Cesarean scar pregnancy: issues in management

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

How to perform standardized sonographic examination of Cesarean scar pregnancy in the first trimester

Early diagnosis and appropriate management of Cesarean scar pregnancy (CSP) are crucial to prevent severe complications, such as uterine rupture, severe hemorrhage and placenta accreta spectrum disorders. In this article, we provide a step-by-step tutorial for the standardized sonographic evaluation of CSP in the first trimester. Practical steps for performing a standardized transvaginal ultrasound examination to diagnose CSP are outlined, focusing on criteria and techniques essential for accurate identification and classification. Key sonographic markers, including gestational sac location, cardiac activity, placental implantation and myometrial thickness, are detailed. The evaluation process is presented according to assessment of the uterine scar, differential diagnosis, detailed CSP evaluation and CSP classification. This step-by-step tutorial emphasizes the importance of scanning in two planes (sagittal and transverse), utilizing color or power Doppler and differentiating CSP from other low-lying pregnancies. The CSP classification is described in detail and is based on the location of the largest part of the gestational sac relative to the uterine cavity and serosal lines. This descriptive classification is recommended for clinical use to stimulate uniform description and evaluation. Such a standardized sonographic evaluation of CSP in the first trimester is essential for early diagnosis and management, helping to prevent life-threatening complications and to preserve fertility. Training sonographers in detailed evaluation techniques and promoting awareness of CSP are critical. The structured approach to CSP diagnosis presented herein is supported by a free e-learning course available online. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Efficacy and safety of treatment modalities for cesarean scar pregnancy: a systematic review and network meta-analysis

OBJECTIVE

Cesarean scar pregnancy may lead to varying degrees of complications. There are many treatment methods for it, but there are no unified or recognized treatment strategies. This systematic review and network meta-analysis aimed to observe the efficacy and safety of treatment modalities for patients with cesarean scar pregnancy.

DATA SOURCES

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from their inception to January 31, 2024. In addition, relevant reviews and meta-analyses were manually searched for additional references.

STUDY ELIGIBILITY CRITERIA

Our study incorporated head-to-head trials involving a minimum of 10 women diagnosed with cesarean scar pregnancy through ultrasound imaging or magnetic resonance imaging, encompassing a detailed depiction of primary interventions and any supplementary measures. Trials with a Newcastle-Ottawa scale score <4 were excluded because of their low quality.

METHODS

We conducted a random-effects network meta-analysis and review for cesarean scar pregnancy. Group-level data on treatment efficacy and safety, reproductive outcomes, study design, and demographic characteristics were extracted following a predefined protocol. The quality of studies was assessed using the Cochrane risk-of-bias tools for randomized controlled trials and the Newcastle‒Ottawa scale for cohort studies and case series. The main outcomes were efficacy (initial treatment success) and safety (complications), of which summary odds ratios and the surface under the cumulative ranking curve using pairwise and network meta-analysis with random effects.

RESULTS

Seventy-three trials (7 randomized controlled trials) assessing a total of 8369 women and 17 treatment modalities were included. Network meta-analyses were rooted in data from 73 trials that reported success rates and 55 trials that reported complications. The findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage demonstrated the highest cure rates, as evidenced by surface under the cumulative ranking curve rankings of 91.2, 88.2, 86.9, and 75.3, respectively. When compared with suction curettage, the odds ratios (95% confidence intervals) for efficacy were as follows: 6.76 (1.99-23.01) for laparoscopy, 5.92 (1.47-23.78) for transvaginal resection, 5.00 (1.99-23.78) for hysteroscopic curettage, and 3.27 (1.08-9.89) for high-intensity focused ultrasound combined with suction curettage. Complications were more likely to occur after receiving uterine artery chemoembolization, suction curettage, methotrexate+hysteroscopic curettage, and systemic methotrexate; hysteroscopic curettage, high-intensity focused ultrasound combined with suction curettage, and Lap were safer than the other options derived from finite evidence; and the confidence intervals of all the data were wide.

CONCLUSION

Our findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage procedures exhibit superior efficacy with reduced complications. The utilization of methotrexate (both locally guided injection and systemic administration) as a standalone medical treatment is not recommended.

Common and Uncommon Gestational Complications in Radiological Practice: An Overview

Gestational complications are common in radiological practice and can be identified and evaluated using various imaging methods. Each complication typically presents with specific imaging features; however, there is a lack of comprehensive literature that consolidates this information to facilitate a diagnostic algorithm and focused study. In this context, this review aims to revisit the theoretical basis of differentials in pregnancy-related complications, discussing classic imaging features and providing examples of key features for each diagnosis. The focus is on essential information for accurate diagnosis, emphasizing the role of radiologists in contributing to better outcomes.

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

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

Prevalence, Determinants, and Management Options of Scar Site Pregnancy in Women With Previous Cesarean Section: A Study From the Al-Qassim Region

INTRODUCTION

Pregnancy located outside the uterine cavity following a cesarean section has become more prevalent in recent years due to the increase in cesarean section delivery. This study sought to investigate the prevalence, determinants, and treatment options of scar site pregnancy among women who sought maternal and child health services in a hospital in Buraydah, Al-Qassim region, Saudi Arabia.

METHODS

Utilizing a quantitative retrospective case-control design, 50 women were recruited and assigned to the two groups evenly. Demographic data and risk factors were assessed using a questionnaire, and data were analyzed using SPSS version 27 at a 95% confidence interval and presented in tables and figures.

RESULTS

Fifty-eight percent of the participants were aged 35 years and above, with 38% reporting a parity of 1-3. Logistic regression revealed that parity (odds ratio (OR) = 10.975, 95% confidence interval (CI) = 0.887-135.861, and p-value = 0.062), the interval between the last and present pregnancies (OR = 0.056, 95% CI = 0.005-0.668, p-value = 0.023), intrauterine contraceptive device (IUCD) use in the last year (OR = 0.070, 95% CI = 0.006 -0.780, p-value = 0.031) were statistically significant in predicting cesarean scar pregnancy. Combined methotrexate and aspiration were the most prevalent treatment options for scar site pregnancy in this study.

CONCLUSION

Scar site pregnancy is a maternal health complication that affects women across all healthcare settings, and its prevalence is not clear due to underdiagnosis and underreporting. The risk of scar site pregnancy increased with an increase in the number of childbirths (parity) and the interval between the last and current pregnancies.

A rare case report of heterotopic cesarean scar pregnancy in the 8th week of gestation that was managed successfully by exploratory laparotomy with dilation and curettage

Key Clinical Message

Swift and precise identification of heterotopic cesarean scar pregnancy, coupled with standardized treatment approaches for handling possible serious complications, form an essential component in reaching favorable outcomes for patients experiencing this rare type of pregnancy.

Abstract

Heterotopic pregnancy (HP) denotes a form of multiple gestation where intrauterine and ectopic pregnancies coexist. Cesarean scar ectopic pregnancy, on the other hand, involves the implantation of a fetus over the previous cesarean scar. This condition poses a significant risk of uterine rupture, which may lead to serious health complications, and even death. We report a case of a fit 37-year-old woman with two previous cesarean deliveries who was diagnosed with a heterotopic cesarean scar pregnancy at 8 weeks gestation following symptoms of lower abdominal pain and delayed menstruation. Both pregnancies demonstrated cardiac activity and the portion of the myometrium located between the bladder wall and the gestational sac was noted to exhibit considerable thinness. The patient underwent an exploratory laparotomy coupled with dilation and curettage and recovered uneventfully. The proper management of a HCSP requires timely diagnosis through ultrasonography. Early diagnosis allows for immediate intervention to prevent complications such as uterine rupture or potentially lethal bleeding.

Ruptured Caesarean Scar Ectopic Pregnancy: A Rare Case of Obstetric Hemorrhage

Caesarean scar ectopic pregnancy is the rarest form of ectopic pregnancy. Nowadays, with the rise in caesarean deliveries, along with better awareness and improvement in ultrasound diagnosis, there is an increase in the number and detection of caesarean scar ectopic pregnancy. A 28-year-old female patient with one previous caesarean delivery and a spontaneous abortion at three months visited the obstetrics emergency department due to three months of amenorrhea, abdominal pain, and vaginal bleeding on and off for two days. The patient was noticed to have severe anemia. After stabilizing the patient with blood transfusion, a laparotomy was performed with the presentation of hemoperitoneum and caesarean scar rupture. Fetus and soft vascular mass seen protruding from the previous scar were extracted. The caesarean scar site was repaired in layers.

