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Pekar-Zlotin M, Maymon R, Nimrodi M, Zur-Naaman H, Melcer Y. Evaluation of Cesarean section scar using saline contrast sonohysterography in women with previous Cesarean scar pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:551-555. [PMID: 37983614 DOI: 10.1002/uog.27540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To evaluate Cesarean scar defects using saline contrast sonohysterography (SCSH) in women with a history of Cesarean scar pregnancy (CSP). METHODS A cohort of 38 non-pregnant women with a history of CSP treated with combined local and systemic methotrexate was investigated prospectively by SCSH. For the purpose of analysis, they were classified, according to the modified Delphi consensus criteria for CSP in early gestation, into three subgroups based on the depth of the gestational sac herniation in the midsagittal plane. Subgroup A included eight (21.1%) cases, in which the largest part of the gestational sac protruded towards the uterine cavity; Subgroup B included 20 (52.6%) cases, in which the largest part of the gestational sac was embedded in the myometrium; and Subgroup C included 10 (26.3%) cases, in which the gestational sac was located partially outside the outer contour of the cervix or uterus. RESULTS SCSH revealed that all women in Subgroup C had a uterine niche. The median niche length (P = 0.006) and depth (P = 0.015) were significantly greater in Subgroup C than in Subgroups A or B. The median residual myometrial thickness (RMT) was significantly lower in Subgroup C than in Subgroups A or B (P = 0.006). CONCLUSIONS Women with prior CSP who had a gestational sac protruding beyond the serosal line had a significantly greater niche length and depth, and lower RMT. This knowledge may guide individualized risk counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M Pekar-Zlotin
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - R Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - M Nimrodi
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - H Zur-Naaman
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Y Melcer
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
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Pekar-Zlotin M, Zur-Naaman H, Maymon R, Tsviban A, Melcer Y. Outcomes of Cesarean Scar Pregnancies in Early Gestation According to the New Delphi Consensus Criteria. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2039-2044. [PMID: 36929872 DOI: 10.1002/jum.16222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/10/2023] [Accepted: 03/01/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Clinical evaluation of the new Delphi consensus definition of cesarean scar pregnancy (CSP) in early gestation. METHODS A retrospective cohort of 36 women diagnosed with CSP and treated with combined local and systemic methotrexate (MTX) between 2008 and 2021. The CSPs were classified according to the new Delphi consensus criteria into three subgroups based on the depth of the gestational sac herniation in the sagittal plane. Subgroup A included 8 (22.2%) cases in which the largest part of the gestational sac protruded toward the uterine cavity. Subgroup B included 22 (61.1%) cases in which the largest part of the gestational sac was embedded in the myometrium, and subgroup C included 6 (16.7%) cases in which the gestational was partially located outside the outer contour of the cervix or uterus. RESULTS The β-HCG level upon admission was significantly lower in subgroup A than in subgroups B or C (11,075 ± 7109, 18,787 ± 16,585, and 58,273 ± 55,267 mIU/mL, respectively, P = .01). All subgroup C patients had repeated courses of MTX and surgical interventions (laparotomy, uterine artery embolization, and operative hysteroscopy) at double the rate of subgroups A or B (100, 50, and 40.9%, respectively, P = .036). The duration of hospitalization was significantly shorter in subgroup A than in subgroups B or C (1.9 ± 1.5, 2.1 ± 1.1, and 5.4 ± 4.9 days, P = .01). CONCLUSIONS The outcome according to Delphi consensus criteria for defining CSP in early gestation has implications for clinical decision-making, patient care, and the follow-up of CSP.
