Uterine Artery Embolization Versus Methotrexate for Cesarean Scar Pregnancy in a Chinese Population: A Meta-analysis

Laparoscopic Management of Cesarean Scar Pregnancy with Temporary Clipping of Anterior Trunk of Hypogastric Arteries: A Case Report

A cesarean scar ectopic pregnancy (CSP) represents an uncommon yet potentially life-threatening condition requiring immediate and efficient management. We present a case of a 32-year-old woman diagnosed with a scar pregnancy at 8 weeks of gestation. Laparoscopic surgical management was chosen due to its minimally invasive nature and potential for preserving fertility. During the procedure, temporary clipping of uterine arteries was employed to control intraoperative bleeding. The patient recovered well postoperatively with no complications. This case highlights the feasibility and effectiveness of laparoscopic intervention combined with temporary uterine artery clipping in the management of scar pregnancies, offering a valuable approach for clinicians faced with similar cases. Through this report, we aim to contribute to the existing literature on the optimal management of CSP and highlight the efficacy of laparoscopic surgery in this context.

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.

Efficacy and safety of high-intensity focused ultrasound combined with suction curettage for the treatment of caesarean scar pregnancy: a systematic review and single-arm meta-analysis

PURPOSE

Caesarean scar pregnancy (CSP) presents a significant clinical challenge owing to the associated risks of uterine scar rupture, severe haemorrhage and adverse maternal outcomes. This study aimed to assess the safety and efficacy of combining high-intensity focused ultrasound (HIFU) with suction curettage for treating CSP.

METHODS

We conducted a comprehensive search in four databases, namely PubMed, Web of Science, Embase and Cochrane Library, to identify published studies evaluating the use of HIFU combined with suction curettage to treat CSP. Intraoperative blood loss, treatment success rate, and reproductive results were the primary outcomes assessed.

RESULTS

A total of 18 studies involving 1251 patients with CSP, all of whom received preoperative HIFU therapy were included. The average hospital stay was 6.22 days, the intraoperative blood loss was 26.29 ml and the incidence of adverse events was 15.60%, including abdominal or lower limb pain, fever, vaginal bleeding, haematuria and vomiting. Furthermore, post-treatment follow-up showed that serum β-human chorionic gonadotropin levels were rapidly normalized (average of 25.48 days) and menstruation returned (average of 33.03 days). The treatment had a remarkable success rate of 97.60% and a subsequent pregnancy rate of 68.70%.

CONCLUSION

While the combination of HIFU and suction-curettage may induce common adverse effects such as lower abdominal or limb pain, these reactions typically do not necessitate therapeutic intervention. Additionally, the size of the gestational sac is a determinant of the procedure's success. In conclusion, HIFU combined with suction curettage demonstrates promising clinical efficacy, safety and favourable reproductive outcomes in managing CSP.

Analysis of risk factors for patients with cesarean scar pregnancy treated with methotrexate combined with suction curettage

PURPOSE

To analyze the predictive value of clinical and ultrasound parameters for treatment failure after administration of methotrexate (MTX) in combination with suction curettage (SC) in treatment of cesarean scar pregnancy (CSP) in the early first trimester.

METHODS

In this retrospective cohort study, electronic medical records of patients diagnosed with CSP and initially treated between 2015 and 2022 with MTX combined with SC were reviewed and outcome data were collected.

RESULTS

127 patients met inclusion criteria. 25 (19.69%) required additional treatment. Logistic regression analysis indicated that factors independently associated with the need for additional treatment included progesterone level > 25 mIU/mL (OR: 1.97; 95% CI: 0.98-2.87, P = 0.039), abundant blood flow (OR: 5.19; 95% CI: 2.44-16.31, P = 0.011), gestational sac size > 3 cm (OR: 2.54; 95% CI: 1.12-6.87, P = 0.029), and the myometrial thickness between the bladder and gestational sac < 2.5 mm (OR: 3.48; 95% CI: 1.91-6.98, P = 0.015).

CONCLUSIONS

Our study identified several factors which increase the need for additional treatment following the initial treatment of CSP with MTX and SC. Alternative therapy should be considered if these factors are present.

