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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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Nijjar S, Ngo A, de Braud LV, Stempel CV, Bottomley C, Jauniaux E, Jurkovic D. Surgical evacuation combined with Shirodkar cervical suture and selective uterine artery embolization: A fertility preserving treatment for 10-15 weeks' live cesarean scar ectopic pregnancies. Acta Obstet Gynecol Scand 2024; 103:1054-1062. [PMID: 38366724 PMCID: PMC11103148 DOI: 10.1111/aogs.14803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/23/2023] [Accepted: 01/28/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Cesarean scar ectopic pregnancies (CSEPs) are associated with significant maternal morbidity and termination is often recommended in the early first trimester. Management of more advanced cases is challenging due to higher risks of major intraoperative hemorrhage. Hysterectomy is currently the intervention of choice for advanced cases. This study aimed to investigate if advanced live CSEPs could be managed effectively conservatively using suction curettage and interventional radiology. MATERIAL AND METHODS A retrospective single-center cohort study was performed. A total of 371 women diagnosed with CSEP were identified between January 2008 and January 2023. A total of 6% (22/371) women had an advanced live CSEP with crown-rump length (CRL) of ≥40 mm (≥10 weeks' gestation). Of these, 77% (17/22) opted for surgical intervention, whilst the remaining five continued their pregnancies. A preoperative ultrasound was performed in each patient. All women underwent suction curettage under ultrasound guidance and insertion of Shirodkar cervical suture as a primary hemostatic measure combined with uterine artery embolization (UAE) if required. The primary outcome was rate of blood transfusion. Secondary outcomes were estimated intraoperative blood loss, UAE, intensive care unit admission, reintervention, hysterectomy, hospitalization duration and rate of retained products of conception. Descriptive statistics were used to describe these variables. RESULTS Median CRL of the 17 patients included was 54.1 mm (range: 40.0-85.7) and median gestational age based on CRL was 12 + 3 weeks (range: 10 + 6-15 + 0). On preoperative ultrasound scan placental lacunae were recorded in 76% (13/17) of patients and color Doppler score was ≥3 in 67% (10/15) of patients. At surgery, Shirodkar cervical suture was used in all cases. It was successful in achieving hemostasis by tamponade in 76% (13/17) of patients. In the remaining 24% (4/17) patients tamponade failed to achieve complete hemostasis and UAE was performed to stop persistent arterial bleeding into the uterine cavity. Median intraoperative blood loss was 800 mL (range: 250-2500) and 41% (7/17) women lost >1000 mL. 35% (6/17) needed blood transfusion. No women required hysterectomy. CONCLUSIONS Surgical evacuation with Shirodkar cervical suture and selective UAE is an effective treatment for advanced live CSEPs.
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Affiliation(s)
- Simrit Nijjar
- Department of Obstetrics and Gynaecology, EGA Institute for Women's Health, Faculty of Population Health SciencesUniversity College LondonLondonUK
| | - An Ngo
- Department of Interventional RadiologyUniversity College HospitalLondonUK
- Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
| | - Lucrezia V. de Braud
- Department of Obstetrics and Gynaecology, EGA Institute for Women's Health, Faculty of Population Health SciencesUniversity College LondonLondonUK
| | - Conrad Von Stempel
- Department of Interventional RadiologyUniversity College HospitalLondonUK
- Division of Surgery and Interventional ScienceUniversity College LondonLondonUK
| | - Cecilia Bottomley
- Department of Obstetrics and Gynaecology, EGA Institute for Women's Health, Faculty of Population Health SciencesUniversity College LondonLondonUK
| | - Eric Jauniaux
- Department of Obstetrics and Gynaecology, EGA Institute for Women's Health, Faculty of Population Health SciencesUniversity College LondonLondonUK
| | - Davor Jurkovic
- Department of Obstetrics and Gynaecology, EGA Institute for Women's Health, Faculty of Population Health SciencesUniversity College LondonLondonUK
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Kaelin Agten A, Jurkovic D, Timor-Tritsch I, Jones N, Johnson S, Monteagudo A, Huirne J, Fleisher J, Maymon R, Herrera T, Prefumo F, Contag S, Cordoba M, Manegold-Brauer G. First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry. Am J Obstet Gynecol 2024; 230:669.e1-669.e19. [PMID: 37865390 DOI: 10.1016/j.ajog.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry. OBJECTIVE This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies. STUDY DESIGN We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions. RESULTS Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9). CONCLUSION A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment.
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Affiliation(s)
| | | | | | - Nia Jones
- University of Nottingham, Nottingham, United Kingdom
| | - Susanne Johnson
- Princess Anne Hospital, University Hospitals Southampton, Southampton, United Kingdom
| | | | - Judith Huirne
- Amsterdam University Medical Centers, Amsterdam, Netherlands
| | | | - Ron Maymon
- Department of Obstetrics and Gynecology, Shamir Medical Center (Assaf Harofeh), Be'er Ya'akov, Israel
| | | | - Federico Prefumo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Stephen Contag
- Division of Maternal Fetal Medicine, University of Minnesota, Minneapolis, MN
| | | | - Gwendolin Manegold-Brauer
- Division of Gynecologic and Prenatal Ultrasound, Department of Obstetrics and Gynecology, University of Basel, Basel, Switzerland.
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Amro B, Ramirez M, Farhan R, Abdulrahim M, Hakim Z, Alsuwaidi S, Alzahmi E, Tahlak M, Koninckx PR, Wattiez A. Isthmoceles - Accuracy of imaging diagnosis and clinical correlation with histology: A prospective cohort study. Facts Views Vis Obgyn 2024; 16:173-183. [PMID: 38950531 DOI: 10.52054/fvvo.16.2.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Background Isthmoceles are a growing clinical concern. Objectives To evaluate the accuracy of diagnosis of isthmoceles by imaging and to correlate the dimensions with clinical symptoms and histopathology. Materials and Methods Prospective study of women (n=60) with ≥1 C-section undergoing hysterectomy. Isthmoceles were measured by imaging before surgery and macroscopically on the specimen after hysterectomy, followed by histological analysis. Main outcome measures Accuracy of isthmocele diagnosis, correlation with clinical symptoms, and histopathological findings. Result By imaging, isthmoceles were slightly deeper (P=0.0176) and shorter (P=0.0045) than macroscopic measurements. Differences were typically small (≤3mm). Defined as an indentation of ≥2 mm at site of C-section scar, imaging diagnosed 2 isthmoceles consequently not seen by histology and missed 3. Number of prior C-sections increased isthmocele severity but neither the incidence nor the remaining myometrial thickness (RMT) did. Severity correlated positively with symptoms and histology. However, clinical use was limited. Histological analysis revealed presence of thick wall vessels in 100%, elastosis in 40%, and adenomyosis in 38%. Isthmocele lining was asynchronous with the menstrual phase in 31%. Conclusions Dimensions of isthmoceles by imaging were largely accurate with occasionally large differences observed. Number of C-sections did not increase isthmocele incidence, only severity. Indication for surgery remains clinical, considering dimensions and symptoms. What is new? Dimensions of isthmoceles should be confirmed before surgery since uterine contractions might change those dimensions. Symptoms increase with dimensions of isthmoceles but are not specific. Endometrial lining within the isthmocele can be asynchronous with the menstrual phase.
