Conservative treatment by chemotherapy and uterine arteries embolization of a cesarean scar pregnancy

Potential Risk Factors for Developing Cesarean Scar Pregnancy in Women With a History of Cesarean Section

OBJECTIVES

Cesarean scar pregnancy (CSP) occurs in 0.2%-0.5% of women with a previous cesarean section globally. Multiple factors influence the development of CSP; however, to date, the critical factors contributing to the development of CSP have not been fully explored due to its relatively low incidence. Moreover, CSP can be clinically categorized into type 1 and type 2 CSP. In this retrospective study with a large sample size, we investigated potential risk factors that could contribute to CSP development.

METHODS

Two hundred-one women diagnosed with CSP, either type 1 or type 2 CSP, and 1700 pregnant women with a history of cesarean section but without CSP diagnosis in subsequent pregnancy were included. Gravidity, previous live birth(s), consecutive cesarean section(s), surgical abortion(s), the interval between the pregnancies, and maternal age were compared between the 2 groups.

RESULTS

Gravidity, the number of previous live births, the number of previous consecutive cesarean sections, and the number of surgical abortions were significantly associated with CSP development in women with a past cesarean section. This association was regardless of the subtypes of CSP. Notably, the interval between 2 pregnancies was also significantly associated with CSP development, but this association was only seen in type 2 CSP. However, maternal age was not an independent risk factor for CSP development. Additionally, a higher incidence of CSP was observed in China compared to that reported in the literature.

CONCLUSION

In addition to a previous cesarean section, our study highlights at the number of surgical abortions also contributes to the development of CSP.

Systemic Immune-Inflammation Indices Could Be Additional Predictive Markers for Cesarean Scar Pregnancy

PROBLEM

Cesarean scar pregnancy (CSP) is characterized by a gestational sac fully or partially implanted in the scar from a previous cesarean section. Systemic immune-inflammation indices (SIIs) have recently been discussed as additional diagnostic markers in placenta accreta and preeclampsia. CSP shares a similar pathogenesis with these diseases, suggesting that assessing the SIIs and neutrophil-to-lymphocyte ratio (NLR) could enhance additional predictability in diagnosing CSP.

METHOD OF STUDY

In this study, we analyzed the complete blood counts between 264 women who were confirmed with CSP by ultrasound and 295 women who underwent elective termination.

RESULTS

The mean counts of total white cells and neutrophils were significantly higher, whereas the counts of monocytes, lymphocytes, and platelets were significantly lower in the CSP group compared to the control group (p < 0.001). Additionally, the SII, systemic inflammation response index (SIRI), or NLR was significantly higher in the CSP group compared to the control group (p < 0.0001). Given the limited effect of SII and SIRI on the increased risk of developing CSP, the optimal cut-off value for NLR in predicting CSP was 2.87 (area under the curve [AUC] 0.656, 68% sensitivity). The optimal cut-off value for NLR in predicting type 2 CSP was 2.91 (AUC 0.690, 71% sensitivity).

CONCLUSIONS

Although ultrasound or magnetic resonance imaging images are a gold standard for visualizing the gestational sac's location in the diagnosis of CSP, assessing peripheral blood tests is cost-effective, and NLR may provide additional diagnosis value for CSP.

Medical Management of Cesarean Scar Ectopic Pregnancy: A Unique Approach

One of the rarest types of ectopic pregnancy, with an incidence of 1:1,800, is cesarean scar ectopic pregnancy. Here, we report the case of a 28-year-old woman who had undergone two previous cesarean sections. She arrived at our labor room with per vaginal spotting and abdominal pain with an ultrasound that revealed a cesarean scar ectopic pregnancy. The initial beta-human chorionic gonadotropin (β-hCG) value upon admission was 27,133 mIU/mL. Her ultrasound findings were confirmed with magnetic resonance imaging. Opting for combined medical management, we successfully treated her using systemic methotrexate and mifepristone, avoiding surgical intervention despite high β-hCG values. There is currently no established standardized treatment for cesarean scar ectopic pregnancies, and we feel that treatment must be tailored to every patient's individual needs. Our experience suggests that combining mifepristone and systemic methotrexate can be an effective approach with better curative effects, emphasizing the need for further research.

Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis

The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Scarred for life: a review of cesarean section scar pregnancy and potential pitfalls in diagnosis

Cesarean section scar pregnancy (CSSP) is defined as abnormal implantation of a gestational sac on or in a previous cesarean section scar. There is an increasing incidence of detection of CSSP, likely in part due to the growing rates of cesarean deliveries and the improved rates of detection with advancing ultrasound technology. Diagnosis of CSSP is critical due to the potentially life-threatening complications to the mother if left untreated. Pelvic ultrasound is the imaging modality of choice in the initial evaluation of suspected CSSP, with MRI potentially useful if ultrasound findings are equivocal, or if confirmation is requested prior to definitive intervention. Early and accurate diagnosis of CSSP allows for prompt management to avoid severe complications and the potential to preserve the uterus and future fertility. A combination of medical and surgical treatment strategies may be needed with specific therapy tailored to each patient. Follow-up after treatment should include serial beta-hCG levels and possible repeat imaging if there is clinical concern for complications or treatment failure. This article will provide a comprehensive review of this uncommon but important phenomenon, detailing the pathophysiology and types of CSSP, imaging presentations, potential pitfalls in diagnosis, and management options.

Definition and diagnosis of cesarean scar ectopic pregnancies

Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy, where the pregnancy implants into a myometrial defect caused by a cesarean scar. Its incidence is predicted to increase, given the global increase in cesarean deliveries. As most cesarean scar ectopic pregnancies present as failing pregnancies or patients choose termination of pregnancy, there are limited data on their natural history. However, early first trimester diagnosis is essential, given the associated significant maternal morbidity. Transvaginal sonography is generally considered to be the optimal method for diagnosing cesarean scar ectopic pregnancy. There is no evidence that MRI adds to the diagnostic accuracy, and it is therefore not recommended for routine evaluation of cesarean scar ectopic pregnancy. There is no agreed reference standard for the diagnosis of cesarean scar ectopic pregnancy; therefore, the validity of several proposed sonographic diagnostic criteria reported by different authors remains unknown. There are also various suggested classification systems for cesarean scar ectopic pregnancy, which divide them in differet types. However, the proposals are very heterogeneous, and superiority of one classification system over another is yet to be established.

Ultrasound for monitoring twin cesarean scar pregnancy following feticide

Objective

Implantation of the conceptus in a twin cesarean scar pregnancy (CSP) is considered the rarest type of ectopic pregnancy. Preserving the fetus in utero and effectively dealing with CSP can be challenging. This study aimed to determine the clinical value of ultrasonography by monitoring imaging changes in twin CSP following selective feticide.

Methods

Ultrasonographic and clinical data were collected from four patients with twin CSP who were treated between December 2017 and December 2018 at our hospital.

Results

All patients had a history of cesarean section, followed by a heterotopic CSP, with one embryo implanted into the uterine cavity and the other located in the anterior isthmus. All of the patients were pregnant with twins with double chorionic and amniotic sacs, and all gave birth in our hospital. The patients underwent feticide at 8 to 9 weeks of gestation, after which we focused on monitoring the implantation. Delivery was performed by cesarean section according to scores of an ultrasonic scoring system and clinical manifestations. The patients’ uterus was preserved and they recovered.

Conclusions

This study shows that ultrasound is useful for determining the timing of clinical termination of CSP by selective feticide.

Approaches in the Treatment of Cesarean Scar Pregnancy and Risk Factors for Intraoperative Hemorrhage: A Retrospective Study

Background: Cesarean scar pregnancy (CSP) involves a rare form of placental attachment that often leads to life-threatening conditions. The best treatment for CSP has been debated for decades. We aimed to evaluate the different treatments for CSP and analyzed the risk factors for intraoperative hemorrhage.

Methods: CSP patients treated at the Affiliated Hospital of Jiangnan University were reviewed retrospectively from January 2014 to 2020. CSP was classified into three types based on the location and shape of gestational tissue, blood flow features, and thickness of the myometrium at the incision site. The clinical characteristics, types, approaches of treatment, and clinical outcomes of CSP were analyzed.

Results: A total of 55 patients were included in this study, 29 (52.7%) of whom underwent transvaginal curettage after uterine artery embolization (UAE) and 22 (40%) of whom underwent transabdominal ultrasound-guided hysteroscopic curettage (USHC) in type I and II. Four patients (7.3%) classified as type III underwent laparoscopic cesarean scar resection (LCSR). Intraoperative blood loss, blood transfusion rate, and scar diverticulum were significantly higher in type II than in type I (P < 0.05). Even though USHC showed no differences in intraoperative blood loss, length of stay, and scar diverticulum compared with curettage after UAE (P > 0.05), superiority was found in surgical time and hospitalization cost (P < 0.05). Furthermore, the type of CSP (OR = 10.53, 95% CI: 1.69–65.57; P = 0.012) and diameter of the gestational sac (OR = 25.76, 95% CI: 2.67–248.20; P = 0.005) were found to be risk factors for intraoperative hemorrhage.

Conclusions: Transabdominal ultrasound-guided hysteroscopic curettage is an effective and relatively safe treatment option for patients with CSP. Type of CSP and diameter of the gestational sac were found to be associated with excessive intraoperative hemorrhage.

