Cesarean scar pregnancy and early placenta accreta share common histology

Imaging Modalities for the Diagnosis of Placenta Accreta Spectrum

Placenta accreta spectrum (PAS) is the result of the invasion of the placental trophoblasts into the myometrium. The rate of PAS continues to increase due to the increased number of cesarean sections. Other risk factors include increasing maternal age, multiparity, uterine surgeries, and placenta previa. Due to the high risk of maternal morbidity and mortality, prenatal diagnosis is essential to ensure proper resources and surgical planning before delivery. Ultrasound is considered the gold standard for diagnosis of PAS. Ultrasound findings include placental lacuna, loss of placental clear space, lower uterine segment thickness, and increased vascularity between the placenta and bladder.

Recent Advances in Diagnosis and Management of Cesarean Scar Pregnancy

Cesarean scar pregnancy (CSP) is among the most severe iatrogenic complications of cesarean delivery (CD) and is associated with a high risk of severe hemorrhage, uterine rupture, and progression towards placenta accreta spectrum disorders. Prenatal diagnosis of CSP has been recently standardized through a modified Delphi consensus, which also allows risk stratification according of this anomaly. However, several issues on the management of CSP are still under debate. The aim of the present review is to provide an up-to-date on the diagnosis and management of CSP.

Analysis of reproductive outcomes after cesarean scar pregnancy surgery: a multicenter retrospective study

Objective

This study aimed to analyze the outcome of postoperative re-pregnancies in patients with a cesarean scar pregnancy (CSP) and investigate the factors influencing the occurrence of recurrent cesarean section scar pregnancy (RCSP).

Methods

A retrospective analysis was performed on the clinical data of 105 patients with CSP who had undergone surgical treatment and were admitted to the Minda Hospital affiliated with Hubei University for Nationalities, Henan Provincial People's Hospital, Linyi People's Hospital, and Weifang People's Hospital from January 2015 to May 2021. The reproductive outcomes of these patients were monitored, and the factors influencing the occurrence of RCSP were analyzed.

Results

In this study, it was found that the reproductive outcomes of patients with CSP after surgery included ectopic pregnancy, normal intrauterine pregnancy, RCSP, and abortion. The postoperative re-pregnancy rate was 51.72% (105/203), and the postoperative RCSP rate was 13.33% (14/105). The number of cesarean sections (OR = 2.004, 95% CI: 1.412-22.579, p < 0.001) was identified as an independent risk factor for the occurrence of RCSP, and the intraoperative removal of the uterine scar (OR = 0.045, 95% CI: 0.005-190.400, p = 0.002) was determined as an independent protective factor for the occurrence of RCSP.

Conclusion

For patients with residual reproductive requirements after CSP surgery, the removal of uterine scar tissue during the operation can be contemplated. Subsequent postoperative re-pregnancy demands close surveillance and follow-up during gestation, with appropriate termination of pregnancy when warranted. For patients without reproductive needs after surgery, contraception is recommended to prevent the occurrence of RCSP.

Successful management of cesarean scar pregnancy progressive to placenta accreta spectrum: An uncommon condition in Vietnam and mini-review of the literature

INTRODUCTION AND IMPORTANCE

Cesarean scar pregnancy (CSP) is an uncommon ectopic pregnancy that could be progressive to the placenta accreta spectrum (PAS). It is defined as abnormal trophoblast invasion of part or all of the placenta into the myometrium of the uterine wall, with varying degrees of severity. These abnormal pathologies of placental implantation could lead to life-threatening complications for pregnant women.

CASE PRESENTATION

A 39-year-old female patient was transferred to our consultant hospital for the diagnosis of CSP at 6 weeks of gestational age (GA). Due to asymptomatic presentation, the patient requested continuing pregnancy despite the high risk of uterine rupture and massive hemorrhage. The pregnant woman was strictly monitored on clinical aspects and ultrasound findings. Noticely, the PAS was suspected at 15-16 weeks of GA, and PAS type percreta was diagnosed at 22 weeks of GA. However, the woman continued her pregnancy and a planned cesarean delivery was performed at 34 weeks 6 days of GA. Additionally, modified one-step conservative surgery (MOSCUS) was successfully applied for uterine preservation. The materno-fetal outcomes were favorable.

CLINICAL DISCUSSION

CSP is related to highly severe complications during pregnancy and the possibility of PAS. A timely termination of pregnancy ought to be discussed with the patient upon diagnosis. However, a proper management is more challenging for women desiring pregnancy.

CONCLUSION

A continuing pregnancy and strict monitoring with a multidisciplinary team could be considered if the patient refuses medical abortion in cases of CSP progressive to PAS. Further data is needed on this entity.

Potential Risk Factors for Developing Cesarean Scar Pregnancy in Women With a History of Cesarean Section

OBJECTIVES

Cesarean scar pregnancy (CSP) occurs in 0.2%-0.5% of women with a previous cesarean section globally. Multiple factors influence the development of CSP; however, to date, the critical factors contributing to the development of CSP have not been fully explored due to its relatively low incidence. Moreover, CSP can be clinically categorized into type 1 and type 2 CSP. In this retrospective study with a large sample size, we investigated potential risk factors that could contribute to CSP development.

METHODS

Two hundred-one women diagnosed with CSP, either type 1 or type 2 CSP, and 1700 pregnant women with a history of cesarean section but without CSP diagnosis in subsequent pregnancy were included. Gravidity, previous live birth(s), consecutive cesarean section(s), surgical abortion(s), the interval between the pregnancies, and maternal age were compared between the 2 groups.

RESULTS

Gravidity, the number of previous live births, the number of previous consecutive cesarean sections, and the number of surgical abortions were significantly associated with CSP development in women with a past cesarean section. This association was regardless of the subtypes of CSP. Notably, the interval between 2 pregnancies was also significantly associated with CSP development, but this association was only seen in type 2 CSP. However, maternal age was not an independent risk factor for CSP development. Additionally, a higher incidence of CSP was observed in China compared to that reported in the literature.

CONCLUSION

In addition to a previous cesarean section, our study highlights at the number of surgical abortions also contributes to the development of CSP.

The value of cesarean scar diverticulum in diagnosis of adverse events during dilatation and curettage in patient with cesarean scar pregnancy

OBJECTIVE

The aim of the present study was to explore the relationship between the size of cesarean scar diverticulum (CSD) measured on preoperative magnetic resonance imaging (MRI) and adverse events during dilatation and curettage (D&C) procedure in patients with cesarean scar pregnancy (CSP).

METHODS

The MRI of 197 CSP patients from October 2019 to August 2023 were retrospectively reviewed. The volume, area, and depth of CSD, residual myometrium thickness (RMT), and gestational sac diameter were recorded and tested for correlation with intraoperative estimated blood loss (EBL), and operation time and for any association with the intraoperative adverse events (intraoperative massive hemorrhage [39 cases] and D&C procedure failure [15 cases]). The Spearman test was used to characterize the correlation between the five MRI variables and both the EBL and operation time. The correlation between the five MRI variables and intraoperative adverse events was evaluated with student's t test and Mann-Whitney U test. Diagnostic power of the MRI variables was evaluated by the area under receiver operating characteristic curve (AUC).

RESULTS

The volume, area, and depth of CSD and gestational sac diameter were positively correlated with both EBL and operation time, with the CSD volume having the highest correlation with them (r = 0.543 and 0.461, respectively). Conversely, the RMT displayed a negative correlation with the EBL and operation time. All five MRI variables were significantly associated with both intraoperative massive hemorrhage and D&C failure (all P < 0.001). The CSD volume demonstrated the highest AUC for diagnosing intraoperative massive hemorrhage and D&C failure at 0.893 (95% CI: 0.82-0.92) and 0.901 (95% CI: 0.85-0.94), respectively. The optimal cutoff values for CSD volume in predicting massive hemorrhage and D&C failure were determined to be 5.41 and 8.92 cm3, respectively, with corresponding sensitivities/specificities of 92.31/74.68 and 93.33/82.42, respectively.

CONCLUSION

Quantifying the size of CSD based on preoperative MRI could aid in evaluating risk during D&C in CSP patients, with CSD volume possessing higher diagnostic efficacy than the other four MRI indicators.

