The diagnosis, treatment, and follow-up of cesarean scar pregnancy

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

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

First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry

BACKGROUND

A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry.

OBJECTIVE

This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies.

STUDY DESIGN

We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions.

RESULTS

Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9).

CONCLUSION

A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment.

A combination of laparoscopy and bilateral uterine artery occlusion for the treatment of type II cesarean scar pregnancy: a retrospective analysis

OBJECTIVE

We investigated the efficacy of a combination of laparoscopy and bilateral uterine artery occlusion (BUAO) for the treatment of type II cesarean scar pregnancy (CSP).

METHODS

Patients with type II CSP underwent laparoscopy + bilateral uterine artery embolization (control group) or laparoscopy + BUAO (study group). Data regarding the duration of surgery, intraoperative hemorrhage, postoperative complications, the duration of the hospital stay, and the costs of hospitalization were retrospectively collected. One year later, the time to the return of the β-human chorionic gonadotropin (β-hCG) concentration to normal and to the return of menstruation were compared.

RESULTS

The duration of surgery, time to the return of menstruation, and incidence of postoperative complications in the study group were significantly less than in the control group, but there was no significant difference in the time for β-hCG to return to normal or the volume of intraoperative hemorrhage. The duration of hospitalization and costs for the control group were higher than those for the study group.

CONCLUSION

Laparoscopy in combination with BUAO is associated with minimal trauma, rapid recovery, a short duration of surgery, low cost of hospitalization, and a low postoperative complication rate. Thus, it represents a useful new surgical treatment for type II CSP.

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.

Cesarean Scar Pregnancy: Results of Treatment Using a Double-Balloon Cervical Ripening Catheter

Background

Being considered a life-threatening condition, cesarean scar pregnancy (CSP) leads to loss of fertility, severe bleeding, and even maternal mortality. We intended to assess the effect of double-balloon cervical ripening catheter insertion on CSP termination before nine weeks of gestation.

Method

All participants were diagnosed CSP by abdominal and transvaginal ultrasound. The cases were treated with a sterile, double-balloon cervical ripening catheter inserted with real-time transabdominal ultrasound guidance and removed three days later. The control group consisted of patients treated with systemic methotrexate with or without fetal reduction.

Results

Thirty-five patients were eligible for double-balloon ripening and 32 for MTX therapy; the treatment in cases failed in five of the patients. Success rate difference between two methods was insignificant (Pearson Chi-square: 0.383, p-value: 0.536). There were significant differences regarding the time to normal menstruation (OR: 1.303) and the thickness of the myometrium after surgery (OR: 4.721), but there was no significant difference in the time resolve of either β-HCG or residue of pregnancy.

Conclusion

Double-balloon cervical ripening insertion yields acceptable results for terminating CSP. This strategy does not cause bleeding and even prevents it with its tamponade properties. Additionally, this treatment is minimally invasive simple with low morbidity.

The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy

Cesarean scar pregnancy (CSP) is among the most severe complications of cesarean delivery. CSP refers to the abnormal implantation of the gestational sac in the area of the prior cesarean delivery (CD), potentially leading to severe hemorrhage, uterine rupture, or development of placenta accreta spectrum disorders (PAS). The management of women with CSP has not been standardized yet. In women who opted for termination, discussion about the treatments should consider maternal symptoms, gestational age at intervention, and the future reproductive risk. A multitude of treatments, either medical or surgical, for CSP has been reported in the published literature. The present review aims to provide up-to-date information on a recently introduced minimally invasive treatments for CSP, including the single and double balloon catheter. The methodology of using the single or double catheter is described in a step-by-step fashion illustrated by pictures as well as video recordings. Both catheters have their deserved place to be used as a primary method for terminating scar pregnancies as well as using them as adjuncts to other treatments. They were successfully used by multiple individual practitioners and institutions due to their simplicity and low complication rates. The rare, but possible post-procedure complications such as recurrent CSP and enhanced myometrial vascularity are also mentioned.

Outcomes of prophylactic lauromacrogol injection versus non-injection in patients with endogenous cesarean scar pregnancy treated by hysteroscopic surgery: a retrospective cohort study

BACKGROUND

This study aimed to investigate the efficacy of hysteroscopic surgery for endogenous cesarean scar pregnancy (CSP) and the value of prophylactic ultrasound-guided local injection of lauromacrogol.

METHODS

This retrospective study included 131 patients diagnosed with endogenous CSP who underwent hysteroscopic surgery at the Hangzhou Fuyang Women and Children Hospital between January 2018 and May 2022. Lauromacrogol (10-20 mL) was administered within 24 h preoperatively using an ultrasound-guided vaginal injection to 78 patients (L group) versus not administered to 53 patients (non-L group). Their clinical data and outcomes were analyzed.

