Cesarean scar pregnancy: issues in management

Interventions for non-tubal ectopic pregnancy

BACKGROUND

Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. Sites include a caesarean scar, the cornua uteri, the ovary, the cervix, and the abdomen. There has been an increasing trend in the occurrence of these rare conditions, especially caesarean scar pregnancy (CSP).

OBJECTIVES

To evaluate the clinical effectiveness and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy in terms of fertility outcomes and complications.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) search portal and nine other databases to 12 December 2019. We handsearched reference lists of articles retrieved and contacted experts in the field to obtain additional data.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) published in all languages that examined the effects and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy.

DATA COLLECTION AND ANALYSIS

We used Cochrane standard methodological procedures. Primary outcomes were treatment success and complications.

MAIN RESULTS

We included five RCTs with 303 women, all reporting Caesarean scar pregnancy. Two compared uterine arterial embolization (UAE) or uterine arterial chemoembolization (UACE) plus methotrexate (MTX) versus systemic MTX and subsequent dilation and suction curettage; one compared UACE plus MTX versus ultrasonography-guided local MTX injection; and two compared suction curettage under hysteroscopy versus suction curettage under ultrasonography after UAE/UACE. The quality of evidence ranged from moderate to very low. The main limitations were imprecision (small sample sizes and very wide confidence intervals (CI) for most analyses), multiple comparisons with a small number of trials, and insufficient data available to assess heterogeneity. UAE/UACE versus systemic MTX prior to suction curettage Two studies reported this comparison. One compared UAE with systemic MTX and one compared UACE plus MTX versus systemic MTX, in both cases followed by a suction curettage. We are uncertain whether UAE/UACE improved success rates after initial treatment (UAE: risk ratio (RR) 1.00, 95% CI 0.90 to 1.12; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.87, 95% CI 0.54 to 1.38; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced rates of complications (UAE: RR 0.47, 95% CI 0.13 to 1.75; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.62, 95% CI 0.26 to 1.48; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced adverse effects (UAE: RR 1.58, 95% CI 0.41 to 6.11; 1 RCT, 72 women; low-quality evidence; UACE: RR 1.16, 95% CI 0.32 to 4.24; 1 RCT, 28 women; low-quality evidence), and it was not obvious that the types of events had similar values to participants (e.g. fever versus vomiting). Blood loss was lower in UAE/UACE groups than systemic MTX groups (UAE: mean difference (MD) -378.70 mL, 95% CI -401.43 to -355.97; 1 RCT, 72 women; moderate-quality evidence; UACE: MD -879.00 mL, 95% CI -1135.23 to -622.77; 1 RCT, 28 women; moderate-quality evidence). Data were not available on time to normalize β-human chorionic gonadotropin (β-hCG). UACE plus MTX versus ultrasonography-guided local MTX injection We are uncertain whether UACE improved success rates after initial treatment (RR 0.95, 95% CI 0.56 to 1.60; 1 RCT, 45 women; very low-quality evidence). Adverse effects: the study reported the same number of failed treatments in each arm (RR 0.88, 95% CI 0.40 to 1.92; 1 RCT, 45 women). We are uncertain whether UACE shortened the time to normalize β-hCG (MD 1.50 days, 95% CI -3.16 to 6.16; 1 RCT, 45 women; very low-quality evidence). Data were not available for complications. Suction curettage under hysteroscopy versus under ultrasonography after UAE/UACE. Two studies reported this comparison. One compared suction curettage under hysteroscopy versus under ultrasonography after UAE, and one compared these interventions after UACE. We are uncertain whether suction curettage under hysteroscopy improved success rates after initial treatment (UAE: RR 0.91, 95% CI 0.81 to 1.03; 1 RCT, 66 women; very low-quality evidence; UACE: RR 1.02, 95% CI 0.96 to 1.09; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced rates of complications (UAE: RR 4.00, 95% CI 0.47 to 33.91; 1 RCT, 66 women; very low-quality evidence; UACE: RR 0.18, 95% CI 0.01 to 3.72; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced adverse effects (UAE: RR 3.09, 95% CI 0.12 to 78.70; 1 RCT, 66 women; very low-quality evidence; UACE: not estimable; 1 RCT, 92 women; very low-quality evidence). We are uncertain whether suction curettage under hysteroscopy shortened the time to normalize β-hCG (UAE: MD 4.03 days, 95% CI -1.79 to 9.85; 1 RCT, 66 women; very low-quality evidence; UACE: MD 0.84 days, 95% CI -1.90 to 3.58; 1 RCT, 92 women; low-quality evidence). Non-tubal ectopic pregnancy other than CSP No studies reported on non-tubal ectopic pregnancies in locations other than on a caesarean scar.

AUTHORS' CONCLUSIONS

For Caesarean scar pregnancies (CSP) it is uncertain whether there is a difference in success rates, complications, or adverse events between UAE/UACE and administration of systemic MTX before suction curettage (low-quality evidence). Blood loss was lower if suction curettage is conducted after UAE/UACE than after administration of systemic MTX (moderate-quality evidence). It is uncertain whether there is a difference in treatment success rates, complications, adverse effects or time to normalize β-hCG between suction curettage under hysteroscopy and under ultrasonography (very low-quality evidence). There are no studies of non-tubal ectopic pregnancy other than CSP and RCTs for these types of pregnancy are unlikely.

Association of hemorrhage at termination in caesarean scar pregnancy using the crossover sign of ultrasound image

PURPOSE

To analyze whether crossover sign (COS) can help predict the risk of bleeding during surgical evacuation in patients with caesarean scar pregnancy (CSP).

METHODS

This study retrospectively analyzed the clinical presentations, ultrasound images and treatment outcomes of patients with CSP. The relationship among the gestational sac, caesarean scar and the anterior uterine wall, defined as the COS, was analyzed to predict the risk of severe bleeding during surgical evacuation in these patients. All patients were categorized according to the relationship between the endometrial line and the superior-inferior diameter of the gestational sac into crossover sign-1 and crossover sign-2 groups. The Mann-Whitney U test was used to compare the data with non-normal distribution, and logistic regression analysis was performed to identify the correlates of severe bleeding.

RESULTS

A total of 74 patients were included. In COS-1 group (n = 21), 16 (76.19%) patients suffered heavy bleeding(≥200 mL) during surgical evacuation, while COS-2 group (n = 53) had only 1(11.89%) patient complaint of heavy bleeding (≥200 mL) (P < 0.01). Adverse surgical outcomes were more common in women with COS-1. Logistic regression analysis showed that COS-1 (OR, 7.93; 95% CI, 1.35-46.67) was independently associated with severe bleeding.

CONCLUSION

COS can help predict who has a higher risk of severe hemorrhage in patients with CSP and guide the clinical treatment selection for optimal management of this condition.

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

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Exclusive use of intrasac potassium chloride and methotrexate for treating cesarean scar pregnancy: effectiveness and subsequent fecundity

STUDY QUESTION

Is exclusive use of intragestational sac potassium chloride (KCl) and methotrexate (MTX) effective in the management of viable cesarean scar pregnancy (CSP)?

SUMMARY ANSWER

Exclusive use of intragestational sac KCl and MTX was effective in the management of viable CSP.

