Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes

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.

Early first-trimester transvaginal ultrasound screening for cesarean scar pregnancy in patients with previous cesarean delivery: analysis of the evidence

Obstetric hemorrhage is a leading cause of maternal morbidity and mortality. An important etiology of obstetric hemorrhage is placenta accreta spectrum. In the last 2 decades, there has been increased clinical experience of the devastating effect of undiagnosed, as well as late diagnosed, cases of cesarean scar pregnancy. There is a growing body of evidence suggesting that cesarean scar pregnancy is an early precursor of second- and third-trimester placenta accreta spectrum. As such, cesarean scar pregnancy should be diagnosed in the early first trimester. This early diagnosis could be achieved by introducing regimented sonographic screening in pregnancies of patients with previous cesarean delivery. This opinion article evaluates the scientific and clinical basis of whether cesarean scar pregnancy, with special focus on its early first-trimester discovery, complies with the accepted requirements of a screening test. Each of the 10 classical screening criteria of Wilson and Jungner were systematically applied to evaluate if the criteria were met by cesarean scar pregnancy, to analyze if it is possible and realistic to carry out screening in a population-wide fashion.

The Cesarean Scar of Pregnancy: Ultrasound Findings and Expectant Management Outcomes

OBJECTIVE

The nomenclature has evolved from low implantation to cesarean scar pregnancy (CSP) and criteria are recommended for identification and management. Management guidelines include pregnancy termination due to life-threatening complications. This article applies ultrasound (US) parameters recommended by the Society for Maternal Fetal Medicine (SMFM) in women who were expectantly managed.

STUDY DESIGN

Pregnancies were identified between March 1, 2013 and December 31, 2020. Inclusion criteria were women with CSP or low implantation identified on US. Studies were reviewed for niche, smallest myometrial thickness (SMT), and location of basalis blinded to clinical data. Clinical outcomes, pregnancy outcome, need for intervention, hysterectomy, transfusion, pathologic findings, and morbidities were obtained by chart review.

RESULTS

Of 101 pregnancies with low implantation, 43 met the SMFM criteria at < 10 weeks and 28 at 10 to 14 weeks. At < 10 weeks, SMFM criteria identified 45out of 76 women; of these 13 required hysterectomy; there were 6 who required hysterectomy but did not meet the SMFM criteria. At 10 to < 14 weeks, SMFM criteria identified 28 out of 42 women; of these 15 required hysterectomy. US parameters yielded significant differences in women requiring hysterectomy, at < 10 weeks and 10 to < 14 weeks' gestational age epochs, but the sensitivity, specificity, positive (PPV), and negative predictive values (NPV) of these US parameters have limitations in identifying invasion to determine management. Of the 101 pregnancies, 46 (46%) failed < 20 weeks, 16 (35%) required medical/surgical management including 6 hysterectomies, and 30 (65%) required no intervention. There were 55 pregnancies (55%) that progressed beyond 20 weeks. Of these, 16 required hysterectomy (29%) while 39 (71%) did not. In the overall cohort of 101, 22 (21.8%) required hysterectomy and an additional16 (15.8%) required some type of intervention, while 66.7% required no intervention.

CONCLUSION

SMFM US criteria for CSP have limitations for discerning clinical management due to lack of discriminatory threshold.

KEY POINTS

· The SMFM US criteria for CSP at <10 or <14 weeks have limitations for clinical management.. · The sensitivity and specificity of the ultrasound findings limit the utility for management. · The SMT of <1 mm is more discriminating than <3 mm for hysterectomy..

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.

Dichorionic diamniotic heterotopic twin gestation with cesarean section scar implantation and placenta increta

Heterotopic cesarean scar pregnancy is an extremely rare form of pregnancy and is defined as an intrauterine pregnancy coexisting with an ectopic pregnancy implanted in the cesarean scar. Cesarean scar ectopic pregnancy can also be a precursor for placenta accreta spectrum, a potentially life-threatening condition in which the placenta is abnormally adherent to the uterine myometrium and possibly adjacent organs. Although cesarean scar ectopic pregnancies are rare, there has been an increase in their incidence due to the rise in cesarean deliveries. We present the case of a 35-year-old patient with a heterotopic pregnancy with ectopic implantation in a cesarean scar and associated placenta increta, as well as the radiologic evaluation of placenta accreta spectrum and subsequent management.

Different management strategies for cesarean scar pregnancy: Short-term outcomes and reproductive prognosis

PURPOSE

To investigate the impact on future reproductive potential of systemic methotrexate (MTX) administration, uterine artery embolization (UAE) and expectant management as treatments of caesarean scar pregnancy (CSP) and to assess their efficacy and safety.

BASIC PROCEDURES

We retrospectively analysed patients with a diagnosis of CSP treated in a five years' period (2014-2018). Hospitalization, hCG normalization, menstrual cycle recovery, ultrasound restitutio ad integrum times, reproductive desire accomplishment after the resolution of the picture, and outcomes of subsequent pregnancies were considered. Only patients for whom complete diagnosis, treatment and follow-up data were available could be considered for study entry.