RESULTS

Mean gestational age, gestational mass size, and uterine scar thickness and median preoperative blood β-human chorionic gonadotropin levels of the non-L versus L groups were 46.26 versus 45.01 days, 2.05 versus 2.39 cm, 0.35 versus 0.32 cm, and 19850.0 versus 26790.0 U/L, respectively (P > 0.05 for each). The non-L and L groups had similar success rates (98.1% vs. 98.7%, P = 1.0). Complications related to lauromacrogol administration, including abdominal pain, massive bleeding, and bradycardia, were experienced by 46.2% (36/78; P < 0.001) of L group patients. The non-L had a significantly shorter mean hospital stay (4.85 ± 1.12 vs 5.44 ± 1.08 days) and lower total cost (6148.75 ± 1028.71 vs 9016.61 ± 1181.19) (P < 0.01).

CONCLUSIONS

Hysteroscopic surgery is effective and safe for patients with endogenous CSP. Prophylactic lauromacrogol injection increases the incidence of complications and costs. Direct hysteroscopic surgery can reduce pain and financial burden in patients with endogenous CSP and save medical resources for other patients.

Methotrexate treatment of very high β-HCG ectopic pregnancy on previous cesarean scar: A case report

Ectopic pregnancy in a previous caesarean scar is a rare, potentially life-threatening situation that can cause massive bleeding and uterine rupture. Clinical symptoms can range from vaginal bleeding with or without pain, to uterine rupture with hypovolemic shock. Early diagnosis is possible by ultrasound examination, and it is very important because it leads to prompt management, improving maternal morbidity and mortality as well as future fertility. The current case report refers to a G3P2 woman with a history of 2 previous caesarean deliveries, who was diagnosed with an ectopic pregnancy on the caesarean scar using ultrasonography. The patient was treated with methotrexate both systemic and into the sac, as well as with injection into the sac of 5mEq potassium chloride. The woman was followed up until measurements of serum β-Human Chorionic Gonadotropin were within nonpregnant levels. There is no clear-cut best way to handle cesarean scar pregnancy. Pregnancy with a cesarean scar should be identified and treated as soon as possible in order to avoid serious problems and preserve fertility. However, even more advanced cesarean scar pregnancies can be managed conservatively at first, when a highly expertized team in a tertiary hospital is available.

Hysteroscopic resection vs ultrasound-guided dilation and evacuation for treatment of cesarean scar ectopic pregnancy: a randomized clinical trial

BACKGROUND

Cesarean scar ectopic pregnancy is a type of ectopic pregnancy in which the fertilized egg is implanted in the muscle or fibrous tissue of the scar after a previous cesarean delivery. The condition can be catastrophic if not managed on time and can lead to significant morbidity and mortality. Several approaches have been studied for the management of cesarean scar ectopic pregnancy in women who opted for termination of pregnancy with no consensus on the best treatment modality reached so far.

OBJECTIVE

This study aimed to compare the success rate of hysteroscopic resection vs ultrasound-guided dilation and evacuation for the treatment of cesarean scar ectopic pregnancy.

STUDY DESIGN

This was a parallel group, nonblinded, randomized clinical trial conducted at a single center in Italy. Women with singleton gestations at <8 weeks and 6 days of gestation were included in the study. Inclusion criteria were women with a cesarean scar ectopic pregnancy with positive embryonic heart activity who opted for termination of pregnancy. Patients were randomized 1:1 to receive either hysteroscopic resection (ie, intervention group) or ultrasound-guided dilation and evacuation (ie, control group). Both groups received 50 mg/m2 of methotrexate intramuscularly at the time of randomization (day 1) and another dose at day 3. A third dose of methotrexate was planned in case of persistence of positive fetal heart activity at day 5. Participants received either ultrasound-guided dilation and evacuation or hysteroscopic resection from 1 to 5 days after the last dose of methotrexate. Hysteroscopic resection was performed under spinal anesthesia using a 15 Fr bipolar mini-resectoscope. Dilation and evacuation were performed by vacuum aspiration with a Karman cannula, followed by sharp curettage, if necessary, under ultrasound guidance. The primary outcome was the success rate of the treatment protocol, defined as no further treatment required until the complete resolution of the cesarean scar ectopic pregnancy. Resolution of the cesarean scar ectopic pregnancy was evaluated based on decline of beta-hCG and the absence of residual gestational material in the endometrial cavity. Treatment failure was defined as the necessity for further treatment required until the complete resolution of the cesarean scar ectopic pregnancy. A sample size calculation indicated that 54 participants were required to test the hypothesis RESULTS: A total of 54 women were enrolled and randomized. Number of previous cesarean deliveries ranged from 1 to 3. Overall, 10 women received a third dose of methotrexate with 7 of 27 (25.9%) participants in the hysteroscopic resection group and 3 of 27 (11.1%) in the dilation and evacuation group. The success rate was 100% (27/27) in the hysteroscopic resection group and 81.5% (22/27) in the dilation and evacuation group (relative risk, 1.22; 95% confidence interval, 1.01-1.48). Additional procedures were required in 5 cases of the control group, namely 3 hysterectomies, 1 laparotomic uterine segmental resection, and 1 hysteroscopic resection. The length of stay in the hospital was 9.0±2.9 days in the intervention group and 10.0±3.5 days in the control group (mean difference, -1.00 days; 95% confidence interval, -2.71 to 0.71). No cases of admission to intensive care unit or maternal death were reported.

