The diagnosis, treatment, and follow-up of cesarean scar pregnancy

Cesarean scar pregnancy: noninvasive and effective treatment with high-intensity focused ultrasound

OBJECTIVE

The aim of this preliminary study was to investigate whether ultrasound-guided high-intensity focused ultrasound (HIFU) can play a role in treating cesarean scar pregnancy (CSP).

STUDY DESIGN

Between November 2011 and December 2012, 16 patients with CSP were treated with ultrasound-guided HIFU ablation. Successful treatment was defined as disappearance of CSP mass, undetectable serum beta human chorionic gonadotropin, and no serious complications such as severe bleeding, uterine rupture, or hysterectomy.

RESULTS

All patients were successfully treated in the outpatient department and none required readmission. After 2-5 treatment sessions, the mean time for achieving undetectable serum beta human chorionic gonadotropin was 4.94 ± 2.32 weeks, and the mean time for CSP mass disappearance was 6.69 ± 3.36 weeks. Three patients experienced moderate abdominal pain that subsided in 1-2 days, and nine patients experienced mild vaginal bleeding (<30 mL) that resolved within 2-3 days. All 16 patients had recovered their normal menstruation function at follow-up.

CONCLUSION

These preliminary results suggest that ultrasound-guided HIFU ablation is a noninvasive, feasible, and effective method for the treatment of CSP.

Low-lying-implantation ectopic pregnancy: a cluster of cesarean scar, cervico-isthmus, and cervical ectopic pregnancies in the first trimester

OBJECTIVE

To describe the treatment outcomes of aberrant ectopic implantations in the lower segment of the uterus in a cohort population and to evaluate whether or not low-lying-implantation ectopic pregnancy (LLIEP), a new term, is appropriate to include in the traditional diagnoses of cervical pregnancy (CP), cesarean scar pregnancy (CSP), and other unusual aberrant implantations in the lower segment of the uterus in the first trimester, in terms of clinical characteristics, treatment, and prognosis.

MATERIALS AND METHODS

Forty-two women with ectopic pregnancies of <12 weeks' gestational age from July 2003 to December 2008 were prospectively studied. Each patient underwent an ultrasound evaluation by an experienced consultation team and was grouped into the CP, CSP, or cervico-isthmic pregnancy (CIP) group. Patients underwent either suction dilatation and curettage (D and C) alone, or laparoscopic uterine artery blockage followed by suction D and C, to remove the aberrant trophoblasts without other adjuvant treatments. Clinical characteristics and biochemical factors, including obstetric history, patient age, body mass index (BMI), gestational age, serum hematocrit and β-hCG level, operation method, operation time, and intraoperative blood loss were evaluated.

RESULTS

There were no significant differences in patient age (mean = 34.1 ± 6.4 years), previous number of cesarean deliveries (mean = 1.5 ± 0.8), gestational age (mean = 6.9 ± 1.2 weeks), serum β-hCG (mean = 35,384.3 ± 41,726.9 mIU/mL), operation time (mean = 60.3 ± 46.6 minutes), and surgical blood loss (mean = 124.7 ± 191.5 mL) among the three patient groups. The uterus was successfully preserved in all patients after treatment.

CONCLUSION

The prognosis of surgical management for ectopic implantations in the lower segment of the uterus is good. The new term LLIEP seems appropriate to cover all forms of aberrant ectopic implantations in the lower segment of the uterus in the first trimester, in terms of treatment efficacy. The use of LLIEP for preoperative ultrasound diagnosis would enable the clinician to diagnose unusual cases more easily, without the need to change the current treatment policy.

Cesarean scar pregnancy is a precursor of morbidly adherent placenta

OBJECTIVE

To provide further sonographic, clinical and histological evidence that Cesarean scar pregnancy (CSP) is a precursor to and an early form of second- and third-trimester morbidly adherent placenta (MAP).

METHODS

This is a report of 10 cases of CSP identified early, in which the patients decided to continue the pregnancy, following counseling that emphasized the possibility of both significant pregnancy complications and a need for hysterectomy. Pregnancies were followed at 2-4-week intervals with ultrasound scans and customary monitoring. The aim was for patients to reach near term or term and then undergo elective Cesarean delivery and, if necessary, hysterectomy. Charts, ultrasound images, operative reports and histopathological examinations of the placentae were reviewed.