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Affiliation(s)
- Marina Pekar-Zlotin
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hili Zur-Naaman
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anna Tsviban
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Morlando M, Buca D, Timor-Tritsch I, Cali G, Palacios-Jaraquemada J, Monteagudo A, Khalil A, Cennamo C, La Manna V, Liberati M, D'Amico A, Nappi L, Colacurci N, D'Antonio F. Reproductive outcome after cesarean scar pregnancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2020; 99:1278-1289. [PMID: 32419158 DOI: 10.1111/aogs.13918] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION To evaluate subsequent reproductive among women with a prior cesarean scar pregnancy (CSP). MATERIAL AND METHODS MEDLINE, Embase and ClinicalTrials.gov databases were searched. Inclusion criteria were women with a prior CSP, defined as the gestational sac or trophoblast within the dehiscence/niche of the previous cesarean section scar or implanted on top of it. The primary outcome was the recurrence of CSP; secondary outcomes were the chance of achieving a pregnancy after CSP, miscarriage, preterm birth, uterine rupture and the occurrence of placenta accreta spectrum disorders. Subgroup analysis according to the management of CSP (surgical vs non-surgical) was also performed. Random effect meta-analyses of proportions were used to analyze the data. RESULTS Forty-four studies (3598 women with CSP) were included. CSP recurred in 17.6% of women. Miscarriage, preterm birth and placenta accreta spectrum disorders complicated 19.1% (65/341), 10.3% (25/243) and 4.0% of pregnancies, and 67.0% were uncomplicated. When stratifying the analysis according to the type of management, CSP recurred in 21% of women undergoing surgical and in 15.2% of those undergoing non-surgical management. Placenta accreta spectrum disorders complicated 4.0% and 12.0% of cases, respectively. CONCLUSIONS Women with a prior CSP are at high risk of recurrence, miscarriage, preterm birth and placenta accreta spectrum. There is still insufficient evidence to elucidate whether the type of management adopted (surgical vs non-surgical) can impact reproductive outcome after CSP. Further large, prospective studies sharing an objective protocol of prenatal management and long-term follow up are needed to establish the optimal management of CSP and to elucidate whether it may affect its risk of recurrence and pregnancy outcome in subsequent gestations.
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Affiliation(s)
- Maddalena Morlando
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Danilo Buca
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Ilan Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
| | - Giuseppe Cali
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Villa Sofia Cervello, Palermo, Italy.,Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Jose Palacios-Jaraquemada
- Center for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, London, UK
| | - Carmen Cennamo
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Viviana La Manna
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco Liberati
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Alice D'Amico
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Luigi Nappi
- Fetal Medicine Unit, Department of Medical and Surgical Sciences, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Nicola Colacurci
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco D'Antonio
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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Alvarez-Sarrado L, De Bonrostro-Torralba C, Espiau-Romera A, Benito-Vielba M, Lasierra-Beamonte A, Campillos-Maza JM. Ultrasound-guided intrasacular injection of methotrexate in the management of ectopic pregnancies with embryo. A 12 year experience report in a tertiary hospital. Eur J Obstet Gynecol Reprod Biol 2020; 251:180-183. [PMID: 32505791 DOI: 10.1016/j.ejogrb.2020.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of combined-therapy with ultrasound guided intrasacular injection of 50 mg of methotrexate (MTX) and a 50 mg/m2 dose of systemic MTX in uncomplicated ectopic pregnancies with ultrasonographic evidence of embryonic structures in the gestational sac. STUDY DESIGN We designed a retrospective study including 60 patients to assess the efficacy of combined MTX treatment and to determine which clinical or ultrasonographic variables could be associated with successful medical treatment. Failed medical treatment was defined when surgery was needed. For statistical analysis, we developed a descriptive analysis and a univariate logistic regression study. RESULTS Medical approach was effective in 73.3 % of patients. MTX treatment was successful in 32 (68.1 %) out of 47 tubal pregnancies None of the 4 cervical or 2 abdominal pregnancies required surgery. Six (85.7 %) out of 7 cornual pregnancies were successfully treated. No statistically significant differences were found in the success rates according to clinical data, ultrasound or analytic characteristics of women. CONCLUSION Combined MTX therapy could be an effective and safe alternative in ectopic pregnancies with embryo in hemodynamically stable women. Clinical, ultrasound or analytic characteristics of patients should not entail a contraindication. In locations where surgery implies a technical difficulty, this option may decrease morbimortality rates frequently associated to a more invasive alternative.
