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Wenqiang D, Novin A, Liu Y, Afzal J, Suhail Y, Liu S, Gavin NR, Jorgensen JR, Morosky CM, Figueroa R, Schmidt TA, Sanders M, Brewer MA, Kshitiz. Scar matrix drives Piezo1 mediated stromal inflammation leading to placenta accreta spectrum. Nat Commun 2024; 15:8379. [PMID: 39333481 PMCID: PMC11436960 DOI: 10.1038/s41467-024-52351-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 09/03/2024] [Indexed: 09/29/2024] Open
Abstract
Scar tissue formation is a hallmark of wound repair in adults and can chronically affect tissue architecture and function. To understand the general phenomena, we sought to explore scar-driven imbalance in tissue homeostasis caused by a common, and standardized surgical procedure, the uterine scar due to cesarean surgery. Deep uterine scar is associated with a rapidly increasing condition in pregnant women, placenta accreta spectrum (PAS), characterized by aggressive trophoblast invasion into the uterus, frequently necessitating hysterectomy at parturition. We created a model of uterine scar, recapitulating PAS-like invasive phenotype, showing that scar matrix activates mechanosensitive ion channel, Piezo1, through glycolysis-fueled cellular contraction. Piezo1 activation increases intracellular calcium activity and Protein kinase C activation, leading to NF-κB nuclear translocation, and MafG stabilization. This inflammatory transformation of decidua leads to production of IL-8 and G-CSF, chemotactically recruiting invading trophoblasts towards scar, initiating PAS. Our study demonstrates aberrant mechanics of scar disturbs stroma-epithelia homeostasis in placentation, with implications in cancer dissemination.
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Affiliation(s)
- Du Wenqiang
- Department of Biomedical Engineering, University of Connecticut Health Center, Farmington, CT, USA
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, USA
| | - Ashkan Novin
- Department of Biomedical Engineering, University of Connecticut Health Center, Farmington, CT, USA
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, USA
| | - Yamin Liu
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, USA
| | - Junaid Afzal
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Yasir Suhail
- Department of Biomedical Engineering, University of Connecticut Health Center, Farmington, CT, USA
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, USA
| | - Shaofei Liu
- Department of Biomedical Engineering, University of Connecticut Health Center, Farmington, CT, USA
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, USA
| | - Nicole R Gavin
- Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, CT, USA
| | - Jennifer R Jorgensen
- Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, CT, USA
| | - Christopher M Morosky
- Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, CT, USA
| | - Reinaldo Figueroa
- Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center, Hartford, CT, USA
| | - Tannin A Schmidt
- Department of Biomedical Engineering, University of Connecticut Health Center, Farmington, CT, USA
| | - Melinda Sanders
- Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, CT, USA
- Department of Pathology, University of Connecticut Health Center, Farmington, CT, USA
| | - Molly A Brewer
- Department of Obstetrics and Gynecology, University of Connecticut Health Center, Farmington, CT, USA
| | - Kshitiz
- Department of Biomedical Engineering, University of Connecticut Health Center, Farmington, CT, USA.
- Department of Biomedical Engineering, University of Connecticut, Storrs, CT, USA.
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Gao J, Jiang N, Chen Q, Zhao M, Tang Y. Systemic Immune-Inflammation Indices Could Be Additional Predictive Markers for Cesarean Scar Pregnancy. Am J Reprod Immunol 2024; 92:e13924. [PMID: 39221973 DOI: 10.1111/aji.13924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/20/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024] Open
Abstract
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.
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Affiliation(s)
- Jing Gao
- Department of Medical Laboratory, Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China
| | - Nanyan Jiang
- Department of Medical Laboratory, Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China
| | - Qi Chen
- Department of Obstetrics and Gynaecology, The University of Auckland, Auckland, New Zealand
| | - Min Zhao
- Department of Gynaecology, Wuxi Maternity and Child Health Hospital, Jiangnan University, Wuxi, China
| | - Yunhui Tang
- Department of Family Planning, Obstetrics and Gynaecology Hospital of Fudan University, Shanghai, China
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Premkumar A, Huysman B, Cheng C, Einerson BD, Moayedi G. Placenta accreta spectrum in the second trimester: a clinical conundrum in procedural abortion care. Am J Obstet Gynecol 2024:S0002-9378(24)00820-2. [PMID: 39117028 DOI: 10.1016/j.ajog.2024.07.045] [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: 03/14/2024] [Revised: 07/25/2024] [Accepted: 07/31/2024] [Indexed: 08/10/2024]
Abstract
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.
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Affiliation(s)
- Ashish Premkumar
- Department of Obstetrics and Gynecology, Pritzker School of Medicine, The University of Chicago, Chicago IL.
| | - Bridget Huysman
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis MO
| | - CeCe Cheng
- Department of Obstetrics and Gynecology, Long School of Medicine, University of Texas Health Science Center San Antonio, San Antonio, TX
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT
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Timor-Tritsch IE, Monteagudo A, Goldstein SR. Early first-trimester transvaginal ultrasound screening for cesarean scar pregnancy in patients with previous cesarean delivery: analysis of the evidence. Am J Obstet Gynecol 2024:S0002-9378(24)00732-4. [PMID: 38955324 DOI: 10.1016/j.ajog.2024.06.041] [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: 08/20/2023] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/04/2024]
Abstract
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.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, Hackensack Meridian School of Medicine, Nutley, NJ.
| | - Ana Monteagudo
- Department of Obstetrics and Gynecology, Icahn School of Medicine, New York, NY
| | - Steven R Goldstein
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY
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Kaelin Agten A, Jurkovic D, Timor-Tritsch I, Jones N, Johnson S, Monteagudo A, Huirne J, Fleisher J, Maymon R, Herrera T, Prefumo F, Contag S, Cordoba M, Manegold-Brauer G. First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry. Am J Obstet Gynecol 2024; 230:669.e1-669.e19. [PMID: 37865390 DOI: 10.1016/j.ajog.2023.10.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023]
Abstract
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.
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Affiliation(s)
| | | | | | - Nia Jones
- University of Nottingham, Nottingham, United Kingdom
| | - Susanne Johnson
- Princess Anne Hospital, University Hospitals Southampton, Southampton, United Kingdom
| | | | - Judith Huirne
- Amsterdam University Medical Centers, Amsterdam, Netherlands
| | | | - Ron Maymon
- Department of Obstetrics and Gynecology, Shamir Medical Center (Assaf Harofeh), Be'er Ya'akov, Israel
| | | | - Federico Prefumo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Stephen Contag
- Division of Maternal Fetal Medicine, University of Minnesota, Minneapolis, MN
| | | | - Gwendolin Manegold-Brauer
- Division of Gynecologic and Prenatal Ultrasound, Department of Obstetrics and Gynecology, University of Basel, Basel, Switzerland.
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Spong CY, Yule CS, Fleming ET, Lafferty AK, McIntire DD, Twickler DM. The Cesarean Scar of Pregnancy: Ultrasound Findings and Expectant Management Outcomes. Am J Perinatol 2024; 41:e1445-e1450. [PMID: 36809793 PMCID: PMC11132851 DOI: 10.1055/a-2040-1458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/26/2023] [Indexed: 02/23/2023]
Abstract
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..
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Affiliation(s)
- Catherine Y. Spong
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health, Dallas, Texas
| | - Casey S. Yule
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health, Dallas, Texas
| | - Elaine T. Fleming
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
- Parkland Health, Dallas, Texas
| | - Ashlyn K. Lafferty
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Donald D. McIntire
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Diane M. Twickler
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, Texas
- Departments of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas
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Dar P, Doulaveris G. First-trimester screening for placenta accreta spectrum. Am J Obstet Gynecol MFM 2024; 6:101329. [PMID: 38447672 DOI: 10.1016/j.ajogmf.2024.101329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
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.
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Affiliation(s)
- Pe'er Dar
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine (Drs Dar and Doulaveris), Bronx, NY.
| | - Georgios Doulaveris
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine (Drs Dar and Doulaveris), Bronx, NY
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Shen M, Li L, Zhu L, Liu J, Lin T, Liu X. Predictive value of crossover sign for outcome of ultrasound-guided vacuum aspiration in women with Cesarean scar pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:544-550. [PMID: 37610656 DOI: 10.1002/uog.27459] [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: 02/19/2023] [Revised: 07/18/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
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.