The effectiveness of hysteroscopy for the treatment of cesarean scar pregnancy: a retrospective cohort study

BACKGROUND

Cesarean scar pregnancy (CSP) is a long-term complication of cesarean section characterized by the localization of a subsequent gestational sac within the scar area or niche developed as a result of a previous cesarean section. Its incidence has increased substantially because of the high global cesarean section rate in recent decades. Several surgical and drug treatments exist for this condition; however, there is currently no optimal treatment. This study compared the effectiveness of direct hysteroscopic removal of the gestational tissue and hysteroscopy combined with vacuum suction for the treatment of CSP.

METHODS

From 2017 to 2023, 521 patients were diagnosed with CSP at our hospital. Of these patients, 45 underwent hysteroscopy. Among them, 28 underwent direct hysteroscopic removal (hysteroscopic removal group) and 17 underwent hysteroscopy combined with vacuum suction (hysteroscopic suction group). The clinical characteristics and outcomes of the hysteroscopic removal group and hysteroscopic suction group were analyzed.

RESULTS

Among the 45 patients, the amount of bleeding and hospitalization cost were significantly higher in the hysteroscopic removal group than in the hysteroscopic suction group (33.8 mL vs. 9.9 mL, P < 0.001; and 8744.0 yuan vs. 5473.8 yuan, P < 0.001; respectively). The operation time and duration of hospitalization were significantly longer in the hysteroscopic removal group than in the hysteroscopic suction group (61.4 min vs. 28.2 min, P < 0.001; and 3.8 days vs. 2.4 days, P = 0.026; respectively). Three patients in the hysteroscopic removal group had uterine perforation and received laparoscopic repair during operation. No complications occurred in the hysteroscopic suction group. One patient in the hysteroscopic removal group received ultrasound-guided suction curettage due to postoperative moderate vaginal bleeding, and one patient in the hysteroscopic suction group received ultrasound-guided suction curettage due to postoperative gestational residue and elevated serum beta-human chorionic gonadotropin levels. Reproductive function was preserved in all patients.

CONCLUSIONS

Hysteroscopy is an effective method for treating CSP. Compared with direct hysteroscopic removal, hysteroscopy combined with vacuum suction is more suitable for CSP. However, multicenter prospective studies with large sample sizes are required for verification of these findings.

Diagnostic value of enhanced-contrast ultrasound for cesarean scar pregnancy: A systematic review

BACKGROUND

Cesarean scar pregnancy, an uncommon ectopic pregnancy in which the embryo is implanted in the cesarean scar, poses significant risks without prompt diagnosis and treatment. Its prevalence has risen alongside increased cesarean section rates. Despite various treatment approaches, consensus remains elusive. Ultrasonography, particularly contrast-enhanced ultrasonography, shows promise in cesarean scar pregnancy diagnosis.

MAIN BODY

This systematic review, following PRISMA guidelines, explores contrast-enhanced ultrasound's diagnostic potential in cesarean scar pregnancy. We searched PubMed, Scopus, Web of Science, and Google Scholar up to August 2023. Selection involved two stages: title/abstract screening and full-text assessment. The included studies investigated contrast-enhanced ultrasound's diagnostic value in cesarean scar pregnancy, provided adequate data, and were peer-reviewed in English. Quality assessment followed the QUADAS-2 criteria. We extracted the diagnostic accuracy metrics: sensitivity, specificity, and accuracy. Out of 193 records, five studies met the inclusion criteria (2016-2020, China). Contrast-enhanced ultrasound displayed sensitivities of 77%-100% and specificities of 95%-100%. Two studies reported accuracy of 96.9%-97.8%. Compared with conventional ultrasound, contrast-enhanced ultrasound exhibited superior sensitivity, specificity, and accuracy. It also outperformed transvaginal ultrasound.

CONCLUSION

Enhanced-contrast ultrasound holds promise for diagnosing and managing cesarean scar pregnancy by visualizing scar vascularization in real-time, thereby reducing severe complication risks. This review highlights contrast-enhanced ultrasound as a transformative diagnostic tool for cesarean scar pregnancy management, despite existing evidence limitations.

Clinical efficacy and risk factors for suction curettage and hysteroscopy in patients with type I and II cesarean scar pregnancy

OBJECTIVE

To investigate the clinical efficacy and evaluate risk factors for suction curettage (SC) and hysteroscopy in the treatment of type I and II cesarean scar pregnancy (CSP).

METHODS

This was a retrospective study including 100 women diagnosed with type I/II CSP. Patients were treated with either ultrasound-guided SC (SC group) or hysteroscopy resection (surgery group). The success rates, mean operation time, hospitalization duration, hospitalization cost, risk factors, adverse events, and complications were analyzed.

RESULTS

The success rate of the SC and surgery groups were 85% and 100%, respectively, and the difference was statistically significant (P = 0.032). There was one case of type I CSP and eight cases of type II CSP that failed SC treatment. No failed cases were found in the surgery group. Analysis of the causes of treatment failure revealed that diameter of the gestational sac was a risk factor for SC failure (odds ratio, 19.66 [95% confidence interval {CI}, 1.70-227.72], P = 0.017). Comparing the clinical outcomes between the SC and surgery groups, although the mean operation time of the SC group was significantly shorter than the surgery group (15 [CI, 15-20] vs. 30 [CI, 27-40], P = 0.001), the cost and duration of hospitalization were significantly lower in the surgery group than that in the SC group. No significant differences were observed for adverse events and complications between the two groups (P > 0.05).

CONCLUSION

Hysteroscopy is an effective and economical method for treating type I/II CSP. Moreover, SC is not recommended for patients with type I/II CSP with a gestation age ≥8 weeks.

Treatments for cesarean scar pregnancy: 11-year experience at a medical center

BACKGROUND

Cesarean scar pregnancy (CSP) is a long-term complication after cesarean section that can cause severe maternal morbidity and mortality. Although a variety of treatments have been described, there is no consensus as to the optimal management approach. Many grading systems for CSP have been proposed, among which the classification made by the consensus of Chinese experts in 2016 was shown to provide improved treatment guidance for clinical practice. The purpose of the present study was to analyze the success rate of different treatments for each type of CSP as classified according to the Chinese Expert's Consensus (2016), and to develop a management strategy for CSP.

METHODS

A retrospective study was performed among patients diagnosed with CSP at Shandong Provincial Hospital between January 2009 and December 2019. We reviewed clinical characteristics, treatment methods, and subsequent outcomes; and analyzed these endpoints using the statistical software package SPSS 22.0 (SPSS, Inc., Chicago, IL).

RESULTS

For type I CSP, systemic methotrexate (MTX) administration exhibited a success rate of 79.2% for type Ia and 14.3% for type Ib. Local and systemic MTX administration success rates were 88.9% for type Ia and 66.7% for type Ib. Dilation and curettage (D&C), curettage after uterine artery embolization (UAE + C), and hysteroscopic curettage (H + C) were 100% successful. For type II, UAE + C, H + C, and laparoscopy combined with hysteroscopic curettage (L + H+C) were 100% successful. D&C had a success rate of 97.0% for type IIa and 88.9% for type IIb. The success rate of systemic MTX administration was 52.0% for type IIa and 62.5% for type IIb. Both UAE + C and L + H+C had 100% success rates for type IIIa CSPs, while for type IIIb, the success rate was 87.9% for UAE + C vs. 96.6% for L + H+C.

CONCLUSIONS

For type I CSPs, D&C was quick, easy, and safe; for type II, H + C was more suitable. For type III and some type II patients who wished to undergo simultaneous repair of the cesarean defect, L + H+C was the optimal method. UAE can be used as a complementary option instead of a prophylactic measure, and when difficulties with endoscopic surgeries were encountered, conversion to laparotomy was the ultimate treatment.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Scar Ectopic Pregnancy as an Uncommon Site of Ectopic Pregnancy: A Case Report and Literature Review

A cesarean scar pregnancy is a rare type of ectopic pregnancy that occurs when a fertilized egg implants in the scar from a previous cesarean section. It is a serious condition that can lead to significant morbidity and mortality if not managed promptly and appropriately. In this literature review and case report, we discuss the etiology, diagnosis, and management of cesarean scar pregnancy. We conducted a comprehensive search of relevant literature using electronic databases and included studies that reported on the diagnosis and management of cesarean scar pregnancy. We also present a case report of a patient with cesarean scar pregnancy who was managed surgically. The diagnosis of cesarean scar pregnancy is primarily done via transvaginal or transabdominal ultrasound, and medical or surgical management can be used depending on the gestational age, hemodynamic status, and patient preferences. The surgical approach, which involves hysteroscopy, laparoscopy, or laparotomy, is usually preferred, since it is associated with fast recovery and lower recurrence rates. However, it is crucial to consider the patient's plans for future fertility when selecting the management approach. In conclusion, cesarean scar pregnancy is a rare but potentially life-threatening condition that requires prompt and appropriate management. Early diagnosis and treatment can prevent significant morbidity and mortality, and surgical management is usually preferred due to its higher success rates and lower recurrence rates.