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Affiliation(s)
- Leticia Alvarez-Sarrado
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Miguel Servet Maternal University Hospital, Paseo Isabel la Católica, 1-3, 50009 Zaragoza, Spain.
| | - Carlos De Bonrostro-Torralba
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Miguel Servet Maternal University Hospital, Paseo Isabel la Católica, 1-3, 50009 Zaragoza, Spain.
| | - Andrea Espiau-Romera
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Miguel Servet Maternal University Hospital, Paseo Isabel la Católica, 1-3, 50009 Zaragoza, Spain.
| | - Marta Benito-Vielba
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Miguel Servet Maternal University Hospital, Paseo Isabel la Católica, 1-3, 50009 Zaragoza, Spain.
| | - Ana Lasierra-Beamonte
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Miguel Servet Maternal University Hospital, Paseo Isabel la Católica, 1-3, 50009 Zaragoza, Spain.
| | - Jose Manuel Campillos-Maza
- Maternal-Fetal Medicine Unit, Department of Obstetrics, Miguel Servet Maternal University Hospital, Paseo Isabel la Católica, 1-3, 50009 Zaragoza, Spain.
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Jachymski T, Moczulska H, Guzowski G, Pomorski M, Piątek S, Zimmer M, Rokita W, Wielgoś M, Sieroszewski P. Conservative treatment of abnormally located intrauterine pregnancies (cervical and cesarean scar pregnancies): a multicenter analysis (Polish series). J Matern Fetal Neonatal Med 2018; 33:993-998. [PMID: 30122076 DOI: 10.1080/14767058.2018.1514009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Tomasz Jachymski
- Department of Fetal Medicine and Gynaecology, Medical University of Lodz, Lodz, Poland
| | - Hanna Moczulska
- Department of Fetal Medicine and Gynaecology, Medical University of Lodz, Lodz, Poland.,Department of Clinical Genetics, Medical University of Lodz, Lodz, Poland
| | - Grzegorz Guzowski
- Department of Fetal Medicine and Gynaecology, Medical University of Lodz, Lodz, Poland
| | - Michał Pomorski
- II Department of Gynaecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Szymon Piątek
- 1st Department of Obstetrics and Gynaecology, Medical University of Warsaw, Warsaw, Poland
| | - Mariusz Zimmer
- II Department of Gynaecology and Obstetrics, Wroclaw Medical University, Wroclaw, Poland
| | - Wojciech Rokita
- Department of Obstetrics and Gynaecology, the Jan Kochanowski University in Kielce, Kielce, Poland
| | - Mirosław Wielgoś
- 1st Department of Obstetrics and Gynaecology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Sieroszewski
- Department of Fetal Medicine and Gynaecology, Medical University of Lodz, Lodz, Poland
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Tuncay G, Karaer A, Coskun EI, Melekoglu R. Treatment of unruptured cornual pregnancies by local injections of methotrexate or potassium chloride under transvaginal ultrasonographic guidance. Pak J Med Sci 2018; 34:1010-1013. [PMID: 30190771 PMCID: PMC6115548 DOI: 10.12669/pjms.344.14600] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To demonstrate the outcome of intralesional management and show the safety of local treatment of cornual pregnancy. Methods Eight patients were treated with local methotrexate or potassium chloride injection. All patients underwent transvaginal ultrasound examination and were diagnosed by the criteria defined by Timor-Tritsch. In the case of fetal heart beat observation, potassium chloride was injected; and in the case of no heart beat detection, methotrexate was used. A follicle aspiration needle was inserted directly into the gestational sac under transvaginal guidance. Results Although it has been considered to be a risk factor, none of the patients in our study had previous ectopic pregnancy, history of infertility / in vitro fertilization, or cornual pregnancy. One of the patients had a medical history of abortion. In four cases, methotrexate was injected, and three patients received potassium chloride as a local treatment. None of the patients had any complication in the peri- or postoperative period. Conclusion Using a local approach, the treatment agent can reach the area of the cornual pregnancy in high concentrations. Based on this case series, a local approach seems to be an effective and fertility-sparing method for treating unruptured cornual pregnancies.