MAIN FINDINGS

A total of 21 patients were included. Three of them were managed expectantly. In two cases spontaneous abortion occurred and one case underwent caesarean delivery at 35 weeks of gestation for complete placenta previa with hysterectomy for post partum haemorrhage. Seven patients were treated with systemic MTX. Median [IQR] times of hospitalization, hCG normalization, menstrual cycle recovery and ultrasound restitutio ad integrum were 21 days [10-26 days], 52 days [18-64 days], 8 weeks [6-10 weeks] and 8 weeks [6-11 weeks] respectively. At the end of follow up, 80% (95%CI [38-96%]) of patients with reproductive desire achieved at least one live birth. Eleven patients were treated with UAE combined with MTX. Median [IQR] times of hospitalization, hCG normalization, menstrual cycle recovery and ultrasound restitutio ad integrum were 14 days [12-20 days], 43 days [30-52 days], 8 weeks [4-12 weeks] and 8 weeks [8-10 weeks], respectively. Of those who expressed a reproductive desire after treatment, 80% (95%CI [49-94%]) achieved at least one live birth. In all included patients, the menstrual cycle was restored.

PRINCIPAL CONCLUSIONS

Reproductive potential of women treated for CSP was preserved after both systemic MTX administration and systemic MTX combined with UAE. Both strategies proved to be safe.

Cesarean Scar Pregnancy: A systematic review on expectant management

A Cesarean Scar Pregnancy (CSP) is a variant of uterine ectopic pregnancy defined by full or partial implantation of the gestational sac in the scar of a previous cesarean section. The continuous increase of Cesarean Deliveries is causing a parallel increase in CSP and its complications. Considering its high morbidity, the most usual recommendation has been termination of pregnancy in the first trimester; however, several cases progress to viable births. The aim of this systematic review is to evaluate the outcome of CSP managed expectantly and understand whether sonographic signs could correlate to the outcomes. An online-based search of PubMed and Cochrane Library Databases was used to gather studies including women diagnosed with a CSP who were managed expectantly. The description of all cases was analysed by the authors in order to obtain information for each outcome. 47 studies of different types were retrieved, and the gestational outcome was available in 194 patients. Out of these, 39 patients (20,1%) had a miscarriage and 16 (8,3%) suffered foetal death. 50 patients (25,8%) had a term delivery and 81 (41,8%) patients had a preterm birth, out of which 27 (13,9%) delivered before 34 weeks of gestation. In 102 (52,6%) patients, a hysterectomy was performed. Placenta Accreta Spectrum (PAS) was a common disorder among CSP and was linked to a higher rate of complications such as foetal death, preterm birth, hysterectomy, haemorrhagic morbidity and surgical complications. Some of the analysed articles showed that sonographic signs with specific characteristics, such as type II and III CSP classification, Crossover Sign - 1, "In the niche" implantation and lower myometrial thickness could be related to worse outcomes of CSP. This article provides a good understanding of CSP as an entity that, although rare, presents with a high rate of relevant morbidity. It is also understood that pregnancies with confirmed PAS had an even higher rate of morbidity. Some sonographic signs were shown to predict the prognosis of these pregnancies and further investigation is necessary to validate one or more signs so they can be used for a more reliable counselling of women with CSP.

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.

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.

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.

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).

Caesarean Scar Pregnancy: A Case Report

Caesarean scar pregnancy is a potentially life-threatening gynaecological condition, becoming more common due to steadily increasing rate of caesarean sections worldwide. More than one-third of women presenting with caesarean scar pregnancy are asymptomatic, but over the time if left untreated this condition can lead to the uterine rupture and massive maternal haemorrhage. Therefore it is necessary to diagnose and manage caesarean scar pregnancies properly at the beginning of the first trimester. We present the case of woman with three previous caesarean sections, who was diagnosed with complicated caesarean scar pregnancy and then successfully managed using surgical intervention.

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.

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.

Hysteroscopic treatment of Cesarean Scar Pregnancy: A systematic review

More than 30 regimens, medical and surgical, have been described for the treatment of Cesarean Scar Pregnancies (CSPs). This study aims to collect and analyze data in the published literature regarding the hysteroscopic management of CSPs focusing on efficacy and complications. Using a protocol registered with Prospero (#CRD42021242314), the electronic databases PubMed/Medline, Scopus, Clinical-Trials.gov and the Cochrane Library were comprehensively searched, from their inception to June 2020. Medical Subject Headings terms such as caesarean ectopic, hysteroscopy and endoscopy were used for the identification of the relevant records. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to design the present systematic review. Eligible articles assessing the role of hysteroscopy in CSP were considered the studies published in peer-reviewed journals. Any studies with less than 10 cases or articles that insufficiently detailed the treatment regimen, the outcomes, and the success rate, were excluded. Selected articles were assessed for the level of evidence, based on Oxford Centre for Evidence-based Medicine guidelines. The methodologic quality, including the risk of bias, was evaluated with the employment of the Effective Public Health Practice Project Quality Assessment Tool. Ten out of 613 studies were included in the present review comprising 812 women with CSP treated by hysteroscopy. The treatment modalities were divided into three categories: (i) hysteroscopic resection of CSP, (ii) hysteroscopy after preoperative use of HIFU and (iii) preoperative use of UAE before hysteroscopic treatment. The overall success rate of hysteroscopic treatment on CSP cases was 91%, whereas the rate of hemorrhage or excessive vaginal bleeding (>500 mL) and the rate of hysterectomy were 1.66% and 0.28% respectively. According to the results of this systematic review, hysteroscopy appears to be a safe and effective procedure for CSP management. Current findings are primarily based on retrospective studies with poor methodological quality. Multicenter, well-designed studies are needed to draw definite conclusions.