Effectiveness and safety of prophylactic abdominal aortic balloon occlusion for patients with type III caesarean scar pregnancy: a prospective cohort study

BACKGROUND

Caesarean scar pregnancy (CSP) is a special type of ectopic pregnancy with a high risk of massive haemorrhage. Few studies have focused on the efficacy of prophylactic abdominal aortic balloon occlusion as a minimally invasive method in caesarean section. This study aimed to evaluate the effectiveness and safety of prophylactic abdominal aortic balloon occlusion for patients with type III CSP.

METHODS

This was a prospective cohort study. Patients with type III CSP in the First Affiliated Hospital of Zhengzhou University from January 2020 to June 2022 were enrolled. Eligible patients received prophylactic abdominal aortic balloon occlusion (defined as the AABO group) or uterine artery embolization (defined as the UAE group) before laparoscopic surgery. Clinical outcomes included intraoperative blood loss, body surface radiation dose, hospitalization expenses, and time to serum β-hCG normalization, and safety were also assessed.

RESULTS

A total of 68 patients met the criteria for the study, of whom 34 patients were in the AABO group and 34 patients were in the UAE group. The median intraoperative blood loss in the AABO and UAE groups was 17.5 (interquartile ranges [IQR]: 10, 45) and 10 (IQR: 6.25, 20) mL, respectively (P = 0.264). The body surface radiation dose of the AABO group was much lower than that of the UAE group (5.22 ± 0.44 vs. 1441.85 ± 11.59 mGy, P < 0.001). The AABO group also had lower hospitalization expenses than the UAE group (2.42 ± 0.51 vs. 3.42 ± 0.85 *10^5 yuan, P < 0.001). The average time to serum β-hCG normalization in the AABO group was 28.9 ± 3.21 d, which was similar to that in the UAE group (30.3 ± 3.72 d, P = 0.099). In addition, the incidence of adverse events in the AABO group was lower than that in the UAE group (5.9% vs. 58.8%, P < 0.001).

CONCLUSION

Prophylactic AABO was equally as effective as UAE in patients with type III CSP but was safer than UAE during and after the operation.

Assessment of Female Pelvic Pathologies: A Cross-Sectional Study Among Patients Undergoing Magnetic Resonance Imaging for Pelvic Assessment at the Maternity and Children Hospital, Qassim Region, Saudi Arabia

Background and objectives Pelvic pathologies affect females in all age groups. They vary in size and location and can be wide in classification, such as masses, ectopic pregnancy, ovarian torsion, and ruptured ovarian follicles. Patients commonly present with gynecological complaints such as menstrual irregularities, abnormal pelvic bleeding, and infertility. Extra-gynecological symptoms such as dysuria and painful defecation can also manifest. To diagnose these pathologies, magnetic resonance imaging (MRI) and other imaging modalities can be useful alongside history and physical examination for early clinical diagnosis. Due to the importance of prevalence rate in predicting pathologies in a certain age and due to the lack of research studies on pelvic MRI studies in Qassim region, Saudi Arabia, this study aimed to demonstrate the wide spectrum of female pelvic pathologies that can be diagnosed using MRI in Qassim region, Saudi Arabia.  Methods and results A cross-sectional study was conducted among patients referred to the MRI Department for evaluation of female pelvic pathologies at the Department of Radiology at Maternity and Children Hospital in Buraydah, Qassim region, Saudi Arabia. A total of 325 patients were included in the study, with the majority being in the age group of 31-40 years. Fibroids were the most common pathology, being present in more than one-fifth of the study sample, followed by neoplastic growths and placental pathologies. Inflammatory pathologies were the least common pathologies, being present in approximately 5% of the participants. Statistically significant associations were found between the age groups, and the presence of anomalies (p = 0.009), existence of neoplastic changes (p < 0.001), presence of placental pathologies (p < 0.001), inflammatory changes (p = 0.025), and adenomyosis (p = 0.028). Conclusion MRI data offer important new information about the prevalence of various disorders among different age groups in the Qassim region of Saudi Arabia. Younger age groups had much higher rates of anomalies, whereas older age groups had much lower rates. Adenomyosis and neoplastic alterations were more prevalent in the later age groups, but endometrioma was more prevalent in younger age groups. Placental pathologies were more prevalent in women in their middle years, while scar pregnancy was more prevalent in women between 31 and 40 years of age. Younger people, especially those between 16 and 20 years of age, were more likely to experience inflammatory alterations. In the younger age group, there was no discernible association between age and the prevalence of normal outcomes. These findings help us understand how different illnesses manifest differently as we get older and emphasize the value of taking aging into account when diagnosing and treating disorders.

Cesarean scar ectopic pregnancy: nuances in diagnosis and treatment

A cesarean scar ectopic pregnancy (CSEP) occurs when the embryo implants on the scar of a previous cesarean delivery. The number of births delivered by cesarean section has climbed by 50% over the last decade, from a nadir of 20.7% in 1996 to 32.1% in 2021. As a result, the incidence of CSEP has also increased. Because CSEP may cause serious morbidity such as life-threatening hemorrhage, uterine rupture, placental accreta spectrum, hysterectomy, and even mortality, accurate diagnosis and appropriate management of this condition are essential. This review focuses on the etiology, incidence, clinical diagnosis, and management of CSEPs.

Cesarean scar ectopic partial molar pregnancy: A case report and a review of literature

A scar ectopic pregnancy exhibiting hydatidiform features is an extremely rare and clinically challenging entity. Delayed diagnosis and failure to treat such cases promptly can lead to devastating consequences. In this report, we present a case of cesarean scar ectopic partial molar pregnancy in a 37-year-old woman who presented with complaints of vaginal discharge with streaks of blood and lower abdominal pain. Diagnostic laparoscopy revealed an abnormal mass of brown soft tissue in the anterior wall of the uterus, measuring 13.0 × 9.0 × 2.0 cm, raising suspicion (in the context of elevated serum human chorionic gonadotropin levels) of a scar ectopic pregnancy. Open laparotomy was performed, and the scar ectopic mass was successfully removed. The histologic examination of the tissue revealed a partial hydatidiform mole. The patient experienced a full recovery postoperatively, with serum human chorionic gonadotropin levels gradually declining to normal values. This report is unique in its presentation of the clinicopathological features of cesarean scar ectopic molar pregnancy and the successful management of the condition.

Analysis of risk factors for patients with cesarean scar pregnancy treated with methotrexate combined with suction curettage

PURPOSE

To analyze the predictive value of clinical and ultrasound parameters for treatment failure after administration of methotrexate (MTX) in combination with suction curettage (SC) in treatment of cesarean scar pregnancy (CSP) in the early first trimester.

METHODS

In this retrospective cohort study, electronic medical records of patients diagnosed with CSP and initially treated between 2015 and 2022 with MTX combined with SC were reviewed and outcome data were collected.

RESULTS

127 patients met inclusion criteria. 25 (19.69%) required additional treatment. Logistic regression analysis indicated that factors independently associated with the need for additional treatment included progesterone level > 25 mIU/mL (OR: 1.97; 95% CI: 0.98-2.87, P = 0.039), abundant blood flow (OR: 5.19; 95% CI: 2.44-16.31, P = 0.011), gestational sac size > 3 cm (OR: 2.54; 95% CI: 1.12-6.87, P = 0.029), and the myometrial thickness between the bladder and gestational sac < 2.5 mm (OR: 3.48; 95% CI: 1.91-6.98, P = 0.015).

CONCLUSIONS

Our study identified several factors which increase the need for additional treatment following the initial treatment of CSP with MTX and SC. Alternative therapy should be considered if these factors are present.

