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Qu W, Li H, Zhang T, Zhang Y, Ban Y, Li N, Jiang J, Xie J, Shi W, Hao Y, Li R, Liu W, Cui B. Comparison of different treatment strategies in the management of endogenic caesarean scar pregnancy: a multicentre retrospective study. BMC Pregnancy Childbirth 2022; 22:404. [PMID: 35549886 PMCID: PMC9103451 DOI: 10.1186/s12884-022-04633-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background The aim of this study was to evaluate the effectiveness and safety of different treatment strategies for endogenic caesarean scar pregnancy (CSP) patients. Methods According to Vial’s standard, we defined endogenic-type CSP as (1) the gestational sac growing towards the uterine cavity and (2) a greater than 0.3 cm thickness of myometrial tissue at the caesarean scar. A total of 447 endogenic CSP patients out of 527 patients from 4 medical centres in China were enrolled in this study. A total of 120 patients were treated with methotrexate (MTX) followed by surgery, 106 received ultrasound-guided curettage directly and 221 received curettage combined with hysteroscopy. The clinical information and clinical outcomes of these patients were reviewed. Successful treatment was defined as (1) no additional treatment needed, (2) no retained mass of conception and (3) serum β subunit of human chorionic gonadotropin (β-hCG) level returning to a normal level within 4 weeks. The success rate was analysed based on these factors. Result Among 447 patients, no significant difference was observed in baseline characteristics between groups except for foetal heartbeat. The success rate was significantly different (p<0.001) among the three groups. The highest success rate of 95.9% was noted in the hysteroscopy group, and the lowest success rate of 84.0% was noted in the curettage group. In addition, the MTX group reported the longest hospital stay and highest expenses, but the curettage group showed the shortest and lowest expenses, respectively. Nevertheless, no difference in blood loss was observed between the groups. Conclusion The combination of curettage and hysteroscopy represents the most effective strategy. Pretreatment with MTX did not result in better clinical outcomes. Ultrasound-guided curettage directly should not be considered a first-line treatment choice for endogenic CSP patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04633-y.
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Affiliation(s)
- Wenjie Qu
- Department of Gynaecology and Obstetrics, Qilu Hospital of Shandong University, No.107 Wenhua West Road, Jinan, Jinan, 250012, China
| | - Hua Li
- Department of Gynaecology and Obstetrics, Taian Central Hospital, No.29 Longtan Road Taishan District, Tai'an City, Jinan, 250012, China
| | - Teng Zhang
- Department of Gynaecology and Obstetrics, Qilu Hospital of Shandong University, No.107 Wenhua West Road, Jinan, Jinan, 250012, China
| | - Yuan Zhang
- Department of Gynaecology and Obstetrics, Qilu Hospital of Shandong University, No.107 Wenhua West Road, Jinan, Jinan, 250012, China
| | - Yanli Ban
- Department of Gynaecology and Obstetrics, Qilu Hospital of Shandong University, No.107 Wenhua West Road, Jinan, Jinan, 250012, China
| | - Ningfeng Li
- Department of Gynaecology and Obstetrics, Qilu Hospital of Shandong University, No.107 Wenhua West Road, Jinan, Jinan, 250012, China.,Cheeloo College of Medicine, Shandong University, No.44 Wenhua West Road, Jinan, Jinan, 250012, China
| | - Jingyan Jiang
- Department of Obstetrics and Gynaecology, Jinan Central Hospital, No.105 Jiefang Road, Jinan, Jinan, 250012, China
| | - Juan Xie
- Department of Gynaecology and Obstetrics, Taian Central Hospital, No.29 Longtan Road Taishan District, Tai'an City, Jinan, 250012, China
| | - Wentian Shi
- Obstetrics and Gynaecology Department, Liaocheng People's Hospital, NO.67 Dongchang West Road, Liaocheng City Jinan, 250012, China
| | - Yiping Hao
- Department of Gynaecology and Obstetrics, Qilu Hospital of Shandong University, No.107 Wenhua West Road, Jinan, Jinan, 250012, China.,Cheeloo College of Medicine, Shandong University, No.44 Wenhua West Road, Jinan, Jinan, 250012, China
| | - Ruowen Li
- Department of Gynaecology and Obstetrics, Qilu Hospital of Shandong University, No.107 Wenhua West Road, Jinan, Jinan, 250012, China.,Cheeloo College of Medicine, Shandong University, No.44 Wenhua West Road, Jinan, Jinan, 250012, China
| | - Wei Liu
- Obstetrics and Gynaecology Department, Liaocheng People's Hospital, NO.67 Dongchang West Road, Liaocheng City Jinan, 250012, China.
| | - Baoxia Cui
- Department of Gynaecology and Obstetrics, Qilu Hospital of Shandong University, No.107 Wenhua West Road, Jinan, Jinan, 250012, China.
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Fu L, Luo Y, Huang J. Cesarean scar pregnancy with expectant management. J Obstet Gynaecol Res 2022; 48:1683-1690. [PMID: 35384174 PMCID: PMC9324103 DOI: 10.1111/jog.15258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 03/15/2022] [Accepted: 03/27/2022] [Indexed: 11/30/2022]
Abstract
Aim This study aimed to ascertain whether the lower anterior myometrial thickness (MT) between the bladder and the gestational sac in early pregnancy can be used to predict clinical outcomes in women with cesarean scar pregnancy (CSP) after expectant management. Methods We retrospectively analyzed the clinical data and early pregnancy ultrasound images of 21 patients who received expectant management for CSP. Among them, 11 patients with serious complications during pregnancy, such as intraoperative blood loss ≥1000 mL or with severe forms of morbidly adherent placenta (MAP; placenta increta or placenta percreta), were assigned to group A. The remaining 10 patients without serious complications during pregnancy were assigned to group B. The difference in MT between groups A and B was analyzed using nonparametric Mann–Whitney U test. Results There was a statistically significant difference in MT between the groups (U = 20.000, p = 0.013). The area under the receiver operating characteristics (ROC) curve was 0.818, and the optimal cut‐off value for MT was 3.3 mm. Conclusion Lower anterior MT around the gestational sac was correlated with severe complications, such as massive intraoperative bleeding or severe forms of MAP in patients with CSP.
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Affiliation(s)
- Liye Fu
- Department of Medical Imaging, Medical College of Yangtze University, Jingzhou, Hubei, China.,Department of Ultrasonography, Changsha Hospital for Maternal and Child Health Care, Changsha, Hunan, China
| | - Yingchun Luo
- Department of Ultrasonography, Maternal and Child Health Hospital of Hunan Province, Changsha, Hunan, China
| | - Jinbai Huang
- Department of Medical Imaging, Medical College of Yangtze University, Jingzhou, Hubei, China.,Department of Medical Imaging, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei, China
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Jordans IPM, Verberkt C, De Leeuw RA, Bilardo CM, Van Den Bosch T, Bourne T, Brölmann HAM, Dueholm M, Hehenkamp WJK, Jastrow N, Jurkovic D, Kaelin Agten A, Mashiach R, Naji O, Pajkrt E, Timmerman D, Vikhareva O, Van Der Voet LF, Huirne JAF. Definition and sonographic reporting system for Cesarean scar pregnancy in early gestation: modified Delphi method. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:437-449. [PMID: 34779085 PMCID: PMC9322566 DOI: 10.1002/uog.24815] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE To develop a standardized sonographic evaluation and reporting system for Cesarean scar pregnancy (CSP) in the first trimester, for use by both general gynecology and expert clinics. METHODS A modified Delphi procedure was carried out, in which 28 international experts in obstetric and gynecological ultrasonography were invited to participate. Extensive experience in the use of ultrasound to evaluate Cesarean section (CS) scars in early pregnancy and/or publications concerning CSP or niche evaluation was required to participate. Relevant items for the detection and evaluation of CSP were determined based on the results of a literature search. Consensus was predefined as a level of agreement of at least 70% for each item, and a minimum of three Delphi rounds were planned (two online questionnaires and one group meeting). RESULTS Sixteen experts participated in the Delphi study and four Delphi rounds were performed. In total, 58 items were determined to be relevant. We differentiated between basic measurements to be performed in general practice and advanced measurements for expert centers or for research purposes. The panel also formulated advice on indications for referral to an expert clinic. Consensus was reached for all 58 items on the definition, terminology, relevant items for evaluation and reporting of CSP. It was recommended that the first CS scar evaluation to determine the location of the pregnancy should be performed at 6-7 weeks' gestation using transvaginal ultrasound. The use of magnetic resonance imaging was not considered to add value in the diagnosis of CSP. A CSP was defined as a pregnancy with implantation in, or in close contact with, the niche. The experts agreed that a CSP can occur only when a niche is present and not in relation to a healed CS scar. Relevant sonographic items to record included gestational sac (GS) size, vascularity, location in relation to the uterine vessels, thickness of the residual myometrium and location of the pregnancy in relation to the uterine cavity and serosa. According to its location, a CSP can be classified as: (1) CSP in which the largest part of the GS protrudes towards the uterine cavity; (2) CSP in which the largest part of the GS is embedded in the myometrium but does not cross the serosal contour; and (3) CSP in which the GS is partially located beyond the outer contour of the cervix or uterus. The type of CSP may change with advancing gestation. Future studies are needed to validate this reporting system and the value of the different CSP types. CONCLUSION Consensus was achieved among experts regarding the sonographic evaluation and reporting of CSP in the first trimester. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- I. P. M. Jordans
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”, Amsterdam UMClocation VU Medical CenterAmsterdamThe Netherlands
| | - C. Verberkt
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”Amsterdam UMC, location AMCAmsterdamThe Netherlands
| | - R. A. De Leeuw
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”Amsterdam UMC, location AMCAmsterdamThe Netherlands
- Department of Obstetrics and GynecologyAmsterdam UMC, location AMCAmsterdamThe Netherlands
| | - C. M. Bilardo
- Department of Obstetrics and Gynecology, Amsterdam UMClocation VU Medical CenterAmsterdamThe Netherlands
| | - T. Van Den Bosch
- Department of Obstetrics and GynecologyUniversity Hospitals KU LeuvenLeuvenBelgium
- Laboratory for Tumor Immunology and ImmunotherapyKU LeuvenLeuvenBelgium
| | - T. Bourne
- Department of Obstetrics and GynecologyImperial College LondonLondonUK
| | - H. A. M. Brölmann
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”Amsterdam UMC, location AMCAmsterdamThe Netherlands
| | - M. Dueholm
- Department of Obstetrics and GynecologyAarhus University HospitalAarhusDenmark
| | - W. J. K. Hehenkamp
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”Amsterdam UMC, location AMCAmsterdamThe Netherlands
- Department of Obstetrics and GynecologyAmsterdam UMC, location AMCAmsterdamThe Netherlands
| | - N. Jastrow
- Department of Obstetrics and GynecologyHôpitaux Universitaires de GenèveGenevaSwitzerland
| | - D. Jurkovic
- Department of Obstetrics and GynecologyUniversity College HospitalLondonUK
| | - A. Kaelin Agten
- Department of Obstetrics and Gynecology, Nottingham University Hospitals NHSQueen's Medical CentreNottinghamUK
| | - R. Mashiach
- Department of Obstetrics and GynecologySheba Medical CenterRamat GanIsrael
- Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | - O. Naji
- Department of Obstetrics and GynecologyImperial College LondonLondonUK
| | - E. Pajkrt
- Department of Obstetrics and GynecologyAmsterdam UMC, location AMCAmsterdamThe Netherlands
| | - D. Timmerman
- Department of Obstetrics and GynecologyUniversity Hospitals KU LeuvenLeuvenBelgium
| | - O. Vikhareva
- Department of Obstetrics and Gynecology, Skåne University Hospital MalmöLund UniversityMalmöSweden
| | - L. F. Van Der Voet
- Department of Obstetrics and GynecologyDeventer HospitalDeventerThe Netherlands
| | - J. A. F. Huirne
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”, Amsterdam UMClocation VU Medical CenterAmsterdamThe Netherlands
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”Amsterdam UMC, location AMCAmsterdamThe Netherlands
- Department of Obstetrics and GynecologyAmsterdam UMC, location AMCAmsterdamThe Netherlands
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Saccone G, Mastantuoni E, Ferrara C, Sglavo G, Zizolfi B, De Angelis M, Di Spiezio Sardo A. Hysteroscopic resection vs dilation and evacuation for treatment of caesarean scar pregnancy: study protocol for a randomised controlled trial. Facts Views Vis Obgyn 2022; 14:83-86. [PMID: 35373552 PMCID: PMC9612857 DOI: 10.52054/fvvo.14.1.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Caesarean scar pregnancy (CSP) is a type of ectopic pregnancy where the fertilised egg is implanted in the muscle or fibrous tissue of the scar after a previous caesarean section. Management options for women who opted for termination of CSP include sharp curettage, dilation and evacuation (D&E), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolisation with curettage and/or methotrexate administration. Recently hysteroscopic resection has also been proposed as an alternative option. Objective To compare the surgical outcome of hysteroscopic resection with dilation and evacuation (D&E) for the treatment of caesarean scar pregnancy (CSP). Methods Parallel-group, non-blinded, randomised clinical trial conducted at a single centre in Italy. Eligible women are those with singleton gestations at less than 9 weeks of gestation, and with thickness of myometrial layer ≥1 mm at the level of the ectopic. Inclusion criteria are women with CSP with positive embryonic/fetal heart activity who opted for termination of pregnancy. Patients will be randomised 1:1 to receive either hysteroscopic resection (i.e. intervention group) or D&E (i.e. control group). In both groups, 50 mg/m2 (based on DuBois formula for body surface area) of methotrexate (MTX) will be injected intramuscularly at the time of randomisation (day 1) and another dose at day 3. A third dose of MTX is planned in case of persistence of fetal heart activity on day 5. Participants will receive either D&E or hysteroscopic resection from 3 to 7 days after the last dose of MTX. A sample size of 54 women is planned. Main Outcome Measures The primary outcome is the success rate of the treatment protocol, defined as no requirement for further treatment until complete resolution of the CSP as demonstrated by negative beta hCG levels and absence of residual gestational material on ultrasound examination.. Study hypothesis Hysteroscopic surgery is superior to D&E for the treatment of CSP. What is new? The results of the trial will provide information on the best treatment for CSP.