CONCLUSION

Hysteroscopic resection was associated with an increased success rate in the treatment of cesarean scar ectopic pregnancy when compared with ultrasound-guided dilation and evacuation.

Cesarean scar ectopic pregnancy: nuances in diagnosis and treatment

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

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

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

Diagnosis and Management of Cesarean Scar Ectopic Pregnancy: A Case Study

A cesarean scar ectopic pregnancy (CSEP) designates an ectopic pregnancy within the myometrium of a past uterine incision. Early diagnosis through transvaginal ultrasonography is crucial as an untreated CSEP can lead to serious complications, including hemorrhage, loss of future fertility, and maternal death. We present a case of a 33-year-old female with five previous cesarean sections, who presented at seven weeks of gestation with concerns of a CSEP. Here, we highlight the importance of early diagnosis and maintaining high clinical suspicion in women with multiple previous cesarean sections who present with menstrual abnormalities. The CSEP is a serious condition and requires a high index of suspicion during diagnosis and follow-up. Ultrasound scanning and training should be readily available to quickly identify and treat this life-threatening condition.

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.

Outcomes of Cesarean Scar Pregnancies in Early Gestation According to the New Delphi Consensus Criteria

OBJECTIVES

Clinical evaluation of the new Delphi consensus definition of cesarean scar pregnancy (CSP) in early gestation.

METHODS

A retrospective cohort of 36 women diagnosed with CSP and treated with combined local and systemic methotrexate (MTX) between 2008 and 2021. The CSPs were classified according to the new Delphi consensus criteria into three subgroups based on the depth of the gestational sac herniation in the sagittal plane. Subgroup A included 8 (22.2%) cases in which the largest part of the gestational sac protruded toward the uterine cavity. Subgroup B included 22 (61.1%) cases in which the largest part of the gestational sac was embedded in the myometrium, and subgroup C included 6 (16.7%) cases in which the gestational was partially located outside the outer contour of the cervix or uterus.

RESULTS

The β-HCG level upon admission was significantly lower in subgroup A than in subgroups B or C (11,075 ± 7109, 18,787 ± 16,585, and 58,273 ± 55,267 mIU/mL, respectively, P = .01). All subgroup C patients had repeated courses of MTX and surgical interventions (laparotomy, uterine artery embolization, and operative hysteroscopy) at double the rate of subgroups A or B (100, 50, and 40.9%, respectively, P = .036). The duration of hospitalization was significantly shorter in subgroup A than in subgroups B or C (1.9 ± 1.5, 2.1 ± 1.1, and 5.4 ± 4.9 days, P = .01).

CONCLUSIONS

The outcome according to Delphi consensus criteria for defining CSP in early gestation has implications for clinical decision-making, patient care, and the follow-up of CSP.

Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis

The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

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.

Single-dose methotrexate-based protocol for the treatment of caesarean scar pregnancy and successive pregnancy outcomes

The incidence of caesarean scar pregnancy (CSP) increases in recent years. Yet, the best mode of treatment and its effects on successive pregnancies is not well established. The aim of this study was to investigate the success rate of single-dose methotrexate (MTX) in the management of CSP, and the outcomes of subsequent pregnancies in a retrospective cohort study. All women who were treated for CSPs between the years 2011 and 2019 were included. Treatment included systemic MTX and ultrasound-guided needle aspiration (UGNA) in cases with active foetal heartbeat. Overall, 34 women were diagnosed with CSP, of whom 31 were treated with systemic MTX. Twelve patients (38.7%) needed additional curettage or hysteroscopy. The only identified risk factor for failure of MTX-based treatment was time interval between the previous caesarean delivery and CSP (22 vs 34 months, p = 0.04). Twelve women had a subsequent pregnancy. Five pregnancies ended in term delivery, three in preterm delivery, three in abortion and one woman had a recurrent CSP. The study conclusion is that a single dose MTX with UGNA in cases of active heartbeat is an effective mode of treatment in cases of CSP with good sequential pregnancy outcomes. Longer time interval from the previous caesarean delivery was identified as a risk factor for failure of conservative management.