WHAT IS KNOWN ALREADY

Owing to a paucity of randomized studies on management of CSP, evidence-based management remains unclear. Intragestational sac KCl or MTX along with either systemic MTX or surgical intervention, such as uterine artery embolization or dilation and curettage, has proved to be effective in the management of CSP. Furthermore, there are limited data in the literature on the use of exclusive intragestational sac KCl and MTX for management of CSP and subsequent fecundity.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study was conducted from June 2017 to September 2019. We recruited nine CSP patients referred to our unit. There was no lost to follow-up noted.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients with an ultrasound diagnosis of CSP who fulfilled the inclusion criteria were recruited. The study was conducted in a tertiary care center. Clinical symptoms, pregnancy viability, gestational age and human chorionic gonadotrophin (HCG) values determined the management in each individual case. Accordingly, patients were grouped into the expectant management (Group I, n = 3) and intragestational sac KCl with MTX (Group II, n = 6) groups. Demographic details, clinical characteristics, ultrasound details at diagnosis, post-treatment HCG normalization time, menses resumption, mass resolution and subsequent fecundity were noted. Descriptive statistics were used for analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the nine patients with CSP, six patients had viable CSP and required intervention. Out of these, four patients expressed a desire for future fertility. Mean gestational age at treatment among patients in Group II was 54.33 ± 7.51 days (range 46–65). Mean HCG value at the time of diagnosis was 84 110 ± 38 679.39 IU/l in Group II patients as compared with 2512 ± 709.36 in Group I. HCG had decreased by 92.7 ± 3.78% 2 weeks after intervention and normalized (<5 IU/l) by 53.5 ± 14.97 days. No major complications occurred and additional treatment was not required in these patients. Menstruation had resumed by 26 ± 6.6 days after treatment in Group II. On follow up, a small unresolved mass was present in two patients and the cesarean scar niche was visible in the remaining four patients. Out of the four patients desirous of future conception, three conceived naturally and one delivered a term baby via repeat lower segment cesarean section.

LIMITATIONS, REASONS FOR CAUTION

The main limitation of our study was small sample size. All the patients were asymptomatic at presentation and hence we cannot comment on use of this method in those presenting with active vaginal bleeding.

WIDER IMPLICATIONS OF THE FINDINGS

Intragestational sac KCl plus MTX may be a highly effective approach for the management of viable CSP despite high initial HCG values. There seems to be no need for any further intervention. It can be considered as the first line minimally invasive treatment option in patients desirous of future fertility. Nevertheless, accumulation of further cases is required to validate this treatment modality.

STUDY FUNDING/COMPETING INTERESTS

No specific funding was received to undertake this study. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A

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

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

Serum β-human chorionic gonadotropin profile and its correlations with ultrasound parameters in low-lying-implantation ectopic pregnancy in the first trimester

AIM

Cervical pregnancy (CP) and cesarean scar pregnancy (CSP), defined as low-lying-implantation ectopic pregnancy (LLIEP), are rare conditions of aberrant implantation around the lowest portion of the uterus. This study aimed to illustrate the serum β-human chorionic gonadotropin (β-hCG) profile of LLIEP and to explore its implications with the clinical characteristics.

METHODS

Women with LLIEP during the first trimester were retrospectively evaluated at a tertiary referral center from August 1999 to July 2016. Demographic and clinical data were recorded, including maternal age, gestational age (GA), serum β-hCG level, maximal diameter of the gestational mass/sac (MDM/MDS) by ultrasonography and CSP implantation types. The serum β-hCG level was measured on the day of ultrasound imaging. The significance of pretreatment the serum β-hCG level and its correlations with the clinical characteristics were analyzed.

RESULTS

A total of 88 LLIEP with 64 CSP and 24 CP was included. The mean GA at the time of diagnosis was 7 weeks (range, 5-12 weeks). The β-hCG concentrations rapidly increased from GA 5 to 9 weeks and fluctuated thereafter. The β-hCG levels correlated positively with GA and ultrasound MDM/MDS. In the CSP group, there was no difference in the β-hCG level between superficial and deep implantation types. β-hCG levels demonstrated no significant differences among simple and complicated LLIEP.

CONCLUSION

This study established the serum β-hCG profile in LLIEP in the first trimester. The exponential increase of β-hCG levels was similar to that of normal intrauterine pregnancies. The β-hCG levels were not associated with placentation complexity of CSP. Higher β-hCG levels did not implicate less success in conservative surgical management.

Outcomes of subsequent pregnancies in patients following treatment of cesarean scar pregnancy with high intensity focused ultrasound followed by ultrasound-guided dilation and curettage

Objective: To evaluate the outcomes of subsequent pregnancies in patients with a history of cesarean scar pregnancy (CSP) treated with high intensity focused ultrasound (HIFU) followed by ultrasound-guided dilation and curettage (USg-D&C). Methods: A retrospective analysis was performed on data collected from 154 patients with CSP who were treated by HIFU followed by USg-D&C in Suining Central Hospital between January 2015 and January 2018. Among them, 28 patients wanted to conceive following treatment. Baseline characteristics, treatment results, intraoperative hemorrhages during USg-D&C, post-curettage serum beta human chorionic gonadotropin (β-hCG) levels and vaginal bleeding were investigated. Subsequent pregnancy outcomes, including intervals between pregnancy and treatment of CSP, complications during pregnancy, and outcomes of newborns were evaluated. Results: All patients with CSP were successfully treated by HIFU combined with USg-D&C. Of the 28 CSP patients who intended to conceive after the treatment, 23 patients (82.14%) successfully conceived. The average interval between conception and HIFU treatment was 18.38 ± 10.04 months. Eighteen patients (78.26%) had an intrauterine pregnancy, in which 12 had delivery by cesarean section, 1 had an ongoing pregnancy, and 5 had an abortion in the first trimester. Among the other 5 women, 3 had tubal ectopic pregnancy and 2 had recurrent CSP. These five patients underwent laparoscopy within the first trimester. Conclusion: HIFU followed by USg-D&C is an effective and safe treatment for patients with CSP who wish to conceive. Prospective multi-center studies with larger sample sizes and longer follow-up periods are needed to compare this treatment with others.

Caesarean scar ectopic pregnancy: Experience from an Australian tertiary centre

BACKGROUND

Despite the rising incidence of caesarean scar pregnancy (CSP), as yet there are no consensus or evidence-based guidelines for management.

AIMS

To review diagnosis, treatment and management of all women with CSP over a 5 year period at Mater Mothers' Hospital, Brisbane, Australia.

MATERIALS AND METHODS

Retrospective cohort study of CSP between 2013-2018. Data reviewed included demographics, presenting symptoms, gestational age, ultrasound findings, human chorionic gonadotrophin levels, treatment success, complications, and if available, subsequent pregnancy outcomes.

RESULTS

Twenty-eight women were treated for CSP during the study period. Initial diagnosis was delayed in ten (36%). Overall success rates of initial treatment were 22/28 (79%). Of the six cases of failed treatment, five had been treated with systemic methotrexate alone. All women requiring further intervention had fetal pole present, and 50% had fetal cardiac activity. Failure rate of systemic methotrexate alone was 5/11 (45%). Eleven women deemed appropriate for conservative management did not require further treatment or experience complications. Nine women had data available for subsequent pregnancies, of whom two developed placenta accreta.

CONCLUSION

This study provides data that may assist in guideline development and decision-making for management of CSP. Conservative management in carefully selected women appeared to be safe. Nearly half of women treated with systemic methotrexate alone required another treatment modality, suggesting a role for intralesional treatment, particularly in the presence of fetal pole ± fetal cardiac activity. More than one in five women with documented subsequent pregnancies were diagnosed with placenta accreta.

Identifying possible risk factors for cesarean scar pregnancy based on a retrospective study of 291 cases

Aim

Cesarean scar pregnancy (CSP) is a rare but life‐threatening type of ectopic pregnancy. This study's aim is to investigate the clinical characteristics and possible risk factors for cesarean scar pregnancy.

Methods

A clinically randomized, unpaired and retrospective case–control study was implemented. A study group of 291 CSP patients and a control group of 317 full‐term pregnant women with a history of cesarean section (CS) were recruited in our hospital from May 2013 to October 2018. Their demographic characteristics and medical and obstetric history were collected.

Results

Only symptoms suggestive of an impending abortion, such as vaginal bleeding with or without abdominal pain, were identified as the clinical characteristics of CSP. Maternal age older than 35 years, gravidity higher than 3 (especially gravidity higher than 5), more than two induced abortions (especially more than five abortions), an interval of less than 5 years (especially less than 2 years) between the current pregnancy and the last CS, history of CS performed in a rural hospital, history of induced abortions after CS and retroposition of the uterus were possible independent risk factors for CSP.