Cesarean section scar pregnancy: Challenges in choosing treatment approach

Choosing a treatment approach of Cesarean section scar pregnancy is challenging and requires making women aware of material risks inherent in the different approaches that they perceive as having potential impact on their live or quality of life.

When to perform curettage after uterine artery embolization for cesarean scar pregnancy: a clinical study

Background

Prophylactic uterine artery embolization (UAE) combined with subsequent curettage is suggested as an effective and minimally invasive treatment strategy for cesarean scar pregnancy (CSP) with a high bleeding risk. However, the timing of curettage after UAE remains to be studied. Thus, we aimed to identify the optimal time interval to perform curettage after UAE in patients with CSP.

Methods

We conducted a retrospective cohort study in a large medical center for women and children in Southwest China. CSP patients treated by UAE combined with subsequent curettage were included and grouped by the treatment time interval between these two procedures. The clinical outcomes among arms were compared by univariate and multivariable analysis.

Results

Our study included 314 CSP patients who received this combination treatment in our department from January 2014 to December 2019. The median time interval between UAE and curettage was 48 h, with a range of 12-168 h among all participants. Thirty-two patients (10.2%) experienced intraoperative hemorrhage (blood loss ≥200 mL). Intrauterine balloon tamponade was used in 17 cases (5.4%). In 14 cases (4.5%), the procedure was converted to laparoscopy (or laparotomy). In the cohort study, patients with longer treatment intervals had more intraoperative blood loss and a higher incidence of complications than those with shorter intervals (P < 0.05). The rates of intraoperative bleeding were 5.0% for patients who received curettage within 24 h after UAE (Arm 1) and 19.4% for those who had a treatment interval longer than 72 h (Arm 4). In the multivariable logistic regression model of bleeding, a treatment interval > 72 h had an adjusted odds ratio of 3.37 (95% confidence interval: 1.40-8.09).

Conclusion

We suggest that curettage not be delayed longer than 72 h after UAE in this combined treatment of CSP.

Cesarean Scar Ectopic Pregnancy-Case Series: Treatment Decision Algorithm and Success with Medical Treatment

Background: Cesarean scar ectopic pregnancies are a rare form of extrauterine pregnancies, yet their incidence has increased along with the rise in the number of cesarean deliveries. As with other ectopic pregnancies, cesarean scar ectopic pregnancies pose a greater risk for maternal hemorrhage and ultimately maternal mortality. Case presentation: We present a series of clinical cases of cesarean scar ectopic pregnancy diagnosed by transvaginal ultrasonography. Each patient received an individualized treatment: the rate of success depended on the particular maternal condition in each case. Due to the low frequency of this entity, there are no clear protocols for its treatment and thus there are numerous options for treatment and follow-up: expectant management, medical therapy, surgical intervention, uterine artery embolization or a combined approach. Each method has different levels of success and is dependent on the surgeon’s skill and patient presentation. A transvaginal ultrasound is necessary to obtain the fine details of the gestation sac and its relation to the scar and must be followed by a meticulous abdominal scan with a full bladder. Conclusion: Herein, we present a rare pathological phenomenon whose frequency is on the rise, and for which transvaginal ultrasound and flow Doppler provide high diagnostic accuracy. Early diagnosis of cesarean scar ectopic pregnancies offers treatment options that may help avoid uterine rupture and bleeding, thus preserving the uterus and future fertility.

Suction Curettage and Foley Balloon as a First-Line Treatment Option for Caesarean Scar Pregnancy and Reproductive Outcomes

Background

Caesarean scar pregnancy (CSP) is associated with various serious pregnancy complications. This study presents the outcomes of patients treated with suction curettage and Foley balloon as the first-line treatment for CSP as well as their future outcomes in terms of successful pregnancy.

Methods

Of the 44 patients diagnosed with CSP between January 2015 and April 2019, 42 who provided consent for the termination of pregnancy and who simultaneously underwent the transabdominal ultrasound-guided suction curettage + Foley balloon treatment were included in the study. These patients were then contacted and interviewed to collect data concerning their post-treatment number of pregnancies, number of miscarriages, number of live or dead births, mode of delivery, delivery time as well as whether any abnormal placental invasion or uterine ruptures developed.