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Affiliation(s)
- M Shen
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - L Li
- Department of Ultrasound, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - L Zhu
- Department of Ultrasound, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - J Liu
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - T Lin
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - X Liu
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
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Aryananda RA, Duvekot JJ, Van Beekhuizen HJ, Cininta NI, Ariani G, Dachlan EG. Transabdominal and transvaginal ultrasound findings help to guide the clinical management of placenta accreta spectrum cases. Acta Obstet Gynecol Scand 2024; 103:93-102. [PMID: 37968904 PMCID: PMC10755131 DOI: 10.1111/aogs.14715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/29/2023] [Accepted: 10/22/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION The clinical management of placenta accreta spectrum (PAS) depends on placental topography and vascular involvement. Our aim was to determine whether transabdominal and transvaginal ultrasound signs can predict PAS management. MATERIAL AND METHODS We conducted a retrospective cohort study of consecutive prenatally suspected PAS cases in a single tertiary-care PAS center between January 2021 and July 2022. When PAS was confirmed during surgery, abdominal and transvaginal ultrasound scans were analyzed in relation to PAS management. The preferred surgical approach of PAS was one-step conservative surgery (OSCS). Massive blood loss and PAS topography in the lower bladder trigone necessitated cesarean hysterectomy. Transvaginal ultrasound-diagnosed intracervical hypervascularity was split into three categories based on their quantity. Anatomically, the internal cervical os is located at the level of the bladder trigone and was used as landmark for upper and lower bladder trigone PAS. RESULTS Ninety-one women underwent OSCS and 35 women underwent cesarean hysterectomy (total 126 women with PAS). Abdominal and transvaginal ultrasound features differed significantly between women that underwent OSCS and cesarean hysterectomy: decreased myometrial thickness (<1 mm), 82.4% vs. 100%, p = 0.006; placental bulge, 51.6% vs. 94.3%, p < 0.001; bladder wall interruption, 62.6% vs. 97.1%, p < 0.001; abnormal placental lacunae, 75.8% vs. 100%, p < 0.001; hypervascularity (large lacunae feeding vessels, 57.8% vs. 94.6%, p < 0.001; parametrial hypervascularity, 15.4% vs. 60%, p < 0.001; the rail sign, 6.6% vs. 28.6%, p = 0.003; three-dimensional Doppler intra-placental hypervascularity, 81.3% vs. 100%, p < 0.001; intracervical hypervascularity 60.4% vs. 94.3%, p < 0.001); and cervical length 2.5 ± 0.94 vs. 2.2 ± 0.73, p = 0.038. Other ultrasound signs were not significantly different. The results of multivariable logistic regression showed placental bulge (odds ratio [OR] 9.3; 95% CI 1.9-44.3; p = 0.005), parametrial hypervascularity (OR 4.1; 95% CI 1.541-11.085; p = 0.005), and intracervical hypervascularity (OR 9.2; 95% CI 1.905-44.056; p = 0.006) were weak predictors of OSCS. Intracervical hypervascularity Grade 1 (vascularity <50% of cervical tissue) was more present in OSCS than higher gradings two and three (91% vs. 27.6% vs. 14.3%; p < 0.001). CONCLUSIONS Cesarean hysterectomy is associated with the PAS signs of placental bulge and Grade 2 and 3 intracervical hypervascularity. OSCS is associated with intracervical hypervascularity Grade 1 on transvaginal ultrasound. Prospective validation is required to formulate predictors for PAS management.
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Affiliation(s)
- Rozi Aditya Aryananda
- Department of Obstetrics and Gynecology, Dr. Soetomo Academic General HospitalUniversitas AirlanggaSurabayaIndonesia
- Department of Obstetrics & GynecologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Johannes J. Duvekot
- Department of Obstetrics & GynecologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Heleen J. Van Beekhuizen
- Department of Obstetrics & GynecologyErasmus University Medical CenterRotterdamThe Netherlands
- Department of Gynecological Oncology, Erasmus MC Cancer CenterErasmus University Medical CenterRotterdamThe Netherlands
| | - Nareswari Imanadha Cininta
- Department of Obstetrics and Gynecology, Dr. Soetomo Academic General HospitalUniversitas AirlanggaSurabayaIndonesia
| | - Grace Ariani
- Department of Anatomical Pathology, Dr. Soetomo Academic General HospitalUniversitas AirlanggaSurabayaIndonesia
| | - Erry Gumilar Dachlan
- Department of Obstetrics and Gynecology, Dr. Soetomo Academic General HospitalUniversitas AirlanggaSurabayaIndonesia
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Timor-Tritsch IE, Kaelin Agten A, Monteagudo A, Calỉ G, D'Antonio F. The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy. Best Pract Res Clin Obstet Gynaecol 2023; 91:102409. [PMID: 37716338 DOI: 10.1016/j.bpobgyn.2023.102409] [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: 02/20/2023] [Revised: 08/02/2023] [Accepted: 08/17/2023] [Indexed: 09/18/2023]
Abstract
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.
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Affiliation(s)
| | - Andrea Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, L8 7SS, United Kingdom
| | - Ana Monteagudo
- Icahn School of Medicine. Carnegie Maternal Fetal Associates New York, USA
| | - Giuseppe Calỉ
- Maternal Fetal Medicine Unit AO Villa Sofia-Cervello, Italy
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Zhao H, Liu C, Fu H, Abeykoon SDI, Zhao X. Subsequent pregnancy outcomes and risk factors following conservative treatment for placenta accreta spectrum: a retrospective cohort study. Am J Obstet Gynecol MFM 2023; 5:101189. [PMID: 37832645 DOI: 10.1016/j.ajogmf.2023.101189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/27/2023] [Accepted: 10/09/2023] [Indexed: 10/15/2023]
Abstract
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.
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Affiliation(s)
- Huidan Zhao
- Department of Obstetrics and Gynecology, First affiliated hospital of Zhengzhou University, School of International Education, Zhengzhou University, Zhengzhou, China; Obstetric Emergency and Critical Care Medicine of Henan Province, Zhengzhou, China (Dr H Zhao, Ms Liu, and Dr X Zhao)
| | - Chuanna Liu
- Department of Obstetrics and Gynecology, First affiliated hospital of Zhengzhou University, School of International Education, Zhengzhou University, Zhengzhou, China; Obstetric Emergency and Critical Care Medicine of Henan Province, Zhengzhou, China (Dr H Zhao, Ms Liu, and Dr X Zhao)
| | - Hanlin Fu
- Department of Obstetrics and Gynecology, First affiliated hospital of Zhengzhou University, School of International Education, Zhengzhou University, Zhengzhou, China
| | | | - Xianlan Zhao
- Department of Obstetrics and Gynecology, First affiliated hospital of Zhengzhou University, School of International Education, Zhengzhou University, Zhengzhou, China; Obstetric Emergency and Critical Care Medicine of Henan Province, Zhengzhou, China (Dr H Zhao, Ms Liu, and Dr X Zhao).
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de Mello PV, Bruns RF, Klas CF, Hammes LR. Re: Correspondence on "Expectant management of viable cesarean scar pregnancies: a systematic review". Arch Gynecol Obstet 2023; 308:1915-1916. [PMID: 36738317 DOI: 10.1007/s00404-023-06931-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 02/05/2023]
Affiliation(s)
- Paula Vieira de Mello
- Department of Obstetrics and Gynecology, Universidade Federal do Paraná, Curitiba-Paraná, Brazil.
| | - Rafael Frederico Bruns
- Department of Obstetrics and Gynecology, Universidade Federal do Paraná, Curitiba-Paraná, Brazil
| | - Cynthia Fontoura Klas
- Obstetrics and Gynecology Program, Universidade Federal do Paraná, Curitiba-Paraná, Brazil
| | - Larissa Raso Hammes
- Obstetrics and Gynecology Program, Universidade Federal do Paraná, Curitiba-Paraná, Brazil
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Morlando M, Conte A, Schiattarella A. Reproductive outcome after cesarean scar pregnancy. Best Pract Res Clin Obstet Gynaecol 2023; 91:102362. [PMID: 37355427 DOI: 10.1016/j.bpobgyn.2023.102362] [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: 04/16/2023] [Accepted: 05/09/2023] [Indexed: 06/26/2023]
Abstract
Cesarean scar pregnancy (CSP) rate is rising worldwide, in parallel with the rising rates of cesarean delivery. Multiple therapeutic strategies and a timely diagnosis have led to a successful management in most cases, with many women preserving fertility after treatment. Despite this, still little is known regarding pregnancy outcomes after a CSP. The main adverse outcomes reported after CSP are recurrence of CSP, miscarriage, preterm birth, placenta accreta spectrum (PAS) disorders and uterine rupture. In addition, little is known about the influence of the different treatments on subsequent pregnancy outcomes after a CSP. Being aware of the impact of the different management strategies on the fertility outcomes is highly relevant to counsel pregnant women after a CSP. The aim of this manuscript is to provide an up-to-date review of the reproductive outcomes of women with a history of CSP and of the influence of various treatments on subsequent pregnancy outcomes.
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Affiliation(s)
- Maddalena Morlando
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy.
| | - Anna Conte
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
| | - Antonio Schiattarella
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
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Meyer R, Friedrich L, Plaschkes R, Toussia-Cohen S, Levin G, Weissbach T, Kassif E, Mashiach R. Clinical implications of a cesarean scar pregnancy sonographic evaluation and reporting system. Eur J Obstet Gynecol Reprod Biol 2023; 291:247-251. [PMID: 37944212 DOI: 10.1016/j.ejogrb.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/29/2023] [Accepted: 11/03/2023] [Indexed: 11/12/2023]
Abstract
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.
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Affiliation(s)
- Raanan Meyer
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel; School of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, CA, United States; The Dr. Pinchas Bornstein Talpiot Medical Leadership Program, Sheba Medical Center, Tel Hashomer, Ramat-Gan, Israel.
| | - Lior Friedrich
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Roni Plaschkes
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Shlomi Toussia-Cohen
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel
| | - Gabriel Levin
- Lady Davis Institute for Cancer Research, Jewish General Hospital, McGill University, Quebec, Canada
| | - Tal Weissbach
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel; School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Eran Kassif
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel; School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Mashiach
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel; School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Wang F, Vaught A, Rosner M, Baschat A, Darwin K, Halscott T, Kush M, Miller J, Gomez E. Dichorionic diamniotic heterotopic twin gestation with cesarean section scar implantation and placenta increta. Radiol Case Rep 2023; 18:4006-4011. [PMID: 37691758 PMCID: PMC10491656 DOI: 10.1016/j.radcr.2023.08.075] [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: 07/05/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023] Open
Abstract
Heterotopic cesarean scar pregnancy is an extremely rare form of pregnancy and is defined as an intrauterine pregnancy coexisting with an ectopic pregnancy implanted in the cesarean scar. Cesarean scar ectopic pregnancy can also be a precursor for placenta accreta spectrum, a potentially life-threatening condition in which the placenta is abnormally adherent to the uterine myometrium and possibly adjacent organs. Although cesarean scar ectopic pregnancies are rare, there has been an increase in their incidence due to the rise in cesarean deliveries. We present the case of a 35-year-old patient with a heterotopic pregnancy with ectopic implantation in a cesarean scar and associated placenta increta, as well as the radiologic evaluation of placenta accreta spectrum and subsequent management.