Endometrium-Free Closure Technique During Cesarean Delivery for Reducing the Risk of Niche Formation and Placenta Accreta Spectrum Disorders

OBJECTIVE

To examine the prevalence and severity of postcesarean residual niche, evaluated using saline infusion sonohysterography, in an expanded cohort of women with one prior cesarean delivery and to assess the effect of uterine closure technique on the risk of placenta accreta spectrum (PAS) disorders.

METHODS

This secondary analysis includes 70 patients who underwent saline infusion sonohysterography after one prior cesarean delivery. Patients were grouped according to hysterotomy closure technique: two-layer endometrium-free closure (technique A), and two- or one-layer routine closures (technique B). Niche dimensions and residual myometrial thickness were measured. The primary outcome was clinically significant niche (depth larger than 2 mm), a risk factor for PAS. Groups were compared using χ2, unpaired t test, Kruskal-Wallis, and logistic regression with significance at P<.05.

RESULTS

There were 33 patients in the technique A group and 37 patients in the technique B group. Technique A was associated with smaller niche dimensions (P=.018 for width, .005 for depth, and .002 for length), and exhibited thicker residual myometrial thickness (8.5 mm vs 5.5 mm, P=.041) and a lower incidence of clinically significant niches. The odds of having a clinically significant niche were 27 times higher in the technique B group (adjusted odds ratio 27.1, 95% CI, 4.35-168.81, P<.001).

CONCLUSION

Uterine closure techniques are associated with the development and size of postcesarean residual niches, which are critical risk factors for PAS disorders. Use of an endometrium-free closure technique during primary cesarean delivery is associated with a reduced risk of future niche formation and PAS complications.

Placenta accreta spectrum in the second trimester: a clinical conundrum in procedural abortion care

Given the limitations in perioperative management strategies available at freestanding abortion clinics, abortion providers must commonly discern which patients are too complicated for procedural abortions at their center and must be referred for a hospital-based abortion. The need to transition from freestanding clinics to hospital-based abortion care can lead to delays in completing an abortion and significant social, economic, and psychological repercussions for the pregnant individual. One significant clinical problem that exemplifies the issue of who can be safely taken care of at a freestanding abortion clinic is when the placenta accreta spectrum is suspected. Placenta accreta spectrum is one of the major contributors to maternal morbidity and mortality in the United States, requiring coordinated multidisciplinary management to ensure the safest outcome for the pregnant individual. In this Clinical Opinion, we review the literature focused on identifying individuals at risk for placenta accreta spectrum >14+0 weeks gestation, delineate an algorithm to improve the frequency of timely referrals to hospital-based abortion providers, and propose next steps for future training goals and research on placenta accreta spectrum in the second trimester between complex family planning and maternal-fetal medicine subspecialists.

Sonographic Assessment of Isthmocele and Its Obstetric Complications in Subsequent Pregnancies: A Pictorial Review

Cesarean scar defect represents a significant pathology attributed to the rising prevalence of cesarean deliveries. While not commonplace, these lesions can give rise to severe obstetric consequences during subsequent pregnancies. Given the potential complications, it is advisable to screen for uterine niches using transvaginal ultrasound (TVUS) or contrast-enhanced TVUS for individuals planning to conceive. Surgical repair and correction of these lesions can be crucial in averting obstetric and perinatal complications in future pregnancies. Furthermore, timely sonographic evaluation and reporting of isthmocele-related obstetric complications can help avoid serious issues.

Advanced repair of recurrent and low-large hysterotomy defects using a myometrial glide flap

BACKGROUND

The resolution of factors linked to the recurrence of cesarean section defects can be accomplished through a comprehensive technique that effectively addresses the dehiscent area, eliminates associated intraluminal fibrosis, and establishes a vascularized anterior wall by creating a sliding myometrial flap.

OBJECTIVE

Propose a comprehensive surgical repair for recurrent and large low hysterotomy defects in women seeking pregnancy or recurrent spotting.

STUDY DESIGN

A retrospective cohort analysis included 54 patients aged 25-41 with recurrent large cesarean scar defects treated at Otamendi, CEMIC, and Valle de Lili hospitals. Comprehensive surgical repair was performed by suprapubic laparotomy, involving a wide opening of the vesicouterine space, removal of the dehiscent cesarean scar and all intrauterine abnormal fibrous tissues, using a glide myometrial flap, and intramyometrial injection of autologous platelet-rich plasma. Qualitative variables were determined, and descriptive statistics were employed to analyze the data in absolute frequencies or percentages. The data obtained were processed using the InfostatTM statistic program.

RESULTS

Following the repair, all women experienced normal menstrual cycles and demonstrated an adequate lower uterine segment thickness, with no evidence of healing defects. All patients experienced early ambulation and were discharged within 24 h. Uterine hemostasis was achieved at specific points, minimizing the use of electrocautery. The standard duration of the procedure was 60 min (skin-to-skin), and the average bleeding was 80-100 ml. No perioperative complications were recorded. A control T2-weighted MRI was performed six months after surgery. All patients displayed a clean, unobstructed endometrial cavity with a thick anterior wall (Median: 14.98 mm, IQR 13-17). Twelve patients became pregnant again, all delivered by cesarean between 36.1 and 38.0 weeks, with a mean of 37.17 weeks. The thickness of the uterine segment before cesarean ranged between 3 and 7 mm, with a mean of 3.91 mm. No cases of placenta previa, dehiscence, placenta accreta spectrum (PAS), or postpartum hemorrhage were reported.

CONCLUSIONS

The comprehensive repair of recurrent low-large defects offers a holistic solution for addressing recurrent hysterotomy defects. Innovative repair concepts effectively address the wound defect and associated fibrosis, ensuring an appropriate myometrial thickness through a gliding myometrial flap.

Early first-trimester transvaginal ultrasound screening for cesarean scar pregnancy in patients with previous cesarean delivery: analysis of the evidence

Obstetric hemorrhage is a leading cause of maternal morbidity and mortality. An important etiology of obstetric hemorrhage is placenta accreta spectrum. In the last 2 decades, there has been increased clinical experience of the devastating effect of undiagnosed, as well as late diagnosed, cases of cesarean scar pregnancy. There is a growing body of evidence suggesting that cesarean scar pregnancy is an early precursor of second- and third-trimester placenta accreta spectrum. As such, cesarean scar pregnancy should be diagnosed in the early first trimester. This early diagnosis could be achieved by introducing regimented sonographic screening in pregnancies of patients with previous cesarean delivery. This opinion article evaluates the scientific and clinical basis of whether cesarean scar pregnancy, with special focus on its early first-trimester discovery, complies with the accepted requirements of a screening test. Each of the 10 classical screening criteria of Wilson and Jungner were systematically applied to evaluate if the criteria were met by cesarean scar pregnancy, to analyze if it is possible and realistic to carry out screening in a population-wide fashion.

Management of blood loss in second-trimester abortion

PURPOSE OF REVIEW

While major complications in second-trimester abortion are rare, blood loss and hemorrhage are among the most common and have the potential for high morbidity. Here, we review the current literature on risk factors, prevention, and treatment of blood loss in second-trimester abortion.

RECENT FINDINGS

A comprehensive approach to hemorrhage during second-trimester abortions is essential. Understanding hemorrhage risk factors, prevention strategies, and treatment options makes second-trimester abortion safer. Some pharmacologic methods may both prevent and treat excessive blood loss. Mechanical methods are primarily used for treatment. Key risk factors include prior uterine scars, gestational duration, insufficient cervical preparation, high BMI, procedural inexperience, fetal demise, and halogenated anesthetics. Developing evidence-based protocols for and further research into hemorrhage related complications are crucial for improving safety in second-trimester abortion care.

SUMMARY

Prevention of hemorrhage improves outcomes. However data are limited. For treatment, this includes using pharmacological interventions and mechanical methods. Identifying high-risk patients and implementing preprocedural optimization are proactive measures that aid in decreasing the occurrence and severity of blood loss and hemorrhage.

