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Yung KK, Lee LLL, Choy KW, Cheung ECW, Chan SSC, Cheung RYK. Treatment Outcomes of Cesarean Scar Pregnancy Under a Novel Classification System: A Retrospective Cohort Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:1421-1433. [PMID: 38634558 DOI: 10.1002/jum.16464] [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: 09/19/2023] [Revised: 04/02/2024] [Accepted: 04/06/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES To determine whether the new classification system published by Jordans et al for cesarean scar pregnancy (CSP) can guide management and treatment outcomes. METHODS A retrospective study of women diagnosed with CSP from October 2010 to December 2022 in a single tertiary center was performed. Sonographic records of these women were classified into three types according to the classification published by Jordans et al. Treatment outcomes were compared across each type of CSP. RESULTS The study included a total of 84 women, where 60 (71.4%), 17 (20.2%), and 7 (8.3%) of them were categorized into Type 1, 2, and 3 CSP, respectively. A total of 47 (55.9%) women were managed with methotrexate, 22 (26.2%) underwent surgical management of the CSP without removal of the Cesarean section (CS) niche, and 11 (13.1%) underwent surgery to remove the CSP and the CS niche. Overall treatment success rates for medical management and surgical management were 70 and 97%, respectively. Four women were managed expectantly and continued their pregnancies, among which three carried beyond 34 weeks and had good neonatal outcomes. CONCLUSIONS The classification as published by Jordans et al is easily replicable and readily implemented clinically. Our findings show that a higher proportion of Type 1 and Type 2 CSP were treated successfully by a less invasive medical approach with a high success rate, whereas most Type 3 CSP required surgical resection to successfully remove the CSP and the CS niche. Prospective studies are required to confirm these findings and further validate the clinical utility of this nomenclature system.
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Affiliation(s)
- Kar Kei Yung
- Department of Obstetrics and Gynecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Loreta Lai Loi Lee
- Department of Obstetrics and Gynecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Kwong Wai Choy
- Department of Obstetrics and Gynecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Eva Chun Wai Cheung
- Department of Obstetrics and Gynecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Symphorosa Shing Chee Chan
- Department of Obstetrics and Gynecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
| | - Rachel Yau Kar Cheung
- Department of Obstetrics and Gynecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, Hong Kong
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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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Pekar-Zlotin M, Maymon R, Nimrodi M, Zur-Naaman H, Melcer Y. Evaluation of Cesarean section scar using saline contrast sonohysterography in women with previous Cesarean scar pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:551-555. [PMID: 37983614 DOI: 10.1002/uog.27540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To evaluate Cesarean scar defects using saline contrast sonohysterography (SCSH) in women with a history of Cesarean scar pregnancy (CSP). METHODS A cohort of 38 non-pregnant women with a history of CSP treated with combined local and systemic methotrexate was investigated prospectively by SCSH. For the purpose of analysis, they were classified, according to the modified Delphi consensus criteria for CSP in early gestation, into three subgroups based on the depth of the gestational sac herniation in the midsagittal plane. Subgroup A included eight (21.1%) cases, in which the largest part of the gestational sac protruded towards the uterine cavity; Subgroup B included 20 (52.6%) cases, in which the largest part of the gestational sac was embedded in the myometrium; and Subgroup C included 10 (26.3%) cases, in which the gestational sac was located partially outside the outer contour of the cervix or uterus. RESULTS SCSH revealed that all women in Subgroup C had a uterine niche. The median niche length (P = 0.006) and depth (P = 0.015) were significantly greater in Subgroup C than in Subgroups A or B. The median residual myometrial thickness (RMT) was significantly lower in Subgroup C than in Subgroups A or B (P = 0.006). CONCLUSIONS Women with prior CSP who had a gestational sac protruding beyond the serosal line had a significantly greater niche length and depth, and lower RMT. This knowledge may guide individualized risk counseling. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M Pekar-Zlotin
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - R Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - M Nimrodi
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - H Zur-Naaman
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Y Melcer
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (formerly Assaf Harofeh Medical Center), Zerifin, Israel, affiliated with the School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
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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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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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Yara N, Kinjyo Y, Chinen Y, Kinjo T, Mekaru K. Placenta Accreta Spectrum with Ureteral Invasion due to Progression of Cesarean Scar Pregnancy. Case Rep Obstet Gynecol 2023; 2023:9065978. [PMID: 37840656 PMCID: PMC10576643 DOI: 10.1155/2023/9065978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/14/2023] [Accepted: 09/16/2023] [Indexed: 10/17/2023] Open
Abstract
Expectant management is not recommended for cesarean scar pregnancies because they are often associated with placenta accreta, cesarean hysterectomy, and massive life-threatening hemorrhages during delivery. Herein, we report a case of placenta accreta spectrum with ureteral invasion due to the progression of a cesarean scar pregnancy. Case. A 41-year-old woman, with a history of three cesarean sections and two miscarriages, was referred to our hospital at 25 weeks of gestation with a diagnosis of placenta accreta spectrum and bladder invasion. Although the gestational sac was located anterior to the lower uterine segment, a cesarean-scar pregnancy was not diagnosed. A cesarean hysterectomy was performed at 31 weeks of gestation with the placement of an aortic balloon. The placenta was found to adhere to the ureter with more than the expected parenchymal tissue displacement (FIGO Classification 3b). The ureter was not obstructed and was preserved by leaving the placenta slightly on the ureteral side. Postoperatively, a ureteral stent was placed because of the ureteral stricture in the area where the placenta had adhered. Two months after surgery, the ureteral stent was removed after observing an improvement in stenosis. An adherent placenta due to continued cesarean scar pregnancy should be managed by assuming placental invasion beyond the parenchyma into the ureter.
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Affiliation(s)
- Nana Yara
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, Japan
| | - Yoshino Kinjyo
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, Japan
| | - Yukiko Chinen
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, Japan
| | - Tadatsugu Kinjo
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, Japan
| | - Keiko Mekaru
- Department of Obstetrics and Gynecology, Graduate School of Medicine, University of the Ryukyus, Japan
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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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Pekar-Zlotin M, Zur-Naaman H, Maymon R, Tsviban A, Melcer Y. Outcomes of Cesarean Scar Pregnancies in Early Gestation According to the New Delphi Consensus Criteria. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:2039-2044. [PMID: 36929872 DOI: 10.1002/jum.16222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/10/2023] [Accepted: 03/01/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES Clinical evaluation of the new Delphi consensus definition of cesarean scar pregnancy (CSP) in early gestation. METHODS A retrospective cohort of 36 women diagnosed with CSP and treated with combined local and systemic methotrexate (MTX) between 2008 and 2021. The CSPs were classified according to the new Delphi consensus criteria into three subgroups based on the depth of the gestational sac herniation in the sagittal plane. Subgroup A included 8 (22.2%) cases in which the largest part of the gestational sac protruded toward the uterine cavity. Subgroup B included 22 (61.1%) cases in which the largest part of the gestational sac was embedded in the myometrium, and subgroup C included 6 (16.7%) cases in which the gestational was partially located outside the outer contour of the cervix or uterus. RESULTS The β-HCG level upon admission was significantly lower in subgroup A than in subgroups B or C (11,075 ± 7109, 18,787 ± 16,585, and 58,273 ± 55,267 mIU/mL, respectively, P = .01). All subgroup C patients had repeated courses of MTX and surgical interventions (laparotomy, uterine artery embolization, and operative hysteroscopy) at double the rate of subgroups A or B (100, 50, and 40.9%, respectively, P = .036). The duration of hospitalization was significantly shorter in subgroup A than in subgroups B or C (1.9 ± 1.5, 2.1 ± 1.1, and 5.4 ± 4.9 days, P = .01). CONCLUSIONS The outcome according to Delphi consensus criteria for defining CSP in early gestation has implications for clinical decision-making, patient care, and the follow-up of CSP.
