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Alameddine S, Lucidi A, Jurkovic D, Timor Tritsch I, Coutinho CM, Ranucci L, Buca D, Khalil A, Jauniaux E, Mappa I, D'Antonio F. Treatments for cesarean scar pregnancy: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2024; 37:2327569. [PMID: 39385517 DOI: 10.1080/14767058.2024.2327569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 10/12/2024]
Abstract
OBJECTIVE To report the outcome of cesarean scar pregnancy (CSP) undergoing treatment. METHODS MEDLINE, Embase and CINAHL databases were searched. Inclusion criteria were women with CSP undergoing treatment. The primary outcome was successful treatment for CSP, defined as no need for additional medical or surgical strategies. Secondary outcomes were the type of additional treatment (surgical or medical), need for blood transfusion, emergency laparotomy, hysterectomy, post-treatment complications.All these outcomes were explored in women undergoing single and compound treatments for CSP. Furthermore, we performed a separate sub-group analysis only including studies which reported on the outcomes of elective treatments. Random effects meta-analyses were used to analyze the data and results reported as pooled proportions or odd ratio (OR). RESULTS 176 studies (13431 women with CSP undergoing treatment) were included.Successful treatment after primary intervention was achieved in 86.2% (95% CI 82.3-89.7) of women with CSP undergoing treatment with ultrasound guided suction curettage, 72.4% (95% CI 64.8-79.3) with systemic MTX, 81.6% (95% CI 72.3-89.3) with local MTX, 83.9% (95% CI 66.7-95.6) with interventional radiology, 90.42% (95% CI 82.9-96.0) with hysteroscopy, 96.1% (95% CI (92.3-98.6) with laparoscopy and 92.6 with high intensity focused ultrasound (95% CI 78.2-99.6). Post-treatments complications were reported in 3.5% (95% CI 1.7-6.0) of women treated with systemic MTX, 5.9% (95% CI 0.8-15.1) with local MTX or KCl, 1.2% (95% CI 0.1-3.5) with interventional radiology, 1.4% (95% CI 0.4-2.9) with hysteroscopy, 5.5% (95% CI 0.4-25.7) with high intensity focused ultrasound and in none of the cases treated with ultrasound guided suction curettage.When considering compound treatments, successful resolution of CSP was achieved in 91.9% (95% CI 88.0-95.10) of women treated with interventional radiology followed by curettage, 83.3% (95% CI 68.8-93.8) with systemic MTX and curettage, 79.4% (95% CI 56.3-95.2) with local MTX and curettage, 96.2% (95% CI 92.3-98.7) with curettage followed by single or double balloon insertion in the uterine cavity, 98.3% (95% CI 95.9-99.7) with high intensity focused ultrasound followed by curettage, 91.1% (95% CI 3.4-97.0) with interventional radiology followed by removal of CSP with hysteroscopy, 64.3% (95% CI 13.8-99.2) with interventional radiology and systemic MTX and in 95.5% (95% CI 92.9-97.5) with curettage and hysteroscopy.When considering studies reporting a comparison between different treatments, there was no difference between systemic vs local MTX in the primary outcome. Curettage was associated with a higher chance of achieving a successful treatment. CONCLUSIONS A multitude of treatments for CSP have been reported in the published literature. All treatments described for CSP are apparently equally effective in treating this condition. The findings from this systematic review highlight the need for adopting a common definition and outcome reporting of CSP to better elucidate its natural history, estimate the magnitude of maternal complication after treatment and design appropriately powered RCT to elucidate the optimal treatment of CSP according to its ultrasound phenotype and gestational age at treatment, in terms of effective resolution of the condition and risk of post-intervention complications.
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Affiliation(s)
- Sara Alameddine
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Alessandro Lucidi
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Davor Jurkovic
- Institute for Women's Health, University College London, London, United Kingdom
| | | | - Conrado Milani Coutinho
- Department of Gynecology and Obstetrics, Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ludovica Ranucci
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Danilo Buca
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Asma Khalil
- Fetal medicine Unit, St. George's University of London, UK
| | - Eric Jauniaux
- EGA Institute for Women's Health, University College London, London, UK
| | - Ilenia Mappa
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
| | - Francesco D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
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Yang M, Cao L, Yan J, Tang Y, Cao N, Huang L. Risk factors associated with the failure of initial treatment for cesarean scar pregnancy. Int J Gynaecol Obstet 2023; 162:937-944. [PMID: 36971491 DOI: 10.1002/ijgo.14761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 02/13/2023] [Accepted: 03/07/2022] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To explore the factors related to cesarean scar pregnancy (CSP) treatment failure under different treatment strategies. METHODS This is a cohort study that consecutively included 1637 patients with CSP. Characteristics including age, gravidity, parity, previous uterine curettages, time since the last cesarean section, gestational age, mean sac diameter, initial serum β-human chorionic gonadotropin, distance between gestational sac and serosal layer, CSP subtype, classification of blood flow abundance, fetal heartbeat presence, and intraoperative bleeding were recorded. Four strategies were performed separately on these patients. Binary logistic regression analysis was used to analyze the risk factors for initial treatment failure (ITF) under the different treatment strategies. RESULTS The treatment methods failed in 75 CSP patients, and succeeded in 1298 patients. The analysis found that the presence of a fetal heartbeat was significantly associated with ITF of strategy 1, 2 and 4 (P < 0.05); sac diameter was associated with ITF of strategy 1 and 2 (P < 0.05); gestational age was associated with initial treatment failure of strategy 2 (P < 0.05). CONCLUSION There was no difference of the failure rate between ultrasound-guided evacuation and hysteroscopy-guided evacuation for CSP treatment with or without uterine artery embolization pretreatment. Sac diameter, fetal heartbeat presence, and gestational age were all associated with CSP initial treatment failure.
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Affiliation(s)
- Mengjia Yang
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lili Cao
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jinyu Yan
- Shanxi Tumor Hospital, Taiyuan, China
| | - Yibo Tang
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Nanyu Cao
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lili Huang
- Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Nijjar S, Jauniaux E, Jurkovic D. Surgical evacuation of cesarean scar ectopic pregnancies. Best Pract Res Clin Obstet Gynaecol 2023; 89:102361. [PMID: 37356118 DOI: 10.1016/j.bpobgyn.2023.102361] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 04/13/2023] [Accepted: 05/02/2023] [Indexed: 06/27/2023]
Abstract
Cesarean scar ectopic pregnancy is associated with significant maternal morbidity, including severe hemorrhage, need for the blood transfusion and hysterectomy. Early diagnosis is therefore key in ensuring timely management, with consensus being that treatment before 9 weeks of gestation leads to reduced morbidity. There is no universally adopted management protocol for cesarean scar ectopic pregnancy, but surgical management generally has a higher success rate than medical management. The primary surgical treatment modalities are suction evacuation versus resection of the pregnancy via multiple routes. Adjuncts that have been shown to successfully minimize bleeding with surgical management include cervical cerclage, balloon catheter, and uterine artery embolization. However, there remains a lack of high-quality evidence regarding what is the best surgical treatment option for cesarean scar ectopic pregnancy, and therefore it is essential that clinicians provide tailored management to patients considering the presenting symptoms and local expertise with various surgical techniques.
