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Wang H, Xue F, Wang W. A combination of laparoscopy and bilateral uterine artery occlusion for the treatment of type II cesarean scar pregnancy: a retrospective analysis. J Int Med Res 2024; 52:3000605241241010. [PMID: 38663910 PMCID: PMC11047230 DOI: 10.1177/03000605241241010] [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: 12/16/2023] [Accepted: 03/04/2024] [Indexed: 04/28/2024] Open
Abstract
OBJECTIVE We investigated the efficacy of a combination of laparoscopy and bilateral uterine artery occlusion (BUAO) for the treatment of type II cesarean scar pregnancy (CSP). METHODS Patients with type II CSP underwent laparoscopy + bilateral uterine artery embolization (control group) or laparoscopy + BUAO (study group). Data regarding the duration of surgery, intraoperative hemorrhage, postoperative complications, the duration of the hospital stay, and the costs of hospitalization were retrospectively collected. One year later, the time to the return of the β-human chorionic gonadotropin (β-hCG) concentration to normal and to the return of menstruation were compared. RESULTS The duration of surgery, time to the return of menstruation, and incidence of postoperative complications in the study group were significantly less than in the control group, but there was no significant difference in the time for β-hCG to return to normal or the volume of intraoperative hemorrhage. The duration of hospitalization and costs for the control group were higher than those for the study group. CONCLUSION Laparoscopy in combination with BUAO is associated with minimal trauma, rapid recovery, a short duration of surgery, low cost of hospitalization, and a low postoperative complication rate. Thus, it represents a useful new surgical treatment for type II CSP.
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Affiliation(s)
- Hongyan Wang
- Department of Gynecology, The First Affiliated Hospital of Xi’an Medical University, Xi’an, Shaanxi Province, China
| | - Fangfang Xue
- Department of Gynecology, The First Affiliated Hospital of Xi’an Medical University, Xi’an, Shaanxi Province, China
| | - Wenying Wang
- Department of Gynecology, The First Affiliated Hospital of Xi’an Medical University, Xi’an, Shaanxi Province, China
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Shai D, Meyer R, Levin G, Touval O, Ben-David A, Yagel I, Mashiach R, Cohen SB. Single-dose methotrexate-based protocol for the treatment of caesarean scar pregnancy and successive pregnancy outcomes. HUM FERTIL 2023; 26:582-588. [PMID: 34459324 DOI: 10.1080/14647273.2021.1969598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Daniel Shai
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gabriel Levin
- Department of Gynecologic Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Or Touval
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alon Ben-David
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Itai Yagel
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Mashiach
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shlomo B Cohen
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Cheng XL, Cao XY, Wang XQ, Lin HL, Fang JC, Wang L. Diagnosing early scar pregnancy in the lower uterine segment after cesarean section by intracavitary ultrasound. World J Clin Cases 2022; 10:547-553. [PMID: 35097080 PMCID: PMC8771384 DOI: 10.12998/wjcc.v10.i2.547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/14/2021] [Accepted: 11/28/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Xiao-Ling Cheng
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Xiao-Yan Cao
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Xiao-Qian Wang
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Heng-Li Lin
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Jin-Chuan Fang
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
| | - Lin Wang
- Department of Ultrasonography, Women and Children Health Institute Futian Shenzhen, Shenzhen 518026, Guangdong Province, China
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Yüksel Şimşek S, Şimşek E, Alkaş Yağınç D, Baran ŞY, Çok T, Bulgan Kılıçdağ E. Outcomes of cesarean scar pregnancy treatment: Do we have options? Turk J Obstet Gynecol 2021; 18:85-91. [PMID: 34082520 PMCID: PMC8191324 DOI: 10.4274/tjod.galenos.2021.77535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: To investigate the success and complications of medical and surgical modalities used in the treatment of cesarean scar pregnancies. Materials and Methods: Medical and surgical approaches that have been used to treat cesarean scar pregnancies were evaluated retrospectively, Local, systemic, and combined methotrexate treatments were grouped as the medical approach, and dilatation and evacuation, hysteroscopic resection, laparoscopic and laparotomic approaches were grouped as the surgical approach. Fifty-three patients were diagnosed as having cesarean scar pregnancy during the study period, 48 of whom were included in the final analysis. Eighteen patients were treated with medical interventions and 30 patients were treated surgically. Results: The success rate of surgical modalities was 96.6% and the medical treatment success was 33% (p<0.001). The complication rate was higher with medical approaches compared with surgical methods (66% vs 3.3%, respectively; p<0.001). Conclusion: Surgical intervention seems safer and more successful than medical treatment.