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Affiliation(s)
- Gorkem Tuncay
- Dr. Gorkem Tuncay MD. Assistant Professor, Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Abdullah Karaer
- Dr. Abdullah Karaer MD. Associate Professor, Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Ebru Inci Coskun
- Dr. Ebru Inci Coskun MD. Assistant Professor, Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, Malatya, Turkey
| | - Rauf Melekoglu
- Dr. Rauf Melekoglu MD. Assistant Professor, Department of Obstetrics and Gynecology, Inonu University Faculty of Medicine, Malatya, Turkey
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7
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Jayaram PM, Okunoye GO, Konje J. Caesarean scar ectopic pregnancy: diagnostic challenges and management options. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/tog.12355] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Pradeep M Jayaram
- Sidra Medical and Research Centre & Weill Cornell Medical College; Doha PO Box 26999 Qatar
| | - Gbemisola O Okunoye
- Sidra Medical and Research Centre & Weill Cornell Medical College; Doha PO Box 26999 Qatar
| | - Justin Konje
- Women's Services Clinical Management Group; Sidra Medical and Research Centre; Doha PO Box 26999 Qatar
- University of Leicester; UK
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Bringley J, Denefrio C, Rijhsinghani A. Twin cesarean scar ectopic pregnancy treated with systemic and local methotrexate. Am J Obstet Gynecol 2017; 216:77.e1-77.e2. [PMID: 27640939 DOI: 10.1016/j.ajog.2016.09.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 09/05/2016] [Accepted: 09/07/2016] [Indexed: 10/21/2022]
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Kolanska K, Cohen J, Zanini-Grandon AS, Belghiti J, Bornes M, Daraï E. [How I do… in situ methotrexate injection in the treatment of intramyometrial pregnancy]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2016; 44:435-436. [PMID: 27426691 DOI: 10.1016/j.gyobfe.2016.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 06/09/2016] [Indexed: 06/06/2023]
Affiliation(s)
- K Kolanska
- Service de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris, GRC 6-UPMC centre expert en endométriose (C3E), UMRS 938, université Pierre-et-Marie-Curie-Paris-6, 75020 Paris, France
| | - J Cohen
- Service de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris, GRC 6-UPMC centre expert en endométriose (C3E), UMRS 938, université Pierre-et-Marie-Curie-Paris-6, 75020 Paris, France.
| | - A S Zanini-Grandon
- Service de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris, GRC 6-UPMC centre expert en endométriose (C3E), UMRS 938, université Pierre-et-Marie-Curie-Paris-6, 75020 Paris, France
| | - J Belghiti
- Service de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris, GRC 6-UPMC centre expert en endométriose (C3E), UMRS 938, université Pierre-et-Marie-Curie-Paris-6, 75020 Paris, France
| | - M Bornes
- Service de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris, GRC 6-UPMC centre expert en endométriose (C3E), UMRS 938, université Pierre-et-Marie-Curie-Paris-6, 75020 Paris, France
| | - E Daraï
- Service de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris, GRC 6-UPMC centre expert en endométriose (C3E), UMRS 938, université Pierre-et-Marie-Curie-Paris-6, 75020 Paris, France
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10
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Cohen J, Kolanska K, Zanini-Grandon AS, Belghiti J, Thomassin-Naggara I, Bazot M, Bornes M, Daraï E. Treatment of Intramyometrial Pregnancy by In Situ Injection of Methotrexate. J Minim Invasive Gynecol 2016; 24:335-337. [PMID: 27241811 DOI: 10.1016/j.jmig.2016.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/17/2016] [Accepted: 05/19/2016] [Indexed: 11/18/2022]
Abstract
Intramyometrial ectopic pregnancies are rare, and various management modalities have been described. We report a patient with intramyometrial pregnancy who was successfully treated by in situ injection of methotrexate (MTX) after the failure of 2 intramuscular injections of MTX. We emphasize the difficult management of intramyometrial pregnancy and show that in situ MTX injection may be indicated for this particular type of ectopic pregnancy.
