1
|
Timor-Tritsch IE, Horwitz G, D'Antonio F, Monteagudo A, Bornstein E, Chervenak J, Messina L, Morlando M, Cali G. Recurrent Cesarean scar pregnancy: case series and literature review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:121-126. [PMID: 33411387 DOI: 10.1002/uog.23577] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/18/2020] [Accepted: 09/22/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To determine the rate of recurrent Cesarean scar pregnancy (CSP) in our clinical practices and to evaluate whether the mode of treatment of a CSP is associated with the risk of recurrent CSP, as well as to review the published literature on recurrent CSP. METHODS We performed a retrospective search of our six obstetric and gynecological departmental ultrasound databases for all CSPs and recurrent CSPs between 2010 and 2019. We extracted various data, including number of CSPs with follow-up, number of cases attempting and number achieving pregnancy following treatment of CSP and number of recurrent CSPs, as well as details of the treatment of the original CSP. After analyzing the clinical data, we evaluated whether the mode of treatment terminating the previous CSP was associated with the risk of recurrent CSP. We also performed a PubMed search for: 'recurrent Cesarean scar pregnancy' and 'recurrent Cesarean scar ectopic pregnancy'. Articles were reviewed for year of publication, and extraction and analysis of the same data as those obtained from our departmental databases were performed. RESULTS Our database search identified 252 cases of CSP. The overall rate of clinical follow-up ranged between 71.4% and 100%, according to treatment site (mean, 90.9%). Among these, 105 women had another pregnancy after treatment of the previous CSP. Of these, 36 (34.3%) pregnancies were recurrent CSP, with 27 women having a single recurrence and three women having multiple recurrences, one with two, one with three and one with four. We did not find any particular single or combination treatment mode terminating the previous CSP to be associated with recurrent CSP. The literature search identified 17 articles that yielded sufficient information for us to evaluate their reported prevalence of recurrent CSP. These reported 1743 primary diagnoses of CSP, of which 944 had reliable follow-up. Data were available for 489 cases that attempted to conceive again after treatment of a previous CSP, and on the 327 pregnancies achieved. Of these, 67 (20.5%) were recurrent CSP. CONCLUSIONS On the basis of our pooled clinical data and review of the literature, recurrent CSP is apparently more common than was previously assumed based upon mostly single-case reports or series with few cases. This should be borne in mind when counseling patients undergoing treatment for CSP regarding their risk of recurrence. We found no obvious causal relationship or association between the type of treatment of the previous CSP and recurrence of CSP. Patients who become pregnant after treatment of a CSP should be encouraged to have an early (5-7-week) first-trimester transvaginal scan to determine the location of the gestation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - G Horwitz
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - F D'Antonio
- Department of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - A Monteagudo
- Carnegie Imaging for Women, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - E Bornstein
- Department of Obstetrics and Gynecology, Division of MFM Lenox Hill Hospital, New York, NY, USA
| | - J Chervenak
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - L Messina
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - M Morlando
- Department of Woman, Child and General and Special Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - G Cali
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| |
Collapse
|
2
|
Wu J, Ye J, OuYang Z, Wan Z, Zhang Q, Zhong B, Wei S. Outcomes of reproduction following cesarean scar pregnancy treatment: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 262:80-92. [PMID: 33993066 DOI: 10.1016/j.ejogrb.2021.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To explore the reproductive outcomes of women with a history of cesarean scar pregnancy (CSP) and the influence of various treatments on subsequent pregnancy outcomes. STUDY DESIGN The PubMed, Embase, Medline, Cochrane Library and ClinicalTrial.gov databases were searched for studies with the outcomes of pregnancy after CSP treatment. Studies that reported reproductive outcomes after CSP with more than 5 followed cases were included. The main data collected includes the treatment methods of CSP and subsequent pregnancy outcomes. The main information includes intrauterine pregnancy, recurrent CSP (RCSP), and spontaneous miscarriage, while the secondary information includes complications during pregnancies and the outcomes of childbirths. According to different treatments (conservative treatment, surgical treatment without resection of cesarean scar, and surgical treatment with resection of cesarean scar), a stratified analysis was carried out to compare the influence of treatments on subsequent pregnancy outcomes. RESULTS A total of 32 studies including 3380 cases of CSP met the inclusion criteria, of which 583 cases conceived again after treatment (including 292 cases of unexpected pregnancy), and finally 178 cases delivered successfully. The follow-up time ranged from 3 to 72 months. Among women with fertility requirements, a total of 291 cases in 403 women were successfully conceived during the follow-up period in 15 studies. Thence the pregnancy rate of women with fertility requirements was 76.2 %. Among all of the 583 successfully conceived women, 83.4 % of them had intrauterine pregnancy, while 15.3 % of cases were RCSP. The total ectopic pregnancy rate reached 16.6 %, covering RCSP and other sites of ectopic pregnancy. 14.6 % of intrauterine pregnancy experienced spontaneous miscarriage. The intrauterine pregnancy rates of the conservative treatment group, the surgical treatment without resection of cesarean scar group, and the surgical treatment with resection of cesarean scar group were 93.1 %, 80.1 % and 86.0 % respectively; the corresponding RCSP rates were 6.9 %, 15.6 % and 14.0 % respectively; and the corresponding spontaneous miscarriage rates were 20.7 %, 13.9 % and 22.2 % respectively. CONCLUSION The outcomes of reproduction after CSP included intrauterine pregnancy, RCSP and other sites of ectopic pregnancy. Women with a history of CSP still have a high pregnancy rate, but the risk of RCSP and spontaneous miscarriage is also increased. It is impossible to clarify the effect of different treatments on subsequent pregnancy. Whether the resection and repair of cesarean scar can ameliorate reproductive outcomes needs to be further assessed. Further large-scale prospective studies, even RCTs with long-term follow-up are needed to expound the outcomes of reproduction after CSP and the effect of different treatments on subsequent reproductive outcomes.