Efficacy and Safety of High-intensity Focused Ultrasound Compared with Uterine Artery Embolization in Cesarean Section Pregnancy: A Meta-analysis

OBJECTIVE

To investigate the efficacy and safety of high-intensity focused ultrasound (HIFU) compared with uterine artery embolization (UAE) in cesarean section pregnancy (CSP) and to calculate the success rate of HIFU.

DATA SOURCES

We searched PubMed, Cochrane, Scopus, Web of Science, and Embase on September 30, 2022, and the related studies were independently reviewed by 2 researchers.

METHODS OF STUDY SELECTION

Medical subject headings and relevant terms from other articles were used for the database search. Patients with CSP who underwent HIFU were included in this analysis. The following results were recorded: success rate, intraoperative blood loss, time for serum beta-human chorionic gonadotropin (beta-HCG) normalization and menstruation recovery, adverse events, hospitalization time, and hospitalization expenses. We used the Newcastle-Ottawa Scale scoring system and the methodological index for nonrandomized studies system to evaluate the quality of the studies.

TABULATION, INTEGRATION, AND RESULTS

Data from 6 studies were used to compare the efficacy and safety of UAE and HIFU. We pooled the success rate of HIFU by including 10 studies. No data overlap between the 10 studies. Success rate was higher in the HIFU group (odds ratio [OR] = 1.90; 95% confidence interval [CI] 1.06-3.41; p = .03; I2 = 0). We performed the meta-analysis of single rate in R 4.2.0 software, and the success rate of HIFU group was 0.94 (95% CI 0.92-0.96; p = .04; I2 = 48%). Intraoperative blood loss (mean difference [MD]= -21.94 mL; 95% CI -67.34 to 23.47; p = .34; I2 = 99%) and time for serum beta-HCG normalization (MD = 3.13 days; 95% CI 0.02-6.25; p = .05; I2 = 70%) were not significantly different. Time to menstruation recovery (MD = 2.72 days; 95% CI 1.32-4.12; p = .0001; I2 = 0) in the UAE group was shorter than that in the HIFU group. Adverse events were not significantly different between the 2 groups (OR = 0.53; 95% CI 0.22-1.29; p = .16; I2 = 81%). Hospitalization time was not significantly different between the HIFU and UAE groups (MD = -0.41 days; 95% CI -1.14 to 0.31; p = .26; I2 = 55%). Hospitalization expenses of the HIFU group were lower than those of the UAE group (MD = -7488.49 yuan; 95% CI -8460.13 to -6516.84; p <.000; I2 = 0). Heterogeneity of the time for beta-HCG normalization, adverse events, and hospitalization time were improved after excluding one study, and HIFU showed better results in the sensitivity analysis of adverse events and hospitalization time.

CONCLUSION

According to our analysis, HIFU demonstrated satisfactory treatment success, accompanied by similar intraoperative blood loss, slower normalization of beta-HCG levels, and menstruation recovery, but potentially shorter hospitalization time, lower adverse events and lower costs than UAE. Therefore, HIFU is an effective, safe, and economical treatment for patients with CSP. These conclusions should be interpreted with caution because of the significant heterogeneity. However, large and strictly designed clinical trials are required to verify these conclusions.

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.

Treatment of Cesarean Scar Ectopic Pregnancy in China with Uterine Artery Embolization-A Systematic Review and Meta-Analysis

Cesarean scar ectopic pregnancy (CSP) is a rare form of ectopic pregnancy, and treatment of CSP with uterine artery embolization (UAE) is a novel approach. With increasing numbers of cesarean sections being performed annually, the incidence of this condition is likely to increase. The authors became aware of an unusually high number of published studies originating in mainland China regarding this unusual treatment and sought to perform a meta-analysis to provide comprehensive evidence on this novel practice.

METHODS

We performed a thorough search and included all forms of quality studies on this topic that reported UAE as a part of first-line management of CSP. We included only studies originating in China. Ultimately, 37 studies were included for qualitative and quantitative synthesis of evidence. After screening retrieved records and extracting data from eligible studies, we pooled continuous data as a mean estimate and 95% confidence interval (CI), and dichotomous data as proportion and 95% CI.

