Risk factors of persistent cesarean scar pregnancy after dilation and curettage: a matched case-control study

Clinical Application of a New Cesarean Scar Pregnancy Classification and Evaluation System and a Risk Scoring System

Objective

Cesarean scar pregnancy (CSP) is an uncommon form of ectopic pregnancy that carries the risk of severe bleeding. To date, there has not been a universally accepted classification and treatment strategy. We performed this study to establish a risk scoring system and new CSP classification system for CSP and evaluate its efficacy.

Methods

A total of five groups were generated based on different methods of treatment, and the factors that increase the risk of intraoperative bleeding were examined in our center from 2013 to 2018. The construction of a risk scoring system in this study was based on the use of the chi-square test and multivariate logistic regression analysis. To determine the appropriate cutoff scores, receiver operating characteristic (ROC) curves and the area under the curve (AUC) were generated.

Results

We identified the main high-risk factors for excessive intraoperative hemorrhage during CSP surgery through univariate and multivariate analyses. Within this investigation, the risk factors included gestational sac location and gestational sac diameter. Through analysis, an optimal cutoff score of 3 was determined, and the area under the ROC curve was calculated to be 0.8113 (95% CI=0.7696-0.8531). A score ranging from 0-3 was classified as low risk, while a score ranging from 5-7 was classified as high risk. Additionally, a new classification system for CSP has been established based on sonographic parameters. We also established a diagnostic and treatment process for CSP patients according to the risk scoring method and new CSP classification.

Conclusion

We identified the high-risk factors associated with bleeding during CSP surgery and developed a scoring system incorporating these factors. The utilization of this novel CSP typing method, in conjunction with the risk scoring system, can effectively inform doctors in their decision-making process concerning treatment strategies for patients with CSP.

Clinical efficacy and risk factors for suction curettage and hysteroscopy in patients with type I and II cesarean scar pregnancy

OBJECTIVE

To investigate the clinical efficacy and evaluate risk factors for suction curettage (SC) and hysteroscopy in the treatment of type I and II cesarean scar pregnancy (CSP).

METHODS

This was a retrospective study including 100 women diagnosed with type I/II CSP. Patients were treated with either ultrasound-guided SC (SC group) or hysteroscopy resection (surgery group). The success rates, mean operation time, hospitalization duration, hospitalization cost, risk factors, adverse events, and complications were analyzed.

RESULTS

The success rate of the SC and surgery groups were 85% and 100%, respectively, and the difference was statistically significant (P = 0.032). There was one case of type I CSP and eight cases of type II CSP that failed SC treatment. No failed cases were found in the surgery group. Analysis of the causes of treatment failure revealed that diameter of the gestational sac was a risk factor for SC failure (odds ratio, 19.66 [95% confidence interval {CI}, 1.70-227.72], P = 0.017). Comparing the clinical outcomes between the SC and surgery groups, although the mean operation time of the SC group was significantly shorter than the surgery group (15 [CI, 15-20] vs. 30 [CI, 27-40], P = 0.001), the cost and duration of hospitalization were significantly lower in the surgery group than that in the SC group. No significant differences were observed for adverse events and complications between the two groups (P > 0.05).

CONCLUSION

Hysteroscopy is an effective and economical method for treating type I/II CSP. Moreover, SC is not recommended for patients with type I/II CSP with a gestation age ≥8 weeks.

Clinical value of ultrasonic indicators in predicting the outcome of caesarean scar pregnancy after pregnancy termination

BACKGROUND

To investigate the predictive value of ultrasound indicators in early pregnancy for the outcome of caesarean scar pregnancy (CSP) after pregnancy termination.

METHODS

This study retrospectively analysed the ultrasound images of 98 CSP patients who underwent transabdominal ultrasound-guided hysteroscopic curettage during early pregnancy at Changsha Hospital for Maternal and Child Health Care between January 2017 and October 2021. Patients were equally divided into a case group and a control group. The case group included 49 CSP patients with postoperative complications, such as intraoperative blood loss ≥ 200 ml or retained products of conception (RPOC). The remaining 49 CSP patients, with similar age and gestational age and with good postoperative outcomes, such as intraoperative blood loss ≤ 50 ml and no RPOC, were included in the control group. CSP was classified into three types according to the location of the gestational sac (GS) relative to the uterine cavity line (UCL) and serosal contour. Differences in ultrasound indicators between the case and control group were compared.

