Hysteroscopic treatment and reproductive outcomes in cesarean scar pregnancy: experience at a single institution

Surgical treatment and reproductive outcomes in caesarean scar pregnancy at a single center

BACKGROUND

To investigate factors associated with different reproductive outcomes in patients with Caesarean scar pregnancies (CSPs).

METHODS

Between May 2017 and July 2022, 549 patients underwent ultrasound-guided uterine aspiration and laparoscopic scar repair at the Gynaecology Department of Hubei Maternal and Child Health Hospital. Ultrasound-guided uterine aspiration was performed in patients with type I and II CSPs, and laparoscopic scar repair was performed in patients with type III CSP. The reproductive outcomes of 100 patients with fertility needs were followed up and compared between the groups.

RESULTS

Of 100 patients, 43% had live births (43/100), 19% had abortions (19/100), 38% had secondary infertility (38/100), 15% had recurrent CSPs (RCSPs) (15/100). The reproductive outcomes of patients with CSPs after surgical treatment were not correlated with age, body mass index, time of gestation, yields, abortions, Caesarean sections, length of hospital stay, weeks of menopause during treatment, maximum diameter of the gestational sac, thickness of the remaining muscle layer of the uterine scar, type of CSP, surgical method, uterine artery embolisation during treatment, major bleeding, or presence of uterine adhesions after surgery. Abortion after treatment was the only risk factor affecting RCSPs (odds ratio 11.25, 95% confidence interval, 3.302-38.325; P < 0.01) and it had a certain predictive value for RCSP occurrence (area under the curve, 0.741).

CONCLUSIONS

The recurrence probability of CSPs was low, and women with childbearing intentions after CSPs should be encouraged to become pregnant again. Abortion after CSP is a risk factor for RCSP. No significant difference in reproductive outcomes was observed between the patients who underwent ultrasound-guided uterine aspiration and those who underwent laparoscopic scar repair for CSP.

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

OBJECTIVE

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

DATA SOURCES

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

STUDY ELIGIBILITY CRITERIA

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Clinical Application of a New Cesarean Scar Pregnancy Classification and Evaluation System and a Risk Scoring System

Objective

Cesarean scar pregnancy (CSP) is an uncommon form of ectopic pregnancy that carries the risk of severe bleeding. To date, there has not been a universally accepted classification and treatment strategy. We performed this study to establish a risk scoring system and new CSP classification system for CSP and evaluate its efficacy.

Methods

A total of five groups were generated based on different methods of treatment, and the factors that increase the risk of intraoperative bleeding were examined in our center from 2013 to 2018. The construction of a risk scoring system in this study was based on the use of the chi-square test and multivariate logistic regression analysis. To determine the appropriate cutoff scores, receiver operating characteristic (ROC) curves and the area under the curve (AUC) were generated.

Results

We identified the main high-risk factors for excessive intraoperative hemorrhage during CSP surgery through univariate and multivariate analyses. Within this investigation, the risk factors included gestational sac location and gestational sac diameter. Through analysis, an optimal cutoff score of 3 was determined, and the area under the ROC curve was calculated to be 0.8113 (95% CI=0.7696-0.8531). A score ranging from 0-3 was classified as low risk, while a score ranging from 5-7 was classified as high risk. Additionally, a new classification system for CSP has been established based on sonographic parameters. We also established a diagnostic and treatment process for CSP patients according to the risk scoring method and new CSP classification.

Conclusion

We identified the high-risk factors associated with bleeding during CSP surgery and developed a scoring system incorporating these factors. The utilization of this novel CSP typing method, in conjunction with the risk scoring system, can effectively inform doctors in their decision-making process concerning treatment strategies for patients with CSP.

Predicting intraoperative hemorrhage during curettage treatment of cesarean scar pregnancy using free-breathing GRASP DCE-MRI

OBJECTIVE

To explore the feasibility of the golden-angle radial sparse parallel (GRASP) dynamic magnetic resonance imaging (MRI) technique in predicting the intraoperative bleeding risk of scar pregnancy.

METHODS

A total of 49 patients with cesarean scar pregnancy (CSP) who underwent curettage and GRASP-MRI imaging were retrospectively selected between January 2021 and July 2022. The pharmacokinetic parameters, including Wash-in, Wash-out, time to peck (TTP), initial area under the curve (iAUC), the transfer rate constant (Ktrans), constant flow rate (Kep), and volume of extracellular space (Ve), were calculated. The amount of intraoperative bleeding was recorded by a gynecologist who performed surgery, after which patients were divided into non-hemorrhage (blood loss ≤ 200 mL) and hemorrhage (blood loss > 200 mL) groups. The measured pharmacokinetic parameters were statistically compared using the t-test or Mann-Whitney U test with a significant level set to be p < 0.05. The receiver operating characteristic (ROC) curve was constructed, and the area under the curve (AUC) was calculated to evaluate each parameter's capability in intraoperative hemorrhage subgroup classification.

