Cesarean scar pregnancy: issues in management

FundAl Retroflexion (FAR) Angle is a Novel Sonographic Marker Associated With Cesarean Scar Pregnancies in the First Trimester: A Case-Control Study

OBJECTIVES

Early diagnosis of Cesarean scar pregnancies (CSP) remains difficult. This study describes a novel sonographic marker, the FundAl Retroflexion (FAR) angle, that may be used in the first trimester. The objective of the study is to compare the FAR angle between CSP and normal pregnancies.

METHODS

For this case-control study, we reviewed images from our institution's database that were acquired from January 2016 to December 2019. All cases of CSP and randomly selected controls, defined as patients with history of Cesarean delivery and normal implantation, that underwent ultrasound evaluation at <14 weeks were included. The FAR angle, defined as the acute angle created between the endometrial echo and cervical canal, was measured. The mean FAR angle was then compared between the two groups and a receiver operating characteristic (ROC) curve was generated.

RESULTS

We identified 15 cases of CSP during the study period and were able to measure the FAR angle in 14 of the cases. The mean FAR angle was larger in CSP than in normal control pregnancies (45° versus 27°, respectively, P < 0.001). Using an ROC curve, a FAR angle cut off of 40° maximizes the ability to distinguish between CSP from normal pregnancies.

CONCLUSIONS

The FAR angle provides an easily obtainable and numerical measurement. CSP have larger FAR angle compared to normal controls with a distinguishing cut off of 40°. Larger studies are needed to determine if using the FAR angle can improve first trimester diagnosis for CSP.

The Efficacy and Health Economics of Different Treatments for Type 1 Cesarean Scar Pregnancy

Objectives: To evaluate the efficacy and health economics of four treatments for type 1 cesarean scar pregnancy (CSP).

Methods: From January 2009 to December 2018, 326 patients diagnosed with type 1 CSP were examined, among whom 31 received ultrasound-guided local injection of methotrexate (local injection group), 160 patients received uterine artery embolization combined with suction aspiration (UAE group), 25 patients received ultrasound-guided suction aspiration (aspiration group) and 90 received ultrasound-guided local injection of lauromacrogol combined with suction aspiration (lauromacrogol group). Clinical data and outcomes were analyzed. The decision tree model was used to compare the economics of four treatments.

Results: The success rate of the local injection group was 71.0% (22/31), which was significantly different from 98.8% (158/160) of the UAE group and 100.0% (90/90) of the lauromacrogol group. The success rate of the aspiration group was 92.0% (23/25), which was significantly lower than that of the lauromacrogol group. The cost-effectiveness ratio was 1,876.53 yuan for the aspiration group, 2,164.63 yuan for the lauromacrogol group, 4,383.56 yuan for the local injection group, and 7,850.81 yuan for the UAE group. The Incremental cost effectiveness ratio (ICER) of the lauromacrogol group to the aspiration group was 5,477.75 yuan, indicating that if the willing to pay of patients was higher than 5,477.75 yuan, the lauromacrogol group had a cost-effectiveness advantage in treating type 1 CSP, compared to aspiration group. On the contrary, aspiration group has a higher cost-effectiveness advantage. The ICER of the lauromacrogol group to the local injection group or the UAE group were both less than 0, indicating that local injection group and UAE group was not cost-effective in the treatment of type 1 CSP.

Conclusion: For type 1 CSP, the ultrasound-guided local injection of lauromacrogol combined with suction aspiration and ultrasound-guided suction aspiration, are effective and economical, and the choice between the two can be based on the patient’s willing to pay.

Local Methotrexate Injection Followed by Dilation and Curettage for Cesarean Scar Pregnancy: A Prospective Non-randomized Study

Purpose

To evaluate the clinical effects and outcomes of local intra-gestational sac methotrexate injection followed by dilation and curettage for treatment of cesarean scar pregnancies (CSP).

Method

This prospective non-randomized study was conducted on patients diagnosed with CSP between 2018 and 2020 at the Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region. Patients were categorized into two groups according to the treatments, i.e., local intra-gestational sac methotrexate injection followed by dilation and curettage (group A), and uterine artery embolization in combination with dilation and curettage (group B). The choices of treatment reflect the patients' decision after they thoroughly understood the benefits and risks of the two therapies. Clinical data were then collected and compared between these two alternatives.

Results

Seventy-seven patients with CSP were enrolled in the study. Of this total, 41 vs. 36 were respectively categorized into group A and group B. Similar success rates were observed between these two groups (92.7 vs. 97.2%; RR = 27.362, 95% CI: 0.496–1.51E3, p = 0.106). However, the overall occurrence of complications in group A was significant lower when compared with group B (17.1 vs. 52.8%; RR = 0.236, 95% CI: 0.077–0.728, p = 0.012). Lower abdominal pain (unrelated to infection) and intrauterine adhesions were the two primary complications exhibited in group B of the present study, with rates of 38.9 and 22.2% respectively.

Conclusions

Local intra-gestational sac methotrexate injection followed by dilation and curettage is an effective and safe treatment for CSP that also drastically reduces the risks of complications. Further multiple center randomized trials with large series are warranted to confirm these findings.

Diagnostic performance of magnetic resonance imaging and ultrasonography on the detection of cesarean scar pregnancy: A meta-analysis

BACKGROUND

: There is still a debate on which imaging method is the best to diagnose cesarean scar pregnancy (CSP). Accordingly, this study aimed to analyze the diagnostic performance of magnetic resonance imaging (MRI) and ultrasonography (US) on the detection of CSP based on current evidence in the literature.

METHODS

PubMed, Embase, Cochrane, Chinese Biomedical Documentation Service System, WanFang, and China National Knowledge Infrastructure databases were searched up to June 2020. The included studies were all comparisons of MRI and US in the diagnosis of CSP that adopted postoperative histological examination as the reference standard. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and area under the summary receiver operating characteristic curve (AUC) were calculated for MRI and US.

RESULTS

Thirteen studies were included, with a total sample size of 948 patients. The pooled sensitivity, specificity, PLR, NLR, and AUC of MRI in diagnosing CSP were 0.93 (95% CI, 0.91-0.95), 0.83 (95% CI, 0.75-0.89), 5.46 (95% CI, 3.70-8.05), 0.08 (95% CI, 0.06-0.11), and 0.96 (95% CI, 0.93-0.97), respectively; for US they were 0.84 (95% CI, 0.79-0.88), 0.73 (95% CI, 0.62-0.81), 3.06 (95% CI, 2.22-4.21), 0.23 (95% CI, 0.18-0.28), and 0.86 (95% CI, 0.83-0.89), respectively.

CONCLUSION

We found that both MRI and US effectively diagnosed CSP; however, MRI had a higher diagnostic performance in detecting CSP than US.

Safety and efficacy of a single local methotrexate injection for cesarean scar pregnancy

OBJECTIVE

To investigate the safety and efficacy of a single local methotrexate (MTX) injection for the treatment of cesarean scar pregnancy (CSP), assess reproductive outcomes after treatment, and confirm clinical outcomes after the treatment of CSP patients according to the presence of fetal cardiac activity or serum human chorionic gonadotropin (hCG) levels.