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Castro PT, Matos APP, Coutinho CM, Ribeiro G, Araujo Júnior E, Werner H. Is there a role for magnetic resonance imaging in cesarean scar pregnancy after the first trimester? JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:632-634. [PMID: 38471962 DOI: 10.1002/jcu.23670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 03/05/2024] [Indexed: 03/14/2024]
Abstract
Magnetic resonance imaging (MRI) can provide additional information in cases of cesarean scar pregnancy beyond the first trimester. MRI and 3D reconstructions can demonstrate the relationships between the uterus, cervix, bladder, and placenta, improving the spatial perspective of the pelvic anatomy in cases requiring surgical management. MRI and 3D reconstructions can also provide more comprehensive images for parental counseling, virtual and face-to-face multidisciplinary team discussion, and medical record storage.
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Affiliation(s)
| | - Ana Paula Pinho Matos
- Department of Radiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Conrado Milani Coutinho
- Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, University of São Paulo (FMRP-USP), Ribeirão Preto, Brazil
| | - Gerson Ribeiro
- Department of Fetal Medicine, Biodesign Laboratory DASA/PUC, Rio de Janeiro, Brazil
- Department of Radiology, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
- Discipline of Woman Health, Municipal University of São Caetano do Sul (USCS), São Caetano do Sul, Brazil
| | - Heron Werner
- Department of Fetal Medicine, Biodesign Laboratory DASA/PUC, Rio de Janeiro, Brazil
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Fang N, Wong JMK, Reid JA. Letter to the editor for "Hysteroscopic subchorionic injection of methotrexate followed by laparoscopic excision of the gestational sac for the management of cesarean scar ectopic pregnancy: an innovative dual approach of a challenging pathology". Fertil Steril 2024:S0015-0282(24)00458-8. [PMID: 38763470 DOI: 10.1016/j.fertnstert.2024.05.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 05/21/2024]
Affiliation(s)
- Nancy Fang
- Division of Complex Family Planning, Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | - Jacqueline M K Wong
- Division of General Obstetrics and Gynecology, Section of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
| | - Jessica A Reid
- Division of Complex Family Planning, Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, Oregon
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Dar P, Doulaveris G. First-trimester screening for placenta accreta spectrum. Am J Obstet Gynecol MFM 2024; 6:101329. [PMID: 38447672 DOI: 10.1016/j.ajogmf.2024.101329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024]
Abstract
In recent years, there has been a significant rise in cases of placenta accreta spectrum, a group of life-threatening placental disorders that can arise during childbirth. Early detection plays a crucial role in facilitating meticulous delivery planning, ultimately leading to a reduction in mortality and morbidity rates and improved overall outcomes. Although third-trimester ultrasound has traditionally been the primary method for prenatal screening for placenta accreta spectrum, it often falls short in identifying cases or diagnosis is too late for optimal delivery planning. Emerging evidence has highlighted the option of early detection of placenta accreta spectrum indicators during the first trimester of pregnancy. This comprehensive review delves into our current knowledge of sonographic assessment of the uterine cervicoisthmic complex in the first trimester, examining the location and appearance of cesarean scars and exploring first-trimester screening strategies, ultimately paving the way for improved maternal and neonatal outcomes.
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Affiliation(s)
- Pe'er Dar
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine (Drs Dar and Doulaveris), Bronx, NY.
| | - Georgios Doulaveris
- Division of Fetal Medicine and Ultrasound, Department of Obstetrics & Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine (Drs Dar and Doulaveris), Bronx, NY
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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. [PMID: 38634558 DOI: 10.1002/jum.16464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [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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Kłobuszewski B, Szmygin M, Nieoczym K, Kłobuszewska O, Woźniak S, Pyra KK. Advances in Treating Cesarean Scar Pregnancy: A Comprehensive Review of Techniques, Clinical Outcomes, and Fertility Preservation. Med Sci Monit 2024; 30:e943550. [PMID: 38566372 PMCID: PMC11000526 DOI: 10.12659/msm.943550] [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: 12/19/2023] [Accepted: 02/01/2024] [Indexed: 04/04/2024] Open
Abstract
Cesarean scar pregnancy (CSP) is a rare but potentially dangerous condition that occurs when an embryo implants and develops within the scar tissue from a previous cesarean section. Treatment of cesarean scar pregnancy depends on several factors, including the gestational age of the pregnancy, the presence of complications, and the individual patient's circumstances. We performed a systematic review of the published literature on management of cesarean scar pregnancy and the outcomes, complications, and effects on fertility. A systematic review of recent scientific literature published up to April 2023 in the databases PubMed, Google Scholar, and Web of Science was performed according to the PRISMA guidelines. We used the search keywords "cesarean scar pregnancy," "methotrexate," "systemic," "chemoembolization," and "uterine artery embolization." The baseline search resulted in 413 articles. After the exclusion of 342 irrelevant articles, the abstracts and titles of the remaining 71 articles were read for potential inclusion, resulting in exclusion of a further 16 articles. Therefore, the full texts of 55 articles were investigated. Finally, 42 papers were included in the study. The main finding was that chemoembolization is more successful than systemic methotrexate therapy, and is associated with less blood loss and shorter hospital stay. Transarterial chemoembolization appears to be safe and effective method of treatment in patients with CSP and should thus be considered during multidisciplinary evaluation of these patients.
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Affiliation(s)
- Bartosz Kłobuszewski
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland
| | - Maciej Szmygin
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland
- Department of Human Anatomy, Medical University of Lublin, Lublin, Poland
| | - Karolina Nieoczym
- Student Scientific Society at the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland
| | - Olga Kłobuszewska
- Department of Pediatric Radiology, University Pediatric Hospital, Lublin, Poland
| | - Sławomir Woźniak
- Department of Gynecology, Medical University of Lublin, Lublin, Poland
| | - Krzysztof Konrad Pyra
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, Lublin, Poland
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Shen M, Li L, Zhu L, Liu J, Lin T, Liu X. Predictive value of crossover sign for outcome of ultrasound-guided vacuum aspiration in women with Cesarean scar pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:544-550. [PMID: 37610656 DOI: 10.1002/uog.27459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 07/18/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE To examine the value of the crossover sign (COS) in predicting treatment outcome in women with a Cesarean scar pregnancy (CSP) who were treated with ultrasound-guided vacuum aspiration. METHODS This was a retrospective cohort study of women with CSP who underwent ultrasound-guided vacuum aspiration. Based on the relationship between the gestational sac, Cesarean scar and anterior wall of the uterus, CSPs were classified by COS type. Analysis was conducted to investigate the association between COS type (COS-1, COS-2) and treatment outcome. The incidence of treatment failure, retained pregnancy tissue, secondary therapy and bleeding ≥ 200 mL were analyzed. RESULTS In total, 181 eligible patients with CSP, including 90 (49.7%) women with COS-1 and 91 (50.3%) women with COS-2, were analyzed. COS-1 patients had a higher incidence of treatment failure compared with COS-2 patients (25.6% vs 8.8%; P = 0.003), as well as higher rates of retained pregnancy tissue (18.9% vs 6.6%; P = 0.013), secondary therapy (20.0% vs 6.6%; P = 0.002) and bleeding of ≥ 200 mL (13.3% vs 4.4%; P = 0.034). COS-1 and a large gestational sac (30.1-50.0 mm or >50.0 mm in diameter) were associated independently with increased risk of treatment failure (odds ratio, 4.57 (95% CI, 1.66-12.56); P = 0.003, 4.34 (95% CI, 1.35-13.94); P = 0.014 and 10.50 (95% CI, 2.54-43.46); P = 0.001, respectively). CONCLUSIONS Ultrasound evaluation of the relationship between the gestational sac and the endometrial line (COS classification) in women with CSP may help to predict treatment outcome among those undergoing vacuum aspiration. Among COS-1 patients, especially those with a gestational sac diameter of >30.0 mm, vacuum aspiration may be discouraged. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M Shen
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - L Li
- Department of Ultrasound, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - L Zhu
- Department of Ultrasound, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - J Liu
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - T Lin
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - X Liu
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
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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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12
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Araujo Júnior E, Caldas JVJ, Sun SY, Castro PT, Passos JP, Werner H. Placenta acrreta spectrum-first trimester, 2D and 3D ultrasound, and magnetic resonance imaging findings. JOURNAL OF CLINICAL ULTRASOUND : JCU 2024; 52:321-330. [PMID: 38126224 DOI: 10.1002/jcu.23627] [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: 10/10/2023] [Revised: 11/23/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The term placenta accreta spectrum (PAS) is commonly used to describe abnormal trophoblastic invasion of the myometrium, serosa, or organs adjacent to the uterus. It is of great obstetric importance because of its high morbidity, risk of hemorrhage, admission to the intensive care unit, risk of hysterectomy, and high risk of iatrogenic pelvic lesions and even death. These risks are minimized when prenatal diagnosis is performed. Prenatal diagnosis of PAS is based on imaging findings suggestive of abnormal and pathologically adherent placentation, including placental lacunae (intraplacental sonolucent spaces), disruption of the bladder-uterine serosa interface, turbulent flow on color Doppler, and bridging vessels. OBJECTIVE In this article, we review the major prenatal imaging features of PAS using diagnostic modalities (first trimester, two-dimensional ultrasound, three-dimensional ultrasound, and magnetic resonance imaging) for the diagnosis of PAS.