RESULTS

CSP patients treated with protocols including UAE had a mean time of 30 days for serum β-hCG normalization, 95% CI [26.816, 33.881]. They had a mean estimated intraprocedural blood loss of 4.19 ± 3.76 mL, a mean hospital stay of nine days, 95%CI [7.914, 9.876], and a success rate of 93.4%, 95%CI [0.918, 0.951]. The severe complication rate was 1.2%, 95%CI [0.008, 0.017].

CONCLUSION

UAE, in combination with other procedures is being used effectively for the treatment of CSP in China. Protocols including UAE have a success rate of approximately 93.4%, and a severe complication rate of approximately 1.2%. This data's utility is limited by vast differences in the studied protocols and questionable feasibility outside of China.

Endovascular treatment of cesarean scar pregnancy: a retrospective multicentric study

PURPOSE

To assess the role of Uterine Artery Embolization (UAE) to treat cesarean scar pregnancy (CSP) using different embolic materials, focusing on its clinical and technical success rates; the association of UAE with methotrexate (MTX) and/or dilatation & curettage (D&C) was evaluated also.

MATERIALS AND METHODS

A retrospective analysis 33 patients (mean age 35 years) affected by CSP and treated with UAE from March 2012 to 2020 was performed. Dynamic levels of serum β-HCG have been collected until they decreased to normal values after procedures. For the statistical analysis the sample was divided into 2 groups: UAE versus UAE + MTX.

RESULTS

The gestational sac age ranged between 5 and 13 weeks (mean 7 weeks). According to operator's preference, 11 patients (33.33%) were treated with sponge injection, 2 patients (6.06%) with a combination of sponge and microsphere the remaining 20 patients (60.60%) with microspheres alone. No major complications occurred after UAE and D&C, neither side effects related to the MTX administration. Technical and clinical success rates were 97% and 85%, respectively. Mean percentage of β-HCG reduction was 90% (range - 99.92 to + 7.98%). Statistical analysis with linear regression shows a R² value of 0.9624 in UAE group while a R² value of 0.9440 in UAE + MTX group with statistical significance (p < 0.0001). No significative differences were found between the two groups about clinical success rate and embolic material adopted.

CONCLUSION

In this series UAE has been found to be safe and effective for the treatment of CSP.

Comparison of efficacies between ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin and hysteroscopic electro-resection after methotrexate chemotherapy in the treatment of cesarean scar pregnancy

To compare the efficacies between ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin and hysteroscopic electro-resection after methotrexate chemotherapy in the treatment of caesarean scar pregnancy (CSP). 60 patients with CSP admitted to our hospital were selected as the study subjects, and divided into observation group (n = 35) and control group (n = 25) in accordance with the therapeutic options. The observation group was treated with ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, while the control group was treated with hysteroscopic electro-resection after methotrexate chemotherapy. The observation group was superior to the control group in the amount of intraoperative haemorrhage, in-hospital costs, and postoperative time to control vaginal haemorrhage, time to return to a normal serum human chorionic gonadotropin (HCG) level. The observation group had a lower incidence rate of adverse reactions (5.71% vs. 28.00%, p < .05) and a higher first-attempt success rate for treatment (85.71% vs. 84.00%, p > .05) compared with the control group. Ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, exhibiting a higher efficacy, can more effectively shorten the postoperative recovery, reduce adverse reactions, and improve the postoperative quality of life in patients with CSP. IMPACT STATEMENTWhat is already known on this subject? Caesarean scar pregnancy (CSP), a rare form of ectopic pregnancy where the fertilised egg is implanted in the muscle or fibrous tissue of the scar after a previous caesarean section (CS), is a long-term complication of CS that may be life-threatening for parturients. Some therapies have been used to treat CSP, such as uterine artery embolisation and uterine artery embolisation chemotherapy combined with curettage, but the potential adverse effects may affect the ovarian reserve and even affecting the fertility of patients.What do the results of this study add? This study showed that ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, exhibiting a higher efficacy, can more effectively shorten the postoperative recovery, reduce adverse reactions, and improve the postoperative quality of life in patients with CSP.What are the implications of these findings for clinical practice and/or further research? The findings of this study may provide some references for the clinical practitioners and further research and may contribute to the treatment of 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.