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Affiliation(s)
- Marina Pekar-Zlotin
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hili Zur-Naaman
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anna Tsviban
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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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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12
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Wu BT, Feld Z, Creinin MD. Management of cesarean scar ectopic pregnancies at an academic referral center: A case series. Contraception 2023; 123:110021. [PMID: 36940910 DOI: 10.1016/j.contraception.2023.110021] [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: 12/06/2022] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 03/22/2023]
Abstract
OBJECTIVES To describe treatment and outcomes of patients with confirmed cesarean scar ectopic pregnancy (CSEP) at a tertiary referral center. STUDY DESIGN We reviewed a deidentified family planning clinical database for patients seen by our subspecialty service for CSEP from January 2017 through December 2021 in this case series. We extracted referral information, final diagnosis, management, and outcome measures including estimated blood loss, secondary procedures, and treatment complications. RESULTS Of 57 cases referred for suspected CSEPs, 23 (40%) had confirmed diagnoses; one additional case was diagnosed during clinic evaluation for early pregnancy loss. Most (n = 50 [88%]) referrals occurred in the last 2 years of the 5-year study period. Of 24 confirmed CSEP cases, eight were pregnancy losses at the time of diagnosis. Fourteen cases were ≤50 days gestation or gestational size (7 [50%] pregnancy losses) and 10 >50 days gestation (range 39-66 days). We treated all 14 patients ≤50 days primarily with suction aspiration under ultrasound guidance in an operating room with no complications and estimated blood loss of 14 ± 10 mL. Of the 10 patients>50 days (maximum 66 days), seven were managed with primary aspiration of which five were uncomplicated. We treated one patient (57 days) had primary intrauterine double-catheter balloon with immediate hemorrhage requiring uterine artery embolization followed by an uncomplicated suction aspiration. CONCLUSIONS Patients with confirmed CSEPs at 50 days or less gestation or gestational size can likely be primarily treated with suction aspiration with low risk for significant adverse outcomes. Treatment success and complications are directly related to gestational age at treatment. IMPLICATIONS Ultrasound-guided suction aspiration monotherapy should be considered for primary CSEP treatment up to 50 days and, with continued experience, may be reasonable beyond 50 days gestation. Invasive treatments or those that require multiple days and visits, such as methotrexate or balloon catheters, are not necessary for early CSEPs.
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Affiliation(s)
- Brenda T Wu
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Zoe Feld
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA.
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13
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Bartels HC, Brennan DJ, Timor-Tritsch IE, Agten AK. Global variation and outcomes of expectant management of CSP. Best Pract Res Clin Obstet Gynaecol 2023; 89:102353. [PMID: 37329645 DOI: 10.1016/j.bpobgyn.2023.102353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 06/19/2023]
Abstract
The incidence of Cesarean scar pregnancies (CSPs) is rising globally. Ultrasound criteria for the diagnosis of CSPs have been described by the International Society of Ultrasound in obstetrics and gynecology and appear to be well used in various centers around the world. There is no guidance on best practices for expectant management of CSP, and there is considerable variation in how this is offered globally. Many studies have reported significant maternal morbidity in cases of CSP with fetal cardiac activity managed expectantly, largely relating to hemorrhage and cesarean hysterectomy from placenta accreta spectrum. However, high live birth rates are also reported. Literature describing the diagnosis and expectant management of CSP in low-resource settings is lacking. Expectant management in selected cases where no fetal cardiac activity is present is a reasonable option and can be associated with good maternal outcomes. Standardization in reporting different types of CSPs and correlating these with pregnancy outcomes will be an important next step in developing guidance for expectant management of this high-risk pregnancy with a high burden of complications.
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Affiliation(s)
- Helena C Bartels
- Dept of UCD Obstetrics and Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Holles Street, Dublin 2, Ireland.
| | - Donal J Brennan
- University College Dublin Gynaecological Oncology Group (UCD-GOG), Mater Misericordiae University Hospital and St Vincent's University Hospital, Dublin, Ireland.
| | | | - Andrea Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, L8 7SS, United Kingdom.
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14
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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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15
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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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16
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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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17
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Hussein AM, Fox K, Bhide A, Elbarmelgy RA, Elbarmelgy RM, Thabet MM, Jauniaux E. The impact of preoperative ultrasound and intraoperative findings on surgical outcomes in patients at high‐risk of placenta accreta spectrum. BJOG 2022; 130:42-50. [DOI: 10.1111/1471-0528.17286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/26/2022] [Accepted: 08/13/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Ahmed M. Hussein
- Department of Obstetrics and Gynecology University of Cairo Cairo Egypt
| | - Karin Fox
- Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology Baylor College of Medicine Houston Texas USA
| | - Amar Bhide
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, St George's Hospital London
| | | | | | - Mohamed M. Thabet
- Department of Obstetrics and Gynecology University of Cairo Cairo Egypt
| | - Eric Jauniaux
- EGA Institute for Women’s Health Faculty of Population Health Sciences, University College London (UCL), London UK
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18
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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: 21] [Impact Index Per Article: 10.5] [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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19
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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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20
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Relationship of Placental Vascular Indices with Macroscopic, Histopathologic, and Intraoperative Blood Loss in Placenta Accreta Spectrum Disorders. Obstet Gynecol Int 2022; 2022:2830066. [PMID: 35784378 PMCID: PMC9249536 DOI: 10.1155/2022/2830066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/23/2022] [Accepted: 06/07/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction. Placenta accreta spectrum is an obstetrical complication with a high level of morbidity. The 3-dimensional (3D) power Doppler method has been widely used to improve the diagnosis. Therefore, this study aims to elucidate better the relationship of quantitative placental vascular indices towards macroscopic findings, histopathological grading, and intraoperative blood loss in the disorder. Methods. A preliminary study using a cross-sectional design was conducted on 34 clinically diagnosed women with PAS. The 3D power Doppler with the VOCAL II software was used to measure the level of vascularization index (VI), flow index (FI), and vascularization flow index (VFI). Gross anatomical appearance and histopathology results were categorized as accreta, increta, and percreta. In addition, the intraoperative blood loss level was measured, and 1500 mL was the cutoff for massive hemorrhage. Results. The vascularity indexes were VI = 44.2 (23.7–74.9), FI = 35.4 (24.9–57), and VFI = 15.3 (8.5–41.7). The FI value was significant in comparing gross pathological stages (
) and had a moderate positive correlation in relation to blood loss (r = 0.449). VI, FI, and VFI above the cutoff values were shown to be strongly associated with blood loss
1500 cc with aOR 7.00 (95% CI 1.23–39.56), aOR 10.00 (95% CI 1.58–63.09), and aOR 9.16 (95% CI 1.53–54.59), respectively. Conclusion. This preliminary study demonstrated an initial potential of the FI value from 3D USG power Doppler to predict the depth of PAS invasion before surgery and intraoperative blood loss level.
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21
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Shao M, Tang F, Ji L, Hu M, Zhang K, Pan J. The management of caesarean scar pregnancy with or without a combination of methods prior to hysteroscopy: ovarian reserve trends and patient outcomes. J Gynecol Obstet Hum Reprod 2022; 51:102417. [PMID: 35667588 DOI: 10.1016/j.jogoh.2022.102417] [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: 09/03/2021] [Revised: 05/15/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE This study compared the efficacy and safety of a combination of uterine artery embolization or methotrexate before hysteroscopy in the treatment of cesarean scar pregnancy. METHODS We divided 276 cesarean scar pregnancy patients into three groups. Group A underwent direct hysteroscopy; Group B received uterine artery embolization plus hysteroscopy; Group C received the systemic administration of methotrexate prior to hysteroscopy. RESULTS The patients in Group A lost significantly more blood than those in Groups B (P < 0.05). There were no significant differences between the three groups with regards to massive hemorrhage and transfusion (P > 0.05). None of the patients required hysterectomy. Group A was also associated with a significantly shorter period of hospitalization, reduced medical costs, and fewer adverse events than either Group B or C (P < 0.05). Moreover, among women of advanced age (≥35y), the levels of serum anti-Mullerian hormone in Group B were significantly lower than those of the baseline group (P<0.05), which were significantly lower than those in Group A after surgery (4.22 ± 2.35 vs 2.78± 1.89 ng/ml, P < 0.05). CONCLUSION Direct hysteroscopy is a reliable treatment option for most early type I cesarean scar pregnancy patients with a gestational sac. A combination of methotrexate and uterine artery embolization before hysteroscopy in these patients has limited remedial effects. uterine artery embolization may reduce ovarian reserve in patients aged ≥35y.