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Affiliation(s)
- Seda Yüksel Şimşek
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Erhan Şimşek
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Didem Alkaş Yağınç
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Şafak Yılmaz Baran
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Tayfun Çok
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Esra Bulgan Kılıçdağ
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
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Wu J, Ye J, OuYang Z, Wan Z, Zhang Q, Zhong B, Wei S. Outcomes of reproduction following cesarean scar pregnancy treatment: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 262:80-92. [PMID: 33993066 DOI: 10.1016/j.ejogrb.2021.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Jiawen Wu
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Jianbin Ye
- Department of Intensive Care Unit, Puning People's Hospital, Puning, China
| | - Zhenbo OuYang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China.
| | - Zixian Wan
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Qiushi Zhang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Biting Zhong
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Shiyuan Wei
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
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Pristavu A, Vinturache A, Mihalceanu E, Pintilie R, Onofriescu M, Socolov D. Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series. BMC Pregnancy Childbirth 2020; 20:617. [PMID: 33050911 PMCID: PMC7557042 DOI: 10.1186/s12884-020-03237-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022] Open
Abstract
Background There is no clear consensus on the management of caesarean scar pregnancy (CSP), a complex and life-threatening condition. The objective of this study was to present a novel approach to management of CSP that combines medical therapy of multidose methotrexate and mifepristone with active surgical management by uterine curettage and consecutive local haemostasis. Case presentation We report on a prospective case series of six women with first trimester pregnancy, in whom the diagnosis of CSP was confirmed by 2D and color Doppler transvaginal ultrasound and serial hormone chorionic gonadotropin (hCG) testing. Women were between 23 and 36 years old and had at least one previous delivery by caesarean. At admission, gestational age ranged between 6 to 14 weeks, and serum hCG levels between 397 and 23,000 mUI/ml. Upon decision of pregnancy termination, medical management was undertaken in all cases and 1 mg/kg systemic Methotrexate was administered between 1 and 5 daily doses. Mifepristone was part of the treatment in cases with live pregnancy. Surgical management was employed for the cases were an embryo was seen by ultrasound, being prompted by inadequate response to Methotrexate and/or signs of miscarriage with vaginal bleeding. Curettage combined with local isthmic balloon or vaginal pack tamponade prevented further complications. High treatment rates with preservation of fertility was achieved in all patients except one who underwent hysterectomy for invasive placentation. Ultrasound and hCG levels surveillance ensured that the resolution of pregnancy was achieved. Conclusion Women with history of delivery by caesarean section should be carefully monitored in future pregnancies for prompt diagnosis of CSP. Early diagnosis of CSP allows selection of successful conservative therapy. Through this case series we contribute with our experience to the body of knowledge about the management of this serious complication of early pregnancy.
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Affiliation(s)
- Anda Pristavu
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Angela Vinturache
- Department of Obstetrics & Gynaecology, Women's Centre, John Radcliffe University Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK.
| | - Elena Mihalceanu
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Radu Pintilie
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Mircea Onofriescu
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Demetra Socolov
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
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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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Morlando M, Buca D, Timor-Tritsch I, Cali G, Palacios-Jaraquemada J, Monteagudo A, Khalil A, Cennamo C, La Manna V, Liberati M, D'Amico A, Nappi L, Colacurci N, D'Antonio F. Reproductive outcome after cesarean scar pregnancy: A systematic review and meta-analysis. Acta Obstet Gynecol Scand 2020; 99:1278-1289. [PMID: 32419158 DOI: 10.1111/aogs.13918] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION To evaluate subsequent reproductive among women with a prior cesarean scar pregnancy (CSP). MATERIAL AND METHODS MEDLINE, Embase and ClinicalTrials.gov databases were searched. Inclusion criteria were women with a prior CSP, defined as the gestational sac or trophoblast within the dehiscence/niche of the previous cesarean section scar or implanted on top of it. The primary outcome was the recurrence of CSP; secondary outcomes were the chance of achieving a pregnancy after CSP, miscarriage, preterm birth, uterine rupture and the occurrence of placenta accreta spectrum disorders. Subgroup analysis according to the management of CSP (surgical vs non-surgical) was also performed. Random effect meta-analyses of proportions were used to analyze the data. RESULTS Forty-four studies (3598 women with CSP) were included. CSP recurred in 17.6% of women. Miscarriage, preterm birth and placenta accreta spectrum disorders complicated 19.1% (65/341), 10.3% (25/243) and 4.0% of pregnancies, and 67.0% were uncomplicated. When stratifying the analysis according to the type of management, CSP recurred in 21% of women undergoing surgical and in 15.2% of those undergoing non-surgical management. Placenta accreta spectrum disorders complicated 4.0% and 12.0% of cases, respectively. CONCLUSIONS Women with a prior CSP are at high risk of recurrence, miscarriage, preterm birth and placenta accreta spectrum. There is still insufficient evidence to elucidate whether the type of management adopted (surgical vs non-surgical) can impact reproductive outcome after CSP. Further large, prospective studies sharing an objective protocol of prenatal management and long-term follow up are needed to establish the optimal management of CSP and to elucidate whether it may affect its risk of recurrence and pregnancy outcome in subsequent gestations.