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Affiliation(s)
- Felicia Wang
- Johns Hopkins University School of Medicine, 733 North Brdwy, Baltimore, MD 21205, USA
| | - Arthur Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Mara Rosner
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Ahmet Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Kristin Darwin
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Torre Halscott
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Michelle Kush
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jena Miller
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Erin Gomez
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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16
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Fazari A, Mohammed PB, Fahad A. Outcomes of the Expectant Management of 10 Cesarean Scar Pregnancy Cases in Patients Who Refused the Termination of Pregnancy. Cureus 2023; 15:e48921. [PMID: 38106794 PMCID: PMC10725518 DOI: 10.7759/cureus.48921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVE Expectant management of cesarean scar pregnancy (CSP) in patients who refuse termination of pregnancy and continue with placenta accreta spectrum (PAS) is possible with multidisciplinary care and careful monitoring in a tertiary care center. Doctors with the relevant expertise in managing PAS use highly accurate ultrasound as a tool to diagnose, monitor, and manage this disorder, which enables them to determine appropriate surgical strategies and techniques to achieve optimum maternal and fetal outcomes with minimal blood loss and no major maternal mortality and morbidity. In this study, we aim to evaluate expectant management in such patients. MATERIALS AND METHODS This is a retrospective study of 10 patients with a previous history of a uterine scar. Diagnosed with CSP in the first trimester, they refused to terminate their pregnancy and continued with PAS. We studied them over a period of four years from 2018 to 2022 and managed them at Latifa Hospital, Dubai, UAE. RESULTS Of the 10 patients, nine delivered in the third trimester (around 34 weeks gestation), seven underwent elective surgery, and three underwent emergency surgery. Four patients were exogenous cases and six were endogenous cases at diagnosis during early gestation. Seven patients had a cesarean hysterectomy, and three (with focal placenta accreta) had uterine wall reconstruction surgery. Four patients needed blood transfusions. The average duration of surgery was between 2.5 and 5 hours. There were no miscarriages, no maternal and neonatal deaths, and no significant obstetric complications such as rupture of the uterus or major obstetric hemorrhage. CONCLUSION Even though CSP is a potentially life-threatening condition because of serious complications such as PAS if continued, expectant management is possible under multidisciplinary care where the team strictly adheres to clinical protocols and accurate surgery to reduce obstetric hemorrhage.
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Affiliation(s)
- Atif Fazari
- Faculty of Medicine, University of Medical Sciences and Technology, Khartoum, SDN
- Obstetrics and Gynecology, Latifa Hospital, Dubai Academic Health Corporation, Dubai, ARE
| | | | - Asma Fahad
- Obstetrics and Gynecology, Latifa Hospital, Dubai Academic Health Corporation, Dubai, ARE
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17
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Di Spiezio Sardo A, Zizolfi B, Saccone G, Ferrara C, Sglavo G, De Angelis MC, Mastantuoni E, Bifulco G. Hysteroscopic resection vs ultrasound-guided dilation and evacuation for treatment of cesarean scar ectopic pregnancy: a randomized clinical trial. Am J Obstet Gynecol 2023; 229:437.e1-437.e7. [PMID: 37142075 DOI: 10.1016/j.ajog.2023.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 04/02/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Cesarean scar ectopic pregnancy is a type of ectopic pregnancy in which the fertilized egg is implanted in the muscle or fibrous tissue of the scar after a previous cesarean delivery. The condition can be catastrophic if not managed on time and can lead to significant morbidity and mortality. Several approaches have been studied for the management of cesarean scar ectopic pregnancy in women who opted for termination of pregnancy with no consensus on the best treatment modality reached so far. OBJECTIVE This study aimed to compare the success rate of hysteroscopic resection vs ultrasound-guided dilation and evacuation for the treatment of cesarean scar ectopic pregnancy. STUDY DESIGN This was a parallel group, nonblinded, randomized clinical trial conducted at a single center in Italy. Women with singleton gestations at <8 weeks and 6 days of gestation were included in the study. Inclusion criteria were women with a cesarean scar ectopic pregnancy with positive embryonic heart activity who opted for termination of pregnancy. Patients were randomized 1:1 to receive either hysteroscopic resection (ie, intervention group) or ultrasound-guided dilation and evacuation (ie, control group). Both groups received 50 mg/m2 of methotrexate intramuscularly at the time of randomization (day 1) and another dose at day 3. A third dose of methotrexate was planned in case of persistence of positive fetal heart activity at day 5. Participants received either ultrasound-guided dilation and evacuation or hysteroscopic resection from 1 to 5 days after the last dose of methotrexate. Hysteroscopic resection was performed under spinal anesthesia using a 15 Fr bipolar mini-resectoscope. Dilation and evacuation were performed by vacuum aspiration with a Karman cannula, followed by sharp curettage, if necessary, under ultrasound guidance. The primary outcome was the success rate of the treatment protocol, defined as no further treatment required until the complete resolution of the cesarean scar ectopic pregnancy. Resolution of the cesarean scar ectopic pregnancy was evaluated based on decline of beta-hCG and the absence of residual gestational material in the endometrial cavity. Treatment failure was defined as the necessity for further treatment required until the complete resolution of the cesarean scar ectopic pregnancy. A sample size calculation indicated that 54 participants were required to test the hypothesis RESULTS: A total of 54 women were enrolled and randomized. Number of previous cesarean deliveries ranged from 1 to 3. Overall, 10 women received a third dose of methotrexate with 7 of 27 (25.9%) participants in the hysteroscopic resection group and 3 of 27 (11.1%) in the dilation and evacuation group. The success rate was 100% (27/27) in the hysteroscopic resection group and 81.5% (22/27) in the dilation and evacuation group (relative risk, 1.22; 95% confidence interval, 1.01-1.48). Additional procedures were required in 5 cases of the control group, namely 3 hysterectomies, 1 laparotomic uterine segmental resection, and 1 hysteroscopic resection. The length of stay in the hospital was 9.0±2.9 days in the intervention group and 10.0±3.5 days in the control group (mean difference, -1.00 days; 95% confidence interval, -2.71 to 0.71). No cases of admission to intensive care unit or maternal death were reported. CONCLUSION Hysteroscopic resection was associated with an increased success rate in the treatment of cesarean scar ectopic pregnancy when compared with ultrasound-guided dilation and evacuation.
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Affiliation(s)
| | | | - Gabriele Saccone
- Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
| | - Cinzia Ferrara
- Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Gabriella Sglavo
- Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | | | - Enrica Mastantuoni
- Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Giuseppe Bifulco
- Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
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Lin R, DiCenzo N, Rosen T. Cesarean scar ectopic pregnancy: nuances in diagnosis and treatment. Fertil Steril 2023; 120:563-572. [PMID: 37506758 DOI: 10.1016/j.fertnstert.2023.07.018] [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: 05/02/2023] [Revised: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 07/30/2023]
Abstract
A cesarean scar ectopic pregnancy (CSEP) occurs when the embryo implants on the scar of a previous cesarean delivery. The number of births delivered by cesarean section has climbed by 50% over the last decade, from a nadir of 20.7% in 1996 to 32.1% in 2021. As a result, the incidence of CSEP has also increased. Because CSEP may cause serious morbidity such as life-threatening hemorrhage, uterine rupture, placental accreta spectrum, hysterectomy, and even mortality, accurate diagnosis and appropriate management of this condition are essential. This review focuses on the etiology, incidence, clinical diagnosis, and management of CSEPs.
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Affiliation(s)
- Ruby Lin
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
| | - Natalie DiCenzo
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Todd Rosen
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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19
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Dogru S, Atci AA, Akkus F, Erdogan AC, Acar A. Predictability of Hematological Parameters in the Diagnosis of Cesarean Scar Pregnancy. J Lab Physicians 2023; 15:425-430. [PMID: 37564226 PMCID: PMC10411160 DOI: 10.1055/s-0043-1761929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
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.