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Role of Ultrasound in the Assessment and Differential Diagnosis of Pelvic Pain in Pregnancy. Diagnostics (Basel) 2022; 12:diagnostics12030640. [PMID: 35328194 PMCID: PMC8947205 DOI: 10.3390/diagnostics12030640] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/21/2022] [Accepted: 03/01/2022] [Indexed: 02/04/2023] Open
Abstract
Pelvic pain (PP) is common in pregnant women and can be caused by several diseases, including obstetrics, gynaecological, gastrointestinal, genitourinary, and vascular disorders. Timely and accurate diagnosis as well as prompt treatment are crucial for the well-being of the mother and foetus. However, these are very challenging. It should be considered that the physiological changes occurring during pregnancy may confuse the diagnosis. In this setting, ultrasound (US) represents the first-line imaging technique since it is readily and widely available and does not use ionizing radiations. In some cases, US may be conclusive for the diagnosis (e.g., if it detects no foetal cardiac activity in suspected spontaneous abortion; if it shows an extrauterine gestational sac in suspected ectopic pregnancy; or if it reveals a dilated, aperistaltic, and blind-ending tubular structure arising from the cecum in suspicious of acute appendicitis). Magnetic resonance imaging (MRI), overcoming some limits of US, represents the second-line imaging technique when an US is negative or inconclusive, to detect the cause of bowel obstruction, or to characterize adnexal masses.
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Gu Z, Jia P, Gao Z, Gu W, Zhao H, Zhao S. Uterine artery embolization combined with ultrasound-guided dilation and curettage for the treatment of cesarean scar pregnancy: Efficacy and 5–8-year follow-up study. J Interv Med 2022; 5:148-152. [PMID: 36317145 PMCID: PMC9617151 DOI: 10.1016/j.jimed.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/02/2022] [Accepted: 03/10/2022] [Indexed: 11/07/2022] Open
Abstract
Objective To evaluate the efficacy and safety of uterine artery embolization (UAE) combined with dilation and curettage (D&C) using ultrasound as a treatment for cesarean scar pregnancy (CSP) and assess its effect on ovarian and reproductive function. Methods A total of 54 patients with uterine CSP between January 2011 and December 2015 were included in this retrospective study. The patients were treated with UAE combined with D&C using ultrasound for the treatment of CSP and followed up for 5–8 years. Their medical records, medical histories, clinical manifestations, treatment courses, and treatment results were analyzed. Results The 54 patients were initially treated without severe complications. β-Human chorionic gonadotropin (β-hCG) normalization took 36.11 ± 10.73 days (range, 25–84 days), length of hospitalization was 6.6 ± 1.5 days (range, 4–10 days), and total blood loss was 18.48 ± 8.41 mL (range, 5–33 mL). All patients resumed normal menstruation after 33.48 ± 8.71 days (range, 26–70 days). At the 5–8-year follow-up after UAE combined with D&C by ultrasound for the treatment of uterine CSP, the menstrual volume in 32 (59.3%) patients decreased versus before the operation. Compared with pretreatment, the menstrual cycle was prolonged in two (3.7%) cases, shortened in 10 (18.5%) cases, irregular in one (1.9%) case, and unchanged in 39 (72.2%) cases. Three patients conceived naturally and successfully gave birth to healthy children. Seven (12.96%) patients with accidental natural pregnancies chose induced abortion with no significant change in their sex lives. Conclusion UAE combined with D&C using ultrasound for the treatment of uterine CSP is safe and effective and may not affect the fertility of patients aged <40 years. However, menstrual volume may be reduced in some patients.
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Yin Y, Pan F, He M, Zhang C, Liu Y. High intensity focused ultrasound combined with ultrasound-guided suction curettage treatment for cesarean scar pregnancy: a comparison of different HIFU sonication strategies. Int J Hyperthermia 2022; 39:390-396. [PMID: 35196957 DOI: 10.1080/02656736.2022.2044078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE To explore a new high-intensity focused ultrasound (HIFU) sonication strategy for cesarean scar pregnancy (CSP) and to compare the clinical effectiveness and safety of this new HIFU sonication strategy with the conventional HIFU sonication strategy followed by ultrasound-guided dilation and curettage (USg-D&C) for CSP. MATERIALS AND METHODS 91 patients with CSP treated by HIFU and USg-D&C in People's Hospital of Deyang City between January 2017 and December 2019 were retrospectively reviewed in this study. Based on the HIFU sonication strategy, patients were divided to two groups: 44 patients were exposed to 'C-shape' sonication layer by layer around the implantation location of the pregnancy sac (control group), while the other 47 patients were exposed to 'I-shape' sonication layer by layer only on the deep part which close to the bladder of the implantation location of the pregnancy sac (experimental group). The differences in clinical efficacy between the two groups were analyzed. Baseline characteristics, technical parameters of HIFU treatment and USg-D&C data were recorded. Adverse events were also recorded. RESULTS No statistically significant difference was observed between the two groups in baseline characteristics including age, body mass index (BMI), menopause time, largest diameter of gestational sac, pretreatment serum β-hCG, thickness of gestational sac, embedding myometrium, previous cesarean sections and interval from last cesarean section (CS). The average treatment intensity in the experimental group was significantly lower than that in the control group (p < .05). The median sonication time, total energy used for HIFU ablation, and energy efficiency factor (EEF) in the experimental group were significantly lower than the control group (p < .05). No statistically significant difference was observed between the two groups in treatment power and treatment time (p > .05). Sciatic/buttock pain and postoperative lower abdominal pain in the control group were significantly stronger than that in the experimental group (p < .05). There were no statistically significant differences in post-HIFU vaginal bleeding and discharging, urinary tract irritation, the operation time of USg-D&C, the amount of vaginal bleeding during USg-D&C, and the time for serum β-hCG back to a normal level between the two groups (p > .05). CONCLUSIONS The 'I-shape' strategy of HIFU treatment for CSP was effective and safe, with shorter sonication time, less energy input and lower incidence of sonication-related pain occurred in postoperative lower abdominal and sciatic nerve/buttock.
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Affiliation(s)
- Yan Yin
- Department of Obstetrics and Gynaecology, People's Hospital of Deyang City, Deyang, China
| | - Feibao Pan
- Department of Cerebrovascular Disease, Suining Central Hospital, Suining, China
| | - Min He
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Cai Zhang
- State Key Laboratory of Ultrasound in Medicine and Engineering, College of Biomedical Engineering, Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Biomedical Engineering, Chongqing Medical University, Chongqing, China
| | - Yang Liu
- Department of Obstetrics and Gynaecology, People's Hospital of Deyang City, Deyang, China
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Endometriosis and Isthmocele: Common or Rare? J Clin Med 2022; 11:jcm11051158. [PMID: 35268248 PMCID: PMC8911021 DOI: 10.3390/jcm11051158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/13/2022] [Accepted: 02/19/2022] [Indexed: 01/27/2023] Open
Abstract
Higher cesarean section rates and better ultrasound diagnostics have led to a more frequent diagnosis of isthmocele, a cesarean scar defect. Sometimes, endometriosis is found in the isthmocele, but simultaneous extrauterine endometriosis and endometriosis in the isthmocele have not yet been reported. Additionally, the surgical technique to repair the isthmocele is the subject of ongoing controversy. The aim of this study is to analyze a possible correlation between uterine scar (isthmocele) endometriosis and extrauterine endometriosis and to investigate the outcome of laparoscopic isthmocele resection in the rendezvous technique. In this single-center retrospective study, we included 83 women of reproductive age with symptomatic isthmocele undergoing laparoscopic isthmocele repair in rendezvous technique from 2004 to 2020 at the University of Bern. We collected data on patient and surgical characteristics as well as on postoperative outcomes (symptoms, further pregnancy, and pregnancy outcomes) retrospectively. We analyzed and compared these data for patients with and without endometriosis. Endometriosis was diagnosed during surgery in 22 out of 83 operated patients (26.5%). Diagnosis of isthmocele endometriosis (n = 9, 11%) was significantly higher in patients with extrauterine endometriosis (n = 6, p = 0.004). While the duration of surgery was significantly longer for patients with endometriosis (p = 0.006), the groups did not differ with regard to blood loss or complications. In addition, both groups showed similar indications for isthmocele repair (infertility, abnormal uterine bleeding, or dysmenorrhea). Surgery significantly improved abnormal uterine bleeding (χ2 p < 0.001), dysmenorrhea (χ2, p = 0.03), and infertility (χ2, p < 0.001). Regardless of the presence of endometriosis, 25 of 40 (63%) infertile patients became pregnant after surgery. In one out of eight pregnancies, however, we observed scar complications during pregnancy such as uterine scar pregnancy (n = 3), uterine scar dehiscence (n = 3), and placenta previa (n = 1). Endometriosis is a non-negligible intraoperative finding in patients with symptomatic isthmocele. The laparoscopic approach in the rendezvous technique is safe and effective. Therefore, this method should be recommended, especially in women with secondary infertility, and preoperatively simultaneous endometriosis resection should be discussed with the patient. In follow-up, postoperative pregnancies have to be monitored with care.