DESIGN

Retrospective cohort study SETTING: University hospital PATIENTS: Women with CSP INTERVENTIONS: Single local MTX injection under transvaginal ultrasound guidance MEASUREMENTS AND MAIN RESULTS: Forty-five CSP cases were identified; the mean (SD, range) estimated gestational age was 7.7 (1.7, 5.4-12.5) weeks and the mean serum hCG level was 51,801 (40,761, 2,307-187,898) mIU/mL. Three cases required additional treatment with MTX, and none of the cases needed uterine artery embolization or hysterectomy. The success rate for a single dose was 93.3%, and it was 100% if additional treatments with MTX were included. The mean time required for hCG normalization in those with fetal cardiac activity or with an initial level of hCG greater than 100,000 mIU/mL was not significantly longer than that in the controls (93.4 vs. 77.1 days, p=0.12; 113.7 days vs. 83.6 days, p=0.10). Of the 23 women who desired a subsequent pregnancy, 13 delivered 14 healthy newborns after treatment, three had an ongoing pregnancy, and three experienced recurrent CSP.

CONCLUSIONS

A single local MTX injection is safe and effective for the treatment of CSP despite the presence of fetal cardiac activity or any initial level of hCG and may allow the possibility of a subsequent uneventful pregnancy.

High-intensity focused ultrasound compared with uterine artery chemoembolization with methotrexate for the management of cesarean scar pregnancy

OBJECTIVE

To compare the effectiveness and safety of high-intensity focused ultrasound (HIFU) versus uterine artery chemoembolization with methotrexate for the management of cesarean scar pregnancy (CSP).

METHODS

A total of 170 women with CSP were enrolled in the retrospective cohort study from April 2016 to September 2020. One hundred women received HIFU followed by suction curettage, and 70 women were treated with uterine artery chemoembolization followed by suction curettage.

RESULTS

The median blood loss during suction curettage was 20 ml (range 2-800 ml) in the HIFU group versus 20 ml (range 5-200 ml) in the chemoembolization group (P = 0.837). The mean time for β-human chorionic gonadotropin normalization was 28.52 ± 10.82 days versus 26.69 ± 8.97 days (P = 0.246), respectively. The mean time of menstruation recovery was 34.36 ± 10.63 days versus 31.93 ± 8.53 days (P = 0.114), respectively. The incidence of adverse effects in the HIFU group was lower than that in the chemoembolization group (P = 0.028). The median hospitalization time in the HIFU group was longer than that in the chemoembolization group (P = 0.000).

CONCLUSION

HIFU was as effective and safe as uterine artery chemoembolization in the management of CSP, and the incidence of adverse effects was lower.

Arteriovenous Malformation Complicating Cesarean Scar Pregnancy: A Rare Case of Vaginal Bleeding Managed Successfully by Uterine Artery Embolization

Objective: Arteriovenous malformation (AVM) can occur in cesarean scar ectopic pregnancy. The presence of retained product of conception can pose a diagnostic dilemma and clinical presentation could be similar.

Case report: A 27 year old female presented with continuous vaginal bleeding for two and half months following dilatation and evacuation (D&E) done for cesarean scar pregnancy (CSP) of 10 weeks 4days period of gestation. Sonography with color Doppler revealed dilated tortuous vessels around the mass in lower uterine segment suggesting CSP with AVM. Digital subtraction angiography confirmed the diagnosis. Bilateral uterine artery embolization achieved complete devascularisation as confirmed on post intervention angiogram. Patient became symptom free since then.

Conclusion: Uterine artery embolization is an effective mode of treatment of AVM complicating CSP if future fertility is desired.

The effect of ultrasound-guided high-intensity focused ultrasound treatment for cesarean scar pregnancy on ovarian reserve

OBJECTIVE

The aim of this study was to evaluate changes in anti-Müllerian hormone (AMH) levels after ultrasound-guided high-intensity focused ultrasound (USgHIFU) treatment of cesarean scar pregnancy (CSP).

METHODS

A retrospective case series study was conducted in the Affiliated Hospital of North Sichuan Medical College. Thirty-two women with cesarean scar pregnancy who met the inclusion criteria were enrolled in the study between January 2018 and December 2019. All patients underwent USgHIFU treatment with or without suction curettage. Intraoperative blood loss in suction curettage and hysteroscopy procedures, time to return of β-human chorionic gonadotropin (β-hCG) to normal levels, and time to recovery of normal menstruation were recorded. AMH levels before and 3 months after HIFU treatment were compared to determine whether USgHIFU treatment affected ovarian reserve.

RESULTS

AMH levels before and 3 months after HIFU ablation were 1.87 ± 1.19 ng/ml and 1.90 ± 1.17 ng/ml, respectively. There was no significant difference in AMH levels between the two-time points (p > .05). The median volume of intraoperative blood loss was 20 ml, the median time for the serum β-hCG level to return to normal was 35.5 days, and the median time of menstruation recovery was 39 days.

CONCLUSIONS

USgHIFU treatment for CSP was effective and safe without affecting ovarian reserve.

Diagnosis and Management of Cesarean Scar Pregnancy and Placenta Accreta Spectrum: Case Series and Review of the Literature

With an increased cesarean delivery rate, the incidence of abnormal placentation is steadily rising, and it is estimated to be around 1.7 per 1000 pregnancies for cesarean scar pregnancy and 1 per 500 pregnancies for placenta accreta spectrum disorder. Current evidence considers cesarean scar pregnancy and placenta accreta spectrum as being the same condition, with different aspects, of the same spectrum, having higher risks with advancing gestation. We present 7 cases, diagnosed and managed in our hospital, at different gestational ages. Early diagnosis is essential for appropriate counseling and subsequent management, and an ultrasound examination is the reference standard for diagnosis. Screening for an abnormally implanted placenta in the first trimester of pregnancy might improve the perinatal outcome and reduce maternal morbidity and mortality.

An updated guide to the diagnosis and management of cesarean scar pregnancies

PURPOSE OF REVIEW

To review the current literature on the diagnosis and management of cesarean scar pregnancies RECENT FINDINGS: The incidence of cesarean scar pregnancies (CSPs) is increasing as a result of the increasing cesarean section rate, improved diagnostic capabilities, and a growing awareness. CSPs are associated with significant morbidity and early diagnosis is key. Diagnosis is best achieved with transvaginal ultrasound. Sonographic diagnostic criteria have been developed over decades and recently endorsed by the Society for Maternal-Fetal Medicine and other professional societies. The current categorization system differentiates CSPs that are endogenic or 'on the scar' from those that are exogenic or 'in the niche'. Following diagnosis, the challenge remains in determining the optimal management as multiple modalities can be considered. Studies have demonstrated the favorable outcomes with combined local and systemic methotrexate, surgical excision through multiple routes, and adjunctive therapies, such as uterine artery embolization or uterine balloons. The current evidence is insufficient to identify a single best treatment course and a combined approach to treatment is often required.

