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

A combination of laparoscopy and bilateral uterine artery occlusion for the treatment of type II cesarean scar pregnancy: a retrospective analysis

OBJECTIVE

We investigated the efficacy of a combination of laparoscopy and bilateral uterine artery occlusion (BUAO) for the treatment of type II cesarean scar pregnancy (CSP).

METHODS

Patients with type II CSP underwent laparoscopy + bilateral uterine artery embolization (control group) or laparoscopy + BUAO (study group). Data regarding the duration of surgery, intraoperative hemorrhage, postoperative complications, the duration of the hospital stay, and the costs of hospitalization were retrospectively collected. One year later, the time to the return of the β-human chorionic gonadotropin (β-hCG) concentration to normal and to the return of menstruation were compared.

RESULTS

The duration of surgery, time to the return of menstruation, and incidence of postoperative complications in the study group were significantly less than in the control group, but there was no significant difference in the time for β-hCG to return to normal or the volume of intraoperative hemorrhage. The duration of hospitalization and costs for the control group were higher than those for the study group.

CONCLUSION

Laparoscopy in combination with BUAO is associated with minimal trauma, rapid recovery, a short duration of surgery, low cost of hospitalization, and a low postoperative complication rate. Thus, it represents a useful new surgical treatment for type II CSP.

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.

Efficacy, Safety and Outcomes of the Laparoscopic Management of Cesarean Scar Ectopic Pregnancy as a Single Therapeutic Approach: A Case Series

A standardized consensus for the management of cesarean scar pregnancy (CSP) is lacking. The study objective is to evaluate the efficacy, safety and outcomes of the laparoscopic management of CSP as a single therapeutic surgical approach without being preceded by vascular pretreatment or vasoconstrictors injection. This is a retrospective bi-centric study, a case series. Eight patients with a future desire to conceive underwent the laparoscopic treatment of unruptured CSPs. Surgery consisted of "en bloc" excision of the deficient uterine scar with the adherent tissue of conception, followed by immediate uterine repair. The data collected for each patient was age, gestity, parity, number of previous c-sections, pre-pregnancy isthmocele-related symptoms, gestational age, fetal cardiac activity, initial β-human chorionic gonadotropin levels, intra-operative blood loss, blood transfusion, operative time and the postoperative complications, evaluated according to Clavien-Dindo classification. The CSP was successfully removed in all patients by laparoscopy. The surgical outcomes were favorable. All patients with histories of isthmocele-related symptoms reported postoperative resolution of symptoms. The median residual myometrium thickness increased significantly from 1.2 mm pre-operatively to 8 mm 3 to 6 months after surgery. The laparoscopic management seems to be an appropriate treatment of CSP when performed by skilled laparoscopic surgeons. It can be safely proposed as a single surgical therapeutic approach. Larger series and further prospective studies are needed to confirm this observation and to affirm the long-term gynecological and obstetrical outcomes of this management.

Clinical efficacy analysis of laparoscopic uterine artery pre-ligation combined with hysteroscopic curettage in the treatment of type II cesarean scar pregnancy

Objective

To explore and evaluate the clinical therapeutic effect of laparoscopic uterine artery pre-ligation combined with hysteroscopic curettage in the treatment of type II cesarean scar pregnancy.

Methods

This study analyzed the clinical data of patients with cesarean scar pregnancy (CSP) in the Maternal and Child Health Hospital of Hubei Province from 2018 to 2022. A total of 134 patients with type II cesarean section were enrolled, out of which 78 patients were included in the final analysis. Treatment included either uterine artery embolization (UAE) combined with hysteroscopic curettage (n = 37 patients) or laparoscopic uterine artery pre-ligation (LUAP) combined with hysteroscopic curettage (n = 41 patients). The demographic and clinical characteristics of these two groups were recorded, and their short- and long-term complications on follow-up were compared. For patients with subsequent fertility requirements, we followed up these patients for 2 years after surgery, then collected and analyzed the compared subsequent pregnancy outcome.

Results

We found no significant discrepancies in the success rate of operation, length of hospital stay, and intraoperative blood loss between the two different operation modes. The cost of LUAP was significantly lower than that of UAE. Furthermore, the incidence of short-term postoperative complications such as fever and pelvic pain was lower in patients treated with LUAP than in those treated with UAE. In terms of long-term postoperative complications, the recovery time for menstruation in the LUAP group (49.81 ± 11.47) was earlier than that in the UAE group (34.90 ± 7.41) (p < 0.05). Additionally, 4.9% of patients in the LUAP group had decreased menstrual flow, while 59% of patients in the UAE group had a marked decrease in menstrual flow, and the incidence and severity of intrauterine adhesions were significantly lower in the LUAP group than in the UAE group(p < 0.05). Consistent with the aforementioned observations, patients treated with LUAP had better postoperative re-pregnancy outcomes than those treated with UAE.