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Affiliation(s)
- Mingjun Shao
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Fei Tang
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Limei Ji
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Min Hu
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Keke Zhang
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Jiangfeng Pan
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China.
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22
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Grandelis A, Shaffer R, Tonick S. Uncommon Presentations of Ectopic Pregnancy. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anthony Grandelis
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
| | - Robyn Shaffer
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
| | - Shawna Tonick
- Department of Obstetrics and Gynecology, University of Colorado, Aurora, Colorado, USA
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23
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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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24
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Hussein AM, Elbarmelgy RA, Elbarmelgy RM, Thabet MM, Jauniaux E. Prospective evaluation of impact of post-Cesarean section uterine scarring in perinatal diagnosis of placenta accreta spectrum disorder. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:474-482. [PMID: 34225385 PMCID: PMC9311077 DOI: 10.1002/uog.23732] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 06/17/2021] [Accepted: 06/29/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Standardized ultrasound imaging and pathology protocols have recently been developed for the perinatal diagnosis of placenta accreta spectrum (PAS) disorders. The aim of this study was to evaluate prospectively the effectiveness of these standardized protocols in the prenatal diagnosis and postnatal examination of women presenting with a low-lying placenta or placenta previa and a history of multiple Cesarean deliveries (CDs). METHODS This was a prospective cohort study of 84 consecutive women with a history of two or more prior CDs presenting with a singleton pregnancy and low-lying placenta/placenta previa at 32-37 weeks' gestation, who were referred for perinatal care and management between 15 January 2019 and 15 December 2020. All women were investigated using the standardized description of ultrasound signs of PAS proposed by the European Working Group on abnormally invasive placenta. In all cases, the ultrasound features were compared with intraoperative and histopathological findings. Areas of abnormal placental attachment were identified during the immediate postoperative gross examination and sampled for histological examination. The data of a subgroup of 32 women diagnosed antenatally as non-PAS who had complete placental separation at birth were compared with those of 39 cases diagnosed antenatally as having PAS disorder that was confirmed by histopathology at delivery. RESULTS Of the 84 women included in the study, 42 (50.0%) were diagnosed prenatally as PAS and the remaining 42 (50.0%) as non-PAS on ultrasound examination. Intraoperatively, 66 (78.6%) women presented with a large or extended area of dehiscence and 52 (61.9%) with a dense tangled bed of vessels or multiple vessels running laterally and craniocaudally in the uterine serosa. A loss of clear zone was recorded on grayscale ultrasound imaging in all 84 cases, while there was no case with bladder-wall interruption or with a focal exophytic mass. Myometrial thinning (< 1 mm) in at least one area of the anterior uterine wall was found in 41 (97.6%) of the 42 cases diagnosed as non-PAS on ultrasound and 37 (88.1%) of the 42 diagnosed antenatally as PAS. Histological samples were available for all 48 hysterectomy specimens with abnormal placental attachment and for the three cases managed conservatively with focal myometrial resection and uterine reconstruction. Villous tissue was found directly attached to the superficial myometrium (placenta creta) in six of these cases and both creta villous tissue and deeply implanted villous tissue within the uterine wall (placenta increta) were found in the remaining 45 cases. There was no evidence of percreta placentation on histology in any of the PAS cases. Comparison of the main antenatal ultrasound signs and perioperative macroscopic findings between the two subgroups correctly diagnosed antenatally (32 non-PAS and 39 PAS) showed no significant difference with respect to the distribution of myometrial thinning and the presence of a placental bulge on ultrasound and of anterior uterine wall dehiscence intraoperatively. Compared with the non-PAS subgroup, the PAS subgroup showed significantly higher placental lacunae grade (P < 0.001) and more often hypervascularity of the uterovesical/subplacental area (P < 0.001), presence of bridging vessels (P = 0.027) and presence of lacunae feeder vessels (P < 0.001) on ultrasound examination, and increased vascularization of the anterior uterine wall intraoperatively (P < 0.001). CONCLUSIONS Remodeling of the lower uterine segment following CD scarring leads to structural abnormalities of the uterine contour on both ultrasound examination and intraoperatively, independently of the presence of accreta villous tissue on microscopic examination. These anatomical changes are often reported as diagnostic of placenta percreta, including cases with no histological evidence of PAS. Guided histological examination could improve the overall diagnosis of PAS and is essential to obtain evidence-based epidemiologic data. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A. M. Hussein
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - R. A. Elbarmelgy
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - R. M. Elbarmelgy
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - M. M. Thabet
- Department of Obstetrics and GynecologyUniversity of CairoCairoEgypt
| | - E. Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health SciencesUniversity College LondonLondonUK
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Feldman N, Maymon R, Jauniaux E, Manoach D, Mor M, Marczak E, Melcer Y. Prospective Evaluation of the Ultrasound Signs Proposed for the Description of Uterine Niche in Nonpregnant Women. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:917-923. [PMID: 34196967 DOI: 10.1002/jum.15776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/29/2021] [Accepted: 06/04/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To evaluate the new ultrasound-based signs for the diagnosis of post-cesarean section uterine niche in nonpregnant women. METHODS We investigated prospectively a cohort of 160 consecutive women with one previous term cesarean delivery (CD) between December 2019 and 2020. All women were separated into two subgroups according to different stages of labor at the time of their CD: subgroup A (n = 109; 68.1%) for elective CD and CD performed in latent labor at a cervical dilatation (≤4 cm) and subgroup B (n = 51; 31.9%); for CD performed during the active stage of labor (>4 cm). RESULTS Overall, the incidence of a uterine niche was significantly (P < .001) higher in women who had an elective (20/45; 44.4%) compared with those who had an emergent (21/115; 18.3%) CD. Compared with subgroup B, subgroup A presented with a significantly (P = .012) higher incidence of uterine niche located above the vesicovaginal fold and with a significantly (P = .0002) lower proportion of cesarean scar positioned below the vesicovaginal fold. There was a significantly (P < .001) higher proportion of women with a residual myometrial thickness (RMT) > 3 mm in subgroup A than in subgroup B and a significant negative relationship was found between the RMT and the cervical dilatation at CD (r = -0.22; P = .008). CONCLUSIONS Sonographic cesarean section scar assessment indicates that the type of CD and the stage of labor at which the hysterotomy is performed have an impact on the location of the scar and the scarification process including the niche formation and RMT.