Conclusion

CSP is a result of a combination of multiple factors associated with CS. There are no unique early clinical features of CSP. As a unique type of ectopic pregnancy, early diagnosis, early termination and early clearance should be the treatment principles. Further research is needed to evaluate the relationship between the cesarean scar defect and CSP in the future.

MRI of Acute Gynecologic Conditions

Although usually not a first-line imaging modality in the setting of acute pelvic pain, magnetic resonance imaging (MRI) is able to depict and characterize a wide range gynecologic diagnoses with high accuracy. Lack of ionizing radiation renders MRI particularly useful for assessment of pregnant women and children. Furthermore, inherent high soft-tissue resolution of MRI allows accurate diagnosis without intravenous contrast use, which is advantageous for patients with renal insufficiency and pregnant patients. Familiarity with the typical MRI appearance of various acute gynecologic conditions helps establish the correct diagnosis. This article reviews the common MRI findings of acute gynecologic processes, in both pregnant and nonpregnant patients. Level of Evidence: 3 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;51:1291-1309.

Diagnostic and Management Challenges of Caesarean Scar Ectopic Pregnancy in a Lower Middle Income Country

Caesarean scar ectopic pregnancy is defined as the implantation of the blastocyst in a previous Caesarean scar. It is a rare type of ectopic pregnancy. The incidence is however rising due to the increasing rates of Caesarean sections as well as in-vitro fertilization embryo-transfer. It can be diagnosed early by ultrasound. This remains a challenge in lower middle income countries where the availability of high resolution ultrasound and the skill for such sonography may be lacking. Misdiagnosis or a delay in diagnosis often leads to poor treatment outcomes. We present a case of a gravida 3 para 2 + 0 who had laparotomy for a caesarean scar pregnancy and highlight the challenges associated with diagnosis and management of this rare ectopic pregnancy in a lower middle income country.

Comparison Of Three Different Treatment Methods For Cesarean Scar Pregnancy

Background/Aim

Cesarean scar pregnancy is a long term complication of cesarean section. There is a lot of controversy about the best treatment methods. We retrospectively summarized the clinical characteristics of patients with cesarean scar pregnancy and explored the advantages and disadvantages of fertility-preservation treatment method.

Methods

From January 2008 to September 2017, a total of 204 cases of cesarean scar pregnancy were retrospectively reviewed. 145 patients underwent transvaginal clearance, 33 patients underwent endoscopic surgery, and 26 patients underwent uterine artery embolism. The clinical characteristics, diagnosis, various treatment methods, and clinical outcomes were analyzed.

Results

There were no significant differences among the three groups in terms of patient age, number of previous cesarean sections, serum human chorionic gonadotropin, and clinical symptoms. The difference in mean gestational sac diameter (23.5±2.1mm vs 31.3±2.4mm vs 30.8± 1.9mm), surgical time (31.4±2.5min vs. 45.8±2.2min vs. 51.4±1.9min), blood loss (53.3± 5.5mL vs. 105.2±3.2mL vs. 75.6 ±3.5mL), blood transfusion (1/145 case vs.3/33 case vs. 0/26 case), discomfort (1/145 case vs.9/33 case vs. 16/26 case), hospital stay (6.1±1.1 day vs. 7.4±0.9 day vs.18.6±1.5 day), fever duration (1.0±0.5 day vs. 2.1±2.8 day vs. 5.7±3.5 day), and hospital expense (¥ 7825.9±234.9 vs. ¥ 10248.3± 312.9 vs. ¥ 18774.9±243.6) in transvaginal pregnancy tissue clearance, endoscopic surgery, and uterine artery embolism groups were significantly different.

Conclusion

Transvaginal clearance is an effective and relatively safe treatment option for patients with cesarean scar pregnancy.

Risk factors and consequences of undiagnosed cesarean scar pregnancy: a cohort study in China

Background

The historically high cesarean section rate and the recent change in second-child policy could increase the risk of cesarean scar pregnancy (CSP) in China. This study aims to assess risk factors and consequences of undiagnosed CSP in China.

Methods

We conducted a retrospective cohort study between January 2013 and December 2017 in Qingyuan, Guangdong, China. Independent risk factors for undiagnosed CSP at the first contact with healthcare providers were assessed by log binomial regression analysis. Occurrence of serious complications was compared between undiagnosed and diagnosed CSP cases.

Results

A total of 195 women with CSP were included in the analysis. Of them, 81 (41.5%) women were undiagnosed at the first contact with healthcare providers. Women initially cared in primary or secondary hospitals were at increased risk for undiagnosed CSP: adjusted relative risks (95% confidence intervals) were 3.28 (2.06, 5.22) and 1.91 (1.16, 3.13), respectively, compared with women initially cared in the tertiary hospital. Undiagnosed CSP cases had higher incidences in serious complications (11 versus 0) and post-surgery anemia (23 (28.4%) versus 8 (7.0%)), stayed longer in hospital, and cost higher than diagnosed CSP cases.

Conclusions

Initial care provided at primary or secondary maternity care facilities is an important risk factor for undiagnosed CSP, with serious consequences to the affected women.

Cesarean Scar - Unusual Site of Ectopic Pregnancy: A Case Report

Ectopic pregnancy is a leading cause of maternal mortality in the first trimester. It may occur in different anatomic locations with fallopian tube being the most frequent. Cesarean-scar ectopic pregnancy is one of the rarest ectopic pregnancies. We report the case of a 44-year-old woman, gravida 5 para 4, who attended the antenatal clinic after her pregnancy was confirmed by positive urine testing. She underwent transvaginal ultrasound examination which identified the gestational sac with fetal pole and cardiac activity located in the anterior part of the lower uterine segment with empty uterine cavity. Magnetic resonance imaging (MRI) scan had confirmed the diagnosis of cesarean scar ectopic pregnancy. After through discussion on the management options, the patient was treated with intra-gestational sac injection of methotrexate. Four days after the procedure, she developed profuse vaginal bleeding and her hemoglobin showed a drop of 4.9 g/dL. She underwent emergency laparotomy with excision of the ectopic pregnancy. The patient tolerated the procedure well without complications. The serum β-human chorionic gonadotropin level was undetectable on the 35^th day after the methotrexate injection. Caesarean scar pregnancy is an unusual form of ectopic pregnancy. However, clinicians should have a high index of suspicion for this condition as it may result in serious complications, unless promptly managed. MRI is recommended particularly when transvaginal ultrasound scan is inconclusive.

Successful technique of manual vacuum aspiration for treatment of type 2 cesarean scar pregnancies: evaluation of 40 cases

OBJECTIVE

To demonstrate the effectiveness and safety of the defined manual vacuum aspiration (MVA) technique for treatment of type 2 cesarean scar pregnancies (CSPs).

METHODS

We treated 40 patients with CSP by MVA at the Early Pregnancy Clinic of our hospital between 1 January 2012 and 31 December 2014. The files of patients were reviewed and evaluated retrospectively. Eligibility criteria were hemodynamic stability and at least 2 mm myometrial thickness at the anterior part of the CSP. The key-point of successful MVA procedure is to keep away from entering the cesarean scar cavity directly; instead, CSP is displaced from the implantation site by applying vacuum, only while the cannula is passing near.

RESULTS

During the study period, the ratio of CSP to total pregnancies was 1/1000. The ratio of CSP to cesarean delivery (CD) was 1/372. In that time period, CSPs were constituted 4.41% of all ectopic pregnancies. Total of 40 patients were treated with dilatation and MVA. Complications such as excessive hemorrhage, persistence of CSP, and any need of extra intervention were not observed. The beta-hCG values of 21 patients (52.5%) decreased below 10 mIU/mL after the first 15 days, and the rest decreased below 10 mIU/mL after 3 weeks following MVA.

