Hysteroscopic management of cesarean scar ectopic pregnancy

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.

“In Situ” Methotrexate Injection Followed by Hysteroscopic Resection for Caesarean Scar Pregnancy: A Single-Center Experience

Background: We evaluated the efficacy of local methotrexate (MTX) treatment followed by hysteroscopic resection for caesarean scar pregnancy and its impact on future fertility. Methods: Monocentric, prospective, observational study performed in the Haykel Hospital between June 2016 and December 2020. Twenty-one women with caesarean scar pregnancy underwent a transcutaneous ultrasound-guided direct injection of MTX into the gestational sac in an outpatient setting. Hysteroscopic resection of residual trophoblastic retention was then performed according to perisaccular blood flow. Main results: Two patients had complete spontaneous trophoblast expulsion after MTX injection, and hysteroscopy was performed in 19 patients for residual trophoblastic retention 1 to 12 weeks after MTX injection. Successful preservation of a healthy uterus with the combined procedure was obtained in 94.8% of patients. Hemostatic hysterectomy was required in one patient. Mean hospitalization duration was 1.5 days. Three patients had spontaneous pregnancy after the procedure. Conclusion: Direct MTX injection into the gestational sac for caesarean scar pregnancy followed by hysteroscopic resection was an effective technique with a short hospitalization, fertility preservation and a low major complication rate compared with other modalities of treatment reported in the literature. Further larger prospective comparative studies are needed to confirm the efficacy of this procedure.

Cesarean Scar Pregnancy and Successful Ultrasound-Guided Removal after Uterine Artery Ligation

A correct management of cesarean scar pregnancy (CSP) is mandatory to avoid further complications. There is no consensus for the standard therapy and the most frequent methods used are not free from failures and sequelae. A 38-year-old woman was admitted referring amenorrhea lasting 9 weeks, pelvic pain, and vaginal bleeding. She had three previous cesarean sections. Transvaginal ultrasound showed a gestational sac of 16 mm in the cervico-isthmic site and inside the thickness of the uterine wall, and the dosage of beta-human chorionic gonadotropin was 12,770 mU/mL. A diagnosis of CSP was done, and an ultrasound-guided removal after uterine artery cervical branch ligation was performed. The follow-up was uneventful. Even if not yet codified in the literature, our therapeutic procedure should be considered in other similar cases in the future, as it potentially limits the possible iatrogenic problems and reduces intraoperative and postoperative bleeding to a minimum.

The management of caesarean scar pregnancy with or without a combination of methods prior to hysteroscopy: ovarian reserve trends and patient outcomes

STUDY OBJECTIVE

This study compared the efficacy and safety of a combination of uterine artery embolization or methotrexate before hysteroscopy in the treatment of cesarean scar pregnancy.

METHODS

We divided 276 cesarean scar pregnancy patients into three groups. Group A underwent direct hysteroscopy; Group B received uterine artery embolization plus hysteroscopy; Group C received the systemic administration of methotrexate prior to hysteroscopy.

RESULTS

The patients in Group A lost significantly more blood than those in Groups B (P < 0.05). There were no significant differences between the three groups with regards to massive hemorrhage and transfusion (P > 0.05). None of the patients required hysterectomy. Group A was also associated with a significantly shorter period of hospitalization, reduced medical costs, and fewer adverse events than either Group B or C (P < 0.05). Moreover, among women of advanced age (≥35y), the levels of serum anti-Mullerian hormone in Group B were significantly lower than those of the baseline group (P<0.05), which were significantly lower than those in Group A after surgery (4.22 ± 2.35 vs 2.78± 1.89 ng/ml, P < 0.05).

CONCLUSION

Direct hysteroscopy is a reliable treatment option for most early type I cesarean scar pregnancy patients with a gestational sac. A combination of methotrexate and uterine artery embolization before hysteroscopy in these patients has limited remedial effects. uterine artery embolization may reduce ovarian reserve in patients aged ≥35y.

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.

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.

Successful Management of Caesarean Scar Ectopic Pregnancies: A Report of Five Cases

Background:

Cesarean section scar ectopic pregnancy (CSEP) is a rare and potentially life-threatening condition. A standardized management protocol is yet to be established owing to limited data available.