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Affiliation(s)
- Noa Feldman
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK
| | - Danielle Manoach
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Matan Mor
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ewa Marczak
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yaakov Melcer
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center (Formerly Assaf Harofeh Medical Center), Affiliated With the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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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: 34] [Impact Index Per Article: 17.0] [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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Jauniaux E, Jurkovic D, Hussein AM, Burton GJ. New insights into the etiopathology of placenta accreta spectrum. Am J Obstet Gynecol 2022; 227:384-391. [PMID: 35248577 DOI: 10.1016/j.ajog.2022.02.038] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/07/2022] [Accepted: 02/21/2022] [Indexed: 11/19/2022]
Abstract
Placenta accreta has been described as a spectrum of abnormal attachment of villous tissue to the uterine wall, ranging from superficial attachment to the inner myometrium without interposing decidua to transmural invasion through the entire uterine wall and beyond. These descriptions have prevailed for more than 50 years and form the basis for the diagnosis and grading of accreta placentation. Accreta placentation is essentially the consequence of uterine remodeling after surgery, primarily after cesarean delivery. Large cesarean scar defects in the lower uterine segment are associated with failure of normal decidualization and loss of the subdecidual myometrium. These changes allow the placental anchoring villi to implant, and extravillous trophoblast cells to migrate, close to the serosal surface of the uterus. These microscopic features are central to the misconception that the accreta placental villous tissue is excessively invasive and have led to much confusion and heterogeneity in clinical data. Progressive recruitment of large arteries in the uterine wall, that is, helicine, arcuate, and/or radial arteries, results in high-velocity maternal blood entering the intervillous space from the first trimester of pregnancy and subsequent formation of placental lacunae. Recently, guided sampling of accreta areas at delivery has enabled accurate correlation of prenatal imaging data with intraoperative features and histopathologic findings. In more than 70% of samples, there were thick fibrinoid depositions between the tip of most anchoring villi and the underlying uterine wall and around all deeply implanted villi. The distortion of the uteroplacental interface by these dense depositions and the loss of the normal plane of separation are the main factors leading to abnormal placental attachment. These data challenged the classical concept that placenta accreta is simply owing to villous tissue sitting atop the superficial myometrium without interposed decidua. Moreover, there is no evidence in accreta placentation that the extravillous trophoblast is abnormally invasive or that villous tissue can cross the uterine serosa into the pelvis. It is the size of the scar defect, the amount of placental tissue developing inside the scar, and the residual myometrial thickness in the scar area that determine the distance between the placental basal plate and the uterine serosa and thus the risk of accreta placentation.
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Affiliation(s)
- Eric Jauniaux
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, London, United Kingdom.
| | - Davor Jurkovic
- Faculty of Population Health Sciences, Elizabeth Garrett Anderson Institute for Women's Health, Faculty of Population Health Sciences, London, United Kingdom
| | - Ahmed M Hussein
- Department of Obstetrics and Gynecology, University of Cairo, Cairo, Egypt
| | - Graham J Burton
- Department of Physiology, Development, and Neuroscience, University of Cambridge, Cambridge, United Kingdom
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Jauniaux E, Zosmer N, De Braud LV, Ashoor G, Ross J, Jurkovic D. Development of the utero-placental circulation in cesarean scar pregnancies: a case-control study. Am J Obstet Gynecol 2022; 226:399.e1-399.e10. [PMID: 34492222 DOI: 10.1016/j.ajog.2021.08.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/18/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cesarean scar pregnancies carry a high risk of pregnancy complications including placenta previa with antepartum hemorrhage, placenta accreta spectrum, and uterine rupture. OBJECTIVE To evaluate the development of utero-placental circulation in the first half of pregnancy in ongoing cesarean scar pregnancies and compare it with pregnancies implanted in the lower uterine segment above a previous cesarean delivery scar with no evidence of placenta accreta spectrum at delivery STUDY DESIGN: This was a retrospective case-control study conducted in 2 tertiary referral centers. The study group included 27 women who were diagnosed with a live cesarean scar pregnancy in the first trimester of pregnancy and who elected to conservative management. The control group included 27 women diagnosed with an anterior low-lying placenta or placenta previa at 19 to 22 weeks of gestation who had first and early second trimester ultrasound examinations. In both groups, the first ultrasound examination was carried out at 6 to 10 weeks to establish the pregnancy location, viability, and to confirm the gestational age. The utero-placental and intraplacental vasculatures were examined using color Doppler imaging and were described semiquantitatively using a score of 1 to 4. The remaining myometrial thickness was recorded in the study group, whereas the ultrasound features of a previous cesarean delivery scar including the presence of a niche were noted in the controls. Both the cesarean scar pregnancies and the controls had ultrasound examinations at 11 to 14 and 19 to 22 weeks of gestation. RESULTS The mean color Doppler imaging vascularity score in the ultrasound examination at 6 to 10 weeks was significantly (P<.001) higher in the cesarean scar pregnancy group than in the controls. High vascularity scores of 3 and 4 were recorded in 20 of 27 (74%) cases of the cesarean scar pregnancy group. There was no vascularity score of 4, and only 3 of 27 (11%) controls had a vascularity score of 3. In 15 of the 27 (55.6%) cesarean scar pregnancies, the residual myometrial thickness was <2 mm. In the ultrasound examination at 11 to 14 weeks, there was no significant difference between the groups in the number of cases with an increased subplacental vascularity. However, 12 cesarean scar pregnancies (44%) presented with 1 or more placental lacunae whereas there was no case with lacunae in the controls. Of the 18 cesarean scar pregnancies that progressed into the third trimester, 10 of them were diagnosed with placenta previa accreta at birth, including 4 creta and 6 increta. In the 19 to 22 weeks ultrasound examination, 8 of the 10 placenta accreta spectrum patients presented with subplacental hypervascularity, out of which 6 showed placental lacunae. CONCLUSION The vascular changes in the utero-placental and intervillous circulations in cesarean scar pregnancies are due to the loss of the normal uterine structure in the scar area and the development of placental tissue in proximity of large diameter arteries of the outer uterine wall. The intensity of these vascular changes, the development of placenta accreta spectrum, and the risk of uterine rupture are probably related to the residual myometrial thickness of the scar defect at the start of pregnancy. A better understanding of the pathophysiology of the utero-placental vascular changes associated with cesarean scar pregnancies should help in identifying those cases that may develop major complications. It will contribute to providing counseling for women about the risks associated with different management strategies.
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Affiliation(s)
- Eric Jauniaux
- EGA Institute for Women's Health, University College London, London, United Kingdom; Faculty of Population Health Sciences, University College London, London, United Kingdom.
| | - Nurit Zosmer
- Early Pregnancy and Gynaecology Assessment Unit, King's College Hospital, London, United Kingdom
| | - Lucrezia V De Braud
- EGA Institute for Women's Health, University College London, London, United Kingdom; Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Ghalia Ashoor
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, United Kingdom
| | - Jackie Ross
- Early Pregnancy and Gynaecology Assessment Unit, King's College Hospital, London, United Kingdom
| | - Davor Jurkovic
- EGA Institute for Women's Health, University College London, London, United Kingdom; Faculty of Population Health Sciences, University College London, London, United Kingdom
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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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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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The potential risk factors of placenta increta and the role of octamethylcyclotetrasiloxane. Arch Gynecol Obstet 2021; 306:723-734. [PMID: 34820720 DOI: 10.1007/s00404-021-06335-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The study aimed to investigate the potential risk factors for the placenta accreta spectrum (PAS), determine the predictive value of a diagnostic model, and evaluate the effects of octamethylcyclotetrasiloxane (OMCTS) on trophoblast proliferation and migration. METHODS This case-control study included 244 pregnant women with PAS and 327 normal pregnant women who visited Guangzhou Women and Children's Medical Centre, China, from January 2014 to December 2017. Blood was collected from 42 women with PAS and 77 controls, and plasma specimens were analyzed by gas chromatography-time-of-flight mass spectrometry. In addition, the proliferation and migration of trophoblast cells were examined after treatment with OMCTS. RESULTS We found an association between the risk of PAS and clinical factors related to fasting blood glucose levels (BS0, OR = 5.78), as well as factors related to endometrial injury [history of cesarean section (OR = 179.59), uterine scarring (OR = 68.37), and history of abortion (OR = 5.66)]. Equally important, pregnant women with PAS had significantly higher plasma OMCTS concentrations than controls. In vitro, we found that OMCTS could promote the proliferation and migration of HTR8/SVneo cells. The model of combining clinical factors and OMCTS had a good performance in PAS prediction (AUC = 0.97, 95% CI 0.78-0.93). CONCLUSIONS The early diagnosis of PAS in pregnant women requires assessing risk factors, metabolic status, and BS0 levels before 20 weeks of gestation. OMCTS may be related to the development of PAS by promoting trophoblast cell proliferation and migration.