A Comparison of Treatment Options for Type 1 and Type 2 Caesarean Scar Pregnancy: A Retrospective Case Series Study

Background: There is currently no agreement on the optimal management of caesarean scar pregnancy. Caesarean scar pregnancy is currently categorised into two subtypes according to the site of implantation. This may consequently result in the difference in treatment options. However, the comparison of the success rate of each treatment option according to the subtypes has not been fully investigated. Methods: 71 patients who were treated by uterine curettage (D and C), or uterine artery embolization with curettage (UAE) or hysteroscopy in conjunction with laparoscopy between January 2016 and March 2020 were included. Data on maternal age, gestational sac age, the sac diameter, the interval between two pregnancies, the number of previous caesarean sections, amount of bleeding and β-hCG levels were collected and analysed dependent on the subtypes. Results: There was no difference in the clinical parameters of the cases who received different options of treatment, as well as no difference in the clinical parameters between type 1 and type 2 caesarean scar pregnancy. The primary success rate for type 1 caesarean scar pregnancy by D and C, or UAE, or hysteroscopy in conjunction with laparoscopy was 95, or 100 or 100%, respectively. The primary success rate for type 2 caesarean scar pregnancy by D and C, or UAE, or hysteroscopy in conjunction with laparoscopy was 27, or 67, or 95% respectively. Conclusion: Our data demonstrates that hysteroscopy in conjunction with laparoscopy for type 2 caesarean scar pregnancy was the most successful compared to other options, but for type 1 caesarean scar pregnancy, D and C could be the cost-effective option.

Management for delayed diagnosis in cesarean scar pregnancy with hemorrhage intra- or postuterine dilation and curettage

Aim

This study aimed to examine the characteristics, management, and outcomes of delayed diagnosis of cesarean scar pregnancy (CSP) with hemorrhage intra‐ or postuterine curettage for early pregnancy termination.

Methods

The retrospective study, cases were identified from the interrogation of the hospital database and clinical data including the success rate of different treatments, vaginal bleeding time, abnormal beta‐human chorionic gonadotropin (β‐hCG) time, and menstrual recovery time, preservation of uterus were analyzed.

Results

Medical records of 80 confirmed CSP cases with dilation and curettage (D&C) as primary treatment were analyzed; among them, 22 were treated with uterine arterial embolization (UAE) + methotrexate (MTX); 32 with UAE + surgery; 26 with only surgery or resection and repair. Treatment with UAE had less intraoperative blood loss (p < 0.05). UAE + surgery treatment had the highest success rate (96.8%, p < 0.05), the least vaginal bleeding duration after treatment (11.9 ± 9.6 days, p < 0.05), and least β‐hCG normalization time (17.4 ±  7.8 days, p < 0.05).

Conclusion

UAE + surgery treatment is a favorable and effective option to control massive hemorrhage intra‐ or post‐uterine curettage for early CSP termination.

Myometrial thickness overlying cesarean scar pregnancy is significantly associated with isthmocele formation in the third month of the postoperative period

Objective:

To determine some associated factors for isthmocele formation 3 months after the treatment of cesarean scar pregnancy (CSP).

Materials and Methods:

This is a prospective consecutive case series of CSP managed by fertility preservation modalities at a single tertiary care center from May 2016 to March 2019 (n=95). Patients with a diagnosis of CSP were identified and followed prospectively to collect data on the patients’ demographics; detailed medical, surgical, and social history; symptoms; imaging and laboratory parameters at the time of CSP diagnosis and during treatment; treatment modalities, myometrial thickness; and outcomes in terms of isthmocele formation.

Results:

Mean myometrial thickness overlying scar pregnancy was significantly lower in the group with isthmocele formation, and the mean gestational age of scar pregnancy was also significantly lower in the group with isthmocele formation following treatment of scar pregnancy (p<0.05). Multivariate regression analysis was conducted to determine associations between certain variables and isthmocele development, which revealed that the gestational age of scar pregnancy and myometrial thickness were significantly associated with isthmocele formation.

Conclusion:

Myometrial thickness and gestational age of scar pregnancy were significantly associated with isthmocele formation 3 months after treatment.

Suction Curettage and Foley Balloon as a First-Line Treatment Option for Caesarean Scar Pregnancy and Reproductive Outcomes

Background

Caesarean scar pregnancy (CSP) is associated with various serious pregnancy complications. This study presents the outcomes of patients treated with suction curettage and Foley balloon as the first-line treatment for CSP as well as their future outcomes in terms of successful pregnancy.

Methods

Of the 44 patients diagnosed with CSP between January 2015 and April 2019, 42 who provided consent for the termination of pregnancy and who simultaneously underwent the transabdominal ultrasound-guided suction curettage + Foley balloon treatment were included in the study. These patients were then contacted and interviewed to collect data concerning their post-treatment number of pregnancies, number of miscarriages, number of live or dead births, mode of delivery, delivery time as well as whether any abnormal placental invasion or uterine ruptures developed.