The Effectiveness of Combined Local and Systemic Methotrexate Treatment in Cesarean Scar Pregnancy Weeks 8 to 14

Objectives

This study aims to identify the success rate and correlated factors of combined local and systemic methotrexate (MTX) injection treatment in cesarean scar pregnancy (CSP).

Materials and Methods

The combined local and systemic MTX administration has been used for CSP weeks 8-14 at Tu Du Maternal Hospital; however, its effectiveness and correlated factors have not been closely investigated. This is a retrospective case series of 123 CSP patients between 8 and 14 weeks of gestation who were treated at Tu Du Hospital from the year 2016 to 2020.

Results

The success rate, uterine-sparing rate, and side effects of MTX treatment are 50.4%, 95%, and 17.2%, respectively. The factors related to treatment failure with statistical significance included gestational age (odds ratio [OR] = 3.99), residual myometrial thickness >3 mm (OR = 0.37), and postprocedure gestational sac diameter (OR = 1.09).

Conclusion

Combined local and systemic MTX injection is minimally invasive and effective in CSP weeks 8-14. Therefore, it should be utilized routinely.

Methotrexate for CSPs

Expectant management of a cesarean scar pregnancy (CSP) is associated with a high risk of severe maternal morbidity. Therefore, most experts recommend immediate termination after the diagnosis of a CSP. However, there is no consensus about the optimal management of a CSP in terms of efficacy, safety, and preservation of future fertility. Methotrexate (MTX) is a folic acid antagonist that has been largely used to treat tubal ectopic pregnancies. This review summarizes the current knowledge and uncertainties about the administration of MTX as a medical or non-invasive option to terminate a CSP; the preferred injection route (systemic or local/intragestational), the comparison with other treatment modalities, and the prognostic factors for MTX success will be discussed, as well as the recommendations from scientific societies.

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.

Global variation and outcomes of expectant management of CSP

The incidence of Cesarean scar pregnancies (CSPs) is rising globally. Ultrasound criteria for the diagnosis of CSPs have been described by the International Society of Ultrasound in obstetrics and gynecology and appear to be well used in various centers around the world. There is no guidance on best practices for expectant management of CSP, and there is considerable variation in how this is offered globally. Many studies have reported significant maternal morbidity in cases of CSP with fetal cardiac activity managed expectantly, largely relating to hemorrhage and cesarean hysterectomy from placenta accreta spectrum. However, high live birth rates are also reported. Literature describing the diagnosis and expectant management of CSP in low-resource settings is lacking. Expectant management in selected cases where no fetal cardiac activity is present is a reasonable option and can be associated with good maternal outcomes. Standardization in reporting different types of CSPs and correlating these with pregnancy outcomes will be an important next step in developing guidance for expectant management of this high-risk pregnancy with a high burden of complications.

Subsequent fertility after cesarean scar pregnancy: a retrospective analysis

BACKGROUND

Cesarean scar pregnancy (CSP) refers to the implantation and growth of the gestational sac at a uterine scarring site due to a previous cesarean section. The effects of CSP on subsequent fertility have emerged as a clinical issue of importance in gynecology and obstetrics in China owing to the increasing rate of cesarean section over the past 30 years in combination with the abolition of the national family planning policy, allowing for subsequent pregnancies. Therefore, we aimed to investigate the effects of CSP treatment on subsequent fertility and pregnancy outcomes.

METHODS

The study consecutively enrolled 499 women treated for CSP at Taizhou Hospital between January 2009 and December 2018. The study outcomes were the rate of secondary infertility and pregnancy outcomes. Clinical information was collected at the time of admission for CSP treatment. Information on subsequent fertility and pregnancy outcomes was collected via telephonic follow-up.