CONCLUSIONS

This MVA technique for treatment of CSP is easily applicable and effective method with high success and low complication rates. For appropriately selected patients, we think that this method can be considered as the first- line treatment.

Cesarean Scar Pregnancy, Incidence, and Recurrence: Five-Year Experience at a Single Tertiary Care Referral Center

OBJECTIVE

To describe the treatment and subsequent pregnancy outcomes in patients with cesarean scar pregnancies at a single institution over 5 years.

METHODS

This is a case series of all cesarean scar pregnancies diagnosed from May 2013 to March 2018 at Yale-New Haven Hospital. Data were collected on each patient using electronic medical record review and included patient demographics; medical, surgical, and obstetric history; pregnancy characteristics; treatment modalities used; response to therapy; complications; and subsequent pregnancy outcomes.

RESULTS

Thirty cases of cesarean scar pregnancies were diagnosed in 26 patients, including one recurrence in one patient and three recurrences in another. Forty-six percent of cesarean scar pregnancies were in Hispanic women. The median number of prior cesarean deliveries was two. Mean gestational age at the time of diagnosis was 46 days (SD±10). Fetal cardiac activity was detected in 18 cases. Three patients initially were erroneously diagnosed with a viable intrauterine pregnancy and failed medical termination. Others opted for termination through systemic methotrexate alone (n=4), systemic and local methotrexate (n=12), systemic and local methotrexate with potassium chloride injected into the gestational sac (n=3), potassium chloride injection with laparotomy and wedge resection (n=1), methotrexate with bilateral uterine artery embolization (n=2), or intrauterine balloon (n=4). Five patients who underwent expectant management or methotrexate therapy had retained products of conception and required hysteroscopy and curettage. One patient opted for hysterectomy after failed curettage. After complete resolution of cesarean scar pregnancies, there were 10 subsequent spontaneous conceptions in eight patients, including four recurrent cesarean scar pregnancies, four term pregnancies, and one spontaneous abortion. One viable normally located pregnancy is ongoing.

CONCLUSION

There is a wide array of treatment modalities available for cesarean scar pregnancies. Women with a cesarean scar pregnancy are at risk for its recurrence in the future, although normal pregnancy after a cesarean scar pregnancy is also possible. Safe outcomes depend on timely diagnosis and multidisciplinary care by skilled clinicians.

Risk Factor for Residue After Uterine Artery Chemotherapy and Embolization in Combination with Dilatation and Curettage for Treating Caesarean Scar Pregnancy

Objective

We aimed to investigate the potential risk factors for residual lesions after uterine artery chemotherapy and embolization (UACE) in combination with dilatation and curettage (D&C) in patients with cesarean scar pregnancy (CSP).

Settings

Retrospective case-control study.

Method

Univariate analysis and logistic analysis were applied to analyze these data to assess the risk factor of residue after UACE in combination with D&C.

Results

Gestational age, human chorionic gonadotropin (HCG) level, and the gestation sac (GS) evagination to the bladder were the risk factors for the postoperative lesion. The most relevant was GS evagination to the bladder, followed by the preoperative HCG level and the gestational age. We defined the cut-off value of gestational age as 28 days with a sensitivity and specificity of 100 and 0, respectively.

Conclusion

In cases with GS evagination to bladder and HCG of >28,113.65 mIU/ml as well as a gestational age of >28 days, the possibility of residual lesions was high.

Comparing the Efficacy and Safety of High-Intensity Focused Ultrasound and Uterine Artery Embolization in Caesarean Scar Pregnancy: A Meta-analysis

INTRODUCTION

High-intensity focused ultrasound (HIFU) followed by curettage and uterine artery embolization (UAE) followed by curettage are two methods of treatment for caesarean scar pregnancy (CSP). There is currently no consistent evidence concerning any difference in efficacy and safety between UAE and HIFU. Therefore, a meta-analysis was performed to compare the efficacy and safety of HIFU and UAE in the treatment of CSP.

METHODS

Studies published in PubMed, Cochrane, Embase, Web of Science, Chinese BioMedical Literature Service System, and Chinese National Knowledge Infrastructure databases were searched and the main outcomes in the studies were extracted.

RESULTS

Of 8 studies and 715 patients included in this study, 388 and 327 patients were in the HIFU group and UAE groups, respectively. Compared with the UAE group, patients in the HIFU group had less blood loss [weighted mean difference (WMD) = - 22.58 ml; 95% confidence interval (CI) - 44.45 to - 0.70; p < 0.05), lower incidence of adverse events [odds ratio (OR) = 0.17; 95% CI 0.06-0.46; p < 0.05); shorter duration of hospital stay (WMD = - 0.96 days; 95% CI - 1.88 to - 0.03; p < 0.05); and a longer β-human chorionic gonadotropin normalisation time (WMD = 9.59 days; 95% CI 1.66-17.52; p < 0.05).

CONCLUSION

Patients in the HIFU group appeared to have better outcomes than those in the UAE group; thus, HIFU may be a priority option for the early management of CSP. However, this needs to be confirmed by multi-centre, large-scale randomised controlled trials.

Cesarean Scar Pregnancy Complicated with Placenta Percreta

Introduction:

Cesarean scar pregnancy is potentially life-threatening condition because of heavy complications and includes adherent placenta: accreta, increta or percreta as a result of deep placental invasion.

Aim:

To present a rare case of ectopic cesarean scar pregnancy combined with placenta percreta in 38-year old woman who undergone previous cesarean section delivery.

Case report:

A multiparous woman aged 38 years with prior cesarean section delivery, admitted first time to the Clinic in 7th week of gestation, due to her medical record (light bleeding). Diagnosis was: graviditas hbd 7, gemellar pregnancy, blighted ovum gemellus I, graviditas isthmico-cervicalis gemellus II. Due to diagnosis it was performed vacuum aspiration et curettage and woman leaved hospital same day. One month later same woman was admitted again to the Clinic due to bleeding and ultrasound finding suspicious to residual trophoblastic tissue. Beta human chorionic gonadotropin serum concentration at the day of admittance was 8,419 IU/ml. Ultrasound finding showed inhomogeneous supracervical formation with dimension 2,73x1,89 cm with increased vascularity and resistant index 0.36 and suspicious placenta increta. We made decision to surgery, and performed hysterectomy in view of heavy intraoperative haemorrhage. Woman was discharged at fifth day after surgery in good condition. Histological finding showed cervical pregnancy complicated with placenta percreta parietis isthmicocervicalis of the uterus.

Conclusion:

We showed the importance of early and opportune diagnosis of cervical pregnancy specially complicated with one of kind of throphoblastic disease, to prevent life-threatening complication.

Rupture of a caesarean scar ectopic pregnancy: A case report

BACKGROUND

Caesarean scar pregnancy is an uncommon form of ectopic pregnancy characterized by implantation into the site of a caesarean scar. Common clinical features include vaginal bleeding and abdominal pain; however, a significant proportion of cases are asymptomatic. The primary diagnostic modality is transvaginal ultrasound. There is no current consensus on best-practice management.

CASE PRESENTATION

A 36-year-old woman, G7P2, presented to an early-pregnancy service with vaginal spotting and an ultrasound scan demonstrating a live caesarean scar ectopic pregnancy at 8 + 5 weeks' gestation. On examination she was hemodynamically stable with a soft abdomen. She was advised to have dilation and curettage (D&C) under ultrasound guidance; however, she was concerned that she might require more extensive surgery, such as a hysterectomy and so requested non-surgical management. On day 1 she underwent ultrasound-guided embryocide with lignocaine followed by inpatient multi-dose systemic methotrexate. Her beta-human gonadotrophic hormone level decreased. Repeat ultrasound on day 18 demonstrated a persistent caesarean scar ectopic pregnancy with increased vascularity, and so uterine artery embolization (UAE) was performed with a view to D&C the following day. This plan was altered to expectant management with ongoing follow-up by a different clinician who had had previous success with UAE alone. On day 35 the patient presented with life-threatening vaginal bleeding that required an emergency total abdominal hysterectomy.