Collapse
Affiliation(s)
- Jiawen Wu
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Jianbin Ye
- Department of Intensive Care Unit, Puning People's Hospital, Puning, China
| | - Zhenbo OuYang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China.
| | - Zixian Wan
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Qiushi Zhang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Biting Zhong
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Shiyuan Wei
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| |
Collapse
|
3
|
Timor-Tritsch I, Buca D, Di Mascio D, Cali G, D'Amico A, Monteagudo A, Tinari S, Morlando M, Nappi L, Greco P, Rizzo G, Liberati M, Jose-Palacios-Jaraquemada, D'Antonio F. Outcome of cesarean scar pregnancy according to gestational age at diagnosis: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 258:53-59. [PMID: 33421811 DOI: 10.1016/j.ejogrb.2020.11.036] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/11/2020] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- Ilan Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
| | - Danilo Buca
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Daniele Di Mascio
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Italy
| | - Giuseppe Cali
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Villa Sofia Cervello, Palermo, Italy
| | - Alice D'Amico
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Tinari
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Maddalena Morlando
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynaecology, University of Foggia, Italy
| | - Pantaleo Greco
- Department of Morphology, Surgery and Experimental Medicine, Institute of Obstetrics and Gynaecology, University of Ferrara, Italy
| | - Giuseppe Rizzo
- Università di Roma Tor Vergata, Division of Maternal Fetal Medicine, Ospedale Cristo Re, Rome, Italy; The First I.M. Sechenov Moscow State Medical University, Department of Obstetrics and Gynecology, Moscow, Russia
| | - Marco Liberati
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Jose-Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - Francesco D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy.
| |
Collapse
|
4
|
Bağlı İ, Bakır MS, Doğan Y, Erdem S, Taşın C, Demirel NU, Kulahçıoğlu Mİ. Is suction curettage an effective treatment alternative for cesarean scar pregnancies? Eur J Obstet Gynecol Reprod Biol 2021; 258:193-197. [PMID: 33450710 DOI: 10.1016/j.ejogrb.2021.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 11/19/2020] [Accepted: 01/02/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVES The study aims to evaluate the success rate of suction curettage (SC) as a first line treatment with or without use of foley balloon tamponade for cesarean scar pregnancy (CSP) and to determine the risk factors for failure of treatment. STUDY DESIGN The study was retrospective and included 36 CSP cases who underwent SC for treatment. Presence of pain with active bleeding and > 10 weeks of gestation were taken as the exclusion criterion. The procedure was performed under sonographic guidance. After the procedure, in patients who had a hemorrhage foley catheter was inserted into the uterine cavity. SC failure was defined as a requirement of secondary intervention. CSP types, myometrial thickness in the scar area, fetal cardiac activity, initial Beta human chorionic gonadotropin levels (β-HCG), history of vaginal delivery were compared between successful and failed groups. RESULT Of 36 patients, 31 had favorable results with SC ± foley balloon tamponade. Success rate was found to be 86 % (31/36) as the first line therapy. Foley catheter was applied for 23 patients, among them, four were in the failed group and 19 were in the favorable group. In the failed group, two patients had emergent laparotomy, two had repeat SC the day after the initial treatment and one patient was treated with systemic MTX. Fetal cardiac activity and presence of embryonic pole were not different between the groups (p = 1.000, p = 0.829 respectively). Myometrial thickness in the failed group was less than the successful group, this difference was significant (p = 0.033). CSP types, initial β-HCG levels and history of vaginal delivery were not different between the groups (p = 0.149, p = 0.372 and p = 0.404 respectively). CONCLUSION SC may be considered as a first line therapy for CSPs, and and in patients complicated with hemorrhage foley balloon tamponade can be used easily. Thinner myometrium at previous cesarean scar can be considered as a risk factor for failure of SC in patients with CSP.