SUMMARY

Successful outcomes while minimizing complications can be achieved with a multidisciplinary, collaborative effort. Guidelines for cesarean scar pregnancies will continue to evolve as the published reports grow.

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.

Cesarean section scar pregnancy: Challenges in choosing treatment approach

Choosing a treatment approach of Cesarean section scar pregnancy is challenging and requires making women aware of material risks inherent in the different approaches that they perceive as having potential impact on their live or quality of life.

Risk prediction of major haemorrhage with surgical treatment of live cesarean scar pregnancies

OBJECTIVE

To evaluate the association between demographic and ultrasound variables and major intra-operative blood loss during surgical transcervical evacuation of live caesarean scar pregnancies.

STUDY DESIGN

This was a retrospective cohort study conducted in a tertiary referral center between 2008 and 2019. We included all women diagnosed with a live caesarean scar ectopic pregnancy who chose to have surgical management in the study center. A preoperative ultrasound was performed in each patient. All women underwent transcervical suction curettage under ultrasound guidance. Our primary outcome was the rate of postoperative blood transfusion. The secondary outcomes were estimated intra-operative blood loss (ml), rate of retained products of conception, need for repeat surgery, need for uterine artery embolization and hysterectomy rate. Descriptive statistics were used to describe the variables. Univariate and multivariable logistic regression models were constructed using the relevant covariates to identify the significant predictors for severe blood loss.

RESULTS

During the study period, 80 women were diagnosed with a live caesarean scar pregnancy, of whom 62 (78%) opted for surgical management at our center. The median crown-rump length was 9.3 mm (range 1.4-85.7). Median blood loss at the time of surgery was 100 ml (range, 10-2300), and six women (10%; 95%CI 3.6-20) required blood transfusion. Crown-rump length and presence of placental lacunae were significant predictive factors for the need for blood transfusion and blood loss > 500 ml at univariate analysis (p < .01); on multivariate analysis, only crown-rump length was a significant predictor for need for blood transfusion (OR = 1.072; 95% CI 1.02-1.11). Blood transfusion was required in 6/18 (33%) cases with the crown-rump length ≥ 23 mm (≥9⁺⁰ weeks of gestation), but in none of 44 women presenting with a crown-rump length < 23 mm (p < .01).

CONCLUSION

The risk of severe intraoperative bleeding and need for blood transfusion during or after surgical evacuation of live caesarean scar pregnancies increases with gestational age and is higher in the presence of placental lacunae. One third of women presenting at ≥ 9 weeks of gestation required blood transfusion and their treatment should be ideally arranged in specialized tertiary centers.

Expectant management of cesarean scar pregnancy in 13 patients

OBJECTIVE

To monitor Cesarean scar pregnancy (CSP) patients preferring to continue their pregnancy and analyze their clinical characteristics as well as maternal and fetal outcomes.

METHODS

A retrospective cohort study including 13 pregnant women diagnosed with CSP (including types I, II, III) and continued their pregnancy with cautious monitoring at Peking University First Hospital between January, 2014 and December, 2018.

RESULTS

8/13 (61.5%) of them delivered after 28 weeks and finally gave birth to healthy babies with 3 term births and 5 preterm births (one of them which suspected placenta percreta received hysterectomy for massive bleeding and hemorrhagic shock at 34 weeks). 2/13 (15.4%) of them terminated their pregnancy at second trimester by Cesarean section for ultrasonic manifestation of placenta percreta with or without threatened uterine rupture. 1/13 (7.7%) of them went through induced labor due to inevitable abortion and needed dilatation and evacuation afterwards at 20 weeks. 2/13 (15.4%) of those patients with twin pregnancy chose fetal reduction to keep the non-CSP fetus at 8 weeks and 11 weeks. No maternal or fetal death was observed.

CONCLUSIONS

During expectant management, type I CSP patients were at little risk for developing into placenta percreta and rather save for continue pregnancy to having babies. Type II and type III CSP patients usually ended up with placenta percreta and better terminated their pregnancy immediately.

A Comparison of Treatment Options for Type 1 and Type 2 Caesarean Scar Pregnancy: A Retrospective Case Series Study

Background: There is currently no agreement on the optimal management of caesarean scar pregnancy. Caesarean scar pregnancy is currently categorised into two subtypes according to the site of implantation. This may consequently result in the difference in treatment options. However, the comparison of the success rate of each treatment option according to the subtypes has not been fully investigated. Methods: 71 patients who were treated by uterine curettage (D and C), or uterine artery embolization with curettage (UAE) or hysteroscopy in conjunction with laparoscopy between January 2016 and March 2020 were included. Data on maternal age, gestational sac age, the sac diameter, the interval between two pregnancies, the number of previous caesarean sections, amount of bleeding and β-hCG levels were collected and analysed dependent on the subtypes. Results: There was no difference in the clinical parameters of the cases who received different options of treatment, as well as no difference in the clinical parameters between type 1 and type 2 caesarean scar pregnancy. The primary success rate for type 1 caesarean scar pregnancy by D and C, or UAE, or hysteroscopy in conjunction with laparoscopy was 95, or 100 or 100%, respectively. The primary success rate for type 2 caesarean scar pregnancy by D and C, or UAE, or hysteroscopy in conjunction with laparoscopy was 27, or 67, or 95% respectively. Conclusion: Our data demonstrates that hysteroscopy in conjunction with laparoscopy for type 2 caesarean scar pregnancy was the most successful compared to other options, but for type 1 caesarean scar pregnancy, D and C could be the cost-effective option.

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.

Ectopic pregnancy: a single-center experience over ten years

PURPOSE

The aim of this study was to investigate characteristics associated with ectopic pregnancy (EP) that could be utilized for predicting morbidity or mortality.

METHODS

This was a retrospective analysis of pregnancy-related records from a tertiary center over a period of ten years. Data on age, gravidity, parity, EP risk, amenorrhea duration, abdominal pain presence and location, β-human chorionic gonadotropin (β-HCG) level, ultrasound findings, therapeutic intervention, exact EP implantation site and length of hospital stay (LOS) were obtained from the database. The LOS was used as a proxy for morbidity and was tested for an association with all variables. All statistical analyses were conducted with Stata® (ver. 16.1, Texas, USA).

RESULTS

The incidence of EP in a cohort of 30,247 pregnancies over a ten-year period was 1.05%. Patients presented with lower abdominal pain in 87.9% of cases, and the likelihood of experiencing pain was tenfold higher if fluid was detectable in the pouch of Douglas. Only 5.1% of patients had a detectable embryonic heartbeat, and 18.15% had one or more risk factors for EP. While most EPs were tubal, 2% were ovarian. The LOS was 1.9 days, and laparoscopic intervention was the main management procedure. The cohort included one genetically proven dizygotic heterotopic pregnancy (incidence, 3.3 × 10^- 5) that was diagnosed in the 7th gestational week. The only association found was between the β-HCG level and LOS, with a linear regression β coefficient of 0.01 and a P-value of 0.04.