Methotrexate-Induced Toxicity After Ultrasound-Guided Intragestational Injection in a Patient with Caesarean Scar Pregnancy-A Case Report

Background and Objectives: Caesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy in which the early pregnancy implants at the site of the uterine scar. Methotrexate (MTX) in lower doses can be used to treat CSPs. However, MTX administration is associated with a spectrum of side effects that include hematological toxicities. This case report presents a CSP treated with an intragestational injection of MTX and subsequently developed pancytopenia. Materials and Methods: A 23-year-old woman at six weeks and six days of pregnancy was referred as a potential case of CSP. After establishing the diagnosis, she was treated with a transvaginal ultrasound-guided intragestational administration of 80 mg MTX (adjusted to 50 mg/m2 body surface area) under sedation. Results: On day four after the MTX injection, she developed oral ulcers, fever, and pruritic phlyctenular maculopapular rash. Subsequently, the patient developed febrile neutropenia and was admitted to the Intensive Care Unit. On day six, a subsequent exacerbation of the rash was observed with the formation of blisters and purplish spots with concurrent odynophagia and sialorrhea. Ultimately, the patient developed pancytopenia due to bone marrow suppression. Fifteen days after MTX administration, the patient recovered and was discharged from the hospital hemodynamically stable, afebrile, with dropping β-hcg levels, and in good clinical condition. Conclusions: Although methotrexate administration is the preferred option for the treatment of cesarean scar pregnancies, clinicians should be aware of the fact that its use entails potential risks, even when it is used locally. To our knowledge, this case is the first description of pancytopenia due to bone marrow suppression following a single low dose of intragestational methotrexate injection.

Systemic Immune-Inflammation Indices Could Be Additional Predictive Markers for Cesarean Scar Pregnancy

PROBLEM

Cesarean scar pregnancy (CSP) is characterized by a gestational sac fully or partially implanted in the scar from a previous cesarean section. Systemic immune-inflammation indices (SIIs) have recently been discussed as additional diagnostic markers in placenta accreta and preeclampsia. CSP shares a similar pathogenesis with these diseases, suggesting that assessing the SIIs and neutrophil-to-lymphocyte ratio (NLR) could enhance additional predictability in diagnosing CSP.

METHOD OF STUDY

In this study, we analyzed the complete blood counts between 264 women who were confirmed with CSP by ultrasound and 295 women who underwent elective termination.

RESULTS

The mean counts of total white cells and neutrophils were significantly higher, whereas the counts of monocytes, lymphocytes, and platelets were significantly lower in the CSP group compared to the control group (p < 0.001). Additionally, the SII, systemic inflammation response index (SIRI), or NLR was significantly higher in the CSP group compared to the control group (p < 0.0001). Given the limited effect of SII and SIRI on the increased risk of developing CSP, the optimal cut-off value for NLR in predicting CSP was 2.87 (area under the curve [AUC] 0.656, 68% sensitivity). The optimal cut-off value for NLR in predicting type 2 CSP was 2.91 (AUC 0.690, 71% sensitivity).

CONCLUSIONS

Although ultrasound or magnetic resonance imaging images are a gold standard for visualizing the gestational sac's location in the diagnosis of CSP, assessing peripheral blood tests is cost-effective, and NLR may provide additional diagnosis value for CSP.

Cesarean Scar Ectopic Pregnancy: A Do-Not-Miss Diagnosis

The rate of cesarean section (CS) for delivery has increased internationally, reaching 50% in some countries. Abnormal implantation of a new pregnancy at the site of the prior hysterotomy is an important complication because of the risks of hemorrhage, uterine rupture, and progression to placenta accreta spectrum (PAS), a condition with high morbidity with potential for catastrophic obstetric hemorrhage, maternal and fetal mortality, and loss of fertility. Cesarean scar ectopic pregnancy (CSEP) is the recommended term to describe these pregnancies, which are recognized on the basis of the sac implantation site, growth pattern, and associated abnormal perfusion. The true incidence of CSEP is unknown because the condition is likely underdiagnosed and underreported. The 2022 Society for Maternal-Fetal Medicine consult series notes that severe maternal morbidity and mortality are linked to difficulty in making the diagnosis of CSEP. The authors review the signs of CSEP at imaging, some pitfalls that may lead to delayed or missed diagnosis, and the consequences thereof. CSEPs must be differentiated from low implantation of a normal pregnancy, cervical ectopic pregnancy, and evolving pregnancy loss. Early recognition allows prompt and safe treatment that is usually surgical. Early treatment results in decreased health care costs, a shorter hospital stay, preservation of fertility, and prevention of iatrogenic preterm delivery, which is typical in cases that progress to PAS. Hysterectomy has serious negative psychologic consequences for patients of childbearing age; early diagnosis and prompt treatment of CSEP can prevent this often-ignored complication. ©RSNA, 2024 Supplemental material is available for this article.

First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry

BACKGROUND

A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry.

OBJECTIVE

This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies.

STUDY DESIGN

We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions.

RESULTS

Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9).

CONCLUSION

A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment.

The Cesarean Scar of Pregnancy: Ultrasound Findings and Expectant Management Outcomes

OBJECTIVE

The nomenclature has evolved from low implantation to cesarean scar pregnancy (CSP) and criteria are recommended for identification and management. Management guidelines include pregnancy termination due to life-threatening complications. This article applies ultrasound (US) parameters recommended by the Society for Maternal Fetal Medicine (SMFM) in women who were expectantly managed.

STUDY DESIGN

Pregnancies were identified between March 1, 2013 and December 31, 2020. Inclusion criteria were women with CSP or low implantation identified on US. Studies were reviewed for niche, smallest myometrial thickness (SMT), and location of basalis blinded to clinical data. Clinical outcomes, pregnancy outcome, need for intervention, hysterectomy, transfusion, pathologic findings, and morbidities were obtained by chart review.

RESULTS

Of 101 pregnancies with low implantation, 43 met the SMFM criteria at < 10 weeks and 28 at 10 to 14 weeks. At < 10 weeks, SMFM criteria identified 45out of 76 women; of these 13 required hysterectomy; there were 6 who required hysterectomy but did not meet the SMFM criteria. At 10 to < 14 weeks, SMFM criteria identified 28 out of 42 women; of these 15 required hysterectomy. US parameters yielded significant differences in women requiring hysterectomy, at < 10 weeks and 10 to < 14 weeks' gestational age epochs, but the sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of these US parameters have limitations in identifying invasion to determine management. Of the 101 pregnancies, 46 (46%) failed < 20 weeks, 16 (35%) required medical/surgical management including 6 hysterectomies, and 30 (65%) required no intervention. There were 55 pregnancies (55%) that progressed beyond 20 weeks. Of these, 16 required hysterectomy (29%) while 39 (71%) did not. In the overall cohort of 101, 22 (21.8%) required hysterectomy and an additional16 (15.8%) required some type of intervention, while 66.7% required no intervention.

CONCLUSION

SMFM US criteria for CSP have limitations for discerning clinical management due to lack of discriminatory threshold.

KEY POINTS

· The SMFM US criteria for CSP at <10 or <14 weeks have limitations for clinical management.. · The sensitivity and specificity of the ultrasound findings limit the utility for management. · The SMT of <1 mm is more discriminating than <3 mm for hysterectomy..

First-trimester screening for placenta accreta spectrum

In recent years, there has been a significant rise in cases of placenta accreta spectrum, a group of life-threatening placental disorders that can arise during childbirth. Early detection plays a crucial role in facilitating meticulous delivery planning, ultimately leading to a reduction in mortality and morbidity rates and improved overall outcomes. Although third-trimester ultrasound has traditionally been the primary method for prenatal screening for placenta accreta spectrum, it often falls short in identifying cases or diagnosis is too late for optimal delivery planning. Emerging evidence has highlighted the option of early detection of placenta accreta spectrum indicators during the first trimester of pregnancy. This comprehensive review delves into our current knowledge of sonographic assessment of the uterine cervicoisthmic complex in the first trimester, examining the location and appearance of cesarean scars and exploring first-trimester screening strategies, ultimately paving the way for improved maternal and neonatal outcomes.

Predictive value of crossover sign for outcome of ultrasound-guided vacuum aspiration in women with Cesarean scar pregnancy

OBJECTIVE

To examine the value of the crossover sign (COS) in predicting treatment outcome in women with a Cesarean scar pregnancy (CSP) who were treated with ultrasound-guided vacuum aspiration.