Case Presentation:

In this paper, five cases of CSEP over a period of 18 months at a tertiary referral hospital, managed medically with methotrexate administered both systemically and into the gestational sac at the time of feticide with potassium chloride (KCL) are presented. Surgical management was the second line therapy when medical treatment failed.

Conclusion:

With rising trends in cesarean deliveries, CSEP may be a challenge which requires close investigation regarding its diagnosis and treatment on the merits of case studies and available healthcare facilities.

Successful Use of Myosure in the Management of Cesarean Scar Ectopic Pregnancy

Cesarean scar pregnancy (CSP) is a very serious complication of a prior cesarean delivery. The major risks associated with CSP are uncontrolled hemorrhage and uterine rupture, potentially leading to future infertility. Management of CSP remains a major obstetric challenge without a well-defined therapeutic procedure. Dilation & curettage is a commonly used procedure for the treatment of CSP. However, it can be ineffective and often leads to definite infertility. Therefore, we present a case of the successful use of an alternative procedure, Myosure® hysteroscopy, in the treatment of CSP. We herein report the case of a 32-year-old G5P3013 woman who presented with vaginal bleeding and past history of three cesarean sections. She was found to have a CSP with fetal pole and cardiac activity at 6 weeks 2 days. The patient was initially treated with a systemic methotrexate injection, but there was persistence of cardiac activity. A second course of methotrexate was administered into the gestational sac, which systemically led to successful fetal cardiac arrest and downtrend of beta-human chorionic gonadotropin (HCG) level. A dilation & curettage procedure was not successful in removing products of conception. A Myosure hysteroscopy procedure, however, was successful in removing products of conception. The patient was discharged after a negative ultrasound and beta-HCG level. In our review of the literature, we found that there is no general consensus on the management of cesarean scar ectopic pregnancies. To date, there is no literature cited about the use of Myosure for cesarean scar ectopic pregnancies. However, our case suggests that Myosure can be effective for CSP and this warrants a larger-scale controlled study to better evaluate this as a treatment for this condition.

Cesarean Scar Pregnancy Treated by Artery Embolization Combined with Diode Laser: A Novel Approach for a Rare Disease

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy which represents a consequence of a previous cesarean section. It is associated with major maternal morbidity and mortality and has potential implications on future fertility. Because of possible serious complications, CSP should be swiftly diagnosed and treated. There is no management protocol for this rare, life-threatening condition, and each patient should be evaluated individually. Several types of conservative treatment have been used to treat cesarean scar pregnancy: dilation and curettage (D&C), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolization with curettage and/or methotrexate administration. In our study we present a cesarean scar pregnancy of a 40-year-old woman who was treated with angiographic uterine artery embolization (UAE) followed by hysteroscopic diode laser resection. Our combined UAE–hysteroscopic laser surgery appears to offer an effective, safe, and minimally invasive surgical treatment.

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

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

Methotrexate injection for interstitial pregnancy: Hysteroscopic conservative mini-invasive approach

Background

Interstitial localisation of ectopic pregnancy is associated with high rates of maternal morbidity and mortality. Considering the rarity of interstitial pregnancy, the optimal treatment regimen remains unclear. We propose the management of interstitial pregnancy with local methotrexate injection using a combined hysteroscopic and ultrasonographic approach.

Technique

Hysteroscopy was performed under local anaesthesia in the operating room, using a 2.9-mm Hopkins II Forward-Oblique Telescope 30° endoscope with a 4.3-mm inner sheath and 5 FR instruments. A needle was pushed into the cornual region injecting methotrexate solution directly into the gestational sac and into the myometrial tissue tangentially at the four cardinal points. A contemporary transabdominal ultrasound (US) was performed in order to reduce risks of complications.

Experience

Five patients with an US diagnosis of interstitial ectopic pregnancy admitted to our department between January 2016 and September 2019 were managed with a local hysteroscopic injection of methotrexate. The technique was effective in all patients and no surgical complications occurred during or after the procedure. Three patients were evaluated for tubal patency with contrast ultrasonography confirming bilateral tubal patency 9 months from treatment, while one patient had a spontaneous birth 22 months from their initial surgery.