RESULTS

Among the 499 women who met the inclusion criteria for CSP, 48 were lost to follow-up. Most women (74.9%, 338/451) did not express the desire for a subsequent pregnancy after CSP treatment. Among the 113 women who initially desired a subsequent pregnancy, 62 finally abandoned fertility plans. Among the 51 women who pursued pregnancy, 48 pregnancies were recorded in 43 women, infertility secondary to CSP treatment was identified in 15.7% (8/51) of women, and 60.8% (31/51) of women achieved full-term pregnancy, with placenta accreta spectrum identified in two women, one requiring a hysterectomy during cesarean section due to massive bleeding. Among the 16 women treated with uterine artery embolization combined with uterine aspiration and 18 women treated by ultrasound-guided local lauromacrogol injection combined with uterine aspiration, a successful full-term pregnancy rate of 68.8% (11/16) and 88.9% (16/18), respectively, was achieved. There were five cases of recurrent CSP among all 76 pregnancies (6.6%).

CONCLUSION

Over a long-term follow-up of women after CSP treatment, a high successful fertility rate was identified, with also an increased CSP recurrence rate. Uterine artery embolization combined with uterine aspiration and ultrasound-guided local lauromacrogol injection combined with uterine aspiration showed high rates of successful post-treatment fertility and pregnancy.

Cesarean Scar Ectopic Pregnancy Clinical Classification System With Recommended Surgical Strategy

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Is High-intensity Focused Ultrasound Superior to Uterine Artery Embolization in Cesarean Scar Pregnancy and Subsequent Pregnancy Outcomes? A Meta-analysis of the Chinese Population

OBJECTIVE

High-intensity focused ultrasound (HIFU) followed by curettage or uterine artery embolization (UAE) followed by curettage are relatively effective methods for cesarean scar pregnancy (CSP), which can provide a high success rate and repregnancy while reducing blood loss and adverse events. Therefore, we conducted this meta-analysis to evaluate the efficacy, safety, and pregnancy outcomes of HIFU groups versus UAE groups with CSP.

DATA SOURCES

The PubMed, EMBASE, Cochrane, China National Knowledge Infrastructure, and Wanfang databases were systematically searched to find studies that compared the therapeutic effects of HIFU groups versus UAE groups.

METHODS OF STUDY SELECTION

Our primary end points were blood loss, adverse events, success rate, and repregnancy. We implemented random-effects models or fixed-effects models to evaluate the pooled data.

TABULATION, INTEGRATION, AND RESULTS

Thirty-four eligible items were included in studies. The blood loss was significantly reduced in HIFU groups compared with UAE groups (standardized mean difference = -1.45, 95% confidence interval [CI], 2.21 to -0.68; p <.001). Significantly fewer adverse events occurred in the HIFU groups than in UAE groups (odds ratio [OR] = 0.36, 95% CI, 0.23-0.57; p <.001). The success rate of HIFU groups was higher than that of UAE groups (OR = 1.56, 95% CI, 1.05-2.32; p = .03). There were more pregnancies in HIFU groups than in UAE groups (OR = 1.64, 95% CI, 1.28-2.11; p <.001).

CONCLUSION

In the CSP, the effect of HIFU groups was better than that of UAE groups: less blood loss, high success rate, fewer adverse events, and favorable fertility protection. Thus, it is a promising therapeutic method for patients.

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

AIM

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

MATERIALS

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

RESULTS

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

CONCLUSION

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

Cesarean Scar Pregnancies Treated by Uterine Artery Chemotherapy Embolization Combined With Ultrasound-Guided Dilation and Curettage: A Retrospective Study

OBJECTIVES

To explore the effect of cesarean scar pregnancy (CSP) treatment by comparing uterine artery chemotherapy embolization (UACE) combined with dilation and curettage (D&C) with or without ultrasound guidance.

METHODS

CSP patients treated with UACE combined with D&C from January 2013 to December 2020 at Shuguang Hospital, affiliated to Shanghai University of Traditional Chinese Medicine were included in this retrospective study. The patients were divided into groups A and B according to whether D&C was guided by ultrasound.

RESULTS

Forty-eight patients with CSP diagnosed by transvaginal ultrasound were included in this study, whose gestational age was <8 weeks. There were no significant differences in the basic clinical characteristics of the two groups. The success rates of the 2 groups were no significant difference, 100% (27/27) in group A and 85.7% (18/21) in group B. The maximal intraoperative blood loss of group A was 100 mL and that of group B was 150 mL. There was no uterine perforation during the operation. Ultrasound guidance can shorten the D&C operation time, reduce intraoperative bleeding during D&C, and decrease the residual rate of trophoblastic tissue after D&C.

CONCLUSIONS

Ultrasound guidance can improve the safety and efficiency of UACE combined with D&C in the treatment of CSP and reduce its complications. We believe it is an optimal treatment for CSP patients who do not plan to have children in the future.

