Laparoscopic management of an ectopic pregnancy in a lower segment cesarean section scar: A review and case report

Clinical efficacy of laparoscopic surgery used for the excision of villus tissue and the repair of uterine scar in patients with cesarean scar pregnancy-II

The present study described the clinical presentation of patients with cesarean scar pregnancy type II (CSP)-II diagnosed by ultrasound or magnetic resonance imaging, who underwent laparoscopic surgery resection or hysteroscopic treatment. The aim of the present study was to evaluate the outcomes of different treatments for CSP. The patients with CSP-II were assigned to the laparoscopy and hysteroscopy groups according to the type of surgery performed. The general indicators and post-operative outcomes were compared between the two groups. Statistically significant differences (P<0.05) were noted in the treatment efficacy indices between the two groups. The laparoscopic group exhibited a lower value of β-human chorionic gonadotropin (β-HCG) following surgery (P=0.017), a shorter time required for β-HCG to return to normal levels (P=0.001), a reduced post-operative thickness of the uterine scar (P<0.001) and a reduced menstruation recovery time (P<0.001). However, no significant differences were noted in blood loss during operation (P>0.05). On the whole, the data indicated that the laparoscopic resection of the scar with gestational tissue and wound repair may be used to preserve the uterus and may thus be an effective method for CSP-II. The appropriate treatment needs to be selected according to the condition of each patient. Based on the latter and on the available technology, priority may perhaps be given to laparoscopic surgery.

Laparoscopic management of cesarean scar pregnancy: Report of two cases with video-presentation of different operative techniques and literature review

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. We present two different techniques of laparoscopic management of CSP, with the concomitant repair of the coexisting uterine isthmocele. The first case is a combination of diagnostic hysteroscopy and laparoscopic extraction of conception products, and the second technique is a combination of laparoscopy and guided Dilation & Curettage. We also conducted a thorough review of the literature to present all cases of laparoscopic treatment of CSP, focusing on the surgical technique, the operation outcome, and the future pregnancies. Laparoscopy is a potential effective treatment of CSP.

Cesarean Scar Pregnancy: Diagnosis and Pathogenesis

Cesarean scar pregnancy is a potentially dangerous consequence of a previous cesarean delivery. If unrecognized and inadequately managed, it can lead to untoward complications throughout all three trimesters of the pregnancy. The rate of occurrence parallels the mounting rate of cesarean sections. The late consequences of cesarean delivery, such as placenta previa and placenta accrete, were known for a long time. However, it took more than a decade for the obstetric community to make the connection between the cesarean scar pregnancy and the placenta accreta spectrum. This article discusses the pathogenesis and diagnosis of cesarean scar pregnancy.

Clinical Efficacy and Safety of Uterine Artery Embolization (UAE) versus Laparoscopic Cesarean Scar Pregnancy Debridement Surgery (LCSPDS) in Treatment of Cesarean Scar Pregnancy

Background

The present study aimed to compare the clinical efficacy and safety of uterine artery embolization (UAE) vs. laparoscopic cesarean scar pregnancy debridement surgery (LCSPDS) in the treatment of patients with cesarean scar pregnancy (CSP).

Material/Methods

A retrospective analysis was performed on 87 CSP patients from March 2012 to February 2017. For the included 87 cases, 51 were treated with UAE and 36 were treated with LCSPDS. The operation success rate, intraoperative blood loss, operation time, length of hospital stay, perioperative complications, and β-HCG level were compared.

Results

For the UAE group, 41 patients underwent successful surgeries (80.4% success rate), and 36 cases in the LCSPDS group were successfully treated, with no case of perioperative death. In the UAE group, the operation time, intraoperative blood loss, and length of hospital stay were 82.23±45.21 min, 112.58±68.54 mL, and 12.56±3.03 days, respectively. In the LCSPDS group, the operation time, intraoperative blood loss, and length of hospital stay were 85.45±30.02 min, 108.56±54.12 mL and 7.65±2.48 days, respectively. The length of hospital stay for the UAE group was significantly longer than in the LCSPDS group (P<0.05).

Conclusions

UAE and LCSPDS each have their own advantages and disadvantages in treating CSP. Thus, appropriate individualized surgical programs based on specific patient circumstances are needed to avoid indiscriminately performing complete uterine cavity curettage.

