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Palacios-Jaraquemada JM, Basanta NA, Nieto-Calvache ÁJ. Advanced repair of recurrent and low-large hysterotomy defects using a myometrial glide flap. J Matern Fetal Neonatal Med 2024; 37:2365344. [PMID: 38945839 DOI: 10.1080/14767058.2024.2365344] [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: 04/22/2024] [Accepted: 06/03/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND The resolution of factors linked to the recurrence of cesarean section defects can be accomplished through a comprehensive technique that effectively addresses the dehiscent area, eliminates associated intraluminal fibrosis, and establishes a vascularized anterior wall by creating a sliding myometrial flap. OBJECTIVE Propose a comprehensive surgical repair for recurrent and large low hysterotomy defects in women seeking pregnancy or recurrent spotting. STUDY DESIGN A retrospective cohort analysis included 54 patients aged 25-41 with recurrent large cesarean scar defects treated at Otamendi, CEMIC, and Valle de Lili hospitals. Comprehensive surgical repair was performed by suprapubic laparotomy, involving a wide opening of the vesicouterine space, removal of the dehiscent cesarean scar and all intrauterine abnormal fibrous tissues, using a glide myometrial flap, and intramyometrial injection of autologous platelet-rich plasma. Qualitative variables were determined, and descriptive statistics were employed to analyze the data in absolute frequencies or percentages. The data obtained were processed using the InfostatTM statistic program. RESULTS Following the repair, all women experienced normal menstrual cycles and demonstrated an adequate lower uterine segment thickness, with no evidence of healing defects. All patients experienced early ambulation and were discharged within 24 h. Uterine hemostasis was achieved at specific points, minimizing the use of electrocautery. The standard duration of the procedure was 60 min (skin-to-skin), and the average bleeding was 80-100 ml. No perioperative complications were recorded. A control T2-weighted MRI was performed six months after surgery. All patients displayed a clean, unobstructed endometrial cavity with a thick anterior wall (Median: 14.98 mm, IQR 13-17). Twelve patients became pregnant again, all delivered by cesarean between 36.1 and 38.0 weeks, with a mean of 37.17 weeks. The thickness of the uterine segment before cesarean ranged between 3 and 7 mm, with a mean of 3.91 mm. No cases of placenta previa, dehiscence, placenta accreta spectrum (PAS), or postpartum hemorrhage were reported. CONCLUSIONS The comprehensive repair of recurrent low-large defects offers a holistic solution for addressing recurrent hysterotomy defects. Innovative repair concepts effectively address the wound defect and associated fibrosis, ensuring an appropriate myometrial thickness through a gliding myometrial flap.
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Affiliation(s)
- José M Palacios-Jaraquemada
- OB-GYN Department, Otamendi Hospital, City of Buenos Aires, Argentina
- OB-GYN Department, CEMIC University Hospital, Buenos Aires, Argentina
- Anatomy Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Nicolás A Basanta
- OB-GYN Department, Otamendi Hospital, City of Buenos Aires, Argentina
- Anatomy Department, School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
- Fernández Hospital, City of Buenos Aires, Argentina
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Kennedy A, Debbink M, Griffith A, Kaiser J, Woodward P. Cesarean Scar Ectopic Pregnancy: A Do-Not-Miss Diagnosis. Radiographics 2024; 44:e230199. [PMID: 38843098 DOI: 10.1148/rg.230199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
The rate of cesarean section (CS) for delivery has increased internationally, reaching 50% in some countries. Abnormal implantation of a new pregnancy at the site of the prior hysterotomy is an important complication because of the risks of hemorrhage, uterine rupture, and progression to placenta accreta spectrum (PAS), a condition with high morbidity with potential for catastrophic obstetric hemorrhage, maternal and fetal mortality, and loss of fertility. Cesarean scar ectopic pregnancy (CSEP) is the recommended term to describe these pregnancies, which are recognized on the basis of the sac implantation site, growth pattern, and associated abnormal perfusion. The true incidence of CSEP is unknown because the condition is likely underdiagnosed and underreported. The 2022 Society for Maternal-Fetal Medicine consult series notes that severe maternal morbidity and mortality are linked to difficulty in making the diagnosis of CSEP. The authors review the signs of CSEP at imaging, some pitfalls that may lead to delayed or missed diagnosis, and the consequences thereof. CSEPs must be differentiated from low implantation of a normal pregnancy, cervical ectopic pregnancy, and evolving pregnancy loss. Early recognition allows prompt and safe treatment that is usually surgical. Early treatment results in decreased health care costs, a shorter hospital stay, preservation of fertility, and prevention of iatrogenic preterm delivery, which is typical in cases that progress to PAS. Hysterectomy has serious negative psychologic consequences for patients of childbearing age; early diagnosis and prompt treatment of CSEP can prevent this often-ignored complication. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Anne Kennedy
