - Johannes J Duvekot
- a Department of Obstetrics and Gynaecology , Erasmus MC University Medical Center , Rotterdam , The Netherlands
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Jauniaux E, Bhide A, Kennedy A, Woodward P, Hubinont C, Collins S. FIGO consensus guidelines on placenta accreta spectrum disorders: Prenatal diagnosis and screening. Int J Gynaecol Obstet 2018; 140:274-280. [PMID: 29405319 DOI: 10.1002/ijgo.12408] [Citation(s) in RCA: 183] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, UK
| | - Amar Bhide
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, St George's Hospital, London, UK
| | - Anne Kennedy
- Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Paula Woodward
- Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Corrine Hubinont
- Department of Obstetrics, Saint Luc University Hospital, University of Louvain, Brussels, Belgium
| | - Sally Collins
- Nuffield Department of Obstetrics and Gynecology, University of Oxford, John Radcliffe Hospital, Oxford, UK.,Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK
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Chai ZY, Yu L, Liu MM, Zhu TW, Qi F. Evaluation of the Efficacy of Ultrasound-Guided Local Lauromacrogol Injection Combined with Aspiration for Cesarean Scar Pregnancy: A Novel Treatment. Gynecol Obstet Invest 2017; 83:306-312. [PMID: 29208846 DOI: 10.1159/000485099] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 11/07/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To evaluate the efficacy of ultrasound-guided local lauromacrogol injection combined with aspiration for treating cesarean scar pregnancy (CSP). METHODS From July 2016 to December 2016, 18 patients diagnosed with CSP were treated with ultrasound-guided local lauromacrogol injection combined with aspiration. Clinical data and outcome were analysed. RESULTS All patients were treated successfully. The amount of bleeding ranged between 10 and 50 mL. The duration of hospitalization ranged between 2 and 11 days. Serum β-human chorionic gonadotropin (β-hCG) decreased to the nondetectable level within 19-41 days. Menstruation recovery occurred after 10-24 days of normalization of serum β-hCG level. Reproductive functions were preserved, and there were no untoward effects or complications. CONCLUSIONS Ultrasound-guided local lauromacrogol injection combined with aspiration is an effective CSP therapy, as it was associated with a high success rate, short hospitalization and fast recovery. However, its wider application and popularization have to be validated on a larger patient population affected by CSP.
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Affiliation(s)
- Ze-Ying Chai
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Affiliated with Wenzhou Medical University, Linhai, China
| | - Li Yu
- Department of Ultrasonography, Taizhou Hospital of Zhejiang Province, Affiliated with Wenzhou Medical University, Linhai, China
| | - Man-Man Liu
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Affiliated with Wenzhou Medical University, Linhai, China
| | - Tong-Wei Zhu
- Department of Ultrasonography, Taizhou Hospital of Zhejiang Province, Affiliated with Wenzhou Medical University, Linhai, China
| | - Feng Qi
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Affiliated with Wenzhou Medical University, Linhai, China
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Maheux-Lacroix S, Li F, Bujold E, Nesbitt-Hawes E, Deans R, Abbott J. Cesarean Scar Pregnancies: A Systematic Review of Treatment Options. J Minim Invasive Gynecol 2017; 24:915-925. [DOI: 10.1016/j.jmig.2017.05.019] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/29/2017] [Accepted: 05/31/2017] [Indexed: 10/19/2022]
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66
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The value of transvaginal ultrasound in clinical surgical treatment of cesarean scar pregnancy. ACTA ACUST UNITED AC 2017; 37:536-540. [DOI: 10.1007/s11596-017-1769-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 06/05/2017] [Indexed: 10/18/2022]
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Papillon-Smith J, Sobel ML, Niles KM, Solnik MJ, Murji A. Surgical Management Algorithm for Caesarean Scar Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:619-626. [DOI: 10.1016/j.jogc.2017.01.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/28/2017] [Accepted: 01/29/2017] [Indexed: 11/17/2022]
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Özcan HÇ, Uğur MG, Balat Ö, Sucu S, Mustafa A, Bayramoğlu Tepe N, Uğur BK. Is ultrasound-guided suction curettage a reliable option for treatment of cesarean scar pregnancy? A cross-sectional retrospective study. J Matern Fetal Neonatal Med 2017; 31:2953-2958. [DOI: 10.1080/14767058.2017.1359827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Hüseyin Çağlayan Özcan
- Department of Obstetrics and Gynecology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Mete Gurol Uğur
- Department of Obstetrics and Gynecology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Özcan Balat
- Department of Obstetrics and Gynecology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Seyhun Sucu
- Department of Obstetrics and Gynecology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Aynur Mustafa