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Affiliation(s)
- Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
- Discipline of Woman Health, Municipal University of São Caetano do Sul (USCS), São Caetano do Sul, SP, Brazil
| | - João Victor Jacomele Caldas
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Sue Yasaki Sun
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Pedro Teixeira Castro
- Department of Fetal Medicine, Biodesign Laboratory DASA/PUC, Rio de Janeiro-RJ, Brazil
| | - Jurandir Piassi Passos
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, SP, Brazil
| | - Heron Werner
- Department of Fetal Medicine, Biodesign Laboratory DASA/PUC, Rio de Janeiro-RJ, Brazil
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Fu P, Zhang L, Zhou T, Wang S, Liu R. Clinical Application of a New Cesarean Scar Pregnancy Classification and Evaluation System and a Risk Scoring System. Int J Gen Med 2024; 17:115-126. [PMID: 38249619 PMCID: PMC10799619 DOI: 10.2147/ijgm.s445327] [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: 10/18/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
Objective Cesarean scar pregnancy (CSP) is an uncommon form of ectopic pregnancy that carries the risk of severe bleeding. To date, there has not been a universally accepted classification and treatment strategy. We performed this study to establish a risk scoring system and new CSP classification system for CSP and evaluate its efficacy. Methods A total of five groups were generated based on different methods of treatment, and the factors that increase the risk of intraoperative bleeding were examined in our center from 2013 to 2018. The construction of a risk scoring system in this study was based on the use of the chi-square test and multivariate logistic regression analysis. To determine the appropriate cutoff scores, receiver operating characteristic (ROC) curves and the area under the curve (AUC) were generated. Results We identified the main high-risk factors for excessive intraoperative hemorrhage during CSP surgery through univariate and multivariate analyses. Within this investigation, the risk factors included gestational sac location and gestational sac diameter. Through analysis, an optimal cutoff score of 3 was determined, and the area under the ROC curve was calculated to be 0.8113 (95% CI=0.7696-0.8531). A score ranging from 0-3 was classified as low risk, while a score ranging from 5-7 was classified as high risk. Additionally, a new classification system for CSP has been established based on sonographic parameters. We also established a diagnostic and treatment process for CSP patients according to the risk scoring method and new CSP classification. Conclusion We identified the high-risk factors associated with bleeding during CSP surgery and developed a scoring system incorporating these factors. The utilization of this novel CSP typing method, in conjunction with the risk scoring system, can effectively inform doctors in their decision-making process concerning treatment strategies for patients with CSP.
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Affiliation(s)
- Peiying Fu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Ling Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Ting Zhou
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Shixuan Wang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
| | - Ronghua Liu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China
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Fu L, Yuan H, Cao H, Zhou Q, Tan X, Guo J. Clinical value of ultrasonic indicators in predicting the outcome of caesarean scar pregnancy after pregnancy termination. BMC Pregnancy Childbirth 2023; 23:863. [PMID: 38102587 PMCID: PMC10722759 DOI: 10.1186/s12884-023-06197-x] [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: 10/24/2022] [Accepted: 12/12/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND To investigate the predictive value of ultrasound indicators in early pregnancy for the outcome of caesarean scar pregnancy (CSP) after pregnancy termination. METHODS This study retrospectively analysed the ultrasound images of 98 CSP patients who underwent transabdominal ultrasound-guided hysteroscopic curettage during early pregnancy at Changsha Hospital for Maternal and Child Health Care between January 2017 and October 2021. Patients were equally divided into a case group and a control group. The case group included 49 CSP patients with postoperative complications, such as intraoperative blood loss ≥ 200 ml or retained products of conception (RPOC). The remaining 49 CSP patients, with similar age and gestational age and with good postoperative outcomes, such as intraoperative blood loss ≤ 50 ml and no RPOC, were included in the control group. CSP was classified into three types according to the location of the gestational sac (GS) relative to the uterine cavity line (UCL) and serosal contour. Differences in ultrasound indicators between the case and control group were compared. RESULTS There were significant differences between the case and control groups in the mean gestational sac diameter (MGSD), residual myometrium thickness (RMT) between the GS and the bladder, blood flow around the GS at the site of the previous caesarean incision, and types of CSP (P < 0.05). The rs of each ultrasound indicator were as follows: 0.258, -0.485, 0.369, 0.350. The optimal threshold for predicting good postoperative outcomes, such as intraoperative blood loss ≤ 50 ml and no RPOC, by receiver operating characteristic (ROC) curve analysis of the RMT was 2.3 mm. CONCLUSION Our findings show that the RMT, blood flow around the GS at the site of the previous caesarean incision, and types of CSP have a low correlation with postoperative complications, such as intraoperative blood loss ≥ 200 ml or RPOC, of early pregnancy termination in patients with CSP. To some extent, this study may be helpful for clinical prognostic prediction of patients with CSP and formulation of treatment strategies. Given the low correlation between these three indicators and postoperative complications, further studies are needed to identify indicators that can better reflect the postoperative outcomes of CSP patients.