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Diakosavvas M, Kathopoulis N, Angelou K, Chatzipapas I, Zacharakis D, Kypriotis K, Grigoriadis T, Protopapas A. Hysteroscopic treatment of Cesarean Scar Pregnancy: A systematic review. Eur J Obstet Gynecol Reprod Biol 2022; 270:42-49. [PMID: 35016136 DOI: 10.1016/j.ejogrb.2021.12.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 12/24/2021] [Accepted: 12/30/2021] [Indexed: 11/04/2022]
Abstract
More than 30 regimens, medical and surgical, have been described for the treatment of Cesarean Scar Pregnancies (CSPs). This study aims to collect and analyze data in the published literature regarding the hysteroscopic management of CSPs focusing on efficacy and complications. Using a protocol registered with Prospero (#CRD42021242314), the electronic databases PubMed/Medline, Scopus, Clinical-Trials.gov and the Cochrane Library were comprehensively searched, from their inception to June 2020. Medical Subject Headings terms such as caesarean ectopic, hysteroscopy and endoscopy were used for the identification of the relevant records. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to design the present systematic review. Eligible articles assessing the role of hysteroscopy in CSP were considered the studies published in peer-reviewed journals. Any studies with less than 10 cases or articles that insufficiently detailed the treatment regimen, the outcomes, and the success rate, were excluded. Selected articles were assessed for the level of evidence, based on Oxford Centre for Evidence-based Medicine guidelines. The methodologic quality, including the risk of bias, was evaluated with the employment of the Effective Public Health Practice Project Quality Assessment Tool. Ten out of 613 studies were included in the present review comprising 812 women with CSP treated by hysteroscopy. The treatment modalities were divided into three categories: (i) hysteroscopic resection of CSP, (ii) hysteroscopy after preoperative use of HIFU and (iii) preoperative use of UAE before hysteroscopic treatment. The overall success rate of hysteroscopic treatment on CSP cases was 91%, whereas the rate of hemorrhage or excessive vaginal bleeding (>500 mL) and the rate of hysterectomy were 1.66% and 0.28% respectively. According to the results of this systematic review, hysteroscopy appears to be a safe and effective procedure for CSP management. Current findings are primarily based on retrospective studies with poor methodological quality. Multicenter, well-designed studies are needed to draw definite conclusions.
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Affiliation(s)
- Michail Diakosavvas
- Endoscopic Surgery Unit, 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528 Athens, Greece.
| | - Nikolaos Kathopoulis
- Endoscopic Surgery Unit, 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528 Athens, Greece
| | - Kyveli Angelou
- Endoscopic Surgery Unit, 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528 Athens, Greece
| | - Ioannis Chatzipapas
- Endoscopic Surgery Unit, 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528 Athens, Greece
| | - Dimitrios Zacharakis
- Endoscopic Surgery Unit, 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528 Athens, Greece
| | - Konstantinos Kypriotis
- Endoscopic Surgery Unit, 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528 Athens, Greece
| | - Themos Grigoriadis
- Endoscopic Surgery Unit, 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528 Athens, Greece
| | - Athanasios Protopapas
- Endoscopic Surgery Unit, 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, National and Kapodistrian University of Athens, 80 Vasilissis Sofias Avenue, 11528 Athens, Greece
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Malhotra N, Noor N, Bansal P, Sharma KA. Successful Management of Caesarean Scar Ectopic Pregnancies: A Report of Five Cases. J Reprod Infertil 2021; 22:220-224. [PMID: 34900643 PMCID: PMC8607874 DOI: 10.18502/jri.v22i3.6723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 09/17/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Cesarean section scar ectopic pregnancy (CSEP) is a rare and potentially life-threatening condition. A standardized management protocol is yet to be established owing to limited data available. Case Presentation: In this paper, five cases of CSEP over a period of 18 months at a tertiary referral hospital, managed medically with methotrexate administered both systemically and into the gestational sac at the time of feticide with potassium chloride (KCL) are presented. Surgical management was the second line therapy when medical treatment failed. Conclusion: With rising trends in cesarean deliveries, CSEP may be a challenge which requires close investigation regarding its diagnosis and treatment on the merits of case studies and available healthcare facilities.
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Affiliation(s)
- Neena Malhotra
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Nilofar Noor
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
| | - Piyush Bansal
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Nagpur, India
| | - K Aparna Sharma
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
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The effect of prophylactic uterine artery embolization on reproductive outcomes in patients with cesarean scar pregnancy: a propensity score-matched study. Arch Gynecol Obstet 2021; 305:651-659. [DOI: 10.1007/s00404-021-06347-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 11/22/2021] [Indexed: 02/06/2023]
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Miller CE, McKenna MM. Is hysteroscopic treatment of cesarean scar pregnancy the best option? Fertil Steril 2021; 116:1567. [PMID: 34742554 DOI: 10.1016/j.fertnstert.2021.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Charles E Miller
- Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois
| | - Mary M McKenna
- Department of Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital, Park Ridge, Illinois
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Yu L, Yang B, Xu Q, Teng Y, Xue Z. A study on the timing of uterine artery embolization followed by pregnancy excision for cesarean scar pregnancy: a prospective study in China. BMC Pregnancy Childbirth 2021; 21:697. [PMID: 34654394 PMCID: PMC8518328 DOI: 10.1186/s12884-021-04180-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cesarean scar pregnancy (CSP) remains a sporadic and special form of ectopic pregnancy in which the fertilized ovum is implanted on a previous cesarean scar within 12 weeks. This study aims to evaluate the optimal time interval between uterine artery embolization (UAE) and curettage modalities in order to provide the best clinical outcomes. METHODS From January 2018 to December 2020, we recruited 61 patients with CSP. They were randomly divided into two groups depending on whether the time interval between UAE and dilatation and curettage (D&C) requires additional hospitalization: 31 patients received prophylactic UAE followed by D&C on the same day (0-12 h; group A) and 30 patients need hospitalization (12-72 h; group B). The clinical characteristics, diagnostic data, and outcomes of the two groups were compared and analyzed. RESULTS A total of 59 (96.72%) cases had responded well to the first treatment. One patient in each arm undergone retreatment, but none of the 61 patients needed additional hysterectomy. There was no considerable relationship between the two groups with respect to the intraoperative hemorrhage during D&C, serum index (containing β-hCG, hemoglobin, CRP, and D-dimer) on the first day after D&C, side effects (containing fever and abdominal pain), renal, hepatic, and coagulation function, time of CSP residual mass disappearance, and hospitalization cost. The time of serum β-hCG resolution after surgery was 41.22 ± 14.97 days in group A and 66.67 ± 36.64 days in group B (P = 0.027), and group A treatment resulted in a shorten hospital stay as compared with group B (4.81 ± 2.74 days vs. 6.80 ± 2.14 days, P < 0.001). However, the average hourly serum β-hCG decrease rate within 24 h and the leukocytes on the first day after D&C in group B were superior than in group A (P < 0.050). CONCLUSION For patients with CSP, UAE followed by D&C on the same day (0-12 h) appears to have more advantages in hospitalization and recovery time, while the long time interval (12-72 h) may have a lower risk of inflammation and a more rapid decrease in serum β-hCG level within 24 h after D&C surgery. The treatment of CSP should be individualized based on the conditions of patients.
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Affiliation(s)
- Liping Yu
- The Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Bikang Yang
- The Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Qinyang Xu
- The Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Yincheng Teng
- The Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
| | - Zhuowei Xue
- The Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
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Heidar Z, Zadeh Modarres S, Abediasl Z, Khaghani A, Salehi E, Esfidani T. Cesarean scar pregnancy treatment: a case series. J Med Case Rep 2021; 15:506. [PMID: 34625100 PMCID: PMC8501523 DOI: 10.1186/s13256-021-03081-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 08/24/2021] [Indexed: 01/19/2023] Open
Abstract
Background Cesarean scar pregnancy is a complicated and potentially life-threatening type of ectopic pregnancy. This study reports two women with cesarean scar pregnancy who were successfully treated with systemic methotrexate administration, and two other women who needed local re-administration of methotrexate after systemic injection. Case presentation Four Iranian pregnant women aged 29–34 years who were between 5 to 7 gestational weeks with cesarean scar pregnancy diagnosis are described. After a single dose of systemic methotrexate injection, the level of serum beta-human chorionic gonadotropin decreased in two of the women, while fetal activity was observed in the other two women. In the latter patients, methotrexate was injected under transvaginal ultrasound guidance into the gestational sac. As a result, the serum beta-human chorionic gonadotropin level first increased and then decreased in these patients. During the follow-up period, all the patients were stable and no complications were observed. Serum beta-human chorionic gonadotropin levels reached the non-pregnancy range from 4 to 9 weeks after treatment. Conclusion When diagnosed at early gestation, cesarean scar pregnancy can be treated successfully with methotrexate administration alone. The clinicians should be aware that the beta-human chorionic gonadotropin level may initially increase after methotrexate injection in some patients. However, the final outcome will be promising if the patients remain stable.
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Affiliation(s)
- Zahra Heidar
- Clinical Research Development Center, Mahdiyeh Educational Hospital, Shahid Beheshti University of Medical Sciences, Shishe Gar Khaneh Alley, Fadaian Islam Ave, Shoosh Sq, Tehran, Iran
| | - Shahrzad Zadeh Modarres
- Clinical Research Development Center, Mahdiyeh Educational Hospital, Shahid Beheshti University of Medical Sciences, Shishe Gar Khaneh Alley, Fadaian Islam Ave, Shoosh Sq, Tehran, Iran
| | - Zhila Abediasl
- Clinical Research Development Center, Mahdiyeh Educational Hospital, Shahid Beheshti University of Medical Sciences, Shishe Gar Khaneh Alley, Fadaian Islam Ave, Shoosh Sq, Tehran, Iran
| | - Arezo Khaghani
- Clinical Research Development Center, Mahdiyeh Educational Hospital, Shahid Beheshti University of Medical Sciences, Shishe Gar Khaneh Alley, Fadaian Islam Ave, Shoosh Sq, Tehran, Iran
| | - Ensieh Salehi
- Fertility and Infertility Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Tayebeh Esfidani
- Clinical Research Development Center, Mahdiyeh Educational Hospital, Shahid Beheshti University of Medical Sciences, Shishe Gar Khaneh Alley, Fadaian Islam Ave, Shoosh Sq, Tehran, Iran.