RESULTS

The ultrasound diagnosis of CSP was made before 10 weeks. By the second trimester, all patients exhibited sonographic signs of MAP. Nine of the 10 patients delivered liveborn neonates between 32 and 37 weeks. In the tenth pregnancy, progressive shortening of the cervix and intractable vaginal bleeding prompted termination, with hysterectomy, at 20 weeks. Two other patients in the cohort had antepartum complications (bleeding at 33 weeks in one case and contractions at 32 weeks in the other). All patients underwent hysterectomy at the time of Cesarean delivery, with total blood loss ranging from 300 to 6000 mL. Placenta percreta was the histopathological diagnosis in all 10 cases.

CONCLUSION

The cases in this series validate the hypothesis that CSP is a precursor of MAP, both sharing the same histopathology. Our findings provide evidence that can be used to counsel patients with CSP, to enable them to make an informed choice between first-trimester termination and continuation of the pregnancy, with its risk of premature delivery and loss of uterus and fertility.

Ultrasound evaluation of the first trimester

Ultrasound is a valuable diagnostic test throughout the first trimester of pregnancy. Early in this trimester, it is used to distinguish between normal intrauterine, failed intrauterine, and ectopic pregnancies. Later it can be used with maternal blood tests to screen for trisomy 21 and other forms of aneuploidy, and in some centers to assess fetal anatomy and diagnose structural anomalies. First trimester sonography is also useful for accurate assessment of gestational age. This article reviews these applications, the approach to establishing diagnoses, and ways to avoid diagnostic mistakes that can lead to serious errors in patient management and adverse pregnancy outcome.

Cesarean scar pregnancy and early placenta accreta share common histology

OBJECTIVE

To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

METHODS

The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined.

RESULTS

Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93).

CONCLUSIONS

EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

Biometric sonographic findings of abnormally adherent trophoblastic implantations on cesarean delivery scars

OBJECTIVES

The purpose of this study was to review first-trimester transvaginal sonograms of patients with cervicoisthmic implantations and prior cesarean deliveries to determine whether sonographic biometric measurements can distinguish between abnormally adherent trophoblastic implantations and normally implanted pregnancies.

METHODS

Our database was reviewed from October 2006 through December 2011 for patients with first-trimester sonographic diagnoses of cervicoisthmic implantations and previous cesarean deliveries. Biometric measurements of the smallest distance from the anterior trophoblastic border to the uterine serosa were performed on transvaginal sagittal images of the uterus. Outcomes were classified into 5 categories: cesarean scar pregnancy, placental invasion (accreta/increta/percreta), previa without invasion, spontaneous abortion, and delivered intrauterine pregnancy. Statistical methods included analysis of variance with the Tukey range test and Student t test.

RESULTS

Of 77 studies, outcome data were available for 56 patients. The mean gestational age was 8.8 weeks (minimum, 2.0 weeks; maximum, 14.9 weeks). The anterior trophoblastic border distances from the uterine serosa were significantly smaller in cesarean scar pregnancies (mean, 1.6 mm; SD, 0.6 mm) and placental invasion pregnancies (mean, 2.2 mm; SD, 1.0 mm) than the normally implanted groups (mean, 7.9 mm, SD, 3.3 mm; P < .0001).

CONCLUSIONS

Smaller trophoblastic border distances to the anterior uterine serosa are seen in abnormally adherent trophoblastic implantations, and these distances distinguish them from other pregnancy outcomes.

Minimally invasive surgery to manage a complicated case of a caesarean scar ectopic pregnancy

A 30-year-old woman, gravida 3 para 1, presented at 5 weeks of amenorrhoea with vaginal spotting and mild abdominal pain. A transvaginal scan confirmed a caesarean scar pregnancy (CSP). Serum hCG level at presentation was 4357. She declined treatment initially, but eventually underwent laparoscopic-guided suction curettage and excision of CSP. hCG was undetectable at 5 weeks postoperatively. She had an uneventful recovery and was advised to take oral contraceptives.