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Affiliation(s)
- Liye Fu
- Department of Ultrasound, Changsha Hospital for Maternal & Child Health Care Affiliated to Hunan Normal University, Changsha, Hunan, 410000, China
| | - Hongxia Yuan
- Department of Ultrasound, Changsha Hospital for Maternal & Child Health Care Affiliated to Hunan Normal University, Changsha, Hunan, 410000, China.
| | - Hong Cao
- Department of Ultrasound, Changsha Hospital for Maternal & Child Health Care Affiliated to Hunan Normal University, Changsha, Hunan, 410000, China
| | - Qichang Zhou
- Department of Ultrasound, the Second Xiangya Hospital of Central South University, Changsha, Hunan, 410000, China
| | - Xiaotan Tan
- Department of Ultrasound, Changsha Hospital for Maternal & Child Health Care Affiliated to Hunan Normal University, Changsha, Hunan, 410000, China
| | - Jun Guo
- Department of Ultrasound, Changsha Hospital for Maternal & Child Health Care Affiliated to Hunan Normal University, Changsha, Hunan, 410000, China
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Salem Wehbe G, Amara IA, Nisolle M, Badr DA, Timmermans M, Karampelas S. Efficacy, Safety and Outcomes of the Laparoscopic Management of Cesarean Scar Ectopic Pregnancy as a Single Therapeutic Approach: A Case Series. J Clin Med 2023; 12:7673. [PMID: 38137743 PMCID: PMC10743864 DOI: 10.3390/jcm12247673] [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: 10/13/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 12/24/2023] Open
Abstract
A standardized consensus for the management of cesarean scar pregnancy (CSP) is lacking. The study objective is to evaluate the efficacy, safety and outcomes of the laparoscopic management of CSP as a single therapeutic surgical approach without being preceded by vascular pretreatment or vasoconstrictors injection. This is a retrospective bi-centric study, a case series. Eight patients with a future desire to conceive underwent the laparoscopic treatment of unruptured CSPs. Surgery consisted of "en bloc" excision of the deficient uterine scar with the adherent tissue of conception, followed by immediate uterine repair. The data collected for each patient was age, gestity, parity, number of previous c-sections, pre-pregnancy isthmocele-related symptoms, gestational age, fetal cardiac activity, initial β-human chorionic gonadotropin levels, intra-operative blood loss, blood transfusion, operative time and the postoperative complications, evaluated according to Clavien-Dindo classification. The CSP was successfully removed in all patients by laparoscopy. The surgical outcomes were favorable. All patients with histories of isthmocele-related symptoms reported postoperative resolution of symptoms. The median residual myometrium thickness increased significantly from 1.2 mm pre-operatively to 8 mm 3 to 6 months after surgery. The laparoscopic management seems to be an appropriate treatment of CSP when performed by skilled laparoscopic surgeons. It can be safely proposed as a single surgical therapeutic approach. Larger series and further prospective studies are needed to confirm this observation and to affirm the long-term gynecological and obstetrical outcomes of this management.
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Affiliation(s)
- Georges Salem Wehbe
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Free University of Brussels, 1020 Brussels, Belgium; (G.S.W.); (I.A.A.); (D.A.B.)
| | - Inesse Ait Amara
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Free University of Brussels, 1020 Brussels, Belgium; (G.S.W.); (I.A.A.); (D.A.B.)
| | - Michelle Nisolle
- Department of Obstetrics and Gynecology, Hospital the Citadelle, University of Liege, 4000 Liege, Belgium; (M.N.); (M.T.)
| | - Dominique A. Badr
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Free University of Brussels, 1020 Brussels, Belgium; (G.S.W.); (I.A.A.); (D.A.B.)
| | - Marie Timmermans
- Department of Obstetrics and Gynecology, Hospital the Citadelle, University of Liege, 4000 Liege, Belgium; (M.N.); (M.T.)
| | - Stavros Karampelas
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Free University of Brussels, 1020 Brussels, Belgium; (G.S.W.); (I.A.A.); (D.A.B.)
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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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Rao J, Fan D, Li P, Li Y, Hu P, Wu Z, He J, Liu X, Peng B, Guo X, Liu Z. Prediction of vaginal birth after cesarean in China. Int J Gynaecol Obstet 2023; 163:202-210. [PMID: 37096667 DOI: 10.1002/ijgo.14801] [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: 12/26/2022] [Revised: 03/29/2023] [Accepted: 03/31/2023] [Indexed: 04/26/2023]
Abstract
OBJECTIVE This study aimed to develop and validate a prediction model of vaginal birth after cesarean delivery (VBAC) in China. METHODS A nomogram for effective prediction of VBAC of singleton, cephalic and one previous low-transverse cesarean section deliveries was created by comparing the combinations of ultrasonographic and non-ultrasonographic factors from five hospitals between 2018 and 2019. RESULTS A total of 1066 women were included. Of the women who underwent trial of labor after cesarean (TOLAC), 854 (80.1%) had a VBAC. Ultrasound factors included reached a higher area under the curve (AUC) combined with non-ultrasonographic factors. Of the three ultrasonographic factors analyzed, the best predictive factor for successful TOLAC was fetal abdominal circumference. A nomogram was generated with eight validated factors, including maternal age, gestational week, height, previous vaginal delivery, Bishop score, dilatation of the cervix at the time of admission, body mass index at delivery, and fetal abdominal circumference by ultrasound. The trained and validated AUC were 0.719 (95% confident interval 0.674-0.764) and 0.774 (95% confident interval 0.712-0.837), respectively. CONCLUSION Our VBAC nomogram based on obstetric factors and fetal abdominal circumference obtained by ultrasound could be used to counsel women who are considering TOLAC.
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Affiliation(s)
- Jiaming Rao
- Foshan Fetal Medicine Institute, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University (Foshan Maternity & Child Healthcare Hospital), Foshan, Guangdong, China
| | - Dazhi Fan
- Foshan Fetal Medicine Institute, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University (Foshan Maternity & Child Healthcare Hospital), Foshan, Guangdong, China
| | - Pengsheng Li
- Foshan Fetal Medicine Institute, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University (Foshan Maternity & Child Healthcare Hospital), Foshan, Guangdong, China
| | - Yiying Li
- Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University (Foshan Maternity & Child Healthcare Hospital), Foshan, Guangdong, China
| | - Pengzhen Hu
- Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University (Foshan Maternity & Child Healthcare Hospital), Foshan, Guangdong, China
| | - Zhaoxia Wu
- Department of Obstetrics, Nanhai Maternity & Child Healthcare Hospital, Foshan, Guangdong, China
| | - Jieyun He
- Department of Obstetrics, Shunde Maternity & Child Healthcare Hospital, Foshan, Guangdong, China
| | - Xinjuan Liu
- Department of Obstetrics, The People's Hospital of Gaoming, Foshan, Guangdong, China
| | - BingJie Peng
- Department of Obstetrics, Sanshui Maternity & Child Healthcare Hospital, Foshan, Guangdong, China
| | - Xiaoling Guo
- Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University (Foshan Maternity & Child Healthcare Hospital), Foshan, Guangdong, China
| | - Zhengping Liu
- Foshan Fetal Medicine Institute, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University (Foshan Maternity & Child Healthcare Hospital), Foshan, Guangdong, China
- Department of Obstetrics, Affiliated Foshan Maternity & Child Healthcare Hospital, Southern Medical University (Foshan Maternity & Child Healthcare Hospital), Foshan, Guangdong, China
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Gao F, Lu Y, Guo X, Gao J, Wang W, Cheng J, Fu L. Complex Blood Supply Patterns in Cesarean Scar Pregnancy: Insights from Digital Subtraction Angiography Imaging. Med Sci Monit 2023; 29:e940133. [PMID: 37653724 PMCID: PMC10478579 DOI: 10.12659/msm.940133] [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: 02/27/2023] [Accepted: 05/31/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Understanding the blood supply pattern of cesarean scar pregnancy (CSP) can effectively help to determine the best choice of treatment. The aim of this study was to investigate the blood supply pattern and outcomes of patients with CSP through digital subtraction angiography (DSA) imaging. MATERIAL AND METHODS This was a retrospective cohort study. Patients were divided into 2 groups according to the type of CSP. The DSA images of these patients were reviewed, including the type of blood supply, dominant vessel, and collateral blood supply to the gestational sac. The clinical outcomes were analyzed between the 2 groups. RESULTS Thirty-seven patients with type I and 29 patients with type II CSP were enrolled in this study. Type II CSP showed a higher proportion of rich blood supply than type I (44.83% vs 29.72%, P>0.05). Compared with type II CSP, type I CSP tended to have bilateral dominant blood supply predominance (67.57% vs 41.38%, P<0.05). The incidence of collateral blood supply was 5.41% in the type I CSP group and 31.03% in the type II CSP group (P<0.05). In the type II CSP group, multiple collateral blood vessels were found in 4 patients. The superior vesicle artery was the most common source of collateral blood supply in both groups. Two patients with type II CSP suffered massive bleeding during surgery after uterine artery embolization (UAE). None of the patients received a hysterectomy. CONCLUSIONS UAE is safe and effective for both types of CSP. The blood supply pattern is more complex and abnormal in type II CSP. More attention should be paid to the collateral blood supply to achieve complete embolization during the UAE procedure in the case of type II CSP.