Conclusion

The hysteroscopic ultrasound-guided approach combined with the local injection of methotrexate is a minimally invasive conservative approach that seems to be promising in the management of interstitial ectopic pregnancy.

Pituitrin local injection versus uterine artery embolization in the management of cesarean scar pregnancy: A retrospective cohort study

AIM

To compare the effect of pituitrin local injection (PIT) and uterine artery embolization (UAE) as pretreatment before surgery during the management of cesarean scar pregnancy (CSP).

METHODS

Forty-nine CSP patients diagnosed in our department of Suzhou Ninth People's Hospital from October 2017 to October 2019. All patients underwent hysteroscopy and negative pressure aspiration (for type I CSP) or laparoscopic wedge-resection (for type II and III CSP) following one of the preoperative treatments: PIT group (n = 26) and UAE group (n = 23). The baseline clinical data, intraoperative blood loss, blood transfusion rate, postoperative hospital stay, hospitalization expenses, postoperative pain, postoperative fever, postoperative serum β-human chorionic gonadotropin (β-hCG) level, and pregnancy outcome were reviewed and analyzed.

RESULTS

There was no significant difference (p ≥ 0.05) between two groups in baseline characteristics including age, gravidity, previous cesarean section times, interval since last cesarean delivery, menolipsis time, maximum diameter of gestational sac or mass under ultrasound, fetal cardiac activity and preoperative β-hCG level. There was no significant difference in blood loss, transfusion rate, and postoperative β-hCG reduction percentage (p ≥ 0.05) either. The postoperative hospital stay, hospitalization expenses, postoperative pain, and postoperative fever rate in PIT group were significantly lower than those in UAE group (p < 0.05). Moreover, β-hCG level of all patients turned negative 1 month after surgery successfully.

CONCLUSIONS

PIT pretreatment seems to be a same effective, more economical, and with fewer side effects pretreatment method compared to traditional UAE pretreatment in the management of CSP.

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

Background

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

Methods

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

Results

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

Conclusion

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

Management of Non-Tubal Ectopic Pregnancies: A Single Center Experience

Non-tubal ectopic pregnancies (NT-EPs) are rare but potentially life-threatening conditions. The incidence ranges are between 5-8.3% of all ectopic pregnancies. For this retrospective observational study, 16 patients with NT-EP and treated from January 2014 to May 2020 were recruited. Demographic details, symptoms, Beta human chorionic gonadotrophin (β-hCG) levels, ultrasound findings, management and treatment outcomes were presented. In hemodynamically stable patients, diagnosis was made using ultrasounds and β-hCG levels. Laparoscopy was essential to identify and remove the ectopic pregnancy in clinical unstable patients. A radical laparoscopic approach was chosen in one case of cervical pregnancy diagnosed late in the first trimester. Medical treatment and minimally invasive procedure, alone or combined, resulted in effective strategies in asymptomatic women with an early diagnosis of NT-EP. We report cases of cervical pregnancies successfully treated by hysteroscopy alone or combined with medical treatment, the first case of scar pregnancy treated by mini-reseptoscope and curettage and the fifth case of interstitial pregnancy treated with Methotrexate and Mifepristone. In this manuscript we report a single center experience in the management of NT-EPs with the aim of outlining the importance of the early diagnosis for a minimally invasive treatment in order to reduce maternal morbidity and mortality and preserve future fertility.

A Retrospective Analysis of the Treatment of Cesarean Scar Pregnancy by High-Intensity Focused Ultrasound, Uterine Artery Embolization and Surgery

Objective: This study aims to retrospectively analyze the clinical curative effects of surgery, uterine artery embolization (UAE), and high-intensity focused ultrasound (HIFU) in order to provide the theory and evidences for selecting the optimal treatment for cesarean scar pregnancy (CSP).

Methods: Women with CSP were treated with surgery (laparoscopic, hysteroscopy, and hysteroscopy–laparoscopic surgery), UAE combined with curettage, and HIFU combined with curettage. The general conditions and therapeutic effects, including vital signs during the operation, discomfort of discharge, cure rate, total blood loss, decline in the rate of hCG, and hospital stay, were compared and analyzed.