CONCLUSION

EP is a relatively common condition affecting approximately 1% of all pregnancies. β-HCG correlates with EP-related morbidity, but the overall morbidity rate of EP is low regardless of the implantation site. Laparoscopic surgery is an effective therapeutic procedure that is safe for managing EP, even in cases of heterotopic pregnancy.

A Scary Complication: Single-center Study on Management and Outcome of Cesarean Scar Pregnancy

A cesarean scar pregnancy (CSP) is a scary and life-threatening complication of cesarean section (CS). Nevertheless, the incidence of CS is constantly growing. The CSP incidence is 0,15% of pregnancies after CS which represents 6,1% of all ectopic pregnancies in women with condition after CS. Therefore, it should be more present in the clinical daily routine. From mild nonspecific symptoms to hypovolemic shock, diagnosis and therapy must be performed quickly. With the progressive growth of the scar pregnancy, a uterine rupture involves the risk of severe bleeding, and an emergency hysterectomy could be necessary. Prolongation of pregnancy has been successful only in a few cases. We report 11 cases from our hospital in the past 10 years. In the discussion, treatment options of this complication with an increasing incidence, which is associated with serious morbidity and mortality, are presented based on the current literature. Treatment options include drug therapy, but also surgical or combined procedures with radiological intervention.

Potential risk factors for caesarean scar pregnancy: a retrospective case-control study

STUDY QUESTION

What are the important risk factors for having a caesarean scar pregnancy (CSP)?

SUMMARY ANSWER

Independent risk factors were smoking in the first trimester, higher parity, and previous caesarean section (CS) before the index caesarean delivery.

WHAT IS KNOWN ALREADY

A spectrum of risk factors for CSP has been suggested but not proven: parity, number of previous caesarean section, elective as opposed to emergency CS, IVF-pregnancy, breech presentation, previous gynaecological surgery as well as suture technique.

STUDY DESIGN SIZE DURATION

This retrospective case-control study included 31 women with a CSP during the period 2003-2018 treated at a tertiary care centre for gynaecology and reproduction. A control cohort of 8300 women with a history of a CS and a subsequent delivery during the same time period was formed.

PARTICIPANTS/MATERIALS SETTING METHODS

Variables describing demography, lifestyle factors, and reproductive and obstetric history were retrieved from medical records and the obstetric hospital database. Logistic regression analyses were applied to identify potential risk factors.

MAIN RESULTS AND THE ROLE OF CHANCE

In a multivariable analysis, smoking in first trimester (adjusted odds ratio (OR) 3.03, 95% CI 1.01-9.07), higher parity (adjusted OR 1.30, 95% CI 1.03-1.64) and previous CS in addition to the preceding CS (adjusted OR 3.43, 95% CI 1.35-8.66) were independently predictive of a CSP. An elective CS at the index pregnancy was associated with an increased risk of CSP but did not remain significant in the multivariable analysis.

LIMITATIONS REASONS FOR CAUTION

CSP is a very rare phenomenon and several of the risk factor estimates are imprecise. Nevertheless, significant risk factors could be identified. Another limitation is the lack of electronically recorded details on suture techniques.

WIDER IMPLICATIONS OF THE FINDINGS

The identified factors, namely higher parity and previous CS before the index caesarean section, are in accordance with previously suggested risk factors. Whether there is a true risk association between elective CS and future CSP needs to be investigated further. Smoking in the first trimester is a new finding, which has a plausible rationale. These factors should be recognised when counselling women after a caesarean delivery, particularly in a subsequent pregnancy with early complications.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by a grant from the Swedish state under the agreement between the Swedish government and the county councils the ALF-agreement (ALFGBG-720291). None of the authors has any conflict of interest to declare.

Cell-based endometrial regeneration: current status and future perspectives

Endometrial-related disorders including Asherman's syndrome, thin endometrium, pelvic organ prolapse, and cesarean scar pregnancies can be accompanied by different symptoms such as amenorrhea, infertility, abnormal placental implantation and recurrent miscarriage. Different methods have been introduced to overcome these problems such as surgery and hormonal therapy but none of them has shown promising outcomes. On the other hand, the development of novel regenerative therapeutic strategies has opened new avenues for the treatment of endometrial-related deficiencies. In this regard, different types of scaffolds, acellular matrices and also cell therapy with adult or stem cells have been investigated for the treatment of endometrial-related deficiencies. In this paper, we review the current status of cell-based endometrium regeneration using scaffold dependent and scaffold-free methods and future perspectives in this field. Moreover, we discuss the endometrial diseases that can be candidates for cell-based treatments. Also, the cells with the potential for endometrial regeneration are explained.

Successful Conservative Treatment of Cesarean Scar Ectopic Pregnancy with Local Injections of Absolute Ethanol

Cesarean scar ectopic pregnancy (CSEP) is becoming more common worldwide. Here, we report a case of cesarean scar pregnancy successfully treated using transvaginal ethanol injection. A 31-year-old female (gravida 3, para 2) with two prior cesarean sections presented at 9 weeks and 3 days of pregnancy. Her serum human chorionic gonadotropin level was 91,798 mIU/mL. CSEP was confirmed by transvaginal ultrasonography, pelvic magnetic resonance imaging, and color Doppler ultrasonography. Transvaginal absolute ethanol local injection under transvaginal ultrasound guidance was performed. She was discharged 7 days after treatment with no complications and resumed normal menses 1 month after treatment. We describe a safe and successful treatment option for CSEP.

Cesarean Scar Pregnancy Treated by Artery Embolization Combined with Diode Laser: A Novel Approach for a Rare Disease

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy which represents a consequence of a previous cesarean section. It is associated with major maternal morbidity and mortality and has potential implications on future fertility. Because of possible serious complications, CSP should be swiftly diagnosed and treated. There is no management protocol for this rare, life-threatening condition, and each patient should be evaluated individually. Several types of conservative treatment have been used to treat cesarean scar pregnancy: dilation and curettage (D&C), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolization with curettage and/or methotrexate administration. In our study we present a cesarean scar pregnancy of a 40-year-old woman who was treated with angiographic uterine artery embolization (UAE) followed by hysteroscopic diode laser resection. Our combined UAE–hysteroscopic laser surgery appears to offer an effective, safe, and minimally invasive surgical treatment.

Cesarean Scar Ectopic Pregnancy: A Diagnostic and Management Challenge

Cesarean section scar pregnancy is the rarest form of ectopic pregnancy. Cesarean scar ectopic pregnancy poses a diagnostic and management challenge, and if not diagnosed and adequately treated in early pregnancy, it may lead to considerable maternal morbidity or mortality. We describe the presentation, workup including radiology studies, and subsequent management plan of a cesarean scar ectopic pregnancy in a 34-year-old female with a history of four previous cesarean sections. We were successful in treating this rare form of ectopic pregnancy without any maternal morbidity with a combination of medical and surgical management.