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Affiliation(s)
- Feng Gao
- Department of Radiology, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, PR China
| | - Yu Lu
- Department of Ultrasound, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, PR China
| | - Xiaoqing Guo
- Department of Obstetrics and Gynecology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, PR China
| | - Jie Gao
- Department of Radiology, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, PR China
| | - Wenjing Wang
- Department of Radiology, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, PR China
| | - Jiejun Cheng
- Department of Radiology, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, PR China
| | - Le Fu
- Department of Radiology, Shanghai Key Laboratory of Maternal-Fetal Medicine, Shanghai Institute of Maternal-Fetal Medicine and Gynecologic Oncology, Shanghai First Maternity and Infant Hospital, School of Medicine, Tongji University, Shanghai, PR China
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Itani S, Jabin M, Dasara H, Forehand K, DePrisco G. Diagnosis and Management of Cesarean Scar Ectopic Pregnancy: A Case Study. Cureus 2023; 15:e45160. [PMID: 37842351 PMCID: PMC10573662 DOI: 10.7759/cureus.45160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/17/2023] Open
Abstract
A cesarean scar ectopic pregnancy (CSEP) designates an ectopic pregnancy within the myometrium of a past uterine incision. Early diagnosis through transvaginal ultrasonography is crucial as an untreated CSEP can lead to serious complications, including hemorrhage, loss of future fertility, and maternal death. We present a case of a 33-year-old female with five previous cesarean sections, who presented at seven weeks of gestation with concerns of a CSEP. Here, we highlight the importance of early diagnosis and maintaining high clinical suspicion in women with multiple previous cesarean sections who present with menstrual abnormalities. The CSEP is a serious condition and requires a high index of suspicion during diagnosis and follow-up. Ultrasound scanning and training should be readily available to quickly identify and treat this life-threatening condition.
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Affiliation(s)
- Sabine Itani
- Medicine, Texas A&M College of Medicine, Bryan, USA
| | | | | | | | - Gregory DePrisco
- Diagnostic Radiology, Baylor University Medical Center, Dallas, USA
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20
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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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21
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Dominguez JA, Pacheco LA, Moratalla E, Carugno JA, Carrera M, Perez-Milan F, Caballero M, Alcázar JL. Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:336-344. [PMID: 36730180 DOI: 10.1002/uog.26171] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/28/2022] [Accepted: 01/17/2023] [Indexed: 06/18/2023]
Abstract
The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J A Dominguez
- IERA (Instituto Extremeño de Reproducción Asistida), Badajoz, Spain
| | | | - E Moratalla
- Department of Obstetrics and Gynecology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J A Carugno
- Minimally Invasive Gynecology Division, University of Miami, Miami, FL, USA
| | - M Carrera
- Department Obstetrics and Gynecology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - F Perez-Milan
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - M Caballero
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - J L Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain
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22
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Teng D, Gao H, Li Y, Meng T, Shi X, Shi J. Clinical efficacy analysis of laparoscopic uterine artery pre-ligation combined with hysteroscopic curettage in the treatment of type II cesarean scar pregnancy. Front Med (Lausanne) 2023; 10:1234499. [PMID: 37601781 PMCID: PMC10436082 DOI: 10.3389/fmed.2023.1234499] [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: 06/04/2023] [Accepted: 07/06/2023] [Indexed: 08/22/2023] Open
Abstract
Objective To explore and evaluate the clinical therapeutic effect of laparoscopic uterine artery pre-ligation combined with hysteroscopic curettage in the treatment of type II cesarean scar pregnancy. Methods This study analyzed the clinical data of patients with cesarean scar pregnancy (CSP) in the Maternal and Child Health Hospital of Hubei Province from 2018 to 2022. A total of 134 patients with type II cesarean section were enrolled, out of which 78 patients were included in the final analysis. Treatment included either uterine artery embolization (UAE) combined with hysteroscopic curettage (n = 37 patients) or laparoscopic uterine artery pre-ligation (LUAP) combined with hysteroscopic curettage (n = 41 patients). The demographic and clinical characteristics of these two groups were recorded, and their short- and long-term complications on follow-up were compared. For patients with subsequent fertility requirements, we followed up these patients for 2 years after surgery, then collected and analyzed the compared subsequent pregnancy outcome. Results We found no significant discrepancies in the success rate of operation, length of hospital stay, and intraoperative blood loss between the two different operation modes. The cost of LUAP was significantly lower than that of UAE. Furthermore, the incidence of short-term postoperative complications such as fever and pelvic pain was lower in patients treated with LUAP than in those treated with UAE. In terms of long-term postoperative complications, the recovery time for menstruation in the LUAP group (49.81 ± 11.47) was earlier than that in the UAE group (34.90 ± 7.41) (p < 0.05). Additionally, 4.9% of patients in the LUAP group had decreased menstrual flow, while 59% of patients in the UAE group had a marked decrease in menstrual flow, and the incidence and severity of intrauterine adhesions were significantly lower in the LUAP group than in the UAE group(p < 0.05). Consistent with the aforementioned observations, patients treated with LUAP had better postoperative re-pregnancy outcomes than those treated with UAE. Conclusions Based on the findings, LUAP combined with hysteroscopic curettage is a safe and effective surgical scheme for the treatment of type II CSPs. In addition, compared with UAE, LUAP is associated with a lower surgical cost, fewer short and long-term complications, and better postoperative pregnancy outcomes. Thus, it should be widely applied in patients with type II CSPs.