Other treatments for CSP

Caesarean scar pregnancy (CSP) is an increasingly common clinical conundrum. The non-curettage surgical management of CSP can be categorised into hysteroscopic, vaginal, laparoscopic, and open removal modalities and the choice of treatment is surgeon-dependent. A systematic review of original studies reporting surgical treatment outcomes of CSP until March 2023 was conducted to evaluate the non-curettage surgical management of this highly morbid condition. A total of 60 studies of mostly weak methodological quality were identified involving 6720 CSP cases. Success rates were generally high across all treatment modalities although highest in vaginal and laparoscopic excisional approaches. Morbidity was most associated with haemorrhage although unplanned hysterectomy rates remained low across all treatment groups. Subsequent pregnancies are associated with morbidity despite being underreported and the impact of CSP treatment on future pregnancy is poorly understood. Substantive study heterogeneity precludes meta-analyses of pooled data and treatment superiority has not been demonstrated.

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

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

Emergency internal iliac artery temporary occlusion after massive hemorrhage during surgery of cesarean scar pregnancy: A case report

BACKGROUND

Cesarean scar pregnancy (CSP) is rare but may result in uterine rupture during pregnancy or massive hemorrhage during abortion procedures. Awareness of this condition is increasing, and most patients with CSP are now diagnosed early and can be managed safely. However, some atypical patients are misdiagnosed, and their surgical risks are underestimated, increasing the risk of fatal hemorrhage.

CASE SUMMARY

A 27-year-old Asian woman visited our institution because of abnormal pregnancy, and she was diagnosed with a hydatidiform mole through trans-vaginal ultrasound (TVS). Under hysteroscopy, a large amount of placental tissue was found in the scar of the lower uterine segment, and a sudden massive hemorrhage occurred during the removal process. The bilateral internal iliac arteries were temporarily blocked under laparoscopy, and scar resection and repair were rapidly performed. She was discharged in good condition 5 d after the operation.

CONCLUSION

Although TVS is widely used in the diagnosis of CSP, delays in the diagnosis of atypical CSP remain. Surgical treatment following internal iliac artery temporary occlusion may be an appropriate management method for unanticipated massive hemorrhage during CSP surgery.

Efficacy and Safety of High-intensity Focused Ultrasound Compared with Uterine Artery Embolization in Cesarean Section Pregnancy: A Meta-analysis

OBJECTIVE

To investigate the efficacy and safety of high-intensity focused ultrasound (HIFU) compared with uterine artery embolization (UAE) in cesarean section pregnancy (CSP) and to calculate the success rate of HIFU.

DATA SOURCES

We searched PubMed, Cochrane, Scopus, Web of Science, and Embase on September 30, 2022, and the related studies were independently reviewed by 2 researchers.

METHODS OF STUDY SELECTION

Medical subject headings and relevant terms from other articles were used for the database search. Patients with CSP who underwent HIFU were included in this analysis. The following results were recorded: success rate, intraoperative blood loss, time for serum beta-human chorionic gonadotropin (beta-HCG) normalization and menstruation recovery, adverse events, hospitalization time, and hospitalization expenses. We used the Newcastle-Ottawa Scale scoring system and the methodological index for nonrandomized studies system to evaluate the quality of the studies.

TABULATION, INTEGRATION, AND RESULTS

Data from 6 studies were used to compare the efficacy and safety of UAE and HIFU. We pooled the success rate of HIFU by including 10 studies. No data overlap between the 10 studies. Success rate was higher in the HIFU group (odds ratio [OR] = 1.90; 95% confidence interval [CI] 1.06-3.41; p = .03; I2 = 0). We performed the meta-analysis of single rate in R 4.2.0 software, and the success rate of HIFU group was 0.94 (95% CI 0.92-0.96; p = .04; I2 = 48%). Intraoperative blood loss (mean difference [MD]= -21.94 mL; 95% CI -67.34 to 23.47; p = .34; I2 = 99%) and time for serum beta-HCG normalization (MD = 3.13 days; 95% CI 0.02-6.25; p = .05; I2 = 70%) were not significantly different. Time to menstruation recovery (MD = 2.72 days; 95% CI 1.32-4.12; p = .0001; I2 = 0) in the UAE group was shorter than that in the HIFU group. Adverse events were not significantly different between the 2 groups (OR = 0.53; 95% CI 0.22-1.29; p = .16; I2 = 81%). Hospitalization time was not significantly different between the HIFU and UAE groups (MD = -0.41 days; 95% CI -1.14 to 0.31; p = .26; I2 = 55%). Hospitalization expenses of the HIFU group were lower than those of the UAE group (MD = -7488.49 yuan; 95% CI -8460.13 to -6516.84; p <.000; I2 = 0). Heterogeneity of the time for beta-HCG normalization, adverse events, and hospitalization time were improved after excluding one study, and HIFU showed better results in the sensitivity analysis of adverse events and hospitalization time.

CONCLUSION

According to our analysis, HIFU demonstrated satisfactory treatment success, accompanied by similar intraoperative blood loss, slower normalization of beta-HCG levels, and menstruation recovery, but potentially shorter hospitalization time, lower adverse events and lower costs than UAE. Therefore, HIFU is an effective, safe, and economical treatment for patients with CSP. These conclusions should be interpreted with caution because of the significant heterogeneity. However, large and strictly designed clinical trials are required to verify these conclusions.

Definition and diagnosis of cesarean scar ectopic pregnancies

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.

Cesarean Scar Ectopic Pregnancy Clinical Classification System With Recommended Surgical Strategy

OBJECTIVE

To establish a new cesarean scar ectopic pregnancy clinical classification system with recommended individual surgical strategy and to evaluate its clinical efficacy in treatment of cesarean scar ectopic pregnancy.

METHODS

This retrospective cohort study included patients with cesarean scar ectopic pregnancy in Qilu Hospital in Shandong, China. From 2008 to 2015, patients with cesarean scar ectopic pregnancy were included to determine risk factors for intraoperative hemorrhage during cesarean scar ectopic pregnancy treatment. Univariable analysis and multivariable logistic regression analyses were used to explore the independent risk factors for hemorrhage (300 mL or greater) during a cesarean scar ectopic pregnancy surgical procedure. The model was internally validated with a separate cohort. Receiver operating characteristic curve methodology was used to identify optimal thresholds for the identified risk factors to further classify cesarean scar ectopic pregnancy risk, and the recommended operative treatment was established for each classification group by expert consensus. A final cohort of patients from 2014 to 2022 were classified according to the new classification system, and the recommended surgical procedure and clinical outcomes were abstracted from the medical record.

RESULTS

Overall, 955 patients with first-trimester cesarean scar ectopic pregnancy were included; 273 were used to develop a model to predict intraoperative hemorrhage with cesarean scar ectopic pregnancy, and 118 served as an internal validation group for the model. Anterior myometrium thickness at the scar (adjusted odds ratio [aOR] 0.51, 95% CI 0.36-0.73) and average diameter of the gestational sac or mass (aOR 1.10, 95% CI 1.07-1.14) were independent risk factors for intraoperative hemorrhage of cesarean scar ectopic pregnancy. Five clinical classifications of cesarean scar ectopic pregnancy were established on the basis of the thickness and gestational sac diameter, and the optimal surgical option for each type was recommended by clinical experts. When the classification system was applied to a separate cohort of 564 patients with cesarean scar ectopic pregnancy, the overall success rate of recommended first-line treatment with the new classification grouping was 97.5% (550/564). No patients needed to undergo hysterectomy. Eighty-five percent of patients had a negative serum β-hCG level within 3 weeks after the surgical procedure; 95.2% of patients resumed their menstrual cycles within 8 weeks.

CONCLUSION

Anterior myometrium thickness at the scar and the diameter of the gestational sac were confirmed to be independent risk factors for intraoperative hemorrhage during cesarean scar ectopic pregnancy treatment. A new clinical classification system based on these factors with recommended surgical strategy resulted in high treatment success rates with minimal complications.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Rare Concomitant Cesarean Scar Ectopic Pregnancy With Tubal Ectopic Pregnancy: A Case Report

A cesarean ectopic pregnancy is the rarest of all pregnancies and occurs when pregnancy implants on a cesarean scar. Incidence estimated in overall cesarean delivery is 1/1,800-1/2,500. Following a cesarean procedure, this abnormal embryo implantation into the uterine myometrium and fibrous tissues has a high rate of morbidity and mortality. The most common type of ectopic pregnancy is tubal ectopic pregnancy, and both their incidence and their frequency are rising. Early detection and treatment of ectopic pregnancy are crucial since delays in these processes might result in maternal death and morbidity. We are reporting a case of two concurrent pregnancies in a 27-year-old female with two separate implantation sites. The simultaneous occurrence of a tubal and an ectopic scar pregnancy was highly unusual. Early detection and treatment of ectopic pregnancy help prevent complications, death, and morbidity because it is a potentially fatal condition.