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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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Chen ZY, Zhou Y, Qian Y, Luo JM, Huang XF, Zhang XM. Management of heterotopic cesarean scar pregnancy with preservation of intrauterine pregnancy: A case report. World J Clin Cases 2021; 9:6428-6434. [PMID: 34435008 PMCID: PMC8362565 DOI: 10.12998/wjcc.v9.i22.6428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/24/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Heterotopic cesarean scar pregnancy (HCSP) is very rare and has a high risk of massive uterine bleeding. Preservation of concurrent intrauterine pregnancy (IUP) is one of the great challenges in the management of HCSP. No universal treatment protocol has been established when IUP is desired to be preserved.
CASE SUMMARY We report a case of HCSP at 8+ wk gestation in a 34-year-old woman with stable hemodynamics. A two-step intervention was applied. Selective embryo aspiration was performed first, and surgical removal of ectopic gestational tissue by suction and curettage was performed 2 d later. Both steps were performed under ultrasound guidance. The patient had an uneventful course, and a healthy baby was delivered at 34+6 wk gestation.
CONCLUSION Selective embryo aspiration followed by suction and curettage was successful in the preservation of IUP in the management of HCSP. This approach is an alternative option for HCSP in the first trimester when the IUP is desired to be preserved.
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Affiliation(s)
- Zheng-Yun Chen
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Yong Zhou
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Yue Qian
- Department of Sonography, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Jia-Min Luo
- Department of Sonography, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Xiu-Feng Huang
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Xin-Mei Zhang
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
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An updated guide to the diagnosis and management of cesarean scar pregnancies. Curr Opin Obstet Gynecol 2021; 32:255-262. [PMID: 32618745 DOI: 10.1097/gco.0000000000000644] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW To review the current literature on the diagnosis and management of cesarean scar pregnancies RECENT FINDINGS: The incidence of cesarean scar pregnancies (CSPs) is increasing as a result of the increasing cesarean section rate, improved diagnostic capabilities, and a growing awareness. CSPs are associated with significant morbidity and early diagnosis is key. Diagnosis is best achieved with transvaginal ultrasound. Sonographic diagnostic criteria have been developed over decades and recently endorsed by the Society for Maternal-Fetal Medicine and other professional societies. The current categorization system differentiates CSPs that are endogenic or 'on the scar' from those that are exogenic or 'in the niche'. Following diagnosis, the challenge remains in determining the optimal management as multiple modalities can be considered. Studies have demonstrated the favorable outcomes with combined local and systemic methotrexate, surgical excision through multiple routes, and adjunctive therapies, such as uterine artery embolization or uterine balloons. The current evidence is insufficient to identify a single best treatment course and a combined approach to treatment is often required. SUMMARY Successful outcomes while minimizing complications can be achieved with a multidisciplinary, collaborative effort. Guidelines for cesarean scar pregnancies will continue to evolve as the published reports grow.
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De Braud LV, Knez J, Mavrelos D, Thanatsis N, Jauniaux E, Jurkovic D. Risk prediction of major haemorrhage with surgical treatment of live cesarean scar pregnancies. Eur J Obstet Gynecol Reprod Biol 2021; 264:224-231. [PMID: 34332219 DOI: 10.1016/j.ejogrb.2021.07.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 06/29/2021] [Accepted: 07/19/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the association between demographic and ultrasound variables and major intra-operative blood loss during surgical transcervical evacuation of live caesarean scar pregnancies. STUDY DESIGN This was a retrospective cohort study conducted in a tertiary referral center between 2008 and 2019. We included all women diagnosed with a live caesarean scar ectopic pregnancy who chose to have surgical management in the study center. A preoperative ultrasound was performed in each patient. All women underwent transcervical suction curettage under ultrasound guidance. Our primary outcome was the rate of postoperative blood transfusion. The secondary outcomes were estimated intra-operative blood loss (ml), rate of retained products of conception, need for repeat surgery, need for uterine artery embolization and hysterectomy rate. Descriptive statistics were used to describe the variables. Univariate and multivariable logistic regression models were constructed using the relevant covariates to identify the significant predictors for severe blood loss. RESULTS During the study period, 80 women were diagnosed with a live caesarean scar pregnancy, of whom 62 (78%) opted for surgical management at our center. The median crown-rump length was 9.3 mm (range 1.4-85.7). Median blood loss at the time of surgery was 100 ml (range, 10-2300), and six women (10%; 95%CI 3.6-20) required blood transfusion. Crown-rump length and presence of placental lacunae were significant predictive factors for the need for blood transfusion and blood loss > 500 ml at univariate analysis (p < .01); on multivariate analysis, only crown-rump length was a significant predictor for need for blood transfusion (OR = 1.072; 95% CI 1.02-1.11). Blood transfusion was required in 6/18 (33%) cases with the crown-rump length ≥ 23 mm (≥9+0 weeks of gestation), but in none of 44 women presenting with a crown-rump length < 23 mm (p < .01). CONCLUSION The risk of severe intraoperative bleeding and need for blood transfusion during or after surgical evacuation of live caesarean scar pregnancies increases with gestational age and is higher in the presence of placental lacunae. One third of women presenting at ≥ 9 weeks of gestation required blood transfusion and their treatment should be ideally arranged in specialized tertiary centers.
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Affiliation(s)
- Lucrezia V De Braud
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Jure Knez
- Clinic for Gynecology, University Medical Centre Maribor, Maribor, Slovenia
| | - Dimitrios Mavrelos
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Nikolaos Thanatsis
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Eric Jauniaux
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, United Kingdom
| | - Davor Jurkovic
- Institute for Women's Health, Faculty of Population Health Sciences, University College London, London, United Kingdom.
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Wu J, Ye J, OuYang Z, Wan Z, Zhang Q, Zhong B, Wei S. Outcomes of reproduction following cesarean scar pregnancy treatment: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 262:80-92. [PMID: 33993066 DOI: 10.1016/j.ejogrb.2021.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To explore the reproductive outcomes of women with a history of cesarean scar pregnancy (CSP) and the influence of various treatments on subsequent pregnancy outcomes. STUDY DESIGN The PubMed, Embase, Medline, Cochrane Library and ClinicalTrial.gov databases were searched for studies with the outcomes of pregnancy after CSP treatment. Studies that reported reproductive outcomes after CSP with more than 5 followed cases were included. The main data collected includes the treatment methods of CSP and subsequent pregnancy outcomes. The main information includes intrauterine pregnancy, recurrent CSP (RCSP), and spontaneous miscarriage, while the secondary information includes complications during pregnancies and the outcomes of childbirths. According to different treatments (conservative treatment, surgical treatment without resection of cesarean scar, and surgical treatment with resection of cesarean scar), a stratified analysis was carried out to compare the influence of treatments on subsequent pregnancy outcomes. RESULTS A total of 32 studies including 3380 cases of CSP met the inclusion criteria, of which 583 cases conceived again after treatment (including 292 cases of unexpected pregnancy), and finally 178 cases delivered successfully. The follow-up time ranged from 3 to 72 months. Among women with fertility requirements, a total of 291 cases in 403 women were successfully conceived during the follow-up period in 15 studies. Thence the pregnancy rate of women with fertility requirements was 76.2 %. Among all of the 583 successfully conceived women, 83.4 % of them had intrauterine pregnancy, while 15.3 % of cases were RCSP. The total ectopic pregnancy rate reached 16.6 %, covering RCSP and other sites of ectopic pregnancy. 14.6 % of intrauterine pregnancy experienced spontaneous miscarriage. The intrauterine pregnancy rates of the conservative treatment group, the surgical treatment without resection of cesarean scar group, and the surgical treatment with resection of cesarean scar group were 93.1 %, 80.1 % and 86.0 % respectively; the corresponding RCSP rates were 6.9 %, 15.6 % and 14.0 % respectively; and the corresponding spontaneous miscarriage rates were 20.7 %, 13.9 % and 22.2 % respectively. CONCLUSION The outcomes of reproduction after CSP included intrauterine pregnancy, RCSP and other sites of ectopic pregnancy. Women with a history of CSP still have a high pregnancy rate, but the risk of RCSP and spontaneous miscarriage is also increased. It is impossible to clarify the effect of different treatments on subsequent pregnancy. Whether the resection and repair of cesarean scar can ameliorate reproductive outcomes needs to be further assessed. Further large-scale prospective studies, even RCTs with long-term follow-up are needed to expound the outcomes of reproduction after CSP and the effect of different treatments on subsequent reproductive outcomes.