Maternal Morbidity After Double Balloon Catheter Management of Cesarean Scar and Cervical Pregnancies

We performed a retrospective cohort study of all Type 1 cesarean scar pregnancies (n=18) or cervical pregnancies (n=5) at an academic tertiary center after treatment with a cervical double balloon catheter from 2018 to 2022 to evaluate outcomes and maternal morbidity. Cervical double balloon catheter treatment was associated with no cases (95% confidence interval 0-16%) of maternal hemorrhage treated with transfusion, hysterectomy, or ICU admission. Treatment was successfully performed by nine different obstetrics and gynecology specialists.

Safe Service Delivery of a Complex Early Pregnancy Problem: Caesarean Scar Pregnancy

Caesarean Scar Pregnancy (CSP) is an ectopic pregnancy with implantation into the niche of the uterine scar. We aimed to describe the local management of consecutive cases of CSP to develop a standard operating procedure (SOP). Between December 2019 and June 2022, there were 19,100 maternities. Of these, 23 were CSPs in 19 patients. Median BMI was 29 (range 20.5-52), median number of Caesarean deliveries (CS) was 2 (range 1-4) and 7/23 (30%) were cigarette smokers. At diagnosis, 9/23 were live pregnancies, 3/23 were retained products of conception (RPOC), 9/23 were pregnancies of uncertain viability (PUV), and 2/23 were non-viable. In six, the initial management was expectant, surgical suction evacuation with transrectal ultrasound guidance in 16, and one had a hysterectomy. The median blood loss was 100 mL (range 50-2000 mL). Two patients (9%) required a blood transfusion. Median hospital stay was 1 day (range 0-4). At follow-up after 10 weeks, no patients had an ongoing haematoma, and one had significant RPOC electing hysterectomy. Eight women were known to have 9 subsequent pregnancies (recurrent CSP n = 4, livebirth n = 2, miscarriage n = 2, tubal ectopic n = 1). Outcomes as rated by low blood loss, short hospital stay, and rare need for further intervention were favorable. Factors associated included prompt ultrasonographic diagnosis, availability of transrectal ultrasound guided surgery, and specialist follow-up, which form the basis of the SOP.

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).

Reproductive outcomes of cesarean scar pregnancies treated with uterine artery embolization combined with curettage

OBJECTIVE

The aim of this study was to review the reproductive outcomes of women with a cesarean scar pregnancy (CSP) treated with dilation and curettage (D&C) after uterine artery embolization (UAE).

MATERIALS AND METHODS

This was a retrospective study to review women who received UAE followed by D&C for CSP between January 2010 and December 2019 at the Changhua Christian Hospital, Changhua in Taiwan. Data were collected from both electronic and paper medical records. Patients were contact via phone call to follow up reproductive outcomes between January 2021 and March 2021. These subsequent reproductive outcomes (including pregnancy rate, secondary infertility rate, miscarriage rate, live birth rate, and recurrent CSP rate) were recorded and analyzed.

RESULTS

A total of 53 cases of women who received UAE followed by D&C for CSP were identified. The women's average age was 34.8 ± 5.1 years. The mean gestational age at diagnosis was 6.2 ± 1.1 weeks. The mean level for human chorionic gonadotropin was 23,407.7 ± 29,105.5 mIU/ml. The average of blood loss during D&C was 19.2 ± 43.6 ml. The average hospitalization time after D&C was 3.5 ± 1.1 days. Of the 53 cases, 10 patients were lost to follow-up and 43 patients agreed to follow-up on reproductive outcomes in 2021. Twenty-three patients who desired to conceive were analyzed. Nineteen out of these 23 women (82.6%) succeeded in conceiving again and gave birth to 15 healthy babies (78.9%). Only one woman (1/19, 5.3%) experienced recurrence of CSP. The average time interval between previous CSP treatment and subsequent conception was 10.4 ± 6.7 months.

CONCLUSION

UAE combined with curettage treatment in CSP patients results in a positive rate of subsequent pregnancy outcomes. This minimally invasive procedure may be considered as one of the treatment options for CSP, as it enables preservation of fertility after treatment.

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.

Local Injection of Methotrexate Ultrasound guided-transvaginal

Non-tubal ectopic pregnancies can be located in the uterine portion of the tube (interstitial or cornual), in the cervix (cervical), in a caesarean scar, in the ovary, or intra-abdominally. Even though they are rare, they are associated with a high mortality. Invasive surgeries such as cornuectomy and hysterectomy were common to treat them in case of hemorrhage. Thanks to recent advances in imaging techniques, diagnosis of non-tubal ectopic pregnancy is made earlier and conservative management has been developed in order to respect fertility of patients. Beyond these treatments, systemic or local injection of Methotrexate shows very good success. In the article, we aimed to describe the technics of vaginal injection of in situ methotrexate with ultrasound guidance.

