Caesarean scar pregnancy

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.

[Uterine ishtmique transmural hernia: results of its repair on symptoms and fertility]

OBJECTIVE

To study the effect of the surgical repair (isthmorraphy) of the large scar dehiscence after cesarean on symptoms and fertility for women who desire pregnancy.

PATIENTS AND METHODS

In this retrospective study, 14 symptomatic patients, who desire a new pregnancy underwent a surgical repair by laparotomy, laparoscopic or vaginal technique. Five women experienced failure of Assistance Reproductive Technique (IVF or ICSI) for idiopathic secondary infertility. The dehiscent scars were evaluated by ultrasound, hysterography, hysteroscopy and magnetic resonance imaging.

OUTCOME

Symptoms improvement was found in 92% of case. Ten pregnancy (71%) was obtained after surgical repair, 6 spontaneous and 4 after Assistance Reproductive Technique. Among the 5 women initially followed in the reproductive unit, 4 became pregnant, 3 after IVF or ICSI and 1 spontaneous. No operative complication occurred. The subsequent pregnancy was unremarkable with no uterine rupture.

DISCUSSION

Large scar defect after cesarean can take shape of a complete absent of the anterior wall of the uterus. No incident has been proved in this condition. There is a lack of data concerning these isthmocele. The experience of hysteroscopic repair cannot be applied to these real large diverticule of the scar cesarean. The results of this study suggest a link between the isthmocele and reversible symptoms after surgery. The first results concerning the subsequent fertility after surgical repair seem interesting

CONCLUSION

When a large scare defect (isthmocele) is found in symptomatic woman (pelvic pain, bleeding uterine, infertility), a surgical repair can be proposed, especially for woman who desire a new pregnancy.

Cervicoisthmic pregnancy near cesarean scar after oocyte donation in premature ovarian failure: literature review starting from a single case

OBJECTIVE

This study aimed to identify the best management options in decision making in cases of cervicoisthmic and cesarean scar pregnancies and rare forms of ectopic pregnancies with high rates of pregnancy-related morbidity in the first trimester, more commonly associated with assisted reproductive medicine.

MATERIALS AND METHODS

We performed a literature review of the description of a case report of a cervicoisthmic pregnancy near a cesarean scar in a premature ovarian failure woman. She obtained pregnancy after ovum donation, hormonal therapy, and in vitro fertilization. The researchers focused on the MEDLINE/PubMed database articles on ectopic pregnancies, particularly on cesarean scar pregnancies, cervical pregnancies, and ectopic pregnancies after in vitro fertilization in English-language journals published from January 1996 to December 2011.

RESULTS

The conservative or nonconservative options for medical or surgical treatments are disposables. Moreover, in literature, no consensus was found about the best treatment method.

CONCLUSIONS

Obstetricians should pay great attention to a possible cesarean scar pregnancy in patients with risk factors in their medical history. Until now, the rarity of these findings does not allow the definition of a commonly accepted management, so the best personalized approach may be guided by early recognition, close surveillance, and appropriate counseling. Further investigations are necessary to recognize high-risk factors for all ectopic pregnancies and those unique to cesarean scar ectopic pregnancies.

Emergent complications of assisted reproduction: expecting the unexpected

With the increasing popularity of assisted reproductive technology (ART), radiologists are more likely to encounter associated complications, especially in an emergency setting. These complications include ovarian hyperstimulation syndrome (OHSS), ovarian torsion, and ectopic and heterotopic pregnancy. OHSS occurs following ovulation induction or ovarian stimulation and manifests with bilateral ovarian enlargement by multiple cysts, third-spacing of fluids, and clinical findings ranging from gastrointestinal discomfort to life-threatening renal failure and coagulopathy. Enlarged hyperstimulated ovaries are at risk for torsion. Clinical symptoms are often nonspecific, and ovarian torsion should be suspected and excluded in any female patient undergoing infertility treatment who presents with severe abdominal pain. The most consistent imaging finding is asymmetric enlargement of the twisted ovary. There is also an increased risk for ectopic pregnancy following ART, with a relative increased risk for rarer and more lethal forms, including interstitial and cervical ectopic pregnancies. Heterotopic pregnancy refers to simultaneous intrauterine and ectopic pregnancies and has an incidence of 1%-3% in ART patients. Careful evaluation of the adnexa is critical in this patient population, even when an intrauterine pregnancy has been confirmed. Ultrasonography is the first-line imaging modality for the evaluation of complications of ART, although nonspecific symptoms may sometimes lead to cross-sectional imaging being performed. Familiarity with the multimodality imaging appearance of these entities will allow accurate and timely diagnosis and help avert potentially fatal consequences.

