Conservative management of Caesarean scar pregnancies with systemic multidose methotrexate: predictors of treatment failure and reproductive outcomes

Surgical treatment and reproductive outcomes in caesarean scar pregnancy at a single center

BACKGROUND

To investigate factors associated with different reproductive outcomes in patients with Caesarean scar pregnancies (CSPs).

METHODS

Between May 2017 and July 2022, 549 patients underwent ultrasound-guided uterine aspiration and laparoscopic scar repair at the Gynaecology Department of Hubei Maternal and Child Health Hospital. Ultrasound-guided uterine aspiration was performed in patients with type I and II CSPs, and laparoscopic scar repair was performed in patients with type III CSP. The reproductive outcomes of 100 patients with fertility needs were followed up and compared between the groups.

RESULTS

Of 100 patients, 43% had live births (43/100), 19% had abortions (19/100), 38% had secondary infertility (38/100), 15% had recurrent CSPs (RCSPs) (15/100). The reproductive outcomes of patients with CSPs after surgical treatment were not correlated with age, body mass index, time of gestation, yields, abortions, Caesarean sections, length of hospital stay, weeks of menopause during treatment, maximum diameter of the gestational sac, thickness of the remaining muscle layer of the uterine scar, type of CSP, surgical method, uterine artery embolisation during treatment, major bleeding, or presence of uterine adhesions after surgery. Abortion after treatment was the only risk factor affecting RCSPs (odds ratio 11.25, 95% confidence interval, 3.302-38.325; P < 0.01) and it had a certain predictive value for RCSP occurrence (area under the curve, 0.741).

CONCLUSIONS

The recurrence probability of CSPs was low, and women with childbearing intentions after CSPs should be encouraged to become pregnant again. Abortion after CSP is a risk factor for RCSP. No significant difference in reproductive outcomes was observed between the patients who underwent ultrasound-guided uterine aspiration and those who underwent laparoscopic scar repair for CSP.

Cesarean Scar Pregnancy With Surgical and Conservative Managements: A Case Report

A cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. Proper diagnosis and management of CSP are incredibly important secondary to the risk of uterine rupture and life-threatening hemorrhage. Various medical and surgical management have been described previously. This report looks at two cases of CSP diagnosed at an urban hospital in Atlanta, Georgia. The first woman was 30 years old with a history of five prior CS. She was referred from an abortion clinic for CSP at 6 weeks 2 days gestation. She did not desire future fertility and opted for a hysterectomy. The second woman was 38 years old with a history of three prior CS presenting with vaginal bleeding and abdominal pain and found to have a CSP with a gestation sac measuring 5 weeks 1 day. Given the patient's desires for future fertility, she was treated with a two-dose regimen of systemic intramuscular methotrexate (MTX) at 1 mg/kg with successful resolution of CSP and subsequent intrauterine pregnancy. Due to the high risk of uterine rupture and hemorrhage with CSP, it is important to have a high index of suspicion for diagnosis. Due to the rarity of CSP, and thus difficulty creating quality prospective trials, there is no consensus on the best management yet. Although conservative treatment carries high failure risk, shared decision-making incorporating future fertility desires should be considered when determining management of CSP, and when surgical management is considered a minimally invasive approach should be the standard of care in surgical management.

Single-dose methotrexate-based protocol for the treatment of caesarean scar pregnancy and successive pregnancy outcomes

The incidence of caesarean scar pregnancy (CSP) increases in recent years. Yet, the best mode of treatment and its effects on successive pregnancies is not well established. The aim of this study was to investigate the success rate of single-dose methotrexate (MTX) in the management of CSP, and the outcomes of subsequent pregnancies in a retrospective cohort study. All women who were treated for CSPs between the years 2011 and 2019 were included. Treatment included systemic MTX and ultrasound-guided needle aspiration (UGNA) in cases with active foetal heartbeat. Overall, 34 women were diagnosed with CSP, of whom 31 were treated with systemic MTX. Twelve patients (38.7%) needed additional curettage or hysteroscopy. The only identified risk factor for failure of MTX-based treatment was time interval between the previous caesarean delivery and CSP (22 vs 34 months, p = 0.04). Twelve women had a subsequent pregnancy. Five pregnancies ended in term delivery, three in preterm delivery, three in abortion and one woman had a recurrent CSP. The study conclusion is that a single dose MTX with UGNA in cases of active heartbeat is an effective mode of treatment in cases of CSP with good sequential pregnancy outcomes. Longer time interval from the previous caesarean delivery was identified as a risk factor for failure of conservative management.