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Affiliation(s)
- Dan Teng
- Medical College, Wuhan University of Science and Technology, Wuhan, China
| | - Han Gao
- Department of Gynecology Hubei Province Maternal and Infant Health Hospital, Tongji Medical College, Huazhong University of Science and Technology. Wuhan, China
| | - Yanli Li
- Department of Gynecology Hubei Province Maternal and Infant Health Hospital, Tongji Medical College, Huazhong University of Science and Technology. Wuhan, China
| | - Tingzhu Meng
- Medical College, Wuhan University of Science and Technology, Wuhan, China
| | - Xiuting Shi
- Medical College, Wuhan University of Science and Technology, Wuhan, China
| | - Jie Shi
- Department of Gynecology Hubei Province Maternal and Infant Health Hospital, Tongji Medical College, Huazhong University of Science and Technology. Wuhan, China
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23
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Huang J, Phillips C, Moshiri M. Scarred for life: a review of cesarean section scar pregnancy and potential pitfalls in diagnosis. Abdom Radiol (NY) 2023; 48:2672-2683. [PMID: 37204508 DOI: 10.1007/s00261-023-03953-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/20/2023]
Abstract
Cesarean section scar pregnancy (CSSP) is defined as abnormal implantation of a gestational sac on or in a previous cesarean section scar. There is an increasing incidence of detection of CSSP, likely in part due to the growing rates of cesarean deliveries and the improved rates of detection with advancing ultrasound technology. Diagnosis of CSSP is critical due to the potentially life-threatening complications to the mother if left untreated. Pelvic ultrasound is the imaging modality of choice in the initial evaluation of suspected CSSP, with MRI potentially useful if ultrasound findings are equivocal, or if confirmation is requested prior to definitive intervention. Early and accurate diagnosis of CSSP allows for prompt management to avoid severe complications and the potential to preserve the uterus and future fertility. A combination of medical and surgical treatment strategies may be needed with specific therapy tailored to each patient. Follow-up after treatment should include serial beta-hCG levels and possible repeat imaging if there is clinical concern for complications or treatment failure. This article will provide a comprehensive review of this uncommon but important phenomenon, detailing the pathophysiology and types of CSSP, imaging presentations, potential pitfalls in diagnosis, and management options.
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Affiliation(s)
- Jennifer Huang
- Department of Radiology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA.
- PGY-5 Chief Resident, Diagnostic Radiology Residency, Vanderbilt University Medical Center, 1161 21st Ave South, Nashville, TN, 37232, USA.
| | - Catherine Phillips
- Department of Radiology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
| | - Mariam Moshiri
- Department of Radiology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
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24
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Dominoni M, Gardella B, Perotti F, Galotti AMC, Cesari S, Spinillo A. Challenges in scar pregnancy evolution: a Gordian Knot. Arch Gynecol Obstet 2023; 308:641-642. [PMID: 36512114 DOI: 10.1007/s00404-022-06873-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy.
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy.
| | - Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy
| | - Francesca Perotti
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy
| | - Anna Maria Clelia Galotti
- Unit of Radiology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy
| | - Stefania Cesari
- Department of Pathology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy
| | - Arsenio Spinillo
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy
- Department of Obstetrics and Gynecology, Fondazione IRCCS Policlinico San Matteo, Viale Camillo Golgi 19, 27100, Pavia, Italy
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25
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Klein Meuleman SJM, Min N, Hehenkamp WJK, Post Uiterweer ED, Huirne JAF, de Leeuw RA. The definition, diagnosis, and symptoms of the uterine niche - A systematic review. Best Pract Res Clin Obstet Gynaecol 2023; 90:102390. [PMID: 37506497 DOI: 10.1016/j.bpobgyn.2023.102390] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023]
Abstract
Of all neonates, 21% are delivered by cesarean section (CS). A long-term maternal complication of an SC is a uterine niche. The aim of this review is to provide an overview of the current literature on imaging techniques and niche-related symptomatology. We performed systematic searches on imaging and niche symptoms. For both searches, 87 new studies were included. Niche evaluation by transvaginal sonography (TVS) or contrast sonohysterography (SHG) proved superior over hysteroscopy or magnetic resonance imaging. Studies that used SHG in a random population identified a niche prevalence of 42%-84%. Niche prevalence differed based on niche definition, symptomatology, and imaging technique. Most studies reported an association with gynecological symptoms, poor reproductive outcomes, obstetrical complications, and reduced quality of life. In conclusion, non-invasive TVS and SHG are the superior imaging modalities to diagnose a niche. Niches are prevalent and strongly associated with gynecological symptoms and poor reproductive outcomes.
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Affiliation(s)
- S J M Klein Meuleman
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - N Min
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - W J K Hehenkamp
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - E D Post Uiterweer
- Amsterdam University Medical Center, Location Amsterdam Medical Center, Uterine Repair Center, Department of Obstetrics & Gynaecology, Meibergdreef 9, Amsterdam, the Netherlands.
| | - J A F Huirne
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
| | - R A de Leeuw
- Amsterdam University Medical Center, Location Vrije Universiteit Amsterdam, Department of Obstetrics & Gynaecology, De Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Reproduction and Development, Amsterdam, the Netherlands.
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26
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Noël L, Chantraine F. Methotrexate for CSPs. Best Pract Res Clin Obstet Gynaecol 2023; 89:102364. [PMID: 37354647 DOI: 10.1016/j.bpobgyn.2023.102364] [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: 04/07/2023] [Revised: 05/22/2023] [Accepted: 05/23/2023] [Indexed: 06/26/2023]
Abstract
Expectant management of a cesarean scar pregnancy (CSP) is associated with a high risk of severe maternal morbidity. Therefore, most experts recommend immediate termination after the diagnosis of a CSP. However, there is no consensus about the optimal management of a CSP in terms of efficacy, safety, and preservation of future fertility. Methotrexate (MTX) is a folic acid antagonist that has been largely used to treat tubal ectopic pregnancies. This review summarizes the current knowledge and uncertainties about the administration of MTX as a medical or non-invasive option to terminate a CSP; the preferred injection route (systemic or local/intragestational), the comparison with other treatment modalities, and the prognostic factors for MTX success will be discussed, as well as the recommendations from scientific societies.
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Affiliation(s)
- Laure Noël
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Liège, Citadelle Hospital, 4000 Liège, Belgium.
| | - Frédéric Chantraine
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Liège, Citadelle Hospital, 4000 Liège, Belgium.