Results: For the 154 CSP patients, the cure rate of surgery (n = 95) was 97.89%, the cure rate of UAE (n = 32) was 43.74%, and the cure rate of HIFU (n = 27) was 70.37%. The difference was statistically significant (P < 0.05). Furthermore, the hCG level of surgical patients quickly declined, whereas HIFU slowly declined. The difference between the decline rate of hCG and mean hospitalization time was statistically significant (P < 0.05). UAE was good for CSP with gestational age <60 days and diameter of gestational sac <40 mm. Furthermore, HIFU was well for CSP patients with a gestational age of <55 days and a gestational sac diameter of <30 mm. Surgery was suitable for any type of these cases.

Conclusion: CSP patients with short gestational age and small gestational sac can be treated with surgery, UAE, and HIFU, and achieve safe and effective therapeutic effects. Surgery is also a good choice for CSP for patients with a long gestational age, a large gestational sac diameter, high levels of hCG, or an ample blood supply.

Cesarean Scar Pregnancy: Patient Counseling and Management

There is no universally agreed upon and adopted management protocol supported by professional societies in the United States or around the world for the treatment of cesarean scar pregnancy. There is a wide range of management options in the literature, and many of them can to lead to severe bleeding complications, which can result in loss of fertility or even maternal death. If inadequately managed, it can lead to untoward complications throughout all 3 trimesters of the pregnancy. Early detection of CSP has a paramount clinical importance.

Role of collateral embolization in addition to uterine artery embolization followed by hysteroscopic curettage for the management of cesarean scar pregnancy

Background

The aim of this study was to assess the feasibility, safety and outcome of the embolization of non-gonadal collateral supplying gestational sac (GS) in addition to uterine artery embolization (UAE), followed by hysteroscopic curettage for the management of cesarean scar pregnancy (CSP).

Methods

A retrospective study was undertaken from January 2012 to September 2018 in 24 CSP patients in whom non-gonadal collaterals supplying GS were identified by arterial angiography performed immediately after UAE. These patients underwent attempt collateral embolization in addition to UAE, followed by hysteroscopic curettage for the management of CSP. The 24 patients were divided into two groups based on whether they underwent technically successful collateral embolization (UAE-SCE group) or failed collateral embolization (UAE-FCE group) in addition to UAE. The baseline characteristics and clinical outcomes including time for serum β-human chorionic gonadotropin (β-hCG) levels normalization, blood loss, secondary anemia, and pelvic pain were compared between the two groups. The paired t test and Man Whitney test were used for comparisons of discrete and numerical variables, respectively.

Results

Collateral embolization was techinically successful in 16 (66.7%, 16/24) patients and failed in the other 8 (33.3%, 8/24) patients. There were no significant differences between the two groups in baseline characteristics. The mean blood loss and secondary anemia in the UAE-SCE group were significantly less than UAE-FCE group. No significant difference was found between the two groups in the mean time for β-hCG levels normalization and pelvic pain.

Conclusions

During the management of UAE combined with hysteroscopic curettage for CSP, additional embolization of non-gonadal collateral supplying GS during UAE is feasible and safe in patients with non-gonadal collateral supplying GS, and the additional embolization of the collateral may reduce blood bloss related to hysteroscopic curettage.

[Cesarean-scar pregnancy: about a case and literature review]

La grossesse sur cicatrice de césarienne est une forme rare de la grossesse ectopique qui peut engager le pronostic vital et fonctionnel de la patiente par hémorragie ou par rupture utérine précoce. Nous rapportons le cas d'une grossesse ectopique sur cicatrice de césarienne diagnostiquée à 7 semaines d'aménorrhée suite à des métrorragies chez une patiente de 23 ans, 3^ème geste 2^ème pare, porteuse d'un utérus bi-cicatriciel. Grâce à l'échographie endovaginale le diagnostic a été précoce et le traitement a été conservateur. A travers cette observation et la lumière d'une revue de la littérature, nous discuterons les caractéristiques diagnostiques et thérapeutiques de cette rare entité, dont la connaissance par les praticiens permet d'améliorer le pronostic.