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Abstract
Cesarean scar ectopic pregnancy (SEP), a rare type of ectopic pregnancy, is the implantation of a gestational sac in the myometrium and fibrous tissues at the site of a previous uterine scar (mostly cesarean section scar). The condition can be catastrophic if not managed on time, leading to significant morbidity and mortality. Early diagnosis made by transvaginal ultrasonography and a high degree of suspicion for the probability of SEP in previous uterine surgery patients may help in the initiation and success of conservative treatment, prevention of complications, and preservation of fertility. We present here the analysis of 22 cases of SEP managed at our institute between 2013 to 2020. The mean gestational age at the time of diagnosis was 8.6±2.2 weeks. The majority of the women presented with either pain or bleeding, but few cases (7 cases) were asymptomatic and were diagnosed with SEP during routine obstetric ultrasonography. Out of these cases, a single case was admitted with shock due to uterine rupture. The mean serum β-hCG level was 29,543 mIU/ml (range, 2105-61590). Asymptomatic patients with low serum β-hCG levels(<15,000 mIU/ml) were given a single dose of methotrexate. Methotrexate was given as a single dose or 4 doses regimen in total 13 cases. Laparotomy with wedge resection of the scar ectopic was done in 8 cases. Overall primary treatment success was recorded in 20 of 22 cases (91%). 2 cases underwent dilatation and curettage due to retained product of conception after primary treatment with methotrexate. The serum β-hCG levels were normalized in an average time period of 53 days. This retrospective case series has proved the role of early and accurate diagnosis of SEP for initiating the treatment in order to minimize maternal morbidity and mortality related to this rare and unusual form of ectopic pregnancy.
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Affiliation(s)
- Ipsita Mohapatra
- Obstetrics and Gynecology, All India Institute of Medical Sciences Kalyani, Kalyani, IND
| | - Subha R Samantray
- Obstetrics and Gynecology, All India Institute of Medical Sciences Kalyani, Kalyani, IND
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An updated guide to the diagnosis and management of cesarean scar pregnancies. Curr Opin Obstet Gynecol 2021; 32:255-262. [PMID: 32618745 DOI: 10.1097/gco.0000000000000644] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Ahmed HEF, Bako A. Cesarean section scar pregnancy: Challenges in choosing treatment approach. Clin Case Rep 2021; 9:e04592. [PMID: 34429990 PMCID: PMC8365394 DOI: 10.1002/ccr3.4592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 05/24/2021] [Accepted: 06/28/2021] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Huda Elfadil Faki Ahmed
- Department of Obstetrics and GynaecologyWomen’s Wellness and Research Center (WWRC)Hamad Medical CorporationDohaQatar
| | - Abdulmalik Bako
- Department of Obstetrics and GynaecologyWomen’s Wellness and Research Center (WWRC)Hamad Medical CorporationDohaQatar
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Cesarean Scar Ectopic Pregnancy: A Case Report. J Emerg Nurs 2021; 47:693-695. [PMID: 34243986 DOI: 10.1016/j.jen.2021.05.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/21/2021] [Accepted: 05/26/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND A cesarean scar pregnancy is a rare, life-threatening obstetric emergency. Early recognition and prompt treatment of cesarean scar pregnancy is essential because of the risk for long-term reproductive complications associated with this condition. CASE PRESENTATION A 33-year-old gravida 6 para 5 female presented to the emergency department with pain to the suprapubic area. Following assessment and diagnostic testing, she was diagnosed with a cesarean scar pregnancy. The patient was admitted to the women's services department where she received a multidose regimen of methotrexate. The patient was discharged home, and no further surgical interventions were necessary. Two months after her visit to the emergency department, the patient has not had any complications related to the cesarean scar pregnancy. CONCLUSION This manuscript outlines the case of a patient presenting to the emergency department with a cesarean scar pregnancy that was promptly recognized and treated. It is important for emergency nurses to quickly recognize the risk factors and clinical presentation of a cesarean scar pregnancy to reduce maternal morbidity and mortality.
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Torre A, Verspyck E, Hamamah S, Thomassin I, Thornton J, Fauconnier A, Crochet P. [Cesarean scare niche: Definition, diagnosis, risk factors, prevention, symptoms, adverse effects, and treatments]. ACTA ACUST UNITED AC 2021; 49:858-868. [PMID: 34144220 DOI: 10.1016/j.gofs.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To review the definitions, diagnostic methods, risk factors, symptoms, and treatments for caesarean scar niche. METHODS Review of the literature, critical reflection, and pragmatic advice. RESULTS There is no consensus on the definition of caesarean scar niche. Some suggest an indentation≥2mm of the myometrium of the caesarean scar, but this is present in more than half of women with caesarean history and takes no account of woman's symptoms. The most popular diagnostic method is ultrasound±hysterosonography. Risks factors for niche are multiple Caesareans, Cesarean during labor with too low incision, and retroverted uterus. Symptoms include abnormal gynaecologic bleeding and pelvic pain, and their presence establish the "Caesarean scar syndrome". The risks of pregnancy with niche is poorly studied, but pregnancy is not contraindicated, even if the niche is untreated. The treatment of caesarean scar niche is mainly surgery and conservative. The former should be reserved for symptomatic patients, and those with secondary infertility and fertility treatment failure. Patients with residual myometrium thickness≥2.5mm may benefit from first-line hysteroscopic treatment, whereas a laparoscopic or vaginal approach could be offered in other cases. CONCLUSIONS A pragmatic definition of caesarean scar niche as a disease including symptoms is the necessary prerequisite for the management of women. The treatment is mainly surgical, or conservative depending on the desire for subsequent pregnancy.
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Affiliation(s)
- A Torre
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Maternity building of the City Hospital, Hucknall Road, NG5 1PB Nottingham, Royaume-Uni; Service de gynécologie-obstétrique, CHU de Rouen, Université de Rouen, Rouen, France.
| | - E Verspyck
- Service de gynécologie-obstétrique, CHU de Rouen, Université de Rouen, Rouen, France
| | - S Hamamah
- Univ Montpellier, Inserm U1203, EmbryoPluripotency, Montpellier, France; IRMB, Univ Montpellier, Inserm, Montpellier, France; CHU Montpellier, ART/PGD Department, Arnaud de Villeneuve Hospital, Montpellier, France
| | - I Thomassin
- Department of Imaging, Hopital Tenon, AP-HP, 75020 Paris, France
| | - J Thornton
- Division of Child Health, Obstetrics & Gynaecology, University of Nottingham, Maternity building of the City Hospital, Hucknall Road, NG5 1PB Nottingham, Royaume-Uni
| | - A Fauconnier
- Department of Biology, Medicine and Health, Research unit EA7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, Versailles St-Quentin University, Montigny-le-Bretonneux, France; Department of Gynecology and Obstetrics, Intercommunal Hospital Center of Poissy-St Germain en Laye, Poissy, France
| | - P Crochet
- Department of Obstetrics and Gynecology, Assistance Publique-Hôpitaux de Marseille, La Conception Hospital, Aix Marseille Université, Marseille, France
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Shen F, Lv H, Wang L, Zhao R, Tong M, Lee ACL, Guo F, Chen Q. A Comparison of Treatment Options for Type 1 and Type 2 Caesarean Scar Pregnancy: A Retrospective Case Series Study. Front Med (Lausanne) 2021; 8:671035. [PMID: 34211987 PMCID: PMC8240870 DOI: 10.3389/fmed.2021.671035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/14/2021] [Indexed: 12/02/2022] Open
Abstract
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.
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Affiliation(s)
- Fanghua Shen
- Department of Obstetrics and Gynaecology, Suzhou Ninth People's Hospital, Suzhou, China
| | - Hongdao Lv
- Department of Obstetrics and Gynaecology, Suzhou Ninth People's Hospital, Suzhou, China
| | - Liming Wang
- Department of Obstetrics and Gynaecology, Suzhou Ninth People's Hospital, Suzhou, China
| | - Ruiheng Zhao
- Department of Obstetrics and Gynaecology, Suzhou Ninth People's Hospital, Suzhou, China
| | - Mancy Tong
- Department of Obstetrics, Gynaecology and Reproductive Sciences, Yale School of Medicine, New Haven, CT, United States
| | - Arier Chi-Lun Lee
- Section of Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Auckland, New Zealand
| | - Fang Guo
- The Hospital of Obstetrics and Gynaecology, Fudan University, Shanghai, China
| | - Qi Chen
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
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Tang Y, Zhang Y, Tang H, Che J, Feng H, Yao X, Chen Q. A Comparison of Ultrasound Guided Curettage With and Without Uterine Artery Embolization on Controlling Intraoperative Blood Loss for a Cesarean Scar Pregnancy Treatment: Study Protocol for a Randomized Clinical Trial. Front Endocrinol (Lausanne) 2021; 12:651273. [PMID: 34194390 PMCID: PMC8237711 DOI: 10.3389/fendo.2021.651273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/11/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Cesarean scar pregnancy affects 6% of all ectopic pregnancies in women with prior cesarean section, and there is currently no consensus on the optimal treatment. Options of surgical treatment have a risk of intraoperative blood loss; therefore, uterine artery embolization (UAE) has been considered as an option of reducing intraoperative blood loss. However, UAE may be overused in clinical practice, especially in China. We present this protocol for a randomized clinical trial investigating the necessity of performing UAE for cesarean scar pregnancy, in combination with surgical suction curettage, taking into account the different subtypes of cesarean scar pregnancy. We recently developed a risk-scoring system (QRS) to estimate intraoperative blood loss, with 93.8% sensitivity and 6.3% false negative. Through this randomized clinical trial, we will retrospectively validate the QRS score on predicting intraoperative blood loss. Methods and Analysis We propose undertaking a randomized clinical trial sequentially recruiting 200 patients. All the patients will randomly receive ultrasound guided curettage with or without UAE. Data on the subtypes of cesarean scar pregnancy (Types 1 and II and III) detected by ultrasound will be collected before operation. The score on estimating intraoperative blood loss assessed by our recently developed quantitative risk-scoring system (QRS) will be collected before the operation. We will primarily compare the duration of the operation, intraoperative blood loss, and complications between the two groups. We will also retrospectively analyze the association of subtypes of cesarean scar pregnancy and the options of treatment and validate the QRS score. Outcomes of subsequent pregnancy within the 2-year follow-up will be secondary outcomes. Trial Registration Number [website], identifier ChiCTR2100041654.
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Affiliation(s)
- Yunhui Tang
- Department of Family Planning, The Hospital of Obstetrics & Gynaecology, Fudan University, Shanghai, China
| | - Yi Zhang
- Department of Obstetrics & Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Hanqing Tang
- School of Medicine, Nantong University, Nantong, China
| | - Jiahui Che
- Department of Gynaecology, The Hospital of Obstetrics & Gynaecology, Fudan University, Shanghai, China
| | - Hua Feng
- Unit of Cervical Disease, The Hospital of Obstetrics & Gynaecology, Fudan University, Shanghai, China
| | - Xiaoying Yao
- Department of Family Planning, The Hospital of Obstetrics & Gynaecology, Fudan University, Shanghai, China
| | - Qi Chen
- Department of Obstetrics & Gynaecology, The University of Auckland, Auckland, New Zealand
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Yüksel Şimşek S, Şimşek E, Alkaş Yağınç D, Baran ŞY, Çok T, Bulgan Kılıçdağ E. Outcomes of cesarean scar pregnancy treatment: Do we have options? Turk J Obstet Gynecol 2021; 18:85-91. [PMID: 34082520 PMCID: PMC8191324 DOI: 10.4274/tjod.galenos.2021.77535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
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.