Scar Pregnancy a Diagnostic Conundrum: A Case Report

Cesarean scar pregnancy is a rare form of ectopic pregnancy which may lead to uterine rupture and catastrophic hemorrhage. We report a case of cesarean scar pregnancy in a 35-year-old female with the past history of cesarean section presented with complaints of amenorrhoea for 6 weeks and non-specific periumbilical pain. Two Transvaginal sonography was done 48 hours apart which suggested a cesarean scar pregnancy in one and cervical pregnancy on the other. Magnetic Resonace Imaging showed a well-defined cystic lesion of (21x19)mm² embedded within the previous cesarean scar which confirmed the diagnosis of cesarean scar pregnancy. Laparotomy unveiled uterus around 6 weeks size and a (3x3)cm² bulge was noted at the site of previous scar in lower uterine segment, where a small incision was given and the gestational sac was removed following which the uterine incision was closed with 2-0 polyglactin suture. High index of suspicion and prompt diagnosis is of paramount for reducing morbidity and mortality.

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.

Suction Curettage and Foley Balloon as a First-Line Treatment Option for Caesarean Scar Pregnancy and Reproductive Outcomes

Background

Caesarean scar pregnancy (CSP) is associated with various serious pregnancy complications. This study presents the outcomes of patients treated with suction curettage and Foley balloon as the first-line treatment for CSP as well as their future outcomes in terms of successful pregnancy.

Methods

Of the 44 patients diagnosed with CSP between January 2015 and April 2019, 42 who provided consent for the termination of pregnancy and who simultaneously underwent the transabdominal ultrasound-guided suction curettage + Foley balloon treatment were included in the study. These patients were then contacted and interviewed to collect data concerning their post-treatment number of pregnancies, number of miscarriages, number of live or dead births, mode of delivery, delivery time as well as whether any abnormal placental invasion or uterine ruptures developed.

Results

Transabdominal ultrasound-guided suction curettage + Foley balloon was simultaneously performed as the first-line treatment in 42 patients with CSP. In two of these cases, wherein post-treatment level of β-hCG reached a plateau, single-dose systemic methotrexate was administered. Emergency surgical intervention, hysterectomy, massive blood transfusion and additional systemic methotrexate administration were not required. Twenty-six of 42 patients could be contacted. 18/26 were trying to conceive. 6/18 patients had secondary infertility, and 12/18 patients managed to conceive. 8/12 had caesarean delivery at full term. 1/12 was 16-week pregnant, 1/12 had tubal ectopic pregnancy and 2/12 had first-trimester abortus.

Conclusion

When administered as the first-line treatment for CSP, the suction curettage + Foley balloon treatment is a highly successful, cheap and easily performed minimally invasive method that requires only a short hospital stay, making it comfortable for patients. Compared with other uterine-sparing methods, it does not harm fertility and has positive effects on patients’ future fertility outcomes.

Rapid β-human chorionic gonadotropin detection in urine with electric-double-layer gated field-effect transistor biosensors and a handheld device

In this experimental study, a portable biosensor was developed to detect β-human chorionic gonadotropin (β-hCG), which is extensively used in pregnancy tests and serves as a biomarker for ectopic pregnancy. The sensor used is an electric-double-layer field-effect transistor biosensor with the extended-gate design. Bias voltage is applied on the sensor to measure the resulting drain current signals. Gold electrode surface is functionally activated with an anti-β-hCG antibody to capture β-hCG protein. Fluorescence imaging technique is utilized to confirm the surface functionalization. The biosensor demonstrates a dynamically wide range of molecules as detection targets at very low sample concentrations, which shows the potential to detect ectopic pregnancy in very early stages and easily keep track of its periodic changes. It can be produced en masse and does not use additional labels/reagents or pre-processing techniques for the sample. This biosensor can significantly reduce the manufacturing costs and is comparable with the currently available commercial ß-hCG assays. It is suitable for early diagnosis of ectopic pregnancy with low cost and easy operation at home with urine samples.

Outcome of cesarean scar pregnancy according to gestational age at diagnosis: A systematic review and meta-analysis

OBJECTIVE

The association between the most severe types of placenta accreta spectrum disorders and caesarean scar pregnancy (CSP) poses the question of whether early diagnosis may impact the clinical outcome of these anomalies. The aim of this study is to report the outcome of cesarean scar pregnancy (CSP) diagnosed in the early (≤9 weeks) versus late (>9 weeks) first trimester of pregnancy.

STUDY DESIGN

Medline, Embase and Clinicaltrail.gov databases were searched. Studies including cases of CSP with an early (≤9 weeks of gestation) compared to a late (>9 weeks) first trimester diagnosis of CSP, followed by immediate treatment, were included in this systematic review. The primary outcome was a composite measure of severe maternal morbidity including either severe first trimester bleeding, need for blood transfusion, uterine rupture or emergency hysterectomy. The secondary outcomes were the individual components of the primary outcome. Random-effect meta-analyses were used to combine data.

RESULTS

Thirty-six studies (724 women with CSP) were included. Overall, composite adverse outcome complicated 5.9 % (95 % CI 3.5-9.0) of CSP diagnosed ≤9 weeks and 32.4 % (95 % CI 15.7-51.8) of those diagnosed >9 weeks. Massive hemorrhage occurred in 4.3 % (95 % CI 2.3-7.0) of women with early and in 28.0 % (95 % CI 14.1-44.5) of those with late first trimester diagnosis of CSP, while the corresponding figures for the need for blood transfusion were 1.5 % (95 % CI 0.6-2.8) and 15.8 % (95 % CI 5.5-30.2) respectively. Uterine rupture occurred in 2.5 % (95 % CI 1.2-4.1) of women with a prenatal diagnosis of CSP ≤ 9 weeks and in 7.5 % (95 % CI 2.5-14.9) of those with CSP > 9 weeks, while an emergency intervention involving hysterectomy was required in 3.7 % (95 % CI 2.2-5.4) and 16.3 % (95 % CI5.9-30.6) respectively. When computing the risk, early diagnosis of CSP was associated with a significantly lower risk of composite adverse outcome, (OR: 0.14; 95 % CI 0.1-0.4 p < 0.001).

CONCLUSIONS

Early first trimester diagnosis of CSP is associated with a significantly lower risk of maternal complications, thus supporting a policy of universal screening for these anomalies in women with a prior cesarean delivery although the cost-effectiveness of such policy should be tested in future studies.

Laparoscopic treatment of recurrent and chemoresistant cesarean scar choriocarcinoma

Depending on the developing laparoscopic technique and experience, the treatment of cesarean scar choriocarcinoma can be safely performed laparoscopically by experts.

A stepwise approach to robotic assisted excision of a cesarean scar pregnancy

Objective

To develop a stepwise approach to robotic assisted excision of cesarean scar pregnancy (CSP) with metroplasty.

Methods

This illustrative video presentation demonstrating CSP, the criteria for ultrasound diagnosis, and a step-by-step approach for robotic assisted excision of CSP and multi-layer hysterotomy closure at a tertiary medical center.