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Affiliation(s)
- Simrit Nijjar
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Davor Jurkovic
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
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Leanza V, Incognito GG, Gulino FA, Tuscano A, Cimino M, Palumbo M. Cesarean Scar Pregnancy and Successful Ultrasound-Guided Removal after Uterine Artery Ligation. Case Rep Obstet Gynecol 2023; 2023:6026206. [PMID: 37123052 PMCID: PMC10147527 DOI: 10.1155/2023/6026206] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 03/24/2023] [Accepted: 04/17/2023] [Indexed: 05/02/2023] Open
Abstract
A correct management of cesarean scar pregnancy (CSP) is mandatory to avoid further complications. There is no consensus for the standard therapy and the most frequent methods used are not free from failures and sequelae. A 38-year-old woman was admitted referring amenorrhea lasting 9 weeks, pelvic pain, and vaginal bleeding. She had three previous cesarean sections. Transvaginal ultrasound showed a gestational sac of 16 mm in the cervico-isthmic site and inside the thickness of the uterine wall, and the dosage of beta-human chorionic gonadotropin was 12,770 mU/mL. A diagnosis of CSP was done, and an ultrasound-guided removal after uterine artery cervical branch ligation was performed. The follow-up was uneventful. Even if not yet codified in the literature, our therapeutic procedure should be considered in other similar cases in the future, as it potentially limits the possible iatrogenic problems and reduces intraoperative and postoperative bleeding to a minimum.
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Affiliation(s)
- Vito Leanza
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Giosuè Giordano Incognito
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Ferdinando Antonio Gulino
- Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione Garibaldi Nesima, Catania, Italy
| | - Attilio Tuscano
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Monia Cimino
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Marco Palumbo
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
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Marchand GJ, Masoud AT, Coriell C, Ulibarri H, Parise J, Arroyo A, Goetz S, Moir C, Moberly A, Govindan M. Treatment of Cesarean Scar Ectopic Pregnancy in China with Uterine Artery Embolization-A Systematic Review and Meta-Analysis. J Clin Med 2022; 11:7393. [PMID: 36556010 PMCID: PMC9783593 DOI: 10.3390/jcm11247393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/28/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Greg J. Marchand
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Ahmed Taher Masoud
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
- Faculty of Medicine, Fayoum University, Fayoum 63514, Egypt
| | - Catherine Coriell
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Hollie Ulibarri
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Julia Parise
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Amanda Arroyo
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Sydnee Goetz
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Carmen Moir
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Atley Moberly
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
| | - Malini Govindan
- Marchand Institute for Minimally Invasive Surgery, Mesa, AZ 85209, USA
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Endovascular treatment of cesarean scar pregnancy: a retrospective multicentric study. LA RADIOLOGIA MEDICA 2022; 127:1313-1321. [PMID: 36167883 DOI: 10.1007/s11547-022-01536-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 07/25/2022] [Indexed: 12/15/2022]
Abstract
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.
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Uterine Artery Embolization Combined with Subsequent Suction Evacuation as Low-Risk Treatment for Cesarean Scar Pregnancy. Diagnostics (Basel) 2021; 11:diagnostics11122350. [PMID: 34943587 PMCID: PMC8700670 DOI: 10.3390/diagnostics11122350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/25/2021] [Accepted: 12/07/2021] [Indexed: 11/26/2022] Open
Abstract
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.
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Yang J, Li B, Liu J, Zeng W, Hong L. A New Modified Hysteroscopic-Laparoscopic Surgery for Cesarean Scar Pregnancy of Stable Type III. Int J Gen Med 2021; 14:2289-2295. [PMID: 34113158 PMCID: PMC8184249 DOI: 10.2147/ijgm.s308768] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 05/18/2021] [Indexed: 11/23/2022] Open
Abstract
Objective To introduce a modified hysteroscopic-laparoscopic operation for cesarean scar pregnancy (CSP) of stable type III. Patients and Methods We retrospectively studied the case notes of 31 patients with stable type III cesarean scar pregnancy who underwent hysteroscopic-laparoscopic surgery in our hospital. Thirteen patients received the modified hysteroscopic-laparoscopic surgery (modified surgery group), and eighteen patients received traditional hysteroscopic-laparoscopic surgery (traditional surgery group). Results There was no significant difference in patients' age, gestational age, number of previous cesarean sections, the serum human chorionic gonadotropin (hCG) level before surgery, gestational sac diameter, myometrium thickness between the two groups. In the modified hysteroscopic-laparoscopic surgery, the mean surgical time was 50.45±24.45 mins, the mean length of stay in hospital was 4.50±0.50 days, which was significantly shorter than the traditional surgery group (84.75±33.28 mins and 5.50±0.75 days, respectively). And the intraoperative hemorrhage in the modified group was also less than that in the traditional group (40.50±12.25 mL vs 75.33±25.45mL). Whereas the time for hCG normalization, postoperative vaginal bleeding and menstrual recovery had no significant difference between the modified surgery group and the traditional surgery group. There was no recurrence of CSP in both groups. Conclusion The modified hysteroscopic-laparoscopic surgery had shorter operation time, less blood loss, and sooner recovery time after surgery compared to traditional hysteroscopic-laparoscopic surgery, which could be more beneficial to our patients and should be applied in clinics generally.
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Affiliation(s)
- Jiang Yang
- Department of Gynecology and Obstetrics, Renmin Hospital of Wuhan University, Hubei, People's Republic of China
| | - Bingshu Li
- Department of Gynecology and Obstetrics, Renmin Hospital of Wuhan University, Hubei, People's Republic of China
| | - Jin Liu
- Department of Gynecology and Obstetrics, Renmin Hospital of Wuhan University, Hubei, People's Republic of China
| | - Wanlin Zeng
- Department of Gynecology and Obstetrics, Renmin Hospital of Wuhan University, Hubei, People's Republic of China
| | - Li Hong
- Department of Gynecology and Obstetrics, Renmin Hospital of Wuhan University, Hubei, People's Republic of China
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Cesarean Scar Pregnancy Treated by Artery Embolization Combined with Diode Laser: A Novel Approach for a Rare Disease. ACTA ACUST UNITED AC 2021; 57:medicina57050411. [PMID: 33922785 PMCID: PMC8146286 DOI: 10.3390/medicina57050411] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/12/2021] [Accepted: 04/22/2021] [Indexed: 11/22/2022]
Abstract
Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy which represents a consequence of a previous cesarean section. It is associated with major maternal morbidity and mortality and has potential implications on future fertility. Because of possible serious complications, CSP should be swiftly diagnosed and treated. There is no management protocol for this rare, life-threatening condition, and each patient should be evaluated individually. Several types of conservative treatment have been used to treat cesarean scar pregnancy: dilation and curettage (D&C), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolization with curettage and/or methotrexate administration. In our study we present a cesarean scar pregnancy of a 40-year-old woman who was treated with angiographic uterine artery embolization (UAE) followed by hysteroscopic diode laser resection. Our combined UAE–hysteroscopic laser surgery appears to offer an effective, safe, and minimally invasive surgical treatment.