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Affiliation(s)
- Seda Yüksel Şimşek
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Erhan Şimşek
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Didem Alkaş Yağınç
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Şafak Yılmaz Baran
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Tayfun Çok
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Esra Bulgan Kılıçdağ
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
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Hüner B, Lato K, Reister F, Janni W, Deniz M. A Scary Complication: Single-center Study on Management and Outcome of Cesarean Scar Pregnancy. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:311-316. [PMID: 33979891 PMCID: PMC10183945 DOI: 10.1055/s-0041-1728781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
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.
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Affiliation(s)
- Beate Hüner
- Department of Obstetrics and Gynecology, Ulm University, Ulm, Germany
| | - Krisztian Lato
- Department of Obstetrics and Gynecology, Ulm University, Ulm, Germany
| | - Frank Reister
- Department of Obstetrics and Gynecology, Ulm University, Ulm, Germany
| | - Wolfgang Janni
- Department of Obstetrics and Gynecology, Ulm University, Ulm, Germany
| | - Miriam Deniz
- Department of Obstetrics and Gynecology, Ulm University, Ulm, Germany
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Cesarean scar pregnancy: Reproductive outcome after robotic laparoscopic removal with simultaneous repair of the uterine defect. Eur J Obstet Gynecol Reprod Biol 2021; 262:40-44. [PMID: 33984726 DOI: 10.1016/j.ejogrb.2021.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/23/2021] [Accepted: 05/01/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe perioperative adverse events, fertility and obstetric outcome, following a robot assisted laparoscopic approach for treating Cesarean scar pregnancies (CSP). STUDY DESIGN A retrospective case series of 14 consecutive women with a CSP and a wish for and attempts towards subsequent pregnancies, having undergone minimal invasive surgical treatment at two tertiary referral Swedish centers (Dep's of Obstetrics and Gynecology Skåne University Hospital, Lund, and Södersjukhuset, Stockholm) between 2008 and 2019. The surgery was performed by temporary intraoperative occlusion of the uterine blood supply, removal of the CSP and repair of the niche, by the use of robot assisted laparoscopy (Da Vinci surgical robot, Intuitive Surgical, Sunnyvale, CA). RESULTS All surgeries were uneventful with a median bleeding of 75 mL. One woman had a postoperative Clavien-Dindo complication grade IIIa (hysteroscopic resection of an isthmic synechiae). During follow up nine women (64 %) conceived naturally; eight of these had an uneventful pregnancy and a full-term Cesarean delivery and one had recurrent CSP and Cesarean with simultaneous hysterectomy in gestational week 33. CONCLUSION A robotic removal of a CSP with simultaneous repair of the defect is a feasible option with acceptable reproductive outcome and should be considered when counseling women with a wish for future childbirth in cases of a live CSP and a thin, or absent, myometrium in the niche. A temporary intraoperative occlusion of the uterine blood supply may be useful in cases of live pregnancies and/or high serum β-hCG levels.
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75
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Mitsui T, Mishima S, Ohira A, Tani K, Maki J, Eto E, Hayata K, Masuyama H. hCG values and gestational sac size as indicators of successful systemic methotrexate treatment in cesarean scar pregnancy. Taiwan J Obstet Gynecol 2021; 60:454-457. [DOI: 10.1016/j.tjog.2021.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 12/26/2022] Open
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76
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Gull B, Klerelid V, Jormeus A, Strandell A. Potential risk factors for caesarean scar pregnancy: a retrospective case-control study. Hum Reprod Open 2021; 2021:hoab019. [PMID: 33959686 PMCID: PMC8087894 DOI: 10.1093/hropen/hoab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/22/2021] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- B Gull
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - V Klerelid
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - A Jormeus
- Department of Gynecology, Närhälsan Kungshöjd, Gothenburg, Region Västra Götaland, Sweden
| | - A Strandell
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden.,Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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77
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Mo X, Tang S, Li C. Management for delayed diagnosis in cesarean scar pregnancy with hemorrhage intra- or postuterine dilation and curettage. J Obstet Gynaecol Res 2021; 47:2014-2020. [PMID: 33779116 PMCID: PMC8252716 DOI: 10.1111/jog.14771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/27/2021] [Accepted: 03/10/2021] [Indexed: 12/01/2022]
Abstract
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.
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Affiliation(s)
- Xuetang Mo
- The Third Affiliated Hospital of Guangzhou Medical University and Key Laboratory for Major Obstetric Diseases, Guangzhou, China.,Gynaecological Laboratory, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Shiyan Tang
- The Third Affiliated Hospital of Guangzhou Medical University and Key Laboratory for Major Obstetric Diseases, Guangzhou, China.,Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Cuilan Li
- The Third Affiliated Hospital of Guangzhou Medical University and Key Laboratory for Major Obstetric Diseases, Guangzhou, China.,OB-GYN Associate of Advantia Health, Silver Spring, Maryland, USA
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78
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Wang J, Zhao R, Qian H, Lv H. Pituitrin local injection versus uterine artery embolization in the management of cesarean scar pregnancy: A retrospective cohort study. J Obstet Gynaecol Res 2021; 47:1711-1718. [PMID: 33749101 DOI: 10.1111/jog.14720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/12/2021] [Accepted: 02/06/2021] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Jianing Wang
- Department of Gynecology, Suzhou Ninth People's Hospital, Suzhou, China
| | - Ruiheng Zhao
- Department of Gynecology, Suzhou Ninth People's Hospital, Suzhou, China
| | - Huiying Qian
- Department of Gynecology, Suzhou Ninth People's Hospital, Suzhou, China
| | - Hongdao Lv
- Department of Gynecology, Suzhou Ninth People's Hospital, Suzhou, China
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79
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Aslan M, Yavuzkir Ş. Suction Curettage and Foley Balloon as a First-Line Treatment Option for Caesarean Scar Pregnancy and Reproductive Outcomes. Int J Womens Health 2021; 13:239-245. [PMID: 33654437 PMCID: PMC7914068 DOI: 10.2147/ijwh.s294520] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/04/2021] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Melike Aslan
- Obstetrics and Gynecology Department, Fırat University Medicine Faculty Hospital, Elazığ, Turkey
| | - Şeyda Yavuzkir
- Obstetrics and Gynecology Department, Fırat University Medicine Faculty Hospital, Elazığ, Turkey
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80
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Brar R, Saha PK, Bagga R. Termination of pregnancy may not be the only option for women diagnosed with live caesarean scar pregnancy at an early gestation: Lights and shadows. Aust N Z J Obstet Gynaecol 2021; 60:987-988. [PMID: 33373052 DOI: 10.1111/ajo.13251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/09/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Rinnie Brar
- Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pradip Kumar Saha
- Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rashmi Bagga
- Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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81
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Mosconi C, Crocetti L, Bruno A, Candita G, Cappelli A, Perrone O, Golfieri R, Cioni R. Scar Pregnancy and Extrauterine Implants. Semin Ultrasound CT MR 2021; 42:46-55. [PMID: 33541589 DOI: 10.1053/j.sult.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cesarean scar pregnancy (CSP) is a rare occurrence consisting in the implantation of the embryo within the myometrium of a prior cesarean delivery scar. The CSP could be a dangerous condition for women because of the related complications such as placenta previa or accreta, uterine rupture, and hemorrhage. Therefore, early diagnosis and rapid treatment are crucial. Extrauterine implants or ectopic pregnancy (EP) consists in the implantation of an embryo in a site other than the endometrium of the uterine cavity. It occurs in 1%-2% of all reported pregnancies. The most common extrauterine location is the fallopian tube, which represents 96% of cases. The diagnosis of CSP and EP is based on history, clinical examination, levels of serum β-human chorionic gonadotropin (β-hCG), and ultrasonography findings. In last 20 years, new treatments were developed, varying from medical management, minimally invasive surgical approach and local treatment including systemic or local infusion of metotrexate (MTX), and uterine artery embolization (UAE). UAE has been used widely to control hemorrhage and preserve the uterus and it is considered an affective adjuvant treatment of CSP and EP, especially associated with other therapies.
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Affiliation(s)
- Cristina Mosconi
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Laura Crocetti
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Antonio Bruno
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Gianvito Candita
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alberta Cappelli
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Orsola Perrone
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Roberto Cioni
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
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Kumari V, Kumar H, Datta MR. The Importance of Ectopic Mindedness: Scar Ectopic Pregnancy, a Diagnostic Dilemma. Cureus 2021; 13:e13089. [PMID: 33728112 PMCID: PMC7933601 DOI: 10.7759/cureus.13089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
There has been a consistent rise in ectopic pregnancies due to increase in maternal age, infertility treatment, cesarean sections, smoking among women, and use of contraceptives. With the extratubal ectopic pregnancies accounting for only 4% of the total ectopic pregnancies, scar pregnancies are even more of a rare entity with their incidence being less than 1%. We hereby present two cases of ectopic pregnancies, which though managed successfully presented a huge diagnostic challenge in the first case while the diagnosis was completely missed in the second case, hence, emphasizing the need for ectopic mindedness when dealing with early pregnancies.
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Affiliation(s)
- Vina Kumari
- Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, IND
| | | | - Mamta R Datta
- Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, IND
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83
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Rajadurai SM, Wong A, Brooks DM, Vance C. Combined interventional radiology and surgical management of a complex caesarean scar ectopic pregnancy. J Med Imaging Radiat Oncol 2021; 65:728-730. [PMID: 33410239 DOI: 10.1111/1754-9485.13137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
Caesarean scar ectopic pregnancies are rare but growing in incidence due to increasing rates of caesarean deliveries. These cases have historically been treated with either medical or surgical management which both have significant limitations. More recently, uterine artery embolisation (UAE) has shown significant promise in the treatment of this condition. We present the case of a complex patient with a caesarean scar ectopic successfully managed with combined UAE and surgery.