RESULTS

There were significant differences between the case and control groups in the mean gestational sac diameter (MGSD), residual myometrium thickness (RMT) between the GS and the bladder, blood flow around the GS at the site of the previous caesarean incision, and types of CSP (P < 0.05). The rs of each ultrasound indicator were as follows: 0.258, -0.485, 0.369, 0.350. The optimal threshold for predicting good postoperative outcomes, such as intraoperative blood loss ≤ 50 ml and no RPOC, by receiver operating characteristic (ROC) curve analysis of the RMT was 2.3 mm.

CONCLUSION

Our findings show that the RMT, blood flow around the GS at the site of the previous caesarean incision, and types of CSP have a low correlation with postoperative complications, such as intraoperative blood loss ≥ 200 ml or RPOC, of early pregnancy termination in patients with CSP. To some extent, this study may be helpful for clinical prognostic prediction of patients with CSP and formulation of treatment strategies. Given the low correlation between these three indicators and postoperative complications, further studies are needed to identify indicators that can better reflect the postoperative outcomes of CSP patients.

MRI-based scoring model to predict massive hemorrhage during dilatation and curettage in patients with cesarean scar pregnancy

OBJECTIVE

To construct a scoring model based on MRI signs to predict massive hemorrhage during dilatation and curettage in cesarean scar pregnancy (CSP) patients.

MATERIALS AND METHODS

The MRIs of CSP patients admitted to a tertiary referral hospital between February 2020 and July 2022 were retrospectively reviewed. The included patients were randomly assigned to the training and validation cohorts. The univariate and multivariate logistic regression analyses were adopted to identify the independent risk factors for massive hemorrhage (the amount of bleeding ≥ 200 ml) during the dilatation and curettage. A scoring model predicting intraoperative massive hemorrhage was established where each positive independent risk factor was assigned 1 point, and the predictive power of this model was evaluated both in the training and validation cohorts via the receiver operating characteristic curve.

RESULTS

A total of 187 CSP patients were enrolled, who were divided into the training cohort (31 in 131 patients had massive hemorrhage) and validation cohort (10 in 56 patients had massive hemorrhage). The independent risk factors for intraoperative massive hemorrhage included cesarean section diverticulum area (OR = 6.957, 95% CI 1.993-21.887; P = 0.001), uterine scar thickness (OR = 5.113, 95% CI 2.086-23.829; P = 0.025) and gestational sac diameter (OR = 3.853, 95% CI 1.103-13.530; P = 0.025). A scoring model with a total point of 3 was developed and the CSP patients were divided into low-risk (Total points < 2) and high-risk groups (Total points ≥ 2) for intraoperative massive hemorrhage accordingly. This model possessed high prediction performance both in the training cohort (area under the curve [AUC] = 0.896, 95% CI 0.830-0.942) and validation cohort (AUC = 0.915, 95% CI 0.785-1.000).

CONCLUSION

We first constructed a MRI-based scoring model for predicting intraoperative massive hemorrhage in CSP patients, which could help the decision-making of the patients' therapy strategies. Low-risk patients can be cured by D&C alone to reduce the financial burden, while high-risk patients require more adequate preoperative preparation or consideration of changing surgical approaches to reduce bleeding risk.

Predictive factors analysis of cesarean scar pregnancy treated by local injection of Lauromacrogol combined with curettage

To explore factors related to local injection of Lauromacrogol combined with curettage in the treatment of cesarean scar pregnancy. A total of 24 successful and 8 unsuccessful cases were included. The age, gravidity, parity, times of cesarean section, interval from the last cesarean section, preoperative human chorionic gonadotropin (HCG), HCG on the first day after operation, decreasing rate of HCG on the first day after operation, average diameter of gestational sac, and preoperative vaginal bleeding days were analyzed. There were no significant differences of age, gravidity, parity, previous cesarean section times between groups. The differences of preoperative HCG, HCG on the first day after operation, the decreasing rate of HCG, gestational sac diameter, preoperative vaginal bleeding days were statistically significant between groups. The interval from the last cesarean section and the decreasing rate of HCG were protective factors, while the mean diameter of gestational sac and period of vaginal bleeding before operation were risk factors for the success of the treatment. The mean diameter of gestational sac owned the best predictive value.