CONCLUSIONS

Caesarean scar pregnancies are uncommon. Multiple treatment strategies have been employed, with variable degrees of success. Further research into risk stratification and management are needed to guide clinician and patient decision making.

Early clinical features and risk factors for cesarean scar pregnancy: a retrospective case-control study

The aim of this study was to investigate early clinical features and risk factors for cesarean scar pregnancy (CSP). Study group of 206 CSP patients out of 6853 women with early pregnancies, diagnosed from 2014 to 2016 was compared with a randomly selected control group of 412 patients. Early clinical features for CSP were vaginal bleeding (OR: 9.65; 95% CI: 5.67-16.41), lower abdominal pain (OR: 3.8; 95% CI: 1.52-9.54) and increased white blood cells (OR: 1.30; 95% CI: 1.12-1.50). Important risk factors for CSP were artificial abortion within the last pregnancy (OR: 4.13; 95% CI: 2.23-7.66), 0 ∼ 1 year and 2 ∼ 3 year interval between present and last pregnancy (OR: 2.27; 95% CI: 1.11-4.67 and OR: 2.15; 95% CI: 1.15-4.03). Pregnancy problems are important issues within the scope of 'Gynecological Endocrinology'. Vaginal bleeding and lower abdominal pain, although unspecific, could be early clinical symptoms of CSP, especially if main risk factors exist such as abortion within the last pregnancy and short interval to the last pregnancy. Knowing this can help for prevention and early diagnosis CSP which can reduce life-threatening complications such as massive hemorrhage and can avoid hysterectomy. Consequence also must be to avoid unwanted pregnancies by using effective contraception, especially in risk patients.

Direct Methotrexate Injection into the Gestational Sac for Nontubal Ectopic Pregnancy: A Review of Efficacy and Outcomes from a Single Institution

STUDY OBJECTIVE

To evaluate the efficacy of nontubal ectopic pregnancy (NTEP) management with direct methotrexate (MTX) injection into the gestational sac.

DESIGN

A retrospective chart review.

SETTING

A tertiary academic and teaching hospital.

PATIENTS

All cases of confirmed NTEP were retrospectively identified from 2012 to 2017.

INTERVENTIONS

Ultrasound-guided direct injection of MTX into the fetal pole and surrounding gestational sac and a single dose of systemic MTX with or without fetal intracardiac injection of potassium chloride.

MEASUREMENTS AND MAIN RESULTS

Treatment failure, complications from treatment, operating time, and days to negative serum human chorionic gonadotropin (hCG) after treatment were measured. Fourteen women (age 34 ± 5.2 years) with NTEP underwent direct MTX injection (cesarean scar, n = 4; interstitial, n = 6; cervical, n = 4). The mean estimated gestational age was 49 ± 11, CI (43, 56 days). One patient required laparoscopic intervention with a failure rate of 1 of 14 (a double interstitial, heterotopic pregnancy). There were no other major complications. The time in the operating room was similar for all NTEP types. The average time to negative serum hCG was not different for cesarean scar (84.5 ± 36 days), cervical pregnancies (70.5 ± 19 days), or interstitial pregnancies (45.3 ± 38 days, p = .15).

CONCLUSION

Direct MTX injection into the gestational sac for NTEP treatment is safe and effective. The failure rate of 7% is considerably lower than what was previously reported for a failure of systemic MTX in similar cases (25%). Resolution of serum hCG after treatment can be quite prolonged even in uncomplicated cases.

Delayed diagnosis of a cesarean scar pregnancy: a case report

Background

Cesarean scar pregnancy is rare but may be related to early uterine rupture and may result in massive hemorrhage. Nowadays, most cesarean scar pregnancies are diagnosed early and can be managed properly. However, diagnoses of cesarean scar pregnancies that develop in the obstetrical area are sometimes delayed.

Case presentation

A 28-year-old Asian woman visited our institution because of suspected cesarean scar pregnancy. Ultrasonography and computed tomography confirmed a cesarean scar pregnancy with a live fetus with a crown-rump length of 4.83 cm, corresponding to 11 weeks 6 days of gestation. Initially, we injected 50 mg of methotrexate in the amniotic sac under transabdominal ultrasonographic guidance. However, fetal cardiac activity was still observed 2 days later. We decided to perform open laparotomy because of the possibility of massive bleeding. The gestational sac was removed, as well as most of the trophoblastic tissues that were adherent and invading the wall of the lower uterine segment. She was discharged in good condition 5 days after the operation.

Conclusions

Despite the popular use of ultrasonography in prenatal care, diagnosis of cesarean scar pregnancy is still delayed. Surgical treatment with local methotrexate injection could be an option for the management of advanced cesarean scar pregnancy.

Minimally Invasive Treatment of Cesarean Scar and Cervical Pregnancies Using a Cervical Ripening Double Balloon Catheter: Expanding the Clinical Series

The efficacy of treating cesarean scar pregnancies and cervical pregnancies with the Cook® cervical ripening balloon catheter, in a multicenter office-based setting is reported. Thirty-eight women were treated. Insertion of the catheter was performed under real-time ultrasound guidance. Patients received adjuvant systemic methotrexate, prophylactic oral antibiotics, and oral pain medication. Serum human chorionic gonadotropin and ultrasound scans were followed serially until resolution. Thirty-seven patients were successfully treated, requiring no further procedures. We found that the Cook cervical ripening balloon technique is a simple, effective, outpatient, minimally invasive treatment with few complications noted in this expanded series.

Diagnosis of Placental Position by Early First-Trimester Ultrasound: A Pilot Study

OBJECTIVE

Conventional wisdom is that placental location cannot be identified before 8 weeks' gestation when the placenta first becomes hyperechogenic on ultrasound. We sought to evaluate whether placental location could be reliably diagnosed between 5 and 6 weeks' gestation.

MATERIALS AND METHODS

This was a retrospective analysis of prospectively acquired data. Early placental location was diagnosed by evaluation of the embryonal and yolk sac position inside the gestational sac on transvaginal ultrasound. Placental position was described as anterior, posterior, fundal, or lateral. Early and mid-pregnancy placental locations were compared and coded as being the same, having migrated to an adjacent surface, or being on an opposite surface.

RESULTS

A total of 111 patients met study criteria, providing 141 placental locations, comprising 85 singleton and reduced pregnancies and 28 dichorionic twin pregnancies. The most common placental location was anterior in both singleton and twin/triplet pregnancies. Placental location at the mid-pregnancy ultrasound was consistent with early pregnancy location in 100% of cases, with 79.5% (112/141) being on the same surface and 20.5% (29/141) having expanded onto an adjacent surface. Placental location was not associated with pregnancy outcome, although our study may have been underpowered to detect a significant difference.

CONCLUSIONS

Placental location diagnosed at 5 to 6 weeks' gestation is consistent with the location on mid-pregnancy ultrasound. Excluding the presence of an ectopic, cornual, or cesarean section scar and uterine subseptation pregnancy in early first trimester would allow a more effective tailoring of pregnancy follow-up.

Multimodality imaging of acute locoregional and systemic complications in the setting of assisted reproduction

Over the past 40 years since the first in vitro fertilization was performed, both the role of assisted reproductive technology (ART) in establishing viable pregnancy as well as the available treatment options have expanded enormously. Annually in the USA, nearly 2% of pregnancies now employ some form of ART assistance, with in vitro fertilization (IVF) being the most commonly utilized methodology. Both maternal and fetal risks are elevated in ART pregnancies, the latter including adverse outcome due to both increased gestational number as well as advanced maternal age. Maternal risks may be divided into locoregional and systemic complications. Adverse pelvic complications include those relating to gamete harvesting and transfer, ovarian hyperstimulation, the sequela of ectopic and heterotopic pregnancies, as well as ovarian torsion, all of which are elevated in the ART cohort. Ovarian hyperstimulation syndrome is the most commonly encountered complication, with both systemic and pelvic features relating to increased vascular permeability, hemoconcentration, and ascites. While life-threatening cases are relatively rare, moderate and severe manifestations may occur in up to 10% of ART cycles and, as such, are a not infrequent cause for ER visitation. Familiarity with the clinical and imaging manifestations of ART complications as well as their prognostic implications will facilitate a timely diagnosis and assist the interpreting radiologist in best expediting appropriate clinical care. In this article, we will briefly discuss the current methodology of ART then present an imaging-based multimodality review of the potentially encountered adverse maternal sequela, highlighting key diagnostic features and differential considerations as well as potential prognostic implications.