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Mosconi C, Crocetti L, Bruno A, Candita G, Cappelli A, Perrone O, Golfieri R, Cioni R. Scar Pregnancy and Extrauterine Implants. Semin Ultrasound CT MR 2021; 42:46-55. [PMID: 33541589 DOI: 10.1053/j.sult.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cesarean scar pregnancy (CSP) is a rare occurrence consisting in the implantation of the embryo within the myometrium of a prior cesarean delivery scar. The CSP could be a dangerous condition for women because of the related complications such as placenta previa or accreta, uterine rupture, and hemorrhage. Therefore, early diagnosis and rapid treatment are crucial. Extrauterine implants or ectopic pregnancy (EP) consists in the implantation of an embryo in a site other than the endometrium of the uterine cavity. It occurs in 1%-2% of all reported pregnancies. The most common extrauterine location is the fallopian tube, which represents 96% of cases. The diagnosis of CSP and EP is based on history, clinical examination, levels of serum β-human chorionic gonadotropin (β-hCG), and ultrasonography findings. In last 20 years, new treatments were developed, varying from medical management, minimally invasive surgical approach and local treatment including systemic or local infusion of metotrexate (MTX), and uterine artery embolization (UAE). UAE has been used widely to control hemorrhage and preserve the uterus and it is considered an affective adjuvant treatment of CSP and EP, especially associated with other therapies.
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Affiliation(s)
- Cristina Mosconi
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Laura Crocetti
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Antonio Bruno
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Gianvito Candita
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alberta Cappelli
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Orsola Perrone
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Roberto Cioni
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
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Abstract
BACKGROUND Non-tubal ectopic pregnancy is the implantation of an embryo at a site lying outside the uterine cavity or fallopian tubes. Sites include a caesarean scar, the cornua uteri, the ovary, the cervix, and the abdomen. There has been an increasing trend in the occurrence of these rare conditions, especially caesarean scar pregnancy (CSP). OBJECTIVES To evaluate the clinical effectiveness and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy in terms of fertility outcomes and complications. SEARCH METHODS We searched the Cochrane Gynaecology and Fertility (CGF) Group Specialised Register of Controlled Trials, CENTRAL, MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) search portal and nine other databases to 12 December 2019. We handsearched reference lists of articles retrieved and contacted experts in the field to obtain additional data. SELECTION CRITERIA We included randomized controlled trials (RCTs) published in all languages that examined the effects and safety of surgery, medical treatment, and expectant management of non-tubal ectopic pregnancy. DATA COLLECTION AND ANALYSIS We used Cochrane standard methodological procedures. Primary outcomes were treatment success and complications. MAIN RESULTS We included five RCTs with 303 women, all reporting Caesarean scar pregnancy. Two compared uterine arterial embolization (UAE) or uterine arterial chemoembolization (UACE) plus methotrexate (MTX) versus systemic MTX and subsequent dilation and suction curettage; one compared UACE plus MTX versus ultrasonography-guided local MTX injection; and two compared suction curettage under hysteroscopy versus suction curettage under ultrasonography after UAE/UACE. The quality of evidence ranged from moderate to very low. The main limitations were imprecision (small sample sizes and very wide confidence intervals (CI) for most analyses), multiple comparisons with a small number of trials, and insufficient data available to assess heterogeneity. UAE/UACE versus systemic MTX prior to suction curettage Two studies reported this comparison. One compared UAE with systemic MTX and one compared UACE plus MTX versus systemic MTX, in both cases followed by a suction curettage. We are uncertain whether UAE/UACE improved success rates after initial treatment (UAE: risk ratio (RR) 1.00, 95% CI 0.90 to 1.12; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.87, 95% CI 0.54 to 1.38; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced rates of complications (UAE: RR 0.47, 95% CI 0.13 to 1.75; 1 RCT, 72 women; low-quality evidence; UACE: RR 0.62, 95% CI 0.26 to 1.48; 1 RCT, 28 women; low-quality evidence). We are uncertain whether UAE/UACE reduced adverse effects (UAE: RR 1.58, 95% CI 0.41 to 6.11; 1 RCT, 72 women; low-quality evidence; UACE: RR 1.16, 95% CI 0.32 to 4.24; 1 RCT, 28 women; low-quality evidence), and it was not obvious that the types of events had similar values to participants (e.g. fever versus vomiting). Blood loss was lower in UAE/UACE groups than systemic MTX groups (UAE: mean difference (MD) -378.70 mL, 95% CI -401.43 to -355.97; 1 RCT, 72 women; moderate-quality evidence; UACE: MD -879.00 mL, 95% CI -1135.23 to -622.77; 1 RCT, 28 women; moderate-quality evidence). Data were not available on time to normalize β-human chorionic gonadotropin (β-hCG). UACE plus MTX versus ultrasonography-guided local MTX injection We are uncertain whether UACE improved success rates after initial treatment (RR 0.95, 95% CI 0.56 to 1.60; 1 RCT, 45 women; very low-quality evidence). Adverse effects: the study reported the same number of failed treatments in each arm (RR 0.88, 95% CI 0.40 to 1.92; 1 RCT, 45 women). We are uncertain whether UACE shortened the time to normalize β-hCG (MD 1.50 days, 95% CI -3.16 to 6.16; 1 RCT, 45 women; very low-quality evidence). Data were not available for complications. Suction curettage under hysteroscopy versus under ultrasonography after UAE/UACE. Two studies reported this comparison. One compared suction curettage under hysteroscopy versus under ultrasonography after UAE, and one compared these interventions after UACE. We are uncertain whether suction curettage under hysteroscopy improved success rates after initial treatment (UAE: RR 0.91, 95% CI 0.81 to 1.03; 1 RCT, 66 women; very low-quality evidence; UACE: RR 1.02, 95% CI 0.96 to 1.09; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced rates of complications (UAE: RR 4.00, 95% CI 0.47 to 33.91; 1 RCT, 66 women; very low-quality evidence; UACE: RR 0.18, 95% CI 0.01 to 3.72; 1 RCT, 92 women; low-quality evidence). We are uncertain whether suction curettage under hysteroscopy reduced adverse effects (UAE: RR 3.09, 95% CI 0.12 to 78.70; 1 RCT, 66 women; very low-quality evidence; UACE: not estimable; 1 RCT, 92 women; very low-quality evidence). We are uncertain whether suction curettage under hysteroscopy shortened the time to normalize β-hCG (UAE: MD 4.03 days, 95% CI -1.79 to 9.85; 1 RCT, 66 women; very low-quality evidence; UACE: MD 0.84 days, 95% CI -1.90 to 3.58; 1 RCT, 92 women; low-quality evidence). Non-tubal ectopic pregnancy other than CSP No studies reported on non-tubal ectopic pregnancies in locations other than on a caesarean scar. AUTHORS' CONCLUSIONS For Caesarean scar pregnancies (CSP) it is uncertain whether there is a difference in success rates, complications, or adverse events between UAE/UACE and administration of systemic MTX before suction curettage (low-quality evidence). Blood loss was lower if suction curettage is conducted after UAE/UACE than after administration of systemic MTX (moderate-quality evidence). It is uncertain whether there is a difference in treatment success rates, complications, adverse effects or time to normalize β-hCG between suction curettage under hysteroscopy and under ultrasonography (very low-quality evidence). There are no studies of non-tubal ectopic pregnancy other than CSP and RCTs for these types of pregnancy are unlikely.
