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Silva B, Viana Pinto P, Costa MA. Cesarean Scar Pregnancy: A systematic review on expectant management. Eur J Obstet Gynecol Reprod Biol 2023; 288:36-43. [PMID: 37421745 DOI: 10.1016/j.ejogrb.2023.06.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023]
Abstract
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.
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Affiliation(s)
- Beatriz Silva
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Pedro Viana Pinto
- Department of Biomedicine, Service of Anatomy, Faculty of Medicine, University of Porto, Porto, Portugal; Gynecology and Obstetrics Service, University Hospital Center São João, Porto, Portugal.
| | - Maria Antónia Costa
- Gynecology and Obstetrics Service, University Hospital Center São João, Porto, Portugal; Department of Gynecology-Obstetrics and Paediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
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Timor-Tritsch IE, Monteagudo A, Calì G, D'Antonio F, Agten AK. Cesarean Scar Pregnancy: Patient Counseling and Management. Obstet Gynecol Clin North Am 2020; 46:813-828. [PMID: 31677756 DOI: 10.1016/j.ogc.2019.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Health, 550 1st Avenue, New York, NY 10016, USA.
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calì
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - Francesco D'Antonio
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Andrea Kaelin Agten
- Nottingham University Hospitals NHS, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
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Timor-Tritsch IE, D'Antonio F, Calí G, Palacios-Jaraquemada J, Meyer J, Monteagudo A. Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:156-163. [PMID: 30677186 DOI: 10.1002/uog.20225] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 12/05/2018] [Accepted: 12/07/2018] [Indexed: 06/09/2023]
Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - F D'Antonio
- Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø, Norway
| | - G Calí
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - J Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - J Meyer
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - A Monteagudo
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Caserta NMG, Bacha AM, Grassiotto OR. Cesarean scar ectopic pregnancy: invasion of the bladder wall detected by magnetic resonance imaging. Radiol Bras 2017; 50:197-198. [PMID: 28670032 PMCID: PMC5487235 DOI: 10.1590/0100-3984.2014.1855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Although cesarean scar ectopic pregnancy continues to be the rarest form of
ectopic pregnancy, its incidence is increasing because of the worldwide increase
in the number of cesarean deliveries. If the diagnosis is delayed, there is a
high risk of severe hemorrhage and death, whereas early diagnosis can minimize
the complications associated with the condition. Here, we report a case in which
invasion of the bladder wall was identified by magnetic resonance imaging.
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Affiliation(s)
- Nelson Marcio Gomes Caserta
- PhD, Tenured Associate Professor, Department of Radiology, Faculty of Medical Sciences, FCM-Unicamp, Campinas, SP, Brazil
| | - Angela Maria Bacha
- PhD, Professor, Department of Gynecology and Obstetrics, Faculty of Medical Sciences, FCM-Unicamp, Campinas, SP, Brazil
| | - Oswaldo R Grassiotto
- PhD, Professor, Department of Gynecology and Obstetrics, Faculty of Medical Sciences, FCM-Unicamp, Campinas, SP, Brazil
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Panelli DM, Phillips CH, Brady PC. Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review. FERTILITY RESEARCH AND PRACTICE 2015; 1:15. [PMID: 28620520 PMCID: PMC5424401 DOI: 10.1186/s40738-015-0008-z] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 09/29/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ectopic pregnancy is a potentially life-threatening condition occurring in 1-2 % of all pregnancies. The most common ectopic implantation site is the fallopian tube, though 10 % of ectopic pregnancies implant in the cervix, ovary, myometrium, interstitial portion of the fallopian tube, abdominal cavity or within a cesarean section scar. FINDINGS Diagnosis involves a combination of clinical symptoms, serology, and ultrasound. Medical management is a safe and effective option in most clinically stable patients. Patients who have failed medical management, are ineligible, or present with ruptured ectopic pregnancy or heterotopic pregnancy are most often managed with excision by laparoscopy or, less commonly, laparotomy. Management of nontubal ectopic pregnancies may involve medical or surgical treatment, or a combination, as dictated by ectopic pregnancy location and the patient's clinical stability. Following tubal ectopic pregnancy, the rate of subsequent intrauterine pregnancy is high and independent of treatment modality. CONCLUSION This review describes the incidence, risk factors, diagnosis, and management of tubal and non-tubal ectopic and heterotopic pregnancies, and reviews the existing data regarding recurrence and future fertility.