When a cesarean section scar is more than an innocent bystander in a subsequent pregnancy: Ultrasound to the rescue

Over the years, cesarean section has played a pivotal role in reducing maternal and perinatal morbidity and mortality. With the rising trend of this surgery, a substantial number of pregnant women have a cesarean section scar. The scar can serve as the abode of grave conditions in subsequent pregnancies, namely cesarean scar pregnancy, morbidly adherent placenta, and scar dehiscence. Sonography has emerged as a robust tool for the diagnosis of these potentially life-threatening conditions. This review highlights the key sonographic features of various complications that can occur at the cesarean scar site in subsequent pregnancies. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:319-327, 2017.

Correlation or Causation? A Case Report of Endometriosis within a Caesarean Scar Defect

Introduction

Caesarean scar defect is a well-recognised complication of caesarean section. It can cause secondary infertility, although the mechanism is still poorly understood.

Case description

We present the case of a patient diagnosed with a caesarean scar defect on transvaginal ultrasound, following referral for secondary infertility. During laparoscopy performed with concurrent hysteroscopy, the caesarean scar defect was found to be continuous with an endometriotic nodule in the uterovesical peritoneum. This was excised along with other endometriosis implants. Histopathology of the resected defect also showed endometriosis.

Conclusions

This case illustrates a possible link between caesarean scar defect and endometriosis, and highlights the benefit of laparoscopy to allow additional treatment of coexisting pathology, such as endometriosis, that could also contribute to infertility.

Reproductive outcomes after previous cesarean scar pregnancy: Follow up of 189 women

OBJECTIVE

To investigate the reproductive and pregnancy outcomes of women after previous Cesarean Scar Pregnancy.

MATERIALS AND METHODS

From January 2009 to December 2013, a total of 214 patients with CSP received surgical evacuation treatment by means of dilation and suction evacuation and local resection of the ectopic gestational mass. A telephone follow-up was conducted every year after CSP treatment. The follow-up was ended on December 2014.

RESULTS

Twenty-five patients were lost to follow-up due to loss of contacts. The previous medical records of the remaining 189 women were reviewed. Fifty-eight women wished to give birth again. However, 48 (82.8%, 48/58) of them stopped the attempts to get pregnant because they were afraid of recurrent CSP and the high risk of uterine rupture during the subsequent pregnancy. The other 10 women spontaneously attempted to get pregnant again, among whom 6 (60%, 6/10) succeeded with the birth of 7 healthy babies. A total of 32 women conceived again, either in plan or by chance. Five women (15.6%, 5/32) experiencing recurrent CSP.

CONCLUSION

Even though our result did not necessarily represent the true recurrence rate, our study provided some evidence about the likelihood of fertility and recurrence risk for future pregnancies after previous CSP.

Curettage after uterine artery embolization combined with methotrexate treatment for caesarean scar pregnancy

In the present study, we evaluated the diagnosis and management modalities of caesarean scar pregnancy (CSP). Thirty patients diagnosed with CSP were retrospectively studied between February, 2010 and February, 2012. Twenty-five patients were offered prophylactic uterine artery embolization (UAE) and methotrexate (MTX) prior to uterine suction curettage. Five cases were referred from other hospitals where the initial management with uterine suction curettage had resulted in uncontrollable massive haemorrhage, 4 of the cases had UAE and one proceeded immediately to hysterectomy. In the 25 patients treated with prophylactic UAE and MTX, 12 had laparoscopy-guided curettage and 13 had ultrasound-guided curettage without complication. The results showed that the 25 patients with CSP, who received prophylactic UAE and MTX prior to uterine curettage, recovered without complications. Five patients referred from other hospitals, where uterine curettage was the primary procedure, had severe complications including uncontrolled vaginal bleeding and uterine rupture. Four of the five patients were treated successfully with emergency UAE and the remaining patient underwent emergency hysterectomy as ultrasound examination detected significant haemorrhage between the uterus and the bladder. Of the 25 patients who received prophylactic UAE combined with MTX, there were no reports of irregular menstruation or serious adverse effects. Notably, the decrease in serum human chorionic gonadotropin (HCG) levels 3 days post-surgery was greater with ultrasound-guided curettage (84.3±5.5%) than with laparoscopy-guided curettage (76.3±10.2%). In summary, the data suggested that prophylactic UAE with MTX followed by ultrasound-guided curettage is the most effective therapeutic approach in CSP.

Cesarean scar pregnancy and early placenta accreta share common histology

OBJECTIVE

To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

METHODS

The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined.

RESULTS

Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93).