- Department of Obstetrics and Gynecology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Neslihan Bayramoğlu Tepe
- Department of Obstetrics and Gynecology, School of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Berna Kaya Uğur
- Department of Anesthesiology and Reanimation, School of Medicine, Gaziantep University, Gaziantep, Turkey
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Hong Y, Guo Q, Pu Y, Lu D, Hu M. Outcome of high-intensity focused ultrasound and uterine artery embolization in the treatment and management of cesarean scar pregnancy: A retrospective study. Medicine (Baltimore) 2017; 96:e7687. [PMID: 28746234 PMCID: PMC5627860 DOI: 10.1097/md.0000000000007687] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The aim of the study was to compare the efficacy and safety between high-intensity focused ultrasound (HIFU) treatment and uterine artery embolization (UAE) treatment; we retrospectively analyzed 152 cases with cesarean scar pregnancy (CSP). Based on our inclusion and exclusion criteria, 152 patients (average age, 31.8 ± 4.6 years old) with CSP were eligible for the HIFU group (85 patients) or the UAE group (77 patients). All patients in 2 groups received the treatment with suction curettage under hysteroscopy prior to HIFU or UAE treatment and followed up for 12 months. The assessment criteria of treatment efficacy included the success rate, intraoperative blood loss, duration of vaginal bleeding, normal menstrual function recovery time, time for β-human chorionic gonadotrophin (β-HCG) back to normal level, duration of hospital stays, and other adverse effects. Following up for 12 months, the HIFU group was of less intraoperative blood loss (76.38 ± 22.89 vs 114.42 ± 30.34 mL, P = .02), shorter duration of postoperative vaginal bleeding (11.28 ± 3.65 vs 15.77 ± 7.24 days, P = .01) and lower adverse effects rate comparing to the UAE group. However, the HIFU group have longer time for the β-HCG recovery to the normal level (35.28 ± 9.86 vs 29.91 ± 7.29, P = .03). Additionally, there were no significantly statistic differences between the 2 groups in baseline characteristics, success rate, and average time of gestational sac disappeared and menstrual recovery and hospital stay. Thus, we concluded that the method of both HIFU and UAE combined with suction curettage under hysteroscopy is safe and effective in the management of CSP. Meanwhile, HIFU is a better therapy option than UAE for those women who are seeking complete relieve of symptom to gain fertility.
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Affiliation(s)
- Yufeng Hong
- Department of Gynecology, The Second Affiliated Hospital of Shaanxi University of Chinese Medicine, Xianyang, Shaanxi
| | | | | | - Dongmei Lu
- Department of Birth Control, Tangshan Maternity and Child Health Care Hospital, Tangshan, Hebei
| | - Min Hu
- Emergency Department, Changhai Hospital, Shanghai, China
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Qian ZD, Weng Y, Du YJ, Wang CF, Huang LL. Management of persistent caesarean scar pregnancy after curettage treatment failure. BMC Pregnancy Childbirth 2017; 17:208. [PMID: 28666477 PMCID: PMC5493865 DOI: 10.1186/s12884-017-1395-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 06/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background Caesarean scar pregnancy (CSP) is a late serious complication of caesarean section. The incidence of CSP has increased worldwide in recent years. Early diagnosis and prompt therapy are crucial to avoid catastrophic complications. There are various strategies for CSP treatment, but there is no consensus on the best management for CSP. Dilation and curettage (D&C) and hysteroscopy are common and effective treatments with their advantages and disadvantages. No in-depth study of the clinical effects of hysteroscopic management of CSP after D&C treatment failure has been conducted. The purpose of this study is to evaluate the effectiveness and safety of hysteroscopic removal of residual CSP tissue (persistent CSP) as a rescue after failed D&C management. Methods This is a retrospective clinical research study. Forty-five patients underwent operative hysteroscopy to remove the residual gestational tissue in the caesarean scar after failed D&C treatment. The clinical characteristics and outcomes of hysteroscopic surgeries of 45 CSP cases were investigated. All data analyses were conducted with SPSS 17.0. Results Forty-three CSP cases after unsuccessful curettage treatment were successfully treated by operative hysteroscopy. The estimated intraoperative blood loss was 20.00 (10.00–500.00) mL, the hysteroscopic operating time was 20.00 (15.00–45.00) min, the decline of serum β-hCG the day after surgery was 71.91 ± 14.05%, the total hospitalisation time was 7.87 ± 2.26 days, the medical cost was 13,682.71 ± 3553.77 China Yuan (CNY), the time of bleeding after surgery was 7.42 ± 2.48 days, and the time of serum β-hCG resolution after surgery was 13.84 ± 9.83 days. Follow-up after discharge demonstrated that there were no severe complications for any patients. Conclusions Hysteroscopy therapy could treat persistent CSP effectively and safely after curettage treatment failure. Therapy should be individualised, and the risks and cost of the hysteroscopy procedure and anaesthesia must be considered and fully discussed with the patients before surgery.