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Affiliation(s)
- Ying Long
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Huili Zhu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yuanyuan Hu
- Department of Obstetrics and Gynaecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Licong Shen
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Jing Fu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Wei Huang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
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Elmokadem AH, Abdel-Wahab RM, El-Zayadi AA, Elrakhawy MM. Uterine Artery Embolization and Methotrexate Infusion as Sole Management for Caesarean Scar and Cervical Ectopic Pregnancies: A Single-Center Experience and Literature Review. Can Assoc Radiol J 2019; 70:307-316. [DOI: 10.1016/j.carj.2018.12.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/12/2018] [Accepted: 12/06/2018] [Indexed: 12/20/2022] Open
Abstract
Introduction The incidence of caesarean scar pregnancy (CSP) and cervical pregnancy (CP) has increased significantly in recent years. The related hemorrhage can be lethal and often needs hysterectomy. This study aims to assess the technical and clinical results of uterine artery embolization (UAE) combined with intra-arterial methotrexate (MTX) infusion for CSP and CP. Methods A retrospective study was conducted for 11 patients (age range from 25–40 years, mean; 31.8 y) with CSP (7/11) and CP (4/11). The diagnosis was confirmed by elevated b-hCG levels (mean 31.245 mIU/mL) with sonography and/or magnetic resonance imaging. They were treated with UAE using particulate embolic material. In all patients, the infusion of MTX (50 mg/m2) was performed before UAE. Follow-up periods after UAE ranged between 6-24 months included weekly sonography and b-hCG level assessment. A literature review was performed using standard online search tools. Results In 10 patients, UAE controlled active vaginal bleeding and reduced post-procedural b-hCG levels significantly by the second week. One patient presented with persistent elevated b-hCG level and vaginal rebleeding. The rebleeding was successfully controlled by second UAE procedure. The ectopic pregnancies were resolved, and the uterus was preserved in all patients. No major complications were detected. Normal menses resumed within 2 months after UAE. Two patients had subsequent natural successful intrauterine pregnancies. Conclusion UAE combined with intra-arterial MTX infusion resulted in resolution of ectopic pregnancies with control of hemorrhage and without hysterectomy in this small group of patients.
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Affiliation(s)
- Ali H. Elmokadem
- Diagnostic and Interventional Radiology Department, Mansoura University, Mansoura, Egypt
| | - Rihame M. Abdel-Wahab
- Diagnostic and Interventional Radiology Department, Mansoura University, Mansoura, Egypt
| | - Ahmed A. El-Zayadi
- Gynecology and Obstetrics Department, Mansoura University, Dakahlia, Egypt
| | - Mohamed M. Elrakhawy
- Diagnostic and Interventional Radiology Department, Mansoura University, Mansoura, Egypt
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Guo J, Yu J, Zhang Q, Song X. Clinical Efficacy and Safety of Uterine Artery Embolization (UAE) versus Laparoscopic Cesarean Scar Pregnancy Debridement Surgery (LCSPDS) in Treatment of Cesarean Scar Pregnancy. Med Sci Monit 2018; 24:4659-4666. [PMID: 29978852 PMCID: PMC6069508 DOI: 10.12659/msm.907404] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Junhong Guo
- Department of Obstetrics and Gynecology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Jiangtao Yu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Qing Zhang
- Department of Obstetrics and Gynecology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Xiaojie Song
- Department of Obstetrics and Gynecology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
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Docheva N, Slutsky ED, Borella N, Mason R, Van Hook JW, Seo-Patel S. The Rising Triad of Cesarean Scar Pregnancy, Placenta Percreta, and Uterine Rupture: A Case Report and Comprehensive Review of the Literature. Case Rep Obstet Gynecol 2018; 2018:8797643. [PMID: 29984018 PMCID: PMC6011134 DOI: 10.1155/2018/8797643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 04/26/2018] [Indexed: 11/23/2022] Open
Abstract
As the rate of cesarean sections continues to rapidly rise, knowledge of diagnosis and management of cesarean scar pregnancies (CSPs) is becoming increasingly more relevant. CSPs rest on the continuum of placental abnormalities which include morbidly adherent placenta (accreta, increta, and percreta). A CSP poses a clinical challenge which may have significant fetal and maternal morbidity. At this point, no clear management guidelines and recommendations exist. Herein we describe the case of a second trimester CSP with rapid diagnosis and management in a tertiary care center. The case underscores the need for well-coordinated mobilization of resources and a multidisciplinary approach. A review of the literature is performed and deficits in universal management principles are underscored.
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Affiliation(s)
- Nikolina Docheva
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Emily D. Slutsky
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Nicolette Borella
- Mercyhurst University, Department of Biology, Eerie, Pennsylvania, USA
| | - Renee Mason
- Promedica Physicians Obstetrics-Gynecology, Maumee, Ohio, USA
| | - James W. Van Hook
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Sonyoung Seo-Patel
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
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Tumenjargal A, Tokue H, Kishi H, Hirasawa H, Taketomi-Takahashi A, Tsushima Y. Uterine Artery Embolization Combined with Dilation and Curettage for the Treatment of Cesarean Scar Pregnancy: Efficacy and Future Fertility. Cardiovasc Intervent Radiol 2018; 41:1165-1173. [PMID: 29546456 DOI: 10.1007/s00270-018-1934-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/06/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate the efficacy and safety of uterine artery embolization (UAE) followed by dilation and curettage (D&C) as a treatment for cesarean scar pregnancy (CSP) and to assess pregnancy outcomes after the treatment. MATERIALS AND METHODS We retrospectively analyzed 33 CSP patients treated with UAE followed by D&C. The serum level of beta human chorionic gonadotropin (β-hCG) normalization, hospitalization, menstruation, and successful pregnancy after treatment was assessed as clinical and pregnancy outcomes. RESULTS A total of 33 patients were initially treated without severe complications. However, four patients required additional systemic chemotherapy. β-hCG normalization took 35.5 ± 14.9 days (range 13-79), and the hospitalization was 6.5 ± 2.5 days (2-15). All patients resumed normal menstruation after 36 ± 19.2 days (12-86). Of 16 of 33 patients who desired pregnancy after the treatment, seven patients (43.8%) had uneventful parturition. CONCLUSIONS UAE combined with D&C was efficient and safe for CSP management. This minimally invasive procedure may be considered as one of the treatment options which enable preservation of fertility after treatment.