Methotrexate for CSPs

Expectant management of a cesarean scar pregnancy (CSP) is associated with a high risk of severe maternal morbidity. Therefore, most experts recommend immediate termination after the diagnosis of a CSP. However, there is no consensus about the optimal management of a CSP in terms of efficacy, safety, and preservation of future fertility. Methotrexate (MTX) is a folic acid antagonist that has been largely used to treat tubal ectopic pregnancies. This review summarizes the current knowledge and uncertainties about the administration of MTX as a medical or non-invasive option to terminate a CSP; the preferred injection route (systemic or local/intragestational), the comparison with other treatment modalities, and the prognostic factors for MTX success will be discussed, as well as the recommendations from scientific societies.

Can uterine niche be prevented?

Uterine niche is a potential significant consequence of Caesarean section and is diagnosed by ultrasound. The timing of Caesarean section (during pre, early or advanced labour), location of the incision (distance from the internal os), techniques for opening and closing the uterine cavity, and bladder flap have been frequently mentioned in the literature, however, these factors continue to be a source of disagreement with respect to whether they increase the risk of uterine niche or protect against this complication. In this review, we outline and discuss the possible risk factors that may be responsible for this entity. The main factor upon which obstetricians can act is the rate of first Caesarean section, which can and should be reduced. Moreover, a rather high incision at a distance from the internal os, and a sparing use of bladder detachment should be always kept in mind as well.

A study on the timing of uterine artery embolization followed by pregnancy excision for cesarean scar pregnancy: a prospective study in China

BACKGROUND

Cesarean scar pregnancy (CSP) remains a sporadic and special form of ectopic pregnancy in which the fertilized ovum is implanted on a previous cesarean scar within 12 weeks. This study aims to evaluate the optimal time interval between uterine artery embolization (UAE) and curettage modalities in order to provide the best clinical outcomes.

METHODS

From January 2018 to December 2020, we recruited 61 patients with CSP. They were randomly divided into two groups depending on whether the time interval between UAE and dilatation and curettage (D&C) requires additional hospitalization: 31 patients received prophylactic UAE followed by D&C on the same day (0-12 h; group A) and 30 patients need hospitalization (12-72 h; group B). The clinical characteristics, diagnostic data, and outcomes of the two groups were compared and analyzed.

RESULTS

A total of 59 (96.72%) cases had responded well to the first treatment. One patient in each arm undergone retreatment, but none of the 61 patients needed additional hysterectomy. There was no considerable relationship between the two groups with respect to the intraoperative hemorrhage during D&C, serum index (containing β-hCG, hemoglobin, CRP, and D-dimer) on the first day after D&C, side effects (containing fever and abdominal pain), renal, hepatic, and coagulation function, time of CSP residual mass disappearance, and hospitalization cost. The time of serum β-hCG resolution after surgery was 41.22 ± 14.97 days in group A and 66.67 ± 36.64 days in group B (P = 0.027), and group A treatment resulted in a shorten hospital stay as compared with group B (4.81 ± 2.74 days vs. 6.80 ± 2.14 days, P <  0.001). However, the average hourly serum β-hCG decrease rate within 24 h and the leukocytes on the first day after D&C in group B were superior than in group A (P <  0.050).

CONCLUSION

For patients with CSP, UAE followed by D&C on the same day (0-12 h) appears to have more advantages in hospitalization and recovery time, while the long time interval (12-72 h) may have a lower risk of inflammation and a more rapid decrease in serum β-hCG level within 24 h after D&C surgery. The treatment of CSP should be individualized based on the conditions of patients.