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Affiliation(s)
- Sukran Dogru
- Division of Perinatology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Asli Altinordu Atci
- Division of Perinatology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Fatih Akkus
- Division of Perinatology, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Arif Caner Erdogan
- Department of Gynecology and Obstetrics, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Ali Acar
- Department of Gynecology and Obstetrics, Meram Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
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Silva B, Viana Pinto P, Costa MA. Cesarean Scar Pregnancy: A systematic review on expectant management. Eur J Obstet Gynecol Reprod Biol 2023; 288:36-43. [PMID: 37421745 DOI: 10.1016/j.ejogrb.2023.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023]
Abstract
A Cesarean Scar Pregnancy (CSP) is a variant of uterine ectopic pregnancy defined by full or partial implantation of the gestational sac in the scar of a previous cesarean section. The continuous increase of Cesarean Deliveries is causing a parallel increase in CSP and its complications. Considering its high morbidity, the most usual recommendation has been termination of pregnancy in the first trimester; however, several cases progress to viable births. The aim of this systematic review is to evaluate the outcome of CSP managed expectantly and understand whether sonographic signs could correlate to the outcomes. An online-based search of PubMed and Cochrane Library Databases was used to gather studies including women diagnosed with a CSP who were managed expectantly. The description of all cases was analysed by the authors in order to obtain information for each outcome. 47 studies of different types were retrieved, and the gestational outcome was available in 194 patients. Out of these, 39 patients (20,1%) had a miscarriage and 16 (8,3%) suffered foetal death. 50 patients (25,8%) had a term delivery and 81 (41,8%) patients had a preterm birth, out of which 27 (13,9%) delivered before 34 weeks of gestation. In 102 (52,6%) patients, a hysterectomy was performed. Placenta Accreta Spectrum (PAS) was a common disorder among CSP and was linked to a higher rate of complications such as foetal death, preterm birth, hysterectomy, haemorrhagic morbidity and surgical complications. Some of the analysed articles showed that sonographic signs with specific characteristics, such as type II and III CSP classification, Crossover Sign - 1, "In the niche" implantation and lower myometrial thickness could be related to worse outcomes of CSP. This article provides a good understanding of CSP as an entity that, although rare, presents with a high rate of relevant morbidity. It is also understood that pregnancies with confirmed PAS had an even higher rate of morbidity. Some sonographic signs were shown to predict the prognosis of these pregnancies and further investigation is necessary to validate one or more signs so they can be used for a more reliable counselling of women with CSP.
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Affiliation(s)
- Beatriz Silva
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Pedro Viana Pinto
- Department of Biomedicine, Service of Anatomy, Faculty of Medicine, University of Porto, Porto, Portugal; Gynecology and Obstetrics Service, University Hospital Center São João, Porto, Portugal.
| | - Maria Antónia Costa
- Gynecology and Obstetrics Service, University Hospital Center São João, Porto, Portugal; Department of Gynecology-Obstetrics and Paediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
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Dominguez JA, Pacheco LA, Moratalla E, Carugno JA, Carrera M, Perez-Milan F, Caballero M, Alcázar JL. Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:336-344. [PMID: 36730180 DOI: 10.1002/uog.26171] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/28/2022] [Accepted: 01/17/2023] [Indexed: 06/18/2023]
Abstract
The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J A Dominguez
- IERA (Instituto Extremeño de Reproducción Asistida), Badajoz, Spain
| | | | - E Moratalla
- Department of Obstetrics and Gynecology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J A Carugno
- Minimally Invasive Gynecology Division, University of Miami, Miami, FL, USA
| | - M Carrera
- Department Obstetrics and Gynecology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - F Perez-Milan
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - M Caballero
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - J L Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain
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22
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Bhide A. Routine screening for placenta accreta spectrum. Best Pract Res Clin Obstet Gynaecol 2023; 90:102392. [PMID: 37541113 DOI: 10.1016/j.bpobgyn.2023.102392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/04/2023] [Accepted: 07/06/2023] [Indexed: 08/06/2023]
Abstract
Screening for clinically significant placenta accreta spectrum (PAS) is possible with a high degree of accuracy (both sensitivity and specificity >90-95%). The group of women to focus on are those with placenta previa and one or more prior Cesarean deliveries. Screening for PAS not associated with placenta previa is not as productive, and several false negatives have been described. The results of the screening program indicate that women have a low or high probability of PAS. Screen-positive women or those with uncertain ultrasound features should be referred to a center of excellence. Those confirmed to have a high probability of PAS should electively be delivered at such centers.
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Huang J, Phillips C, Moshiri M. Scarred for life: a review of cesarean section scar pregnancy and potential pitfalls in diagnosis. Abdom Radiol (NY) 2023; 48:2672-2683. [PMID: 37204508 DOI: 10.1007/s00261-023-03953-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/20/2023]
Abstract
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.
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Affiliation(s)
- Jennifer Huang
- Department of Radiology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA.
- PGY-5 Chief Resident, Diagnostic Radiology Residency, Vanderbilt University Medical Center, 1161 21st Ave South, Nashville, TN, 37232, USA.
| | - Catherine Phillips
- Department of Radiology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
| | - Mariam Moshiri
- Department of Radiology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
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24
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Einerson BD, Gilner JB, Zuckerwise LC. Placenta Accreta Spectrum. Obstet Gynecol 2023; 142:31-50. [PMID: 37290094 PMCID: PMC10491415 DOI: 10.1097/aog.0000000000005229] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/08/2023] [Indexed: 06/10/2023]
Abstract
Placenta accreta spectrum (PAS) is one of the most dangerous conditions in pregnancy and is increasing in frequency. The risk of life-threatening bleeding is present throughout pregnancy but is particularly high at the time of delivery. Although the exact cause is unknown, the result is clear: Severe PAS distorts the uterus and surrounding anatomy and transforms the pelvis into an extremely high-flow vascular state. Screening for risk factors and assessing placental location by antenatal ultrasonography are essential for timely diagnosis. Further evaluation and confirmation of PAS are best performed in referral centers with expertise in antenatal imaging and surgical management of PAS. In the United States, cesarean hysterectomy with the placenta left in situ after delivery of the fetus is the most common treatment for PAS, but even in experienced referral centers, this treatment is often morbid, resulting in prolonged surgery, intraoperative injury to the urinary tract, blood transfusion, and admission to the intensive care unit. Postsurgical complications include high rates of posttraumatic stress disorder, pelvic pain, decreased quality of life, and depression. Team-based, patient-centered, evidence-based care from diagnosis to full recovery is needed to optimally manage this potentially deadly disorder. In a field that has relied mainly on expert opinion, more research is needed to explore alternative treatments and adjunctive surgical approaches to reduce blood loss and postoperative complications.
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Affiliation(s)
- Brett D Einerson
- Department of Obstetrics & Gynecology, University of Utah Health, Salt Lake City, Utah; Duke University, Durham, North Carolina; and Vanderbilt University Medical Center, Nashville, Tennessee
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Nijjar S, Jauniaux E, Jurkovic D. Definition and diagnosis of cesarean scar ectopic pregnancies. Best Pract Res Clin Obstet Gynaecol 2023; 89:102360. [PMID: 37356119 DOI: 10.1016/j.bpobgyn.2023.102360] [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: 04/01/2023] [Revised: 05/10/2023] [Accepted: 05/14/2023] [Indexed: 06/27/2023]
Abstract
Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy, where the pregnancy implants into a myometrial defect caused by a cesarean scar. Its incidence is predicted to increase, given the global increase in cesarean deliveries. As most cesarean scar ectopic pregnancies present as failing pregnancies or patients choose termination of pregnancy, there are limited data on their natural history. However, early first trimester diagnosis is essential, given the associated significant maternal morbidity. Transvaginal sonography is generally considered to be the optimal method for diagnosing cesarean scar ectopic pregnancy. There is no evidence that MRI adds to the diagnostic accuracy, and it is therefore not recommended for routine evaluation of cesarean scar ectopic pregnancy. There is no agreed reference standard for the diagnosis of cesarean scar ectopic pregnancy; therefore, the validity of several proposed sonographic diagnostic criteria reported by different authors remains unknown. There are also various suggested classification systems for cesarean scar ectopic pregnancy, which divide them in differet types. However, the proposals are very heterogeneous, and superiority of one classification system over another is yet to be established.
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Affiliation(s)
- Simrit Nijjar
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Davor Jurkovic
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
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26
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Hameed MSS, Wright A, Chern BSM. Cesarean Scar Pregnancy: Current Understanding and Treatment Including Role of Minimally Invasive Surgical Techniques. Gynecol Minim Invasive Ther 2023; 12:64-71. [PMID: 37416110 PMCID: PMC10321345 DOI: 10.4103/gmit.gmit_116_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/29/2022] [Accepted: 01/10/2023] [Indexed: 07/08/2023] Open
Abstract
The incidence of cesarean scar pregnancy (CSP) is increasing reflecting the global increase in cesarean section (CS) rate which has almost doubled since 2000. CSP differs from other types of ectopic pregnancy in its ability to progress while still carrying a significant risk of maternal morbidity. Little is known about precise etiology or natural history although current interest in the pathology of placenta accretes spectrum disorders might be enlightening. Early detection and treatment of CSP are challenging. Once diagnosed, the recommendation is to offer early termination of pregnancy because of the potential risks of continuing the pregnancy. However, as the likelihood of future pregnancy complications for any CSP varies depending on its individual characteristics, this might not always be necessary nor might it be the patient's preferred choice if she is asymptomatic, hemodynamically stable, and wants a baby. The literature supports an interventional rather than a medical approach but the safest and most efficient clinical approach to CSP in terms of treatment modality and service delivery has yet to be determined. This review aims to provide an overview of CSP etiology, natural history, and clinical implications. Treatment options and methods of CSP repair are discussed. We describe our experience in a large tertiary center in Singapore with around 16 cases/year where most treatment modalities are available as well as an "accreta service" for continuing pregnancies. We present a simple algorithm for approach to management including a method of triaging for those CSPs suitable for minimally invasive surgery.