Caesarean Scar Pregnancy: A Case Report and a Literature Review

Background and Objectives: Caesarean scar pregnancy (CSP) refers to placental implantation on or in the scar of a previous caesarean section and represents a potentially life-threatening condition. CSP is considered a diagnostic challenge in obstetrics, with the diagnosis relying mainly on transvaginal ultrasound (TVS) and the management depending upon case presentation and available healthcare infrastructures. Case Presentation: We present a case of 34-year-old G3P2 with a history of two-previous caesarean sections referred to the outpatient gynaecology clinic of our Department at the 7th week (7/40) of gestation with abnormal early pregnancy TVS findings, illustrating the gestational sac attached to the caesarean scar and a foetal pole with evidence of foetal cardiac activity. We discuss the outcome of an alternative combined medical and surgical approach we followed as well as an updated review of the current literature. Conclusions: The ideal management of CSP requires tertiary centers, equipment availability and experienced healthcare professionals capable of dealing with any possible complication, as well as individualized treatment based on each case presentation.

Hysteroscopic resection vs dilation and evacuation for treatment of caesarean scar pregnancy: study protocol for a randomised controlled trial

Background

Caesarean scar pregnancy (CSP) is a type of ectopic pregnancy where the fertilised egg is implanted in the muscle or fibrous tissue of the scar after a previous caesarean section. Management options for women who opted for termination of CSP include sharp curettage, dilation and evacuation (D&E), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolisation with curettage and/or methotrexate administration. Recently hysteroscopic resection has also been proposed as an alternative option.

Objective

To compare the surgical outcome of hysteroscopic resection with dilation and evacuation (D&E) for the treatment of caesarean scar pregnancy (CSP).

Methods

Parallel-group, non-blinded, randomised clinical trial conducted at a single centre in Italy. Eligible women are those with singleton gestations at less than 9 weeks of gestation, and with thickness of myometrial layer ≥1 mm at the level of the ectopic. Inclusion criteria are women with CSP with positive embryonic/fetal heart activity who opted for termination of pregnancy. Patients will be randomised 1:1 to receive either hysteroscopic resection (i.e. intervention group) or D&E (i.e. control group). In both groups, 50 mg/m2 (based on DuBois formula for body surface area) of methotrexate (MTX) will be injected intramuscularly at the time of randomisation (day 1) and another dose at day 3. A third dose of MTX is planned in case of persistence of fetal heart activity on day 5. Participants will receive either D&E or hysteroscopic resection from 3 to 7 days after the last dose of MTX. A sample size of 54 women is planned.

Main Outcome Measures

The primary outcome is the success rate of the treatment protocol, defined as no requirement for further treatment until complete resolution of the CSP as demonstrated by negative beta hCG levels and absence of residual gestational material on ultrasound examination..

Study hypothesis

Hysteroscopic surgery is superior to D&E for the treatment of CSP.

What is new?

The results of the trial will provide information on the best treatment for CSP.

Evaluation of the treatment of high intensity focused ultrasound combined with suction curettage for exogenous cesarean scar pregnancy

PURPOSE

To evaluate the effectiveness of high-intensity focused ultrasound (HIFU) combined with suction curettage in the treatment of exogenous cesarean scar pregnancy (CSP).

METHODS

A retrospective single-center observational study was conducted. A total of 41 patients diagnosed with exogenous CSP were enrolled in this study. All patients received HIFU combined with suction curettage.

RESULTS

Twenty-nine patients were administered one session of HIFU ablation. In addition, the other 12 patients received 2 HIFU sessions. Suction curettage was performed in all patients after HIFU, and no patient was converted to laparoscopy or hysterectomy. The mean blood loss during suction curettage was 99 ml. Three patients received two sessions of suction curettage. The success rate of our study was 92.68%. The mean time for serum β-HCG normalization was 23.18 ± 3.13 days. The average menstruation recovery time was 29.38 ± 3.34 days. Based on the blood loss during suction curettage, 41 patients were divided into a bleeding group and a control group. The size of the gestational sac in the bleeding group (3.80 ± 0.87 cm) was larger than that in the control group (3.39 ± 0.77 cm) (P < 0.05). The thickness of the myometrium between the bladder and gestational sac in the bleeding group (2.37 ± 0.89 mm) was less than that in the control group (2.75 ± 0.75 mm) (P < 0.05).