Results

Transabdominal ultrasound-guided suction curettage + Foley balloon was simultaneously performed as the first-line treatment in 42 patients with CSP. In two of these cases, wherein post-treatment level of β-hCG reached a plateau, single-dose systemic methotrexate was administered. Emergency surgical intervention, hysterectomy, massive blood transfusion and additional systemic methotrexate administration were not required. Twenty-six of 42 patients could be contacted. 18/26 were trying to conceive. 6/18 patients had secondary infertility, and 12/18 patients managed to conceive. 8/12 had caesarean delivery at full term. 1/12 was 16-week pregnant, 1/12 had tubal ectopic pregnancy and 2/12 had first-trimester abortus.

Conclusion

When administered as the first-line treatment for CSP, the suction curettage + Foley balloon treatment is a highly successful, cheap and easily performed minimally invasive method that requires only a short hospital stay, making it comfortable for patients. Compared with other uterine-sparing methods, it does not harm fertility and has positive effects on patients’ future fertility outcomes.

Comparison Of Three Different Treatment Methods For Cesarean Scar Pregnancy

Background/Aim

Cesarean scar pregnancy is a long term complication of cesarean section. There is a lot of controversy about the best treatment methods. We retrospectively summarized the clinical characteristics of patients with cesarean scar pregnancy and explored the advantages and disadvantages of fertility-preservation treatment method.

Methods

From January 2008 to September 2017, a total of 204 cases of cesarean scar pregnancy were retrospectively reviewed. 145 patients underwent transvaginal clearance, 33 patients underwent endoscopic surgery, and 26 patients underwent uterine artery embolism. The clinical characteristics, diagnosis, various treatment methods, and clinical outcomes were analyzed.

Results

There were no significant differences among the three groups in terms of patient age, number of previous cesarean sections, serum human chorionic gonadotropin, and clinical symptoms. The difference in mean gestational sac diameter (23.5±2.1mm vs 31.3±2.4mm vs 30.8± 1.9mm), surgical time (31.4±2.5min vs. 45.8±2.2min vs. 51.4±1.9min), blood loss (53.3± 5.5mL vs. 105.2±3.2mL vs. 75.6 ±3.5mL), blood transfusion (1/145 case vs.3/33 case vs. 0/26 case), discomfort (1/145 case vs.9/33 case vs. 16/26 case), hospital stay (6.1±1.1 day vs. 7.4±0.9 day vs.18.6±1.5 day), fever duration (1.0±0.5 day vs. 2.1±2.8 day vs. 5.7±3.5 day), and hospital expense (¥ 7825.9±234.9 vs. ¥ 10248.3± 312.9 vs. ¥ 18774.9±243.6) in transvaginal pregnancy tissue clearance, endoscopic surgery, and uterine artery embolism groups were significantly different.

Conclusion

Transvaginal clearance is an effective and relatively safe treatment option for patients with cesarean scar pregnancy.

Efficacy of contrast-enhanced ultrasound for diagnosis of cesarean scar pregnancy type

OBJECTIVES

We compared the clinical efficacy of contrast-enhanced ultrasound (CEUS) to transvaginal ultrasound (TVS) for diagnosing cesarean scar pregnancy (CSP).

METHODS

A total of 485 cases of suspected CSP were recruited from January 2017 to March 2018. All received TVS and CEUS by two sonologists blinded to diagnosis by the other. Diagnostic features of CSP that significantly differed between modalities by univariate analysis (P < .05) were included in a logistic regression model. The sensitivity, specificity, positive likelihood ratio (+LR), negative likelihood ratio (-LR), and accuracy (ACC) of CSP diagnosis by TVS and CEUS were compared according to operational and pathological outcomes as the reference standard.

RESULTS

There were 220 CSP cases (including 85 cases of type I, 93 of type II, and 42 of type III). The sensitivities of CEUS for detection of types I - III CSP were 94.1%, 92.5%, and 97.6%, respectively, and corresponding sensitivities of TVS were 82.4%, 80.6%, and 95.2%. Compared to TVS, CEUS yielded significantly better overall sensitivity (97.27% vs 88.18%), specificity (96.60% vs 75.47%), +LR (28.60 vs 3.59), -LR (0.03 vs 0.16), and diagnostic ACC (96.9% vs 81.23%) (all P < .001).

CONCLUSIONS

CEUS is superior to TVS for detecting cesarean scar pregnancy and distinguishing among CSP types.

Risk factors and consequences of undiagnosed cesarean scar pregnancy: a cohort study in China

Background

The historically high cesarean section rate and the recent change in second-child policy could increase the risk of cesarean scar pregnancy (CSP) in China. This study aims to assess risk factors and consequences of undiagnosed CSP in China.