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Affiliation(s)
- Mohamed Siraj Shahul Hameed
- Division of Obstetrics and Gynaecology, Department of Minimally Invasive Surgery, K. K. Women’s and Children’s Hospital, Singapore
| | - Ann Wright
- Division of Obstetrics and Gynaecology, Department of Maternal Fetal Medicine, K. K. Women’s and Children’s Hospital, Singapore
| | - Bernard Su Min Chern
- Division of Obstetrics and Gynaecology, Department of Minimally Invasive Surgery, K. K. Women’s and Children’s Hospital, Singapore
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Aiob A, Gaziyev Z, Mikhail SM, Wolf M, Lowenstein L, Odeh M. The value of a simple sonographic screening test for placenta accreta spectrum prediction: A case-control study. Aust N Z J Obstet Gynaecol 2023; 63:228-233. [PMID: 36068725 DOI: 10.1111/ajo.13611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Placenta accreta spectrum (PAS) represents life-threatening conditions; however, early diagnosis reduces complications and mortality rates. AIMS To develop and evaluate the accuracy of a simple sonographic screening test for PAS prediction. MATERIALS AND METHODS A retrospective case-control study of 481 women with singleton pregnancies at 28 weeks or later, with a scarred uterus or placenta praevia, who underwent sonographic testing for PAS detection during 2010-2020. We compared demographic and sonographic features, and delivery outcomes between women who were and were not confirmed to have a PAS condition at delivery. We evaluated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and predictive probability for the sonographic screening model. RESULTS Among all the women with at least one sonographic sign (large lacunae or loss of clear zone), the odds ratio (OR) of PAS was 21.7 (95% CI, 16.7-70.4), among those with placenta praevia (and at least one sonographic sign), the OR was 41.9 (95% CI, 15.8-111). For the screening model (the combinations of placental location (major or minor placenta praevia) with at least one sonographic sign (large lacunae or loss of clear zone)), sensitivity, specificity, PPV, NPV and predicted probability were 94.9% (85.8-98.9%), 91.5% (88.4-93.9%), 60.9% (50.1-70.9%), 99.2% (97.7-99.8%) and 92.3%, respectively. CONCLUSIONS A combination of simple ultrasound signs for PAS screening may be highly effective for prenatal assessment and prediction of placenta accreta. This screening test can be carried out as routine pregnancy follow-up for women with risk factors for PAS.
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Affiliation(s)
- Ala Aiob
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Ziyada Gaziyev
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya, Israel
| | - Susana Mustafa Mikhail
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Maya Wolf
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Lior Lowenstein
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
| | - Marwan Odeh
- Department of Obstetrics and Gynaecology, Galilee Medical Centre, Nahariya and Azrieli Faculty of Medicine, Bar Ilan University, Safed, Israel
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Capannolo G, D'Amico A, Alameddine S, Di Girolamo R, Khalil A, Calì G, Trish IT, Coutinho CM, Herrera M, Liberati M, Lucidi A, Palacios-Jaraquemada J, Buca D, D'Antonio F. Placenta accreta spectrum disorders clinical practice guidelines: A systematic review. J Obstet Gynaecol Res 2023; 49:1313-1321. [PMID: 36796351 DOI: 10.1111/jog.15544] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 12/28/2022] [Indexed: 02/18/2023]
Abstract
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.
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Affiliation(s)
- Giulia Capannolo
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Alice D'Amico
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Sara Alameddine
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Raffaella Di Girolamo
- Department of Public Health, School of Medicine, Federico II, University of Naples, Naples, Italy
| | - Asma Khalil
- Fetal Medicine Unit, Saint George's Hospital, London, UK
| | - Giuseppe Calì
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Ilan T Trish
- Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Health, New York, New York, USA
| | - Conrado M Coutinho
- Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo: Ribeirão Preto, São Paulo, Brazil
| | - Mauricio Herrera
- Maternal fetal medicine, Obstetric Department, Clinica Colsanitas Bogotà, Bogota, Colombia
| | - Marco Liberati
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Alessandro Lucidi
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | | | - Danilo Buca
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Francesco D'Antonio
- Centre for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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29
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D'Antonio F, Calagna G, Sara T, Gaspare C, Chiantera V, Calì G. Abnormal placenta implantation. Integration between first- and third-trimester imaging in predicting the severity of Placenta Accreta Spectrum (PAS) disorders. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:311-317. [PMID: 36468282 DOI: 10.1002/jcu.23312] [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: 07/29/2022] [Accepted: 08/09/2022] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- Francesco D'Antonio
- Department of Obstetrics and Gynaecology, Centre for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Gloria Calagna
- Gynecology and Obstetrics, "Villa Sofia Cervello" Hospital, University of Palermo, Palermo, Italy
| | - Tinari Sara
- Department of Obstetrics and Gynaecology, Centre for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - Cucinella Gaspare
- Gynecology and Obstetrics, "Villa Sofia Cervello" Hospital, University of Palermo, Palermo, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Giuseppe Calì
- Fondazione per gli Studi sulla Riproduzione Umana, Clinica Candela, Palermo, Italy
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30
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Management of caesarean scar pregnancy with ultrasound guided suction curettage followed by foley balloon catheter placement. J Gynecol Obstet Hum Reprod 2022; 51:102471. [DOI: 10.1016/j.jogoh.2022.102471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/20/2022]
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31
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Vieira de Mello P, Bruns RF, Fontoura Klas C, Raso Hammes L. Expectant management of viable cesarean scar pregnancies: a systematic review. Arch Gynecol Obstet 2022:10.1007/s00404-022-06835-3. [DOI: 10.1007/s00404-022-06835-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022]
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Abstract
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.
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Abstract
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.
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Aslan K, Aslan EK, Mesut C, Orhan A, Uncu G. Laparoscopic Management for Complications of Cesarean-Scar Pregnancy. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Affiliation(s)
- Kiper Aslan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Bursa Uludag University, Görükle/Bursa, Turkey
| | - Elif Külahci Aslan
- Department of Obstetrics and Gynecology, Bursa Jimer Hospital, Bursa, Turkey
| | - Cagatay Mesut
- Department of Obstetrics and Gynecology, Faculty of Medicine, Bursa Uludag University, Görükle/Bursa, Turkey
| | - Adnan Orhan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Bursa Uludag University, Görükle/Bursa, Turkey
| | - Gürkan Uncu
- Department of Obstetrics and Gynecology, Faculty of Medicine, Bursa Uludag University, Görükle/Bursa, Turkey
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Li XM, Xu XF, Wang NN, Yao L. Clinical efficacy of laparoscopic surgery used for the excision of villus tissue and the repair of uterine scar in patients with cesarean scar pregnancy-II. MEDICINE INTERNATIONAL 2022; 2:23. [PMID: 36699505 PMCID: PMC9829210 DOI: 10.3892/mi.2022.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/25/2022] [Indexed: 02/01/2023]
Abstract
The present study described the clinical presentation of patients with cesarean scar pregnancy type II (CSP)-II diagnosed by ultrasound or magnetic resonance imaging, who underwent laparoscopic surgery resection or hysteroscopic treatment. The aim of the present study was to evaluate the outcomes of different treatments for CSP. The patients with CSP-II were assigned to the laparoscopy and hysteroscopy groups according to the type of surgery performed. The general indicators and post-operative outcomes were compared between the two groups. Statistically significant differences (P<0.05) were noted in the treatment efficacy indices between the two groups. The laparoscopic group exhibited a lower value of β-human chorionic gonadotropin (β-HCG) following surgery (P=0.017), a shorter time required for β-HCG to return to normal levels (P=0.001), a reduced post-operative thickness of the uterine scar (P<0.001) and a reduced menstruation recovery time (P<0.001). However, no significant differences were noted in blood loss during operation (P>0.05). On the whole, the data indicated that the laparoscopic resection of the scar with gestational tissue and wound repair may be used to preserve the uterus and may thus be an effective method for CSP-II. The appropriate treatment needs to be selected according to the condition of each patient. Based on the latter and on the available technology, priority may perhaps be given to laparoscopic surgery.
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Affiliation(s)
- Xiao Man Li
- Department of Obstetrics and Gynecology, Zhengzhou Yi He Hospital, Zhengzhou, Henan 450000, P.R. China,Correspondence to: Dr Xiao Man Li, Department of Obstetrics and Gynecology, Zhengzhou Yi He Hospital, 69 NongYeDong Road, Zhengzhou, Henan 450000, P.R. China
| | - Xiao Feng Xu
- Department of Obstetrics and Gynecology, Zhengzhou Yi He Hospital, Zhengzhou, Henan 450000, P.R. China
| | - Ning Ning Wang
- Department of Obstetrics and Gynecology, Zhengzhou Yi He Hospital, Zhengzhou, Henan 450000, P.R. China
| | - Li Yao
- Department of Obstetrics and Gynecology, Zhengzhou Yi He Hospital, Zhengzhou, Henan 450000, P.R. China
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Miller R, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy. Am J Obstet Gynecol 2022; 227:B9-B20. [PMID: 35850938 DOI: 10.1016/j.ajog.2022.06.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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).