Magnetic resonance imaging of common, uncommon, and rare implantation sites in ectopic pregnancy

OBJECTIVE

To review the MRI appearances of tubal and non-tubal implantation sites in ectopic pregnancy.

CONCLUSION

Transvaginal ultrasound is the primary imaging modality in ectopic pregnancy and MRI is used as a problem-solving tool in selected indications as detailed in the article. MRI features of tubal, interstitial, cervical, cesarean scar, cornual, ovarian, abdominal, and heterotopic pregnancies are provided to familiarize the radiologists with their appearances thereby assisting them in making early and accurate diagnosis.

Lower uterine segment thickness in assessing whether cesarean scar pregnancy patients could be treated with suction curettage

Background: To find a suitable indicator in selecting appropriate patients with cesarean scar pregnancy (CSP) for treatment with ultrasound-guided suction curettage alone.Methods: A retrospective review of all women with CSP treated at the Tongji Hospital, Wuhan, China, between 1 January 2013 and 31 December 2015 was conducted. The women were grouped according to the following management options: ultrasound-guided suction curettage only (Group 1); combination with other therapeutic options (Group 2). The clinical characteristics and outcomes were analyzed.Results: Of 174 patients with lower uterine segment myometrium thickness ≥0.2 cm, 93 (53.4%) patients underwent ultrasound-guided suction curettage only, 81 (46.6%) patients underwent a combination with other therapeutics. Clinical characteristics of women who underwent ultrasound-guided suction curettage alone did not significantly differ from those who were treated with combination. Intraoperative blood loss and length of stay differed significantly between the two groups.Conclusions: In appropriate CSP cases with lower uterine segment myometrium thickness more than 0.2 cm, ultrasound-guided suction curettage appears to be a reliable treatment option producing satisfying success rates, lower blood loss, and a shorter hospital-stay compared to combined therapies.

Conservative treatment of abnormally located intrauterine pregnancies (cervical and cesarean scar pregnancies): a multicenter analysis (Polish series)

Objectives: To analyze the effectiveness and outcome of conservative treatment in cases of abnormally located intrauterine pregnancies (cervical and cesarean scar).Study design: A retrospective analysis was performed of 30 pregnant women hospitalized due to abnormally located intrauterine pregnancies. The analyzed group comprised 24 pregnant women with abnormally located pregnancies. The patients were divided into two groups: the first group consisted of patients treated systemically with methotrexate, while the second of those treated locally by administration of methotrexate (MTX) and/or potassium chloride (KCl) by gestational sac puncture.Results: The analyzed group comprised 24 pregnant women with abnormally located pregnancies. Eight patients were diagnosed with cervical pregnancy (CP) and 16 patients were diagnosed with cesarean scar pregnancy (CSP). Six patients were excluded from the study: two with spontaneous abortions, two heterotopic pregnancies, and two cornual pregnancies. Twelve analyzed patients underwent MTX systemic administration (five patients with CP, seven with CSP). In five patients, systemic treatment was ineffective; they were qualified for additional local therapy with gestational sac (GS) puncture and MTX or KCl administration to the sac and additional administration of MTX to the trophoblast area. In second group of 12 patients (three CP, nine CSP), local treatment (GS puncture with MTX or MTX + KCl) was used as the first line treatment. One patient underwent combined treatment (local + systemic).Conclusions: Conservative treatment should be the gold standard procedure in abnormally located intrauterine pregnancies. It is noticeable that MTX / KCl is more effective in a direct administration to the GS. In four cases, systemic MTX did not produce the desired effects. In these cases, the treatment was assisted by local administration of MTX or KCl, resulting in the termination of an abnormally located pregnancy.

Successful management of a spontaneous viable monochorionic diamniotic twin pregnancy on cesarean scar with systemic methotrexate: A case report

RATIONALE

Cesarean scar twin pregnancy is exceedingly rare and it remains to be a life-threatening condition even in the early weeks of gestation. Because of its rare occurrence, there is no consensus on the treatment modality of cesarean ectopic pregnancy.

PATIENT CONCERNS

A 41-year-old, woman, gravida 7, para 6, with a history of low transverse cesarean section 2 years back presented with an estimated 6 weeks gestational age and viable spontaneous twin, monochorionic diamniotic gestation. The patient presented to the Emergency Department with complaints of vaginal bleeding and mild lower abdominal pain for 5 days.

DIAGNOSES

An ultrasound examination was performed demonstrating a single intrauterine gestational sac with 2 viable embryos (monochorionic diamniotic) implanted in the lower uterine segment at the level of the prior cesarean section scar. A diagnosis of viable cesarean scar twin pregnancy was made.

INTERVENTIONS

A 2 doses of 50 mg/m methotrexate (MTX) was given intramuscularly. The response to the treatment was monitored by serial beta-human chorionic gonadotropin (β-hCG) and ultrasound.

OUTCOMES

Patient was followed up with β-hCG weekly levels which became 0 after 68 days of treatment. During the follow-up, the patient was asymptomatic, no side effects of MTX were noticed.

LESSONS

We reported a rare case of viable monochorionic diamniotic twin pregnancy on a cesarean scar that was successfully treated with systemic MTX without any additional therapy. Additionally, the decline of β-hCG in twin ectopic cesarean scar pregnancy appears to be similar to a singleton ectopic pregnancy.

Successful Treatment of Cesarean Scar Pregnancy With Suction Curettage: Our Experiences in Early Pregnancy

Background

Cesarean scar pregnancy is an ectopic pregnancy embedded in the myometrium of a cesarean scar. Several types of conservative treatment have been used to treat cesarean scar pregnancy, but no management protocol has been established for this rare, life-threatening condition. The purpose of this study was to evaluate the feasibility of suction curettage as a first-line treatment in early cesarean scar pregnancy.

Methods

During a 4-year period, 19 cases of cesarean scar pregnancy were diagnosed at Süleymaniye Maternity Hospital in Istanbul, Turkey. Suction curettage and Foley balloon tamponade were performed as a first-line treatment in 13 patients. Medical records and treatment results of the patients were evaluated.

Results

The mean maternal age was 32.5 years (range, 24-39 years). The mean gestational sac diameter was 13.65 mm (range, 7.6-27 mm), and mean endometrial thickness was 10.7 mm (range, 6.7-14.6 mm). A measurable fetal pole for crown-rump length was available for 6 (46.1%) patients. None of the fetuses had cardiac activity. Suction curettage under ultrasound guidance and Foley balloon tamponade were successful as the primary treatment in 13 of 13 patients. No major complications occurred during or after the procedure.

Conclusion

Our data suggest that surgical evacuation under ultrasound guidance with Foley balloon tamponade is a safe and successful treatment modality in carefully selected patients with early cesarean scar pregnancy.

Successful management of cesarean scar pregnancy with vacuum extraction under ultrasound guidance

Aim

Cesarean scar pregnancy (CSP) is a rare type of ectopic pregnancy. The gestational sac is implanted in the myometrium at the site of a previous cesarean section. Mothers with CSP are faced with risks of unpredictable massive bleeding or more fatal complications. The purpose of this retrospective study was to assess the feasibility, efficacy, and reliability of the intraoperative ultrasound‐guided vacuum aspiration method as an effective treatment option for CSP.