Results

Transabdominal ultrasound-guided suction curettage + Foley balloon was simultaneously performed as the first-line treatment in 42 patients with CSP. In two of these cases, wherein post-treatment level of β-hCG reached a plateau, single-dose systemic methotrexate was administered. Emergency surgical intervention, hysterectomy, massive blood transfusion and additional systemic methotrexate administration were not required. Twenty-six of 42 patients could be contacted. 18/26 were trying to conceive. 6/18 patients had secondary infertility, and 12/18 patients managed to conceive. 8/12 had caesarean delivery at full term. 1/12 was 16-week pregnant, 1/12 had tubal ectopic pregnancy and 2/12 had first-trimester abortus.

Conclusion

When administered as the first-line treatment for CSP, the suction curettage + Foley balloon treatment is a highly successful, cheap and easily performed minimally invasive method that requires only a short hospital stay, making it comfortable for patients. Compared with other uterine-sparing methods, it does not harm fertility and has positive effects on patients’ future fertility outcomes.

Outcome of cesarean scar pregnancy according to gestational age at diagnosis: A systematic review and meta-analysis

OBJECTIVE

The association between the most severe types of placenta accreta spectrum disorders and caesarean scar pregnancy (CSP) poses the question of whether early diagnosis may impact the clinical outcome of these anomalies. The aim of this study is to report the outcome of cesarean scar pregnancy (CSP) diagnosed in the early (≤9 weeks) versus late (>9 weeks) first trimester of pregnancy.

STUDY DESIGN

Medline, Embase and Clinicaltrail.gov databases were searched. Studies including cases of CSP with an early (≤9 weeks of gestation) compared to a late (>9 weeks) first trimester diagnosis of CSP, followed by immediate treatment, were included in this systematic review. The primary outcome was a composite measure of severe maternal morbidity including either severe first trimester bleeding, need for blood transfusion, uterine rupture or emergency hysterectomy. The secondary outcomes were the individual components of the primary outcome. Random-effect meta-analyses were used to combine data.

RESULTS

Thirty-six studies (724 women with CSP) were included. Overall, composite adverse outcome complicated 5.9 % (95 % CI 3.5-9.0) of CSP diagnosed ≤9 weeks and 32.4 % (95 % CI 15.7-51.8) of those diagnosed >9 weeks. Massive hemorrhage occurred in 4.3 % (95 % CI 2.3-7.0) of women with early and in 28.0 % (95 % CI 14.1-44.5) of those with late first trimester diagnosis of CSP, while the corresponding figures for the need for blood transfusion were 1.5 % (95 % CI 0.6-2.8) and 15.8 % (95 % CI 5.5-30.2) respectively. Uterine rupture occurred in 2.5 % (95 % CI 1.2-4.1) of women with a prenatal diagnosis of CSP ≤ 9 weeks and in 7.5 % (95 % CI 2.5-14.9) of those with CSP > 9 weeks, while an emergency intervention involving hysterectomy was required in 3.7 % (95 % CI 2.2-5.4) and 16.3 % (95 % CI5.9-30.6) respectively. When computing the risk, early diagnosis of CSP was associated with a significantly lower risk of composite adverse outcome, (OR: 0.14; 95 % CI 0.1-0.4 p < 0.001).

CONCLUSIONS

Early first trimester diagnosis of CSP is associated with a significantly lower risk of maternal complications, thus supporting a policy of universal screening for these anomalies in women with a prior cesarean delivery although the cost-effectiveness of such policy should be tested in future studies.

Use of Magnetic Resonance Imaging (MRI) in the Management of Diagnostic Uncertainty in Low-Resource Settings: A Case Report of Cesarean Ectopic Pregnancy in a Tertiary Hospital in Ghana

Patient: Female, 35-year-old

Final Diagnosis: Cesarean section ectopic pregnancy

Symptoms: Amenorrhea

Medication:—

Clinical Procedure: Exploratory laparotomy • MRI • ultrasonography

Specialty: Obstetrics and Gynecology

Conservative treatment in non-tubal ectopic pregnancy and predictors of treatment failure

OBJECTIVES

To find possible predictive factors to predict the failure of conservative treatment of non-tubal ectopic pregnancy. For that purpose, we assessed the rate of failure, complications and need for additional interventions of the different primary treatment regimens in non-tubal ectopic pregnancies that occurred in our center.

STUDY DESIGN

Retrospective single-center study conducted at Hospital Clínic of Barcelona (Spain). Conservative treatment regimens included medical (systemic single or multiple dose methotrexate; ultrasound-guided intrasaccular injection of methotrexate or chloride potassium; surgical (oophorectomy in case of ovarian ectopic pregnancy, surgical curettage). The main outcome measures were success of primary treatment and the need for additional interventions. The secondary outcomes were success rate of conservative treatment, incidence of complications, days to discharge from the hospital, days until negative β-hCG, days until complete resolution of the process. Possible predictor factors for primary treatment failure were assessed.