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Chen YT, Chen YC, Chen M, Chang YJ, Yang SH, Tsai HD, Wu CH. Reproductive outcomes of cesarean scar pregnancies treated with uterine artery embolization combined with curettage. Taiwan J Obstet Gynecol 2022; 61:601-605. [PMID: 35779907 DOI: 10.1016/j.tjog.2021.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The aim of this study was to review the reproductive outcomes of women with a cesarean scar pregnancy (CSP) treated with dilation and curettage (D&C) after uterine artery embolization (UAE). MATERIALS AND METHODS This was a retrospective study to review women who received UAE followed by D&C for CSP between January 2010 and December 2019 at the Changhua Christian Hospital, Changhua in Taiwan. Data were collected from both electronic and paper medical records. Patients were contact via phone call to follow up reproductive outcomes between January 2021 and March 2021. These subsequent reproductive outcomes (including pregnancy rate, secondary infertility rate, miscarriage rate, live birth rate, and recurrent CSP rate) were recorded and analyzed. RESULTS A total of 53 cases of women who received UAE followed by D&C for CSP were identified. The women's average age was 34.8 ± 5.1 years. The mean gestational age at diagnosis was 6.2 ± 1.1 weeks. The mean level for human chorionic gonadotropin was 23,407.7 ± 29,105.5 mIU/ml. The average of blood loss during D&C was 19.2 ± 43.6 ml. The average hospitalization time after D&C was 3.5 ± 1.1 days. Of the 53 cases, 10 patients were lost to follow-up and 43 patients agreed to follow-up on reproductive outcomes in 2021. Twenty-three patients who desired to conceive were analyzed. Nineteen out of these 23 women (82.6%) succeeded in conceiving again and gave birth to 15 healthy babies (78.9%). Only one woman (1/19, 5.3%) experienced recurrence of CSP. The average time interval between previous CSP treatment and subsequent conception was 10.4 ± 6.7 months. CONCLUSION UAE combined with curettage treatment in CSP patients results in a positive rate of subsequent pregnancy outcomes. This minimally invasive procedure may be considered as one of the treatment options for CSP, as it enables preservation of fertility after treatment.
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Affiliation(s)
- Yi-Ting Chen
- Department of Obstetrics and Gynecology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yu-Ching Chen
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
| | - Ming Chen
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Jun Chang
- Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shiao-Hsuan Yang
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
| | - Horng-Der Tsai
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan
| | - Cheng-Hsuan Wu
- Department of Obstetrics and Gynecology, Changhua Christian Hospital, Changhua, Taiwan; NUWA Fertility Center, Taichung, Taiwan; School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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Jurkovic D, Tellum T, Kirk E. Cesarean scar pregnancy IS an ectopic pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:831-832. [PMID: 35642911 DOI: 10.1002/uog.24921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/22/2022] [Indexed: 05/27/2023]
Affiliation(s)
- D Jurkovic
- Institute for Women's Health, University College Hospital, London, UK
| | - T Tellum
- Department of Gynecology, Oslo University Hospital, Oslo, Norway
| | - E Kirk
- Early Pregnancy and Emergency Gynaecology Unit, Royal Free London NHS Foundation Trust, London, UK
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Fu L, Luo Y, Huang J. Cesarean scar pregnancy with expectant management. J Obstet Gynaecol Res 2022; 48:1683-1690. [PMID: 35384174 PMCID: PMC9324103 DOI: 10.1111/jog.15258] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 03/15/2022] [Accepted: 03/27/2022] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Liye Fu
- Department of Medical Imaging, Medical College of Yangtze University, Jingzhou, Hubei, China.,Department of Ultrasonography, Changsha Hospital for Maternal and Child Health Care, Changsha, Hunan, China
| | - Yingchun Luo
- Department of Ultrasonography, Maternal and Child Health Hospital of Hunan Province, Changsha, Hunan, China
| | - Jinbai Huang
- Department of Medical Imaging, Medical College of Yangtze University, Jingzhou, Hubei, China.,Department of Medical Imaging, The First Affiliated Hospital of Yangtze University, Jingzhou, Hubei, China
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D'Antonio F, Timor-Tritsch IE, Khalil A, Calì G. New classification of placenta accreta spectrum disorders should include presence of Cesarean scar pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:563. [PMID: 35363411 DOI: 10.1002/uog.24880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/20/2022] [Indexed: 06/14/2023]
Affiliation(s)
- F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - G Calì
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Villa Sofia Cervello, Palermo, Italy
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Timor-Tritsch IE. A Cesarean scar pregnancy is not an ectopic pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:424-427. [PMID: 35266211 DOI: 10.1002/uog.24877] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/10/2022] [Accepted: 01/20/2022] [Indexed: 06/14/2023]
Affiliation(s)
- I E Timor-Tritsch
- NYU Langone Health, Department of Obstetrics and Gynecology, 550 First Avenue, New York, NY, 10016, USA
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Jordans IPM, Verberkt C, De Leeuw RA, Bilardo CM, Van Den Bosch T, Bourne T, Brölmann HAM, Dueholm M, Hehenkamp WJK, Jastrow N, Jurkovic D, Kaelin Agten A, Mashiach R, Naji O, Pajkrt E, Timmerman D, Vikhareva O, Van Der Voet LF, Huirne JAF. Definition and sonographic reporting system for Cesarean scar pregnancy in early gestation: modified Delphi method. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:437-449. [PMID: 34779085 PMCID: PMC9322566 DOI: 10.1002/uog.24815] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 10/30/2021] [Accepted: 11/05/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE To develop a standardized sonographic evaluation and reporting system for Cesarean scar pregnancy (CSP) in the first trimester, for use by both general gynecology and expert clinics. METHODS A modified Delphi procedure was carried out, in which 28 international experts in obstetric and gynecological ultrasonography were invited to participate. Extensive experience in the use of ultrasound to evaluate Cesarean section (CS) scars in early pregnancy and/or publications concerning CSP or niche evaluation was required to participate. Relevant items for the detection and evaluation of CSP were determined based on the results of a literature search. Consensus was predefined as a level of agreement of at least 70% for each item, and a minimum of three Delphi rounds were planned (two online questionnaires and one group meeting). RESULTS Sixteen experts participated in the Delphi study and four Delphi rounds were performed. In total, 58 items were determined to be relevant. We differentiated between basic measurements to be performed in general practice and advanced measurements for expert centers or for research purposes. The panel also formulated advice on indications for referral to an expert clinic. Consensus was reached for all 58 items on the definition, terminology, relevant items for evaluation and reporting of CSP. It was recommended that the first CS scar evaluation to determine the location of the pregnancy should be performed at 6-7 weeks' gestation using transvaginal ultrasound. The use of magnetic resonance imaging was not considered to add value in the diagnosis of CSP. A CSP was defined as a pregnancy with implantation in, or in close contact with, the niche. The experts agreed that a CSP can occur only when a niche is present and not in relation to a healed CS scar. Relevant sonographic items to record included gestational sac (GS) size, vascularity, location in relation to the uterine vessels, thickness of the residual myometrium and location of the pregnancy in relation to the uterine cavity and serosa. According to its location, a CSP can be classified as: (1) CSP in which the largest part of the 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. The type of CSP may change with advancing gestation. Future studies are needed to validate this reporting system and the value of the different CSP types. CONCLUSION Consensus was achieved among experts regarding the sonographic evaluation and reporting of CSP in the first trimester. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- I. P. M. Jordans
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”, Amsterdam UMClocation VU Medical CenterAmsterdamThe Netherlands
| | - C. Verberkt
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”Amsterdam UMC, location AMCAmsterdamThe Netherlands
| | - R. A. De Leeuw
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”Amsterdam UMC, location AMCAmsterdamThe Netherlands
- Department of Obstetrics and GynecologyAmsterdam UMC, location AMCAmsterdamThe Netherlands
| | - C. M. Bilardo
- Department of Obstetrics and Gynecology, Amsterdam UMClocation VU Medical CenterAmsterdamThe Netherlands
| | - T. Van Den Bosch
- Department of Obstetrics and GynecologyUniversity Hospitals KU LeuvenLeuvenBelgium
- Laboratory for Tumor Immunology and ImmunotherapyKU LeuvenLeuvenBelgium
| | - T. Bourne
- Department of Obstetrics and GynecologyImperial College LondonLondonUK
| | - H. A. M. Brölmann
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”Amsterdam UMC, location AMCAmsterdamThe Netherlands
| | - M. Dueholm
- Department of Obstetrics and GynecologyAarhus University HospitalAarhusDenmark
| | - W. J. K. Hehenkamp
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”Amsterdam UMC, location AMCAmsterdamThe Netherlands
- Department of Obstetrics and GynecologyAmsterdam UMC, location AMCAmsterdamThe Netherlands
| | - N. Jastrow
- Department of Obstetrics and GynecologyHôpitaux Universitaires de GenèveGenevaSwitzerland
| | - D. Jurkovic
- Department of Obstetrics and GynecologyUniversity College HospitalLondonUK
| | - A. Kaelin Agten
- Department of Obstetrics and Gynecology, Nottingham University Hospitals NHSQueen's Medical CentreNottinghamUK
| | - R. Mashiach
- Department of Obstetrics and GynecologySheba Medical CenterRamat GanIsrael
- Sackler School of MedicineTel Aviv UniversityTel AvivIsrael
| | - O. Naji
- Department of Obstetrics and GynecologyImperial College LondonLondonUK
| | - E. Pajkrt
- Department of Obstetrics and GynecologyAmsterdam UMC, location AMCAmsterdamThe Netherlands
| | - D. Timmerman
- Department of Obstetrics and GynecologyUniversity Hospitals KU LeuvenLeuvenBelgium
| | - O. Vikhareva
- Department of Obstetrics and Gynecology, Skåne University Hospital MalmöLund UniversityMalmöSweden
| | - L. F. Van Der Voet
- Department of Obstetrics and GynecologyDeventer HospitalDeventerThe Netherlands
| | - J. A. F. Huirne
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”, Amsterdam UMClocation VU Medical CenterAmsterdamThe Netherlands
- Department of Obstetrics and Gynecology, Research Institute “Amsterdam Reproduction and Development”Amsterdam UMC, location AMCAmsterdamThe Netherlands
- Department of Obstetrics and GynecologyAmsterdam UMC, location AMCAmsterdamThe Netherlands
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Saleh MM, Mallmann MR, Essakly A, Drebber U, Kleinert R, Kütting F, Bratke G, Müller AM. Placental Invasion into the Small Bowel Intestine Through a Myomectomy Scar: A Case Report With Literature Review. Int J Gynecol Pathol 2022; 41:151-156. [PMID: 33782340 DOI: 10.1097/pgp.0000000000000778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although extremely rare, uterine damage after hysteroscopic myomectomy sets the precondition for various life-threatening placental attachment disorders like placenta percreta (PP) or scar pregnancy. Due to vast clinical similarities, these terms are often used interchangeably. We report a case of a 47-yr-old patient at 27 wk + 4 d of gestation who presented with rectal bleeding. Clinical history revealed a previous uterine posterior wall myomectomy. The patient received intensive diagnostic work-up including sonography and magnetic resonance imaging. Under the suspicion of a bleeding Meckel diverticulum, an emergency laparotomy was performed. Intraoperatively it was observed that the placental tissue infiltrated the small bowel intestine at the location of the previous myomectomy. The adjacent intestine and the infiltrating placenta were surgically removed. The placenta could be easily detached from the uterus, which is why no hysterectomy was performed. Retrospectively, no radiologic or clinical hints of PP or scar pregnancy were evident before the surgery. Moreover, the pathologic work-up carried out afterwards proved no histopathologic evidence for PP. Our case underlines several clinical and pathologic difficulties. First, invasive placenta disorders including infiltration of intestinal organs have to be considered even after minor surgical interventions such as myomectomy. Second, clinical presentation is extremely variable and sometimes misleading, depending on the localization and the type of invasion. Our case underlines the importance of histopathologic work-up for distinguishing between various placenta attachment disorders such as PP and scar pregnancy. Given the large overlap in clinical presentation, pathophysiology and definition, we propose that the current definitions for PP and scar pregnancy have to be carefully reevaluated and broadened.