Methods

We undertook a retrospective analysis of CSP patients who had undergone the vacuum aspiration method, by reviewing patient records from the period October 2015 to January 2018. All of the operations were carried out under general anesthesia, with patients in the lithotomy position, using suprapubic ultrasonography guidance. A vacuum aspirator was used to aspirate the whole pregnancy material without perforating the previous cesarean section scar.

Results

Ten women with CSP were managed successfully by ultrasound‐guided vacuum extraction without complications or further interventions, such as reoperation or methotrexate administration. Three of the 10 patients needed uterine Foley catheter tampon (50 cc) for 4 h after vacuum extraction alone was applied. During the study period, two additional patients who did not meet the criteria for the vacuum extraction method alone were managed with methotrexate plus vacuum application. Because of the rarity of the condition, the majority of CSPs are case reports or small case series reported in published works, with no consensus on the preferred course of treatment.

Conclusion

The vacuum extraction method seems to be a good and practical way of treating CSP. Comparisons of efficacy should be undertaken but large sample sizes are required. We hope this study brings a new perspective for larger sample‐sized studies, considering the technique is feasible and applicable.

Cesarean Scar Pregnancy: A Case Series of Diagnosis, Treatment, and Results

The aim was to collect cases of cesarean scar pregnancy (CSP) and describe the evolution of diagnosis, treatment modalities, and outcome. A retrospective cohort study was conducted of patients who had been diagnosed with CSP. Treatment decision was made according to the type of CSP, levels of beta human chorionic gonadotropin (hCG), and estimated vascularity. Forty cases with CSP were recorded. Overall success of the primary treatment was recorded among 30 of 40 cases (75%) and significantly correlated with degree of vascularity, type of CSP, and beta hCG levels. The treatment methods included serial methotrexate in 20 cases; 15 of them (75%) were successful. In this specific group, we found type 2 scar and high vascularity to be significantly associated with treatment failure. In conclusion, cases with type 2 CSP, high vascularity, and high beta hCG levels should be considered high risk, and extra caution should be taken in choosing treatment modality and follow-up.

Management of Caesarean scar pregnancy with or without methotrexate before curettage: human chorionic gonadotropin trends and patient outcomes

Background

To evaluate the effects of systemic methotrexate in cesarean scar pregnancy (CSP) patients treated with ultrasound-guided suction curettage.

Methods

A retrospective review of all women presenting with CSP treated with ultrasound-guided suction curettage at Tongji Hospital, Wuhan, China, between January 1, 2013 and December 31, 2015, was conducted. Patients were grouped into those not treated with methotrexate before curettage (group 1), treated with methotrexate by intramuscular injection (group 2) and treated with methotrexate by intravenous injection (group 3). The clinical characteristics and outcomes were analyzed.

Results

Among 107 patients, 47 patients were not treated with methotrexate before curettage, 46 patients had methotrexate administered by intramuscular injection and 14 patients had methotrexate injected intravenously. There were no significant differences among the groups in basic and clinical characteristics, such as age, gravity, parity, positive fetal heart beat and gestational age at diagnosis. Patients presented similar initial human chorionic gonadotropin (hCG) levels in all groups. After treatment with methotrexate or curettage, the percentage changes and varied ranges of the hCG levels were also similar in all groups. There were no significant differences in intraoperative blood loss and retained products of conception among the three groups. However group 1 had significantly shorter hospital stays than the two groups that were treated with methotrexate (p<0.001).

Conclusion

By grouping CSP patients who shared similar age, gravity, parity, fetal heart beat positive and gestational age at diagnosis, we found that the presence or absence of methotrexate treatment before curettage resulted in comparable outcomes and hCG levels, although patients who were not treated with methotrexate had significantly shorter stays in the hospital.

Placenta Site Trophoblastic Tumor and Choriocarcinoma from Previous Cesarean Section Scar: Case Reports

Choriocarcinoma and placental site trophoblastic tumor (PSTT) are rare varieties of gestational trophoblastic disease (GTD). PSTT alone constitutes about 1-2% of all trophoblastic tumors, which presents at early reproductive age and the serum beta-hCG level is much lower than choriocarcinoma. This tumor usually invades the myometrium and its depth of penetration is a prognostic factor. The first case report is regarding a 33-year-old woman with vaginal bleeding 3 months after abortion. The ultrasound exhibited heterogeneous and hypervascular mass related to previous cesarean scar. Serum beta-hCG level was 67 mIU/ml and chemotherapy was administered. However, due to severe vaginal bleeding and no regression in mass size, total abdominal hysterectomy was performed. Histopathological examination and IHC staining confirmed PSTT from previous cesarean section. The second case report is regarding a 33-year-old woman with cervicoisthmic choriocarcinoma, which was mistaken as cesarean scar pregnancy. The ultrasonography and elevated serum beta-hCG level suggested cesarean scar pregnancy. The patient was treated with methotrexate without any effect. Eventually, cervicoisthmic choriocarcinoma was detected after hysterectomy. A diagnostic error was made leading to possible uterus perforation along with incorrect chemotherapy that resulted in a life-threatening condition. It is concluded that PSTT and choriocarcinoma are the two important differential diagnoses of sustained elevated beta-hCG when imaging evidence is also suggestive. Although PSTT and cervicoisthmic choriocarcinoma are rare, they do exist and are on the rise.

The Rising Triad of Cesarean Scar Pregnancy, Placenta Percreta, and Uterine Rupture: A Case Report and Comprehensive Review of the Literature

As the rate of cesarean sections continues to rapidly rise, knowledge of diagnosis and management of cesarean scar pregnancies (CSPs) is becoming increasingly more relevant. CSPs rest on the continuum of placental abnormalities which include morbidly adherent placenta (accreta, increta, and percreta). A CSP poses a clinical challenge which may have significant fetal and maternal morbidity. At this point, no clear management guidelines and recommendations exist. Herein we describe the case of a second trimester CSP with rapid diagnosis and management in a tertiary care center. The case underscores the need for well-coordinated mobilization of resources and a multidisciplinary approach. A review of the literature is performed and deficits in universal management principles are underscored.

Caesarean scar pregnancy in the UK: a national cohort study

OBJECTIVE

To estimate the incidence of caesarean scar pregnancy (CSP) and to describe the management outcomes associated with this condition.

DESIGN

A national cohort study using the UK Early Pregnancy Surveillance Service (UKEPSS).

SETTING

86 participating Early Pregnancy Units.

POPULATION

All women diagnosed in the participating units with CSP between November 2013 and January 2015.

METHODS

Cohort study of women identified through the UKEPSS monthly mailing system.

MAIN OUTCOME MEASURES

Incidence, clinical outcomes and complications.

RESULTS

102 cases of CSP were reported, with an estimated incidence of 1.5 per 10 000 (95% CI 1.1-1.9) maternities. Full outcome data were available for 92 women. Management was expectant in 21/92 (23%), medical in 15/92 (16%) and surgical in 56/92 (61%). The success rates of expectant, medical and surgical management were 43% (9/21), 46% (7/15) and 96% (54/56), respectively. The complication rates were 15/21 (71%) with expectant, 9/15 (60%) with medical and 20/56 (36%) with surgical management. Discharge from care (median number of days) was 82 (range 37-174) with expectant, 21 (range 10-31) with medical and 11 (range 4-49) with surgical management.

CONCLUSIONS

Surgical management appears to be associated with a high success rate, low complication rate and short post-treatment follow up.

TWEETABLE ABSTRACT

Surgery for CSP appears to be successful, with low complication rates and short post-treatment follow up.

A Novel Treatment for Cervical and Cesarean Section Scar Pregnancies by Transvaginal Injection of Absolute Ethanol to Trophoblasts: Efficacy in 19 Cases

STUDY OBJECTIVE

To evaluate the efficacy of a nonsurgical treatment for cervical pregnancy (CP) and cesarean section scar pregnancy (CSP).