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Affiliation(s)
- Amartuvshin Tumenjargal
- Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
- Department of Obstetrics and Gynecology, Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
| | - Hiroyuki Tokue
- Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan.
| | - Hiroshi Kishi
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi, Gunma, 371-8511, Japan
| | - Hiromi Hirasawa
- Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Ayako Taketomi-Takahashi
- Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
| | - Yoshito Tsushima
- Department of Diagnostic Radiology and Nuclear Medicine, Gunma University Graduate School of Medicine, 3-39-22 Showa, Maebashi, Gunma, 371-8511, Japan
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Maheux-Lacroix S, Li F, Bujold E, Nesbitt-Hawes E, Deans R, Abbott J. Cesarean Scar Pregnancies: A Systematic Review of Treatment Options. J Minim Invasive Gynecol 2017; 24:915-925. [DOI: 10.1016/j.jmig.2017.05.019] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/29/2017] [Accepted: 05/31/2017] [Indexed: 10/19/2022]
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17
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Singh D, Kaur L. When a cesarean section scar is more than an innocent bystander in a subsequent pregnancy: Ultrasound to the rescue. JOURNAL OF CLINICAL ULTRASOUND : JCU 2017; 45:319-327. [PMID: 28440856 DOI: 10.1002/jcu.22485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 02/17/2017] [Accepted: 03/13/2017] [Indexed: 06/07/2023]
Abstract
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.
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Affiliation(s)
- Divya Singh
- Prime Imaging and Prenatal Diagnostics, SCO 155, Sector 24 D, Chandigarh, India, 160023
| | - Ladbans Kaur
- Prime Imaging and Prenatal Diagnostics, SCO 155, Sector 24 D, Chandigarh, India, 160023
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18
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Cesarean Scar Pregnancy: A Systematic Review. J Minim Invasive Gynecol 2017; 24:731-738. [DOI: 10.1016/j.jmig.2017.02.020] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/22/2017] [Accepted: 02/24/2017] [Indexed: 12/24/2022]
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Qian ZD, Weng Y, Du YJ, Wang CF, Huang LL. Management of persistent caesarean scar pregnancy after curettage treatment failure. BMC Pregnancy Childbirth 2017; 17:208. [PMID: 28666477 PMCID: PMC5493865 DOI: 10.1186/s12884-017-1395-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 06/22/2017] [Indexed: 11/10/2022] Open
Abstract
Background Caesarean scar pregnancy (CSP) is a late serious complication of caesarean section. The incidence of CSP has increased worldwide in recent years. Early diagnosis and prompt therapy are crucial to avoid catastrophic complications. There are various strategies for CSP treatment, but there is no consensus on the best management for CSP. Dilation and curettage (D&C) and hysteroscopy are common and effective treatments with their advantages and disadvantages. No in-depth study of the clinical effects of hysteroscopic management of CSP after D&C treatment failure has been conducted. The purpose of this study is to evaluate the effectiveness and safety of hysteroscopic removal of residual CSP tissue (persistent CSP) as a rescue after failed D&C management. Methods This is a retrospective clinical research study. Forty-five patients underwent operative hysteroscopy to remove the residual gestational tissue in the caesarean scar after failed D&C treatment. The clinical characteristics and outcomes of hysteroscopic surgeries of 45 CSP cases were investigated. All data analyses were conducted with SPSS 17.0. Results Forty-three CSP cases after unsuccessful curettage treatment were successfully treated by operative hysteroscopy. The estimated intraoperative blood loss was 20.00 (10.00–500.00) mL, the hysteroscopic operating time was 20.00 (15.00–45.00) min, the decline of serum β-hCG the day after surgery was 71.91 ± 14.05%, the total hospitalisation time was 7.87 ± 2.26 days, the medical cost was 13,682.71 ± 3553.77 China Yuan (CNY), the time of bleeding after surgery was 7.42 ± 2.48 days, and the time of serum β-hCG resolution after surgery was 13.84 ± 9.83 days. Follow-up after discharge demonstrated that there were no severe complications for any patients. Conclusions Hysteroscopy therapy could treat persistent CSP effectively and safely after curettage treatment failure. Therapy should be individualised, and the risks and cost of the hysteroscopy procedure and anaesthesia must be considered and fully discussed with the patients before surgery.
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Affiliation(s)
- Zhi-Da Qian
- Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang Province, 310006, People's Republic of China.
| | - Yue Weng
- Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang Province, 310006, People's Republic of China
| | - Yong-Jiang Du
- Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang Province, 310006, People's Republic of China
| | - Chun-Fen Wang
- Maternal and Child Health Institute of Lin'an City, 25 Jiangnan Road, Lin'an, Zhejiang Province, 311300, People's Republic of China
| | - Li-Li Huang
- Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang Province, 310006, People's Republic of China
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Safety and Efficacy of Uterine Artery Embolization in Ectopic Pregnancies Refractory to Systemic Methotrexate Treatment: A Single-Center Study. Cardiovasc Intervent Radiol 2017; 40:1351-1357. [PMID: 28462440 DOI: 10.1007/s00270-017-1664-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND To investigate the use of uterine artery embolization (UAE) to manage ectopic pregnancies that are refractory to systemic methotrexate (MTX) therapy and plagued by persistently high serum β-human chorionic gonadotrophin (hCG) levels and vaginal bleeding. The safety and efficacy of UAE were addressed. MATERIALS AND METHODS A retrospective review was conducted for thirteen patients (mean age 35.2 years; range 28-41 years), who were treated between December 2006 and June 2016. Each was subjected to UAE due to persistently high serum β-hCG levels and vaginal bleeding after systemic MTX therapy for ectopic pregnancy. Embolic agents used were non-spherical polyvinyl alcohol or gelatin sponge particles. Post-treatment follow-up was performed by monitoring for clinical signs of vaginal bleeding, serum β-hCG testing, and transvaginal US. Outcomes were technical success, clinical success, and complications. RESULTS Median follow-up period was 172.5 days (range 30-600 days). Technical success was achieved in all 13 patients (100%). In 10 patients, vaginal bleeding resolved after one UAE attempt (clinical success 76.0%). Rebleeding in other three (23.1%) was controlled through repeat UAE. Seven patients (53.8%) had additional dilatation and curettage to remove gestational sac remnants. All ectopic pregnancies were successfully treated by UAE, with normalization of serum β-hCG levels during follow-up monitoring (P = 0.01). Uterine preservation was achieved in all 13 patients, without major procedural complications. CONCLUSION UAE appears safe and effective as treatment of ectopic pregnancies marked by persistently high serum β-hCG levels and vaginal bleeding after systemic MTX treatment.