Uterine Artery Embolization Combined with Subsequent Suction Evacuation as Low-Risk Treatment for Cesarean Scar Pregnancy

Objective: The aim of this study is to propose a standardized management of care for patients diagnosed with cesarean scar pregnancy (CSP). There are two types of CSP: Type 1 (on the scar) vs. type 2 (in the niche). To date there is no international standard to predict the extent of invasion or the optimal management of CSP. Materials and methods: We used intramuscular methotrexate injection followed by uterine artery embolization combined with suction evacuation as a conservative approach for the treatment of seven patients diagnosed with CSP. Our inclusion criteria, to be satisfied simultaneously, were established as follows: (1) patients with CSP; (2) early gestational age ≤ 9 weeks, and (3) written consent of the proposed treatment of the patient. Results: This course of treatment produced a positive outcome in all cases. We did not have any complications (e.g., emergency hysterectomy, perforation of the uterine cavity, severe hemorrhage, or endometritis) during the procedures or in the follow-up. The most important predictors of successful management are early diagnosis of CSP and orientation of the invasive trophoblast opposite to the scar. Conclusions: The main finding from this series of cases is that associating systemic methotrexate and uterine artery embolization provides efficient and low-risk management of CSP. This treatment regime is adequate for both types of CSPs. We consider that early localization diagnosis of pregnancy following a cesarean delivery is mandatory for CSP morbidity prevention.

High-intensity focused ultrasound compared with uterine artery chemoembolization with methotrexate for the management of cesarean scar pregnancy

OBJECTIVE

To compare the effectiveness and safety of high-intensity focused ultrasound (HIFU) versus uterine artery chemoembolization with methotrexate for the management of cesarean scar pregnancy (CSP).

METHODS

A total of 170 women with CSP were enrolled in the retrospective cohort study from April 2016 to September 2020. One hundred women received HIFU followed by suction curettage, and 70 women were treated with uterine artery chemoembolization followed by suction curettage.

RESULTS

The median blood loss during suction curettage was 20 ml (range 2-800 ml) in the HIFU group versus 20 ml (range 5-200 ml) in the chemoembolization group (P = 0.837). The mean time for β-human chorionic gonadotropin normalization was 28.52 ± 10.82 days versus 26.69 ± 8.97 days (P = 0.246), respectively. The mean time of menstruation recovery was 34.36 ± 10.63 days versus 31.93 ± 8.53 days (P = 0.114), respectively. The incidence of adverse effects in the HIFU group was lower than that in the chemoembolization group (P = 0.028). The median hospitalization time in the HIFU group was longer than that in the chemoembolization group (P = 0.000).

CONCLUSION

HIFU was as effective and safe as uterine artery chemoembolization in the management of CSP, and the incidence of adverse effects was lower.

The effect of ultrasound-guided high-intensity focused ultrasound treatment for cesarean scar pregnancy on ovarian reserve

OBJECTIVE

The aim of this study was to evaluate changes in anti-Müllerian hormone (AMH) levels after ultrasound-guided high-intensity focused ultrasound (USgHIFU) treatment of cesarean scar pregnancy (CSP).

METHODS

A retrospective case series study was conducted in the Affiliated Hospital of North Sichuan Medical College. Thirty-two women with cesarean scar pregnancy who met the inclusion criteria were enrolled in the study between January 2018 and December 2019. All patients underwent USgHIFU treatment with or without suction curettage. Intraoperative blood loss in suction curettage and hysteroscopy procedures, time to return of β-human chorionic gonadotropin (β-hCG) to normal levels, and time to recovery of normal menstruation were recorded. AMH levels before and 3 months after HIFU treatment were compared to determine whether USgHIFU treatment affected ovarian reserve.

RESULTS

AMH levels before and 3 months after HIFU ablation were 1.87 ± 1.19 ng/ml and 1.90 ± 1.17 ng/ml, respectively. There was no significant difference in AMH levels between the two-time points (p > .05). The median volume of intraoperative blood loss was 20 ml, the median time for the serum β-hCG level to return to normal was 35.5 days, and the median time of menstruation recovery was 39 days.

CONCLUSIONS

USgHIFU treatment for CSP was effective and safe without affecting ovarian reserve.

