Lower uterine segment thickness in assessing whether cesarean scar pregnancy patients could be treated with suction curettage

The value of ultrasound parameters in predicting the efficacy of transabdominal ultrasound-guided suction curettage alone in the treatment of cesarean scar pregnancy

OBJECTIVE

To investigate the value of ultrasound parameters in assessing the efficacy of transabdominal ultrasound (TAUS)-guided suction curettage alone for cesarean scar pregnancy (CSP).

METHODS

Secondary retrospective analysis of a prospective study consisted of 137 women diagnosed with CSP who were performed TAUS-guided suction curettage alone for the first time at Maternity and Child Health Care of Guangxi Zhuang Autonomous Region in China. Prior to surgery, an ultrasound examination was conducted. Based on the need for secondary intervention, the patients were categorized into failure group and success group, and the predictive factors for failure of TAUS-guided suction curettage alone were analyzed.

RESULTS

Multivariate logistic regression showed that maximum diameter of the gestational sac>29 mm (odds ratio [OR] = 4.043, 95% CI: 1.100-14.862), residual myometrium thickness ≤1.8 mm (OR = 3.719, 95% CI: 1.148-12.048) and chorionic villi thickness at the scar >4.7 mm (OR = 15.327, 95% CI: 4.617-50.881) were independent predictors of failure in TAUS-guided suction curettage alone for CSP. Furthermore, the logistic regression model that was jointly constructed by these three predictors demonstrated an area under the curve, sensitivity, specificity, and Youden index of 0.913, 0.912, 0.864, and 0.776, respectively.

CONCLUSION

The maximum diameter of the gestational sac, residual myometrium thickness, and chorionic villi thickness at the scar has certain predictive efficacy of TAUS-guided suction curettage alone for CSP. Nevertheless, it is more valuable to apply the model of this study, composed of the three ultrasound parameters, for this prediction purpose.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Ultrasound-guided suction curettage followed by cervico-isthmic placement of foley three-way catheter for cesarean scar pregnancy's treatment. Retrospective study

OBJECTIVES

Cesarean scar pregnancy (CSP) is a rare dangerous condition with still no consensus on standard treatment. Suction curettage has been used as the first-line treatment for CSP with controversial outcomes. This study evaluates efficacy of ultrasound-guided suction curettage (UGSC) followed by cervical-isthmic placement of silicon semirigid three-way foley catheter.

MATERIALS AND METHODS

This study included 24 women with CSP. Preoperative ultrasound study was conducted. UGSC followed by placement of catheter was performed in all patients. The success rate and incidence of major complication, surgical time and hospital stay were recorded.

RESULTS

The success rate of UGSC followed by placement of foley catheter was 100%, effectively reduced major complications and none of the patients had a blood loss higher than 900 ml. Median hospital stay was 2 days and median foley stay was 1 day. Surgery had limited last with a median of 17 minutes.

CONCLUSION

UGSC followed by foley placement is a safe effective treatment for CSP with a clinical resolution of 100%. The catheter is easy to place under ultrasound guidance and prevents bleeding, reducing major procedures to solve the bleeding. Suction curettage in CSP treatment should be performed under ultrasound guidance and followed by cervical-isthmic placement of foley balloon.

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.

Efficacy of suction curettage as the first-line treatment of cesarean scar pregnancy: A retrospective study

OBJECTIVE

There is still no consensus on a safe and efficient treatment modality for cesarean scar pregnancy (CSP), which is known to cause severe complications, such as life-threatening hemorrhage. Suction curettage (SC) has been used as the first-line treatment for CSP with controversial outcomes. In this context, the objective of this study is to analyze the efficacy of SC in the treatment of CSP.

METHODS

The sample of this retrospective study consisted of 64 CSP patients treated using SC between 2012 and 2022. Patients' demographic and clinical variables, including the thickness of the myometrium at the lower uterine segment between the urinary bladder and cesarean scar, were obtained from their medical records. The study's primary outcome was determined as the success rate of SC. Accordingly, the patients were categorized into two groups: successful SC (Group 1) and unsuccessful SC (Group 2).