METHODS

This was a retrospective cohort study of women with CSP who underwent ultrasound-guided vacuum aspiration. Based on the relationship between the gestational sac, Cesarean scar and anterior wall of the uterus, CSPs were classified by COS type. Analysis was conducted to investigate the association between COS type (COS-1, COS-2) and treatment outcome. The incidence of treatment failure, retained pregnancy tissue, secondary therapy and bleeding ≥ 200 mL were analyzed.

RESULTS

In total, 181 eligible patients with CSP, including 90 (49.7%) women with COS-1 and 91 (50.3%) women with COS-2, were analyzed. COS-1 patients had a higher incidence of treatment failure compared with COS-2 patients (25.6% vs 8.8%; P = 0.003), as well as higher rates of retained pregnancy tissue (18.9% vs 6.6%; P = 0.013), secondary therapy (20.0% vs 6.6%; P = 0.002) and bleeding of ≥ 200 mL (13.3% vs 4.4%; P = 0.034). COS-1 and a large gestational sac (30.1-50.0 mm or >50.0 mm in diameter) were associated independently with increased risk of treatment failure (odds ratio, 4.57 (95% CI, 1.66-12.56); P = 0.003, 4.34 (95% CI, 1.35-13.94); P = 0.014 and 10.50 (95% CI, 2.54-43.46); P = 0.001, respectively).

CONCLUSIONS

Ultrasound evaluation of the relationship between the gestational sac and the endometrial line (COS classification) in women with CSP may help to predict treatment outcome among those undergoing vacuum aspiration. Among COS-1 patients, especially those with a gestational sac diameter of >30.0 mm, vacuum aspiration may be discouraged. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Evaluation of Cesarean section scar using saline contrast sonohysterography in women with previous Cesarean scar pregnancy

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.

Conservative treatment of cesarean scar pregnancy with the combination of methotrexate and mifepristone: A systematic review

BACKGROUND

Cesarean scar pregnancy (CSP) has become more frequent as a direct consequence of the increased number of cesarean deliveries and the advances in imaging. Although some cases are characterized by spontaneous resolution, unrecognized or mishandled CSP has the potential to cause both fetal and maternal morbidity and mortality. However, due to its infrequency, there is no agreement on the best management.

OBJECTIVE

The purpose of this study was to evaluate the safety, the risks and effectiveness of medical therapy with methotrexate and mifepristone to better understand its role in CSP therapy.

DESIGN

This study is a systematic review.

DATA SOURCES AND METHODS

The electronic databases PubMed, Medline, and Scopus were comprehensively searched until December 2023. Medical Subject Headings terms (Cesarean scar pregnancy) AND (Methotrexate) AND (Mifepristone) AND (Medical Therapy) were used to identify the relevant records. Due to the rarity of this pathology, the studies included are all case reports or case series. The methodological quality of the included studies was assessed using the JBI Critical Appraisal Checklist for case reports.

RESULTS

We included in our review a total of seven cases reported in five manuscripts at the end of the screening process. Our review suggests that this type of combination treatment can be considered. The success rate is 71.4%. Treatment seems to be most effective when beta human chorionic gonadotropin (B-hCG) is below 5,000 mUi/ml and when the gestational sac is less than 20 mm. The absence of fetal heartbeat seems to be a positive prognostic factor for a positive outcome.

CONCLUSION

Methotrexate and mifepristone administration can be considered as an alternative first-line effective treatment, especially in case of pregnancy with B-hCG <5,000 mUi/ml and when the gestational sac is less than 20 mm. It is important to individualize the management and treatment according to the clinical condition, the patient's age, number of previous cesarean deliveries, willingness to have other children, and the physicians' experience.

The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy

Cesarean scar pregnancy (CSP) is among the most severe complications of cesarean delivery. CSP refers to the abnormal implantation of the gestational sac in the area of the prior cesarean delivery (CD), potentially leading to severe hemorrhage, uterine rupture, or development of placenta accreta spectrum disorders (PAS). The management of women with CSP has not been standardized yet. In women who opted for termination, discussion about the treatments should consider maternal symptoms, gestational age at intervention, and the future reproductive risk. A multitude of treatments, either medical or surgical, for CSP has been reported in the published literature. The present review aims to provide up-to-date information on a recently introduced minimally invasive treatments for CSP, including the single and double balloon catheter. The methodology of using the single or double catheter is described in a step-by-step fashion illustrated by pictures as well as video recordings. Both catheters have their deserved place to be used as a primary method for terminating scar pregnancies as well as using them as adjuncts to other treatments. They were successfully used by multiple individual practitioners and institutions due to their simplicity and low complication rates. The rare, but possible post-procedure complications such as recurrent CSP and enhanced myometrial vascularity are also mentioned.

Subsequent pregnancy outcomes and risk factors following conservative treatment for placenta accreta spectrum: a retrospective cohort study

BACKGROUND

Placenta accreta spectrum can lead to uncontrollable massive hemorrhage in the perinatal period. Currently, the first-line treatment for placenta accreta spectrum recommended worldwide is hysterectomy. However, adverse outcomes after hysterectomy, including surgical complications, such as difficulty in performing the procedure, and sequelae, such as infertility and psychological issues, cannot be ignored. Several surgical approaches for conservative treatment have been proposed. There are few reports on the effectiveness, safety, and long-term complications of conservative treatments, especially subsequent pregnancy outcomes.

OBJECTIVE

This study aimed to investigate the clinical outcomes and identify risk factors of subsequent pregnancies among patients with placenta accreta spectrum who had undergone conservative surgery.

STUDY DESIGN

This was a retrospective cohort study of subsequent pregnancy cases after cesarean delivery with conservative treatment for placenta accreta spectrum from 2011 to 2019 at The First Affiliated Hospital of Zhengzhou University to identify clinical outcomes of subsequent pregnancies and the risk factors of adverse pregnancy outcomes.

RESULTS

A total of 883 patients undergoing conservative surgery were included in this study, among which 604 (68.4%) were successfully followed up. There were 75 successful pregnancies in 72 patients, including 22 full-term or near-term deliveries, 1 induced labor in the second trimester of pregnancy, 6 cesarean scar pregnancies (8.0%), 2 ectopic pregnancies, and 44 first-trimester pregnancies (3 miscarriages and 41 elective abortions and 12 medical abortions and 32 vacuum aspirations). All newborns survived in the 22 full-term or near-term deliveries. Moreover, 5 placenta accreta spectrum cases (22.7%) and 6 placenta previa cases were observed. Postpartum hemorrhage was observed in 2 cases, with an incidence rate of 9.1%. All parameters, including age at subsequent pregnancy, gravidity, number of cesarean deliveries, type of previous placenta accreta spectrum, gestational week of pregnancy termination, interpregnancy interval, and the use of vascular occlusion techniques, were not found to be associated with recurrent placenta accreta spectrum and cesarean scar pregnancy.

CONCLUSION

Our findings show that treatment for placenta accreta spectrum does not automatically preclude a subsequent pregnancy. However, patients should be fully informed about the risk of recurrent placenta accreta spectrum, scar pregnancy, and postpartum hemorrhage.

Clinical implications of a cesarean scar pregnancy sonographic evaluation and reporting system

OBJECTIVES

Recently, a new standardized sonographic evaluation system for cesarean scar pregnancies (CSP) was published. We aimed to evaluate the clinical outcomes of CSP cases according to the new sonographic evaluation and reporting system.

STUDY DESIGN

A retrospective study conducted at a single tertiary center. All CSPs between 1/2011 and 4/2022 were included. Cases were evaluated by expert sonographers and classified into three categories: 1) CSP in which the largest part of the gestational sac (GS) protrudes towards the uterine cavity; 2) CSP in which the largest part of the GS is embedded in the myometrium but does not cross the serosal contour; and 3) CSP in which the GS is partially located beyond the outer contour of the cervix or uterus.Baseline characteristics, management and outcomes were compared between the three categories.

RESULTS

Overall, 55 patients were diagnosed with CSP during the study period; 10 (18.1 %) type 1, 31 (56.3 %) type 2, and 14 (25.4 %) type 3. Baseline characteristics were similar among groups. Compared with type 2 and 3, patients diagnosed with CSP type 1 received less methotrexate treatment [83.9 % and 78.6 % vs. 40.0 %, respectively, p = 0.020]. The rates of need for invasive procedures, urgent procedures, major bleeding, length of hospitalization, and subsequent pregnancies were similar between groups.