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Affiliation(s)
- Jonathan Cohen
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, GRC6-UPMC, Centre Expert en Endométriose (C3E), UMR S938, Université Pierre et Marie Curie Paris 6, Paris, France.
| | - Kamila Kolanska
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, GRC6-UPMC, Centre Expert en Endométriose (C3E), UMR S938, Université Pierre et Marie Curie Paris 6, Paris, France
| | - Anne-Sophie Zanini-Grandon
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, GRC6-UPMC, Centre Expert en Endométriose (C3E), UMR S938, Université Pierre et Marie Curie Paris 6, Paris, France
| | - Jeremie Belghiti
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, GRC6-UPMC, Centre Expert en Endométriose (C3E), UMR S938, Université Pierre et Marie Curie Paris 6, Paris, France
| | - Isabelle Thomassin-Naggara
- Department of Radiology, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, GRC6-UPMC, Centre Expert en Endométriose (C3E), UMR S938, Université Pierre et Marie Curie Paris 6, Paris, France
| | - Marc Bazot
- Department of Radiology, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, GRC6-UPMC, Centre Expert en Endométriose (C3E), UMR S938, Université Pierre et Marie Curie Paris 6, Paris, France
| | - Marie Bornes
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, GRC6-UPMC, Centre Expert en Endométriose (C3E), UMR S938, Université Pierre et Marie Curie Paris 6, Paris, France
| | - Emile Daraï
- Department of Obstetrics, Gynecology, and Reproductive Medicine, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, GRC6-UPMC, Centre Expert en Endométriose (C3E), UMR S938, Université Pierre et Marie Curie Paris 6, Paris, France
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Collins K, Kothari A. Catastrophic consequences of a caesarean scar pregnancy missed on ultrasound. Australas J Ultrasound Med 2015; 18:150-156. [PMID: 28191259 PMCID: PMC5024973 DOI: 10.1002/j.2205-0140.2015.tb00222.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Ectopic pregnancy that implants within the scar tissue of a previous caesarean scar is a situation that is seldom encountered and is almost invariably incompatible with a successful pregnancy. Caesarean scar ectopic pregnancies are fraught with life threatening complications such as scar rupture, significant haemorrhage, disseminated intravascular coagulation and the need for emergency life saving hysterectomy. The clinical diagnosis can be elusive, particularly in the early stages; therefore clinicians should be familiar with the condition's sonographic hallmarks. Early diagnosis and management is the key to preventing these complications. We describe a case of caesarean scar pregnancy which was initially misdiagnosed as “a spontaneous miscarriage in progress”, resulting in uncontrollable bleeding, necessitating an emergency abdominal hysterectomy. We also endeavour to review the literature with regards to the use of ultrasound in its management, treatment and follow up.