Diagnosis of emergencies/urgencies in gynecology and during the first trimester of pregnancy

Several surgical and/or medical emergencies/urgencies may occur in gynecologic patients and in pregnant women during the first trimester. Particularly, ectopic pregnancies, ruptured or hemorrhagic ovarian cysts, ovarian or adnexal torsions, threatened or inevitable miscarriages, phlogistic gynecological disorders, complications involving the uterine fibroids, endometriosis, and spontaneous uterine rupture are possible acute complications. The diagnosis is suspected on the basis of symptoms (acute pelvic and/or abdominal pain, with or without vaginal bleeding or discharge, until acute abdomen with peritonitis), by means physical evaluation (abdominal, pelvic, and bimanual gynecological examinations), by means of transabdominal (TAS) and/or transvaginal (TVS) sonography, and laboratory tests. However, the diagnosis is often not that simple, especially when the symptoms and clinical signs are minimal, and ultrasound (US) examination is not diriment. The differential diagnosis of abdominal/pelvic pain is broad and includes primarily gastrointestinal and urogenital disorders. Generally, TAS should usually be used in conjunction with TVS for evaluation of the female pelvis. If the US examination is not conclusive, CT or MRI, especially in pregnant patients, should be considered.

Ineffectual Medical Treatment of Cesarean Scar Ectopic Pregnancy With Systemic Methotrexate: A Report of Two Cases

The implantation of a pregnancy within the scar of a previous cesarean section is known as a “cesarean scar pregnancy.” Its incidence was reported to be 6.1%. However, with the increasing rates of cesarean sections, the incidence is expected to rise. A variety of conservative and surgical treatment modalities have been proposed for the management of cesarean scar pregnancy; however, there are no optimal universal treatment guidelines because of its rarity. Treatment should be tailored to the individual patient. It is obvious that more scar pregnancies will be seen in the future and therefore a set of criteria for the choice of various modes of management should be developed. Here, we present 2 cases of cesarean scar pregnancies treated with a local injection of potassium chloride after the failure of methotrexate administration.

Hysteroscopy and suction evacuation of cesarean scar pregnancies: a case report and review

Implantation of a pregnancy into the scar of a prior cesarean is an uncommon type of ectopic pregnancy. The incidence of cesarean scar pregnancy is thought to be one in 1800-2216 pregnancies. The increase in the incidence of cesarean scar pregnancy is thought to be a consequence of the increasing rates of cesarean delivery. The natural history of cesarean scar pregnancy is unknown. However, if such a pregnancy is allowed to continue, uterine scar rupture with hemorrhage and possible hysterectomy seem likely. Two early diagnosed cesarean scar pregnancies were treated with hysteroscopy and suction curettage removal. One required intramuscular methotrexate to resolve a persistent cesarean scar ectopic pregnancy. It would seem reasonable that simple suction evacuation would frequently leave chorionic villi imbedded within the cesarean scar, as the pregnancy is not within the endometrial cavity.

The analysis of efficacy and failure factors of uterine artery methotrexate infusion and embolization in treatment of cesarean scar pregnancy

Objectives. This study observes therapeutic efficacy of uterine artery embolization combined with MTX infusion which terminates cesarean scar pregnancy (CSP) and induces three factors which probably relate to failure. Methods. Twenty-three CSP patients were treated with combined uterine artery MTX infusion and embolization. Among them six patients with severe hemorrhage were immediately treated with interventional operation. Clinical effects were estimated by symptoms, serum β-hCG, ultrasound, and MR. Results. Interventional treatments were technologically successful in 22 patients except one. Immediate hemostasis was achieved in all 6 patients with massive colporrhagia. No occurrence of infection and uterine necrosis was observed, but 12 women suffered abdominal pains. Nineteen patients' uteri were preserved, whereas four underwent hysterectomy eventually. Conclusions. Transcatheter arterial chemoembolization is effective to treat high-risk CSP in preference to hysterectomy. To achieve more successful outcomes, three factors should be highlighted: adequate MTX dosage, appropriate embolic material, and complete embolization of target arteries that supply blood to embryo in the scar.