RESULTS

The success rate of SC was determined as 78.1%. The number of previous cesarean deliveries, gestational age, baseline beta-human chorionic gonadotropin (β-hCG) values, and endometrial thickness was significantly higher in Group 2 (p<0.05 for all), whereas the fetal cardiac activity and absence of an embryonic pole were significantly higher in Group 2 (p = 0.001 and p = 0.004, respectively). There was no significant difference between the groups in the thickness of the myometrium at the lower uterine segment (p = 0.890). The hemoglobin levels decreased significantly after SC in both Groups 1 and 2 (p<0.001 and p = 0.009, respectively). There was no significant difference between the groups in preoperative and postoperative hemoglobin values and the decrease in hemoglobin levels (p>0.05).

CONCLUSION

The study findings did not indicate any significant correlation between myometrial thickness at the lower uterine segment and the efficacy of SC in CSP patients. On the other hand, the number of cesarean deliveries, gestational age, baseline β-hCG values, endometrium thickness, fetal cardiac activity, and embryonic pole may be used to predict the outcome of SC in the treatment of CSP.

Evaluation of the treatment of high intensity focused ultrasound combined with suction curettage for exogenous cesarean scar pregnancy

PURPOSE

To evaluate the effectiveness of high-intensity focused ultrasound (HIFU) combined with suction curettage in the treatment of exogenous cesarean scar pregnancy (CSP).

METHODS

A retrospective single-center observational study was conducted. A total of 41 patients diagnosed with exogenous CSP were enrolled in this study. All patients received HIFU combined with suction curettage.

RESULTS

Twenty-nine patients were administered one session of HIFU ablation. In addition, the other 12 patients received 2 HIFU sessions. Suction curettage was performed in all patients after HIFU, and no patient was converted to laparoscopy or hysterectomy. The mean blood loss during suction curettage was 99 ml. Three patients received two sessions of suction curettage. The success rate of our study was 92.68%. The mean time for serum β-HCG normalization was 23.18 ± 3.13 days. The average menstruation recovery time was 29.38 ± 3.34 days. Based on the blood loss during suction curettage, 41 patients were divided into a bleeding group and a control group. The size of the gestational sac in the bleeding group (3.80 ± 0.87 cm) was larger than that in the control group (3.39 ± 0.77 cm) (P < 0.05). The thickness of the myometrium between the bladder and gestational sac in the bleeding group (2.37 ± 0.89 mm) was less than that in the control group (2.75 ± 0.75 mm) (P < 0.05).

CONCLUSION

The results suggested that HIFU combined with suction curettage could be considered an effective treatment for exogenous CSP of < 9 weeks. The size of the gestational sac and the thickness of the myometrium between the bladder and gestational sac might be high-risk factors for blood loss during this treatment.

Evaluation of the necessity of laparoscopic repair of a uterine scar defect for cesarean scar pregnancy

Objective

This study aimed to determine the risk factors associated with the necessity of laparoscopic scar defect repair for cesarean scar pregnancy (CSP).

Methods

We retrospectively analyzed 237 patients with CSP who were treated by ultrasound-guided suction curettage and/or laparoscopy in our hospital from April 2012 to November 2019. A total of 199 of these patients underwent ultrasound-guided suction curettage without uterine scar defect repair, while 38 of these patients underwent laparoscopic resection and uterine scar defect repair. We analyzed various clinical variables and compared the efficacy of treatment between the two groups.

Results

Gestational age, the maximum transverse diameter (MTD) of the gestational sac, myometrial thickness, the operation time, intraoperative blood loss, and the duration of the hospital stay were significantly different between the two groups. Gestational age, the MTD of the gestational sac, and myometrial thickness were independent risk factors for laparoscopic repair.

Conclusions

Gestational age, the MTD of the gestational sac, and myometrial thickness are important factors associated with the necessity for laparoscopic repair of a uterine scar defect.

A review on management of caesarean scar pregnancy

PURPOSE OF REVIEW

To review the current literature on management of cesarean scar pregnancy.

RECENT FINDINGS

Caesarean scar pregnancy (CSP) is a complex pathologic condition, which is strictly related to a previous caesarean section. It is an iatrogenic disorder, that has had an exponential increase over the last few years linked to the parallel increase in the number of caesarean sections. The Society for Maternal-Fetal Medicine (SMFM) confirmed the presence of surgical, medical, and minimally invasive therapies for caesarean scar pregnancy management but the optimal treatment is not known; the main recommendation is to avoid expectant management of CSP (GRADE 1B). The treatments for Caesarean scar pregnancy are multiple, and they include a surgical management, a medical management and a combination between these two types of treatments. Despite the recommendation of SMFM in this review, we also included some cases of conservative management published in the last months.