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Affiliation(s)
- Danielle M. Panelli
- Department of Obstcpetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115 USA
| | - Catherine H. Phillips
- Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA USA
| | - Paula C. Brady
- Department of Obstcpetrics and Gynecology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115 USA
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Abstract
Ectopic pregnancy is directly related to tubal infection, and so prevention of chlamydia and gonorrhea must be the watchword to lower its risk and incidence. With accurate determination of very low human chorionic gonadotropin concentrations and sonography, >85% of women are diagnosed before tubal rupture, which has led to medical therapy and laparoscopic surgery with tubal preservation and the potential for future fertility. Today, early intervention saves lives and reduces morbidity, but ectopic pregnancy still accounts for 4% to 10% of pregnancy-related deaths and leads to a high incidence of ectopic site gestations in subsequent pregnancies.
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Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012; 207:14-29. [PMID: 22516620 DOI: 10.1016/j.ajog.2012.03.007] [Citation(s) in RCA: 366] [Impact Index Per Article: 28.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 01/28/2012] [Accepted: 03/09/2012] [Indexed: 11/29/2022]
Abstract
This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY 10016, USA.
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Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, Pineda G, Arslan AA. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol 2012; 207:44.e1-13. [PMID: 22607667 DOI: 10.1016/j.ajog.2012.04.018] [Citation(s) in RCA: 231] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 03/16/2012] [Accepted: 04/09/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The diagnosis and treatment of cesarean scar pregnancy (CSP) is challenging. The objective of this study was to evaluate the diagnostic method, treatments, and long-term follow-up of CSP. STUDY DESIGN This is a retrospective case series of 26 patients between 6-14 postmenstrual weeks suspected to have CSP who were referred for diagnosis and treatment. The diagnosis was confirmed with transvaginal ultrasound. In 19 of the 26 patients the gestational sac was injected with 50 mg of methotrexate: 25 mg into the area of the embryo/fetus and 25 mg into the placental area; and an additional 25 mg was administered intramuscularly. Serial serum human chorionic gonadotropin determinations were obtained. Gestational sac volumes and vascularization were assessed by 3-dimensional ultrasound and used to monitor resolution of the injected site and outcome. RESULTS The 19 treated pregnancies were followed for 24-177 days. No complications were observed. After the treatment, typically, there was an initial increase in the human chorionic gonadotropin serum concentrations as well as in the volume of the gestational sac and their vascularization. After a variable time period mentioned elsewhere the values decreased, as expected. CONCLUSION Combined intramuscular and intragestational methotrexate injection treatment was successful in treating these CSP.
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Laparoscopic management of cervical–isthmic pregnancy: a proposal method. Fertil Steril 2009; 92:829.e3-6. [DOI: 10.1016/j.fertnstert.2009.05.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 04/21/2009] [Accepted: 05/07/2009] [Indexed: 11/18/2022]
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Moschos E, Sreenarasimhaiah S, Twickler DM. First-trimester diagnosis of cesarean scar ectopic pregnancy. JOURNAL OF CLINICAL ULTRASOUND : JCU 2008; 36:504-511. [PMID: 18393379 DOI: 10.1002/jcu.20471] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Once considered extremely rare, implantation of a pregnancy within the scar of a previous cesarean section is becoming more common. In fact, its incidence is now higher than that of cervical ectopic pregnancies. We identified 5 cases of ectopic pregnancy implanted in a prior cesarean section scar at our institution since 2004. We outline the criteria for the first-trimester sonographic diagnosis of cesarean scar ectopic pregnancy, including a new sign of lower uterine segment ballooning, which has previously not been reported. Clinicians must have a heightened awareness of this serious and potentially fatal pregnancy complication.
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Affiliation(s)
- Elysia Moschos
- Department of Obstetrics and Gynecology, Division of Gynecology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
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Mathe ML, Morau E, Vernhet-Kovacsik H, Picot MC, Boulot P. Impact of the new French clinical practice recommendations in embolization in postpartum and post-abortion hemorrhage: study of 48 cases. J Perinat Med 2008; 35:532-7. [PMID: 18052838 DOI: 10.1515/jpm.2007.113] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIM To evaluate the use of arterial embolization in postpartum hemorrhage (PPH) by comparing the indications, efficacy, times to diagnosis, treatment, and embolization, and conditions of management of patients before and after publication of the Collège National des Gynécologues et Obstétriciens Français clinical practice recommendations (CPR). METHODS Forty-eight patients who underwent embolization between January 2000 and December 2005 were included in a retrospective, descriptive, and comparative study. We compared the management before (n=21) and after (n=27) publication of the CPR. The main outcome measures were time to diagnosis of PPH, time to treatment initiation, time to decision to implement embolization, time to embolization, hemodynamic characteristics. RESULTS The number of embolizations has quadrupled since publication of the CPR, and the time taken to decide on embolization has been reduced by 30%. The success rate was 96%, there were no second embolization procedures, and one complication was recorded (hematoma of pubic symphysis). Hemodynamic status was better in patients treated after the CPR (P=0.003). CONCLUSION Embolization is an effective and safe technique, with a low complication rate. In our healthcare network, the decision to use embolization was faster since the CPR, embolizations have quadrupled, and patients' hemodynamic status has improved.