CONCLUSIONS

No clinically significant differences were found between groups divided by the new standardized sonographic evaluation and reporting system for CSP in pregnancy characteristics, management, and subsequent pregnancy outcomes. Further investigation is required to enable informed management of CSP based on the new sonographic reporting system.

Extensive fundal placenta accreta spectrum (PAS) in a nulliparous patient with an unscarred uterus and systemic lupus erythematosus (SLE) necessitating cesarean hysterectomy at delivery

Placenta accreta spectrum (PAS) defined by various degrees of abnormally invasive placentation is strongly associated with severe maternal morbidity and maternal mortality, mainly reflecting maternal hemorrhage. Predisposing factors for this condition include: multiparity, placenta previa, previous uterine surgeries (previous curettage, cesarean delivery, and myomectomy), smoking and previous PAS. Prenatal sonographic findings associated with PAS include the presence of placenta previa, loss of the hypoechoic retroplacental sonolucency, myometrial thinning, interruption of the irregularity of the bladder wall, excessive vascularity of the uterovesical plane, placental lacunae, increased placental vascularity, bridging vessels with vascularity extending from the placental bed across the uterine wall into the bladder or other pelvic organs. PAS is very rare among nulliparous patients, especially those without previous uterine surgery. We describe an unusual case of PAS in a nulliparous patient with an unscarred uterus and systemic lupus erythematosus in whom a fundal placenta with PAS and thinned and areas of absent myometrium suspected at midtrimester sonography, sustained uterine atony and severe hemorrhage at delivery, necessitated massive blood transfusion and subtotal hysterectomy. Both mother and infant did well. Pathology confirmed PAS and marked uterine thinning. Although PAS most commonly is associated with placenta previa and the presence of previous cesarean delivery, this case emphasizes the need for alertness of at times subtle prenatal sonographic findings of PAS irrespective of placental location even among nulliparous patients, especially those with systemic lupus erythematosus.

Predictability of Hematological Parameters in the Diagnosis of Cesarean Scar Pregnancy

Introduction  Cesarean scar pregnancy (CSP) is an increasing clinical condition that causes serious maternal morbidity and mortality. This study aimed to evaluate if inflammation markers measured by hemogram can aid in the diagnosis of CSP. Materials and Methods  A total of 86 patients were included in the study. The cases were divided as CSP ( n : 42) and normal pregnancy (NP) ( n : 44). At the time of admission, peripheral blood neutrophils, lymphocytes, monocytes, thrombocytes, systemic inflammatory index (SII) (neutrophil × platelet/lymphocyte), neutrophil-lymphocyte ratio, monocyte-lymphocyte ratio, and platelet-lymphocyte ratio were all measured. CSP and NP diagnoses were made by transabdominal or vaginal ultrasonography. Results  In the CSP group, mean age ( p  < 0.001), gravida ( p  < 0.001), parity ( p  < 0.001), number of surviving children ( p  < 0.001), number of abortions ( p  < 0.001), cesarean number ( p  < .001), dilatation and curettage count ( p  = 0.013), monocyte (M) value ( p  = 0.039) and monocyte/lymphocyte value (MLR) ( p  = 0.035) were significantly higher than the control group. The optimal M value cut-off value was found to be > 0.40, the sensitivity value was 78.57, and the specificity value was 50.00. AUC = 0.632 (SE = 0.061) for the MLR value. The optimal MLR cut-off value was found to be > 0.232, the sensitivity value was 61.90, and the specificity value was 63.64. Conclusion  Hemogram parameters, which are simple, inexpensive, and easily accessible, M and MLR are significantly higher in the diagnosis of CSP and can be used as an auxiliary parameter for ultrasonography.

Nontubal ectopic pregnancies: overview of diagnosis and treatment

Nontubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal ectopic pregnancies. Diagnostic and management options may be limited, especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for nontubal ectopic pregnancies.

Scarred for life: a review of cesarean section scar pregnancy and potential pitfalls in diagnosis

Cesarean section scar pregnancy (CSSP) is defined as abnormal implantation of a gestational sac on or in a previous cesarean section scar. There is an increasing incidence of detection of CSSP, likely in part due to the growing rates of cesarean deliveries and the improved rates of detection with advancing ultrasound technology. Diagnosis of CSSP is critical due to the potentially life-threatening complications to the mother if left untreated. Pelvic ultrasound is the imaging modality of choice in the initial evaluation of suspected CSSP, with MRI potentially useful if ultrasound findings are equivocal, or if confirmation is requested prior to definitive intervention. Early and accurate diagnosis of CSSP allows for prompt management to avoid severe complications and the potential to preserve the uterus and future fertility. A combination of medical and surgical treatment strategies may be needed with specific therapy tailored to each patient. Follow-up after treatment should include serial beta-hCG levels and possible repeat imaging if there is clinical concern for complications or treatment failure. This article will provide a comprehensive review of this uncommon but important phenomenon, detailing the pathophysiology and types of CSSP, imaging presentations, potential pitfalls in diagnosis, and management options.

Imaging in gynecological disease (25): clinical and ultrasound characteristics of intramural pregnancy

OBJECTIVE

To describe the clinical and sonographic characteristics of intramural pregnancy, as well as the available management options and treatment outcomes.

METHODS

This was a retrospective single-center study of consecutive patients with a sonographic diagnosis of intramural pregnancy between November 2008 and November 2022. An intramural pregnancy was diagnosed on ultrasound when a pregnancy was implanted within the uterine corpus, above the level of the internal cervical os and separate from the interstitial section of the Fallopian tube, and extended beyond the decidual-myometrial junction. Clinical, ultrasound, relevant surgical and histological information and outcomes were retrieved from each patient's record and analyzed.

RESULTS

Eighteen patients were diagnosed with an intramural pregnancy during the study period. Their median age was 35 (range, 28-43) years and the median gestational age at diagnosis was 8 + 1 (range, 5 + 5 to 12 + 0) weeks. Vaginal bleeding with or without abdominal pain was the most common presenting symptom, recorded in eight patients. Nine (50%) patients had a partial and nine (50%) had a complete intramural pregnancy. Embryonic cardiac activity was present in eight (44%) pregnancies. The majority of pregnancies (n = 10 (56%)) were initially managed conservatively, including expectant management in eight (44%) cases, local injection of methotrexate in one (6%) and embryocide in one (6%). Conservative management was successful in nine of the 10 (90%) pregnancies, with a median time to serum human chorionic gonadotropin resolution of 71 (range, 35-143) days. One patient with an ongoing live pregnancy had an emergency hysterectomy for a major vaginal bleed at 20 weeks' gestation. No other patient managed conservatively experienced any significant complication. The remaining eight (44%) patients had primary surgical treatment, comprising transcervical suction curettage in seven (88%) of these cases, while one patient presented with uterine rupture and underwent emergency laparoscopy and repair.

CONCLUSIONS

We describe the ultrasound features of partial and complete intramural pregnancy, demonstrating key diagnostic features. Our series suggests that, when intramural pregnancy is diagnosed before 12 weeks' gestation, it can be managed either conservatively or by surgery, with preservation of reproductive function in most women. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Imaging the Uterus in Placenta Accreta Spectrum Disorder

Antenatal diagnosis of placenta accreta spectrum (PAS) improves maternal and neonatal outcomes by allowing for multidisciplinary planning and preparedness. Ultrasound is the primary imaging tool. Simplification and standardization of placental evaluation and reporting terminology allows improved communication and understanding between teams. Prior to 10 weeks of gestation, gestational sac position and least myometrial thickness surrounding the gestational sac help PAS diagnosis very early in pregnancy. Late first-, second-, and third-trimester evaluation includes comprehensive evaluation of the placenta, transabdominal and transvaginal with partially full maternal urinary bladder, and by color Doppler. Subsequently, the sonologist should indicate whether the evaluation was optimal or suboptimal; the level of suspicion as low, moderate, or high; and the extent as focal, global, or extending beyond the uterus. Other complementary imaging modalities such as 3D-power Doppler ultrasound, magnetic resonance imaging (MRI), and vascular topography mapping strive to improve antenatal placental evaluation but remain investigational at present. KEY POINTS: · Antenatal imaging, primarily using ultrasound with partially full maternal urinary bladder, is an essential means of evaluation of those at risk for PAS.. · Simplification and standardization of placental evaluation and reporting will allow improved communication between the multidisciplinary teams.. · Gestational sac location prior to 10 weeks of gestation and four markers after that (placental lacunae and echostructure, myometrial thinning, hypoechoic zone with or without bulging between placenta and myometrium, and increased flow on color Doppler)..