Conclusions

Based on the findings, LUAP combined with hysteroscopic curettage is a safe and effective surgical scheme for the treatment of type II CSPs. In addition, compared with UAE, LUAP is associated with a lower surgical cost, fewer short and long-term complications, and better postoperative pregnancy outcomes. Thus, it should be widely applied in patients with type II CSPs.

Laparoscopic management of a second trimester ruptured spontaneous heterotopic tubal pregnancy mimicking ovarian tumour, a case report

BACKGROUND

Laparoscopic surgery in the second trimester of pregnancy is a high risk and demanding operation. Especially when dealing with adnexal pathology, the surgeon should balance between the effort to establish adequate visualisation of the operating field with minimal uterine manipulation and use of energy application to avoid any potential adverse effects on the intrauterine pregnancy.

OBJECTIVE

The video shows laparoscopic surgery performed in the second trimester of pregnancy and highlights modifications to technique to ensure safety. Materials and Methods: We present a case report of spontaneous heterotopic tubal pregnancy that mimicked an ovarian tumour and was managed surgically with a laparoscopy in the second trimester. During surgery, a previously ruptured left tubal pregnancy (? ectopic) was the cause for a concealed hematoma in the pouch of Douglas, misdiagnosed as ovarian tumour. This is one of the few cases of heterotopic pregnancy treated by laparoscopy in the second trimester of pregnancy.

RESULTS

The patient was discharged the day 2 post-operatively, the intrauterine pregnancy progressed, and the patient delivered with a planned caesarean section on the 38th week.

CONCLUSIONS

Laparoscopic surgery, with adjustments, is a safe and effective method to manage adnexal pathology during a second trimester pregnancy.

Caesarean Scar Pregnancy: A Case Report and a Literature Review

Background and Objectives: Caesarean scar pregnancy (CSP) refers to placental implantation on or in the scar of a previous caesarean section and represents a potentially life-threatening condition. CSP is considered a diagnostic challenge in obstetrics, with the diagnosis relying mainly on transvaginal ultrasound (TVS) and the management depending upon case presentation and available healthcare infrastructures. Case Presentation: We present a case of 34-year-old G3P2 with a history of two-previous caesarean sections referred to the outpatient gynaecology clinic of our Department at the 7th week (7/40) of gestation with abnormal early pregnancy TVS findings, illustrating the gestational sac attached to the caesarean scar and a foetal pole with evidence of foetal cardiac activity. We discuss the outcome of an alternative combined medical and surgical approach we followed as well as an updated review of the current literature. Conclusions: The ideal management of CSP requires tertiary centers, equipment availability and experienced healthcare professionals capable of dealing with any possible complication, as well as individualized treatment based on each case presentation.

Hysteroscopic treatment of Cesarean Scar Pregnancy: A systematic review

More than 30 regimens, medical and surgical, have been described for the treatment of Cesarean Scar Pregnancies (CSPs). This study aims to collect and analyze data in the published literature regarding the hysteroscopic management of CSPs focusing on efficacy and complications. Using a protocol registered with Prospero (#CRD42021242314), the electronic databases PubMed/Medline, Scopus, Clinical-Trials.gov and the Cochrane Library were comprehensively searched, from their inception to June 2020. Medical Subject Headings terms such as caesarean ectopic, hysteroscopy and endoscopy were used for the identification of the relevant records. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to design the present systematic review. Eligible articles assessing the role of hysteroscopy in CSP were considered the studies published in peer-reviewed journals. Any studies with less than 10 cases or articles that insufficiently detailed the treatment regimen, the outcomes, and the success rate, were excluded. Selected articles were assessed for the level of evidence, based on Oxford Centre for Evidence-based Medicine guidelines. The methodologic quality, including the risk of bias, was evaluated with the employment of the Effective Public Health Practice Project Quality Assessment Tool. Ten out of 613 studies were included in the present review comprising 812 women with CSP treated by hysteroscopy. The treatment modalities were divided into three categories: (i) hysteroscopic resection of CSP, (ii) hysteroscopy after preoperative use of HIFU and (iii) preoperative use of UAE before hysteroscopic treatment. The overall success rate of hysteroscopic treatment on CSP cases was 91%, whereas the rate of hemorrhage or excessive vaginal bleeding (>500 mL) and the rate of hysterectomy were 1.66% and 0.28% respectively. According to the results of this systematic review, hysteroscopy appears to be a safe and effective procedure for CSP management. Current findings are primarily based on retrospective studies with poor methodological quality. Multicenter, well-designed studies are needed to draw definite conclusions.

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.