Methods

We conducted a retrospective cohort study between January 2013 and December 2017 in Qingyuan, Guangdong, China. Independent risk factors for undiagnosed CSP at the first contact with healthcare providers were assessed by log binomial regression analysis. Occurrence of serious complications was compared between undiagnosed and diagnosed CSP cases.

Results

A total of 195 women with CSP were included in the analysis. Of them, 81 (41.5%) women were undiagnosed at the first contact with healthcare providers. Women initially cared in primary or secondary hospitals were at increased risk for undiagnosed CSP: adjusted relative risks (95% confidence intervals) were 3.28 (2.06, 5.22) and 1.91 (1.16, 3.13), respectively, compared with women initially cared in the tertiary hospital. Undiagnosed CSP cases had higher incidences in serious complications (11 versus 0) and post-surgery anemia (23 (28.4%) versus 8 (7.0%)), stayed longer in hospital, and cost higher than diagnosed CSP cases.

Conclusions

Initial care provided at primary or secondary maternity care facilities is an important risk factor for undiagnosed CSP, with serious consequences to the affected women.

[Cesarean-scar pregnancy: about a case and literature review]

La grossesse sur cicatrice de césarienne est une forme rare de la grossesse ectopique qui peut engager le pronostic vital et fonctionnel de la patiente par hémorragie ou par rupture utérine précoce. Nous rapportons le cas d'une grossesse ectopique sur cicatrice de césarienne diagnostiquée à 7 semaines d'aménorrhée suite à des métrorragies chez une patiente de 23 ans, 3^ème geste 2^ème pare, porteuse d'un utérus bi-cicatriciel. Grâce à l'échographie endovaginale le diagnostic a été précoce et le traitement a été conservateur. A travers cette observation et la lumière d'une revue de la littérature, nous discuterons les caractéristiques diagnostiques et thérapeutiques de cette rare entité, dont la connaissance par les praticiens permet d'améliorer le pronostic.

Uterine Artery Embolization and Methotrexate Infusion as Sole Management for Caesarean Scar and Cervical Ectopic Pregnancies: A Single-Center Experience and Literature Review

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.

A rare case of ectopic pregnancy in a caesarean section scar: a case report

Intramural pregnancy with implantation in a previous caesarean section scar is probably the rarest location for an ectopic pregnancy. Little is known about its incidence and natural history. This rare condition may be accompanied by serious clinical events, such as rupture of the uterus and unrestrainable haemorrhage, which are sometimes treated with hysterectomy causing sterility. Most treatment choices are effectual, such as dilatation and curettage (D and C), excision of trophoblastic tissues using either laparotomy or laparoscopy, systemically administered methotrexate and, more recently, uterine artery embolization. Here, we report a case of an ectopic pregnancy that occurred in the scar of a previous caesarean section, which was diagnosed by transvaginal sonography.

Analysis of risk factors for intraoperative hemorrhage of cesarean scar pregnancy

The current commonly used treatments for cesarean scar pregnancy (CSP) include multiple treatments such as medication, uterine artery embolization, curettage and surgery, and their combinations. However, every treatment option has risks of excessive hemorrhage from uterus. In this study, we retrospectively analyzed the risk factors for intraoperative hemorrhage of different treatments for CSP patients, with the hope to provide the guidance for CSP treatment.Fifty-eight cases of CSP patients who were treated with curettage after medication, curettage after uterine artery embolization, or surgery were retrospectively analyzed and compared for the clinical efficacy, length of hospital stay, and hemorrhage rate. Further, they were divided into the bleeding group (≥200 mL, 15 cases) and the control group (<200 mL, 43 cases). The hemorrhage-related risk factors were subjected to univariate analysis, including age, pregnant times, delivery times, abortion times or curettage times, the time from last cesarean section, menolipsis time, serum human chorionic gonadotropin level, ultrasound typing, maximum diameter of gestational sac or mass under ultrasound, peritrophoblastic blood flow around the mass, and the distance of gestational sac or mass from the uterine serosa layer. The significant indexes in univariate analysis were further analyzed using both receiver operating characteristic (ROC) analysis and multivariate logistic regression analysis.The success rate, length of hospital stay, and hemorrhage rate were not significantly different among the 3 treatment groups (P > .05). Univariate analysis found that patients in the bleeding group had significantly longer menolipsis time and greater maximum diameter than patients in the control group (P < .05). ROC analysis showed that the optimal cutoff for menolipsis time and maximum diameter were 51 days and 27 mm, respectively, and the areas under their corresponding ROC were 0.680 and 0.787, respectively. Multivariate analysis showed that only the maximum diameter in the retrospective equation was of significance (P < .05, odds ratio: 1.067, 95% confidence interval: 1.014∼1.123].All treatments have high success rates and no significant effects on intraoperative bleeding. Both menolipsis time and maximum diameter can be used to predict the risk of intraoperative bleeding, and the latter have a greater predictive value.