Results

Robotic assisted resection is a safe and feasible method to treat cesarean scar ectopic pregnancies. Key ultrasonographic characteristics of CSP are highlighted to facilitate its diagnosis, thus allowing for early intervention with a minimally invasive surgical treatment as necessary. Our patient was a 30-year-old gravida 2 para 1 woman with a history of 1 prior-term low transverse cesarean delivery, who presented with vaginal bleeding in the first trimester and was ultimately diagnosed with CSP. After unsuccessful methotrexate therapy, the patient underwent an uncomplicated robotic assisted excision of her CSP and metroplasty in 2 layers using a stepwise approach: Step 1-Creation of a bladder flap; Step 2-Isolation and excision of CSP; Step 3-Hysterotomy closure in 2 layers; and Step 4-Hysteroscopy.

Conclusion

When diagnosed late, cesarean scar ectopic pregnancy can cause a significant hemorrhage from rupture. Early radiologic diagnosis does not only indicate minimally invasive surgery as a treatment option but also assists with related surgical planning. This video demonstrates a stepwise approach to the robotic assisted excision of CSP with metroplasty. With these 4 simple steps, surgical procedure can be safe and efficient.

Ectopic uterine scar pregnancy: A case report

Introduction

Implantation of a gestational sac in a previous Caesarean section scar of the lower uterine segment is a rare form of ectopic pregnancy.

Case report

We report a case of Caesarean scar ectopic pregnancy in a 25-year-old female, diagnosed by ultrasonography and confirmed by magnetic resonance imaging. We present the clinical details, imaging findings, and management of the patient.

Discussion

Imaging plays an important role in the diagnosis of ectopic pregnancy and ultrasonography is the modality of choice. Ultrasonography features of scar ectopic pregnancy include empty uterus and cervix with normal endometrium and endocervical canal, gestational sac (with embryo and/or yolk sac) in the anterior part of the lower uterine segment in the region of the Caesarean scar with a thin myometrial layer between the bladder wall and gestational sac. Magnetic resonance imaging may be used as an adjunct imaging modality in cases with inconclusive or equivocal sonographic findings. Termination of pregnancy in the first trimester should be considered and treatment options should be individualized as there is no universal agreement on the best or most preferred treatment modality.

Conclusion

Awareness of specific ultrasound features of scar ectopic pregnancy is crucial for early recognition, correct diagnosis, and initiating prompt management to prevent complications.

Outcome of cesarean scar pregnancy treated with local methotrexate injection

Local injection of methotrexate (MTX) has been widely used for caesarean scar pregnancy (CSP), but the optimal candidate remains undetermined. The aim of this study is to determine the risk factors associated with treatment failure among patients who received a single dose of local MTX. This is a retrospective cohort study. Clinical information was compared between treatment success vs. failure groups. Risk factors related to treatment failure were also investigated with multivariate analysis. Of 47 patients diagnosed with CSP, 30 received local MTX injection. The initial serum ß- human chorionic gonadotropin (hCG) level in the failure group was significantly higher than in the success group (p = 0.048), and the cut-off value was 47,000 mIU/ml. The rate of type 2 position of the gestational sac in the failure group was significantly higher than in the treatment success group (p = 0.031). A high initial serum ß-hCG level (≥ 47,000 mIU/ml) was identified as the independent risk factor for treatment failure (adjusted odds ratio = 21.9; 95% confidence interval = 1.3-383.1). Type 2 gestational sac position and a higher level of ß-hCG at diagnosis appear to be associated with poor outcomes after local injection of a single dose of MTX.

Surgical outcomes of cesarean scar pregnancy: an 8-year experience at a single institution

PURPOSE

To summarize the outcomes of different surgical treatment modalities for cesarean scar pregnancy (CSP) at a single institution over 8 years.

METHODS

A case series of patients diagnosed with CSP who were admitted to Nanjing Drum Tower Hospital from January 2011 to December 2018 was retrospectively studied. Medical records of all the patients were carefully reviewed. Data on patient demographics, pregnancy characteristics, treatment modalities, response to therapy, and subsequent pregnancy outcomes were collected and analyzed.

RESULTS

A total of 117 patients undergoing surgical treatments for CSP were included. Thirty-three patients (28.21%) underwent ultrasound-guided curettage; while, 74 (63.25%) and 10 (8.55%) patients received laparoscopy-monitored curettage and laparoscopic CSP resection, respectively. Most of the patients (21/33) who underwent ultrasound-guided surgery had type I CSP; while, 54 out of 84 patients who opted for laparoscopic surgeries had type II CSP. Eleven women underwent a uterine artery embolization procedure before the operation. There was no difference in the use of an intrauterine balloon for hemostasis among the three groups. Only 8 patients needed additional systemic methotrexate treatment. Twenty-four out of 57 women (42.11%) succeeded in conceiving again and gave birth to 21 healthy babies. Only 1 woman (1/24, 4.17%) experienced recurrence of CSP.

CONCLUSIONS

These data indicated the safety and efficiency of ultrasound-guided curettage, laparoscopy-monitored curettage, and laparoscopic CSP resection for the treatment of CSP.

Single- versus multiple-dose methotrexate in cesarean scar pregnancies management: treatment and reproductive outcomes

PURPOSE

We aim to assess the outcome of the treatment of cesarean scar pregnancy (CSP) with single-dose methotrexate (MTX) versus multiple-dose MTX protocols.

METHODS

A retrospective cohort study including two tertiary medical centers was conducted. All women diagnosed with CSPs between the years 2011 and 2019 that were initially managed with systemic MTX were included. Single-dose MTX practiced in one medical center was compared to multiple-dose MTX, practiced in the other medical center.

RESULTS

The study cohort included 31 women in the single dose and 32 women in the multiple-dose MTX groups. Baseline characteristics did not differ between groups. The primary outcome occurred in 12 (38.7%) of the cases in the single-dose group and in 6 (18.8%) in the multiple-dose group (p = 0.083). The rate of conversion to surgical treatment was similar in both groups (4 vs. 5 in the single vs. multiple-dose groups, respectively, p = 0.758). There was no significant difference between the single- and the multiple-dose groups in the administration of blood products (16.1% vs. 3.1%, respectively, p = 0.104), total days of admission (18 ± 9.3 vs. 17 ± 12.8 days, respectively, p = 0.850), and readmission rate (32.3% vs. 21.9%, respectively, p = 0.353). Data regarding sequential pregnancies were available for 11 women in the single and 13 women in the multiple-dose MTX groups. There were no differences between the groups in rates of term deliveries, CSP recurrence, and abortions.

CONCLUSION

Both single- and multiple-dose MTX treatment protocols offer high success rate with a relatively low complication rate in the treatment of CSP.