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Affiliation(s)
- Jiawen Wu
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Jianbin Ye
- Department of Intensive Care Unit, Puning People's Hospital, Puning, China
| | - Zhenbo OuYang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China.
| | - Zixian Wan
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Qiushi Zhang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Biting Zhong
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Shiyuan Wei
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
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Mo R, Kalburgi S, Thakur Y, Jadhav J. Successful hysteroscopy and curettage of a caesarean scar ectopic pregnancy. BMJ Case Rep 2021; 14:14/4/e241183. [PMID: 33858897 PMCID: PMC8055137 DOI: 10.1136/bcr-2020-241183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Caesarean scar ectopic pregnancies are the rarest type of ectopic pregnancy. The optimum management regime is not yet established. We report the case of a 39-year-old woman who presented at 11 weeks gestation with painless vaginal bleeding, having had 2 previous caesarean sections. Ultrasound revealed a gestational sac within the caesarean scar niche. On follow-up, her serial ß human chorionic gonadotropin (ßHCG) measurements fell significantly. The woman initially opted for conservative management but subsequently required surgical management. Hysteroscopy demonstrated a sac within the caesarean scar which was successfully evacuated by ultrasound-guided suction curettage, with no complications. Caesarean scar ectopic pregnancies are becoming increasingly common. Diagnosis is primarily through ultrasound using specified criteria. Management may be conservative, medical or surgical excision depending on the clinical circumstances. Hysteroscopy and suction curettage is an effective therapeutic option for caesarean scar ectopic management.
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Affiliation(s)
- Roxana Mo
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Sujatha Kalburgi
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Yatin Thakur
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Jitendra Jadhav
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
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Impact of location on placentation in live tubal and cesarean scar ectopic pregnancies. Placenta 2021; 108:109-113. [PMID: 33862520 DOI: 10.1016/j.placenta.2021.03.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/23/2021] [Accepted: 03/31/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION The objective of this study was to evaluate the impact of implantation outside the normal intra-uterine endometrium on development of the gestational sac. METHODS We reviewed and compared the ultrasound measurements and vascularity score around the gestational sac in 69 women diagnosed with a live tubal ectopic pregnancy (TEP) and 54 with a cesarean scar ectopic pregnancy (CSP) at 6-11 weeks of gestation who were certain of their last menstrual period. RESULTS The rate of a fetus with a cardiac activity in the study population was significantly (P < 0.001) higher in CSPs than in TEPs. The median maternal age, gravidity and parity were significantly (P =.005; P < 0.001 and P < 0.001, respectively) lower in the TEP than in the CSP group. The number of gestational sac size <5th centile for gestational age was significantly (P < 0.001) higher in the TEP than in the CSP group. There were no differences between the groups for the other ultrasound measurements. In cases matched for gestational age, the gestational sac size was significantly (P < 0.001) smaller in the TEP compared to the CSP group. There was a significant (P < 0.001) difference in the distribution of blood flow score with CSP presenting with higher incidence of moderate and high vascularity than TEP. DISCUSSION Both TEP and CSP are associated with a higher rate of miscarriage than intrauterine pregnancies and the slow development of the gestation sac is more pronounced in TEPs probably as a consequence of a limited access to decidual gland secretions.
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Liu Z, Shi Z, Wei Y, Dai Q, Liu X. Lacunar-like changes of the chorion: can it be a first-trimester ultrasound sign in predicting worse clinical outcome in cesarean scar pregnancy termination? J Matern Fetal Neonatal Med 2021; 34:2355-2362. [PMID: 33685328 DOI: 10.1080/14767058.2021.1888914] [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: 10/22/2022]
Abstract
OBJECTIVE To observe the lacunar-like changes in cesarean scar pregnancy (CSP) ultrasonography in first trimester and to explore its relationship with clinical outcome in early pregnancy termination. METHODS This is a retrospective case-control study. Patients who were diagnosed as CSP and chose to terminate pregnancy from January 2017 to April 2020 were enrolled. According to occurrence of lacunar-like change in chorion membrane, patients were divided into case and control group. The clinical manifestation, laboratory test, ultrasound data, and outcome were compared. RESULTS Fifty-five CSP patients were enrolled with 20 (36.4%) in case group and 35 (63.6%) in control group. As for ultrasound features, the maximum outer diameter of gestational mass (5.6 ± 2.5 cm vs. 3.9 ± 1.5 cm), the maximum thickness of the chorion membrane (median number 1.1 cm vs. 0.7 cm), the longitudinal diameter of the implanting part of gestational mass in uterine lower segment (3.3 ± 1.8 cm vs. 1.2 ± 0.5 cm), uterine lower segment protrusion incidence (12, 60% vs. 2, 5.7%), and the crown-rump length of fetus (median number 1.7 cm vs. 0.7 cm) were bigger or higher in case group than that of the control group; the minimum thickness of the uterine lower segment myometrium (median number 0.08 cm vs. 0.20 cm) was significantly thinner in case group. CDFI grading of case group was different from control group with more cases in higher grades. As for clinical outcome, the patients of case group showed more frequency of CSP lesion resection under open surgery or laparoscopy (7, 35% vs. 1, 2.86%) rather than suction curettage, more blood loss in surgery (median number 35 ml vs. 20 ml) and more hospitalization days (median number 7.5 d vs. 3.5 d) than control group. CONCLUSIONS Lacunar-like change of chorion can be detected in early gestation and may act as a predictor of complicated and worse clinical outcome.
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Affiliation(s)
- Zhenzhen Liu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhimin Shi
- Department of Ultrasound, Haidian Women and Children's Health Care Hospital, Beijing, China
| | - Yao Wei
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Qing Dai
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xinyan Liu
- Department of Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Rethinking Prenatal Screening for Anomalies of Placental and Umbilical Cord Implantation. Obstet Gynecol 2021; 136:1211-1216. [PMID: 33156190 DOI: 10.1097/aog.0000000000004175] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The most common anomalies of implantation of the placenta and umbilical cord include placenta previa, placenta accreta spectrum, and vasa previa, and are associated with considerable perinatal and maternal morbidity and mortality. There is moderate quality evidence that prenatal diagnosis of these conditions improves perinatal outcomes and the performance of ultrasound imaging in diagnosing them is considered excellent. The epidemiology of placenta previa is well known, and it is standard clinical practice to assess placental location at the routine screening second-trimester detailed fetal anatomy ultrasound examination. In contrast, the prevalence of placenta accreta spectrum and vasa previa in the general population is more difficult to evaluate because detailed confirmatory histopathologic data are not available in most studies. The sensitivity and specificity of ultrasonography for the diagnosis of these anomalies is also difficult to assess. Recent epidemiologic studies show an increase in the incidence of placental and umbilical cord implantation anomalies, which may be the result of increased use of assisted reproductive technology and cesarean delivery. There is good evidence to support targeted standardized protocols for women at high risk and that screening and diagnosing placenta accreta spectrum and vasa previa should be integrated into obstetric ultrasound training programs.