Treatment of ectopic pregnancy implanted on cesarea scar: cohort study 2018-2022, Lima, Peru

Objectives

To describe the clinical characteristics and treatment of ectopic pregnancy arising in the cesarean section scar, as well as its complications and obstetric prognosis.

Material and methods

Retrospective cohort study of pregnant women with the diagnosis of a scar pregnancy in accordance with Maternal-Fetal Medicine Society criteria, seen between January 2018 and March 2022 in two high complexity institutions of the social security system, located in Lima, Peru. Consecutive sampling was used. Baseline sociodemographic and clinical variables were measured, including diagnosis, type of treatment, complications and obstetric prognosis. A descriptive analysis was performed.

Results

Out of 29,919 deliveries, 17 patients were included. Of these, 41.2 % received medical management and the rest were treated surgically. Successful management with intra-gestational sac methotrexate was performed in two patients with ectopic pregnancy type 2. Four patients required total hysterectomy. Six patients became pregnant after the treatment and 4 completed their pregnancy with healthy mother and neonate pairs.

Conclusions

Ectopic pregnancy implanted in a cesarean section scar is an infrequent occurrence for which medical and surgical management options are available with apparently good outcomes. Further studies of better methodological quality and random assignment are needed in order to help characterize the safety and effectiveness of the various therapeutic options for women with suspected scar pregnancy.

Caesarean scar pregnancy: is there a light in the end of the tunnel?

PURPOSE

To summarize and present a single tertiary center's 25 years of experience managing patients with caesarean scar pregnancies and their long-term reproductive and obstetric outcomes.

METHODS

A 25-year retrospective study included women diagnosed with CSP from 1996 to 2020 in one tertiary center. Data were retrieved from the medical records and through a telephone interview. Diagnosis was made by sonography and color Doppler. Treatments included methotrexate, suction curettage, hysteroscopy, embolization and wedge resection by laparoscopy or laparotomy as a function of the clinical manifestations, the physicians' decisions, patient counseling, and parental requests.

RESULTS

Analysis of the records recovered 60 cases of CSP (two of whom were recurrent). All patients had complete resolution with no indication for hysterectomy. Thirty-five patients had a long-term follow-up, of whom 24 (68.6%) attempted to conceive again and 22 (91.6%) succeeded. There were 17/22 (77.3%) patients with at least one live birth, 3/22 (13.6%) spontaneous miscarriages and 2/22 (9%) recurrent CSP. The obstetric complications included abnormal placentation 5/19 (26.3%), premature rupture of membranes 2/19 (10.5%), preterm delivery 4/19 (21%) and abnormality of the uterine scar 2/19 (10.5%). There was one case of neonatal death due to complications of prematurity 1/19 (5.2%).

CONCLUSION

CSP treatment focusing on reducing morbidity and preserving fertility has encouraging long-term reproductive and obstetric outcomes. In subsequent pregnancies, we recommend performing an early first trimester vaginal scan to map the location of the new pregnancy, followed by close monitoring given the obstetric complications mentioned above.

Placenta accreta spectrum disorders clinical practice guidelines: A systematic review

OBJECTIVES

To objectively assess the quality of the published clinical practice guidelines (CPGs) on the management of pregnancies complicated by placenta accreta spectrum (PAS)disorders.

METHODS

MEDLINE, Embase, Scopus, and ISI Web of Science databases were searched. The following aspects related to the management of pregnancies with suspected PAS disorders were evaluated: risk factors for PAS, prenatal diagnosis, role of interventional radiology and ureteral stenting, and optimal surgical management. The assessment of risk of bias and quality assessment of the CPGs were performed using the (AGREE II) tool (Brouwers et al., 2010). To define a CPG as of good quality we adopted a cut-off score >60%.

RESULTS

Nine CPGs were included. Specific risk factors for referral were assessed by 44.4% (4/9) of CPGs, mainly consisting in the presence of placenta previa and a prior cesarean delivery or uterine surgery. About 55.6% of CPGs (5/9) suggested ultrasound assessment of women with risk factors for PAS in the second and third trimester of pregnancy and 33.3% (3/9) recommended magnetic resonance imaging (MRI); 88.9% (8/9) of CPGs recommended cesarean delivery at 34-37 weeks of gestation. There was not generally consensus on the use of interventional radiology and ureteral stenting before surgery for PAS. Finally, hysterectomy was the recommend surgical approach by 77.8% (7/9) of the included CPGs.

CONCLUSION

Most of the published CPGs on PAS are generally of good quality. There was general agreement among the different CPGs on PAS as a regard as risk stratification, timing at diagnosis and delivery but not on the indication for MRI, use of interventional radiology and ureteral stenting.

Abnormal placenta implantation. Integration between first- and third-trimester imaging in predicting the severity of Placenta Accreta Spectrum (PAS) disorders

Placenta accreta spectrum (PAS) disorders are pathological conditions correlated to a high risk of adverse maternal surgical outcomes, especially if not diagnosed. In the last 10 years, the literature interest for prenatal diagnosis of PAS disorders has been noticeably greater. More recently, significant progression in prenatal imaging techniques permitted an increase of early identified cases and a more accurate diagnosis of these anomalies, especially in women with multiple risk factors. The aim of this chapter is to give an overhaul on prenatal diagnosis of PAS disorders throughout gestation and to report whether integration between first- and third-trimester ultrasound can predict the development and severity of these anomalies.

Clinical efficacy and re-pregnancy outcomes of patients with previous cesarean scar pregnancy treated with either high-intensity focused ultrasound or uterine artery embolization before ultrasound-guided dilatation and curettage: a retrospective cohort study

BACKGROUND

Cesarean scar pregnancy (CSP) treated with either high-intensity focused ultrasound ablation (HIFU-a) or uterine artery embolization (UAE) combined with ultrasound-guided dilation and curettage (USg-D&C) was effective. However, there is insufficient comparative research evidence on clinical efficacy and subsequent pregnancy outcomes after previous CSP treatment. This study aims to investigate the efficacy, safety, and subsequent pregnancy outcomes of HIFU-a compared to UAE before USg-D&C for the treatment of CSP.

METHODS

Between January 2016 and July 2020, a total of 272 patients received the pretreatment with HIFU-a or UAE(HIFU-a group: n = 118; UAE group: n = 154). The clinical characteristics, treatment success rate, postoperative pregnancy rate and outcome of the two groups were compared and analyzed.

RESULTS

The demographic characteristics of the two groups were similar. After pretreatment, the adverse events rate of HIFU-a group was lower than that of UAE group (10.40% (16/154) vs. 40.70% (48/118), P = 0.00). All patients received the USg-D&C. The HIFU-a group was of less intraoperative blood loss (10.00 (5.00-20.00) vs. 12.50 (5.00-30.00) ml, P = 0.03). There was no statistically significant difference between the two groups in success rates. However, the HIFU-a group was of a shorter duration of postoperative vaginal bleeding (12.00 (9.00-13.00) vs. 14.00 (12.00-15.00) days, P = 0.00). There was no significant difference between the two groups in terms of subsequent pregnancy rates (P = 0.317). However, the recurrent CSP (rCSP) rate in the HIFU-a group was lower than that in the UAE group (7.70% (6/78) vs. 19.70%(13/66), P = 0.03).

CONCLUSIONS

CSP treated with either HIFU-a or UAE combined with USg-D&C was safe and effective. Although no significant difference was found in the subsequent pregnancy outcomes of the two groups, the rCSP was more common in the UAE group. So, we recommend HIFU-a combined with USg-D&C treatment modality.

Caesarean Scar Pregnancy: Single Dose of Intrasac Ultrasound-Guided Methotrexate Injection Seems to be a Safe Option for Treatment

Objective

The purpose of the study was to assess the efficacy of local ultrasound-guided methotrexate injection in patients with caesarean section scar pregnancy, to chart the course of beta-human chorionic gonadotropin levels (HCG) after treatment, and to see if HCG levels are correlated with clinical presentation.