Use of Magnetic Resonance Imaging (MRI) in the Management of Diagnostic Uncertainty in Low-Resource Settings: A Case Report of Cesarean Ectopic Pregnancy in a Tertiary Hospital in Ghana

Patient: Female, 35-year-old

Final Diagnosis: Cesarean section ectopic pregnancy

Symptoms: Amenorrhea

Medication:—

Clinical Procedure: Exploratory laparotomy • MRI • ultrasonography

Specialty: Obstetrics and Gynecology

Risk factors for massive hemorrhage during the treatment of cesarean scar pregnancy: a systematic review and meta-analysis

PURPOSE

Cesarean scar pregnancy (CSP) is one of the serious complications associated with cesarean delivery (CD). This meta-analysis aims to identify risk factors associated with massive hemorrhage during the CSP treatment.

METHODS

Eight electronic databases were searched for case-control studies published before December 31th, 2018, which compared the possible factors causing massive bleeding during the CSP treatment. Quantitative synthesis was performed by RevMan 5.3. Sensitivity analysis and publication bias were performed by Stata 12.0.

RESULTS

Total 20 case - control studies including 3101 CSP patients with previous CD met the inclusion criteria. Bleeding group had 573 patients and the control group had 2528 patients. The risk factors for massive bleeding during CSP treatment included multiple gravidities (MD = 0.15, 95% CI 0.03-0.28, P = 0.73), big maximum diameter of gestation sac (MD = 18.49 mm, 95%CI 15.34-21.65, P < 0.01), high gestational days (MD = 8.98 days, 95% CI 4.12-13.84, P < 0.01), high β-HCG level (MD = 21.39 IU/ml, 95% CI 7.36-35.41, P = 0.03; MD = 3.02 U/ml, 95% CI 0.21-5.84, P < 0.01) and rich blood flow around the lesion (OR = 6.73, 95% CI 3.93-11.51, P = 0.59). While, thick myometrium (MD = - 4.94 mm, 95% CI - 6.12 to - 3.75, P < 0.01) may be protective factor.

CONCLUSIONS

Multiple gravidities, big gestation sac, large gestational days, high serum β-HCG level, abundant blood supply to pregnancy sac and thin myometrium maybe the risk factors for massive bleeding during the CSP treatment.

Evaluation of treatment of previous cesarean scar pregnancy with methotrexate: a systematic review and meta-analysis

BACKGROUND

Previous caesarean scar pregnancy is one type of ectopic pregnancy in myometrium and fibrous tissue of previous caesarean scar. One of the therapeutic methods of this type of ectopic pregnancy is treatment with methotrexate. Given various findings on the treatment of caesarean scar pregnancy with methotrexate and lack of global report in this regard, we aimed to achieve a global report on the treatment of CSP with methotrexate through related literature review and analysis of the results of the studies, to enable more precise planning to reduce complications of CSP.

METHOD

This review study extracted information through searching national and international databases of SID،, Embase, ScienceDirect, ، Scopus, ، PubMed, Web of Science (ISI) between 2003 and January 2020. To perform the meta-analysis, random-effects model and heterogeneity of the studies with I² index were investigated. Data were sanalysed using Comprehensive Meta-Analysis version 2.

RESULTS

In total, 26 articles with a sample size of 600 individuals were enrolled in the meta-analysis. According to the results of the study, the mean level of β-hCG was 28,744.98 ± 4425.1 mIU/ml before the intervention and was 23,836.78 ± 4533.1 mIU/ml after the intervention. The mean intraoperative blood loss (ml) was 4.8 ± 3.76 ml, mean hospital stay (days) was 11.7 ± 1.2 days, mean time for serum-hCG normalization (days) was 41.6 ± 3.2 days, success was 90.7% (95% CI: 86.7-93.5%), and complication was 9% (95% CI: 6.3-12.8%).

CONCLUSION

The results of the current study show methotrexate significantly reduces β-hCG levels and can be effective in treating caesarean scar pregnancy and its complications.

A Pictorial Review of Postpartum Complications

The postpartum period, also known as the puerperium, begins immediately after delivery of the neonate and placenta and ends 6-8 weeks after delivery. The appearance of physiologic uterine changes during puerperium can overlap with that of postpartum complications, which makes imaging interpretation and diagnosis difficult. Obstetric and nonobstetric postpartum complications are a considerable source of morbidity and mortality in women of reproductive age, and the radiologist plays an important role in the assessment of these entities, which often require a multimodality imaging approach. US and contrast material-enhanced CT are the techniques of choice in the emergency department, and they can show characteristic radiologic findings that enable differentiation between normal and abnormal features to help radiologists and emergency department practitioners to reach a correct diagnosis and provide timely treatment. The spectrum of postpartum complications ranges from relatively self-limiting to life-threatening conditions that can be divided into six categories: infectious conditions (endometritis), thrombotic complications (eg, deep vein thrombosis, ovarian vein thrombophlebitis, HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome, or cerebral sinus thrombosis), hemorrhagic conditions (eg, uterine atony, trauma of the lower portion of the genital tract, retained products of conception, uterine artery arteriovenous malformations, or uterine artery pseudoaneurysm), cesarean delivery-related complications (eg, bladder flap hematoma, subfascial hematoma, rectus sheath hematoma, abscess formation, uterine dehiscence, uterine rupture, vesicovaginal fistula, or abdominal wall endometriosis), iatrogenic conditions (eg, uterine perforation), and nonobstetric complications (eg, acute cholecystitis, acute appendicitis, uterine fibroid degeneration, renal cortical necrosis, pyelonephritis, posterior reversible encephalopathy syndrome, or pituitary gland apoplexy). The online slide presentation from the RSNA Annual Meeting is available for this article. ^©RSNA, 2020.

Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series

Background

There is no clear consensus on the management of caesarean scar pregnancy (CSP), a complex and life-threatening condition. The objective of this study was to present a novel approach to management of CSP that combines medical therapy of multidose methotrexate and mifepristone with active surgical management by uterine curettage and consecutive local haemostasis.

Case presentation

We report on a prospective case series of six women with first trimester pregnancy, in whom the diagnosis of CSP was confirmed by 2D and color Doppler transvaginal ultrasound and serial hormone chorionic gonadotropin (hCG) testing. Women were between 23 and 36 years old and had at least one previous delivery by caesarean. At admission, gestational age ranged between 6 to 14 weeks, and serum hCG levels between 397 and 23,000 mUI/ml. Upon decision of pregnancy termination, medical management was undertaken in all cases and 1 mg/kg systemic Methotrexate was administered between 1 and 5 daily doses. Mifepristone was part of the treatment in cases with live pregnancy. Surgical management was employed for the cases were an embryo was seen by ultrasound, being prompted by inadequate response to Methotrexate and/or signs of miscarriage with vaginal bleeding. Curettage combined with local isthmic balloon or vaginal pack tamponade prevented further complications. High treatment rates with preservation of fertility was achieved in all patients except one who underwent hysterectomy for invasive placentation. Ultrasound and hCG levels surveillance ensured that the resolution of pregnancy was achieved.

Conclusion

Women with history of delivery by caesarean section should be carefully monitored in future pregnancies for prompt diagnosis of CSP. Early diagnosis of CSP allows selection of successful conservative therapy. Through this case series we contribute with our experience to the body of knowledge about the management of this serious complication of early pregnancy.