Collapse
Affiliation(s)
- İhsan Bağlı
- University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Department of Obstetrics and Gynecology, Diyarbakır, Turkey.
| | - Mehmet Sait Bakır
- University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Department of Obstetrics and Gynecology, Diyarbakır, Turkey
| | - Yasemin Doğan
- University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Department of Obstetrics and Gynecology, Diyarbakır, Turkey
| | - Selami Erdem
- University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Department of Obstetrics and Gynecology, Diyarbakır, Turkey
| | - Cuma Taşın
- Mersin University, Department of Obstetrics and Gynecology, Mersin, Turkey
| | - Neslihan Uğur Demirel
- University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Department of Obstetrics and Gynecology, Diyarbakır, Turkey
| | - Mehmet İrfan Kulahçıoğlu
- University of Health Sciences Diyarbakir Gazi Yasargil Research and Training Hospital, Department of Obstetrics and Gynecology, Diyarbakır, Turkey
| |
Collapse
|
5
|
Ali H, Chandraharan E. Etiopathogenesis and risk factors for placental accreta spectrum disorders. Best Pract Res Clin Obstet Gynaecol 2020; 72:4-12. [PMID: 32753310 DOI: 10.1016/j.bpobgyn.2020.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 07/03/2020] [Indexed: 11/16/2022]
Abstract
Placenta accreta spectrum (PAS) disorders, comprising placenta accreta, increta, and percreta, are associated with serious maternal morbidity and mortality in both the developed and the developing world. The incidence of PAS has increased in the recent years, and the rising rates of cesarean section rate, placenta accreta in previous pregnancies, and other uterine surgeries including myomectomies and repeated endometrial curettage are implicated in its etiopathogenesis. The absolute risk of PAS increases with the number of previous cesarean sections. The PAS remains undiagnosed in one-half to two-thirds of cases, thus increasing maternal morbidity and mortality. Understanding etiopathogenesis and risk factors of this condition allows early diagnosis and planning of delivery, and thereby would help improve maternal and fetal outcomes.
Collapse
Affiliation(s)
- Humaira Ali
- St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
| | - Edwin Chandraharan
- Global Academy of Medical Education & Training, Office 4, 219 Kensington High Street, Kensington, London, England, W8 6BD, UK.
| |
Collapse
|
6
|
Morlando M, Buca D, Timor-Tritsch I, Cali G, Palacios-Jaraquemada J, Monteagudo A, Khalil A, Cennamo C, La Manna V, Liberati M, D'Amico A, Nappi L, Colacurci N, D'Antonio F. Reproductive outcome after cesarean scar pregnancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2020; 99:1278-1289. [PMID: 32419158 DOI: 10.1111/aogs.13918] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION To evaluate subsequent reproductive among women with a prior cesarean scar pregnancy (CSP). MATERIAL AND METHODS MEDLINE, Embase and ClinicalTrials.gov databases were searched. Inclusion criteria were women with a prior CSP, defined as the gestational sac or trophoblast within the dehiscence/niche of the previous cesarean section scar or implanted on top of it. The primary outcome was the recurrence of CSP; secondary outcomes were the chance of achieving a pregnancy after CSP, miscarriage, preterm birth, uterine rupture and the occurrence of placenta accreta spectrum disorders. Subgroup analysis according to the management of CSP (surgical vs non-surgical) was also performed. Random effect meta-analyses of proportions were used to analyze the data. RESULTS Forty-four studies (3598 women with CSP) were included. CSP recurred in 17.6% of women. Miscarriage, preterm birth and placenta accreta spectrum disorders complicated 19.1% (65/341), 10.3% (25/243) and 4.0% of pregnancies, and 67.0% were uncomplicated. When stratifying the analysis according to the type of management, CSP recurred in 21% of women undergoing surgical and in 15.2% of those undergoing non-surgical management. Placenta accreta spectrum disorders complicated 4.0% and 12.0% of cases, respectively. CONCLUSIONS Women with a prior CSP are at high risk of recurrence, miscarriage, preterm birth and placenta accreta spectrum. There is still insufficient evidence to elucidate whether the type of management adopted (surgical vs non-surgical) can impact reproductive outcome after CSP. Further large, prospective studies sharing an objective protocol of prenatal management and long-term follow up are needed to establish the optimal management of CSP and to elucidate whether it may affect its risk of recurrence and pregnancy outcome in subsequent gestations.