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Affiliation(s)
| | - Avelyn Wong
- Department of Obstetrics, Mercy Hospital for Women, Melbourne, Victoria, Australia
| | | | - Carol Vance
- Department of Obstetrics, Mercy Hospital for Women, Melbourne, Victoria, Australia
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84
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Vimercati A, Dellino M, Crupano FM, Gargano G, Cicinelli E. Ultrasonic assessment of cesarean section scar to vesicovaginal fold distance: an instrument to estimate pre-labor uterine rupture risk. J Matern Fetal Neonatal Med 2021; 35:4370-4374. [PMID: 33397168 DOI: 10.1080/14767058.2020.1849121] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The number of Cesarean sections (CS) is growing worldwide, intensifying the risk of complications in subsequent pregnancies and leading to increased maternal and fetal morbidity and mortality . In particular, the literature shows a higher risk of uterine rupture (UR) in subsequent pregnancy with trial of labor after cesarean section (TOLAC) Furthermore, there are few data about pre-labor UR in scarred uteri. OBJECTIVE Since the key factor for management is timing, the aim of this study was to evaluate the accuracy of prenatal ultrasound (US) of scars in the early determining of pre-labor UR risk in women with a previous CS during their subsequent pregnancy. METHODS From April 2014 to November 2018 a retrospective analysis was performed in order to evaluate the scar to vesicovaginal fold (VVF) distance in three patients with pre-labor UR and in 60 cases of the control group. RESULTS The periconceptional CS scar-VVF distance in the three UR cases resulted significantly increased compared to the controls (23.7 ± 3.5 mm vs 2.3 ± 2.7 mm, p < 005); moreover, a time interval of less than 18 months and a previous pre-labor preterm CS were found as known risk factors. CONCLUSION In this study, a higher uterine incision due to placenta previa or isthmic myoma seems to be correlated with a major risk of UR. Therefore, periconceptional US examination of CS-VVF distance, (which represents the level of the previous CS), seems to be a useful predictive factor of pre-labor UR in subsequent pregnancies.
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Affiliation(s)
- Antonella Vimercati
- Department of Biomedical and Human Oncological Science (DIMO), 2nd Unit of Obstetrics and Gynaecology, University of Bari, Bari, Italy
| | - Miriam Dellino
- Gynecologic Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Francesco Maria Crupano
- Department of Biomedical and Human Oncological Science (DIMO), 2nd Unit of Obstetrics and Gynaecology, University of Bari, Bari, Italy
| | - Giulio Gargano
- Gynecologic Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Ettore Cicinelli
- Department of Biomedical and Human Oncological Science (DIMO), 2nd Unit of Obstetrics and Gynaecology, University of Bari, Bari, Italy
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85
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Sun X, Liu Y, Tang Y, Yu H, Zhao M, Chen Q. Subsequent Fertility in Women Treated for Caesarean Scar Pregnancy With Hysteroscopy: A 5-Year Follow-Up Descriptive Study in a Tertiary Hospital. Front Endocrinol (Lausanne) 2021; 12:659647. [PMID: 34040581 PMCID: PMC8142377 DOI: 10.3389/fendo.2021.659647] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE The outcomes of subsequent pregnancies and fertility in women with a history of caesarean scar pregnancy have not been well described. In this study, we followed up 149 women with a history of caesarean scar pregnancy and analysed the effect on their fertility. METHODS 149 women with a history of caesarean scar pregnancy were followed up for five years. Of them, 53 women had unprotected sexual intercourse attempting to become pregnant again. Data including clinical parameters and treatment options at the time of diagnosis of caesarean scar pregnancy, and the outcomes in subsequent pregnancy were collected. In addition, a questionnaire about the menstrual cycle after treatment was voluntarily completed by these women. RESULTS Of the 53 women, 46 (84%) women had a subsequent pregnancy, while seven (14%) women did not. There was no association between the clinical parameters in previous caesarean scar pregnancy or treatment and future fertility. From the questionnaire, there was no difference seen in the length of the menstrual cycle and menses between the two groups. However, a higher number of women with light menstrual bleeding were seen in women without a subsequent pregnancy (67%), compared with women who did (28%). In addition, six women (13%) who had a subsequent pregnancy experienced foetus death in the first trimester. CONCLUSION We reported that 14% of women with a history of cesarean scar pregnancy did not have a subsequent pregnancy, after unprotected sexual intercourse for more than two years. Light menstrual bleeding after treatment may be associated with this adverse effect. Our findings need to be further investigated with large sample size.
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Affiliation(s)
- Xinyi Sun
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Yang Liu
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Yunhui Tang
- Department of Family Planning, The Hospital of Obstetrics and Gynaecology, Fudan University, Shanghai, China
| | - Hongying Yu
- Department of Ultrasound, The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
| | - Min Zhao
- Department of Gynaecology, The Affiliated Wuxi Maternity and Child Health Care Hospital of Nanjing Medical University, Wuxi, China
- *Correspondence: Min Zhao,
| | - Qi Chen
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
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Erem AS, Konney TO, Appiah-Kubi A, Ankomah K, Amankwa AT, Annan JJK, Tawiah A, Amoako-Adjei BK, Lartey KF, Lawrence ER. 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. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e927496. [PMID: 33370250 PMCID: PMC7774991 DOI: 10.12659/ajcr.927496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Patient: Female, 35-year-old Final Diagnosis: Cesarean section ectopic pregnancy Symptoms: Amenorrhea Medication:— Clinical Procedure: Exploratory laparotomy • MRI • ultrasonography Specialty: Obstetrics and Gynecology
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Affiliation(s)
- Anna Sarah Erem
- Department of Obstetrics and Gynecology, Saba University School of Medicine, Saba, Netherlands Antilles
| | - Thomas Okpoti Konney
- Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Adu Appiah-Kubi
- Department of Obstetrics and Gynecology, University of Health and Allied Sciences, Ho, Ghana
| | - Kwasi Ankomah
- Department of Radiology, Komfo Anokye Teaching Hospital, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Adu Tutu Amankwa
- Department of Radiology, Komfo Anokye Teaching Hospital, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - John Jude Kweku Annan
- Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Augustine Tawiah
- Department of Obstetrics and Gynecology, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | - Kwabena Fosu Lartey
- Department of Anesthesiology, Komfo Anokye Teaching Hospital, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Emma R Lawrence
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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87
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Controversies in family planning: Management of cesarean-scar ectopic pregnancy. Contraception 2020; 103:208-212. [PMID: 33359510 DOI: 10.1016/j.contraception.2020.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 12/14/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022]
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88
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Isono W, Tsuchiya A, Honda M, Saito A, Tsuchiya H, Matsuyama R, Fujimoto A, Kawamoto M, Nishii O. A retrospective study of 323 total laparoscopic hysterectomy cases for various indications and a case report treating caesarean scar pregnancy. J Med Case Rep 2020; 14:243. [PMID: 33308278 PMCID: PMC7734823 DOI: 10.1186/s13256-020-02585-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/12/2020] [Indexed: 11/12/2022] Open
Abstract
Background The application of laparoscopic surgeries has been increasing, and various uterine diseases in addition to leiomyoma/adenomyoma have become indications for total laparoscopic hysterectomy (TLH). Therefore, data acquisition and analysis of TLH procedures, including TLH for rare uterine diseases, have become important for improving surgical procedures and patient selection. To determine the prevalence of and risk factors for the occurrence of intraoperative and postoperative complications of TLH, we performed a multivariate analysis of the records in our hospital. Methods We retrospectively reviewed the medical records of 323 patients who underwent TLH for the treatment of leiomyoma/adenomyoma (278 cases), low-grade (pre)malignant uterine tumours (40 cases) and other rare uterine diseases (5 cases) from January 1, 2015, to December 31, 2019. Of the rare uterine diseases, one case of caesarean scar pregnancy for which TLH was performed is introduced as a case report. To assess the effects of 11 representative factors, including patient characteristics, uterus and leiomyoma sizes, indications for TLH and others, we performed a multivariate logistic regression analysis. Results Among the 323 cases, 20 intraoperative complications and 15 postoperative complications were reported. In the multivariate analysis, “ovarian tumour” and “heavy uterus” were positively associated and “nulliparity” was negatively associated with intraoperative complications. There were no significant risk factors for postoperative complications. The only risk factor for operative complications directly related to the resected uterus was “heavy uterus”. Therefore, we could perform TLH relatively safely for patients with other indications besides leiomyoma/adenomyoma. Conclusions Considering the factors detected in this analysis, the indications for TLH may be expanded. Owing to the increase in TLH for indications other than leiomyoma/adenomyoma, a more accurate determination of the treatment approach can be achieved.
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Affiliation(s)
- Wataru Isono
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1 Kawasaki, Futago Takatsu-ku, Futago, Kanagawa, 213-8507, Japan.
| | - Akira Tsuchiya
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1 Kawasaki, Futago Takatsu-ku, Futago, Kanagawa, 213-8507, Japan
| | - Michiko Honda
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1 Kawasaki, Futago Takatsu-ku, Futago, Kanagawa, 213-8507, Japan
| | - Ako Saito
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1 Kawasaki, Futago Takatsu-ku, Futago, Kanagawa, 213-8507, Japan
| | - Hiroko Tsuchiya
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1 Kawasaki, Futago Takatsu-ku, Futago, Kanagawa, 213-8507, Japan
| | - Reiko Matsuyama
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1 Kawasaki, Futago Takatsu-ku, Futago, Kanagawa, 213-8507, Japan
| | - Akihisa Fujimoto
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1 Kawasaki, Futago Takatsu-ku, Futago, Kanagawa, 213-8507, Japan
| | - Masashi Kawamoto
- Department of Diagnostic Pathology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1 Kawasaki, Takatsu-ku, Futago, Kanagawa, 213-8507, Japan
| | - Osamu Nishii
- Department of Obstetrics and Gynaecology, University Hospital Mizonokuchi, Teikyo University School of Medicine, 5-1-1 Kawasaki, Futago Takatsu-ku, Futago, Kanagawa, 213-8507, Japan
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89
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Risk factors of persistent cesarean scar pregnancy after dilation and curettage: a matched case-control study. Taiwan J Obstet Gynecol 2020; 59:237-242. [PMID: 32127144 DOI: 10.1016/j.tjog.2020.01.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To investigate the risk factors of persistent cesarean scar pregnancy (PCSP) after dilation and curettage (D&C). MATERIALS AND METHODS A retrospective, age-matched case-control study including 45 cases of PCSP patients after D&C was conducted between January 2013 and April 2018. For each case, 4 women who had been diagnosed with CSP and had the same age and same hospitalization period as the case group but no residual CSP tissue after D&C were selected as the controls (Control group, n = 180). Conditional logistic regression analysis was used to assess the risk factors of PCSP after D&C. RESULTS After conditional logistic regression, the 3 factors associated with PCSP after D&C were maximum diameter of CSP mass (or gestational sac) ≥4.5 cm (adjusted odds ratio [aOR] 6.51, 95% CI 1.39-30.47), myometrial thickness at the implantation site <2 mm (aOR 3.58, 95% CI 1.37-9.38) and a ≤66.42% decrease rate in β-hCG levels on the first day after D&C (aOR 18.58, 95% CI 5.80-59.57). ROC analysis showed that the indicator [(hCG0-hCG1)/hCG0*100%] has a good predictive value for PCSP, and the area under the curve (AUC) is 0.745; when the cut-off value is equal to 66.42%, the indicator has the best predictive value, with a sensitivity of 82.2% and a specificity of 67.7%. CONCLUSIONS For these high-risk patients with PCSP, choosing individualized treatment options and proper management could reduce the incidence of PCSP.