RESULTS

A total of 39 cases were included. Primary treatment was successful in 74 % (29/39). The rate of failure of primary treatment was higher in the group with presence of embryo heartbeat than in the group without, 46 % vs. 15 % respectively (p < 0.0001). Among the cases that required additional treatments, none of them required hysterectomy. Presence of embryo heartbeat significantly increased the likelihood of failure of the primary treatment (OR 4.71, 95 % CI 1.03-21.65, p < 0.05). Every doubling of the β-hCG levels increased the risk of treatment failure by 54 % (OR 1.54, 95 % CI 1.03-2.39, p < 0.05).

CONCLUSIONS

Conservative treatment is a safe option for treatment of non-tubal ectopic pregnancy. The presence of embryo heartbeat and β-hCG levels at diagnosis may be used as predictive factors of failure of conservative treatment.

A comparison between laparoscopy and hysteroscopy approach in treatment of cesarean scar pregnancy

The aim of the study was to compare the efficacy of laparoscopy and hysteroscopy for the treatment of cesarean scar pregnancy (CSP) and analyze the clinical factors associated with successful selection for hysteroscopic or laparoscopic treatment of CSP.We retrospectively studied 112 cases of CSP that were treated by laparoscopy and/or hysteroscopy in our hospital from December 2014 to December 2017. In total, 72 of these patients underwent ultrasound-guided curettage and hysteroscopic resection without uterine scar defect repair. Fourty of these patients underwent laparoscopic resection and repair of the uterine scar defect. We analyzed the different clinical variables between the 2 groups and identified the clinical factors which could predict the need for the laparoscopic repair of uterine scar defect. Results showed that laparoscopy and hysteroscopy were safe ways to treat CSP, and no patient underwent hysterectomy. The β-hCG level in both of the 2 groups decreased to normal 4 to 8 weeks after surgery. There were significant differences between the hysteroscopy group and laparoscopy uterine scar repair group in terms of days of amenorrhea, gestational sac diameter, myometrial thickness, operation time, intraoperative blood loss, and hospitalization duration (P < .05). Logistic regression analysis showed that the days of amenorrhea, gestational sac diameter and myometrial thickness were independent risk factors for CSP treated by minimally invasive surgery, which were also shown by ROC curve analysis to be predictors of the need for the repair of the uterine scar defect, with optimal cutoffs of 52.50 days, 3.25 cm, and 2.05 mm, respectively; and the areas under their corresponding ROC were 0.721, 0.851, and 0.927, respectively.We conclude that laparoscopy and hysteroscopy are safe and efficient minimally invasive procedures for the treatment of CSP. The days of amenorrhea, gestational sac diameter and myometrial thickness may be key factors associated with successful selection for hysteroscopic or laparoscopic treatment of CSP.

Point-of-Care Ultrasound Diagnosis of Cesarean Scar Ectopic Pregnancy: A Case Series

BACKGROUND

A cesarean scar pregnancy (CSP) is a clinically important form of ectopic pregnancy that carries a high risk of maternal morbidity and mortality. As the rate of cesarean sections has risen, this diagnosis is becoming an increasingly important consideration for providers caring for patients in early pregnancy.

CASE REPORT

We present three cases of CSPs in which point-of-care ultrasound expedited the diagnosis and treatment in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the risks of an undiagnosed CSP, the increasing incidence of CSP, and the number of effective treatment options available in early gestation, the prompt and accurate diagnosis of CSP remains crucial to its successful management. As such, it is an important diagnosis for the emergency physician to consider when evaluating a patient in early pregnancy.

Risk factors for poor hemostasis of prophylactic uterine artery embolization before curettage in cesarean scar pregnancy

OBJECTIVE

To observe the hemostatic effect of prophylactic uterine artery embolization (UAE) in patients with cesarean scar pregnancy (CSP) and to examine the risk factors for poor hemostasis.

METHODS

Clinical data of 841 patients with CSP who underwent prophylactic UAE and curettage were retrospectively analyzed to evaluate the hemorrhage volume during curettage. A hemorrhage volume ≥200 mL was termed as poor hemostasis. The risk factors of poor hemostasis were analyzed and complications within 60 days postoperation were recorded.

RESULTS

Among the 841 patients, 6.30% (53/841) had poor postoperative hemostasis. The independent risk factors of poor hemostasis were gestational sac size, parity, embolic agent diameter (>1000 μm), multivessel blood supply, and incomplete embolization. The main postoperative complications within 60 days after UAE were abdominal pain, low fever, nausea and vomiting, and buttock pain, with incidence rates of 71.22% (599/841), 47.44% (399/841), 39.12% (329/841), and 36.39% (306/841), respectively.

CONCLUSIONS

Prophylactic UAE before curettage in patients with CSP is safe and effective in reducing intraoperative hemorrhage. Gestational sac size, parity, embolic agent diameter, multivessel blood supply, and incomplete embolization of all arteries supplying blood to the uterus are risk factors of poor hemostasis.

Selection of a correct treatment protocol in caesarean scar pregnancies

OBJECTIVE

This study aims at assessing the effectiveness of various treatment protocols with the help of some parameters in caesarean scar pregnancies.