Uterine Artery Embolization on Serum β-HCG Levels, Fertility Function and Clinical Efficacy in Patients With Cesarean Uterine Scar Pregnancy

Objective

To analyze the therapeutic effect of uterine artery embolisation (UAE) in patients with cesarean section pregnancy (CSP) delivered by cesarean section and the effect on serum human chorionic gonadotrophin (β-HCG) levels and reproductive function.

Methods

In total 142 patients with CSP, The control group (n = 71) received Methotrexate (MTX) with ultrasound monitoring after admission and the research group (n = 71) was treated with UAE on basic of the control group. The two groups were compared in terms of treatment outcome, intraoperative bleeding, bed activity, vaginal bleeding and length of hospital stay, and serum follicle stimulating hormone (FSH), oestradiol (E2), luteinising hormone (LH) and β-HCG levels at 1 month postoperatively. The clinical symptoms (normalization of β-HCG and return of menstruation) and clinical outcomes (normal pregnancy, recurrent scar pregnancy) were compared between the two groups, as well as the occurrence of post-operative complications in both groups.

Results

Compared with the control group, the research group had a higher overall near-term effective rate, a lower recurrence rate of CSP in pregnancy, and a lower complication rate (P < 0.05); meanwhile, the time to get out of bed, postoperative vaginal bleeding, length of hospital stay, normalization of serum β-HCG, and return to menstruation were shorter in the research group than in the control group (P < 0.05); In addition, serum FSH, E2, LH and β-HCG levels improved better in the research group compared with the control group 1 month after surgery (P < 0.05).

Conclusion

The treatment of CSP patients with UAE can reduce the amount of intraoperative bleeding and the duration of vaginal bleeding, promote the improvement of patients' clinical symptoms, have less impact on the disruption of patients' sex hormone balance, reduce patients' surgical risks to a greater extent, preserve patients' normal fertility, and have better application.

Diagnosing early scar pregnancy in the lower uterine segment after cesarean section by intracavitary ultrasound

BACKGROUND

Early scar pregnancy (CSP) in the lower uterine segment after cesarean section is a type of ectopic pregnancy that can cause major complications if left untreated. Transabdominal ultrasound is a common procedure but is influenced by external factors. Thus, intracavitary ultrasound may have better diagnostic efficiency for CSP.

AIM

To assess the value of intracavitary ultrasound for diagnosing CSP in the lower uterine segment after cesarean section.

METHODS

Patients diagnosed with CSP in our hospital from October 2019 to April 2021 were recruited. Transabdominal and intracavitary ultrasound examinations were performed to compare the diagnostic differences for CSP and its types.

RESULTS

Sixty-three patients were diagnosed during the study period. The diagnostic accuracy for CSP was higher in intracavitary ultrasound (96.83%) than in transabdominal ultrasound (84.13%) (P < 0.05). The missed diagnosis and misdiagnosis rates did not differ among the ultrasound types (intra: 0.00% and 3.17%; trans: 4.76% and 11.11%, respectively; P > 0.05). For the diagnostic rates for the CSP types, the rates for gestational sac (100.00% vs 90.48%), heterogeneous mass (93.75% vs 75.00%), and part of the uterine cavity (80.00% vs 60.00%) were higher in intracavitary ultrasound than in transabdominal ultrasound, but the difference was not statistically significant (P > 0.05). For gestational sac CSP patients, intracavitary ultrasound showed that the gestational sac was located in the lower uterine segment scar with abundant peripheral blood flow; the distance between the gestational sac and the serosal layer was 2.42 ± 0.50 cm. Intracavitary ultrasound for heterogeneous mass CSP patients indicated that the mass mainly occurred in the lower anterior uterine wall, protruding into the bladder, and was surrounded by abundant internal and peripheral blood flow; the distance between the mass and serosal layer was 1.79 ± 0.30 cm. For CSP type partly located in the uterine cavity, the gestational sac was partly located in the lower uterine cavity and partly in the scar with abundant internal and peripheral blood flow; the distance between the gestational sac and the serosal layer was 2.29 ± 0.28 cm.

CONCLUSION

Intracavitary ultrasound had a higher diagnostic accuracy and application value for diagnosing CSP than transabdominal ultrasound, with reduced risk of missed diagnoses and misdiagnosis, thereby preventing delayed treatment.

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

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

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.