CONCLUSION

The results suggested that HIFU combined with suction curettage could be considered an effective treatment for exogenous CSP of < 9 weeks. The size of the gestational sac and the thickness of the myometrium between the bladder and gestational sac might be high-risk factors for blood loss during this treatment.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

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

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

Evaluation of the necessity of laparoscopic repair of a uterine scar defect for cesarean scar pregnancy

Objective

This study aimed to determine the risk factors associated with the necessity of laparoscopic scar defect repair for cesarean scar pregnancy (CSP).

Methods

We retrospectively analyzed 237 patients with CSP who were treated by ultrasound-guided suction curettage and/or laparoscopy in our hospital from April 2012 to November 2019. A total of 199 of these patients underwent ultrasound-guided suction curettage without uterine scar defect repair, while 38 of these patients underwent laparoscopic resection and uterine scar defect repair. We analyzed various clinical variables and compared the efficacy of treatment between the two groups.

Results

Gestational age, the maximum transverse diameter (MTD) of the gestational sac, myometrial thickness, the operation time, intraoperative blood loss, and the duration of the hospital stay were significantly different between the two groups. Gestational age, the MTD of the gestational sac, and myometrial thickness were independent risk factors for laparoscopic repair.

Conclusions

Gestational age, the MTD of the gestational sac, and myometrial thickness are important factors associated with the necessity for laparoscopic repair of a uterine scar defect.

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.

Scar Tissue after a Cesarean Section-The Management of Different Complications in Pregnant Women

The definition of a cesarean scar pregnancy (CSP) is the localization of the gestational sac (GS) in the cicatrix tissue, which is created in the front wall of the uterus after a previous cesarean section (CS). The worldwide prevalence of CSP has been growing rapidly. However, there are no general recommendations regarding prophylaxis and treatment of the abnormalities of the anterior wall of the uterus discovered in a non-pregnant myometrium, or how to deal with existing cases of CSP. We present the latest knowledge, a holistic approach to the biology, histology, imaging, and management concerning post-CS scars based on our cases, which were treated in the Department of Pregnancy and Pathology of Pregnancy in the Medical University of Lublin, Poland. In our study, we present images of tissue samples of areas with a cicatrix in the uterus, and ultrasound and MRI images of CSP. We discuss the advances in the biology of the post-CS scar tissue, the prevention techniques used to repair the scar defect (niche) before the pregnancy, and the treatment of different complications of CSP, such as the rupture of the gravid uterus or the dehiscence of the myometrium.

Cesarean scar pregnancy treatment: a case series

Background

Cesarean scar pregnancy is a complicated and potentially life-threatening type of ectopic pregnancy. This study reports two women with cesarean scar pregnancy who were successfully treated with systemic methotrexate administration, and two other women who needed local re-administration of methotrexate after systemic injection.

Case presentation

Four Iranian pregnant women aged 29–34 years who were between 5  to 7 gestational weeks with cesarean scar pregnancy diagnosis are described. After a single dose of systemic methotrexate injection, the level of serum beta-human chorionic gonadotropin decreased in two of the women, while fetal activity was observed in the other two women. In the latter patients, methotrexate was injected under transvaginal ultrasound guidance into the gestational sac. As a result, the serum beta-human chorionic gonadotropin level first increased and then decreased in these patients. During the follow-up period, all the patients were stable and no complications were observed. Serum beta-human chorionic gonadotropin levels reached the non-pregnancy range from 4 to 9 weeks after treatment.

Conclusion

When diagnosed at early gestation, cesarean scar pregnancy can be treated successfully with methotrexate administration alone. The clinicians should be aware that the beta-human chorionic gonadotropin level may initially increase after methotrexate injection in some patients. However, the final outcome will be promising if the patients remain stable.

A review on management of caesarean scar pregnancy

PURPOSE OF REVIEW

To review the current literature on management of cesarean scar pregnancy.

RECENT FINDINGS

Caesarean scar pregnancy (CSP) is a complex pathologic condition, which is strictly related to a previous caesarean section. It is an iatrogenic disorder, that has had an exponential increase over the last few years linked to the parallel increase in the number of caesarean sections. The Society for Maternal-Fetal Medicine (SMFM) confirmed the presence of surgical, medical, and minimally invasive therapies for caesarean scar pregnancy management but the optimal treatment is not known; the main recommendation is to avoid expectant management of CSP (GRADE 1B). The treatments for Caesarean scar pregnancy are multiple, and they include a surgical management, a medical management and a combination between these two types of treatments. Despite the recommendation of SMFM in this review, we also included some cases of conservative management published in the last months.

SUMMARY

Considering all the different approaches on CSP, the management has to be individualized mainly on gestational age and it has to be discussed by a multidisciplinary team, to choose the safest clinical option.