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Jayaram PM, Okunoye GO, Konje J. Caesarean scar ectopic pregnancy: diagnostic challenges and management options. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/tog.12355] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Pradeep M Jayaram
- Sidra Medical and Research Centre & Weill Cornell Medical College; Doha PO Box 26999 Qatar
| | - Gbemisola O Okunoye
- Sidra Medical and Research Centre & Weill Cornell Medical College; Doha PO Box 26999 Qatar
| | - Justin Konje
- Women's Services Clinical Management Group; Sidra Medical and Research Centre; Doha PO Box 26999 Qatar
- University of Leicester; UK
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22
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The first-line approach for cesarean scar pregnancy: The most adopted being not the best. Taiwan J Obstet Gynecol 2016; 55:761-762. [DOI: 10.1016/j.tjog.2016.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2016] [Indexed: 11/18/2022] Open
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23
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Feng Y, Chen S, Li C, Zhang X, Duan H, Sooranna S, Johnson MR, Li J. Curettage after uterine artery embolization combined with methotrexate treatment for caesarean scar pregnancy. Exp Ther Med 2016; 12:1469-1475. [PMID: 27602071 PMCID: PMC4998184 DOI: 10.3892/etm.2016.3489] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/29/2016] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- Ying Feng
- Department of Gynaecology, Beijing Obstetrics and Gynaecology Hospital, Capital Medical University, Beijing 100026, P.R. China
| | - Suwen Chen
- Department of Gynaecology, Beijing Obstetrics and Gynaecology Hospital, Capital Medical University, Beijing 100026, P.R. China
| | - Changdong Li
- Department of Gynaecology, Beijing Obstetrics and Gynaecology Hospital, Capital Medical University, Beijing 100026, P.R. China
| | - Xiaofeng Zhang
- Department of Gynaecology, Beijing Obstetrics and Gynaecology Hospital, Capital Medical University, Beijing 100026, P.R. China
| | - Hua Duan
- Department of Gynaecology, Beijing Obstetrics and Gynaecology Hospital, Capital Medical University, Beijing 100026, P.R. China
| | - Suren Sooranna
- Department of Gynaecology, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Mark R Johnson
- Department of Gynaecology, Imperial College London, Chelsea and Westminster Hospital, London SW10 9NH, UK
| | - Jian Li
- Department of Gynaecology, Beijing Obstetrics and Gynaecology Hospital, Capital Medical University, Beijing 100026, P.R. China
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Qi F, Zhou W, Wang MF, Chai ZY, Zheng LZ. Uterine artery embolization with and without local methotrexate infusion for the treatment of cesarean scar pregnancy. Taiwan J Obstet Gynecol 2016; 54:376-80. [PMID: 26384053 DOI: 10.1016/j.tjog.2015.01.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To compare the clinical value of uterine artery embolization (UAE) with local methotrexate (MTX) infusion to embolization without MTX in the treatment of cesarean scar pregnancies (CSPs). MATERIALS AND METHODS From January 2009 to December 2013, 50 patients with CSP treated with UAE receiving or not receiving local MTX infusion prior to curettage were analyzed retrospectively. Twenty-two patients were offered UAE with local MTX infusion prior to curettage (UAE + MTX group), whereas 28 patients received UAE alone prior to curettage (UAE group). Clinical data and the outcomes were analyzed, followed by a brief review of the published literature summarizing what is known about UAE with and without MTX for the treatment of CSP. RESULTS UAE was successful in 42 of 50 cases (84%), with complications occurring in only five patients. There were no significant differences in the success rate, complication rate, recovery time, or hospitalization costs between the UAE + MTX group and the UAE group. However, blood loss in the UAE + MTX group was significantly higher than in the UAE group. CONCLUSION UAE with or without local MTX infusion might be an effective treatment for CSP. Compared with UAE alone, UAE with local MTX infusion did not dramatically improve the therapeutic effect of UAE. A larger and more comprehensive random control study is warranted to better evaluate the therapeutic effects of UAE in the treatment of CSP.
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Affiliation(s)
- Feng Qi
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Affiliated with Wenzhou Medical College, Linhai, Zhejiang Province, China
| | - Wei Zhou
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Affiliated with Wenzhou Medical College, Linhai, Zhejiang Province, China
| | - Mei-Fen Wang
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Affiliated with Wenzhou Medical College, Linhai, Zhejiang Province, China
| | - Ze-Ying Chai
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Affiliated with Wenzhou Medical College, Linhai, Zhejiang Province, China
| | - Ling-Zhi Zheng
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Affiliated with Wenzhou Medical College, Linhai, Zhejiang Province, China.
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Li Y, Wang W, Yang T, Wei X, Yang X. Incorporating uterine artery embolization in the treatment of cesarean scar pregnancy following diagnostic ultrasonography. Int J Gynaecol Obstet 2016; 134:202-7. [PMID: 27126907 DOI: 10.1016/j.ijgo.2015.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2015] [Revised: 12/16/2015] [Accepted: 03/24/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate combining uterine artery embolization (UAE) with other treatments for cesarean scar pregnancy (CSP). METHODS A retrospective study included patients attending the First affiliated Hospital of Xi'an Jiaotong University, China, between March 1, 2009 and March 31, 2014, who were diagnosed with CSP. Patients were classified by ultrasonography as having endogenous CSP (CSP type I [CSP-I]) or exogenous CSP (CSP type II [CSP-II]). Patient outcomes were compared between patients who underwent treatment that included or excluded UAE. Patient records were reviewed and patients were interviewed by telephone to report on recovery following treatment. RESULTS In total, 52 patients met the inclusion criteria. In patients with CSP-I, the blood loss, length of hospital stay, and time before restoration of normal β human chorionic gonadotropin levels were significantly higher in patients who were treated with methotrexate combined with dilatation and curettage compared with those treated with UAE combined with dilatation and curettage (P<0.05). In patients with CSP-II, blood loss was lower in patients treated with UAE combined with excision compared with excision alone (P<0.001). CONCLUSION Incorporating UAE in the treatment of CSP-I and CSP-II was safe; CSP should be properly classified to select the appropriate treatment.
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Affiliation(s)
- Yang Li
- Department of Gynecology and Obstetrics, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Weiwen Wang
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
| | - Ting Yang
- Department of Gynecology and Obstetrics, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xing Wei
- Department of Gynecology and Obstetrics, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xiaofeng Yang
- Department of Gynecology and Obstetrics, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China.