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Affiliation(s)
| | - Alka Kothari
- The University of QueenslandSt LuciaQueenslandAustralia; Redcliffe HospitalRedcliffeQueenslandAustralia
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12
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Cheung VY. Local Methotrexate Injection as the First-line Treatment for Cesarean Scar Pregnancy: Review of the Literature. J Minim Invasive Gynecol 2015; 22:753-8. [DOI: 10.1016/j.jmig.2015.04.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/08/2015] [Accepted: 04/09/2015] [Indexed: 11/28/2022]
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13
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Framarino-dei-Malatesta M, Piccioni MG, Derme M, Polidori NF, Tibaldi V, Iannini I, Masselli G. Transabdominal ultrasound-guided injection of methotrexate in the treatment of ectopic interstitial pregnancies. JOURNAL OF CLINICAL ULTRASOUND : JCU 2014; 42:522-526. [PMID: 24925856 DOI: 10.1002/jcu.22185] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 01/15/2014] [Accepted: 05/22/2014] [Indexed: 06/03/2023]
Abstract
PURPOSE In a retrospective observational study, we evaluated the feasibility and safety of medical therapy with transabdominal ultrasound-guided injection of methotrexate (MTX) into the gestational sac (GS) in patients with interstitial ectopic pregnancies. METHODS Fourteen interstitial ectopic pregnancies were treated with transabdominal ultrasound-guided injection of MTX (25 mg). All patients were hemodynamically stable. In all patients, the 10-cm distance between the GS and vaginal fornices was ≥10 cm, making transvaginal injection difficult. To evaluate feasibility and safety of the procedure, we assessed complications clinically and with imaging during a 1-year follow-up. RESULTS In all 14 patients, MTX injected locally into the GS successfully terminated the interstitial pregnancy, thereby avoiding surgery. There was no complications during follow-up. CONCLUSIONS The successful outcome in our patients suggests that the transabdominal route is feasible and safe as a nonsurgical option for terminating an ectopic interstitial pregnancy in patients in whom the transvaginal route is contraindicated or difficult, provided the patients are properly selected and operators have sufficient experience with the technique.
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14
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Bodur S, Özdamar Ö, Kılıç S, Gün İ. The efficacy of the systemic methotrexate treatment in caesarean scar ectopic pregnancy: A quantitative review of English literature. J OBSTET GYNAECOL 2014; 35:290-6. [DOI: 10.3109/01443615.2014.954101] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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15
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Nonsurgical Management of Live Tubal Ectopic Pregnancy by Ultrasound-Guided Local Injection and Systemic Methotrexate. J Minim Invasive Gynecol 2014; 21:642-9. [DOI: 10.1016/j.jmig.2014.01.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 01/10/2014] [Accepted: 01/12/2014] [Indexed: 11/18/2022]
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16
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Zhang B, Jiang ZB, Huang MS, Guan SH, Zhu KS, Qian JS, Zhou B, Li MA, Shan H. Uterine artery embolization combined with methotrexate in the treatment of cesarean scar pregnancy: results of a case series and review of the literature. J Vasc Interv Radiol 2013. [PMID: 23177105 DOI: 10.1016/j.jvir.2012.08.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
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.
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Affiliation(s)
- Bo Zhang
- Department of Radiology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
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17
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Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012; 207:14-29. [PMID: 22516620 DOI: 10.1016/j.ajog.2012.03.007] [Citation(s) in RCA: 366] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 01/28/2012] [Accepted: 03/09/2012] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY 10016, USA.
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18
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Szylit NA, Podgaec S, Traina E, Oliveira RDCS. Video laparoscopic intervention for an interstitial pregnancy after failure of clinical treatment. SAO PAULO MED J 2012; 130:202-7. [PMID: 22790554 PMCID: PMC10876192 DOI: 10.1590/s1516-31802012000300011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2011] [Revised: 01/05/2011] [Accepted: 07/11/2011] [Indexed: 11/22/2022] Open
Abstract
CONTEXT Interstitial pregnancy is a rare form of ectopic pregnancy for which the best therapeutic course of action has yet to be determined. Surgical intervention entails a high risk of hemorrhage due to the great vascularization of the cornual region of the uterus. Case descriptions facilitate the analysis of results and aid clinicians in determining the most appropriate course of action in these situations. CASE REPORT In a patient with an ultrasound diagnosis of interstitial pregnancy, clinical treatment using methotrexate was chosen. However, after one week, there was a marked decline in the serum level of the β subunit of chorionic gonadotropin hormone, although an ultrasound examination revealed embryonic cardiac activity. A second dose of the chemotherapy was administered. Embryonic cardiac activity persisted 48 hours later. Video laparoscopy was performed to achieve right-side cornual resection, which resulted in satisfactory resolution of the case.