DESIGN

Retrospective clinical study (Canadian Task Force classification III).

SETTING

Private assisted reproductive technology practice.

PATIENTS

Nineteen women with CP (n = 16) or CSP (n = 3), including 6 patients with positive fetal heartbeat.

INTERVENTION

Transvaginal local injection of absolute ethanol (AE) into the hyperechoic ring (lacunar space) around the gestational sac under ultrasound guidance.

MEASUREMENTS AND MAIN RESULTS

Serum beta-human chorionic gonadotropin (β-hCG) was measured at frequent intervals, and ultrasound and/or magnetic resonance imaging was used to observe the gestational sac. In 9 patients, the serum β-hCG level was effectively reduced with a single AE injection at 2 hours. In the remaining 10 patients, the level decreased but then increased in 4 and slowly decreased in the other 6; all of these 10 patients required 2 to 5 repeat AE injections. In all patients, serum β-hCG level was reduced by 50% within 3 days and decreased to <10% of the initial level within 14 days. In 18 patients (95%), the level was decreased to 1.0 mIU/mL within 40 days. Seven patients were treated on an outpatient basis. Twelve patients received no anesthesia. Five patients subsequently became pregnant, and each had a live birth. There was no recurrent CP or CSP. The procedure was successful in all 19 patients.

CONCLUSION

This procedure is an effective treatment for CP or CSP that could be used in place of conventional surgical interventions and medical treatment using MTX.

Cesarean scar pregnancy - a new challenge for obstetricians

Diagnosis and treatment of ectopic cesarean scar pregnancy has become a challenge for contemporary obstetrics. With an increase in the number of pregnancies concluded with a cesarean section and with the development of transvaginal ultrasonography, the frequency of cesarean scar pregnancy diagnoses has increased as well. The aim of the study is to evaluate various diagnostic methods (ultrasonography in particular) and analyze effective treatment methods for cesarean scar pregnancy. An ultrasound scan, Doppler examination and magnetic resonance imaging are all useful in early detection of asymptomatic cesarean scar pregnancy, thus enabling effective treatment and preservation of fertility. Dilatation and curettage is not recommended as it carries significant risk of bleeding and very high risk of hysterectomy and fertility loss. Systemic methotrexate treatment should not be applied on the routine basis due to its low efficacy, high risk of fertility loss and adverse effects. Local methotrexate therapy (under ultrasound or hysteroscopy guidance) should be considered a perfect management method as it offers fertility preservation in asymptomatic pregnant patients without concomitant hemodynamic disorders. Synchronous usage of several treatment methods is an effective way to manage cesarean scar pregnancy. The combination of local methotrexate with simultaneous aspiration of gestational tissues under ultrasound or hysteroscopy guidance seems optimal. Subsequently, the remaining gestational tissues can be removed hysteroscopically in combination with vascular coagulation at the implantation site. In more advanced cases, local methotrexate treatment should be considered followed by laparoscopic or laparotomic wedge resection with subsequent surgical correction of the cesarean section scar.

Pregnancy in an Abnormal Location

Cesarean scar pregnancy and cervical pregnancy are 2 relatively rare types of abnormally implanted pregnancies. Both if unrecognized can result in significant morbidity to the patient. The most important issue regarding cesarean scar pregnancy and cervical pregnancy is to establish the diagnosis early in order for the patient to be adequately counseled and appropriate management carried out. For both of these conditions early detection and treatment can result in preservation of fertility.

Uterine Artery Embolization Combined with Dilation and Curettage for the Treatment of Cesarean Scar Pregnancy: Efficacy and Future Fertility

PURPOSE

To investigate the efficacy and safety of uterine artery embolization (UAE) followed by dilation and curettage (D&C) as a treatment for cesarean scar pregnancy (CSP) and to assess pregnancy outcomes after the treatment.

MATERIALS AND METHODS

We retrospectively analyzed 33 CSP patients treated with UAE followed by D&C. The serum level of beta human chorionic gonadotropin (β-hCG) normalization, hospitalization, menstruation, and successful pregnancy after treatment was assessed as clinical and pregnancy outcomes.

RESULTS

A total of 33 patients were initially treated without severe complications. However, four patients required additional systemic chemotherapy. β-hCG normalization took 35.5 ± 14.9 days (range 13-79), and the hospitalization was 6.5 ± 2.5 days (2-15). All patients resumed normal menstruation after 36 ± 19.2 days (12-86). Of 16 of 33 patients who desired pregnancy after the treatment, seven patients (43.8%) had uneventful parturition.

CONCLUSIONS

UAE combined with D&C was efficient and safe for CSP management. This minimally invasive procedure may be considered as one of the treatment options which enable preservation of fertility after treatment.

Management of Cesarean Scar Pregnancy: A Single-Institution Retrospective Review

Objective

Cesarean scar pregnancy (CSP) is a rare condition that occurs when the pregnancy implants in a cesarean scar. An early diagnosis and a proper management are fundamental to prevent maternal complications. We review and discuss the different treatment employed in our unit to reduce morbidity, preserve fertility, and predict possible complications.

Methods

The reported treatment has been expectant management, operative hysteroscopy approach, and intramuscular injection of 50 mg methotrexate (MTX), followed by cervical dilation and manual vacuum aspiration (D&S) with a Karman cannula under ultrasound guidance, uterine artery embolization (UAE), and manual vacuum aspiration under ultrasound guidance and uterine artery embolization before surgical laparotomic resection.

Results

Complications were more frequent in women with a history of three or more cesarean section deliveries and with a myometrial thickness thinner than 2 mm. MTX and D&S treatment appear to be most effective and safe at the early age of pregnancy, while UAE and D&S are related to the highest risk of complication in any age of pregnancy.

Conclusion

An appropriate preoperative diagnostic evaluation, the identification of cases at higher risk, and those eligible for a conservative treatment are fundamental to reduce complications.

A large intrauterine vascular lesion developing after the successful treatment of a cesarean scar pregnancy with methotrexate injection

A cesarean scar pregnancy is a rare type of ectopic pregnancy. Induced abortion by local methotrexate (MTX) injection is an effective management approach. We describe a case in which a large intrauterine vascular lesion appeared after the sonographic-guided local injection of MTX, which successfully induced the abortion of the cesarean scar pregnancy. Although a cesarean scar pregnancy may be safely treated with a local MTX injection, close follow-up, including serum β-human chorionic gonadotropin level measurement and Doppler sonography, is needed because an intrauterine vascular lesion could develop even after a successfully induced abortion. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:222-226, 2018.

Menstruation recovery in scar pregnancy patients undergoing UAE and curettage and its influencing factors

This study aims to investigate the menstrual recovery outcome of scar pregnancy patients who received uterine artery embolization combined with curettage, and its influencing factors.The data of 119 patients with scar pregnancy, who received uterine artery embolization combined with curettage between December 2012 and December 2016 in Henan Provincival People's Hospital, were collected. The menstruation recovery of these patients was followed up, and factors that have influence on menstrual blood volume were analyzed using SPSS V.17.0.Follow-up data were available in 101/119 (84.9%) women. The median follow-up time was 22.7 months (range: 1.6-50.6 months); 58 (57.4%) patients had reduced menstrual blood volume, and 2 patients (2%) had amenorrhea. The proportion of patients with reduced menstrual blood volume, who were embolized with polyvinyl alcohol (PVA), PVA combined with gelatin sponge, and gelatin sponge between < and ≥33 years old was 41.7% versus 66.7%, 40% versus 57.1% and 60.6% versus 68.0%. The average age of patients with reduced menstrual blood volume (34.3 years) was greater than patients with normal menstrual blood volume (31.4 years), but the difference was not statistically significant (P = .07).Reduced menstrual blood volume can occur in scar pregnancy patients who received uterine artery embolization combined with curettage. The influence of the embolic agent PVA on menstrual blood volume depends on age, but the difference was not statistically significant.