A Comparison of Ultrasound Guided Curettage With and Without Uterine Artery Embolization on Controlling Intraoperative Blood Loss for a Cesarean Scar Pregnancy Treatment: Study Protocol for a Randomized Clinical Trial

Introduction

Cesarean scar pregnancy affects 6% of all ectopic pregnancies in women with prior cesarean section, and there is currently no consensus on the optimal treatment. Options of surgical treatment have a risk of intraoperative blood loss; therefore, uterine artery embolization (UAE) has been considered as an option of reducing intraoperative blood loss. However, UAE may be overused in clinical practice, especially in China. We present this protocol for a randomized clinical trial investigating the necessity of performing UAE for cesarean scar pregnancy, in combination with surgical suction curettage, taking into account the different subtypes of cesarean scar pregnancy. We recently developed a risk-scoring system (QRS) to estimate intraoperative blood loss, with 93.8% sensitivity and 6.3% false negative. Through this randomized clinical trial, we will retrospectively validate the QRS score on predicting intraoperative blood loss.

Methods and Analysis

We propose undertaking a randomized clinical trial sequentially recruiting 200 patients. All the patients will randomly receive ultrasound guided curettage with or without UAE. Data on the subtypes of cesarean scar pregnancy (Types 1 and II and III) detected by ultrasound will be collected before operation. The score on estimating intraoperative blood loss assessed by our recently developed quantitative risk-scoring system (QRS) will be collected before the operation. We will primarily compare the duration of the operation, intraoperative blood loss, and complications between the two groups. We will also retrospectively analyze the association of subtypes of cesarean scar pregnancy and the options of treatment and validate the QRS score. Outcomes of subsequent pregnancy within the 2-year follow-up will be secondary outcomes.

Trial Registration Number

[website], identifier ChiCTR2100041654.

When to perform curettage after uterine artery embolization for cesarean scar pregnancy: a clinical study

Background

Prophylactic uterine artery embolization (UAE) combined with subsequent curettage is suggested as an effective and minimally invasive treatment strategy for cesarean scar pregnancy (CSP) with a high bleeding risk. However, the timing of curettage after UAE remains to be studied. Thus, we aimed to identify the optimal time interval to perform curettage after UAE in patients with CSP.

Methods

We conducted a retrospective cohort study in a large medical center for women and children in Southwest China. CSP patients treated by UAE combined with subsequent curettage were included and grouped by the treatment time interval between these two procedures. The clinical outcomes among arms were compared by univariate and multivariable analysis.

Results

Our study included 314 CSP patients who received this combination treatment in our department from January 2014 to December 2019. The median time interval between UAE and curettage was 48 h, with a range of 12-168 h among all participants. Thirty-two patients (10.2%) experienced intraoperative hemorrhage (blood loss ≥200 mL). Intrauterine balloon tamponade was used in 17 cases (5.4%). In 14 cases (4.5%), the procedure was converted to laparoscopy (or laparotomy). In the cohort study, patients with longer treatment intervals had more intraoperative blood loss and a higher incidence of complications than those with shorter intervals (P < 0.05). The rates of intraoperative bleeding were 5.0% for patients who received curettage within 24 h after UAE (Arm 1) and 19.4% for those who had a treatment interval longer than 72 h (Arm 4). In the multivariable logistic regression model of bleeding, a treatment interval > 72 h had an adjusted odds ratio of 3.37 (95% confidence interval: 1.40-8.09).

Conclusion

We suggest that curettage not be delayed longer than 72 h after UAE in this combined treatment of CSP.

Is suction curettage an effective treatment alternative for cesarean scar pregnancies?

OBJECTIVES

The study aims to evaluate the success rate of suction curettage (SC) as a first line treatment with or without use of foley balloon tamponade for cesarean scar pregnancy (CSP) and to determine the risk factors for failure of treatment.

STUDY DESIGN

The study was retrospective and included 36 CSP cases who underwent SC for treatment. Presence of pain with active bleeding and > 10 weeks of gestation were taken as the exclusion criterion. The procedure was performed under sonographic guidance. After the procedure, in patients who had a hemorrhage foley catheter was inserted into the uterine cavity. SC failure was defined as a requirement of secondary intervention. CSP types, myometrial thickness in the scar area, fetal cardiac activity, initial Beta human chorionic gonadotropin levels (β-HCG), history of vaginal delivery were compared between successful and failed groups.