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Michelle Debbink
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - April Griffith
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Jennifer Kaiser
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Paula Woodward
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
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Timor-Tritsch IE, Monteagudo A, Goldstein SR. Early first-trimester transvaginal ultrasound screening for cesarean scar pregnancy in patients with previous cesarean delivery: analysis of the evidence. Am J Obstet Gynecol 2024:S0002-9378(24)00732-4. [PMID: 38955324 DOI: 10.1016/j.ajog.2024.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/04/2024]
Abstract
Obstetric hemorrhage is a leading cause of maternal morbidity and mortality. An important etiology of obstetric hemorrhage is placenta accreta spectrum. In the last 2 decades, there has been increased clinical experience of the devastating effect of undiagnosed, as well as late diagnosed, cases of cesarean scar pregnancy. There is a growing body of evidence suggesting that cesarean scar pregnancy is an early precursor of second- and third-trimester placenta accreta spectrum. As such, cesarean scar pregnancy should be diagnosed in the early first trimester. This early diagnosis could be achieved by introducing regimented sonographic screening in pregnancies of patients with previous cesarean delivery. This opinion article evaluates the scientific and clinical basis of whether cesarean scar pregnancy, with special focus on its early first-trimester discovery, complies with the accepted requirements of a screening test. Each of the 10 classical screening criteria of Wilson and Jungner were systematically applied to evaluate if the criteria were met by cesarean scar pregnancy, to analyze if it is possible and realistic to carry out screening in a population-wide fashion.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, Hackensack Meridian School of Medicine, Nutley, NJ.
| | - Ana Monteagudo
- Department of Obstetrics and Gynecology, Icahn School of Medicine, New York, NY
| | - Steven R Goldstein
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY
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Lei Y, Du X, Liu Y, Le F, Zhou J. Surgical treatment and reproductive outcomes in caesarean scar pregnancy at a single center. Reprod Biol Endocrinol 2024; 22:54. [PMID: 38734672 PMCID: PMC11088178 DOI: 10.1186/s12958-024-01225-7] [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: 11/13/2023] [Accepted: 05/01/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND To investigate factors associated with different reproductive outcomes in patients with Caesarean scar pregnancies (CSPs). METHODS Between May 2017 and July 2022, 549 patients underwent ultrasound-guided uterine aspiration and laparoscopic scar repair at the Gynaecology Department of Hubei Maternal and Child Health Hospital. Ultrasound-guided uterine aspiration was performed in patients with type I and II CSPs, and laparoscopic scar repair was performed in patients with type III CSP. The reproductive outcomes of 100 patients with fertility needs were followed up and compared between the groups. RESULTS Of 100 patients, 43% had live births (43/100), 19% had abortions (19/100), 38% had secondary infertility (38/100), 15% had recurrent CSPs (RCSPs) (15/100). The reproductive outcomes of patients with CSPs after surgical treatment were not correlated with age, body mass index, time of gestation, yields, abortions, Caesarean sections, length of hospital stay, weeks of menopause during treatment, maximum diameter of the gestational sac, thickness of the remaining muscle layer of the uterine scar, type of CSP, surgical method, uterine artery embolisation during treatment, major bleeding, or presence of uterine adhesions after surgery. Abortion after treatment was the only risk factor affecting RCSPs (odds ratio 11.25, 95% confidence interval, 3.302-38.325; P < 0.01) and it had a certain predictive value for RCSP occurrence (area under the curve, 0.741). CONCLUSIONS The recurrence probability of CSPs was low, and women with childbearing intentions after CSPs should be encouraged to become pregnant again. Abortion after CSP is a risk factor for RCSP. No significant difference in reproductive outcomes was observed between the patients who underwent ultrasound-guided uterine aspiration and those who underwent laparoscopic scar repair for CSP.