Collapse
Affiliation(s)
- Maddalena Morlando
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Danilo Buca
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Ilan Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
| | - Giuseppe Cali
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Villa Sofia Cervello, Palermo, Italy.,Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Jose Palacios-Jaraquemada
- Center for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, London, UK
| | - Carmen Cennamo
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Viviana La Manna
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco Liberati
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Alice D'Amico
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Luigi Nappi
- Fetal Medicine Unit, Department of Medical and Surgical Sciences, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Nicola Colacurci
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco D'Antonio
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| |
Collapse
|
7
|
Abstract
The placenta accreta spectrum has become an important contributor to severe maternal morbidity. The true incidence is difficult to ascertain, but likely falls near 1/1000 deliveries. This number seems to have increased along with the rate of risk factors. These include placenta previa, previous cesarean section, use of assisted reproductive technologies, uterine surgeries, and advanced maternal age. With increased uterine conservation, previous retained placenta or placenta accreta have become significant risk factors. Understanding placenta accreta spectrum risk factors facilitates patient identification and safe delivery planning. Patients considering elective uterine procedures or delayed childbirth should consider the impact on peripartum morbidity.
Collapse
|
8
|
Cesarean Scar Pregnancies: Incidence and Factors Associated with Conversion to Surgery from Medical Management. J Minim Invasive Gynecol 2018; 26:919-927. [PMID: 30243684 DOI: 10.1016/j.jmig.2018.09.771] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 09/11/2018] [Accepted: 09/14/2018] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE To describe the incidence, management, and complications of cesarean scar pregnancy (CSP) and define risk factors for conversion from medical to surgical treatment of CSP. DESIGN Retrospective clinical study (Canadian Task Force classification II-3). SETTING Tertiary medical center. PATIENTS All patients who were admitted and treated for CSP between 2008 and 2016. INTERVENTIONS The cohort was divided according to management, and demographic, clinical, and sonographic data were collected. Rates of conversion were compared between groups, and risk factors necessitating conversion were sought. MEASUREMENTS AND MAIN RESULTS Forty-six cases of CSP were identified. The incidence of CSP has increased from 0.05% to 0.09% of all deliveries. A regression model for absolute numbers of CSP predicted an additional 0.47 CSP each year (p = .03). The most common treatment modalities were systemic treatment with methotrexate (28.2%) and ultrasound-guided intrasac injection of KCl with systemic treatment of methotrexate (58.7%). The mean sac diameter (MSD) of cases that were converted was 11.2 mm larger than in cases that were not converted (p < .001). No patients with an MSD <10 mm or a trophoblastic mass <20 mm3 were converted to surgical management. Maximal levels of beta human chorionic gonadotropin (β-hCG) were significantly associated with the risk of conversion. Only 6.3% of patients with a β-hCG level <10,000 IU at presentation were converted from medical to surgical management. There was no significant association between fetal cardiac activity and conversion from medical to surgical management. CONCLUSIONS CSP has emerged as an important phenomenon in modern obstetrics and gynecology, and its frequency appears to be on the rise. The preferred method of treatment remains unclear; however, it is possible that a large MSD and trophoblastic mass at presentation should prompt surgical treatment.
Collapse
|
9
|
Recurrent Cesarean Scar Ectopic Pregnancy Treated with Systemic Methotrexate. Case Rep Obstet Gynecol 2017; 2017:9536869. [PMID: 29333307 PMCID: PMC5733213 DOI: 10.1155/2017/9536869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 11/05/2017] [Indexed: 11/18/2022] Open
Abstract
Cesarean scar pregnancy (CSP) is a rare event; however its incidence has been rising due to the increasing rates of cesarean deliveries. The majority of cases present with signs or symptoms requiring surgery, which often results in hysterectomy. The recurrence of CSP is even rarer with only few cases which have been reported. This is a report of recurrent cesarean scar ectopic pregnancy (RCSP) that was promptly diagnosed and managed with only systemic methotrexate. This was a 30-year-old woman, with a history of two prior cesarean deliveries followed by a CSP, who presented at 5 weeks and 3 days of gestation for her first prenatal visit. Transvaginal ultrasound revealed a RCSP. Her serum beta-human chorionic gonadotropin (β-hCG) level was 54,295 IU/L. The first CSP, which was diagnosed at a later stage, was treated with uterine artery embolization and systemic methotrexate leading to complete resolution within 10 weeks. The current ectopic was treated with two doses of systemic methotrexate; her serum β-hCG reached undetectable levels within 7 weeks. Thus, patients with a history of prior CSP should be carefully monitored with transvaginal ultrasound during subsequent pregnancies to allow early diagnosis of RCSP, which could then be treated conservatively.
Collapse
|