RESULTS

Twenty patients had intraoperative hemorrhage (blood loss > 200 mL) during curettage. The hemorrhage group had larger Wash-in, iAUC, Ktrans, Ve, and shorter TTP than the non-hemorrhage group (all P > 0.05). Wash-in had the highest AUC value (0.90), while Ktrans had the lowest value (0.67). Wash-out and Kep were not significantly different between the two groups.

CONCLUSION

GRASP DCE-MRI has the potential to forecast intraoperative hemorrhage during curettage treatment of CSP, with Wash-in exhibiting the highest predictive performance. This data holds promise for advancing personalized treatment. However, further study is required to compare its effectiveness with other risk factors identified through anatomical MRI and ultrasound.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Other treatments for CSP

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

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 Pregnancy: Current Understanding and Treatment Including Role of Minimally Invasive Surgical Techniques

The incidence of cesarean scar pregnancy (CSP) is increasing reflecting the global increase in cesarean section (CS) rate which has almost doubled since 2000. CSP differs from other types of ectopic pregnancy in its ability to progress while still carrying a significant risk of maternal morbidity. Little is known about precise etiology or natural history although current interest in the pathology of placenta accretes spectrum disorders might be enlightening. Early detection and treatment of CSP are challenging. Once diagnosed, the recommendation is to offer early termination of pregnancy because of the potential risks of continuing the pregnancy. However, as the likelihood of future pregnancy complications for any CSP varies depending on its individual characteristics, this might not always be necessary nor might it be the patient's preferred choice if she is asymptomatic, hemodynamically stable, and wants a baby. The literature supports an interventional rather than a medical approach but the safest and most efficient clinical approach to CSP in terms of treatment modality and service delivery has yet to be determined. This review aims to provide an overview of CSP etiology, natural history, and clinical implications. Treatment options and methods of CSP repair are discussed. We describe our experience in a large tertiary center in Singapore with around 16 cases/year where most treatment modalities are available as well as an "accreta service" for continuing pregnancies. We present a simple algorithm for approach to management including a method of triaging for those CSPs suitable for minimally invasive surgery.

Comparative effectiveness of transvaginal repair vs. hysteroscopic resection in patients with symptomatic uterine niche

Objective

To compare the efficacy of transvaginal repair and hysteroscopic resection in improving niche associated postmenstrual spotting.

Methods

The improvement rate of postmenstrual spotting in women who underwent transvaginal repair or hysteroscopic resection treatment was assessed retrospectively in patients accepted at the Niche Sub-Specialty Clinic in International Peace Maternity and Child Health Hospital between June 2017 and June 2019. Postoperative spotting symptom within one year after surgery, pre- and postoperative anatomical indicators, women' satisfaction with menstruation and other perioperative parameters were compared between the two groups.

Results

68 patients in the transvaginal group and 70 patients in the hysteroscopic group were included for analysis. The improvement rate of postmenstrual spotting in the transvaginal group at the 3rd, 6th, 9th, and 12th months after surgery was 87%, 88%, 84%, and 85%, significantly higher than 61%, 68%, 66%, and 68% in the hysteroscopic group, respectively (P < 0.05). The total days of spotting improved significantly at the 3rd month after surgery but did not change over time within one year in each group (P > 0.05). After surgery, the disappearance rates of the niche are 68% in transvaginal group and 38% in hysteroscopic group, however, hysteroscopic resection had shorter operative time and hospitalization duration, less complications, and lower hospitalization costs.

Conclusion

Both treatments can improve the spotting symptom and anatomical structures of uterine lower segments with niches. Transvaginal repair is better in thickening the residual myometrium than hysteroscopic resection, however, hysteroscopic resection has shorter operative time and hospitalization duration, less complications, and lower hospitalization costs.

Two subtypes of surgery-categorized upper-lateral intracavitary pregnancy identified by MRI, a retrospective study

BACKGROUND

The pregnancy outcomes in women with surgery-categorized upper-lateral intracavitary pregnancy (ULIP), previously named angular pregnancy, demonstrate higher heterogeneity than in women with ultrasonography-categorized ULIP. We aimed to use preoperative MRI and correlated clinical characteristics to explore whether the surgery-categorized ULIP comprises obstetric conditions undefined by the current ultrasonography-based diagnostic criteria.