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Zhang-Rutledge K, Pinson K, Perez M, Adami RR, Melber D, Jacobs M, Parast M, Lamale-Smith L, Averbach S, Hahn M, Pretorius D, Ballas J. FundAl Retroflexion (FAR) Angle is a Novel Sonographic Marker Associated With Cesarean Scar Pregnancies in the First Trimester: A Case-Control Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:327-333. [PMID: 33769573 DOI: 10.1002/jum.15704] [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: 09/17/2020] [Revised: 03/05/2021] [Accepted: 03/13/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Early diagnosis of Cesarean scar pregnancies (CSP) remains difficult. This study describes a novel sonographic marker, the FundAl Retroflexion (FAR) angle, that may be used in the first trimester. The objective of the study is to compare the FAR angle between CSP and normal pregnancies. METHODS For this case-control study, we reviewed images from our institution's database that were acquired from January 2016 to December 2019. All cases of CSP and randomly selected controls, defined as patients with history of Cesarean delivery and normal implantation, that underwent ultrasound evaluation at <14 weeks were included. The FAR angle, defined as the acute angle created between the endometrial echo and cervical canal, was measured. The mean FAR angle was then compared between the two groups and a receiver operating characteristic (ROC) curve was generated. RESULTS We identified 15 cases of CSP during the study period and were able to measure the FAR angle in 14 of the cases. The mean FAR angle was larger in CSP than in normal control pregnancies (45° versus 27°, respectively, P < 0.001). Using an ROC curve, a FAR angle cut off of 40° maximizes the ability to distinguish between CSP from normal pregnancies. CONCLUSIONS The FAR angle provides an easily obtainable and numerical measurement. CSP have larger FAR angle compared to normal controls with a distinguishing cut off of 40°. Larger studies are needed to determine if using the FAR angle can improve first trimester diagnosis for CSP.
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Affiliation(s)
- Kathy Zhang-Rutledge
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, La Jolla, California, USA
| | - Kelsey Pinson
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, La Jolla, California, USA
| | - Mishella Perez
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, La Jolla, California, USA
| | - Rebecca R Adami
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, La Jolla, California, USA
| | - Dora Melber
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, La Jolla, California, USA
| | - Marni Jacobs
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, La Jolla, California, USA
| | - Mana Parast
- Department of Pathology, University of California, La Jolla, California, USA
| | - Leah Lamale-Smith
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, La Jolla, California, USA
| | - Sarah Averbach
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, La Jolla, California, USA
| | - Michael Hahn
- Department of Radiology, University of California, La Jolla, California, USA
| | - Dolores Pretorius
- Department of Radiology, University of California, La Jolla, California, USA
| | - Jerasimos Ballas
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, La Jolla, California, USA
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An P, Zhang J, Yang F, Wang Z, Hu Y, Li X. USMRI Features and Clinical Data-Based Model for Predicting the Degree of Placenta Accreta Spectrum Disorders and Developing Prediction Models. Int J Clin Pract 2022; 2022:9527412. [PMID: 35685563 PMCID: PMC9159129 DOI: 10.1155/2022/9527412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/09/2021] [Accepted: 12/31/2021] [Indexed: 11/18/2022] Open
Abstract
AIM This study aimed to investigate the ability of ultrasound/magnetic resonance imaging (MRI) signature and clinical data-based model for preoperatively predicting the degree of placenta accreta spectrum disorders and develop combined prediction models. METHODS The clinicopathological characteristics, prenatal ultrasound images, and MRI features of 132 pregnant women with placenta accreta spectrum disorders at Xiangyang No. 1 People's Hospital were retrospectively reviewed from January 2016 to December 2020. In the training set of 99 patients, the ultrasound/MRI features model, clinical characteristics model, and combined model were developed by multivariate logistic regression analysis to predict the degree of placenta accreta spectrum disorders. The prediction performance of different models was compared using the Delong test. The developed models were validated by assessing their prediction performance in a test set of 33 patients. RESULTS The multivariate logistic regression analysis identified history of abortion, history of endometrial injury, and blurred boundary between the placenta and the myometrium/between the uterine serosa and the bladder to construct a combined model for predicting the degree of placenta accreta spectrum disorders (area under the curve (AUC) = 0.931; 95% confidence interval (CI): 0.882-0.980). The AUC of the clinical characteristics model and ultrasound/MRI features model was 0.858 (95% CI 0.794-0.921) and 0.709 (95% CI 0.624-0.798), respectively. The AUC of the combined model was significantly higher than that of the ultrasound/MRI features model (P < 0.001) or clinical characteristics model (P < 0.0015) in the training set. In the test set, the combined model also showed higher prediction performance. CONCLUSIONS Ultrasound/MRI-based signature is a powerful predictor for the degree of placenta accreta spectrum disorders in an early stage. A combined model (constructed with history of abortion, history of endometrial injury, and blurred boundary between the placenta and the myometrium/between the uterine serosa and the bladder) can improve the accuracy for predicting the degree of placenta accreta spectrum disorders in an early stage.
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Affiliation(s)
- Peng An
- Department of Radiology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, The First Clinical Medical College, 155 Hanzhong Road, Nanjing 210029, Jiangsu Province, China
| | - Junyan Zhang
- Department of Pharmacy and Laboratory, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
| | - Feng Yang
- Department of Radiology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
| | - Zhongqiu Wang
- Department of Radiology, The Affiliated Hospital of Nanjing University of Chinese Medicine, Jiangsu Province Hospital of Chinese Medicine, The First Clinical Medical College, 155 Hanzhong Road, Nanjing 210029, Jiangsu Province, China
| | - Yan Hu
- Department of Pharmacy and Laboratory, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
| | - Xiumei Li
- Department of Radiology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, China
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Yule CS, Lewis MA, Do QN, Xi Y, Happe SK, Spong CY, Twickler DM. Transvaginal Color Mapping Ultrasound in the First Trimester Predicts Placenta Accreta Spectrum: A Retrospective Cohort Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2735-2743. [PMID: 33724510 DOI: 10.1002/jum.15674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 02/01/2021] [Accepted: 02/14/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVES Ultrasound (US) prediction of placenta accreta spectrum (PAS) in the first trimester may be aided by postprocessing mechanisms employing color pixel quantification near the bladder-uterine serosal interface. Our objective was to create a postprocessing algorithm of color images to identify findings associated with PAS and compare quantification to sonologist impression in prospectively obtained cine US images. METHODS Transverse transvaginal (TV) US color cines obtained in the first trimester as part of a prospective study were reviewed. Investigators blinded to clinical outcomes reviewed anonymized cines that were archived and labeled the bladder-uterine serosal interface. Color pixels within 2 cm of the defined bladder-uterine serosal interface were ascertained using a Python-based plugin in the Horos open-source DICOM viewer. A sonologist classified the findings as suspicious for invasion, indeterminate, or normal. Statistical analysis was performed using Wilcoxon rank-sum test, Cochran-Armitage trend test, and calculation of receiver-operating characteristic (ROC) curves. RESULTS Fifty-four studies met inclusion criteria. Of those, six (11%) required hysterectomy with pathologic confirmation of PAS. Women requiring hysterectomy had a significantly higher color Doppler pixel area than those not requiring hysterectomy (P = .0205). A significant trend was identified in the sonologist impression of invasion (P = .0003). ROC's comparing sonologist impression to Doppler color imaging areas were comparable (P = .054). CONCLUSIONS Color Doppler mapping in the first trimester showed an increase in color pixel area near the bladder-uterine serosal interface in women requiring cesarean hysterectomy with histologically confirmed PAS at time of delivery, compared to women without hysterectomy or pathologic evidence of PAS.