Cesarean scar pregnancy treatment: a case series

Background

Cesarean scar pregnancy is a complicated and potentially life-threatening type of ectopic pregnancy. This study reports two women with cesarean scar pregnancy who were successfully treated with systemic methotrexate administration, and two other women who needed local re-administration of methotrexate after systemic injection.

Case presentation

Four Iranian pregnant women aged 29–34 years who were between 5  to 7 gestational weeks with cesarean scar pregnancy diagnosis are described. After a single dose of systemic methotrexate injection, the level of serum beta-human chorionic gonadotropin decreased in two of the women, while fetal activity was observed in the other two women. In the latter patients, methotrexate was injected under transvaginal ultrasound guidance into the gestational sac. As a result, the serum beta-human chorionic gonadotropin level first increased and then decreased in these patients. During the follow-up period, all the patients were stable and no complications were observed. Serum beta-human chorionic gonadotropin levels reached the non-pregnancy range from 4 to 9 weeks after treatment.

Conclusion

When diagnosed at early gestation, cesarean scar pregnancy can be treated successfully with methotrexate administration alone. The clinicians should be aware that the beta-human chorionic gonadotropin level may initially increase after methotrexate injection in some patients. However, the final outcome will be promising if the patients remain stable.

Hysteroscopic treatment and reproductive outcomes in cesarean scar pregnancy: experience at a single institution

OBJECTIVE

To study the risk factors leading to type II/III cesarean scar pregnancy and evaluate the efficacy of hysteroscopic treatment and subsequent reproductive outcomes.

DESIGN

Retrospective study from 2013 to 2018.

SETTING

Inpatient samples.

PATIENT(S)

A total of 439 patients with cesarean scar pregnancy received hysteroscopic treatment. They were grouped according to the type of surgery as hysteroscopy combined with dilation and curettage, systemic methotrexate followed by hysteroscopy combined with dilation and curettage, and uterine artery embolization or laparoscopic ligation of bilateral uterine arteries followed by hysteroscopy combined with dilation and curettage. Cesarean scar pregnancy was classified as types I, II, and III on the basis of the relationship between the gestational sac and myometrial thickness by ultrasound.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Risk factors leading to type II/III cesarean scar pregnancy. The success of hysteroscopic treatment as well as favorable reproductive outcomes.

RESULT(S)

The significant variables were multiple parity, prior cesarean section (CS), hysteroscopic therapy, and dilation and curettage after the last CS between type I and type II/III. There were significant differences among the three groups in symptoms, largest diameter of the gestational sac, presence of fetal heartbeat, myometrial thickness, type of cesarean scar pregnancy, blood loss, length of hospital stay, and expense. The rates of complications and success were 8.2% and 93.6%, respectively. Thirty-seven women conceived again, and 22 women completed a term pregnancy with no uterine rupture. The recurrence rate of cesarean scar pregnancy was 10.8%.

CONCLUSIONS

The type of cesarean scar pregnancy is related to the rates of multiple parity, cesarean deliveries, and dilation and curettage procedures after the last CS. Hysteroscopic therapy is a safe and effective surgical approach with a low risk of subsequent ectopic pregnancy.

Outcomes of reproduction following cesarean scar pregnancy treatment: A systematic review and meta-analysis

OBJECTIVES

To explore the reproductive outcomes of women with a history of cesarean scar pregnancy (CSP) and the influence of various treatments on subsequent pregnancy outcomes.

STUDY DESIGN

The PubMed, Embase, Medline, Cochrane Library and ClinicalTrial.gov databases were searched for studies with the outcomes of pregnancy after CSP treatment. Studies that reported reproductive outcomes after CSP with more than 5 followed cases were included. The main data collected includes the treatment methods of CSP and subsequent pregnancy outcomes. The main information includes intrauterine pregnancy, recurrent CSP (RCSP), and spontaneous miscarriage, while the secondary information includes complications during pregnancies and the outcomes of childbirths. According to different treatments (conservative treatment, surgical treatment without resection of cesarean scar, and surgical treatment with resection of cesarean scar), a stratified analysis was carried out to compare the influence of treatments on subsequent pregnancy outcomes.