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Timor-Tritsch IE. Cesarean scar pregnancy: a therapeutic dilemma. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:32-33. [PMID: 33387410 DOI: 10.1002/uog.23549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 06/12/2023]
Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
- Department of Obstetrics and Gynecology, Division of Ob/Gyn Ultrasound, New York University Langone Health, New York, NY, USA
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Review of MRI imaging for placenta accreta spectrum: Pathophysiologic insights, imaging signs, and recent developments. Placenta 2020; 104:31-39. [PMID: 33238233 DOI: 10.1016/j.placenta.2020.11.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/25/2020] [Accepted: 11/11/2020] [Indexed: 01/05/2023]
Abstract
Placenta Accreta Spectrum (PAS) refers to the range of abnormally adhesive and penetrative placental tissue at a uterine scar. PAS is divided into accreta, increta, and percreta based on degree of myometrial invasion. Its incidence has increased, and PAS is now the leading indication for emergency peripartum hysterectomy in the setting of catastrophic hemorrhage from a non-separating placenta. The recent release of the International Federation of Gynecology and Obstetrics (FIGO) guidelines in 2018 coupled with the joint consensus statement from the Society of Abdominal Radiology (SAR) and European Society of Urogenital Radiology (ESUR) in 2020 reflect decades worth of diagnostic and therapeutic advances in this field. Although the increasing role of MRI in PAS diagnosis is evident, the literature on PAS reveals several disparate but conceptually overlapping MRI signs. Identifying and differentiating between placenta increta and percreta on imaging may be quite challenging even with MRI and sometimes even on final pathology. In this review, we aim to (i) provide a clarified understanding of PAS pathophysiology, (ii) comprehensively review and classify MRI signs based on pathophysiologic underpinnings, (iii) highlight shortcomings in the current PAS literature; and (iv) highlight best practice guidelines for imaging diagnosis of PAS.
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Pristavu A, Vinturache A, Mihalceanu E, Pintilie R, Onofriescu M, Socolov D. Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series. BMC Pregnancy Childbirth 2020; 20:617. [PMID: 33050911 PMCID: PMC7557042 DOI: 10.1186/s12884-020-03237-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022] Open
Abstract
Background There is no clear consensus on the management of caesarean scar pregnancy (CSP), a complex and life-threatening condition. The objective of this study was to present a novel approach to management of CSP that combines medical therapy of multidose methotrexate and mifepristone with active surgical management by uterine curettage and consecutive local haemostasis. Case presentation We report on a prospective case series of six women with first trimester pregnancy, in whom the diagnosis of CSP was confirmed by 2D and color Doppler transvaginal ultrasound and serial hormone chorionic gonadotropin (hCG) testing. Women were between 23 and 36 years old and had at least one previous delivery by caesarean. At admission, gestational age ranged between 6 to 14 weeks, and serum hCG levels between 397 and 23,000 mUI/ml. Upon decision of pregnancy termination, medical management was undertaken in all cases and 1 mg/kg systemic Methotrexate was administered between 1 and 5 daily doses. Mifepristone was part of the treatment in cases with live pregnancy. Surgical management was employed for the cases were an embryo was seen by ultrasound, being prompted by inadequate response to Methotrexate and/or signs of miscarriage with vaginal bleeding. Curettage combined with local isthmic balloon or vaginal pack tamponade prevented further complications. High treatment rates with preservation of fertility was achieved in all patients except one who underwent hysterectomy for invasive placentation. Ultrasound and hCG levels surveillance ensured that the resolution of pregnancy was achieved. Conclusion Women with history of delivery by caesarean section should be carefully monitored in future pregnancies for prompt diagnosis of CSP. Early diagnosis of CSP allows selection of successful conservative therapy. Through this case series we contribute with our experience to the body of knowledge about the management of this serious complication of early pregnancy.
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Affiliation(s)
- Anda Pristavu
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Angela Vinturache
- Department of Obstetrics & Gynaecology, Women's Centre, John Radcliffe University Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK.
| | - Elena Mihalceanu
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Radu Pintilie
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Mircea Onofriescu
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Demetra Socolov
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
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Happe SK, Rac MWF, Moschos E, Wells CE, Dashe JS, McIntire DD, Twickler DM. Prospective First-Trimester Ultrasound Imaging of Low Implantation and Placenta Accreta Spectrum. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1907-1915. [PMID: 32374433 DOI: 10.1002/jum.15295] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 02/27/2020] [Accepted: 03/24/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To prospectively evaluate low implantation of the gestational sac and other first-trimester ultrasound (US) parameters for prediction of placenta accreta spectrum (PAS). METHODS Women with a diagnosis of low implantation on clinically indicated first-trimester US underwent a transvaginal US examination at 10 to 13 weeks' gestation to assess the trophoblast location, anechoic areas, bridging vessels, and smallest myometrial thickness (SMT). The placental location was evaluated in the second trimester, and serial US examinations were performed in cases of low placentation. Placenta accreta spectrum was based on clinical findings and confirmed by histologic results. RESULTS Of 68 women, 40 (59%) had prior cesarean delivery (CD). Hysterectomy was performed in 8, all with prior CD. Of these, 7 (88%) had US suspicion of PAS. In 16 with prior CD and basalis overlying the internal os, 9 (56%) had second-trimester placenta previa, and 7 of 9 (78%) underwent hysterectomy with pathologic confirmation of PAS. Of 28 without prior CD, there were no cases of persistent low placentation in the third trimester regardless of the trophoblast location. Ultrasound parameters associated with PAS were a smaller distance from the inferior trophoblastic border to the external os, disruption of the bladder-serosal interface, bridging vessels, anechoic areas, and the SMT. In women with prior CD, use of the SMT in the sagittal plane yielded an area under the receiver operating characteristic curve of 0.96 (95% confidence interval, 0.91-1.00). CONCLUSIONS First-trimester low implantation increases the risk of persistent placenta previa and PAS in women with prior CD. All parameters were associated with PAS, the most predictive being the SMT.
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Affiliation(s)
- Sarah K Happe
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Martha W F Rac
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas, USA
- Department of Radiology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas, USA
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA
| | | | - C Edward Wells
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Jodi S Dashe
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Donald D McIntire
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas, USA
| | - Diane M Twickler
- Departments of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Parkland Health and Hospital System, Dallas, Texas, USA
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Kutlesic R, Kutlesic M, Vukomanovic P, Stefanovic M, Mostic-Stanisic D. Cesarean Scar Pregnancy Successfully Managed to Term: When the Patient Is Determined to Keep the Pregnancy. ACTA ACUST UNITED AC 2020; 56:medicina56100496. [PMID: 32987706 PMCID: PMC7598584 DOI: 10.3390/medicina56100496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023]
Abstract
Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy, defined as the implantation of the gestational sac at the uterine incision scar of the previous cesarean section. This condition is associated with severe maternal and fetal/neonatal complications, including severe bleeding, rupture of the uterus, fetal demise, or preterm delivery. In view of these, early diagnosis allows the option of termination of pregnancy. In this case report, we present a patient with a cesarean scar pregnancy who was diagnosed at the sixth week of gestation but declined early termination of the pregnancy and was managed to the 38th week. Placenta previa was confirmed in the second trimester. A planned cesarean section was performed that resulted in the birth of a live full-term neonate. Intraoperatively, placenta percreta was diagnosed, and due to uncontrollable bleeding, a hysterectomy was performed. The postoperative course was uneventful. In cases where an early diagnosis of CSP is made, women should be counseled that this will almost certainly evolve to placenta previa, and the associated risks should be explained. Close follow-up of CSP is mandatory if expectant management is selected. Further studies are needed for definitive conclusions and to determine the risks of expectant management.