Treatment of Recurrent Cesarean Scar Pregnancy With Oral Mifepristone, Systemic Methotrexate, and Ultrasound-Guided Suction Dilation and Curettage

Cesarean scar pregnancy (CSP), or pregnancies with implantation in a prior cesarean section scar, are rare but may be becoming more common with an increase in cesarean section deliveries. History of prior CSP may also increase the risk for recurrent CSP. Several treatment options and combinations of treatment options for CSP have been described in the literature. Although the optimal treatment is unclear, the Society of Maternal-Fetal Medicine published recommendation guidelines, which include recommendations for the treatment/termination of CSP pregnancies. Treatment of CSP is recommended with operative resection, ultrasound-guided suction dilation and curettage (D&C), or intragestational methotrexate with or without treatment modalities. This is a case report of a patient with recurrent CSP. Her first CSP was incorrectly diagnosed as an incomplete abortion after unsuccessful treatment with misoprostol alone and ultimately was successfully treated with systemic methotrexate. Her second CSP is the basis of this case report and was successfully treated with oral mifepristone and systemic methotrexate (50 milligrams/meter²) before an ultrasound-guided suction D&C at 10 weeks 1 day gestational age. The combination of mifepristone, systemic methotrexate, and suction D&C under ultrasound guidance as a treatment for recurrent CSP has not previously been described in published literature.

Comparison of clinical safety and efficacy of ultrasound-guided local lauromacrogol injection versus uterine artery embolization in the treatment of caesarean scar pregnancy: a systematic review and meta-analysis

BACKGROUND

The aim of this systematic review and meta-analysis was to introduce the relatively novel method of ultrasound-guided local lauromacrogol injection (USG-LLI) followed by dilatation and curettage for caesarean scar pregnancy (CSP) and to investigate the clinical safety and efficacy between uterine artery embolization (UAE) and USG-LLI in the treatment of CSP.

METHODS

The relevant literature and articles about USG-LLI, UAE and CSP published in eight electronic databases were searched to extract the primary outcomes for the selected articles. Review Manager Software(RevMan) V.5.2 was used for quantitative data synthesis and data analysis. Forest plots, sensitivity analysis and bias analysis were also performed on the included articles.

RESULTS

Of 10 studies included in our search, 623 patients were in the USG-LLI group and 627 patients were in the UAE groups. There were no significant differences between the two groups in terms of success rate, blood loss and time to human chorionic gonadotropin (hCG) normalization. However, USG-LLI group patients than UAE group patients had a shorter duration of hospital stay (mean difference [MD] = -1.97; 95% confidence intervals [CI] -2.63 to -1.31; P < 0.05; I² = 95%), shorter restored menses (MD = -4.84; 95%CI -5.78 to -3.90; P < 0.05; I² = 95%), and lower complication rates [odds ratio(OR) = 0.21; 95%CI:0.15 to 0.30; P < 0.05]; and cheaper on expenses of hospitalization (MD = -8028.29; 95%CI -10,311.18 to -5745.40; P < 0.05; I² = 100%).

CONCLUSIONS

The results demonstrate that USG-LLI is comparable in curative effect and success rates with UAE in the therapy of CSP, but patients in the USG-LLI group seem to have fewer complications rates, shorter duration of hospital stays and lower costs.

Is local methotrexate therapy effective in the treatment of cesarean scar pregnancy? A retrospective cohort study

AIM

To evaluate the success of local methotrexate (MTX) treatment, the side-effect profile and its fertility effect in patients diagnosed with cesarean scar pregnancy.

MATERIALS

This retrospective cohort study included 56 cesarean scar pregnancy patients who applied to Erciyes University Faculty of Medicine, Department of Obstetrics and Gynecology between January 2012 and January 2022 and were treated with ultrasound-guided local MTX. The results of 56 patients with cesarean scar pregnancy who underwent transvaginal ultrasound-guided single-dose local MTX treatment were evaluated. First, the contents of the sac were aspirated, and then 50 mg of MTX was injected into the gestational sac.

RESULTS

The median gestational age at diagnosis was 7 weeks 2 days. The mean beta human chorionic gonadotrophin level was 31 345 ± 37 838 (range: 113-233 835 mIU/mL). Fifty-four patients were successfully treated with local MTX therapy. The interval between the first MTX injection and the normalization of beta human chorionic gonadotrophin was 55.2 ± 41.0 days. None of our patients required surgical treatment. Beta human chorionic gonadotrophin values did not decrease in one patient and she was treated with systemic MTX. Local MTX therapy could not be applied to one patient for technical reasons. Only one patient needed blood transfusion after local MTX. Thirteen patients become pregnant after treatment (76%). No systemic side effects related to MTX were observed in any of the patients.

CONCLUSION

Transvaginal ultrasound-guided single-dose local MTX treatment is an effective, safe, and fertility-preserving treatment method for cesarean scar pregnancy.

Management of cesarean scar pregnancy: Importance of gestational age at diagnosis and disease type-A single center's 5 years of experience involving 223 cases

Objective

This study aims to evaluate the importance of the gestational age at diagnosis and the types of cesarean scar pregnancy (CSP) for treatment outcomes and to identify the optimal treatment based on both the gestational age at diagnosis and the CSP type.

Methods

A retrospective cohort study included 223 pregnant women diagnosed with CSP at Peking University First Hospital, Beijing, China, between 2014 and 2018. All CSP cases underwent ultrasound-guided vacuum aspiration followed by supplementary curettage. Adjuvant treatment modalities included intramuscular injection of systemic methotrexate, uterine artery embolization, and hysteroscopy before ultrasound-guided vacuum aspiration. Linear regression was used to determine the relationship between intraoperative blood loss and gestational age at diagnosis, CSP type, highest β-human chorionic gonadotropin level, and management procedures.

Results

None of the patients required blood transfusions or hysterectomies. Patients presenting at <8, 8-10, and >10 weeks had median estimated blood loss of 5, 10, and 35 ml, respectively. Patients with type I CSP, type II CSP, and type III CSP had median blood loss of 5, 5 and 10 ml, respectively. Multivariate linear regression analysis demonstrated that the gestational age at diagnosis (p < 0.001) and type of CSP (p = 0.023) were independent predictors of intraoperative estimated blood loss. For type I CSP patients, ultrasound-guided vacuum aspiration followed by supplementary curettage alone was performed in 15 of 34 (44.1%) patients, including 12/27 (44.4%) diagnosed at <8 weeks, 2/6 (33.3%) at 8-10 weeks, and 1/1 for >10 weeks. In type II CSP patients, fewer cases were managed by ultrasound-guided vacuum aspiration followed by supplementary curettage alone as the gestational age at diagnosis increased [18/96 (18.8%) for <8 weeks, 7/41 (17.1%) for 8-10 weeks, none for >10 weeks]. Most type III CSP patients (41/45, 91.1%) needed treatments in addition to the ultrasound-guided vacuum aspiration regardless of the gestational age at diagnosis. All CSP patients were treated successfully and did not require readmission or further medical interventions.

Conclusion

Gestational age at diagnosis of CSP and its type show a strong correlation with estimated blood loss during ultrasound-guided vacuum aspiration. With careful management, CSPs may be treated at any gestational week, regardless of their type, with minimal intraoperative bleeding.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Comparison of menstruation recovery after ultrasound-guided suction curettage in patients with cesarean scar pregnancy pretreated using high-intensity focused ultrasound and uterine artery embolization

OBJECTIVES

To investigate the menstruation recovery after two therapeutic regimens, high-intensity focused ultrasound (HIFU) or uterine artery embolization (UAE) combined with ultrasound-guided suction curettage, for premenopausal women with cesarean scar pregnancy (CSP).

MATERIALS AND METHODS

Seventy patients with CSP treated with HIFU followed by ultrasound-guided suction curettage and 63 patients with CSP treated with UAE followed by ultrasound-guided suction curettage in our hospital were retrospectively reviewed. The treatment parameters and the menstrual blood loss (MBL) volume at 6 months after the two therapeutic regimens were compared between the two groups.