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27
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Coutinho CM, Georg AV, Marçal LCA, Nieto-Calvache AJ, Adu-Bredu T, D'Antonio F, Palacios-Jaraquemada JM. Placenta Accreta Spectrum Disorders: Current Recommendations from the Perspective of Antenatal Imaging. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2023; 45:297-302. [PMID: 37494571 PMCID: PMC10371071 DOI: 10.1055/s-0043-1770917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Affiliation(s)
- Conrado Milani Coutinho
- Departament of Ginecology and Obstetrics, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Alexia Viegas Georg
- Departament of Ginecology and Obstetrics, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Ligia Conceição Assef Marçal
- Departament of Ginecology and Obstetrics, Hospital das Clínicas, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Albaro José Nieto-Calvache
- Clínica de Espectro de Acretismo Placentario, Hospital Universitario Fundación Valle del Lili, Cali, Colombia
- Universidad ICESI, Cali, Colombia
| | - Theophilus Adu-Bredu
- Obstetrics and Gynecology Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Francesco D'Antonio
- Center for Fetal Care and High Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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28
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Nijjar S, Jauniaux E, Jurkovic D. Surgical evacuation of cesarean scar ectopic pregnancies. Best Pract Res Clin Obstet Gynaecol 2023; 89:102361. [PMID: 37356118 DOI: 10.1016/j.bpobgyn.2023.102361] [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: 04/13/2023] [Accepted: 05/02/2023] [Indexed: 06/27/2023]
Abstract
Cesarean scar ectopic pregnancy is associated with significant maternal morbidity, including severe hemorrhage, need for the blood transfusion and hysterectomy. Early diagnosis is therefore key in ensuring timely management, with consensus being that treatment before 9 weeks of gestation leads to reduced morbidity. There is no universally adopted management protocol for cesarean scar ectopic pregnancy, but surgical management generally has a higher success rate than medical management. The primary surgical treatment modalities are suction evacuation versus resection of the pregnancy via multiple routes. Adjuncts that have been shown to successfully minimize bleeding with surgical management include cervical cerclage, balloon catheter, and uterine artery embolization. However, there remains a lack of high-quality evidence regarding what is the best surgical treatment option for cesarean scar ectopic pregnancy, and therefore it is essential that clinicians provide tailored management to patients considering the presenting symptoms and local expertise with various surgical techniques.
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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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29
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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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30
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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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31
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Ge I, Geißler C, Geffroy A, Juhasz-Böss I, Wiehle P, Asberger J. Treatment of Cesarean Scar and Cervical Pregnancies Using the Ovum Aspiration Set for Intrachorial Methotrexate Injection as a Conservative, Fertility-Preserving Procedure. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040761. [PMID: 37109719 PMCID: PMC10143318 DOI: 10.3390/medicina59040761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/07/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023]
Abstract
Background and Objectives: Cesarean scar and cervical pregnancies are rare forms of ectopic pregnancies, occurring in 1 in 2000 and 1 in 9000 pregnancies, respectively. Both entities are medically challenging due to their high morbidity and mortality potential. Materials and Methods: In this retrospective study, we analyzed all cesarean scar and cervical pregnancies from 2010 to 2019 in the Department of Gynecology and Obstetrics of the University Hospital Freiburg, treated with both intrachorial (using the ovum aspiration set) and systemic methotrexate application. Results: We identified seven patients with a cesarean scar and four patients with cervical pregnancies. At diagnosis, the median gestational age was 7 + 1 (range: 5 + 5-9 + 5) weeks and the mean value of ß-hCG was 43,536 (range: 5132-87842) mlU/mL. On average, one dose of intrachorial and two doses of systemic methotrexate were administered per patient. The efficacy rate was 72.7% with three patients (27.3%) needing an additional surgical or interventional procedure. The uterus was preserved in 100% of the patients. Out of the eight patients with follow-up data, five reported subsequent pregnancies (62.5%) that resulted in six live births. None had recurrent cesarean scars or cervical pregnancies. In the subgroup analyses, when comparing cesarean scar pregnancies to cervical pregnancies, patient characteristics, treatment modality, and the outcome did not differ significantly, except for parity (2 versus 0, p = 0.02) and the duration since the last pregnancy (3 vs. 0.75 years, p = 0.048). When comparing cases with successful and failed methotrexate-only treatments, the maternal age was significantly higher in the successful group (34 vs. 27 years, p = 0.02). Localization of the gestation, gestational and maternal age, ß-hCG, and history of preceding pregnancies were non-predictive for the efficacy of the treatment. Conclusions: The combined application of intrachorial and systemic methotrexate for the treatment of cesarean scar and cervical pregnancies has been proven effective, well-tolerated, organ- and fertility-conserving with a low complication rate.
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Affiliation(s)
- Isabell Ge
- Department of Obstetrics and Gynaecology, University Hospital of Basel, 4056 Basel, Switzerland
- Breast Center, University Hospital Basel, University of Basel, 4056 Basel, Switzerland
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Carmen Geißler
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Alexandra Geffroy
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Philipp Wiehle
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Jasmin Asberger
- Department of Obstetrics and Gynecology, Medical Center-University Hospital Freiburg, 79106 Freiburg, Germany
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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32
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OuYang ZB, Wei SY, Li HY. Maternal Morbidity After Double Balloon Catheter Management of Cesarean Scar and Cervical Pregnancies. Obstet Gynecol 2023; 141:861. [PMID: 36961967 DOI: 10.1097/aog.0000000000005131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Affiliation(s)
- Zhen-Bo OuYang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
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33
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Verberkt C, Lemmers M, de Leeuw RA, van Mello NM, Groenman FA, Hehenkamp WJ, Huirne JA. Effectiveness, complications, and reproductive outcomes after cesarean scar pregnancy management: a retrospective cohort study. AJOG GLOBAL REPORTS 2022; 3:100143. [PMID: 36691399 PMCID: PMC9860491 DOI: 10.1016/j.xagr.2022.100143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There is a dramatic rise in cesarean deliveries worldwide, leading to higher complication rates in subsequent pregnancies. One of these complications is a cesarean scar pregnancy. During the last decades, treatment options for cesarean scar pregnancies have changed, and less invasive interventions have been employed to preserve fertility and reduce morbidity. However, the optimal treatment approach and the influence of various treatments on reproductive outcomes have to be determined. OBJECTIVE This study aimed to evaluate the short- and long-term outcomes after cesarean scar pregnancy management. STUDY DESIGN We conducted a retrospective cohort study of women determined to have a cesarean scar pregnancy from 2010 to 2021 at a tertiary referral center, the Amsterdam University Medical Center, in the Netherlands. Outcomes of the following management strategies were compared: expectant management, methotrexate, curettage with temporary cervical cerclage, or a laparoscopic niche resection. We performed a curettage if the cesarean scar pregnancy did not cross the serosal line of the uterus, and a laparoscopic niche resection was performed if the cesarean scar pregnancy crossed the serosal line. The main outcomes were treatment efficacy and time to subsequent ongoing pregnancy or pregnancy leading to a live birth. RESULTS Of the 60 included women, 5 (8.3%) were managed expectantly, 8 (13.3%) were treated with methotrexate, 31 (51.8%) were treated with a curettage, and 16 (26.7%) with a laparoscopic niche resection. The groups were not comparable. The gestational age and human chorionic gonadotropin levels were generally higher in women who received methotrexate or a laparoscopic niche resection. Additional treatment in the conservative group was needed for 4 (80%) women after expectant management and for 7 (87.5%) women after methotrexate treatment. In the surgical group, all 31 women treated with a curettage and all 16 treated with a laparoscopic niche resection did not require additional treatment. The subsequent ongoing pregnancy rate after cesarean scar pregnancy management was 81.1% (30/37) among women who wished to conceive, with a live birth rate of 78.4% (29/37); 1 woman was in her third trimester of pregnancy at the time of analyses. The time between cesarean scar pregnancy management and subsequent ongoing pregnancy was 4 months (interquartile range, 3-6; P=.02) after expectant management, 18 months (interquartile range, 13-22) after initial methotrexate treatment, 5 months (interquartile range, 3-14; P=.01) after a curettage, and 6 months (interquartile range, 4-15; P=.03) after a laparoscopic niche resection. CONCLUSION Surgical treatment of a cesarean scar pregnancy led to a high success rate without additional interventions, high pregnancy rates with a short time interval between treatment, and subsequent pregnancy leading to an ongoing pregnancy or live birth. Conservative management, both with expectant management and methotrexate treatment, led to high (re)intervention rates. Different management approaches are indicated for different types of cesarean scar pregnancies.