Sonographic features of placenta accreta after first-trimester abortion

We assessed 5 patients with histologically/clinically confirmed placenta accreta after first-trimester abortion. In 4 patients, sonography showed an unclear endometrium, absence of an endometrium-myometrium interface, a well-vascularized hyperechoic lesion in the uterine body with a low resistive index, and myometrial thinning near the lesion. In 2 patients, contrast-enhanced sonography showed rapid irregular lesion enhancement. Chemotherapy reduced the lesions in 3 patients, and a decreased blood supply increased the resistive index in all lesions. Two patients each underwent hysterectomy and uterine curettage. The fifth patient had a cervical pregnancy; sonography showed a well-vascularized hyperechoic lesion in an enlarged cervix. Methotrexate gradually reduced this lesion. Sonography, especially contrast-enhanced sonography, can detect placenta accreta and guide treatment.

Cesarean scar pregnancy: diagnosis, management, and follow-up

Cesarean scar pregnancy is a very rare form of pregnancy and a life-threatening situation. It has become an important and serious problem over the last 10 years, as a result of the worldwide increase in cesarean births. In this retrospective series, the diagnosis of cesarean scar pregnancy, management, treatment methods, risk factors, and possibility of subsequent normal pregnancy are discussed, and case descriptions are presented.

Does the presence of a Caesarean section scar affect implantation site and early pregnancy outcome in women attending an early pregnancy assessment unit?

STUDY QUESTION

Are there any differences in the location and distance to the internal cervical ostium of the implantation site of the intrauterine gestation sacs, early pregnancy symptoms and pregnancy outcome at 12 weeks gestation between women with and without a previous Caesarean section (CS)?

SUMMARY ANSWER

The presence of a CS scar affects the site of implantation, and the distance between implantation site and the scar is related to the risk of spontaneous abortion. WHAT IS KNOWN ALREADY?: Little is known about the impact of a CS scar on implantation other than the risk of Caesarean scar pregnancy (CSP). Furthermore, there is a paucity of information on how the proximity of implantation to the scar impacts on pregnancy outcome in the first trimester.

STUDY DESIGN, SIZE, AND DURATION

A prospective cohort study conducted over 15 months in the early pregnancy unit of a London Teaching Hospital. Three hundred and eighty women underwent a transvaginal scan at 6-11 weeks of gestation. A total of 170 women had undergone ≥1 CS, and 210 women had no history of CS.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 380 women were recruited as consecutive non-selected cases. The relationship between the implanted sac and the CS scar was assessed by quantifiable measures and by subjective impression. Logistic regression analysis was used to determine the influence of the presence of a CS scar on pregnancy outcome. The final outcome of the study was the viability of the pregnancy at 12 weeks.

MAIN RESULTS AND THE ROLE OF CHANCE

Implantation was most frequently posterior (53%) in the CS group and fundal in the non-CS group (42%). Gestation sac implantation was 8.7 mm lower in the CS group (95% confidence interval (CI) 6.7-10.7, P < 0.0001). Presenting complaints differed in women with and without a previous CS (P = 0.0009). More frequent vaginal bleeding [73 versus 55%, difference -18, 95% CI (-27 to -8%] yet no clearly increased spontaneous abortion rates were noted in the CS group compared with the non-CS group (adjusted odds ratio = 1.1, 95% CI 0.6-1.9, P = 0.74). Subjective impression showed that in eight cases the implantation site crossed the scar, seven of which resulted in spontaneous abortion, while the remaining case survived to term complicated by placenta praevia and post-partum haemorrhage. The subjective impression of the examiner was supported by the measurements of distance between implantation site and CS scar.

LIMITATIONS, REASONS FOR CAUTION

A weakness of the study is the lack of a reference technique to verify the location of implantation.

WIDER IMPLICATIONS OF THE FINDINGS

This study adds further support to the hypothesis that the presence of a CS on the uterus impacts on the implantation site of a future pregnancy. The possibility that the CS scar has an impact on the risk of spontaneous abortion should be further studied. Caution must be exercised when implantation occurs near to, and crosses, a CS scar as this is not always associated with the diagnosis of CSP. A potential limitation of the study is that we did not examine scar dimensions and morphology.

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.