METHODS

A total of 26 patients were assessed in the study. The patients were divided into 4 groups. Group 1 consisted of those who had a wedge resection (n = 7), group 2 those who had a suction curettage (n = 10), group 3 those who had a systemic methotrexate (MTX) (n = 5) and group 4 those who had a systemic + local MTX (n = 4). The ßHcg half-lives, haemoglobin levels at the time of admittance and discharge, and hospital stays of the groups were compared.

RESULTS

The difference between group 1 and group 4 was found significant (p = 0.002) with respect to days of hospital stay. There was no statistically significant difference between the groups with respect to ßHcg half-lives and haemoglobin values.

CONCLUSION

The results of our study showed that there were no significant differences between treatment outcomes when appropriate protocols were employed. Therefore, the important point in CSPs is to assess correctly the type of CSP, the myometrial thickness and the patient's hemodynamic condition and select the most appropriate protocol accordingly rather than trying to establish a single standard treatment protocol.

Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy

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

Cesarean Scar Ectopic Pregnancy: Diagnosis With Ultrasound

We present a rare case of cesarean scar ectopic pregnancy as diagnosed by transvaginal ultrasonography. Cases such as this are rare, but they are becoming more commonly detected with the growing frequency of cesarean sections, improving technology, and provider proficiency with point-of-care ultrasound. Quick identification of this dangerous diagnosis can be life saving for the patient, as the outcomes of ruptured cesarean ectopic pregnancy may include significant hemorrhage, uterine rupture, and possibly maternal death.

Risk factors and consequences of undiagnosed cesarean scar pregnancy: a cohort study in China

Background

The historically high cesarean section rate and the recent change in second-child policy could increase the risk of cesarean scar pregnancy (CSP) in China. This study aims to assess risk factors and consequences of undiagnosed CSP in China.

Methods

We conducted a retrospective cohort study between January 2013 and December 2017 in Qingyuan, Guangdong, China. Independent risk factors for undiagnosed CSP at the first contact with healthcare providers were assessed by log binomial regression analysis. Occurrence of serious complications was compared between undiagnosed and diagnosed CSP cases.

Results

A total of 195 women with CSP were included in the analysis. Of them, 81 (41.5%) women were undiagnosed at the first contact with healthcare providers. Women initially cared in primary or secondary hospitals were at increased risk for undiagnosed CSP: adjusted relative risks (95% confidence intervals) were 3.28 (2.06, 5.22) and 1.91 (1.16, 3.13), respectively, compared with women initially cared in the tertiary hospital. Undiagnosed CSP cases had higher incidences in serious complications (11 versus 0) and post-surgery anemia (23 (28.4%) versus 8 (7.0%)), stayed longer in hospital, and cost higher than diagnosed CSP cases.

Conclusions

Initial care provided at primary or secondary maternity care facilities is an important risk factor for undiagnosed CSP, with serious consequences to the affected women.

Effect and clinical value of coagulation test on adverse reactions of blood transfusion in patients with major bleeding in ectopic pregnancy

Influence and clinical value of coagulation test on adverse reactions of blood transfusion in patients with major bleeding of ectopic pregnancy were analyzed. Six hundred and twenty-seven cases of ectopic pregnancy admitted to Zibo First Hospital from July 2014 to March 2017 were retrospectively analyzed. The 369 patients who had adverse reactions after blood transfusion were selected as the experimental group. Another 258 patients without adverse reaction after blood transfusion were selected as the control group. Blood samples were collected 8 h before and after blood transfusion in both groups, and blood test was performed including blood count (RBC), white blood cell count (WBC), platelet count (PLT), HB, hematocrit (HCT), as well as indicators of coagulation, including thrombin time (TT), prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen (FIB). There was no significant difference between the two groups in blood routine and blood coagulation test (P>0.05). After transfusion, the RBC, WBC, PLT, HB and HCT in the experimental group were significantly lower than those in the control group (P<0.05). TT, PT and APTT were higher than those in the control group (P<0.05), while FIB was significantly lower than that in the control group (P<0.001). The coagulation in the experimental group after blood transfusion was significantly worse than that in the control group. Coagulation test can be used as a marker of adverse reactions after transfusion in patients with massive bleeding in pregnancy, providing reference and guidance for clinical diagnosis and treatment.

New ultrasound grading system for cesarean scar pregnancy and its implications for management strategies: An observational cohort study

A cesarean section pregnancy (CSP) indicated the gestational sac (GS) implanted in the previous cesarean scar. The clinical manifestations of CSP present a wide range of variations, and the optimal management is yet to be defined. We retrospectively enrolled 109 patients with the diagnosis of CSP from our department and categorized them into four grades based on the ultrasound presentation. Grade I CSP indicated the GS embedded in less than one-half thickness of the lower anterior corpus; and grade II CSP represented the GS extended to more than one-half thickness of overlying myometrium. Grade III CSP implied the GS bulged out of the cesarean scar; and grade IV CSP denoted that GS became an amorphous tumor with rich vascularity at the cesarean scar. Seventy-eight women received surgery, and the complication rate was 14.1% (11/78). Linear regression analysis demonstrated a significant association between the invasiveness of the surgery and their ultrasound gradings. The mainstream operation for grade I CSP was transcervical resection, while the majority of grade III and IV patients required hysterotomy or hysterectomy. Another 31 women received chemotherapy with methotrexate as their initial treatment. The success rate for chemotherapy was 61.3%; the remaining patients required further surgery due to persistent CSP or heavy bleeding during or after chemotherapy. Fifteen patients (48.3%) receiving chemotherapy suffered from complications (mostly bleeding). Among them, 7 (22.6%) patients experienced bleeding of more than 1,000 mL, and 9 (29.0%) of these 31 patients required blood transfusions. Our novel ultrasound grading system for CSP may help to communicate between physicians, and determine the optimal surgical strategy. Chemotherapy with methotrexate for CSP is not satisfactory and is associated with a higher rate of complications.