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90
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Mollo A, Battagliese A, Mascolo M, Raffone A, Travaglino A, D'Armiento M, Insabato L, Zullo F. Hysteroscopic Intact Removal of Angular and Caesarean Scar Pregnancy: A Novel and Markedly Less Invasive Surgical Treatment. Gynecol Obstet Invest 2020; 86:55-62. [PMID: 33302286 DOI: 10.1159/000510510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 07/22/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Ectopic pregnancy is the most common cause of mortality during the first trimester of pregnancy, and intrauterine ectopic pregnancies show significantly higher morbidity and mortality than extrauterine ones. Despite being less invasive, safety and effectiveness of the hysteroscopic treatment are still unclear. Moreover, such approach is not standardized. We aimed to evaluate safety and effectiveness of hysteroscopic intact removal of angular or cesarean section scar pregnancies, defining a novel and markedly less invasive hysteroscopic technique with a 5-mm Bettocchi hysteroscope or a 3.5-mm Versascope hysteroscope. MATERIALS AND METHODS Medical records and video archives were reviewed for all the patients with angular or caesarean scar pregnancies treated with hysteroscopic intact removal technique from January 2000 to December 2018 at our Department. Success and complication rates were assessed. RESULTS Four patients with angular (n = 1) or cesarean scar pregnancy (n = 3) met inclusion criteria. Case #1 was treated with bipolar resectoscope, cases #2 and #3 with 5-mm Bettocchi hysteroscope, and case #4 with 3.5-mm Versascope hysteroscope. Cases #2-4 did not require cervical dilatation. Before hysteroscopic treatment, cases #2-4 underwent unsuccessful medical therapy with multiple-dose methotrexate. Hysteroscopic treatment success rate was 100%, while complication rate was 0%. All patients were treated with a novel technique: hysteroscopic intact removal of angular or cesarean scar pregnancies. Such technique was described step-by-step. CONCLUSIONS Hysteroscopic treatment of angular and cesarean scar pregnancies may be a safe and effective minimally invasive option. The novel technique of hysteroscopic intact removal technique may allow a markedly less invasive approach.
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Affiliation(s)
- Antonio Mollo
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi (SA), Italy,
| | - Alessandra Battagliese
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Massimo Mascolo
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Maria D'Armiento
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Luigi Insabato
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Fulvio Zullo
- Gynecology and Obstetrics Unit, Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", University of Salerno, Baronissi (SA), Italy
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91
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Zhang Y, Zhang Z, Liu X, Zhang L, Hong F, Lu M. Risk factors for massive hemorrhage during the treatment of cesarean scar pregnancy: a systematic review and meta-analysis. Arch Gynecol Obstet 2020; 303:321-328. [PMID: 33219842 DOI: 10.1007/s00404-020-05877-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 11/04/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Yuan Zhang
- School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China.,Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, China.,Clinical Research Center, Shandong University, Jinan, China
| | - Zhongyun Zhang
- Department of Endocrinology and Metabolism, Ruijin Hospital of Shanghai Jiao Tong University School of Medicine, Shanghai, China.,School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoyan Liu
- Department of Obstetrics, Qilu Hospital of Shandong University, Jinan, China
| | - Lei Zhang
- Department of Obstetrics, Second Hospital of Shandong University, Jinan, China
| | - Fanzhen Hong
- Department of Obstetrics, Second Hospital of Shandong University, Jinan, China
| | - Ming Lu
- School of Public Health, Cheeloo College of Medicine, Shandong University, Jinan, China. .,Clinical Epidemiology Unit, Qilu Hospital of Shandong University, Jinan, China. .,Clinical Research Center, Shandong University, Jinan, China.
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92
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Capozzi VA, Rosati A, Rumolo V, Ferrari F, Gullo G, Karaman E, Karaaslan O, HacioĞlu L. Novelties of ultrasound imaging for endometrial cancer preoperative workup. Minerva Med 2020; 112:3-11. [PMID: 33205640 DOI: 10.23736/s0026-4806.20.07125-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Endometrial cancer (EC) is the most frequent gynecological cancer. Transvaginal ultrasound (TVU) plays a leading role in the preoperative workup and often is the first diagnostic instrumental examination. Despite expert hands' ultrasound is recommended to assess myometrial invasion in early stage EC, this method is a strictly operator-dependent examination, and varying degrees of sensitivity and specificity have been reported. The present review aims to provide an update of ultrasound imaging in the preoperative work-up for EC patients. EVIDENCE ACQUISITION A double-blind search was performed from May to September 2020. The following keywords: "ultrasound," "transvaginal ultrasound" and "endometrial cancer" were searched in Pubmed search engines, Scopus, and Web of Science. The Prisma statement was followed for the selection of the articles included. EVIDENCE SYNTHESIS The initial search provided 958 studies, of which 11 were included in the analysis. non-English articles, not relevant to the purposes of this study, case reports and articles with fewer than 40 cases were excluded. CONCLUSIONS TVU sensitivity and specificity in myometrial infiltration and cervical invasion is comparable to MRI but has lower costs, greater patient tolerability, and does not require contrast agents. An expert operator should perform the ultrasound examination in patients with suspected EC The presence of myometrial lesions, such as leiomyomas, could lower the diagnostic accuracy of ultrasound, so special attention should be paid to patients with concomitant uterine lesions.
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Affiliation(s)
- Vito A Capozzi
- Department of Gynecology and Obstetrics, University of Parma, Parma, Italy
| | - Andrea Rosati
- Division of Gynecologic Oncology, Department of Women and Children's Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Valerio Rumolo
- Division of Gynecologic Oncology, Department of Women and Children's Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Federico Ferrari
- Department of Women's and Reproductive Health, University of Oxford, Headington, Oxford, UK
| | - Giuseppe Gullo
- Department of Obstetrics and Gynecology, AOOR Villa Sofia Cervello, IVF Public Center, Palermo, Italy
| | - Erbil Karaman
- Department of Gynecology and Obstetrics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey -
| | - Onur Karaaslan
- Department of Gynecology and Obstetrics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Latif HacioĞlu
- Department of Gynecology and Obstetrics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
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93
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A comparison of the effects of Two suture materials on isthmocele formation: A cohort study. J Gynecol Obstet Hum Reprod 2020; 50:101933. [PMID: 33068769 DOI: 10.1016/j.jogoh.2020.101933] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/25/2020] [Accepted: 09/30/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Cesarean scar defects (CSD) are a problem that may lead to complications and excessive cost. The optimal way to suture the uterus is a matter of debate. The aim of this study was to evaluate the effect of two suture materials on cesarean scar niches. STUDY DESIGN This was a cohort study that allocated women into two groups: uterotomy closure with vicryl or catgut sutures. Transvaginal ultrasound (TVUS) was performed six months after the cesarean section (CS) to assess the scar. RESULTS Totally, 250 patients enrolled in this study. After six months, 20 (18.2 %) patients in the catgut suture group and 13 (9.3 %) patients in the vicryl group had isthmocele according to their sonography reports. The prevalence of isthmocele was higher in the catgut group (p = 0.03). The residual myometrial thickness was greater in the vicryl group (4.98 cm ± 2.18) compared to the catgut suture group (3.70 cm ± 1.50; p = 0.001). The prevalence of postoperative gynecological sequelae such as postmenstrual spotting and pain were similar between the two groups. CONCLUSION Vicryl sutures were associated with a lower risk of CSD formation in comparison with catgut sutures.
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94
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Asoglu MR, Celik C, Ozturk E, Cavkaytar S, Bahceci M. Impact of Isthmocele on Assisted Reproductive Treatment Outcomes: An Age-matched Retrospective Study. J Minim Invasive Gynecol 2020; 28:1113-1120. [PMID: 33038520 DOI: 10.1016/j.jmig.2020.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/01/2020] [Accepted: 10/04/2020] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVE To evaluate whether the presence of an ultrasonographic visible isthmocele has an impact on the chance of pregnancy in women undergoing embryo transfer. DESIGN Age-matched retrospective study. SETTING Private-assisted reproductive center. PATIENTS The study included a total of 150 patients with a history of cesarean delivery with 75 isthmocele cases and 75 controls. All patients underwent embryo transfer from January 2017 through June 2018. The diagnosis of isthmocele was based on transvaginal ultrasound assessment. Isthmocele was defined as an anechoic indentation on the previous cesarean scar at the midsagittal plane, with a depth of >1 mm. INTERVENTIONS Embryo transfer. MEASUREMENTS AND MAIN RESULTS The groups were similar in patient and treatment characteristics. The live birth rate was 44% in the isthmocele group and 46.7% in the control group (odds ratio [OR] 0.89; 95% confidence interval [CI], 0.47-1.71; p = .743). The clinical pregnancy rates were 49.3% and 50.7%, respectively (OR, 0.94; 95% CI, 0.50-1.79; p = .870). The miscarriage rate was greater in the isthmocele group (8%) than in the control group (4%); however, it did not reach statistical significance (OR, 2.09; 95% CI, 0.50-8.67; p = .302). The multiple pregnancy rate was similar between the groups (8% vs 5.3%, respectively; OR, 1.54; 95% CI, 0.41-5.70; p = .513). The groups were also similar in ectopic pregnancy rates (p = .560). These outcomes remained similar when adjusted for potential confounders on the regression analysis. CONCLUSION Isthmocele does not seem to have a significant impact on the chance of pregnancy in assisted reproductive treatment settings. However, the embryo transfer procedure may be more difficult in the presence of an isthmocele.
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Affiliation(s)
| | - Cem Celik
- Bahceci Umut Assisted Reproduction Center (Drs. Celik, Ozturk, and Cavkaytar); Department of Obstetrics and Gynecology, School of Medicine, Uskudar University (Dr. Celik), Istanbul, Turkey
| | - Ebru Ozturk
- Bahceci Umut Assisted Reproduction Center (Drs. Celik, Ozturk, and Cavkaytar)
| | - Sabri Cavkaytar
- Bahceci Umut Assisted Reproduction Center (Drs. Celik, Ozturk, and Cavkaytar)
| | - Mustafa Bahceci
- Bahceci Fulya Assisted Reproduction Center (Drs. Asoglu and Bahceci)
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95
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Tian H, Li S, Jia W, Yu K, Wu G. Risk factors for poor hemostasis of prophylactic uterine artery embolization before curettage in cesarean scar pregnancy. J Int Med Res 2020; 48:300060520964379. [PMID: 33467974 PMCID: PMC7967858 DOI: 10.1177/0300060520964379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 09/14/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To observe the hemostatic effect of prophylactic uterine artery embolization (UAE) in patients with cesarean scar pregnancy (CSP) and to examine the risk factors for poor hemostasis. METHODS Clinical data of 841 patients with CSP who underwent prophylactic UAE and curettage were retrospectively analyzed to evaluate the hemorrhage volume during curettage. A hemorrhage volume ≥200 mL was termed as poor hemostasis. The risk factors of poor hemostasis were analyzed and complications within 60 days postoperation were recorded. RESULTS Among the 841 patients, 6.30% (53/841) had poor postoperative hemostasis. The independent risk factors of poor hemostasis were gestational sac size, parity, embolic agent diameter (>1000 μm), multivessel blood supply, and incomplete embolization. The main postoperative complications within 60 days after UAE were abdominal pain, low fever, nausea and vomiting, and buttock pain, with incidence rates of 71.22% (599/841), 47.44% (399/841), 39.12% (329/841), and 36.39% (306/841), respectively. CONCLUSIONS Prophylactic UAE before curettage in patients with CSP is safe and effective in reducing intraoperative hemorrhage. Gestational sac size, parity, embolic agent diameter, multivessel blood supply, and incomplete embolization of all arteries supplying blood to the uterus are risk factors of poor hemostasis.