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Abstract
OBJECTIVE To survey effective treatment strategies for cesarean scar pregnancy (CSP). METHODS The clinical data of 78 patients diagnosed with CSP from January 2010 to December 2013 were reviewed. RESULTS Among these patients, 17 patients were first treated at our hospital; of them, 2 were misdiagnosed. The other 61 patients were referred from other hospitals; of them, 21 were initially misdiagnosed. There were 9 patients who were treated with laparotomy, 50 patients with curettage after uterine artery embolization (UAE) with or without local methotrexate (MTX) infusion, 10 patients with dilatation and curettage, 6 patients with transvaginal sonographic guided local intragestational MTX injection, and 3 patients with systemic MTX injection. All patients finally recovered. Patients with excessive vaginal hemorrhage underwent either emergency UAE treatment or laparotomy. These two treatments had similar success rates (81.82% vs. 100%, χ2 =0.289, P>0.05). CONCLUSIONS The accurate diagnosis of CSP is important. Curettage after UAE with or without local MTX infusion is a safe and effective method.
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Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, Svarre Nielsen H. Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril 2016; 105:958-67. [PMID: 26794422 DOI: 10.1016/j.fertnstert.2015.12.130] [Citation(s) in RCA: 242] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/30/2015] [Accepted: 12/22/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To study treatment modalities for cesarean scar pregnancies (CSPs), focusing on efficacy and complications in relation to study quality. DESIGN Systematic review. SETTING Not applicable. PATIENT(S) A total of 2,037 women with CSP. INTERVENTION(S) Review of MEDLINE, EMBASE, and Cochrane Library to find studies including five or more women. Data were extracted on primary treatment modality/efficacy, complications, and future fertility. The level of evidence was categorized according to Oxford Centre for Evidence-based Medicine guidelines. Quality was assessed using The Cochrane Collaboration's Risk of Bias Tools for Randomized Controlled Trials and the modified Delphi techniques for case series. Meta-analysis was impossible owing to multifarious treatments. MAIN OUTCOME MEASURE(S) Successful first-line treatment. Complications were hysterectomy, laparotomy, bleeding >1,000 mL, or blood transfusion. RESULT(S) Fifty-two studies were included: four randomized, controlled trials and 48 case series. Fifteen of the 52 analyzed studies were scored as high quality. Treatment modalities were condensed to 14 different approaches. Combining study quality, level of evidence, efficacy, and safety, five approaches for treating CSP are recommended, depending on availability, severity of patient symptoms, and surgical skills: [1] resection through a transvaginal approach, [2] laparoscopy, [3] uterine artery embolization in combination with dilatation and curettage and hysteroscopy, [4] uterine artery embolization in combination with dilatation and curettage, and [5] hysteroscopy. CONCLUSION(S) This review recommends treatment options for CSP in clinical practice, based on efficacy and safety. The literature supports an interventional rather than medical approach. Present recommendations are primarily based on case series. Multicenter, well-designed studies are needed to draw definite conclusions on how to treat CSP.
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Affiliation(s)
| | - Elise Hoffmann
- Department of Obstetrics and Gynaecology, Copenhagen University Hospital, Roskilde Sygehus, Roskilde, Denmark
| | - Christian Rifbjerg Larsen
- Centre for Minimal Invasive and Robotic Surgery Research, Departments of Gynecology, General Surgery, and Urology, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
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Collins K, Kothari A. Catastrophic consequences of a caesarean scar pregnancy missed on ultrasound. Australas J Ultrasound Med 2015; 18:150-156. [PMID: 28191259 PMCID: PMC5024973 DOI: 10.1002/j.2205-0140.2015.tb00222.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Ectopic pregnancy that implants within the scar tissue of a previous caesarean scar is a situation that is seldom encountered and is almost invariably incompatible with a successful pregnancy. Caesarean scar ectopic pregnancies are fraught with life threatening complications such as scar rupture, significant haemorrhage, disseminated intravascular coagulation and the need for emergency life saving hysterectomy. The clinical diagnosis can be elusive, particularly in the early stages; therefore clinicians should be familiar with the condition's sonographic hallmarks. Early diagnosis and management is the key to preventing these complications. We describe a case of caesarean scar pregnancy which was initially misdiagnosed as “a spontaneous miscarriage in progress”, resulting in uncontrollable bleeding, necessitating an emergency abdominal hysterectomy. We also endeavour to review the literature with regards to the use of ultrasound in its management, treatment and follow up.
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Affiliation(s)
| | - Alka Kothari
- The University of QueenslandSt LuciaQueenslandAustralia; Redcliffe HospitalRedcliffeQueenslandAustralia
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Zhu X, Deng X, Xiao S, Wan Y, Xue M. A comparison of high-intensity focused ultrasound and uterine artery embolisation for the management of caesarean scar pregnancy. Int J Hyperthermia 2015; 32:144-50. [DOI: 10.3109/02656736.2015.1104733] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Uterine artery embolization combined with curettage vs. methotrexate plus curettage for cesarean scar pregnancy. Arch Gynecol Obstet 2015; 294:71-6. [DOI: 10.1007/s00404-015-3952-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Accepted: 10/28/2015] [Indexed: 11/25/2022]
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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: 103] [Impact Index Per Article: 11.4] [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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Sun YY, Xi XW, Yan Q, Qiao QQ, Feng YJ, Zhu YP. Management of type II unruptured cesarean scar pregnancy: Comparison of gestational mass excision and uterine artery embolization combined with methotrexate. Taiwan J Obstet Gynecol 2015; 54:489-92. [DOI: 10.1016/j.tjog.2015.08.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2014] [Indexed: 10/22/2022] Open
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Yapar Eyi EG. Minimally invasive procedure for type II canal defect caesarean scar pregnancy with cardiac activity and high hCG titres at 8+2 weeks of gestation. CASE REPORTS IN PERINATAL MEDICINE 2015. [DOI: 10.1515/crpm-2014-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Type II caesarean scar pregnancy (CSP) not only poses important maternal hazards, such as severe bleeding, uterine rupture, disseminated intravascular coagulation and maternal death due to its abnormal location and invasive characteristics, but its surgical management may lead to operative complications and even loss of fertility. The sonographic and Doppler findings of a “canal defect CSP” that has previously been hypothesised, but not illustrated, are presented here. A minimally invasive approach was performed in the presence of a 38.3 mm gestational sac (GS) with a crown rump length of 11.3 mm embryo (8+2 weeks of gestation) and cardiac activity with high (118,839.2 mIU/mL) human chorionic gonadotropin (hCG) levels. A transabdominal intragestational sac injection of potassium chloride to stop cardiac activity, and consecutively, methotrexate (MTX) was given before systemic MTX therapy. Embryonic cardiac activity stopped. Systemic methotrexate was repeated 8 days after the procedure. While vaginal bleeding ceased in 3 weeks with gradual shrinkage of the GS, hCG fell to non-pregnant levels within 112 days (16 weeks); complete resolution of the ectopic mass required 8 months. This is the first report presenting the success of a minimally invasive procedure at a hCG level of 118,839.2 mIU/mL with embryonic cardiac activity in type II CSP.