The value of 3-dimensional color Doppler in predicting intraoperative hemorrhage for cesarean scar pregnancy

The aim of this study is to evaluate the efficacy of 3-dimensional (3D) ultrasonography and 3D color power Doppler ultrasound in the management of cesarean scar pregnancy (CSP).A case-control study enrolled 190 CSP patients who underwent uterine artery embolization (UAE) in combination with dilatation and curettage (D&C). The maximum diameter of gestational sac or CSP mass, uterine scar thickness, and resistance index (RI) were measured by 2D ultrasound. The lesion volume, vascular index (VI), flow index (FI), blood vessels, and blood flow index (VFI) were assessed by 3D ultrasound. The changes of these parameters before and after UAE were analyzed. Then, the patients were divided into bleeding group and control group according to the intraoperative hemorrhage during D&C to access and compare the significance of 2D and 3D parameters in intraoperative hemorrhage.The mean VI and the mean VFI were significantly reduced after embolization (P < .01). In the bleeding group, the lesion volume and diameter of gestational sac or CSP mass were significantly larger, VI and VFI were significantly higher, the uterine scar thickness was thinner, and RI was lower (P < .05). The best indicator for prediction of massive intraoperative bleeding was the VI with an area under the curve of 0.870, the best cut-off value of VI was 7.500, and the sensitivity and specificity were 88.2% and 82.4%, respectively. In comparing the receiver operating characteristic curves among 2D and 3D ultrasound parameters, the diagnostic efficacy of lesion volume was significantly higher than maximum diameter (P < .001). The diagnostic efficacy of VI was significantly higher than maximum diameter (P = .020) and RI (P = .011).UAE reduces the number of vessels and the blood flow perfusion obviously; however, it does not reduce lesion size or increases myometrial thickness. Three-dimensional ultrasonography and power Doppler, especially VI, lesion volume may be helpful in predicting excessive bleeding during D&C after UAE.

Gynecological emergency ultrasound in daytime and at night: differences that cannot be ignored

Background

Ultrasonography, the preferred adjunct examination method and the differential diagnostic tool for gynecologic emergency, can reflect the change pattern of gynecological diseases in daytime and at night. The purpose of this study was to analyze the diseases through gynecological emergency ultrasound in daytime and at night and to evaluate the day–night difference in the accuracy of ultrasound diagnosis.

Materials and methods

Retrospective analysis was performed on the 2016 clinical data of the patients who had undergone gynecological emergency ultrasound at The First Affiliated Hospital of Guangxi Medical University, and the results of the ultrasound diagnosis were compared with the clinical diagnosis.

Results

The following categories of gynecologic emergency diseases during the daytime and at night have significant statistical differences in the constituent ratio (P<0.001); ectopic pregnancy, intrauterine pregnancy, acute pelvic inflammatory disease, no organic lesion in uterine and adnexa; while the constituent ratio of abortion and trophoblastic diseases, ovarian tumor, uterine and endometrial lesions, was no statistical difference during the daytime and at night (P>0.05). The overall coincidence rate of ultrasound diagnosis was 96.3% (daytime, 97.9%; night, 86.4%). The coincidence rates of ectopic pregnancy ultrasonography diagnosis in daytime and at night were 96.4 and 75.4%, respectively; the difference was statistically significant (P<0.001).

Conclusion

Since the different constituent ratio of disease between daytime and night gynecological emergency ultrasound was significantly different, and the diagnostic accuracy of ultrasound at night was low; hence, the ultrasound doctor at night should pay attention to improve the accuracy of diagnosis and the ability of differential diagnosis of ectopic pregnancy, and it is suggested that some suspected cases during the night should be reexamined again in the daytime to eliminate the errors resulted from subjective factors.

Uterine Artery Embolization Combined with Dilation and Curettage for the Treatment of Cesarean Scar Pregnancy: Efficacy and Future Fertility

PURPOSE

To investigate the efficacy and safety of uterine artery embolization (UAE) followed by dilation and curettage (D&C) as a treatment for cesarean scar pregnancy (CSP) and to assess pregnancy outcomes after the treatment.

MATERIALS AND METHODS

We retrospectively analyzed 33 CSP patients treated with UAE followed by D&C. The serum level of beta human chorionic gonadotropin (β-hCG) normalization, hospitalization, menstruation, and successful pregnancy after treatment was assessed as clinical and pregnancy outcomes.