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Affiliation(s)
- Yan Lei
- Department of Gynecology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China.
| | - Xin Du
- Department of Gynecology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China
| | - Yu Liu
- Department of Gynecology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China
| | - Fangshu Le
- Department of Gynecology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China
| | - Jianshan Zhou
- Department of Gynecology, Maternal and Child Health Hospital of Hubei Province, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430070, China
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Khoiwal K, Sheoran D, Mishra R, Deshwali A, Chaturvedi J. Laparoscopic Excision of Cesarean Scar Ectopic Pregnancy: An Optimum Management Option. Gynecol Minim Invasive Ther 2024; 13:119-122. [PMID: 38911309 PMCID: PMC11192279 DOI: 10.4103/gmit.gmit_83_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/27/2023] [Accepted: 11/09/2023] [Indexed: 06/25/2024] Open
Abstract
Cesarean scar ectopic pregnancy is a leading cause of life-threatening complications in the first trimester. It poses a diagnostic and management challenge; if not diagnosed and adequately treated in early pregnancy, it may lead to considerable maternal morbidity and mortality. We report a case series of cesarean scar ectopic pregnancies managed successfully by laparoscopy. Laparoscopic excision is the gold standard management approach for cesarean scar ectopic pregnancy.
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Affiliation(s)
- Kavita Khoiwal
- Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India
| | - Deepika Sheoran
- Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India
| | - Ramya Mishra
- Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India
| | - Akanksha Deshwali
- Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India
| | - Jaya Chaturvedi
- Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India
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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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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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Morlando M, Conte A, Schiattarella A. Reproductive outcome after cesarean scar pregnancy. Best Pract Res Clin Obstet Gynaecol 2023; 91:102362. [PMID: 37355427 DOI: 10.1016/j.bpobgyn.2023.102362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 05/09/2023] [Indexed: 06/26/2023]
Abstract
Cesarean scar pregnancy (CSP) rate is rising worldwide, in parallel with the rising rates of cesarean delivery. Multiple therapeutic strategies and a timely diagnosis have led to a successful management in most cases, with many women preserving fertility after treatment. Despite this, still little is known regarding pregnancy outcomes after a CSP. The main adverse outcomes reported after CSP are recurrence of CSP, miscarriage, preterm birth, placenta accreta spectrum (PAS) disorders and uterine rupture. In addition, little is known about the influence of the different treatments on subsequent pregnancy outcomes after a CSP. Being aware of the impact of the different management strategies on the fertility outcomes is highly relevant to counsel pregnant women after a CSP. The aim of this manuscript is to provide an up-to-date review of the reproductive outcomes of women with a history of CSP and of the influence of various treatments on subsequent pregnancy outcomes.
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Affiliation(s)
- Maddalena Morlando
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy.