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Affiliation(s)
- Elif Gul Yapar Eyi
- Obstetrics and Gynaecology/Subdivision of Perinatology, Zekai Tahir Burak Women’s Health Education and Research Hospital, Talatpasa Bulvarı, 06230 Ankara, Turkey
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Wang L, Sun L, Wang L, Chen H, Ouyang X, Qiu H. Laparoscopic temporary bilateral uterine artery occlusion with silicone tubing to prevent hemorrhage during vacuum aspiration of cesarean scar pregnancies. J Obstet Gynaecol Res 2015; 41:1762-8. [PMID: 26178690 DOI: 10.1111/jog.12784] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 04/23/2015] [Accepted: 05/14/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Lingling Wang
- Department of Gynaecology; The Affiliated Chenggong Hospital of Xiamen University; Xiamen People's Republic of China
| | - Lingbin Sun
- Department of Gynaecology; The Affiliated Chenggong Hospital of Xiamen University; Xiamen People's Republic of China
| | - Lijun Wang
- Department of Gynaecology; The Affiliated Chenggong Hospital of Xiamen University; Xiamen People's Republic of China
| | - Huifang Chen
- Department of Gynaecology; The Affiliated Chenggong Hospital of Xiamen University; Xiamen People's Republic of China
| | - Xue Ouyang
- Department of Gynaecology; The Affiliated Chenggong Hospital of Xiamen University; Xiamen People's Republic of China
| | - Huiling Qiu
- Department of Gynaecology; The Affiliated Chenggong Hospital of Xiamen University; Xiamen People's Republic of China
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Qian ZD, Huang LL, Zhu XM. Curettage or operative hysteroscopy in the treatment of cesarean scar pregnancy. Arch Gynecol Obstet 2015; 292:1055-61. [DOI: 10.1007/s00404-015-3730-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
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Le Gall J, Fichez A, Lamblin G, Philip CA, Huissoud C. [Cesarean scar ectopic pregnancies: combined modality therapies with uterine artery embolization before surgical procedure]. ACTA ACUST UNITED AC 2015; 43:191-9. [PMID: 25724449 DOI: 10.1016/j.gyobfe.2015.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 01/29/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To offer a therapeutic management of cesarean scar pregnancies (GSC) in the first trimester of pregnancy with a first approach by uterine artery embolization (UAE) PATIENTS AND METHODS: This study describes seven cases of GSC diagnosed between 2009 and 2013 in the clinic of the University Hospital of the Hospital of Croix-Rousse. We present the symptoms and how imagery has led to the diagnosis and the therapeutic management conducted. RESULTS The mean gestational age at diagnosis was 9 weeks gestation. There were ongoing pregnancies with cardiac activity present for each patient. An additional MRI was performed in five patients. Five patients were treated with methotrexate injection, two patients received the Mifegyne. All patients then received a selective uterine artery embolization. Finally within 48hours, suction curettage was performed in 6 patients. A patient at 13 WA+1 required a subtotal hysterectomy for placenta accreta. Intra-operative complications were represented by a bladder injury, two bleeding of 1000mL in patients at 13 WA+1 and 12 WA. For the 6 cases of GSC with a gestational age less than 10 WA, average blood loss was less than 500mL. Three patients underwent resection of scar isthmocele confirmed by EVAC. An intrauterine pregnancy was carried to term after care. DISCUSSION AND CONCLUSION Cesarean scar pregnancies is a diagnostic and therapeutic challenge, which should be diagnosed as early as soon as possible with care in a medical facility with a uterine artery embolization technical platform. Our protocol combining Mifegyne and methotrexate for termination of pregnancy and uterine artery embolization (UAE) followed by curettage for evacuation of pregnancy allows conservative treatment while minimizing the risk of bleeding (for GSC diagnosed before 10 WA).
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Affiliation(s)
- J Le Gall
- Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France.
| | - A Fichez
- Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - G Lamblin
- Service de gynécologie-obstétrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69500 Bron, France
| | - C A Philip
- Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - C Huissoud
- Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France; Inserm U846, Stem Cell and Brain Research Institute, université de Lyon-1, 18, avenue Doyen-Lepine, 69500 Bron, France; UMR-S 846, 69003 Lyon, France
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Shin SM, Yi KW, Chung HH. Postpartum Uterine Bleeding from the Inferior Mesenteric Artery: Case Report and Review of the Literature. Gynecol Obstet Invest 2015; 80:60-3. [DOI: 10.1159/000367598] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 08/14/2014] [Indexed: 11/19/2022]
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Krissi H, Hiersch L, Stolovitch N, Nitke S, Wiznitzer A, Peled Y. Outcome, complications and future fertility in women treated with uterine artery embolization and methotrexate for non-tubal ectopic pregnancy. Eur J Obstet Gynecol Reprod Biol 2014; 182:172-6. [DOI: 10.1016/j.ejogrb.2014.09.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 09/03/2014] [Accepted: 09/09/2014] [Indexed: 02/08/2023]
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Qian ZD, Zhu XM. Caesarean scar choriocarcinoma: a case report and review of the literature. Eur J Med Res 2014; 19:25. [PMID: 24887563 PMCID: PMC4026121 DOI: 10.1186/2047-783x-19-25] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 05/02/2014] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To report the clinical characteristics, pathologic findings and treatments of a patient with a Caesarean scar choriocarcinoma. PATIENT HISTORY A 22-year-old woman had a diagnosis of primary gestational choriocarcinoma in a uterine Caesarean scar misdiagnosed as a normal Caesarean scar pregnancy. The patient underwent selective uterine artery embolization coupled with methotrexate arterial injection, along with dilatation and curettage of the uterine Caesarean scar. Finally, she received eight courses of multiagent chemotherapy. The reproductive function of the patient was preserved. CONCLUSIONS Primary gestational choriocarcinoma out of the uterine corpus is a rare disease. A Caesarean scar choriocarcinoma is an extremely unusual example of this entity because of its unique position. To the best of our knowledge, this is the first report of this phenomenon. Our experience and a literature review suggest that a clinical diagnosis of a primary gestational choriocarcinoma of the uterine Caesarean scar is difficult to make, and uterine artery embolization is beneficial to prevent massive bleeding before curettage.
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Affiliation(s)
| | - Xiao-Ming Zhu
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, 1 Xueshi Road, Hangzhou, Zhejiang Province 310006, People's Republic of China.
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Cesarean scar pregnancy: a diagnostic dilemma and impending catastrophe. Arch Gynecol Obstet 2013; 289:221-2. [DOI: 10.1007/s00404-013-2947-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 06/28/2013] [Indexed: 10/26/2022]
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