Methods

Between May 2018 and January 2021, data were collected retrospectively from the Early Pregnancy Unit of a tertiary hospital.

Results

Our clinic assessed 20 patients; one disputed terminating the pregnancy and was not included in the research. The remaining 19 patients, with a median age of 34 years, received intragestational sac methotrexate injection under ultrasound guidance. 7w3d was the median gestational age. These women had one to four previous caesarean sections, with a mean of 1.60±9. Patients with caesarean scar pregnancy most typically presented with spotting (42.1%), whereas 26.3% were asymptomatic. Except in cases of pain, the symptomatic women's HCG levels were lower than in the non-symptomatic women. The level of HCG in patients with pain was approximately double that of non-pain patients (p=0.2557). In our series, intragestational sac methotrexate injection was effective in 17/19 women, or 89.5% (95%CI: 75.7-100%). HCG levels were undetectable in 97.6±30 days on average (minimum: 42 days, maximum: 147 days).

Conclusion

Caesarean scar pregnancy is a rare possibly fatal condition with no consensus on the optimal treatment. An experienced Early Pregnancy Unit member performing local methotrexate injections under ultrasound guidance is a feasible and successful strategy in clinically stable patients.

The Confounding Ultrasound Diagnosis of Ectopic Pregnancy: Lessons From Peer Learning

ABSTRACT

As the treatment of ectopic pregnancy (EP) has shifted increasingly to medical therapies, the ultrasound (US) diagnosis of EP must necessarily favor specificity over sensitivity. Our review of peer learning cases of EP and early intrauterine pregnancies found several types of pitfalls and problems, which will be described in this essay. These issues include the following: differentiation of tubal EP from a corpus luteum by echogenicity relative to ovarian parenchyma, push technique, and claw sign; how to distinguish interstitial EP from eccentrically located intrauterine pregnancies (angular); use of trophoblastic flow in abnormal intrauterine locations to help identify cesarean scar or cervical implantations; recognition that hemoperitoneum without visualized EP may be due to EP or hemorrhagic cyst; and that distinguishing an abortion in progress from a pregnancy of unknown location may not always be possible and requires clinical follow-up. This essay will also illustrate the consensus terminology that our radiology department has developed in conjunction with our obstetrics and gynecology colleagues to communicate clear diagnoses and reduce the risk of misdiagnosis and adverse outcomes.

A new era in teaching: how advanced optical recording technology could change the postcesarean delivery complication conundrum

BACKGROUND

The last 4 decades have seen increased complications after cesarean deliveries. Despite an incomplete understanding of their etiology, surgical practices have been adopted, creating disproportionate morbidity and the absence of preventive strategies. Additional research tools are needed for further investigation.

OBJECTIVE

This study aimed to evaluate the VITOM high-definition optical recording system as a tool to highlight cesarean operative steps and surgical techniques and assess the use of its video recordings for operating room team teaching and research potential.

STUDY DESIGN

Contemporaneous cesarean delivery techniques offer no resolution to long-term postcesarean sequelae. From March 2015 to February 2022, a novel tool, VITOM exoscope, was evaluated and used to photograph and video record 104 elective cesarean deliveries. The images were projected on a large screen to be viewed by scrubbed-in and unscrubbed personnel and recorded for future use. During this period, staff participants in 3 designated operating rooms reached 514, including 168 trainee residents, 5 nurse practitioners, 6 physician assistants, 21 medical students, 70 surgical technicians, and 110 circulating nurses. The maternal ages of patients varied from 21 to 49 years. Gestational ages ranged from 28 0/7 to 41 6/7 weeks of gestation. Selected photographs of crucial cesarean surgical steps were taken and printed. Video recordings were stored in designated institutional data storage and uploaded onto a secure drive for further use. After every case, debriefing was held, and subjective opinions were obtained from the various participants.

RESULTS

The VITOM was used for 104 cesarean deliveries. Setup time was reduced from 7 minutes initially to 3 minutes with more experience. All staff participants had only positive evaluations and remarks about the image quality and the clear delineation of specific anatomic landmarks. By polling medical students and residents in training, the VITOM experience was described as very useful and, in a few cases, only somewhat useful. The scrubbed surgical technicians and circulating nurses gained a better understanding of surgical layers, improving their ability to anticipate subsequent surgical steps, thereby streamlining operating flow and efficiency. Unscrubbed personnel could also follow the operation's progression despite being remote from the sterile field. Anesthesiologists could follow the operative field and eventual blood loss in plain view. Recorded videos and still photographs were used at clinical teaching conferences and in peer-reviewed publications, enhancing understanding of cesarean delivery techniques.

CONCLUSION

The VITOM exoscope provided superb image quality, enabling a clear vision of the anatomic structures of the cesarean operation. It is a promising additional research tool to capture important details of the employed surgical techniques and provides a possible insight into long-term postcesarean sequelae.

Variations in uterine closure technique: an institutional survey of obstetricians and implications for patient counseling and prevention of adverse sequelae

OBJECTIVES

To assess the diversity of uterine closure techniques (UCTs) among providers in one institution and evaluate concurrent consideration of adverse outcomes for patient counseling, provisional care, and prevention.

METHODS

Forty-four obstetricians at NYU Langone Health were emailed a survey of their uterine closure technique, patient counseling, and practice experience. Results were stratified by years of practice: ≤5, 5-20, and 20-40 years.

RESULTS

Thirty-nine obstetricians (88.6%) completed the survey. Among those, a blunt uterine opening was preferred by 29 (74.4%), and a mid-lower segment location was favored by 34 (87.2%). At uterine closure, the endometrium was included by 20 (51.3%), with half a centimeter or more incorporated in the myometrial closure, whereas 15 (38.5%) did not factor in the endometrium's presence. Closure duration varied from 1 to 20 min, with 21 (53.9%) lasting 1-5 min and 12 (30.8%) lasting 5-10 min. All physicians were familiar with the potential post-cesarean complications and counseled their patients accordingly; 25 (64.1%) at the first post-op visit while 14 (35.9%) did so before the next conception. Practitioners with fewer years in practice endorsed the safety of up to five consecutive cesarean births, while those with more experience approved up to ten. Thirty-two obstetricians (82.1%) stated that the risk of abnormal placentation is exclusively associated with the number of cesarean sections, whereas five (12.8%) senior obstetricians asserted that individual surgical techniques are most impactful.

CONCLUSIONS

The survey illustrates that various UCTs are performed irrespective of potential adverse sequelae and without consideration for subsequent patient counseling and care. Ongoing research must study the impact of UCT on scar healing to formulate preventive strategies for post-cesarean complications.

Caesarean scar pregnancy: diagnosis, natural history and treatment

PURPOSE OF REVIEW

This review aims at summarizing the latest evidence on diagnosis, natural history and management of caesarean scar pregnancy (CSP).

RECENT FINDINGS

CSP can result in maternal morbidity from major haemorrhage, uterine rupture, placenta accreta spectrum disorders and hysterectomy. Classification of the CSP types, presence of fetal heart activity, gestational age and residual myometrial thickness seem to influence rates of ongoing pregnancy, subsequent development of placenta accreta with expectant management, as well as success and complication rates associated with various methods of pregnancy termination. Expectant management may be appropriate in certain good prognosis cases, such as absent fetal heart activity or when the myometrial layer at the implantation site is relatively thick. Surgical treatments are typically associated with higher success rates, but seem to result in severe haemorrhage more frequently than medical treatments, which have higher failure rates. Although other treatment modalities are available, in general, the size and quality of evidence to guide care provision in CSP is very poor.

SUMMARY

CSP can be associated with severe maternal morbidity but can also lead to a livebirth. There is currently a lack of good-quality evidence to predict the outcome of CSP and provide informed and evidence-based care.

Placenta Accreta Spectrum: Prenatal Diagnosis and Management

The incidence of placenta accreta spectrum (PAS) is increasing and is now about 3 per 1000 deliveries, largely due to the rising cesarean section rate. Ultrasound is the preferred method for diagnosis of PAS. Ultrasound markers include multiple vascular lacunae, loss of the hypoechoic retroplacental zone, abnormalities of the uterine serosa-bladder interface, retroplacental myometrial thickness less than 1 mm, increased placental vascularity, and observation of bridging vessels linking the placenta and bladder. Patients with PAS should be managed by experienced multidisciplinary teams. Hysterectomy is the accepted management of PAS and conservative or expectant management of PAS should be considered investigational.

Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy

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

Extravillous trophoblast invasion and decidualization in cesarean scar pregnancies

INTRODUCTION

The increasing cesarean section rate has led to an increase in the number of subsequent pregnancies resulting in a cesarean scar pregnancy. There appears to be preferential attachment of the blastocyst to the scar site, which may be associated with defective decidua in that region, resulting in abnormal implantation, which can in turn negatively affect the success of the pregnancy. The aim of the current study was to evaluate the extravillous trophoblast, decidua, and myometrium in scar and adjacent non-scar regions of the implantation site of a cesarean scar pregnancy.

MATERIAL AND METHODS

Samples containing a gestational mass were obtained by laparoscopic excision from patients with a cesarean scar pregnancy at 6-11 weeks of gestation as diagnosed by transvaginal or transabdominal ultrasound (n = 8 type II cesarean scar pregnancy). Cesarean scar pregnancy tissues were separated into scar and non-scar regions, and the scar regions were sub-separated into non-implantation and implantation sites. Serial sections were histologically examined after hematoxylin and eosin, Masson's trichrome and immunochemical staining, and changes in the myometrium, extravillous trophoblast, and decidua were evaluated.

RESULTS

In cesarean scar pregnancy, compared with scars not in the implantation site, scars in the implantation site displayed increased fibrosis, and had disrupted myometrium, which was related to varying patterns of E-cadherin expression as a response to extravillous trophoblast invasion. In addition, local decidua was found at the non-scar implantation sites, with multinucleated trophoblast giant cell accumulation and shallow invasion. These features were not evident in the scar implantation sites.

CONCLUSIONS

This study emphasizes that the decidua drives multinucleated trophoblast giant cell differentiation, limiting the degree of invasion. Better characterization of this differentiation process may be helpful for better management and avoidance of the consequences of cesarean scar pregnancy.

Cesarean scar pregnancy with expectant management

Aim

This study aimed to ascertain whether the lower anterior myometrial thickness (MT) between the bladder and the gestational sac in early pregnancy can be used to predict clinical outcomes in women with cesarean scar pregnancy (CSP) after expectant management.

Methods

We retrospectively analyzed the clinical data and early pregnancy ultrasound images of 21 patients who received expectant management for CSP. Among them, 11 patients with serious complications during pregnancy, such as intraoperative blood loss ≥1000 mL or with severe forms of morbidly adherent placenta (MAP; placenta increta or placenta percreta), were assigned to group A. The remaining 10 patients without serious complications during pregnancy were assigned to group B. The difference in MT between groups A and B was analyzed using nonparametric Mann–Whitney U test.

Results

There was a statistically significant difference in MT between the groups (U = 20.000, p = 0.013). The area under the receiver operating characteristics (ROC) curve was 0.818, and the optimal cut‐off value for MT was 3.3 mm.

Conclusion

Lower anterior MT around the gestational sac was correlated with severe complications, such as massive intraoperative bleeding or severe forms of MAP in patients with CSP.

Prospective evaluation of impact of post-Cesarean section uterine scarring in perinatal diagnosis of placenta accreta spectrum disorder

OBJECTIVE

Standardized ultrasound imaging and pathology protocols have recently been developed for the perinatal diagnosis of placenta accreta spectrum (PAS) disorders. The aim of this study was to evaluate prospectively the effectiveness of these standardized protocols in the prenatal diagnosis and postnatal examination of women presenting with a low-lying placenta or placenta previa and a history of multiple Cesarean deliveries (CDs).

METHODS

This was a prospective cohort study of 84 consecutive women with a history of two or more prior CDs presenting with a singleton pregnancy and low-lying placenta/placenta previa at 32-37 weeks' gestation, who were referred for perinatal care and management between 15 January 2019 and 15 December 2020. All women were investigated using the standardized description of ultrasound signs of PAS proposed by the European Working Group on abnormally invasive placenta. In all cases, the ultrasound features were compared with intraoperative and histopathological findings. Areas of abnormal placental attachment were identified during the immediate postoperative gross examination and sampled for histological examination. The data of a subgroup of 32 women diagnosed antenatally as non-PAS who had complete placental separation at birth were compared with those of 39 cases diagnosed antenatally as having PAS disorder that was confirmed by histopathology at delivery.

RESULTS

Of the 84 women included in the study, 42 (50.0%) were diagnosed prenatally as PAS and the remaining 42 (50.0%) as non-PAS on ultrasound examination. Intraoperatively, 66 (78.6%) women presented with a large or extended area of dehiscence and 52 (61.9%) with a dense tangled bed of vessels or multiple vessels running laterally and craniocaudally in the uterine serosa. A loss of clear zone was recorded on grayscale ultrasound imaging in all 84 cases, while there was no case with bladder-wall interruption or with a focal exophytic mass. Myometrial thinning (< 1 mm) in at least one area of the anterior uterine wall was found in 41 (97.6%) of the 42 cases diagnosed as non-PAS on ultrasound and 37 (88.1%) of the 42 diagnosed antenatally as PAS. Histological samples were available for all 48 hysterectomy specimens with abnormal placental attachment and for the three cases managed conservatively with focal myometrial resection and uterine reconstruction. Villous tissue was found directly attached to the superficial myometrium (placenta creta) in six of these cases and both creta villous tissue and deeply implanted villous tissue within the uterine wall (placenta increta) were found in the remaining 45 cases. There was no evidence of percreta placentation on histology in any of the PAS cases. Comparison of the main antenatal ultrasound signs and perioperative macroscopic findings between the two subgroups correctly diagnosed antenatally (32 non-PAS and 39 PAS) showed no significant difference with respect to the distribution of myometrial thinning and the presence of a placental bulge on ultrasound and of anterior uterine wall dehiscence intraoperatively. Compared with the non-PAS subgroup, the PAS subgroup showed significantly higher placental lacunae grade (P < 0.001) and more often hypervascularity of the uterovesical/subplacental area (P < 0.001), presence of bridging vessels (P = 0.027) and presence of lacunae feeder vessels (P < 0.001) on ultrasound examination, and increased vascularization of the anterior uterine wall intraoperatively (P < 0.001).

CONCLUSIONS

Remodeling of the lower uterine segment following CD scarring leads to structural abnormalities of the uterine contour on both ultrasound examination and intraoperatively, independently of the presence of accreta villous tissue on microscopic examination. These anatomical changes are often reported as diagnostic of placenta percreta, including cases with no histological evidence of PAS. Guided histological examination could improve the overall diagnosis of PAS and is essential to obtain evidence-based epidemiologic data. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prospective Evaluation of the Ultrasound Signs Proposed for the Description of Uterine Niche in Nonpregnant Women

OBJECTIVES

To evaluate the new ultrasound-based signs for the diagnosis of post-cesarean section uterine niche in nonpregnant women.

METHODS

We investigated prospectively a cohort of 160 consecutive women with one previous term cesarean delivery (CD) between December 2019 and 2020. All women were separated into two subgroups according to different stages of labor at the time of their CD: subgroup A (n = 109; 68.1%) for elective CD and CD performed in latent labor at a cervical dilatation (≤4 cm) and subgroup B (n = 51; 31.9%); for CD performed during the active stage of labor (>4 cm).

RESULTS

Overall, the incidence of a uterine niche was significantly (P < .001) higher in women who had an elective (20/45; 44.4%) compared with those who had an emergent (21/115; 18.3%) CD. Compared with subgroup B, subgroup A presented with a significantly (P = .012) higher incidence of uterine niche located above the vesicovaginal fold and with a significantly (P = .0002) lower proportion of cesarean scar positioned below the vesicovaginal fold. There was a significantly (P < .001) higher proportion of women with a residual myometrial thickness (RMT) > 3 mm in subgroup A than in subgroup B and a significant negative relationship was found between the RMT and the cervical dilatation at CD (r = -0.22; P = .008).

CONCLUSIONS

Sonographic cesarean section scar assessment indicates that the type of CD and the stage of labor at which the hysterotomy is performed have an impact on the location of the scar and the scarification process including the niche formation and RMT.