RESULTS

A total of 32 studies including 3380 cases of CSP met the inclusion criteria, of which 583 cases conceived again after treatment (including 292 cases of unexpected pregnancy), and finally 178 cases delivered successfully. The follow-up time ranged from 3 to 72 months. Among women with fertility requirements, a total of 291 cases in 403 women were successfully conceived during the follow-up period in 15 studies. Thence the pregnancy rate of women with fertility requirements was 76.2 %. Among all of the 583 successfully conceived women, 83.4 % of them had intrauterine pregnancy, while 15.3 % of cases were RCSP. The total ectopic pregnancy rate reached 16.6 %, covering RCSP and other sites of ectopic pregnancy. 14.6 % of intrauterine pregnancy experienced spontaneous miscarriage. The intrauterine pregnancy rates of the conservative treatment group, the surgical treatment without resection of cesarean scar group, and the surgical treatment with resection of cesarean scar group were 93.1 %, 80.1 % and 86.0 % respectively; the corresponding RCSP rates were 6.9 %, 15.6 % and 14.0 % respectively; and the corresponding spontaneous miscarriage rates were 20.7 %, 13.9 % and 22.2 % respectively.

CONCLUSION

The outcomes of reproduction after CSP included intrauterine pregnancy, RCSP and other sites of ectopic pregnancy. Women with a history of CSP still have a high pregnancy rate, but the risk of RCSP and spontaneous miscarriage is also increased. It is impossible to clarify the effect of different treatments on subsequent pregnancy. Whether the resection and repair of cesarean scar can ameliorate reproductive outcomes needs to be further assessed. Further large-scale prospective studies, even RCTs with long-term follow-up are needed to expound the outcomes of reproduction after CSP and the effect of different treatments on subsequent reproductive outcomes.

Single- versus multiple-dose methotrexate in cesarean scar pregnancies management: treatment and reproductive outcomes

PURPOSE

We aim to assess the outcome of the treatment of cesarean scar pregnancy (CSP) with single-dose methotrexate (MTX) versus multiple-dose MTX protocols.

METHODS

A retrospective cohort study including two tertiary medical centers was conducted. All women diagnosed with CSPs between the years 2011 and 2019 that were initially managed with systemic MTX were included. Single-dose MTX practiced in one medical center was compared to multiple-dose MTX, practiced in the other medical center.

RESULTS

The study cohort included 31 women in the single dose and 32 women in the multiple-dose MTX groups. Baseline characteristics did not differ between groups. The primary outcome occurred in 12 (38.7%) of the cases in the single-dose group and in 6 (18.8%) in the multiple-dose group (p = 0.083). The rate of conversion to surgical treatment was similar in both groups (4 vs. 5 in the single vs. multiple-dose groups, respectively, p = 0.758). There was no significant difference between the single- and the multiple-dose groups in the administration of blood products (16.1% vs. 3.1%, respectively, p = 0.104), total days of admission (18 ± 9.3 vs. 17 ± 12.8 days, respectively, p = 0.850), and readmission rate (32.3% vs. 21.9%, respectively, p = 0.353). Data regarding sequential pregnancies were available for 11 women in the single and 13 women in the multiple-dose MTX groups. There were no differences between the groups in rates of term deliveries, CSP recurrence, and abortions.

CONCLUSION

Both single- and multiple-dose MTX treatment protocols offer high success rate with a relatively low complication rate in the treatment of CSP.

Association of hemorrhage at termination in caesarean scar pregnancy using the crossover sign of ultrasound image

PURPOSE

To analyze whether crossover sign (COS) can help predict the risk of bleeding during surgical evacuation in patients with caesarean scar pregnancy (CSP).