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Affiliation(s)
- Ranko Kutlesic
- Clinic of Gynaecology and Obstetrics, University Clinical Centre Nis, 18000 Nis, Serbia; (P.V.); (M.S.)
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia
- Correspondence:
| | - Marija Kutlesic
- Department of Anaesthesia, Clinic of Gynaecology and Obstetrics, University Clinical Centre Nis, 18000 Nis, Serbia;
| | - Predrag Vukomanovic
- Clinic of Gynaecology and Obstetrics, University Clinical Centre Nis, 18000 Nis, Serbia; (P.V.); (M.S.)
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia
| | - Milan Stefanovic
- Clinic of Gynaecology and Obstetrics, University Clinical Centre Nis, 18000 Nis, Serbia; (P.V.); (M.S.)
- Faculty of Medicine, University of Nis, 18000 Nis, Serbia
| | - Danka Mostic-Stanisic
- Institute of Gynaecology and Obstetrics Belgrade, Clinical centre of Serbia, 11000 Belgrade, Serbia;
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Doulaveris G, Ryken K, Papathomas D, Estrada Trejo F, Fazzari MJ, Rotenberg O, Stone J, Roman AS, Dar P. Early prediction of placenta accreta spectrum in women with prior cesarean delivery using transvaginal ultrasound at 11 to 14 weeks. Am J Obstet Gynecol MFM 2020; 2:100183. [PMID: 33345909 DOI: 10.1016/j.ajogmf.2020.100183] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is a growing body of evidence that sonographic signs of placenta accreta spectrum can be observed in the first trimester of pregnancy. The most significant marker is placental location next to or in the scar niche in women with a prior cesarean delivery. OBJECTIVE This study aimed to assess the performance of transvaginal ultrasound in the early prediction of placenta accreta spectrum in women with a prior cesarean delivery. STUDY DESIGN This was a retrospective cohort of women with a history of cesarean delivery who had transvaginal ultrasound at 11 to 14 weeks' gestation between September 2016 and May 2018. Ultrasound reports were reviewed and graded for suspicion of placenta accreta spectrum as follows: Grade 0 (no suspicion) if the placenta is not next to the scar; Grade 1 (intermediate suspicion) if the placenta is next or on the scar; Grade 2 (high suspicion) if the placenta was inside the scar niche. In addition, all images were reviewed and graded by trained specialists blinded to the outcome. The primary outcome was a histologic diagnosis of placenta accreta spectrum. Sensitivity, specificity, positive predictive value, and negative predictive value of first-trimester transvaginal ultrasound to detect placenta accreta spectrum were assessed. RESULTS In this study, 467 patients were included, and 8 (1.7%) had placenta accreta spectrum at delivery. Using the original report, 442 patients (94.6%) were Grade 0, 20 (4.3%) Grade 1, and 5 (1.1%) Grade 2. The revised grading had 456 patients (97.6%) with Grade 0, 5 (1.1%) with Grade 1, and 6 (1.3%) with Grade 2. Patients with Grade 2 yielded a sensitivity of 62.5% (95% confidence interval, 24.5-91.5), specificity of 100% (95% confidence interval, 99.2-100.0), positive predictive value of 100% (95% confidence interval, 97.0-100.0), and negative predictive value of 99.4% (95% confidence interval, 98.4-99.7). Any sonographic suspicion of placenta accreta spectrum (Grade 1 or Grade 2) had a sensitivity of 75% (95% confidence interval, 34.9-96.8), specificity of 95.9% (95% confidence interval, 93.6-97.5), positive predictive value of 24% (95% confidence interval, 14.8-36.4), and negative predictive value of 99.6% (95% confidence interval, 98.5-99.9). The blinded image review yielded a better specificity (99.1% vs 95.9%; P=.001) and a positive predictive value (63.6% vs 24%; P=.02) with similar sensitivity (87.5% vs 75%; P=.52) and negative predictive value (99.8% vs 99.6%; P=.55). CONCLUSION Transvaginal ultrasound between 11 and 14 weeks' gestation in women a with prior cesarean delivery can identify at least 3 of 4 cases of placenta accreta spectrum. A finding of placental implantation within the scar niche has high positive predictive value for placenta accreta spectrum. Prospective studies are needed to assess routine screening for placenta accreta spectrum at 11 to 14 weeks' gestation in women with a prior cesarean delivery.
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Affiliation(s)
- Georgios Doulaveris
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Katherine Ryken
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Daphne Papathomas
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Fatima Estrada Trejo
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Melissa J Fazzari
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Ohad Rotenberg
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY
| | - Joanne Stone
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashley S Roman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, New York University Langone Health, New York, NY
| | - Pe'er Dar
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
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Yu FNY, Leung KY. Antenatal diagnosis of placenta accreta spectrum (PAS) disorders. Best Pract Res Clin Obstet Gynaecol 2020; 72:13-24. [PMID: 32747328 DOI: 10.1016/j.bpobgyn.2020.06.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 06/22/2020] [Accepted: 06/25/2020] [Indexed: 11/25/2022]
Abstract
Antenatal diagnosis of placenta accreta spectrum (PAS) disorders allows planned management by a multidisciplinary team in a tertiary center, and thus can reduce hemorrhagic morbidity, compared with intrapartum diagnosis. Previous Cesarean section and placenta previa are the two most common risk factors. Prenatal ultrasound is a promising diagnostic tool for PAS in the second or third trimester. Recent evidence shows sonographic markers of PAS can be present in the first trimester. Prenatal ultrasound may help predict the depth and topography of placental invasion which are the major determinants of maternal morbidity. The presence of increased vascularity in the inferior part of the lower uterine segment and the parametrial region is associated with a more severe disorder according to a newly proposed staging system. In this chapter, we will discuss how to improve the prediction of PAS, the depth, and topography of placental invasion.
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Affiliation(s)
- Florrie N Y Yu
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - K Y Leung
- Department of Obstetrics and Gynaecology, Queen Elizabeth Hospital, Hong Kong SAR, China; Gleneagles Hong Kong, Hong Kong SAR, China.
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Jauniaux E, Kingdom JC, Silver RM. A comparison of recent guidelines in the diagnosis and management of placenta accreta spectrum disorders. Best Pract Res Clin Obstet Gynaecol 2020; 72:102-116. [PMID: 32698993 DOI: 10.1016/j.bpobgyn.2020.06.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 06/13/2020] [Indexed: 02/06/2023]
Abstract
Accreta placentation and in particular its invasive forms are impacting maternal health outcomes globally and the prevalence of placenta accreta spectrum (PAS) continues to increase. The Royal College of Obstetricians and Gynaecologists (RCOG) and the American College of Obstetricians and Gynecologists (ACOG) with the Society for Maternal-Fetal Medicine (SMFM) have updated their national guidelines, whereas the Federation International of Gynecology and Obstetrics (FIGO) and the Society of Obstetricians and Gynecologists of Canada (SOGC) have developed new guidelines on the diagnosis and management of PAS. A comparison of these guidelines highlights common strong recommendations on the need to carefully evaluate women at high risk for PAS (e.g. prior uterine surgery presenting with anterior low-lying placenta or placenta previa), using multi-modal ultrasound imaging. For women diagnosed with PAS, multidisciplinary team-based care, with full logistic support structures (immediate access to comprehensive blood products, adult and neonatal intensive care) and established expertise in complex pelvic surgery, is critical to maximise safe outcomes for mothers and newborns.
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Affiliation(s)
- Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - John C Kingdom
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Robert M Silver
- Department of Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
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Abstract
Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of 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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