RESULTS

There was no significant difference in treatment results between the two groups. With regard to postoperative MBL volume, 5 out of 70 patients in the HIFU group and 22 out of 63 patients in UAE group exhibited a reduction in MBL, respectively. Multivariate logistic regression revealed that hypomenorrhea was more likely to occur in the UAE group than in the HIFU group (UAE group vs. HIFU group; OR 11.328, 95% CI 3.158-55.871; p < 0.001).

CONCLUSION

Compared to UAE, HIFU has less influence on postoperative MBL volume, which may be a fertility-sparing option for patients with CSP.

Treatment of Cesarean Scar Ectopic Pregnancy in China with Uterine Artery Embolization-A Systematic Review and Meta-Analysis

Cesarean scar ectopic pregnancy (CSP) is a rare form of ectopic pregnancy, and treatment of CSP with uterine artery embolization (UAE) is a novel approach. With increasing numbers of cesarean sections being performed annually, the incidence of this condition is likely to increase. The authors became aware of an unusually high number of published studies originating in mainland China regarding this unusual treatment and sought to perform a meta-analysis to provide comprehensive evidence on this novel practice.

METHODS

We performed a thorough search and included all forms of quality studies on this topic that reported UAE as a part of first-line management of CSP. We included only studies originating in China. Ultimately, 37 studies were included for qualitative and quantitative synthesis of evidence. After screening retrieved records and extracting data from eligible studies, we pooled continuous data as a mean estimate and 95% confidence interval (CI), and dichotomous data as proportion and 95% CI.

RESULTS

CSP patients treated with protocols including UAE had a mean time of 30 days for serum β-hCG normalization, 95% CI [26.816, 33.881]. They had a mean estimated intraprocedural blood loss of 4.19 ± 3.76 mL, a mean hospital stay of nine days, 95%CI [7.914, 9.876], and a success rate of 93.4%, 95%CI [0.918, 0.951]. The severe complication rate was 1.2%, 95%CI [0.008, 0.017].

CONCLUSION

UAE, in combination with other procedures is being used effectively for the treatment of CSP in China. Protocols including UAE have a success rate of approximately 93.4%, and a severe complication rate of approximately 1.2%. This data's utility is limited by vast differences in the studied protocols and questionable feasibility outside of China.

Laparoscopic Management of Partial Molar Caesarean Scar Ectopic Pregnancy

STUDY OBJECTIVE

To demonstrate laparoscopic management of a molar scar ectopic pregnancy.

DESIGN

Stepwise demonstration of the technique with narrated video footage.

SETTING

Cesarean scar ectopic pregnancy and molar pregnancy are 2 separate extremely rare pathologies with an incidence range from 1/1800 to 1/2500 of all pregnancies for the former [1,2]. The concurrence of both cesarean scar ectopic and molar pregnancy is furthermore exceptionally rare, and there are only 8 reported cases of cesarean scar molar pregnancy in literature till date [3]. There is a high risk of uterine rupture, uncontrolled hemorrhage, hysterectomy, and significant maternal morbidity owing to thin myometrium and fibrous scar after cesarean section [4,5]. Knowledge and awareness about this clinical condition aid in early diagnosis and reduced morbidity. Here, we present a rare case of cesarean scar ectopic pregnancy that was operated for failed medical management and diagnosed to be molar scar ectopic pregnancy intraoperatively.

INTERVENTIONS

Total laparoscopic approach to molar scar ectopic pregnancy excision involved the following steps, strategies to minimize blood loss, and complete enucleation of tissue: (1) Hysteroscopy to localize the scar ectopic and its type and size (2) Bladder dissection to expose scar (3) Intramyometrial injection of vasopressin (4) Use of harmonic scalpel to delineate the gestational sac (5) Complete evacuation of products of conception (6) Excision of scar tissue (7) Uterine repair in 2 layers CONCLUSION: There are only 8 reported cases of cesarean scar molar pregnancy in literature till date, and all patients had at least 2 previous uterine curettages with abnormally increased β-hCG levels. The clinical manifestations were varied, the most common symptom being vaginal bleeding for a period >1 month, including our case [3]. Considering the limitations of ultrasound, magnetic resonance imaging, and serum hCG levels in the differential diagnosis of molar cesarean scar pregnancy from normal cesarean scar pregnancy, postoperative specimen should be sent for histologic examination [6]. As seen in our case, the possibility of molar pregnancy at cesarean scar ectopic site should be kept in mind in cases with rising β-hCG levels despite continuous medical interventions, which was being medically managed for 3 months. Our case is the first to be successfully managed with laparoscopic surgery as the previously reported cases were managed with suction evacuation, chemotherapy, laparotomy, or hysterectomy [3].

Caesarean scar pregnancy: diagnosis, natural history and treatment

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Ectopic Pregnancy

Ectopic pregnancy occurs in 2% of all pregnancies and is a potentially life-threatening emergency. A high level of clinical suspicion is required for any pregnant patient who presents with vaginal bleeding and/or pelvic pain. Workup should begin with immediate triage based on vital signs, a pregnancy test, and transvaginal ultrasound. Ectopic pregnancy can be treated either medically with methotrexate or surgically with either salpingectomy or salpingostomy. Carefully counseled, asymptomatic patients may be candidates for expectant management.

The trend of the distribution of ectopic pregnancy sites and the clinical characteristics of caesarean scar pregnancy

Background

Ectopic pregnancy is a life-threatening occurrence and is an important cause of pregnancy-related mortality. We launched the study to investigate the distribution and its variation trend of the ectopic pregnancy sites and the clinical characteristics of caesarean scar pregnancy, to provide information for further clinical practice.

Methods

A total of 3915 patients were included in our study to calculate the distribution of the implantation sites of ectopic pregnancies. Then, we performed a χ² test for trend and calculated the quantity of each type of ectopic pregnancy during 2012–2015 and 2016–2019 to analyse the variation trend.

Results

(1) The proportion of each site of ectopic pregnancy was as follows: tubal pregnancy (84.70%), ovarian pregnancy (1.56%), caesarean scar pregnancy (8.63%), abdominal pregnancy (0.61%), cornual pregnancy (2.68%), cervical pregnancy (0.49%), heterotopic pregnancy (0.43%). (2) Through the χ² test for trend, the ratio of caesarean scar pregnancy to ectopic pregnancy showed an upward trend (P = 0.005). From 2012 to 2015 and 2016–2019, the ratio of caesarean scar pregnancy to ectopic pregnancy increased from 5.74 to 11.81% (P < 0.001). (3) A total of 72.78% (246/338) caesarean scar pregnancy patients had one caesarean delivery, 25.15% (85/338) had two caesarean deliveries, and 2.07% (7/338) had three caesarean deliveries. A total of 80.18% (271/338) had aborted before. The most common clinical manifestations were amenorrhea (98.52%), abdominal pain (25.74%) and vaginal bleeding (67.76%), the most common sign was uterine enlargement (46.75%).

Conclusion

As the ratio of caesarean scar pregnancy increases, the caesarean delivery rate should be decreased to decrease the morbidity of caesarean scar pregnancy.

Ectopic pregnancy occurs when a fertilized ovum implants outside the endometrium of the uterine cavity, which is a life-threatening occurrence and is an important cause of pregnancy-related mortality. With the increase in pelvic and intrauterine operations, the distribution of ectopic sites has been changing, but the variation has been insufficiently studied. To investigate the distribution of ectopic sites and its variation trend in depth, we collected the data of 3915 ectopic pregnancy cases from the third affiliated hospital of Sun Yat-Sen University.

Through χ² test for trend, the ratio of caesarean scar pregnancy to ectopic pregnancy showed an upward trend (P = 0.005). From 2012 to 2015 and 2016–2019, the ratio of caesarean scar pregnancy to ectopic pregnancy increased from 5.74 to 11.81% (P < 0.001). As the increasing of the ratio of caesarean scar pregnancy to ectopic pregnancy, the clinical characteristics of caesarean scar pregnancy was analysed.

A total of 72.78% (246/338) caesarean scar pregnancy patients had one caesarean delivery, 25.15% (85/338) had two caesarean deliveries, and 2.07% (7/338) had three caesarean deliveries. A total of 80.18% (271/338) had aborted before. The most common clinical manifestations were amenorrhea (98.52%), abdominal pain (25.74%) and vaginal bleeding (67.76%), the most common sign was uterine enlargement (46.75%).