Efficacy comparison of transcatheter arterial embolization with gelatin sponge and polyvinyl alcohol particles for the management of cesarean scar pregnancy and follow-up study

AIM

The aim of this study was to compare the therapeutic efficacy of transcatheter arterial embolization (TAE) with gelatin sponge (GS) and polyvinyl alcohol (PVA) particles for cesarean scar pregnancy (CSP).

METHODS

A total of 35 patients with CSP, who were classified into either the GS group (n = 22) or the PVA group (n = 13), underwent TAE and postoperative ultrasound-guided curettage. Their hospital stay, first-scheme success rate, intra-curettage blood loss, serum β-human chorionic gonadotropin (hCG) level, and other indicators were simultaneously recorded. During the follow-up period, time for the serum β-hCG level to return to normal, time for the return of menstrual cycle, and menstrual blood volume were recorded.

RESULTS

Compared with the GS group, patients in the PVA group: (i) were older; (ii) had greater number of abortions or curettages, and had longer times since last cesarean (P < 0.05); (iii) had similar hospital stay and first-scheme success rate (P > 0.05); (iv) had lower, but not significantly different, hemorrhage rate (7.7% vs 36.4%, P = 0.066); (v) had a significantly higher serum β-hCG level at discharge and a smaller drop in serum β-hCG level from admission to discharge (P < 0.05); (vi) had a similar time for the serum β-hCG level to return to normal (P > 0.05); (vii) had a shorter time for the return of menstrual cycle (P = 0.012); and (viii) had a significantly higher incidence of abnormal menstrual blood volume reduction (50.0% vs 8.3%, P = 0.034).

CONCLUSION

TAE with either GS or PVA particles for CSP treatment had relatively good efficacy. During the selection of the ideal embolic agent, the patient's age, hemorrhage risk, and requirement for protecting ovarian function and reserving fertility should be comprehensively considered.

Uterine artery embolization with and without local methotrexate infusion for the treatment of cesarean scar pregnancy

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.

Ectopic Pregnancy in caesarean section scar: A case report

We report a rare case of ectopic pregnancy occurring in the scar of a previous caesarean section, diagnosed by ultrasonography and confirmed by 3.0-T magnetic resonance imaging of pelvis. We present the clinical details and imaging findings, followed by discussion of the etiology, pathogenesis, and imaging of this condition.

A second trimester caesarean scar pregnancy

Caesarean scar pregnancy, where conceptus is implanted on previous scar, is a rare entity. We present one such case of scar pregnancy presenting to us in the second trimester and was managed with methotrexate and uterine artery embolization, followed by hysterotomy. Uterus could be conserved and hysterectomy could be avoided.

Uterine artery embolization combined with methotrexate in the treatment of cesarean scar pregnancy: results of a case series and review of the literature

PURPOSE

To explore the clinical value of uterine artery embolization (UAE) combined with methotrexate in the treatment of cesarean scar pregnancy (CSP) before and after uterine curettage.

MATERIALS AND METHODS

From August 2009 to April 2012, 15 patients with CSP treated with UAE (before or after uterine curettage) were analyzed retrospectively. Eleven subjects with a definite diagnosis of CSP were offered preventive UAE combined with methotrexate before uterine curettage. The other four patients, who were misdiagnosed as having an intrauterine pregnancy, were treated with emergency UAE for uncontrollable massive hemorrhage after uterine curettage. Clinical data, treatment sequence, and outcome were analyzed, and a brief review of the published literature summarizing UAE in the treatment of CSP was performed.

RESULTS

Eleven patients with definite CSP received preventive UAE combined with methotrexate followed by uterine curettage, and CSP was resolved successfully without hysterectomy. In the four misdiagnosed patients, three were treated successfully with emergency UAE. The other patient underwent uterine curettage and emergency UAE followed by repeat curettage, but hysterectomy was performed because of continued severe hemorrhage.

CONCLUSIONS

Based on a small number of patients, it appears that UAE may be an effective means of treating CSP, including treatment in an emergency setting. Further study is required before the safety and effectiveness of UAE can be confirmed.

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.

The diagnosis, treatment, and follow-up of cesarean scar pregnancy

OBJECTIVE

The diagnosis and treatment of cesarean scar pregnancy (CSP) is challenging. The objective of this study was to evaluate the diagnostic method, treatments, and long-term follow-up of CSP.

STUDY DESIGN

This is a retrospective case series of 26 patients between 6-14 postmenstrual weeks suspected to have CSP who were referred for diagnosis and treatment. The diagnosis was confirmed with transvaginal ultrasound. In 19 of the 26 patients the gestational sac was injected with 50 mg of methotrexate: 25 mg into the area of the embryo/fetus and 25 mg into the placental area; and an additional 25 mg was administered intramuscularly. Serial serum human chorionic gonadotropin determinations were obtained. Gestational sac volumes and vascularization were assessed by 3-dimensional ultrasound and used to monitor resolution of the injected site and outcome.