| | - Anna Conte
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
| | - Antonio Schiattarella
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy
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Timor-Tritsch IE, Monteagudo A, Calì G, Kaelin Agten A, Palacios-Jaraquemada JM, D'Antonio F. Hidden in plain sight: role of residual myometrial thickness to predict outcome of Cesarean scar pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:624-632. [PMID: 37266902 DOI: 10.1002/uog.26246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 06/03/2023]
Affiliation(s)
- I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Hackensack Meridian School of Medicine and Maternal Resources, Hackensack, NJ, USA
| | - A Monteagudo
- Icahn School of Medicine, Carnegie Maternal-Fetal Associates, NY, USA
| | - G Calì
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit, Azienda Ospedaliera Villa Sofia-Cervello, Palermo, Italy
- Maternal-Fetal Unit, Candela Clinic, Palermo, Italy
| | - A Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UK
| | | | - F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
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Huang J, Phillips C, Moshiri M. Scarred for life: a review of cesarean section scar pregnancy and potential pitfalls in diagnosis. Abdom Radiol (NY) 2023; 48:2672-2683. [PMID: 37204508 DOI: 10.1007/s00261-023-03953-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/20/2023]
Abstract
Cesarean section scar pregnancy (CSSP) is defined as abnormal implantation of a gestational sac on or in a previous cesarean section scar. There is an increasing incidence of detection of CSSP, likely in part due to the growing rates of cesarean deliveries and the improved rates of detection with advancing ultrasound technology. Diagnosis of CSSP is critical due to the potentially life-threatening complications to the mother if left untreated. Pelvic ultrasound is the imaging modality of choice in the initial evaluation of suspected CSSP, with MRI potentially useful if ultrasound findings are equivocal, or if confirmation is requested prior to definitive intervention. Early and accurate diagnosis of CSSP allows for prompt management to avoid severe complications and the potential to preserve the uterus and future fertility. A combination of medical and surgical treatment strategies may be needed with specific therapy tailored to each patient. Follow-up after treatment should include serial beta-hCG levels and possible repeat imaging if there is clinical concern for complications or treatment failure. This article will provide a comprehensive review of this uncommon but important phenomenon, detailing the pathophysiology and types of CSSP, imaging presentations, potential pitfalls in diagnosis, and management options.
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Affiliation(s)
- Jennifer Huang
- Department of Radiology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA.
- PGY-5 Chief Resident, Diagnostic Radiology Residency, Vanderbilt University Medical Center, 1161 21st Ave South, Nashville, TN, 37232, USA.
| | - Catherine Phillips
- Department of Radiology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
| | - Mariam Moshiri
- Department of Radiology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
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Nijjar S, Jauniaux E, Jurkovic D. Definition and diagnosis of cesarean scar ectopic pregnancies. Best Pract Res Clin Obstet Gynaecol 2023; 89:102360. [PMID: 37356119 DOI: 10.1016/j.bpobgyn.2023.102360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/10/2023] [Accepted: 05/14/2023] [Indexed: 06/27/2023]
Abstract
Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy, where the pregnancy implants into a myometrial defect caused by a cesarean scar. Its incidence is predicted to increase, given the global increase in cesarean deliveries. As most cesarean scar ectopic pregnancies present as failing pregnancies or patients choose termination of pregnancy, there are limited data on their natural history. However, early first trimester diagnosis is essential, given the associated significant maternal morbidity. Transvaginal sonography is generally considered to be the optimal method for diagnosing cesarean scar ectopic pregnancy. There is no evidence that MRI adds to the diagnostic accuracy, and it is therefore not recommended for routine evaluation of cesarean scar ectopic pregnancy. There is no agreed reference standard for the diagnosis of cesarean scar ectopic pregnancy; therefore, the validity of several proposed sonographic diagnostic criteria reported by different authors remains unknown. There are also various suggested classification systems for cesarean scar ectopic pregnancy, which divide them in differet types. However, the proposals are very heterogeneous, and superiority of one classification system over another is yet to be established.