RESULT

Of 36 patients, 31 had favorable results with SC ± foley balloon tamponade. Success rate was found to be 86 % (31/36) as the first line therapy. Foley catheter was applied for 23 patients, among them, four were in the failed group and 19 were in the favorable group. In the failed group, two patients had emergent laparotomy, two had repeat SC the day after the initial treatment and one patient was treated with systemic MTX. Fetal cardiac activity and presence of embryonic pole were not different between the groups (p = 1.000, p = 0.829 respectively). Myometrial thickness in the failed group was less than the successful group, this difference was significant (p = 0.033). CSP types, initial β-HCG levels and history of vaginal delivery were not different between the groups (p = 0.149, p = 0.372 and p = 0.404 respectively).

CONCLUSION

SC may be considered as a first line therapy for CSPs, and and in patients complicated with hemorrhage foley balloon tamponade can be used easily. Thinner myometrium at previous cesarean scar can be considered as a risk factor for failure of SC in patients with CSP.

Type II caesarean scar pregnancy management by ultrasound-guided local lauromacrogol injection in combination with suction curettage: A case report

INTRODUCTION

The implantation of a gestational sac within the scar of a previous caesarean delivery is defined as caesarean scar pregnancy (CSP), which is classified into two types: CSP I and CSP II. CSP II is life threatening, and no clear consensus for CSP II management exists.

PATIENT CONCERNS

A 31-year-old woman, gravida 1, para 1, with a previous caesarean delivery due to macrosomia, presented with an estimated 45 days of amenorrhea. The patient presented to the emergency department with vaginal bleeding for 1 day and no abdominal pain.

DIAGNOSES

An ultrasound examination was performed demonstrating a viable fetus that was embedded in the caesarean scar area and was bulging through the wall of the uterus into the bladder without contact with the uterine cavity or cervical canal. A diagnosis of type II caesarean scar pregnancy was made.

INTERVENTIONS

Local lauromacrogol was used to reduce the gestational sac blood supply. Suction curettage was performed under the guidance of abdominal ultrasound 24 h later, and the amount of bleeding was 20 mL. The response to the treatment was monitored by serial beta-human chorionic gonadotropin (β-hCG).

OUTCOMES

Patient was followed up with β-hCG weekly levels which became <10 mIU/mL after 4 weeks of treatment.

CONCLUSION

Ultrasound-guided local lauromacrogol injection combined with suction curettage may be a safer and novel therapeutic method.

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.

Scoring system for the prediction of the successful treatment modality in women with cesarean scar pregnancy

OBJECTIVE

To establish a risk scoring system to predict the successful treatment of cesarean scar pregnancy.

METHODS

A prospective observational study was conducted between June 2016 and March 2018 in a tertiary care center. Patients received evacuation followed by uterine artery embolization and laparoscopic local resection/hysterectomy successively as salvage measures if necessary. Optimal scaling regression determined the extent of each potential prognostic factor predicted.

RESULTS

Out of 228 women, 144 cases required evacuation before recovery, 73 women required uterine artery embolization, and 11 women eventually required laparoscopic surgery. Six variables were included in the predictive model: number of cesarean deliveries; maximal diameter of gestational sac; remnant myometrial thickness; grading of Doppler signals; presence of fetal heartbeat; and location of gestational sac. A 10-point scoring system was established by weighting their prediction of the method of successful treatment. In the risk score rank of 1-4, only 4 (2.8%) out of 142 women needed uterine artery embolization as a salvage treatment, while in the risk score rank of 8-10, 41 (80.4%) cases needed uterine artery embolization; laparoscopic operations were performed by physicians for the other 10 (19.6%) cases.

CONCLUSION

The successful treatment of cesarean scar pregnancy was accurately predicted by a 10-point scoring system.

CHINESE CLINICAL TRIALS REGISTRY

ChiCTR-OOC-16008467.

Comparing the Efficacy and Safety of High-Intensity Focused Ultrasound and Uterine Artery Embolization in Caesarean Scar Pregnancy: A Meta-analysis

INTRODUCTION

High-intensity focused ultrasound (HIFU) followed by curettage and uterine artery embolization (UAE) followed by curettage are two methods of treatment for caesarean scar pregnancy (CSP). There is currently no consistent evidence concerning any difference in efficacy and safety between UAE and HIFU. Therefore, a meta-analysis was performed to compare the efficacy and safety of HIFU and UAE in the treatment of CSP.