METHODS

This retrospective study involved 28 women with surgically and pathologically confirmed ULIP from January 2016 to July 2022. Two board-certified radiologists, blinded to the patients' information, independently reviewed the MRI images, and determined each MRI feature, including endometrial thickness (EMT) and peri-gestational sac (GS) endometrial interruption. Disagreements were resolved by discussion to achieve a consensus. Based on the cutoff value of EMT (11.5 mm), the patients were divided into above-cutoff EMT (n = 22) and below-cutoff EMT (n = 6) groups.

RESULTS

Two subtypes of surgery-categorized ULIP were identified. Type-I ULIP (n = 22; EMT ≥ 11.5 mm), when compared to the type-II ULIP (n = 6; EMT < 11.5 mm), demonstrated lower incidence of peri-GS endometrial interruption (2/22 [9.1%] vs 6/6 [100%]; P = 0.001), higher logarithmic ß-human chorionic gonadotropin (ß-hCG) concentration (4.7 ± 0.4 mIU/ml vs 4.2 ± 0.6 mIU/ml; P = 0.026), lower rate of repeated dilatation and curettage (1/22 [4.6%] vs 4/6 [66.7%]; P = 0.003), less intraoperative blood loss (10.1 ± 6.3 ml vs 28.3 ± 18.3 ml; P = 0.001), and shorter hospital stay (2.8 ± 1.7 days vs 7.5 ± 3.8 days; P = 0.001). The peri-GS endometrial interruption negatively correlated with EMT (Odds ratio [OR] = 0.55; P = 0.001) and logarithmic ß-hCG concentration (OR = 0.08; P = 0.045). The below-cutoff EMT negatively correlated with ß-hCG concentration (OR = 0.06; P = 0.021).

CONCLUSIONS

Surgery-categorized ULIP comprised two obstetric conditions among which the type-II ULIP, possessing unique imaging features undocumented in the literature, requires further attention during clinical practice.

Analysis of pregnancy outcomes following surgical treatment of cesarean scar pregnancy

Purpose

To investigate the surgical treatment approaches for patients with Cesarean scar pregnancy (CSP) and the effects on subsequent pregnancy.

Methods

CSP patients admitted to Shengjing Hospital of China Medical University from January 2013 to December 2018 were retrospectively analyzed to collect their clinical characteristics, and follow-up of postoperative pregnancies.

Results

A total of 1126 CSP patients were enrolled in this study, including 595 (52.84%) CSP type I, 415 (36.86%) CSP type II, and 116 (10.30%) CSP type III cases. There were significant differences between the three types of patients in terms of β-HCG levels, gestational sac diameter, clinical symptoms and presence of fetal heartbeat at diagnosis (P < 0.01). Among these, 89.90% of CSP type I, 88.90% of CSP type II and 50% of CSP type III patients were treated with hysteroscopic lesion excision, 7.9% of CSP type I and 2.2% of CSP type II patients underwent ultrasound-monitored curettage, and the remaining patients underwent lesion excision and and simultaneous repair of excised lesions by different routes (trans-laparoscopic, transabdominal or transvaginal methods). And 5.55% of CSP type I, 22.65% of CSP type II and 43.10% of CSP type III patients were treated with adjunctive uterine artery embolization (UAE). The patients were followed up for more than 2 years after surgery. Among the 166 re-pregnancies, 58 (34.94%) were normal pregnancies, 17 patients reoccurred with CSP, the recurrent rate of CSP was 10.24%. All 58 normal pregnancies were terminated by cesarean section, with a mean gestational week of delivery of (38.36 ± 2.25) weeks, a mean birth weight of (3228.45 ± 301.96)g, and the postnatal Apgar score was (9.86 ± 0.23) points at 1 min and all 5 min were 10 points. Logistic regression analysis suggested that the number of previous cesarean deliveries was a risk factor for recurrent CSP (RCSP) (OR = 10.82, 95% CI: 2.52–46.50, P = 0.001).

Conclusions

The type of CSP is related to β-HCG values, presence of fetal heartbeat, gestational sac diameter and clinical symptoms. Hysteroscopic therapy is a commonly used surgical procedure and UAE is often used as an adjuvant treatment. For subsequent pregnancies, the number of previous cesarean deliveries is a risk factor for recurrent CSP.

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

Purpose

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

Method

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

Results

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

Conclusions

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