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Affiliation(s)
- Hongan Tian
- Department of Radiology, Xianning Central Hospital, The First
Affiliated Hospital of Hubei University of Science and Technology, Xianning,
P.R. China
- Department of Radiology, Zhongnan Hospital of Wuhan University,
Wuhan, P.R. China
| | - Shunzhen Li
- Department of Radiology, Xianning Central Hospital, The First
Affiliated Hospital of Hubei University of Science and Technology, Xianning,
P.R. China
| | - Wanwan Jia
- Department of Radiology, Xianning Central Hospital, The First
Affiliated Hospital of Hubei University of Science and Technology, Xianning,
P.R. China
| | - Kaihu Yu
- Department of Radiology, Xianning Central Hospital, The First
Affiliated Hospital of Hubei University of Science and Technology, Xianning,
P.R. China
| | - Guangyao Wu
- Department of Radiology, Zhongnan Hospital of Wuhan University,
Wuhan, P.R. China
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96
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Selection of a correct treatment protocol in caesarean scar pregnancies. Arch Gynecol Obstet 2020; 302:1375-1380. [PMID: 32974746 DOI: 10.1007/s00404-020-05800-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 09/16/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study aims at assessing the effectiveness of various treatment protocols with the help of some parameters in caesarean scar pregnancies. METHODS A total of 26 patients were assessed in the study. The patients were divided into 4 groups. Group 1 consisted of those who had a wedge resection (n = 7), group 2 those who had a suction curettage (n = 10), group 3 those who had a systemic methotrexate (MTX) (n = 5) and group 4 those who had a systemic + local MTX (n = 4). The ßHcg half-lives, haemoglobin levels at the time of admittance and discharge, and hospital stays of the groups were compared. RESULTS The difference between group 1 and group 4 was found significant (p = 0.002) with respect to days of hospital stay. There was no statistically significant difference between the groups with respect to ßHcg half-lives and haemoglobin values. CONCLUSION The results of our study showed that there were no significant differences between treatment outcomes when appropriate protocols were employed. Therefore, the important point in CSPs is to assess correctly the type of CSP, the myometrial thickness and the patient's hemodynamic condition and select the most appropriate protocol accordingly rather than trying to establish a single standard treatment protocol.
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97
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Singh P, Raikar S, Yadav G, Gothwal M, Ghuman N. Pregnancy at the Cesarean Section Scar: Successful Management and Review of Current Literature. ANNALS OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES (INDIA) 2020. [DOI: 10.1055/s-0040-1709225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
AbstractWhen implantation of the early embryo occurs at the scar of previous cesarean, it is called cesarean scar pregnancy. Though in uterus, it behaves like an ectopic pregnancy with risk of rupture and hemoperitoneum. A 37-year-old woman came with missed period and vague abdominal discomfort; she had a positive pregnancy test. She had previous two cesarean sections. The last cesarean section was 12 years ago and the patient was not using any contraception. Her ultrasonography (USG) was inconclusive; β human chorionic gonadotropin was 2,980 mIU/mL. Her repeat USG showed a hypoechoic area at the cesarean scar site, behind the reflection of bladder, separated from bladder by a thin layer of myometrium. She was counseled regarding the management options and prognosis. She was managed with two doses of injection. Methotrexate on day 1 and day 4. β human chorionic gonadotropin was repeated until it was close to normal. USG was also repeated. Cesarean scar pregnancy can be managed by many ways; the one most suitable to the patient with least side effects should be adopted, after adequate counseling of the patient.
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Affiliation(s)
- Pratibha Singh
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Sunil Raikar
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Garima Yadav
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Meenakshi Gothwal
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Navdeep Ghuman
- Department of Obstetrics and Gynecology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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98
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Ou J, Peng P, Li C, Teng L, Liu X. Assessment of the necessity of uterine artery embolization during suction and curettage for caesarean scar pregnancy: a prospective cohort study. BMC Pregnancy Childbirth 2020; 20:378. [PMID: 32600442 PMCID: PMC7325163 DOI: 10.1186/s12884-020-03062-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 06/16/2020] [Indexed: 02/07/2023] Open
Abstract
Background Uterine artery embolization (UAE) followed by suction and curettage is a common conservative treatment for caesarean scar pregnancy (CSP), but the advantages of suction and curettage alone are underestimated due to the lack of standards for selecting appropriate cases for which this approach would be applicable. We sought to identify indicators with which to assess the need for UAE during suction and curettage. Methods The prospective cohort consisted of 105 women diagnosed with CSP in Peking Union Medical College Hospital between January 2016 and September 2018 who were followed up until 60 days after surgery. The main outcome was the therapy used, and secondary outcomes included recovery, bleeding, surgery time, length of hospital stay, and total cost. Results We found that β-human chorionic gonadotropin (β-hCG) levels were significantly lower (P < 0.05), foetal cardiac activity was significantly lower (P < 0.05), the myometrial layer was significantly thicker (P < 0.05), expenditures were lower and lengths of hospital stay were shorter in patients who received suction and curettage alone (the non-UAE group) than in those who received UAE followed by suction and curettage (the UAE+ group). In addition, for CSP patients, UAE might be less necessary when the myometrial thickness is ≥2 mm and the gestational sacmeasures ≤5 cm, and suction and curettage alone may be safer for these patients. Conclusion Suction and curettage alone is a more suitable option than UAE followed by suction and curettage because the former carries a lower cost, shorter length of hospital stay, and lower risk of adverse events. Regarding risk factors, patients with a lower uterine segment thickness ≥ 2 mm and a gestational mass diameter ≤ 5 cm have an increased probability of being successfully treated with suction and curettage alone.
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Affiliation(s)
- Jie Ou
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 ShuaiFu Road, Dongcheng District, Beijing, People's Republic of China
| | - Ping Peng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 ShuaiFu Road, Dongcheng District, Beijing, People's Republic of China
| | - Chunying Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 ShuaiFu Road, Dongcheng District, Beijing, People's Republic of China
| | - Lirong Teng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 ShuaiFu Road, Dongcheng District, Beijing, People's Republic of China
| | - Xinyan Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, No. 1 ShuaiFu Road, Dongcheng District, Beijing, People's Republic of China.
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Huang L, Zhao L, Shi H. Clinical Efficacy of Combined Hysteroscopic and Laparoscopic Surgery and Reversible Ligation of the Uterine Artery for Excision and Repair of Uterine Scar in Patients with Type II and III Cesarean Scar Pregnancy. Med Sci Monit 2020; 26:e924076. [PMID: 32595205 PMCID: PMC7341695 DOI: 10.12659/msm.924076] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background With the changes in China’s family planning policy, the incidence of cesarean scar pregnancy (CSP) significantly increased in recent years. The present study aimed to investigate the clinical efficacy of combined hysteroscopic and laparoscopic surgery and reversible ligation of the uterine artery for cesarean scar excision and repair in patients with type II and III CSP. Material/Methods This was a retrospective study of 173 patients with type II and III CSP. They were assigned to the hysteroscopy and laparoscopy group (group A), hysteroscopy group (group B), and curettage group (group C) according to the surgery they underwent. The surgical indicators (intraoperative bleeding volume and hospital stay), postoperative recovery (time of serum β-hCG returning to the normal, postoperative residual lesion, the thickness of the uterine scar, and recovery time of menstruation), and the postoperative complications were compared among the 3 groups. Results In patients with type II and III CSP, significant differences (P<0.05) were observed between group A vs. groups B and C in terms of the time of serum β-HCG returning to normal, postoperative residual lesions, the thickness of the uterine scar, and recovery time of menstruation, while there were no significant differences in intraoperative bleeding volume and postoperative hospital stay (P>0.05). Conclusions For patients with type II and III CSP, hysteroscopy and laparoscopy surgery and reversible ligation of the uterine artery achieved better clinical outcomes than hysteroscopy or curettage with respect to postoperative recovery. This could be suitable for patients with CSP and desire for fertility.
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Affiliation(s)
- Lina Huang
- Department of Obstetrics and Gynecology, Ningbo Women's and Children's Hospital, Ningbo, Zhejiang, China (mainland)
| | - Lingjun Zhao
- Department of Obstetrics and Gynecology, Ningbo Women's and Children's Hospital, Ningbo, Zhejiang, China (mainland)
| | - Huiwei Shi
- Department of Obstetrics and Gynecology, Ningbo Women's and Children's Hospital, Ningbo, Zhejiang, China (mainland)
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Yoon R, Sasaki K, Miller CE. Laparoscopic Excision of Cesarean Scar Pregnancy with Scar Revision. J Minim Invasive Gynecol 2020; 28:746-747. [PMID: 32603870 DOI: 10.1016/j.jmig.2020.06.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To demonstrate our technique for robot-assisted laparoscopic ectopic pregnancy excision and concomitant scar revision. DESIGN We present a stepwise narrated demonstration of our primary laparoscopic technique. SETTING Although cesarean scar pregnancy is rare, it leads to life-threatening complications and often emergent hysterectomy [1,2]. Because of its rarity, there is a scarcity of centers with high-volume experience with its treatment, and no standardized diagnostic or management guidelines are yet available [3,4]. Recent evidence suggests that primary surgical management may be superior to medical or radiologic management as the latter methods carry a high reintervention rate [5]. An additional consideration in selecting a treatment method is a patient's plans for future fertility, as cesarean scar defects are associated with secondary infertility. Evidence shows that repair of cesarean scar defects decreases the likelihood of future recurrence and secondary infertility, thus it may be pertinent to select a management strategy that allows for the accomplishment of both ectopic pregnancy removal and defect revision. We present our primary laparoscopic approach to ectopic pregnancy excision and revision of the cesarean scar defect using techniques rooted in evidence and robust experience. INTERVENTIONS Robot-assisted laparoscopic excision of a cesarean scar ectopic pregnancy with concomitant scar revision demonstrating key strategies to minimize blood loss and preserve future fertility. (1) A laparoscopic approach allows for concomitant ectopic pregnancy removal followed by cesarean scar revision. (2) Generous use of dilute vasopressin and purposeful application of electrosurgical energy provides hemostasis without the use of more invasive measures such as vascular clips or uterine artery balloons. (3) A multilayer closure is associated with a lower risk of wedge defect formation and uterine rupture. (4) Diagnostic hysteroscopy is a useful tool for identifying the location of the scar defect, assessing for an adequate repair, and identifying potential additional uterine pathology. CONCLUSION Primary laparoscopic management is not only the most effective method with the lowest complication rates but is an approach that allows for simultaneous repair and revision of the cesarean scar defect. We demonstrate easily adaptable techniques for maintaining hemostasis, minimizing injury to normal myometrium, and creating multilayer closures that lead to successful revisions with minimal impact to subsequent fertility.
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Affiliation(s)
- Rachel Yoon
- Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital (Dr. Yoon); The Advanced Gynecologic Institute (Drs. Sasaki and Miller), Park Ridge, Illinois
| | - Kirsten Sasaki
- Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital (Dr. Yoon); The Advanced Gynecologic Institute (Drs. Sasaki and Miller), Park Ridge, Illinois
| | - Charles E Miller
- Department of Obstetrics and Gynecology, Advocate Lutheran General Hospital (Dr. Yoon); The Advanced Gynecologic Institute (Drs. Sasaki and Miller), Park Ridge, Illinois.
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