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Affiliation(s)
- Casey S Yule
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Matthew A Lewis
- Department of Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Quyen N Do
- Department of Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Yin Xi
- Department of Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Clinical Science, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Sarah K Happe
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Catherine Y Spong
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
| | - Diane M Twickler
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
- Department of Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, TX, USA
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47
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Kassas JM, Blue LM, Brenner CA. In Vitro Fertilization in a Nulliparous Female Resulting in Placenta Increta and Postpartum Hemorrhage. Cureus 2021; 13:e18042. [PMID: 34671529 PMCID: PMC8520653 DOI: 10.7759/cureus.18042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/17/2022] Open
Abstract
A 32-year-old female with unexplained infertility delivered a healthy male infant at 39 weeks 0 days gestational age; the pregnancy was facilitated by in vitro fertilization. Shortly after delivery, she was found to have a morbidly adherent placenta. Attempted removal resulted in postpartum hemorrhage and ultimately hysterectomy after attempting multiple fertility preserving methods to achieve hemostatic control. Pathology results revealed a diagnosis of a 0.1 cm placenta increta (Grade 2 placental villi invasion), the least common diagnosis within the placenta accreta spectrum (PAS). Likely due to the small point of trophoblastic invasion, the diagnosis and outcome were not foreseen. This case highlights the need for additional data collection and development of standardized guidelines for the diagnosis and management of PAS, given a patient’s risk factors. Current research may be limited by stigmatization surrounding infertility and reproductive-altering surgeries (e.g. hysterectomy). Additionally, counseling in all stages of pregnancy is critical to achieving the best patient-centered outcomes.
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Affiliation(s)
| | - Lauren M Blue
- Obstetrics and Gynecology, Speare Memorial Hospital, Plymouth, USA
| | - Carol A Brenner
- Osteopathic Medicine, University of New England, Biddeford, USA
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48
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Panaitescu AM, Ciobanu AM, Gică N, Peltecu G, Botezatu R. Diagnosis and Management of Cesarean Scar Pregnancy and Placenta Accreta Spectrum: Case Series and Review of the Literature. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:1975-1986. [PMID: 33274770 DOI: 10.1002/jum.15574] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 06/12/2023]
Abstract
With an increased cesarean delivery rate, the incidence of abnormal placentation is steadily rising, and it is estimated to be around 1.7 per 1000 pregnancies for cesarean scar pregnancy and 1 per 500 pregnancies for placenta accreta spectrum disorder. Current evidence considers cesarean scar pregnancy and placenta accreta spectrum as being the same condition, with different aspects, of the same spectrum, having higher risks with advancing gestation. We present 7 cases, diagnosed and managed in our hospital, at different gestational ages. Early diagnosis is essential for appropriate counseling and subsequent management, and an ultrasound examination is the reference standard for diagnosis. Screening for an abnormally implanted placenta in the first trimester of pregnancy might improve the perinatal outcome and reduce maternal morbidity and mortality.
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Affiliation(s)
- Anca M Panaitescu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Filantropia Clinical Hospital, Bucharest, Romania
| | | | - Nicolae Gică
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Filantropia Clinical Hospital, Bucharest, Romania
| | - Gheorghe Peltecu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Filantropia Clinical Hospital, Bucharest, Romania
| | - Radu Botezatu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
- Filantropia Clinical Hospital, Bucharest, Romania
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49
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Rocha TAH, de Thomaz EBAF, de Almeida DG, da Silva NC, Queiroz RCDS, Andrade L, Facchini LA, Sartori MLL, Costa DB, Campos MAG, da Silva AAM, Staton C, Vissoci JRN. Data-driven risk stratification for preterm birth in Brazil: a population-based study to develop of a machine learning risk assessment approach. LANCET REGIONAL HEALTH. AMERICAS 2021; 3:100053. [PMID: 36777406 PMCID: PMC9904131 DOI: 10.1016/j.lana.2021.100053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/01/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
Abstract
Background Preterm birth (PTB) is a growing health issue worldwide, currently considered the leading cause of newborn deaths. To address this challenge, the present work aims to develop an algorithm capable of accurately predicting the week of delivery supporting the identification of a PTB in Brazil. Methods This a population-based study analyzing data from 3,876,666 mothers with live births distributed across the 3,929 Brazilian municipalities. Using indicators comprising delivery characteristics, primary care work processes, and physical infrastructure, and sociodemographic data we applied a machine learning-based approach to estimate the week of delivery at the point of care level. We tested six algorithms: eXtreme Gradient Boosting, Elastic Net, Quantile Ordinal Regression - LASSO, Linear Regression, Ridge Regression and Decision Tree. We used the root-mean-square error (RMSE) as a precision. Findings All models obtained RMSE indexes close to each other. The lower levels of RMSE were obtained using the eXtreme Gradient Boosting approach which was able to estimate the week of delivery within a 2.09 window 95%IC (2.090-2.097). The five most important variables to predict the week of delivery were: number of previous deliveries through Cesarean-Section, number of prenatal consultations, age of the mother, existence of ultrasound exam available in the care network, and proportion of primary care teams in the municipality registering the oral care consultation. Interpretation Using simple data describing the prenatal care offered, as well as minimal characteristics of the pregnant, our approach was capable of achieving a relevant predictive performance regarding the week of delivery. Funding Bill and Melinda Gates Foundation, and National Council for Scientific and Technological Development - Brazil, (Conselho Nacional de Desenvolvimento Científico e Tecnológico - CNPQ acronym in portuguese) Support of the research project named: Data-Driven Risk Stratification for Preterm Birth in Brazil: Development of a Machine Learning-Based Innovation for Health Care- Grant: OPP1202186.
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Affiliation(s)
- Thiago Augusto Hernandes Rocha
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America,Corresponding author: Thiago Augusto Hernandes Rocha, Duke University
| | | | | | - Núbia Cristina da Silva
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | - Luciano Andrade
- Department of Nursing, State University of the West of Parana, Foz do Iguaçu, Parana, Brazil
| | - Luiz Augusto Facchini
- Department of Social Medicine, Federal University of Pelotas, Pelotas, Rio Grande do Sul, Brazil
| | | | - Dalton Breno Costa
- The Federal University of Health Sciences of Porto Alegre. Porto Alegre, Rio Grande do Sul, Brazil
| | | | | | - Catherine Staton
- Duke Emergency Medicine, Duke University Medical Center, Durham, NC USA. Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - João Ricardo Nickenig Vissoci
- Duke Emergency Medicine, Duke University Medical Center, Durham, NC USA. Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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50
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Hu Q, Li C, Luo L, Li J, Zhang X, Chen S, Yang X. Clinical analysis of second-trimester pregnancy termination after previous caesarean delivery in 51 patients with placenta previa and placenta accreta spectrum: a retrospective study. BMC Pregnancy Childbirth 2021; 21:568. [PMID: 34407784 PMCID: PMC8375210 DOI: 10.1186/s12884-021-04017-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUNDS Pregnancy termination during the second trimester in patients with placenta previa and placenta accreta spectrum (PAS) is a complex and challenging clinical problem. Based on our literature review, there has been a relative increase in the number of such cases being treated by hysterotomy and/or local uterine lesion resection and repair. In the present study, a retrospective analysis was conducted to compare the clinical outcomes when different management strategies were used to terminate pregnancy in the patients with placenta previa and PAS. METHODS A total of 51 patients who underwent pregnancy termination in the second trimester in Beijing Obstetrics and Gynecology Hospital between June 2013 and December 2018 were retrospectively analyzed in this study. All patients having previous caesarean delivery (CD) were diagnosed with placenta previa status and PAS. RESULTS ① Among the 51 patients, 16 cases received mifepristone and misoprostol medical termination, 15 cases received mifepristone and Rivanol medical termination, but 1 of them was transferred to hysterotomy due to failed labor induction, another 20 cases were performed planned hysterotomy. There was no placenta percreta cases and uterine artery embolization (UAE) was all performed before surgery.② There were 31 cases who underwent medical termination and 30 cases were vaginal delivery. Dilation and evacuation (D&E) were used in 20 cases of medical abortion failure and in all 30 cases of difficult manual removal of placental tissue. ③ A statistically significant difference was found among the three different strategies in terms of gestational weeks, the type of placenta previa status, main operative success rate and β-HCG regression time (P < 0.05). ④ There were 4(7.8%) cases who were taken up for hysterectomy because of life-threatening bleeding or severe bacteremia during or after delivery and hysterotomy. The uterus was preserved with the implanted placenta partly or completely left in situ in 47(92.2%) cases. Combined medical and/or surgical management were used for the residual placenta and the time of menstrual recovery was 52(range: 33 to 86) days after pregnancy termination. CONCLUSIONS Terminating a pregnancy by vaginal delivery through medical induction of labor may be feasible if clinicians have an overall understanding of gestational age, the type of placenta previa status, the type of placenta accreta, and patients concerns about preserving fertility. A collaborative team effort in tertiary medical centers with a very experience MDT and combined application of multiple methods is required to optimize patient outcomes.
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Affiliation(s)
- Qiaofei Hu
- Department of Reproduction Regulation, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Changdong Li
- Department of Reproduction Regulation, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Lanrong Luo
- Department of Reproduction Regulation, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Jian Li
- Department of Reproduction Regulation, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Xiaofeng Zhang
- Department of Radiology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Suwen Chen
- Department of Reproduction Regulation, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China.
| | - Xiaokui Yang
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China.
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