RESULTS

The 19 treated pregnancies were followed for 24-177 days. No complications were observed. After the treatment, typically, there was an initial increase in the human chorionic gonadotropin serum concentrations as well as in the volume of the gestational sac and their vascularization. After a variable time period mentioned elsewhere the values decreased, as expected.

CONCLUSION

Combined intramuscular and intragestational methotrexate injection treatment was successful in treating these CSP.

Analysis of cases with cesarean scar pregnancy

AIM

To discuss the early diagnosis and effective treatment strategy of cesarean scar pregnancy (CSP).

MATERIAL AND METHODS

 We reviewed 17 patients in our department diagnosed with CSP between 2005 and 2010, including clinical characteristics, early diagnosis, treatment methods, side-effects and prognosis.

RESULTS

The average duration of gestation at diagnosis was 46 days (range 37-82) and the interval between CSP and last cesarean scar was 6 years (range 2-15). Fourteen (82%) patients presented with slight vaginal bleeding and two (12%) complained of abdominal discomfort. Fourteen patients were diagnosed with CSP by transvaginal color Doppler ultrasonography (TVCDUS). Magnetic resonance imaging (MRI) was performed in two cases of CSP when the diagnosis by TVCDUS was difficult. One patient was diagnosed by histological examination of hysterectomy specimens due to life-threatening bleeding during curettage. Seven patients initially diagnosed with CSP before pregnancy termination were treated conservatively to preserve the uterus without causing maternal complications, ten patients underwent curettage due to incorrect diagnosis, eight patients had excessive vaginal bleeding during curettage and three patients underwent emergency hysterectomy due to hypovolemic shock.

CONCLUSION

CSP does not have any specific symptoms and can be easily diagnosed incorrectly. Confirmation of a portion of gestational sac in the uterus is important and TVCDUS is the first-line tool for early diagnosis of CSP. Physicians never perform curettage at diagnosis with CSP, but curettage after uterine artery embolism or methotrexate are better treatments of choice to terminate CSP.

Caesarean scar pregnancy: a review of management options

PURPOSE OF REVIEW

The current review aims to provide an overview of the already available and emerging treatment modalities for caesarean scar pregnancy (CSP).

RECENT FINDINGS

CSP is a type of ectopic gestation associated with a high risk of serious complications. The cause of this condition and the best management are still unclear. However, some medical and surgical treatment modalities have been suggested. The main objectives in the clinical management of CSP should be the prevention of massive blood loss and the conservation of the uterus to maintain further fertility, women's health and quality of life. Current data suggest that expectant management should not be recommended, whereas there are accumulating data suggesting that early diagnosis offers single or combined medical and surgical treatment options avoiding uterine rupture and haemorrhage, thus preserving the uterus and fertility.

SUMMARY

No universal treatment guidelines for the management of CSP have been published up to now. The lack of data on the best evidence should encourage any individual case report and further multicentre studies for recommendations establishment.

Caesarean scar pregnancy: comparative efficacy and safety of treatment by uterine artery chemoembolization and systemic methotrexate injection

OBJECTIVES

The aim of this study was to investigate the efficacy and safety of uterine artery embolization (UAE) combined with intra-arterial methotrexate (MTX) infusion for the treatment of caesarean scar pregnancy (CSP), compared with systemic MTX injection combined with uterine curettage.

STUDY DESIGN

A retrospective cohort study. An analysis of CSP patients was performed using records from the Department of Obstetrics and Gynecology in Renji Hospital for the period between January 1, 2000 and December 30, 2010. Twenty-two patients received UAE combined with intra-arterial MTX infusion and in this group 16 patients received uterine curettage after UAE, whereas 25 patients received intramuscular MTX injection and subsequent uterine curettage. The clinical information on these patients and clinical outcomes were reviewed.

RESULTS

All patients in the UAE group were treated successfully and 2 patients in the non-UAE group had to undergo hysterectomy or uterine repair. No patients in the UAE group had recurrent vaginal bleeding of more than 100ml/day after treatment, while 8 patients in the non-UAE group did, and this difference was significant. The blood loss during uterine curettage in the UAE group was much less than in non-UAE group. The serum β-hCG level in the UAE group recovered more quickly than in the non-UAE group, and hospital stay was significantly shorter in the UAE group.

CONCLUSIONS

UAE combined with intraarterial MTX infusion turned out to be an effective and safe treatment for CSP.