CONCLUSIONS

EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.

Laparoscopic treatment of placenta percreta retention in a cesarean scar: a case report

Placenta percreta retention within the scar of a previous cesarean section is rare. We report here one of these cases treated successfully by laparoscopy, with uterine repair. Different therapeutic options are described.

Cesarean scar pregnancy: sonographic and magnetic resonance imaging findings, complications, and treatment

A cesarean scar (ectopic) pregnancy occurs when a pregnancy implants on a cesarean scar. This condition is an uncommon but potentially devastating occurrence. The incidence is increasing as cesarean deliveries become more common. Early recognition of the salient sonographic findings is critical because a delay can lead to increased maternal morbidity and mortality. Magnetic resonance imaging is a valuable troubleshooting tool when sonography is equivocal or inconclusive before therapy or intervention. Early diagnosis by sonography directs therapy and improves outcomes by allowing preservation of the uterus and future fertility. We review the imaging features, differential diagnosis, complications, and treatment of cesarean scar pregnancies in the first trimester.

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

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.

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

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.

Caesarean scar pregnancy: a review of management options

PURPOSE OF REVIEW

The current review aims to provide an overview of the already available and emerging treatment modalities for caesarean scar pregnancy (CSP).

RECENT FINDINGS

CSP is a type of ectopic gestation associated with a high risk of serious complications. The cause of this condition and the best management are still unclear. However, some medical and surgical treatment modalities have been suggested. The main objectives in the clinical management of CSP should be the prevention of massive blood loss and the conservation of the uterus to maintain further fertility, women's health and quality of life. Current data suggest that expectant management should not be recommended, whereas there are accumulating data suggesting that early diagnosis offers single or combined medical and surgical treatment options avoiding uterine rupture and haemorrhage, thus preserving the uterus and fertility.

SUMMARY

No universal treatment guidelines for the management of CSP have been published up to now. The lack of data on the best evidence should encourage any individual case report and further multicentre studies for recommendations establishment.

Surgical treatment of ectopic pregnancy

Ectopic pregnancy remains the leading cause of death in the first trimester of pregnancy. Today, serial serum hCG measurements and transvaginal ultrasound examination can provide early detection of most ectopic pregnancies allowing medical treatment with methotrexate. In those who require surgery, the type of procedure depends on the clinical situation and the location of the pregnancy. Most of the cases can and should be performed by laparoscopy. Compared with laparotomy, the laparoscopic approach is associated with many advantages including short hospital stay, low cost and less adhesion formation. In addition, hemoperitoneum is not a contraindication for performing laparoscopy. Linear salpingostomy is the procedure of choice when unruptured tubal pregnancy is found in women who want to preserve their fertility; otherwise, salpingectomy is performed. Fertility performance after salpingostomy and salpingectomy is comparable. Similar to the case with tubal ectopic pregnancy in general, women with non-tubal ectopic pregnancy such as cervical, interstitial, or Caesarean scar pregnancy should be first treated medically with methotrexate. These types of ectopic pregnancies may be associated with massive bleeding during surgery. Precautionary procedures should be considered and these include the placement of an angiographic catheter for possible uterine artery embolization. These pregnancies can also be treated laparoscopically.

Caesarean scar pregnancy

Caesarean scar pregnancy is one of the rarest forms of ectopic pregnancy. Little is known about its incidence and natural history. With increasing incidence of caesarean section worldwide, more and more cases are diagnosed and reported. Transvaginal ultrasound and colour flow Doppler provides a high diagnostic accuracy with very few false positives. A delay in diagnosis and/or treatment can lead to uterine rupture, major haemorrhage, hysterectomy and serious maternal morbidity. Early diagnosis can offer treatment options of avoiding uterine rupture and haemorrhage, thus preserving the uterus and future fertility. Management plan should be individually tailored. Available data suggest that termination of pregnancy is the treatment of choice in the first trimester soon after the diagnosis. Expectant treatment has a poor prognosis because of risk of rupture. There are no reliable scientific data on the risk of recurrence of the condition in future pregnancy, role of the interval between the previous caesarean delivery and occurrence of caesarean scar pregnancy, and effect of caesarean wound closure technique on caesarean scar pregnancy. In this article, we aim to find the demography, pathophysiology, clinical presentation, most appropriate methods of diagnosis and management, with their implications in clinical practice for this condition.

Cesarean scar ectopic pregnancies: etiology, diagnosis, and management

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.