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Affiliation(s)
- Nilson Abrão Szylit
- Birth Control Outpatient Clinic, Instituto Israelita de Responsabilidade Social Albert Einstein, São Paulo, Brazil.
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19
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Maymon R, Svirsky R, Smorgick N, Mendlovic S, Halperin R, Gilad K, Tovbin J. Fertility performance and obstetric outcomes among women with previous cesarean scar pregnancy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2011; 30:1179-1184. [PMID: 21876087 DOI: 10.7863/jum.2011.30.9.1179] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
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.
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MESH Headings
- Abortifacient Agents, Nonsteroidal
- Abortion, Induced/methods
- Adult
- Cesarean Section/adverse effects
- Cicatrix/complications
- Female
- Humans
- Incidence
- Infertility, Female/epidemiology
- Infertility, Female/etiology
- Israel/epidemiology
- Methotrexate
- Pregnancy
- Pregnancy Complications/diagnostic imaging
- Pregnancy Complications/epidemiology
- Pregnancy Complications/therapy
- Pregnancy Outcome
- Pregnancy, Ectopic/diagnostic imaging
- Pregnancy, Ectopic/epidemiology
- Pregnancy, Ectopic/etiology
- Pregnancy, Ectopic/therapy
- Retrospective Studies
- Ultrasonography, Interventional/methods
- Ultrasonography, Prenatal
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Affiliation(s)
- Ron Maymon
- Department of Obstetrics and Gynecology, Assaf Harofeh Medical Center, 70300 Zerifin, Israel.
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20
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An alternative treatment option in tubal ectopic pregnancies with fetal heartbeat: aspiration of the embryo followed by single-dose methotrexate administration. Fertil Steril 2011; 96:79-83. [DOI: 10.1016/j.fertnstert.2011.02.058] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2010] [Revised: 01/19/2011] [Accepted: 02/18/2011] [Indexed: 11/22/2022]
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Kato S, Tanaka T, Terai Y, Yamashita Y, Ohmichi M. Interstitial pregnancy treated by transcervical aspiration of the gestational sac combined with systemic and local administration of methotrexate. J Obstet Gynaecol Res 2011; 37:1250-4. [DOI: 10.1111/j.1447-0756.2010.01508.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ong C, Su LL, Chia D, Choolani M, Biswas A. Sonographic diagnosis and successful medical management of an intramural ectopic pregnancy. JOURNAL OF CLINICAL ULTRASOUND : JCU 2010; 38:320-324. [PMID: 20544869 DOI: 10.1002/jcu.20703] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
We report a case of posterior wall intramural pregnancy in a 36-year-old primigravida at 6 weeks gestation. Sonographic examination showed a viable intramural pregnancy distorting the contour of the uterus. The pregnancy was terminated by intrafetal injection of potassium chloride followed by intra-amniotic methotrexate injection.
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Affiliation(s)
- Clara Ong
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore
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de Vaate AJMB, Brölmann HAM, van der Slikke JW, Wouters MGAJ, Schats R, Huirne JAF. Therapeutic options of caesarean scar pregnancy: case series and literature review. JOURNAL OF CLINICAL ULTRASOUND : JCU 2010; 38:75-84. [PMID: 19902518 DOI: 10.1002/jcu.20648] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
We describe our experience with the treatment of 4 caesarean scar pregnancies and provide an overview of current literature. Four women diagnosed with a caesarean scar pregnancy in our hospital between 1996 and 2007 were treated with local or systemic methotrexate and had a steady decline of the serum beta-hCG level. The uterus was preserved in all women and 3 of them had an uneventful subsequent pregnancy and delivery. We suggest that transcervical needle aspiration of amniotic fluid followed by intra-amniotic injection of methotrexate should be the treatment of choice, followed by surgical treatment only if methotrexate fails.
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