Different treatment modalities for cesarean scar pregnancies: a single-center experience and literature review

PURPOSE

Cesarean scar pregnancy (CSP) remains a sporadic form of ectopic pregnancy associated with a severe life-threatening condition. There is no consensus on the treatment modality or a generally accepted guideline in CSP. This study aims to evaluate the outcomes of the different treatment modalities used in CSP treatment at a single center, as well as a literature review.

METHODS

This is a retrospective case series study that was conducted; all women who diagnosed with CSP between January 2013 and November 2019 at Women's Specialized Hospital, King Fahad Medical City. The clinical characteristics, diagnosis, different treatment modalities, and clinical outcomes were analyzed.

RESULTS

Twenty-seven cases of CSP identified during the study period. The median maternal age was 38 years (range 23-47 years). The gestational age at diagnosis ranged between 5 weeks and 5 days to 13 weeks and 6 days. All diagnoses were made by ultrasound. The absence of embryonic cardiac activity was seen in 10 cases (37.03%). The most commonly used method for first-line treatment was medical treatment. A total of 14 patients (51.85%) were treated with systemic methotrexate (MTX), three (11.1%) intra-sac and systemic MTX, and two (7.4%) intra-cardiac potassium chloride (KCl) along with systemic MTX, five (18.51%) cases had expectant management, one case initially treated with Laparotomy Wedge resection, and one case treated with uterine artery embolization (UAE) and systemic MTX. A total of 20 (74.07%) patients were treated successfully with first-line treatment. Seven (25.92%) patients needed additional second-line treatment. Among them, only one case had surgical intervention. None of the women in the medical treatment group experienced any side effects. Based on ANOVA results, there is no considerable relationship between the mean time of resolution of β-hCG and four treatment modalities for CSP (p = 0.2406). There was no statistical significance when the fetal viability at the time of diagnosis was compared to the need for second-line treatment of CSP (p = 0.58).

CONCLUSION

The treatment of CSP should be individualized based on risk factors. Diagnosis and management of CSP need expertise and a multidisciplinary approach to prevent complications. Early diagnosis and management of cesarean scar ectopic pregnancy remains the mainstay for a successful outcome.

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.

Caesarean scar ectopic pregnancy: Evolution from medical to surgical management

BACKGROUND

Caesarean scar ectopic pregnancy (CSP) is defined as blastocyst implantation occurring in a uterine scar. The incidence of CSP continues to rise with increasing caesarean section rates; prevalence is estimated to be 1:1800 to 1:2226 of all pregnancies. To date, over 30 treatment regimens have been published. The Royal College of Obstetricians and Gynaecologists guidelines (2016) state there is insufficient evidence to support one specific intervention over another.

AIM

To review outcomes of medical and surgical management of CSP cases at a single tertiary centre over a nine-year period, in order to establish the safest and most effective management approach.

MATERIALS AND METHODS

An audit was undertaken of patients treated for CSP between January 2009 and March 2017 at King Edward Memorial Hospital, Western Australia. Patient demographic and treatment outcome data were extracted from medical records.

RESULTS

Fifty-one patients were identified as having CSP diagnosed during this time period, of which five were excluded due to lack of data, leaving a total of 46 cases. The majority of patients (52%, n = 24) elected for initial surgical management, while 41% (n = 19) trialled medical management. Seven percent (n = 3) opted for conservative management. Success rates of surgical, medical and conservative management were 100%, 53% and 0% respectively (P < 0.001). Medical management was associated with prolonged follow-up; there was no difference in complication rates between surgical and medical managements.

CONCLUSIONS

In this audit, surgical management was the most effective way to manage CSP. There was no significant difference in complication rates between the two groups.

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.

Efficacy of different treatment of 134 cases of cesarean scar pregnancy

BACKGROUND

The aim of this study was to compare the clinical efficacy of different methods for treating cesarean scar pregnancy (CSP).

METHODS

The clinical data of 134 patients diagnosed with CSP in the Third Affiliated Hospital of Guangzhou Medical University were retrospectively analyzed. Grouped by treatment plan: pretreatments +ultrasound guided Curettage group (group A), pretreatments+ laparotomy (group B). Group A was sub-grouped according to the pretreatments: ultrasound guided uterine evacuation (A1), uterine arterial embolism (UAE) + ultrasound guided uterine evacuation (A2), high-intensity focused ultrasound (HIFU) + ultrasound guided uterine evacuation (A3); group B was sub-groups according to pretreatments: laparotomy (B1), UAE + laparotomy (B2).

RESULTS

The success rates of treatment in groups A and B were 72.73%-100%, and it was statistically significant (P<0.05) There were no statistically significant in the blood loss and the degree of decrease of β-hCG in these two group (P>0.05). The operation time, length of stay and cost were statistically significant between curettage group and laparotomy group (P<0.05); there was no significant difference in the degree of β-HCG decrease (%) and surgical bleeding volume. The success rate in group A1-A3 was 64.10%, 96.52% and 100% respectively, which was statistically significant (P<0.05). No statistically significant were showed in operation time, Length of stay and the degree of decrease of β-hCG within 5 days after operation in A1-A3 group (P>0.05). The blood loss and cost between A1 and A3 groups were statistically significant (P<0.05). The success rate in group B1-B2 were both 100%, with no statistically significant (P>0.05). There were no statistically significant in operation time, blood loss, degree of decrease of β-hCG, length of stay between the two groups (P>0.05). The cost between the two groups was statistically significant (P<0.05).

CONCLUSIONS

Ultrasound-guided uterine Curettage can be used as a better treatment for type I and II scar pregnancy. UAE or HIFU before Curettage can reduce uterine bleeding, while UAE before the laparotomy did not reduce uterine bleeding.

Managing Ectopic Pregnancies by Targeting Chorionic Villi with a Transvaginal Injection of Ethanol into the Lacunar Space

Methotrexate has been the main mode of non-surgical treatment for ectopic pregnancies. However, we have developed an easier, repeatable method that can be applied even to patients with a high beta-human chorionic gonadotropin (β-hCG) level and/or positive fetal heartbeat, by targeting chorionic villi with a transvaginal injection of absolute ethanol (AE) into the lacunar space (intervillous space). The efficacy and safety of this method were examined in 242 cases of ectopic pregnancy, including 103 with positive fetal heartbeat. Serum β-hCG level was measured at frequent intervals, and transvaginal ultrasonography was performed to observe the gestational sac and hyperechoic inner ring. Of the 242 patients, 222 (91.7%) were successfully treated. The average number of AE injection(s) required was 1.6 (range: 1-5), and the average dose was 3.2 mL. After the treatment, many of the patients tried to conceive again, and 63 of the traceable 145 patients (43.4%), who had fallopian tube pregnancy, and 7 of the traceable 12 patients (58.3%), who had cervical or cesarean scar pregnancies, successfully conceived and delivered babies with no observed side effects. Therefore, this method could be an effective treatment for ectopic pregnancy with the potential to replace conventional surgical interventions and medical treatment using methotrexate.