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Affiliation(s)
- Zhi-Da Qian
- Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang Province, 310006, People's Republic of China.
| | - Yue Weng
- Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang Province, 310006, People's Republic of China
| | - Yong-Jiang Du
- Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang Province, 310006, People's Republic of China
| | - Chun-Fen Wang
- Maternal and Child Health Institute of Lin'an City, 25 Jiangnan Road, Lin'an, Zhejiang Province, 311300, People's Republic of China
| | - Li-Li Huang
- Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang Province, 310006, People's Republic of China
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71
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Ying X, Zheng W, Zhao L, Zhou M, Chen Z. Clinical characteristics and salvage management of persistent cesarean scar pregnancy. J Obstet Gynaecol Res 2017; 43:1293-1298. [PMID: 28612958 PMCID: PMC5575528 DOI: 10.1111/jog.13367] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 01/28/2017] [Accepted: 03/27/2017] [Indexed: 11/28/2022]
Abstract
Aim The study was conducted to illustrate the clinical characteristics and treatment outcomes of patients with persistent cesarean scar pregnancy (PCSP). Methods During a six‐year period, 38 cases of PCSP were diagnosed and treated conservatively to preserve fertility. The clinical presentations, imaging findings and treatment outcomes of these patients were reviewed. Results Fourteen out of 38 women (37%) presenting with PCSP suffered heavy vaginal bleeding. Gestational age at diagnosis was 73.1 ± 21.7 days. The maximum diameter of the PCSP mass was 3.6 ± 1.6 cm. The presence of a rich vascular pattern in the area of the PCSP mass was detected by ultrasound in 33/38 (87%) patients. Six patients with a PCSP gestational age of 64.2 ± 6.2 days and a mass diameter of 2.5 ± 0.6 cm were successfully treated with medical treatment alone and 32 patients with a gestational age of 74.8 ± 23.1 days and a mass diameter of 3.8 ± 1.6 cm were successfully treated with surgical or combined treatment. Conclusions Patients with PCSP are diagnosed at advanced gestational age and are more prone to heavy bleeding. Surgery is the main treatment for PCSP. Medical treatment of PCSP has become an attractive alternative, especially for hemodynamically stable patients with a PCSP mass with a maximum diameter of < 3.5 cm.
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Affiliation(s)
- Xue Ying
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Zheng
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Li Zhao
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Mi Zhou
- Department of Obstetrics and Gynecology, Maternal and Child Health Hospital of Hainan Province, Haikou, China
| | - Zhengyun Chen
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Chiang YC, Tu YA, Yang JH, Lin SY, Lee CN, Shih JC. Risk factors associated with failure of treatment for cesarean scar pregnancy. Int J Gynaecol Obstet 2017; 138:28-36. [PMID: 28319267 DOI: 10.1002/ijgo.12157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 02/02/2017] [Accepted: 03/17/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To identify risk factors associated with treatment failure among women with cesarean scar pregnancy (CSP). METHODS In a retrospective study, the medical records of patients with CSP treated at National Taiwan University Hospital, Taipei, Taiwan, from 1994 to 2015 were reviewed. The women were managed primarily with hysterotomy, evacuation, or methotrexate. Receiver operating characteristic (ROC) curve analysis and logistic regression analysis were used to evaluate the factors associated with treatment failure. RESULTS Among 90 patients, 44 underwent hysterotomy, 18 underwent evacuation, and 28 received methotrexate. The success rates were 100% (44/44) for hysterotomy, 83% (15/18) for evacuation, and 57% (16/28) for methotrexate (P<0.001). ROC curve analysis indicated that a pregnancy length of 8 weeks and a mean sac diameter (MSD) of 4 cm were both predictive of failure of treatment by primary evacuation and methotrexate. In multivariate logistic regression analysis, an MSD of 4 cm or more was the only independent risk factor for treatment failure (odds ratio 68.99, 95% confidence interval 6.27-759.60; P=0.001). CONCLUSION Primary hysterotomy was suitable for treatment of CSP of any size. Failure of primary evacuation or methotrexate usually occurred when the MSD was larger than 4 cm.
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Affiliation(s)
- Ying-Cheng Chiang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yi-An Tu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jehn-Hsiahn Yang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shin-Yu Lin
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chien-Nan Lee
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jin-Chung Shih
- Department of Obstetrics and Gynecology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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