Uterine artery embolization combined with methotrexate in the treatment of cesarean scar pregnancy: results of a case series and review of the literature

PURPOSE

To explore the clinical value of uterine artery embolization (UAE) combined with methotrexate in the treatment of cesarean scar pregnancy (CSP) before and after uterine curettage.

MATERIALS AND METHODS

From August 2009 to April 2012, 15 patients with CSP treated with UAE (before or after uterine curettage) were analyzed retrospectively. Eleven subjects with a definite diagnosis of CSP were offered preventive UAE combined with methotrexate before uterine curettage. The other four patients, who were misdiagnosed as having an intrauterine pregnancy, were treated with emergency UAE for uncontrollable massive hemorrhage after uterine curettage. Clinical data, treatment sequence, and outcome were analyzed, and a brief review of the published literature summarizing UAE in the treatment of CSP was performed.

RESULTS

Eleven patients with definite CSP received preventive UAE combined with methotrexate followed by uterine curettage, and CSP was resolved successfully without hysterectomy. In the four misdiagnosed patients, three were treated successfully with emergency UAE. The other patient underwent uterine curettage and emergency UAE followed by repeat curettage, but hysterectomy was performed because of continued severe hemorrhage.

CONCLUSIONS

Based on a small number of patients, it appears that UAE may be an effective means of treating CSP, including treatment in an emergency setting. Further study is required before the safety and effectiveness of UAE can be confirmed.

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.

Magnetic resonance imaging as an adjunct to ultrasound in evaluating cesarean scar ectopic pregnancy

Cesarean scar pregnancies (CSPs) are a relatively rare form of ectopic pregnancy in which the embryo is implanted within the fibrous scar of a previous cesarean section. A greater number of cases of CSPs are currently being reported as the rates of cesarean section are increasing globally and as detection of scar pregnancy has improved with use of transvaginal ultrasound (TVUS) with color Doppler imaging. Delayed diagnosis and management of this potentially life-threatening condition may result in complications, predominantly uterine rupture and hemorrhage with significant potential maternal morbidity. Diagnosis of a cesarean scar pregnancy (CSP) requires a high index of clinical suspicion, as up to 40% of patients may be asymptomatic. TVUS has a reported sensitivity of 84.6% and has become the imaging examination of choice for diagnosis of a CSP. Magnetic resonance imaging (MRI) has been used in a small number of patients as an adjunct to TVUS. In the present report, MRI is highlighted as a problem-solving tool capable of more precisely identifying the relationship of a CSP to adjacent structures, thereby providing additional information critical to directing appropriate patient management and therapy.

Successful conservative management of ectopic pregnancy in caesarean section scar

Caesarean scar pregnancy is a rare type of ectopic pregnancy. The authors present a 24-year-old woman 5 weeks after her last menstrual period. She had a history of a single caesarean section which was followed by a normal vaginal delivery. Ultrasound imaging revealed a pregnancy in her lower segment caesarean section scar. The decision on the choice of treatment was influenced mainly by the β-human chorionic gonadotropin levels in the patient's blood. Although a few reports have been published on similar cases, spontaneous resolution of a caesarean scar ectopic pregnancy of less than 5 weeks gestation is yet to be reported. The patient is now asymptomatic and her urine pregnancy test has been confirmed negative.

Ruptured ectopic pregnancy in caesarean section scar: a case report

Pregnancy implantation within previous caesarean scar is one of the rarest locations for an ectopic pregnancy. Incidence of caesarean section is increasing worldwide and with more liberal use of transvaginal sonography, more cases of caesarean scar pregnancy are being diagnosed in early pregnancy thus allowing preservation of uterus and fertility. However, a delay in either diagnosis or treatment can lead to uterine rupture, hysterectomy, and significant maternal morbidity. We are reporting a rare case of first trimester caesarean scar pregnancy with viable fetus in the process of rupture, where uterine repair could be done, thus preserving the future fertility.

Caesarean Scar Pregnancy: Treatment with Bilateral Uterine Artery Chemoembolization Combined with Dilation and Curettage

Objective:

This study investigated bilateral uterine artery chemo -embolization (BUACE) combined with dilation and curettage (D&C) in caesarean scar pregnancy (CSP).

Methods:

Nineteen women with CSP were referred for interventional radiology. In 13 patients, BUACE was performed before D&C, following a diagnosis of CSP. A further six patients received BUACE for massive vaginal bleeding after D&C for inevitable miscarriage; the diagnosis of CSP was subsequently confirmed ultrasonographically. BUACE of the uterine arteries was performed using gelfoam particles following intra-arterial infusion of 100 mg/m2 methotrexate.