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Affiliation(s)
- Carry Verberkt
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, VU Medical Center, Amsterdam, The Netherlands (Dr Verberkt)
| | - Marike Lemmers
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
| | - Robert A. de Leeuw
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
| | - Norah M. van Mello
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
| | - Freek A. Groenman
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
| | - Wouter J.K. Hehenkamp
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
| | - Judith A.F. Huirne
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
- Corresponding author:
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Safe Service Delivery of a Complex Early Pregnancy Problem: Caesarean Scar Pregnancy. J Clin Med 2022; 11:jcm11237063. [PMID: 36498640 PMCID: PMC9741336 DOI: 10.3390/jcm11237063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/14/2022] [Accepted: 11/25/2022] [Indexed: 12/02/2022] Open
Abstract
Caesarean Scar Pregnancy (CSP) is an ectopic pregnancy with implantation into the niche of the uterine scar. We aimed to describe the local management of consecutive cases of CSP to develop a standard operating procedure (SOP). Between December 2019 and June 2022, there were 19,100 maternities. Of these, 23 were CSPs in 19 patients. Median BMI was 29 (range 20.5-52), median number of Caesarean deliveries (CS) was 2 (range 1-4) and 7/23 (30%) were cigarette smokers. At diagnosis, 9/23 were live pregnancies, 3/23 were retained products of conception (RPOC), 9/23 were pregnancies of uncertain viability (PUV), and 2/23 were non-viable. In six, the initial management was expectant, surgical suction evacuation with transrectal ultrasound guidance in 16, and one had a hysterectomy. The median blood loss was 100 mL (range 50-2000 mL). Two patients (9%) required a blood transfusion. Median hospital stay was 1 day (range 0-4). At follow-up after 10 weeks, no patients had an ongoing haematoma, and one had significant RPOC electing hysterectomy. Eight women were known to have 9 subsequent pregnancies (recurrent CSP n = 4, livebirth n = 2, miscarriage n = 2, tubal ectopic n = 1). Outcomes as rated by low blood loss, short hospital stay, and rare need for further intervention were favorable. Factors associated included prompt ultrasonographic diagnosis, availability of transrectal ultrasound guided surgery, and specialist follow-up, which form the basis of the SOP.
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Wu DF, Zhang HX, He W, Liu X, Song HM, Yu TF. Experience in management of cesarean scar pregnancy and outcomes in a single center. J Int Med Res 2022; 50:3000605221123875. [PMID: 36262051 PMCID: PMC9585568 DOI: 10.1177/03000605221123875] [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] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE This study aimed to describe our experience of managing cesarean scar pregnancy (CSP) and outcomes depending on ultrasound imaging features. METHODS A retrospective, cohort observational study was performed on 31 consecutive patients with CSP at 6 to 9 weeks of gestation from April 2015 to January 2021. All patients were evaluated for the residual myometrial thickness (RMT), growth direction of the gestational sac (GS), blood flow, and chorionic parenchyma using ultrasonography. Patients underwent curettage or methotrexate (MTX) combined with curettage in CSP depending on the age of the GS. Blood loss of >500 mL with curettage was considered major bleeding. RESULTS Twenty-five (80.6%) patients had successful treatment, and six (19.4%) patients had major bleeding. The incidence of major bleeding was significantly higher in patients with >7 weeks of gestation, types II and III CSP, mixed and exogenous types of the growth direction of the GS, an RMT < 2 mm, and multiple lacunae formation in thickened chorionic parenchyma. CONCLUSIONS The exogenous and mixed types of the GS, an RMT < 2 mm, and multiple lacunae in thickened chorionic parenchyma may be high-risk factors for major hemorrhage by curettage in CSP.
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Affiliation(s)
- Dong-fang Wu
- Department of Ultrasound, Beijing Fengtai Hospital, Capital Medical University, No. 99 Feng Tai South Road, Feng Tai District, Beijing 100071, China
| | - Hong-xia Zhang
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China,Hong-xia Zhang, Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China.
| | - Wen He
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China
| | - Xin Liu
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China
| | - Hai-man Song
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China
| | - Teng-fei Yu
- Department of Ultrasound, Beijing Tiantan Hospital, Capital Medical University, No. 119 4th South Ring West Road, Fengtai District, Beijing 100070, China
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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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Jordans IPM, Verberkt C, de Leeuw RA, Van den Bosch T, Huirne JAF. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:298. [PMID: 35913379 DOI: 10.1002/uog.24964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- I P M Jordans
- Department of Obstetrics and Gynecology, Research Institute 'Amsterdam Reproduction and Development', Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
| | - C Verberkt
- Department of Obstetrics and Gynecology, Research Institute 'Amsterdam Reproduction and Development', Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - R A de Leeuw
- Department of Obstetrics and Gynecology, Research Institute 'Amsterdam Reproduction and Development', Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - T Van den Bosch
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
- Laboratory for Tumor Immunology and Immunotherapy, KU Leuven, Leuven, Belgium
| | - J A F Huirne
- Department of Obstetrics and Gynecology, Research Institute 'Amsterdam Reproduction and Development', Amsterdam UMC, Location VUMC, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Research Institute 'Amsterdam Reproduction and Development', Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
- Department of Obstetrics and Gynecology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
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OuYang Z, Wu J, Wan Z. Pathogenesis and classification of Cesarean scar pregnancy: getting closer to the truth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:297-298. [PMID: 35913382 DOI: 10.1002/uog.24960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 05/27/2023]
Affiliation(s)
- Z OuYang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - J Wu
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Z Wan
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
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Rudaitis V, Maldutytė G, Brazauskienė J, Pavlauskas M, Valančienė D. Caesarean Scar Pregnancy: A Case Report. Acta Med Litu 2022; 29:124-130. [PMID: 36061932 PMCID: PMC9428636 DOI: 10.15388/amed.2022.29.1.17] [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: 03/21/2022] [Revised: 05/24/2022] [Accepted: 05/31/2022] [Indexed: 11/26/2022] Open
Abstract
Caesarean scar pregnancy is a potentially life-threatening gynaecological condition, becoming more common due to steadily increasing rate of caesarean sections worldwide. More than one-third of women presenting with caesarean scar pregnancy are asymptomatic, but over the time if left untreated this condition can lead to the uterine rupture and massive maternal haemorrhage. Therefore it is necessary to diagnose and manage caesarean scar pregnancies properly at the beginning of the first trimester. We present the case of woman with three previous caesarean sections, who was diagnosed with complicated caesarean scar pregnancy and then successfully managed using surgical intervention.
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40
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Jurkovic D, Tellum T, Kirk E. Cesarean scar pregnancy IS an ectopic pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:831-832. [PMID: 35642911 DOI: 10.1002/uog.24921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/22/2022] [Indexed: 05/27/2023]
Affiliation(s)
- D Jurkovic
- Institute for Women's Health, University College Hospital, London, UK
| | - T Tellum
- Department of Gynecology, Oslo University Hospital, Oslo, Norway
| | - E Kirk
- Early Pregnancy and Emergency Gynaecology Unit, Royal Free London NHS Foundation Trust, London, UK
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