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Affiliation(s)
- Marie-Lise Mathe
- Service de Gynécologie Obstétrique C et Médecine Maternofoetale, CHU Arnaud de Villeneuve, Montpellier Cedex 5, France.
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Özkan S, Çalışkan E, Özeren S, Çorakçı A, Çakıroğlu Y, Coşkun E. Three-dimensional ultrasonographic diagnosis and hysteroscopic management of a viable cesarean scar ectopic pregnancy. J Obstet Gynaecol Res 2007; 33:873-7. [DOI: 10.1111/j.1447-0756.2007.00671.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
OBJECTIVE To clarify the appropriate way to diagnose and treat an ectopic pregnancy in the uterine scar of a prior cesarean delivery. DATA SOURCES Articles written in English that were published from January 1966 to August 2005 and quoted in the computerized database MEDLINE/PubMed retrieved by using the words "cesarean section," "cesarean delivery," "cesarean section scar pregnancy," and "ectopic pregnancy." Additional articles were obtained from reference lists of pertinent case reports and reviews. METHODS OF STUDY SELECTION Fifty-nine articles that met the inclusion criteria provided data on the clinical presentation, diagnosis, and treatment modalities of 112 cases of cesarean delivery scar pregnancies. TABULATION, INTEGRATION, AND RESULTS Review of the 112 cases revealed a considerable increase in the incidence of this condition over the last decade, with a current range of 1:1,800 to 1:2,216 normal pregnancies. More than half (52%) of the reported cases had only one prior cesarean delivery. The mean gestational age was 7.5 +/- 2.5 weeks, and the most frequent symptom was painless vaginal bleeding. Endovaginal ultrasonography was the diagnostic method in most cases, with a sensitivity of 84.6% (95% confidence interval 0.763-0.905). Expectant management of 6 patients resulted in uterine rupture that required hysterectomy in 3 patients. Dilation and curettage was associated with severe maternal morbidity. Wedge resection and repair of the implantation site via laparotomy or laparoscopy were successful in 11 of 12 patients. Simultaneous administration of systemic and intragestational methotrexate to 5 women, all with beta-hCG exceeding 10,000 milli-International Units/mL required no further treatment. CONCLUSION Surgical treatment or combined systemic and intragestational methotrexate were both successful in the management of cesarean delivery scar pregnancy. Because subsequent pregnancies may be complicated by uterine rupture, the uterine scar should be evaluated before, as well as during, these pregnancies.
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Affiliation(s)
- Michael A Rotas
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York 11219, USA
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Chang CY, Wu MT, Shih JC, Lee CN. Preservation of Uterine Integrity via Transarterial Embolization under Postoperative Massive Vaginal Bleeding due to Cesarean Scar Pregnancy. Taiwan J Obstet Gynecol 2006; 45:183-7. [PMID: 17197366 DOI: 10.1016/s1028-4559(09)60223-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Cesarean scar pregnancy (CSP) is an uncommon type of ectopic pregnancy. It results in uterine rupture and severe hemorrhage during the proceeding gestation. Whether diagnosed early or not, it may cause maternal mortality or morbidity during emergency management. Life-saving emergency hysterectomy is usually the treatment of choice when there is profuse bleeding intraoperatively or after initial management. CASE REPORT A 38-year-old woman with a history of two previous cesarean deliveries was referred to our clinic under the impression of CSP at 11 weeks' gestation. A viable embryo with a crown-rump length of 4.8 cm in the anterior wall of the uterus at the cervico-isthmic region was detected. Under the confirmation of CSP via ultrasonography, she was admitted for management. During hysterotomy, profuse bleeding with 1,000 mL blood loss was noted. After conservative procedure for hemostasis, however, massive vaginal bleeding persisted. As a result, we immediately transferred the patient to receive transarterial embolization (TAE) for bleeding control. The patient was discharged 4 days after the operation and TAE and her period resumed 1 month later. CONCLUSION Management of CSP is usually accompanied by profuse blood loss. Hysterectomy is inevitable if massive blood loss occurs during surgical intervention. For preservation of fertility and avoidance of mortality, our physicians offered an alternative life-saving policy even under catastrophic blood loss.
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Affiliation(s)
- Chih-Yuan Chang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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