SUMMARY

Considering all the different approaches on CSP, the management has to be individualized mainly on gestational age and it has to be discussed by a multidisciplinary team, to choose the safest clinical option.

Selection of a correct treatment protocol in caesarean scar pregnancies

OBJECTIVE

This study aims at assessing the effectiveness of various treatment protocols with the help of some parameters in caesarean scar pregnancies.

METHODS

A total of 26 patients were assessed in the study. The patients were divided into 4 groups. Group 1 consisted of those who had a wedge resection (n = 7), group 2 those who had a suction curettage (n = 10), group 3 those who had a systemic methotrexate (MTX) (n = 5) and group 4 those who had a systemic + local MTX (n = 4). The ßHcg half-lives, haemoglobin levels at the time of admittance and discharge, and hospital stays of the groups were compared.

RESULTS

The difference between group 1 and group 4 was found significant (p = 0.002) with respect to days of hospital stay. There was no statistically significant difference between the groups with respect to ßHcg half-lives and haemoglobin values.

CONCLUSION

The results of our study showed that there were no significant differences between treatment outcomes when appropriate protocols were employed. Therefore, the important point in CSPs is to assess correctly the type of CSP, the myometrial thickness and the patient's hemodynamic condition and select the most appropriate protocol accordingly rather than trying to establish a single standard treatment protocol.

Preterm Brain Injury, Antenatal Triggers, and Therapeutics: Timing Is Key

With a worldwide incidence of 15 million cases, preterm birth is a major contributor to neonatal mortality and morbidity, and concomitant social and economic burden Preterm infants are predisposed to life-long neurological disorders due to the immaturity of the brain. The risks are inversely proportional to maturity at birth. In the majority of extremely preterm infants (<28 weeks' gestation), perinatal brain injury is associated with exposure to multiple inflammatory perinatal triggers that include antenatal infection (i.e., chorioamnionitis), hypoxia-ischemia, and various postnatal injurious triggers (i.e., oxidative stress, sepsis, mechanical ventilation, hemodynamic instability). These perinatal insults cause a self-perpetuating cascade of peripheral and cerebral inflammation that plays a critical role in the etiology of diffuse white and grey matter injuries that underlies a spectrum of connectivity deficits in survivors from extremely preterm birth. This review focuses on chorioamnionitis and hypoxia-ischemia, which are two important antenatal risk factors for preterm brain injury, and highlights the latest insights on its pathophysiology, potential treatment, and future perspectives to narrow the translational gap between preclinical research and clinical applications.

Assessment of the necessity of uterine artery embolization during suction and curettage for caesarean scar pregnancy: a prospective cohort study

Background

Uterine artery embolization (UAE) followed by suction and curettage is a common conservative treatment for caesarean scar pregnancy (CSP), but the advantages of suction and curettage alone are underestimated due to the lack of standards for selecting appropriate cases for which this approach would be applicable. We sought to identify indicators with which to assess the need for UAE during suction and curettage.

Methods

The prospective cohort consisted of 105 women diagnosed with CSP in Peking Union Medical College Hospital between January 2016 and September 2018 who were followed up until 60 days after surgery. The main outcome was the therapy used, and secondary outcomes included recovery, bleeding, surgery time, length of hospital stay, and total cost.

Results

We found that β-human chorionic gonadotropin (β-hCG) levels were significantly lower (P < 0.05), foetal cardiac activity was significantly lower (P < 0.05), the myometrial layer was significantly thicker (P < 0.05), expenditures were lower and lengths of hospital stay were shorter in patients who received suction and curettage alone (the non-UAE group) than in those who received UAE followed by suction and curettage (the UAE+ group). In addition, for CSP patients, UAE might be less necessary when the myometrial thickness is ≥2 mm and the gestational sacmeasures ≤5 cm, and suction and curettage alone may be safer for these patients.

Conclusion

Suction and curettage alone is a more suitable option than UAE followed by suction and curettage because the former carries a lower cost, shorter length of hospital stay, and lower risk of adverse events. Regarding risk factors, patients with a lower uterine segment thickness ≥ 2 mm and a gestational mass diameter ≤ 5 cm have an increased probability of being successfully treated with suction and curettage alone.