METHODS

This study retrospectively analyzed the clinical presentations, ultrasound images and treatment outcomes of patients with CSP. The relationship among the gestational sac, caesarean scar and the anterior uterine wall, defined as the COS, was analyzed to predict the risk of severe bleeding during surgical evacuation in these patients. All patients were categorized according to the relationship between the endometrial line and the superior-inferior diameter of the gestational sac into crossover sign-1 and crossover sign-2 groups. The Mann-Whitney U test was used to compare the data with non-normal distribution, and logistic regression analysis was performed to identify the correlates of severe bleeding.

RESULTS

A total of 74 patients were included. In COS-1 group (n = 21), 16 (76.19%) patients suffered heavy bleeding(≥200 mL) during surgical evacuation, while COS-2 group (n = 53) had only 1(11.89%) patient complaint of heavy bleeding (≥200 mL) (P < 0.01). Adverse surgical outcomes were more common in women with COS-1. Logistic regression analysis showed that COS-1 (OR, 7.93; 95% CI, 1.35-46.67) was independently associated with severe bleeding.

CONCLUSION

COS can help predict who has a higher risk of severe hemorrhage in patients with CSP and guide the clinical treatment selection for optimal management of this condition.

Exclusive use of intrasac potassium chloride and methotrexate for treating cesarean scar pregnancy: effectiveness and subsequent fecundity

STUDY QUESTION

Is exclusive use of intragestational sac potassium chloride (KCl) and methotrexate (MTX) effective in the management of viable cesarean scar pregnancy (CSP)?

SUMMARY ANSWER

Exclusive use of intragestational sac KCl and MTX was effective in the management of viable CSP.

WHAT IS KNOWN ALREADY

Owing to a paucity of randomized studies on management of CSP, evidence-based management remains unclear. Intragestational sac KCl or MTX along with either systemic MTX or surgical intervention, such as uterine artery embolization or dilation and curettage, has proved to be effective in the management of CSP. Furthermore, there are limited data in the literature on the use of exclusive intragestational sac KCl and MTX for management of CSP and subsequent fecundity.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study was conducted from June 2017 to September 2019. We recruited nine CSP patients referred to our unit. There was no lost to follow-up noted.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients with an ultrasound diagnosis of CSP who fulfilled the inclusion criteria were recruited. The study was conducted in a tertiary care center. Clinical symptoms, pregnancy viability, gestational age and human chorionic gonadotrophin (HCG) values determined the management in each individual case. Accordingly, patients were grouped into the expectant management (Group I, n = 3) and intragestational sac KCl with MTX (Group II, n = 6) groups. Demographic details, clinical characteristics, ultrasound details at diagnosis, post-treatment HCG normalization time, menses resumption, mass resolution and subsequent fecundity were noted. Descriptive statistics were used for analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the nine patients with CSP, six patients had viable CSP and required intervention. Out of these, four patients expressed a desire for future fertility. Mean gestational age at treatment among patients in Group II was 54.33 ± 7.51 days (range 46–65). Mean HCG value at the time of diagnosis was 84 110 ± 38 679.39 IU/l in Group II patients as compared with 2512 ± 709.36 in Group I. HCG had decreased by 92.7 ± 3.78% 2 weeks after intervention and normalized (<5 IU/l) by 53.5 ± 14.97 days. No major complications occurred and additional treatment was not required in these patients. Menstruation had resumed by 26 ± 6.6 days after treatment in Group II. On follow up, a small unresolved mass was present in two patients and the cesarean scar niche was visible in the remaining four patients. Out of the four patients desirous of future conception, three conceived naturally and one delivered a term baby via repeat lower segment cesarean section.

LIMITATIONS, REASONS FOR CAUTION

The main limitation of our study was small sample size. All the patients were asymptomatic at presentation and hence we cannot comment on use of this method in those presenting with active vaginal bleeding.

WIDER IMPLICATIONS OF THE FINDINGS

Intragestational sac KCl plus MTX may be a highly effective approach for the management of viable CSP despite high initial HCG values. There seems to be no need for any further intervention. It can be considered as the first line minimally invasive treatment option in patients desirous of future fertility. Nevertheless, accumulation of further cases is required to validate this treatment modality.

STUDY FUNDING/COMPETING INTERESTS

No specific funding was received to undertake this study. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A