As the ratio of caesarean scar pregnancy increases, the caesarean delivery rate should be decreased to decrease the morbidity of caesarean scar pregnancy.

Extravillous trophoblast invasion and decidualization in cesarean scar pregnancies

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical efficacy and safety of high-intensity focused ultrasound (HIFU) ablation in treatment of cesarean scar pregnancy (CSP) I and II

Objective

To investigate the safety and feasibility of high intensity focused ultrasound (HIFU) ablation followed by ultrasound-guided dilation and curettage (USg-D&C) for two types patients with cesarean scar pregnancy (CSP-I and CSP-II).

Materials and methods

This study was a retrospective analysis of 101 CSP-I patients and 52 CSP-II patients who received HIFU ablation followed by USg-D&C from Jun 2014 to Oct 2020. The diameter of gestational sac/mass, thickness of the intervening myometrium, intraoperative blood loss, operation time, length of hospital stays, adverse effects and β-HCG level in the two groups were compared.

Results

All patients successfully received HIFU ablation under conscious sedation. The median total treatment time of HIFU ablation and median USg-D&C time in the CSP-I group were statistically longer than those in the CSP-II group (P < 0.05). The average intraoperative median blood loss was 39 ml in the CSP-I group and 65 ml in the CSP-II group (P < 0.05). The duration of hospitalization was 7.07 ± 1.83 days in the CSP-I group and 7.18 ± 1.72 days in the CSP-II group (P > 0.05). The average time needed for β-HCG return to normal levels was 26.08 ± 5.02. and 28.15 ± 4.99 days for CSP-I and CSP-II, respectively (P > 0.05). The percentage of adverse effects and complications was not significantly different between the two groups (P > 0.05).

Conclusions

HIFU ablation followed by USg-D&C was safe and effective in treating the CSP-I patients and CSP-II patients, which may be a potential noninvasive therapeutic option for patients with CSP.

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

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

The Role of Transvaginal Two-Dimensional Ultrasound Combined With Color Doppler in the Evaluation of Ovarian Function and Fertility After Uterine Artery Embolization

OBJECTIVE

Our study seeks to assess the value of transvaginal two-dimensional ultrasound combined with color Doppler in evaluating ovarian function and reproductive function after uterine artery embolization (UAE).

METHODS

Totally 64 cases with cesarean scar pregnancy (CSP) were collected. Their information was recorded, including baseline information, intraoperative and postoperative information, preoperative and postoperative uterine receptivity, and preoperative and postoperative levels of sex hormones in serum. Finally, the patients were followed up to observe whether they were pregnant after treatment.

RESULTS

In comparison with 24 hours after UAE, decreases were found in endometrial blood flow pulsatility index (PI), endometrial thickness, ovarian artery peak end-systolic velocity (Vs), ovarian artery resistance index (RI), and the ratio of Vs to peak end-diastolic velocity (S/D) 1 and 3 months after embolization, while Vd increased markedly 3 months after embolization. In addition, in terms of sex hormones, a significant increase was revealed in the level of follicle-stimulating hormone, while the reduction in the levels of luteinizing hormone (LH), estrogen (E2), prolactin (PRL), and progesterone (P) in the first month and the third month of menstrual resumption compared with those before treatment. From the follow-up data, there were 50 cases of pregnancy, including 45 cases of intrauterine pregnancy, 2 cases of tubal pregnancy, and 3 cases of recurrent CSP.

CONCLUSION

UAE is a safe and effective method to prevent massive hemorrhage of CSP. Transvaginal two-dimensional ultrasound combined with color Doppler can more accurately evaluate its therapeutic effect and provide a basis for effective treatment.

Introduction and utility of resuscitative endovascular balloon occlusion of the aorta for cases with a potential high risk of postpartum hemorrhage: A single tertiary care center experience of two cases

Postpartum hemorrhage is an important obstetric complication and the leading cause of maternal mortality worldwide. Occasionally, we encounter unexpected massive postpartum hemorrhage diagnosed for the first time after delivery. Therefore, it is essential to pay attention to patients with a high risk of postpartum hemorrhage. The authors report two cases of patients at high risk of postpartum hemorrhage that were successfully managed by resuscitative endovascular balloon occlusion of the aorta before cesarean section. Case 1: A 32-year-old woman with a history of cesarean section and who conceived using assisted reproductive technology was diagnosed with partial placenta previa at 25 weeks of gestation. Because of tocolysis failure, emergent cesarean section with resuscitative endovascular balloon occlusion of the aorta was performed at 36 weeks of gestation. Natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage. Case 2: A 41-year-old woman with suspected placenta accreta spectrum due to a cesarean scar pregnancy was referred to our hospital at 33 weeks of gestation. A planned cesarean section with resuscitative endovascular balloon occlusion of the aorta was conducted at 37 weeks of gestation. There was no visual evidence of abnormal placental invasion of the myometrium, and natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage.

Definition and sonographic reporting system for Cesarean scar pregnancy in early gestation: modified Delphi method

OBJECTIVE

To develop a standardized sonographic evaluation and reporting system for Cesarean scar pregnancy (CSP) in the first trimester, for use by both general gynecology and expert clinics.

METHODS

A modified Delphi procedure was carried out, in which 28 international experts in obstetric and gynecological ultrasonography were invited to participate. Extensive experience in the use of ultrasound to evaluate Cesarean section (CS) scars in early pregnancy and/or publications concerning CSP or niche evaluation was required to participate. Relevant items for the detection and evaluation of CSP were determined based on the results of a literature search. Consensus was predefined as a level of agreement of at least 70% for each item, and a minimum of three Delphi rounds were planned (two online questionnaires and one group meeting).

RESULTS

Sixteen experts participated in the Delphi study and four Delphi rounds were performed. In total, 58 items were determined to be relevant. We differentiated between basic measurements to be performed in general practice and advanced measurements for expert centers or for research purposes. The panel also formulated advice on indications for referral to an expert clinic. Consensus was reached for all 58 items on the definition, terminology, relevant items for evaluation and reporting of CSP. It was recommended that the first CS scar evaluation to determine the location of the pregnancy should be performed at 6-7 weeks' gestation using transvaginal ultrasound. The use of magnetic resonance imaging was not considered to add value in the diagnosis of CSP. A CSP was defined as a pregnancy with implantation in, or in close contact with, the niche. The experts agreed that a CSP can occur only when a niche is present and not in relation to a healed CS scar. Relevant sonographic items to record included gestational sac (GS) size, vascularity, location in relation to the uterine vessels, thickness of the residual myometrium and location of the pregnancy in relation to the uterine cavity and serosa. According to its location, a CSP can be classified as: (1) CSP in which the largest part of the GS protrudes towards the uterine cavity; (2) CSP in which the largest part of the GS is embedded in the myometrium but does not cross the serosal contour; and (3) CSP in which the GS is partially located beyond the outer contour of the cervix or uterus. The type of CSP may change with advancing gestation. Future studies are needed to validate this reporting system and the value of the different CSP types.

CONCLUSION

Consensus was achieved among experts regarding the sonographic evaluation and reporting of CSP in the first trimester. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Cesarean scar ectopic pregnancies - a retrospective case series at an Australian tertiary referral center

OBJECTIVE

To review the management, success, and complication rates of women who presented with a cesarean scar ectopic pregnancy at an Australian tertiary referral center.

METHODS

A retrospective case series was undertaken. Patients were identified through the hospital's clinical information services coding system and data were collected from medical records.

RESULTS

A total of 38 cases were identified. Patients who were hemodynamically stable were predominantly managed according to local expertise via intramuscular, intra-sac methotrexate or a combination of these two. In some cases, surgical management was preferred.

CONCLUSION

Cesarean scar ectopic pregnancy may be managed both surgically and medically. At institutions where surgical expertise is unavailable, medical management would be valuable with few adverse outcomes identified, provided women have closely monitored follow-up.

High intensity focused ultrasound combined with ultrasound-guided suction curettage treatment for cesarean scar pregnancy: a comparison of different HIFU sonication strategies

OBJECTIVE

To explore a new high-intensity focused ultrasound (HIFU) sonication strategy for cesarean scar pregnancy (CSP) and to compare the clinical effectiveness and safety of this new HIFU sonication strategy with the conventional HIFU sonication strategy followed by ultrasound-guided dilation and curettage (USg-D&C) for CSP.