Analysis on clinical effects of dilation and curettage guided by ultrasonography versus hysteroscopy after uterine artery embolization in the treatment of cesarean scar pregnancy

Purpose

The purpose of this study was to investigate the efficiency, complications, and subsequent fertility outcomes of two methods in treating patients with cesarean scar pregnancy (CSP) after receiving uterine artery embolization (UAE) treatment.

Patients and methods

A total of 62 CSP patients who visited our hospital and underwent UAE from January 2013 to January 2018 were retrospectively analyzed. Patients were either treated by dilation and curettage (D&C) guided by ultrasonography or hysteroscopy. The differences of related clinical indicators, clinical efficacy, complications, and subsequent fertility outcomes between the two groups were analyzed.

Results

The rates of therapeutic success of the ultrasonography group and hysteroscopy group were 84.6% and 95.7%, respectively, the difference was not statistically significant (P=0.243). However, the intraoperative blood loss, duration of hospitalization, and overall complications were significantly lower in hysteroscopy group compared with D&C guided by ultrasonography group (P<0.05 for all). Meanwhile, hysteroscopy had the advantage of discovering potential diverticulum in the lower segment of anterior wall of uterus (P<0.001).

Conclusion

D&C guided by ultrasonography or hysteroscopy for the treatment of CSP after UAE resulted in similarly good clinical outcomes. Compared with treatment of D&C guided by ultrasonography, hysteroscopy had less complications and had the advantages of discovering diverticulum. It can be used as an effective way for the treatment of CSP.

The Rising Triad of Cesarean Scar Pregnancy, Placenta Percreta, and Uterine Rupture: A Case Report and Comprehensive Review of the Literature

As the rate of cesarean sections continues to rapidly rise, knowledge of diagnosis and management of cesarean scar pregnancies (CSPs) is becoming increasingly more relevant. CSPs rest on the continuum of placental abnormalities which include morbidly adherent placenta (accreta, increta, and percreta). A CSP poses a clinical challenge which may have significant fetal and maternal morbidity. At this point, no clear management guidelines and recommendations exist. Herein we describe the case of a second trimester CSP with rapid diagnosis and management in a tertiary care center. The case underscores the need for well-coordinated mobilization of resources and a multidisciplinary approach. A review of the literature is performed and deficits in universal management principles are underscored.

A retrospective comparative study evaluating the efficacy of adding intra-arterial methotrexate infusion to uterine artery embolisation followed by curettage for cesarean scar pregnancy

PURPOSE

The study aimed to compare the efficacy of intra-arterial methotrexate (MTX) infusion combined with uterine artery embolisation (UAE) and uterine curettage with that of UAE and curettage without MTX infusion for the treatment of cesarean scar pregnancy (CSP).

METHODS

In this retrospective study, data of CSP patients admitted from January 2011 to July 2015 were obtained from electronic patient records. Clinical information at baseline and after treatment were extracted and analyzed.

RESULTS

A total of 93 CSP patients were included, with 57 patients receiving UAE followed by curettage (UC) and 36 patients receiving intra-arterial MTX infusion followed by UAE and curettage (MUC). The baseline characteristics were not significantly different between the two groups. Without additional intervention, 32 (88.9%) patients were successfully treated by MUC, and 49 (86.0%) patients were successfully treated by UC, defined by discontinued ectopic conceptus growth, normalized serum β-human chorionic gonadotropin (β-hCG) level, ceased vaginal bleeding and preservation of uterus, with no significant difference between the two groups. Additionally, intra-operative blood loss volume and post-operative bleeding events were not significantly different between the two groups. However, serum β-hCG decline on the first day after surgery was significantly promoted, and the hospitalization length and the time needed for serum β-hCG normalization were significantly shortened by addition of intra-arterial MTX infusion.

CONCLUSIONS

Adding intra-arterial MTX to UAE and curettage significantly promoted post-operative recovery, though success rate and bleeding events were not significantly affected, suggesting that addition of intra-arterial MTX might not be necessary.