Caesarean scar pregnancy at 19 weeks gestation

Due to the increased numbers of caesarean sections in the last decade, women with a caesarean section scar in pregnancy are becoming more commonly diagnosed using ultrasound. One of the rare but more severe complications of this is an implantation of the pregnancy in the caesarean section scar.

Therapeutic options of caesarean scar pregnancy: case series and literature review

We describe our experience with the treatment of 4 caesarean scar pregnancies and provide an overview of current literature. Four women diagnosed with a caesarean scar pregnancy in our hospital between 1996 and 2007 were treated with local or systemic methotrexate and had a steady decline of the serum beta-hCG level. The uterus was preserved in all women and 3 of them had an uneventful subsequent pregnancy and delivery. We suggest that transcervical needle aspiration of amniotic fluid followed by intra-amniotic injection of methotrexate should be the treatment of choice, followed by surgical treatment only if methotrexate fails.

Ectopic pregnancy in a cesarean section scar treated with intramuscular methotrexate and bilateral uterine artery embolization

We report a case of an ectopic pregnancy implanted in the myometrium at the site of a scar from a previous cesarean section that presented with vaginal bleeding and was successfully treated with bilateral uterine artery embolization and intramuscular administration of methotrexate. The combination of minimally invasive interventional techniques and medical therapies can preserve fertility.

Caesarean scar pregnancy

Caesarean scar pregnancy is one of the rarest forms of ectopic pregnancy. Little is known about its incidence and natural history. With increasing incidence of caesarean section worldwide, more and more cases are diagnosed and reported. Transvaginal ultrasound and colour flow Doppler provides a high diagnostic accuracy with very few false positives. A delay in diagnosis and/or treatment can lead to uterine rupture, major haemorrhage, hysterectomy and serious maternal morbidity. Early diagnosis can offer treatment options of avoiding uterine rupture and haemorrhage, thus preserving the uterus and future fertility. Management plan should be individually tailored. Available data suggest that termination of pregnancy is the treatment of choice in the first trimester soon after the diagnosis. Expectant treatment has a poor prognosis because of risk of rupture. There are no reliable scientific data on the risk of recurrence of the condition in future pregnancy, role of the interval between the previous caesarean delivery and occurrence of caesarean scar pregnancy, and effect of caesarean wound closure technique on caesarean scar pregnancy. In this article, we aim to find the demography, pathophysiology, clinical presentation, most appropriate methods of diagnosis and management, with their implications in clinical practice for this condition.

Cesarean scar ectopic pregnancies: etiology, diagnosis, and management

OBJECTIVE

To clarify the appropriate way to diagnose and treat an ectopic pregnancy in the uterine scar of a prior cesarean delivery.

DATA SOURCES

Articles written in English that were published from January 1966 to August 2005 and quoted in the computerized database MEDLINE/PubMed retrieved by using the words "cesarean section," "cesarean delivery," "cesarean section scar pregnancy," and "ectopic pregnancy." Additional articles were obtained from reference lists of pertinent case reports and reviews.

METHODS OF STUDY SELECTION

Fifty-nine articles that met the inclusion criteria provided data on the clinical presentation, diagnosis, and treatment modalities of 112 cases of cesarean delivery scar pregnancies.

TABULATION, INTEGRATION, AND RESULTS

Review of the 112 cases revealed a considerable increase in the incidence of this condition over the last decade, with a current range of 1:1,800 to 1:2,216 normal pregnancies. More than half (52%) of the reported cases had only one prior cesarean delivery. The mean gestational age was 7.5 +/- 2.5 weeks, and the most frequent symptom was painless vaginal bleeding. Endovaginal ultrasonography was the diagnostic method in most cases, with a sensitivity of 84.6% (95% confidence interval 0.763-0.905). Expectant management of 6 patients resulted in uterine rupture that required hysterectomy in 3 patients. Dilation and curettage was associated with severe maternal morbidity. Wedge resection and repair of the implantation site via laparotomy or laparoscopy were successful in 11 of 12 patients. Simultaneous administration of systemic and intragestational methotrexate to 5 women, all with beta-hCG exceeding 10,000 milli-International Units/mL required no further treatment.

CONCLUSION

Surgical treatment or combined systemic and intragestational methotrexate were both successful in the management of cesarean delivery scar pregnancy. Because subsequent pregnancies may be complicated by uterine rupture, the uterine scar should be evaluated before, as well as during, these pregnancies.

A misdiagnosed case of caesarean scar pregnancy

CASE REPORT

We report a case of an ectopic pregnancy in a caesarean section scar, which was initially misdiagnosed despite using ultrasound. For the first time, a strongly vascularised pelvic tumour developed while the titre of serum human chorionic gonadotrophin decreased after a curettage abortion for an unwanted pregnancy.

OUTCOME

Due to uncontrollable haemorrhage, an emergency hysterectomy had to be performed 8 weeks later.