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Affiliation(s)
- Simrit Nijjar
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Davor Jurkovic
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
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El Sabbagh A, Sayour I, Sleiman Z, Centini G, Lazzeri L, Giorgi M, Zupi E, Habib N. “In Situ” Methotrexate Injection Followed by Hysteroscopic Resection for Caesarean Scar Pregnancy: A Single-Center Experience. J Clin Med 2023; 12:jcm12062304. [PMID: 36983303 PMCID: PMC10059207 DOI: 10.3390/jcm12062304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023] Open
Abstract
Background: We evaluated the efficacy of local methotrexate (MTX) treatment followed by hysteroscopic resection for caesarean scar pregnancy and its impact on future fertility. Methods: Monocentric, prospective, observational study performed in the Haykel Hospital between June 2016 and December 2020. Twenty-one women with caesarean scar pregnancy underwent a transcutaneous ultrasound-guided direct injection of MTX into the gestational sac in an outpatient setting. Hysteroscopic resection of residual trophoblastic retention was then performed according to perisaccular blood flow. Main results: Two patients had complete spontaneous trophoblast expulsion after MTX injection, and hysteroscopy was performed in 19 patients for residual trophoblastic retention 1 to 12 weeks after MTX injection. Successful preservation of a healthy uterus with the combined procedure was obtained in 94.8% of patients. Hemostatic hysterectomy was required in one patient. Mean hospitalization duration was 1.5 days. Three patients had spontaneous pregnancy after the procedure. Conclusion: Direct MTX injection into the gestational sac for caesarean scar pregnancy followed by hysteroscopic resection was an effective technique with a short hospitalization, fertility preservation and a low major complication rate compared with other modalities of treatment reported in the literature. Further larger prospective comparative studies are needed to confirm the efficacy of this procedure.
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Affiliation(s)
| | - Ihsan Sayour
- Department of Surgery, Haykel Hospital, Tripoli 1300, Lebanon
| | - Zaki Sleiman
- Department of Obstetrics and Gynecology, Lebanese American University Medical Center-Rizk Hospital, Beirut 1100, Lebanon
| | - Gabriele Centini
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy
- Correspondence: (G.C.); (M.G.); Tel.: +39-0577-586643 (G.C.); +39-0577-586612 (M.G.)
| | - Lucia Lazzeri
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy
| | - Matteo Giorgi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy
- Correspondence: (G.C.); (M.G.); Tel.: +39-0577-586643 (G.C.); +39-0577-586612 (M.G.)
| | - Errico Zupi
- Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy
| | - Nassir Habib
- Department of Obstetrics and Gynecology Francois Quesnay Hospital, 78201 Mantes-La-Jolie, France
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Masten M, Alston M. Treatment of Recurrent Cesarean Scar Pregnancy With Oral Mifepristone, Systemic Methotrexate, and Ultrasound-Guided Suction Dilation and Curettage. Cureus 2023; 15:e36200. [PMID: 37065359 PMCID: PMC10104687 DOI: 10.7759/cureus.36200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Cesarean scar pregnancy (CSP), or pregnancies with implantation in a prior cesarean section scar, are rare but may be becoming more common with an increase in cesarean section deliveries. History of prior CSP may also increase the risk for recurrent CSP. Several treatment options and combinations of treatment options for CSP have been described in the literature. Although the optimal treatment is unclear, the Society of Maternal-Fetal Medicine published recommendation guidelines, which include recommendations for the treatment/termination of CSP pregnancies. Treatment of CSP is recommended with operative resection, ultrasound-guided suction dilation and curettage (D&C), or intragestational methotrexate with or without treatment modalities. This is a case report of a patient with recurrent CSP. Her first CSP was incorrectly diagnosed as an incomplete abortion after unsuccessful treatment with misoprostol alone and ultimately was successfully treated with systemic methotrexate. Her second CSP is the basis of this case report and was successfully treated with oral mifepristone and systemic methotrexate (50 milligrams/meter2) before an ultrasound-guided suction D&C at 10 weeks 1 day gestational age. The combination of mifepristone, systemic methotrexate, and suction D&C under ultrasound guidance as a treatment for recurrent CSP has not previously been described in published literature.