Management of persistent caesarean scar pregnancy after curettage treatment failure

Background

Caesarean scar pregnancy (CSP) is a late serious complication of caesarean section. The incidence of CSP has increased worldwide in recent years. Early diagnosis and prompt therapy are crucial to avoid catastrophic complications. There are various strategies for CSP treatment, but there is no consensus on the best management for CSP. Dilation and curettage (D&C) and hysteroscopy are common and effective treatments with their advantages and disadvantages. No in-depth study of the clinical effects of hysteroscopic management of CSP after D&C treatment failure has been conducted. The purpose of this study is to evaluate the effectiveness and safety of hysteroscopic removal of residual CSP tissue (persistent CSP) as a rescue after failed D&C management.

Methods

This is a retrospective clinical research study. Forty-five patients underwent operative hysteroscopy to remove the residual gestational tissue in the caesarean scar after failed D&C treatment. The clinical characteristics and outcomes of hysteroscopic surgeries of 45 CSP cases were investigated. All data analyses were conducted with SPSS 17.0.

Results

Forty-three CSP cases after unsuccessful curettage treatment were successfully treated by operative hysteroscopy. The estimated intraoperative blood loss was 20.00 (10.00–500.00) mL, the hysteroscopic operating time was 20.00 (15.00–45.00) min, the decline of serum β-hCG the day after surgery was 71.91 ± 14.05%, the total hospitalisation time was 7.87 ± 2.26 days, the medical cost was 13,682.71 ± 3553.77 China Yuan (CNY), the time of bleeding after surgery was 7.42 ± 2.48 days, and the time of serum β-hCG resolution after surgery was 13.84 ± 9.83 days. Follow-up after discharge demonstrated that there were no severe complications for any patients.

Conclusions

Hysteroscopy therapy could treat persistent CSP effectively and safely after curettage treatment failure. Therapy should be individualised, and the risks and cost of the hysteroscopy procedure and anaesthesia must be considered and fully discussed with the patients before surgery.

Hysteroscopic Methotrexate Injection Under Ultrasonographic Guidance for Interstitial Pregnancy

A 36-year-old woman presented with pelvic pain and vaginal blood loss and interstitial pregnancy (a single gestational sac located in the proximity of the right uterine horn, without visualization of an embryo and/or attachments inside) on 2- and 3-dimensional ultrasonographic examination. The patient was clinically stable. Her abdomen was soft with normal peristalsis; superficial and deep palpation were painless, as was decompression. With the patient under general anesthesia, an operative hysteroscopy was performed visually via ultrasound. A slow injection of methotrexate solution was pushed through the right cornual region inside the gestational sac and into the myometrial tissue tangentially at the 4 cardinal points. Twelve weeks later, the patient exhibited normal tubal patency via sonohysterography, as well as a viable pregnancy of 7 weeks' gestation. This minimally invasive approach is well tolerated and shows promise for the management of interstitial pregnancy, with no adverse effect on potential subsequent fertility.

Resection of Cesarean Scar Pregnancy at Six Weeks of Gestation with Laminaria Cervical Dilatation under Sonographic and Hysteroscopic Guidance

In cases of fetal heartbeat- (FHB-) positive cesarean scar pregnancy (CSP), the embryo and placenta grow rapidly week by week. We experienced an FHB-positive CSP case at 6 weeks of gestation and assessed the CSP in detail with transvaginal ultrasound and transabdominal ultrasound (TAUS), preoperatively. We performed Laminaria cervical dilatation under TAUS guidance and performed hysteroscopic resection of the pregnancy conceptus and curettage under hysteroscopic and TAUS guidance. We identified the gestational sac attached to the cesarean scar pouch with small plane, decidua basalis, and chorionic villi and present the clinical history and other findings. We also reviewed the related literature and found 76 previous studies, with six cases of FHB-positive CSP that contained hysteroscopic color images of the CSP. We present a review of selected cases. The implantation site was the anterior wall in almost all cases. Cervical dilatation was mainly performed using a Hegar dilator; ours was the only case using Laminaria dilatation. Transcervical resections were performed mainly under ultrasound guidance, with only one case undergoing laparoscopy. Electrocoagulation was performed in three of the six cases.