METHODS

Studies published in PubMed, Cochrane, Embase, Web of Science, Chinese BioMedical Literature Service System, and Chinese National Knowledge Infrastructure databases were searched and the main outcomes in the studies were extracted.

RESULTS

Of 8 studies and 715 patients included in this study, 388 and 327 patients were in the HIFU group and UAE groups, respectively. Compared with the UAE group, patients in the HIFU group had less blood loss [weighted mean difference (WMD) = - 22.58 ml; 95% confidence interval (CI) - 44.45 to - 0.70; p < 0.05), lower incidence of adverse events [odds ratio (OR) = 0.17; 95% CI 0.06-0.46; p < 0.05); shorter duration of hospital stay (WMD = - 0.96 days; 95% CI - 1.88 to - 0.03; p < 0.05); and a longer β-human chorionic gonadotropin normalisation time (WMD = 9.59 days; 95% CI 1.66-17.52; p < 0.05).

CONCLUSION

Patients in the HIFU group appeared to have better outcomes than those in the UAE group; thus, HIFU may be a priority option for the early management of CSP. However, this needs to be confirmed by multi-centre, large-scale randomised controlled trials.

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.

Cesarean Scar Ectopic Pregnancy: Current Management Strategies

Importance

Cesarean scar ectopic pregnancy (CSEP) has a high rate of morbidity with nonspecific signs and symptoms making identification difficult. The criterion-standard treatment of CSEP has been subject to debate.

Objective

This review defines CSEP, discusses pathogenesis and diagnosis, and compares treatment options and outcomes.

Evidence Acquisition

A literature review was performed utilizing the term cesarean scar ectopic pregnancy and subsequently selecting only meta-analyses and systematic reviews. Only articles published in English were included. Relevant articles within the reviews were analyzed as necessary.

Results

Five basic pathways have been identified in treatment of CSEP: expectant management, medical therapy, surgical intervention, uterine artery embolization, or a combination approach. Expectant management has the highest probability of morbid outcomes, including hemorrhage, uterine rupture, and preterm delivery. Medical management often requires further treatment with additional medication or surgery. Different surgical methods have been explored including uterine artery embolization; dilation and curettage; surgical removal via vaginal, laparoscopic, or laparotomic approach; and hysterectomy. Each method has various levels of success and depends on surgeon skill and patient presentation.

Conclusions

Recent research supports any method that removes the pregnancy and scar to reduce morbidity and promote future fertility. Laparoscopic and transvaginal approaches are options for CSEP treatment, although continued research is required to identify the optimal approach.

Relevance

As cesarean delivery numbers rise, a subsequent increase in CSEPs can be anticipated. The ability to accurately diagnose and treat this morbid condition is vital to the practice of any specialist in general obstetrics and gynecology.

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.

Identification and treatment of gestational trophoblastic neoplasia located in the cesarean scar

OBJECTIVE

To identify the clinical characteristics of, and the diagnostic and therapeutic strategies for, gestational trophoblastic neoplasia (GTN) located in the cesarean scar.

METHODS

The present retrospective analysis was conducted among patients diagnosed with GTN located in the cesarean scar at Peking Union Medical College Hospital, Beijing, China, between June 1, 2006, and May 31, 2016. Clinical features, diagnostic and therapeutic procedures, and outcomes were reviewed.

RESULTS

Of 938 women diagnosed with GTN, 31 (3.3%) patients had GTN located in the cesarean scar. Irregular vaginal bleeding was the main clinical manifestation. Twenty (65%) patients received an accurate diagnosis based on a history of molar pregnancy/a high β-human chorionic gonadotropin level/typical imaging presentations. The remaining 11 patients were initially misdiagnosed; the definitive diagnosis was made by pathology. All patients received chemotherapy; 22 (71%) women also underwent hysterectomy or localized uterine lesion resection because of chemoresistant lesions. All patients had a complete remission; at a median follow-up of 35 months, only 1 (3%) woman had a relapse.

CONCLUSION

Owing to its rarity and nonspecific symptoms, GTN located in the cesarean scar is prone to misdiagnosis. In patients without typical manifestations, the definitive diagnosis often relies on pathology. For treatment, uterine lesion resection is a useful adjunct to chemotherapy.