Results:

BUACE was technically successful and immediate haemostasis was achieved in all patients. Blood loss was significantly greater during D&C undertaken before BUACE compared with D&C after BUACE, but this bleeding was controlled by BUACE. No patient required further surgical intervention and there were no severe complications. The gestational sac and placenta could no longer be detected ultrasonographically and the menstrual cycle returned to normal 2 - 3 months after treatment in all patients.

Conclusions:

BUACE followed by D&C seems to be a safe and effective treatment for CSP and should be considered as a treatment of choice.

Cesarean scar pregnancy: sonographic and magnetic resonance imaging findings, complications, and treatment

A cesarean scar (ectopic) pregnancy occurs when a pregnancy implants on a cesarean scar. This condition is an uncommon but potentially devastating occurrence. The incidence is increasing as cesarean deliveries become more common. Early recognition of the salient sonographic findings is critical because a delay can lead to increased maternal morbidity and mortality. Magnetic resonance imaging is a valuable troubleshooting tool when sonography is equivocal or inconclusive before therapy or intervention. Early diagnosis by sonography directs therapy and improves outcomes by allowing preservation of the uterus and future fertility. We review the imaging features, differential diagnosis, complications, and treatment of cesarean scar pregnancies in the first trimester.

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.

Analysis of cases with cesarean scar pregnancy

AIM

To discuss the early diagnosis and effective treatment strategy of cesarean scar pregnancy (CSP).

MATERIAL AND METHODS

 We reviewed 17 patients in our department diagnosed with CSP between 2005 and 2010, including clinical characteristics, early diagnosis, treatment methods, side-effects and prognosis.

RESULTS

The average duration of gestation at diagnosis was 46 days (range 37-82) and the interval between CSP and last cesarean scar was 6 years (range 2-15). Fourteen (82%) patients presented with slight vaginal bleeding and two (12%) complained of abdominal discomfort. Fourteen patients were diagnosed with CSP by transvaginal color Doppler ultrasonography (TVCDUS). Magnetic resonance imaging (MRI) was performed in two cases of CSP when the diagnosis by TVCDUS was difficult. One patient was diagnosed by histological examination of hysterectomy specimens due to life-threatening bleeding during curettage. Seven patients initially diagnosed with CSP before pregnancy termination were treated conservatively to preserve the uterus without causing maternal complications, ten patients underwent curettage due to incorrect diagnosis, eight patients had excessive vaginal bleeding during curettage and three patients underwent emergency hysterectomy due to hypovolemic shock.

CONCLUSION

CSP does not have any specific symptoms and can be easily diagnosed incorrectly. Confirmation of a portion of gestational sac in the uterus is important and TVCDUS is the first-line tool for early diagnosis of CSP. Physicians never perform curettage at diagnosis with CSP, but curettage after uterine artery embolism or methotrexate are better treatments of choice to terminate CSP.

Caesarean scar pregnancy: a review of management options

PURPOSE OF REVIEW

The current review aims to provide an overview of the already available and emerging treatment modalities for caesarean scar pregnancy (CSP).

RECENT FINDINGS

CSP is a type of ectopic gestation associated with a high risk of serious complications. The cause of this condition and the best management are still unclear. However, some medical and surgical treatment modalities have been suggested. The main objectives in the clinical management of CSP should be the prevention of massive blood loss and the conservation of the uterus to maintain further fertility, women's health and quality of life. Current data suggest that expectant management should not be recommended, whereas there are accumulating data suggesting that early diagnosis offers single or combined medical and surgical treatment options avoiding uterine rupture and haemorrhage, thus preserving the uterus and fertility.

SUMMARY

No universal treatment guidelines for the management of CSP have been published up to now. The lack of data on the best evidence should encourage any individual case report and further multicentre studies for recommendations establishment.

Cesarean scar pregnancy: a rare cause of uterine arteriovenous malformation

A 38-year-old gravida 4, para 2 woman with a history of two Cesarean sections and one curettage was referred to our hospital, because of painless vaginal bleeding and 6 weeks + 2 days of amenorrhea. The first diagnosis was Cesarean scar pregnancy, managed with methotrexate. Subsequently, an arteriovenous malformation developed, which was diagnosed with color Doppler imaging. The diagnosis was confirmed with angiography. Successful bilateral uterine artery embolization was performed with ethylene vinyl alcohol copolymer (Onyx), n-butyl-2-cyanoacrylate (Histoacryl), and gelfoam.

Fertility performance and obstetric outcomes among women with previous cesarean scar pregnancy

OBJECTIVES

The purpose of this study was to assess fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy.

METHODS

We conducted a retrospective study in a large tertiary hospital in Israel. The study included 18 women with a diagnosis of cesarean scar pregnancy between 2000 and 2009.