MATERIALS AND METHODS

91 patients with CSP treated by HIFU and USg-D&C in People's Hospital of Deyang City between January 2017 and December 2019 were retrospectively reviewed in this study. Based on the HIFU sonication strategy, patients were divided to two groups: 44 patients were exposed to 'C-shape' sonication layer by layer around the implantation location of the pregnancy sac (control group), while the other 47 patients were exposed to 'I-shape' sonication layer by layer only on the deep part which close to the bladder of the implantation location of the pregnancy sac (experimental group). The differences in clinical efficacy between the two groups were analyzed. Baseline characteristics, technical parameters of HIFU treatment and USg-D&C data were recorded. Adverse events were also recorded.

RESULTS

No statistically significant difference was observed between the two groups in baseline characteristics including age, body mass index (BMI), menopause time, largest diameter of gestational sac, pretreatment serum β-hCG, thickness of gestational sac, embedding myometrium, previous cesarean sections and interval from last cesarean section (CS). The average treatment intensity in the experimental group was significantly lower than that in the control group (p < .05). The median sonication time, total energy used for HIFU ablation, and energy efficiency factor (EEF) in the experimental group were significantly lower than the control group (p < .05). No statistically significant difference was observed between the two groups in treatment power and treatment time (p > .05). Sciatic/buttock pain and postoperative lower abdominal pain in the control group were significantly stronger than that in the experimental group (p < .05). There were no statistically significant differences in post-HIFU vaginal bleeding and discharging, urinary tract irritation, the operation time of USg-D&C, the amount of vaginal bleeding during USg-D&C, and the time for serum β-hCG back to a normal level between the two groups (p > .05).

CONCLUSIONS

The 'I-shape' strategy of HIFU treatment for CSP was effective and safe, with shorter sonication time, less energy input and lower incidence of sonication-related pain occurred in postoperative lower abdominal and sciatic nerve/buttock.

FundAl Retroflexion (FAR) Angle is a Novel Sonographic Marker Associated With Cesarean Scar Pregnancies in the First Trimester: A Case-Control Study

OBJECTIVES

Early diagnosis of Cesarean scar pregnancies (CSP) remains difficult. This study describes a novel sonographic marker, the FundAl Retroflexion (FAR) angle, that may be used in the first trimester. The objective of the study is to compare the FAR angle between CSP and normal pregnancies.

METHODS

For this case-control study, we reviewed images from our institution's database that were acquired from January 2016 to December 2019. All cases of CSP and randomly selected controls, defined as patients with history of Cesarean delivery and normal implantation, that underwent ultrasound evaluation at <14 weeks were included. The FAR angle, defined as the acute angle created between the endometrial echo and cervical canal, was measured. The mean FAR angle was then compared between the two groups and a receiver operating characteristic (ROC) curve was generated.

RESULTS

We identified 15 cases of CSP during the study period and were able to measure the FAR angle in 14 of the cases. The mean FAR angle was larger in CSP than in normal control pregnancies (45° versus 27°, respectively, P < 0.001). Using an ROC curve, a FAR angle cut off of 40° maximizes the ability to distinguish between CSP from normal pregnancies.

CONCLUSIONS

The FAR angle provides an easily obtainable and numerical measurement. CSP have larger FAR angle compared to normal controls with a distinguishing cut off of 40°. Larger studies are needed to determine if using the FAR angle can improve first trimester diagnosis for CSP.

The Efficacy and Health Economics of Different Treatments for Type 1 Cesarean Scar Pregnancy

Objectives: To evaluate the efficacy and health economics of four treatments for type 1 cesarean scar pregnancy (CSP).

Methods: From January 2009 to December 2018, 326 patients diagnosed with type 1 CSP were examined, among whom 31 received ultrasound-guided local injection of methotrexate (local injection group), 160 patients received uterine artery embolization combined with suction aspiration (UAE group), 25 patients received ultrasound-guided suction aspiration (aspiration group) and 90 received ultrasound-guided local injection of lauromacrogol combined with suction aspiration (lauromacrogol group). Clinical data and outcomes were analyzed. The decision tree model was used to compare the economics of four treatments.

Results: The success rate of the local injection group was 71.0% (22/31), which was significantly different from 98.8% (158/160) of the UAE group and 100.0% (90/90) of the lauromacrogol group. The success rate of the aspiration group was 92.0% (23/25), which was significantly lower than that of the lauromacrogol group. The cost-effectiveness ratio was 1,876.53 yuan for the aspiration group, 2,164.63 yuan for the lauromacrogol group, 4,383.56 yuan for the local injection group, and 7,850.81 yuan for the UAE group. The Incremental cost effectiveness ratio (ICER) of the lauromacrogol group to the aspiration group was 5,477.75 yuan, indicating that if the willing to pay of patients was higher than 5,477.75 yuan, the lauromacrogol group had a cost-effectiveness advantage in treating type 1 CSP, compared to aspiration group. On the contrary, aspiration group has a higher cost-effectiveness advantage. The ICER of the lauromacrogol group to the local injection group or the UAE group were both less than 0, indicating that local injection group and UAE group was not cost-effective in the treatment of type 1 CSP.

Conclusion: For type 1 CSP, the ultrasound-guided local injection of lauromacrogol combined with suction aspiration and ultrasound-guided suction aspiration, are effective and economical, and the choice between the two can be based on the patient’s willing to pay.

Local Methotrexate Injection Followed by Dilation and Curettage for Cesarean Scar Pregnancy: A Prospective Non-randomized Study

Purpose

To evaluate the clinical effects and outcomes of local intra-gestational sac methotrexate injection followed by dilation and curettage for treatment of cesarean scar pregnancies (CSP).

Method

This prospective non-randomized study was conducted on patients diagnosed with CSP between 2018 and 2020 at the Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region. Patients were categorized into two groups according to the treatments, i.e., local intra-gestational sac methotrexate injection followed by dilation and curettage (group A), and uterine artery embolization in combination with dilation and curettage (group B). The choices of treatment reflect the patients' decision after they thoroughly understood the benefits and risks of the two therapies. Clinical data were then collected and compared between these two alternatives.

Results

Seventy-seven patients with CSP were enrolled in the study. Of this total, 41 vs. 36 were respectively categorized into group A and group B. Similar success rates were observed between these two groups (92.7 vs. 97.2%; RR = 27.362, 95% CI: 0.496–1.51E3, p = 0.106). However, the overall occurrence of complications in group A was significant lower when compared with group B (17.1 vs. 52.8%; RR = 0.236, 95% CI: 0.077–0.728, p = 0.012). Lower abdominal pain (unrelated to infection) and intrauterine adhesions were the two primary complications exhibited in group B of the present study, with rates of 38.9 and 22.2% respectively.

Conclusions

Local intra-gestational sac methotrexate injection followed by dilation and curettage is an effective and safe treatment for CSP that also drastically reduces the risks of complications. Further multiple center randomized trials with large series are warranted to confirm these findings.

Diagnostic performance of magnetic resonance imaging and ultrasonography on the detection of cesarean scar pregnancy: A meta-analysis

BACKGROUND

: There is still a debate on which imaging method is the best to diagnose cesarean scar pregnancy (CSP). Accordingly, this study aimed to analyze the diagnostic performance of magnetic resonance imaging (MRI) and ultrasonography (US) on the detection of CSP based on current evidence in the literature.

METHODS

PubMed, Embase, Cochrane, Chinese Biomedical Documentation Service System, WanFang, and China National Knowledge Infrastructure databases were searched up to June 2020. The included studies were all comparisons of MRI and US in the diagnosis of CSP that adopted postoperative histological examination as the reference standard. The pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and area under the summary receiver operating characteristic curve (AUC) were calculated for MRI and US.

RESULTS

Thirteen studies were included, with a total sample size of 948 patients. The pooled sensitivity, specificity, PLR, NLR, and AUC of MRI in diagnosing CSP were 0.93 (95% CI, 0.91-0.95), 0.83 (95% CI, 0.75-0.89), 5.46 (95% CI, 3.70-8.05), 0.08 (95% CI, 0.06-0.11), and 0.96 (95% CI, 0.93-0.97), respectively; for US they were 0.84 (95% CI, 0.79-0.88), 0.73 (95% CI, 0.62-0.81), 3.06 (95% CI, 2.22-4.21), 0.23 (95% CI, 0.18-0.28), and 0.86 (95% CI, 0.83-0.89), respectively.

CONCLUSION

We found that both MRI and US effectively diagnosed CSP; however, MRI had a higher diagnostic performance in detecting CSP than US.