RESULTS

A total of 33 patients were initially treated without severe complications. However, four patients required additional systemic chemotherapy. β-hCG normalization took 35.5 ± 14.9 days (range 13-79), and the hospitalization was 6.5 ± 2.5 days (2-15). All patients resumed normal menstruation after 36 ± 19.2 days (12-86). Of 16 of 33 patients who desired pregnancy after the treatment, seven patients (43.8%) had uneventful parturition.

CONCLUSIONS

UAE combined with D&C was efficient and safe for CSP management. This minimally invasive procedure may be considered as one of the treatment options which enable preservation of fertility after treatment.

Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis

OBJECTIVE

To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP).

METHODS

An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis.

RESULTS

A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case.

CONCLUSIONS

CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Comparison of management regimens following ultrasound diagnosis of nontubal ectopic pregnancies: a retrospective cohort study

OBJECTIVE

To review management options for nontubal ectopic pregnancies.

DESIGN

Retrospective cohort study.

SETTING

Tertiary hospital in Melbourne, Australia.

POPULATION

A total of 100 nontubal pregnancies: 1 abdominal, 32 caesarean scar, 14 cervical, 41 cornual-interstitial, 12 ovarian.

METHODS

Cases were classified according to ectopic site. Management categories were medical, surgical, combination or expectant. Use of minimally invasive approaches (ultrasound-guided intra-sac injections or selective surgical techniques) was identified. Primary management was considered to be successful if no further unplanned interventions were required.

MAIN OUTCOME MEASURES

Success of primary management and frequency of unplanned interventions.

RESULTS

A high rate of success (82%) was demonstrated for all management regimens, with minimal morbidity and no deaths occurring. A high success rate was shown when the primary management regimen was systemic methotrexate or ultrasound-guided intra-sac injection (88%). The success rate for primary surgical management was 57%. High success rates were reported for both primary management with ultrasound-guided injections or in combination with systemic methotrexate (94%) and for primary management with systemic methotrexate alone (81%). Seventy-five per cent of women managed with minimally invasive surgical approaches avoided the need for more extensive surgery, but required longer follow up and additional interventions.

CONCLUSION

Minimally invasive approaches were found to be safe and effective treatment for women desiring to conserve fertility. Ultrasound-guided intra-sac injection and laparoscopic ectopic removal procedures aimed at preserving reproductive organs should be included as minimally invasive primary management tools in addition to the well-recognised option of systemic methotrexate.

TWEETABLE ABSTRACT

Nontubal ectopics: minimally invasive procedures a safe alternative to surgery in selected cases.

Ectopic Pregnancy in a Cesarean Section Scar: Successful Management Using Vacuum Aspiration under Laparoscopic Supervision-Mini Review of Current Literature

A cesarean scar ectopic pregnancy (CSEP) is a fairly uncommon presentation wherein the conceptus is implanted deep in the myometrium and at the exact scar site of the previous cesarean section. There are various CSEP management options that range from medical treatment to surgical interventions such as dilatation and curettage, laparoscopic excision, resection by laparotomy, or, sometimes, a combination of these modalities. Establishing a diagnosis of CSEP can be challenging. Given the relatively rare incidence of CSEP, its management is controversial and current standards of therapy have been derived from data obtained from a limited number of patients. Herein, we present transvaginal ultrasonography (TVUS) imaging findings and management strategies used in a case of CSEP along with the short review of current literature.

Pregnancy, Delivery, and Neonatal Outcomes of In Vitro Fertilization-Embryo Transfer in Patient with Previous Cesarean Scar

Background

What role should previous cesarean section play in affecting clinical pregnancy outcomes and avoiding the complications of in vitro fertilization? In this article, we focus on elective single-embryo transfer (eSET) versus double-embryo transfer (DET) and assess the clinical efficacy and safety of eSET in patients who have a previous cesarean scar.

Material/Methods

The pregnancy, delivery, and neonatal outcomes of 130 patients who had a previous cesarean scar and received in vitro fertilization-embryo transfer (IVF-ET) were retrospectively analyzed. The number of transferred embryos was chosen depending on patients’ desire after acknowledging all benefits and risks, including eSET (eSET group, n=56) and DET (DET group, n=74). A total of 101 patients with previous vaginal delivery receiving IVF-ET in the same period were included as a control group.

Results

The pregnancy rates, multiple birth rates, abortion rates, ectopic pregnancy rates, gestational age at delivery, preterm birth rates, neonatal birth weight, and take-home baby rates were similar between the previous cesarean section group and the previous vaginal delivery group. A previous cesarean section scar did not affect embryo implantation and pregnancy outcomes in IVF. In the eSET and DET groups of previous cesarean section patients, the embryo implantation rates, pregnancy rates, abortion rates, and take-home baby rates were similar. However, the rate of multiple pregnancies reached 50% in the DET group, which led to more preterm births and lower birth weight.

Conclusions

Elective single-embryo transfer is a well-accepted strategy to avoid multiple pregnancies and improve the obstetric and neonatal outcomes of singleton pregnancy in IVF patients with a previous cesarean section.