RESULTS

The incidence of cesarean scar pregnancy among our parturient patients was 1 per 3000 for the general obstetric population and 1 per 531 among those with at least 1 cesarean delivery. Sixteen were treated primarily with methotrexate. Two were treated primarily by surgery, and 2 more were treated by surgery after failed methotrexate treatment. After cesarean scar pregnancy treatment, 7 women conceived spontaneously, and 1 conceived by in vitro fertilization-intracytoplasmic sperm injection. The remaining 10 (55%) did not wish to conceive again. Two of the women who became pregnant (25%) had recurrent cesarean scar pregnancy.

CONCLUSIONS

This study shows encouraging results for fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy. Nevertheless, the risk of recurrent cesarean scar pregnancy is not negligible.

Repercussões da cicatriz uterina resultante de cesariana prévia na dopplervelocimetria das artérias uterinas entre 26 e 32 semanas

OBJETIVO: Avaliar as repercussões da cicatriz uterina na dopplervelocimetria das artérias uterinas, entre 26 e 32 semanas, em gestantes primíparas com uma cesariana prévia, considerando quando esta foi realizada fora (cesárea eletiva) ou durante o trabalho de parto. MATERIAIS E MÉTODOS: Estudo prospectivo transversal em 45 gestantes, divididas em três grupos: 17 gestantes com cicatriz prévia resultante de cesariana eletiva (grupo A); 14 gestantes com uma cicatriz prévia oriunda de cesariana executada em trabalho de parto (grupo B); 14 gestantes cujo único parto anterior foi realizado por via vaginal (grupo C). A dopplervelocimetria das artérias uterinas foi realizada pela via abdominal. Foram calculados as médias, medianas e desvios-padrão (DP) para cada grupo em estudo. Em relação ao índice de pulsatilidade, a comparação dos grupos foi conduzida pelo teste não paramétrico de Kruskal-Wallis. RESULTADOS: Os valores médios do índice de pulsatilidade no grupo A variaram de 0,60 a 1,60 (média: 0,90; DP: 0,29), no grupo B, de 0,53 a 1,43 (média: 0,87; DP: 0,24), e no grupo C, de 0,65 a 1,65 (média: 1,01; DP: 0,37); p = 0,6329. CONCLUSÃO: Não houve repercussões da cicatriz de cesariana prévia na dopplervelocimetria das artérias uterinas avaliadas de 26 a 32 semanas de gestação.

Methotrexate therapy followed by suction curettage followed by Foley tamponade for caesarean scar pregnancy

OBJECTIVES

Caesarean scar pregnancy (CSP) is a very rare and dangerous form of pregnancy because of the increased risk of rupture and excessive hemorrhage. There is currently no consensus on the treatment. We studied if methotrexate (MTX) therapy followed by suction curettage followed by Foley tamponade was a viable treatment for patients with CSP.

STUDY DESIGN

Forty-five patients with CSP in our hospital received a single dose of 50mg/m(2) MTX by intramuscular injection. If gestational cardiac activity was seen on transvaginal ultrasound, local injection of MTX was given. After 7 days, suction curettage was performed to remove the retained products of conception and blood clot (CSP mass) under transabdominal sonography (TAS) guidance. After the suction curettage, a Foley catheter balloon was placed into the isthmic portion of cervix.

RESULTS

Forty-two subjects were successfully treated and 3 subjects failed treatment. The mean estimated blood loss of all 45 patients was 706.89 ± 642.08 (100-3000)ml. The resolution time of the serum β-hCG was 20.62 ± 5.41 (9-33) days. The time to CSP mass disappearance was 12.57 ± 4.37 (8-25) days.

CONCLUSIONS

MTX administration followed by suction curettage followed by Foley tamponade was an effective treatment for caesarean scar pregnancy.

A case of cesarean scar ectopic: a rare but important form of ectopic pregnancy

Introduction

This is a case of a 35-year-old G4P3 female with history of one prior cesarean section who presented to the emergency department with vaginal bleeding. She was found to be pregnant, and an ultrasound identified a cesarean scar ectopic pregnancy.

Methods

This is a case report and brief review of the literature.

Conclusion

Cesarean scar ectopic is a rare form of ectopic pregnancy that implants within the myometrium at the site of a prior cesarean section scar. It carries the potential for serious maternal morbidity and mortality, including complications like uterine rupture, life-threatening hemorrhage, and need for hysterectomy. All sonographers who scan patients in first-trimester pregnancy should be aware of the criteria to diagnose this entity, as cesarean scar ectopic can otherwise be confused with cervicoisthmic pregnancy or spontaneous abortion in progress.