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He C, Xia W, Yan L, Wang Y, Tian Y, Mol BW, Zhang J, Huirne J. Fertility outcomes after hysteroscopic niche resection compared with expectant management in women with a niche in the uterine cesarean scar. Eur J Obstet Gynecol Reprod Biol 2023; 284:136-142. [PMID: 36989689 DOI: 10.1016/j.ejogrb.2023.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 03/01/2023] [Accepted: 03/10/2023] [Indexed: 03/14/2023]
Abstract
OBJECTIVE To determine whether hysteroscopic niche resection (HNR) and expectant management are suitable in women with fertility desire and a niche with a residual myometrium thickness (RMT) ≥ 2.5 mm. STUDY DESIGN This retrospective cohort study was conducted at International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China between September 2016 and December 2021. We reported the fertility outcomes between women (with fertility desire and a niche with RMT ≥ 2.5 mm) who received HNR or expectant management. RESULTS We studied 166 women, of whom 72 accepted HNR and 94 accepted expectant management. The HNR group included more symptomatic women, in terms of postmenstrual spotting or infertility. No differences were found regarding niche measures before treatment. The live birth rate was comparable in both groups (HNR versus expectant management as 55.5% versus 45.7%, risk ratio = 1.48, 95% Cl 0.80-2.75, p = 0.21). The pregnancy rate was higher in HNR group than that in expectant management group (n = 72.2% versus n = 56.4%, risk ratio = 2.01, 95% CI 1.04-3.88, p = 0.04). In a subgroup of women with infertility before entry in the study, HNR resulted in a significant higher live birth rate (p = 0.04) and pregnancy rate (p = 0.01). CONCLUSION In women with infertility with a symptomatic niche with RMT ≥ 2.5 mm, HNR may be superior to expectant management. This retrospective cohort biased selection against a randomized study, our results still need to be validated in the future with larger clinical multicenter randomized controlled trials.
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Affiliation(s)
- Chuqing He
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Wei Xia
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Li Yan
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Yang Wang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Yuan Tian
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Monash University, 246 Clayton Road, Clayton 3168, Victoria, Australia; Aberdeen Centre for Women's Health Research, University of Aberdeen, Aberdeen, UK
| | - Jian Zhang
- Department of Obstetrics and Gynecology, International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China; Shanghai Key Laboratory Embryo Original Diseases, Shanghai, China.
| | - Jaf Huirne
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Centre, Location AMC and VUmc, Amsterdam, The Netherlands
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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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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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17
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Wang J, Pang Q, Wei W, Cheng L, Huang F, Cao Y, Hu M, Yan S, He Y, Wei Z. Definition of large niche after Cesarean section based on prediction of postmenstrual spotting: Chinese cohort study in non-pregnant women. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:450-456. [PMID: 34806258 DOI: 10.1002/uog.24817] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE A large niche after Cesarean section (CS) is associated with long-term complications, of which postmenstrual spotting is associated positively with the size of the niche. However, the diagnosis of a large niche in the literature is inconsistent and the definition is largely subjective. The aim of this study was to generate a definition for a large niche in non-pregnant women based on the presence of postmenstrual spotting. METHODS Women who had undergone CS in our hospital between January 2012 and June 2017 were selected randomly from our database, contacted by telephone and subsequently examined between January 2016 and June 2020. Eligible for inclusion were non-pregnant women who had their last CS more than 1 year earlier and agreed to undergo transvaginal sonography (TVS). All participants underwent examination of their CS scar by TVS (two-dimensional color Doppler) during the midfollicular phase. Niche depth, length, width, residual myometrial thickness (RMT), adjacent myometrial thickness (AMT) and ratio of niche depth/AMT were recorded. Women diagnosed with a niche, defined as an indentation at the site of the CS with a depth of at least 2 mm, were classified into two groups (symptomatic or asymptomatic) according to whether they experienced postmenstrual spotting. Logistic regression analysis was used to establish the best cut-off values for the niche parameters to predict postmenstrual spotting. A new definition was generated based on the niche parameters with the highest area under the receiver-operating-characteristics (ROC) curve (AUC) for the prediction of postmenstrual spotting. RESULTS A total of 727 women who had a CS > 1 year earlier underwent TVS examination, of whom 263 were diagnosed with a niche (prevalence of 36.2%). Of these, 160 women experienced postmenstrual spotting and 103 were asymptomatic. The three variables with the highest AUC for prediction of postmenstrual spotting were niche depth/AMT ratio (AUC, 0.798; 95% CI, 0.745-0.852), niche depth (AUC, 0.731; 95% CI, 0.668-0.795) and RMT (AUC, 0.683; 95% CI, 0.618-0.748). Based on the best cut-offs according to ROC-curve analysis, a large niche was defined as: niche depth ≥ 0.50 cm, RMT ≤ 0.21 cm or niche depth/AMT ratio ≥ 0.56. The prevalence of a large niche according to this definition was 22.4% (163/727). The new definition had a specificity of 61.17% (95% CI, 52.34-70.41%) and sensitivity of 76.87% (95% CI, 70.28-84.16%) for a large niche. CONCLUSION This study has provided a new definition for a large niche after CS. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Wang
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - Q Pang
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - W Wei
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - L Cheng
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - F Huang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - Y Cao
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - M Hu
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, Anhui, China
| | - S Yan
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Y He
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
| | - Z Wei
- Department of Obstetrics & Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
- Anhui Province Key Laboratory of Reproductive Health and Genetics, Hefei, Anhui, China
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Cheng XL, Cao XY, Wang XQ, Lin HL, Fang JC, Wang L. Diagnosing early scar pregnancy in the lower uterine segment after cesarean section by intracavitary ultrasound. World J Clin Cases 2022; 10:547-553. [PMID: 35097080 PMCID: PMC8771384 DOI: 10.12998/wjcc.v10.i2.547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/14/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early scar pregnancy (CSP) in the lower uterine segment after cesarean section is a type of ectopic pregnancy that can cause major complications if left untreated. Transabdominal ultrasound is a common procedure but is influenced by external factors. Thus, intracavitary ultrasound may have better diagnostic efficiency for CSP.
AIM To assess the value of intracavitary ultrasound for diagnosing CSP in the lower uterine segment after cesarean section.
METHODS Patients diagnosed with CSP in our hospital from October 2019 to April 2021 were recruited. Transabdominal and intracavitary ultrasound examinations were performed to compare the diagnostic differences for CSP and its types.
RESULTS Sixty-three patients were diagnosed during the study period. The diagnostic accuracy for CSP was higher in intracavitary ultrasound (96.83%) than in transabdominal ultrasound (84.13%) (P < 0.05). The missed diagnosis and misdiagnosis rates did not differ among the ultrasound types (intra: 0.00% and 3.17%; trans: 4.76% and 11.11%, respectively; P > 0.05). For the diagnostic rates for the CSP types, the rates for gestational sac (100.00% vs 90.48%), heterogeneous mass (93.75% vs 75.00%), and part of the uterine cavity (80.00% vs 60.00%) were higher in intracavitary ultrasound than in transabdominal ultrasound, but the difference was not statistically significant (P > 0.05). For gestational sac CSP patients, intracavitary ultrasound showed that the gestational sac was located in the lower uterine segment scar with abundant peripheral blood flow; the distance between the gestational sac and the serosal layer was 2.42 ± 0.50 cm. Intracavitary ultrasound for heterogeneous mass CSP patients indicated that the mass mainly occurred in the lower anterior uterine wall, protruding into the bladder, and was surrounded by abundant internal and peripheral blood flow; the distance between the mass and serosal layer was 1.79 ± 0.30 cm. For CSP type partly located in the uterine cavity, the gestational sac was partly located in the lower uterine cavity and partly in the scar with abundant internal and peripheral blood flow; the distance between the gestational sac and the serosal layer was 2.29 ± 0.28 cm.
CONCLUSION Intracavitary ultrasound had a higher diagnostic accuracy and application value for diagnosing CSP than transabdominal ultrasound, with reduced risk of missed diagnoses and misdiagnosis, thereby preventing delayed treatment.
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Affiliation(s)
- Xiao-Ling Cheng
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Xiao-Yan Cao
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Xiao-Qian Wang
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Heng-Li Lin
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Jin-Chuan Fang
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Lin Wang
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
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