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Affiliation(s)
- Maddalena Morlando
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Danilo Buca
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Ilan Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
| | - Giuseppe Cali
- Department of Obstetrics and Gynecology, Azienda Ospedaliera Villa Sofia Cervello, Palermo, Italy.,Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Jose Palacios-Jaraquemada
- Center for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, London, UK
| | - Carmen Cennamo
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Viviana La Manna
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco Liberati
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Alice D'Amico
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
| | - Luigi Nappi
- Fetal Medicine Unit, Department of Medical and Surgical Sciences, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Nicola Colacurci
- Department of Woman, Child and General and Special Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco D'Antonio
- Center for High Risk Pregnancy and Fetal Care, Department of Obstetrics and Gynecology, University of Chieti, Chieti, Italy
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Drever N, Bertolone J, Shawki M, Janssens S. Caesarean scar ectopic pregnancy: Experience from an Australian tertiary centre. Aust N Z J Obstet Gynaecol 2020; 60:330-335. [PMID: 31944267 DOI: 10.1111/ajo.13119] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Despite the rising incidence of caesarean scar pregnancy (CSP), as yet there are no consensus or evidence-based guidelines for management. AIMS To review diagnosis, treatment and management of all women with CSP over a 5 year period at Mater Mothers' Hospital, Brisbane, Australia. MATERIALS AND METHODS Retrospective cohort study of CSP between 2013-2018. Data reviewed included demographics, presenting symptoms, gestational age, ultrasound findings, human chorionic gonadotrophin levels, treatment success, complications, and if available, subsequent pregnancy outcomes. RESULTS Twenty-eight women were treated for CSP during the study period. Initial diagnosis was delayed in ten (36%). Overall success rates of initial treatment were 22/28 (79%). Of the six cases of failed treatment, five had been treated with systemic methotrexate alone. All women requiring further intervention had fetal pole present, and 50% had fetal cardiac activity. Failure rate of systemic methotrexate alone was 5/11 (45%). Eleven women deemed appropriate for conservative management did not require further treatment or experience complications. Nine women had data available for subsequent pregnancies, of whom two developed placenta accreta. CONCLUSION This study provides data that may assist in guideline development and decision-making for management of CSP. Conservative management in carefully selected women appeared to be safe. Nearly half of women treated with systemic methotrexate alone required another treatment modality, suggesting a role for intralesional treatment, particularly in the presence of fetal pole ± fetal cardiac activity. More than one in five women with documented subsequent pregnancies were diagnosed with placenta accreta.
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Affiliation(s)
- Natalie Drever
- Department of Obstetrics and Gynaecology, Mater Mothers' Hospital, Brisbane, Queensland, Australia
| | - Julia Bertolone
- Early Pregnancy Assessment Unit, Mater Mother's Hospital, Brisbane, Queensland, Australia
| | - Marwan Shawki
- Department of Obstetrics and Gynaecology, Mater Mothers' Hospital, Brisbane, Queensland, Australia
| | - Sarah Janssens
- Department of Obstetrics and Gynaecology, Mater Mothers' Hospital, Brisbane, Queensland, Australia.,Mater Education, Mater Hospital, Brisbane, Queensland, Australia
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Conservative management of Caesarean scar pregnancies with systemic multidose methotrexate: predictors of treatment failure and reproductive outcomes. Reprod Biomed Online 2019; 39:827-834. [DOI: 10.1016/j.rbmo.2019.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/29/2019] [Accepted: 05/22/2019] [Indexed: 11/22/2022]
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Second Trimester Cervical Ectopic Pregnancy and Hemorrhage: A Case Report and Review of the Literature. Case Rep Obstet Gynecol 2018; 2018:3860274. [PMID: 30225155 PMCID: PMC6129320 DOI: 10.1155/2018/3860274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 08/05/2018] [Accepted: 08/09/2018] [Indexed: 12/27/2022] Open
Abstract
Cervical ectopic pregnancies are a rare occurrence in the United States. Here we present the interdisciplinary and conservative management approach to a cervical ectopic at an advanced gestational age. In addition, we review the surgical management of hemorrhage from cervical ectopic pregnancies, which is often catastrophic and life-threatening.
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