Laparoscopic Treatment of Cesarean Scar Ectopic Pregnancy

Background: An ectopic pregnancy within a Cesarean scar represents a rare type of extrauterine pregnancy in which the fertilized egg nidates in the myometrium of the uterine wall within a scar left from a previous Cesarean delivery. An unrecognized growing Cesarian scar pregnancy may result in uterine rupture, uncontrollable metrorrhagia, and bleeding into the abdominal cavity; therefore, early diagnosis and therapy are necessary to prevent the development of severe complications. Case: A 34-year-old woman after a previous Cesarean delivery presented with amenorrhoa of 7 weeks' duration. Transvaginal ultrasonography revealed an ectopic pregnancy in the Cesarean scar, and a laparoscopic removal of the gestational sac was performed with no complications. Results: Three months later, another laparoscopy with chromopertubation showed no signs of penetration in the suture, both the Fallopian tubes being bilaterally passable. The patient was advised that she could try to achieve pregnancy through spontaneous conception, after which monitoring of the gestational development and a careful assessment of the nidation site would be needed. Conclusions: Laparoscopic surgical management of a viable ectopic pregnancy is technically simple, and is followed by a good recovery. (J GYNECOL SURG 30:309).

Combined laparoscopy and hysteroscopy vs. uterine curettage in the uterine artery embolization-based management of cesarean scar pregnancy: a retrospective cohort study

Background

The number of cesarean scar pregnancy (CSP) has significantly increased in the recent decade. Although uterine artery embolization (UAE) has been adopted to minimize the blood loss during uterine curettage removing of CSP, massive bleeding and uterine rupture can still be frequently encountered. The aim of this study was to compare the efficacy and safety of a novel combined laparoscopy and hysteroscopy technique with the traditional curettage in removing the conceptus and repairing the incision defect following the UAE management of CSP.

Methods

The CSP patients (n = 58) diagnosed between March 1, 2005 and March 1, 2010 were enrolled in three medical centers in Shanghai, China. All of these patients have undergone intra-arterial methotrexate, UAE and one of the following treatments: combined laparoscopy and hysteroscopy (study group, n = 25) and uterine curettage (control group, n = 33). Their medical records and 2-year outcomes were reviewed. The CSP removal rate, amount of blood loss during the treatment, incision repair rate (note: the post-curettage healing process of the incision defect was seen as a form of natural incision repairing, i.e., the self-repair mode), hospital stay, β-hCG regression time and postoperative sequelae were compared between two groups.

Results

The CSP removal rate in the study group (100%) was significantly higher than that (79%) in the control group (p = 0.024). The average blood loss was 78.0 mL in the study group, which was much less than the 258.5 mL (p = 0.004) in the control group. A satisfactory incision repair rate (96%) was achieved in the study group, while it was 25% (p < 0.001) in the control group. Moreover, the study group had significantly shorter hospital stays (p = 0.043) and β-hCG regression times (p = 0.033), lower rates of postoperative abdominal pain (p = 0.035) and menstruation abnormalities (p = 0.043).

Conclusions

Combined laparoscopy and hysteroscopy is much safer and more effective than uterine curettage as a supplementary measure to remove the conceptus and repair the cesarean incision following the UAE management of CSP.

Hysteroscopy and suction evacuation of cesarean scar pregnancies: a case report and review

Implantation of a pregnancy into the scar of a prior cesarean is an uncommon type of ectopic pregnancy. The incidence of cesarean scar pregnancy is thought to be one in 1800-2216 pregnancies. The increase in the incidence of cesarean scar pregnancy is thought to be a consequence of the increasing rates of cesarean delivery. The natural history of cesarean scar pregnancy is unknown. However, if such a pregnancy is allowed to continue, uterine scar rupture with hemorrhage and possible hysterectomy seem likely. Two early diagnosed cesarean scar pregnancies were treated with hysteroscopy and suction curettage removal. One required intramuscular methotrexate to resolve a persistent cesarean scar ectopic pregnancy. It would seem reasonable that simple suction evacuation would frequently leave chorionic villi imbedded within the cesarean scar, as the pregnancy is not within the endometrial cavity.