Management and reproductive counseling in cervical, caesarean scar and interstitial ectopic pregnancies over 11 years: identifying the need for a modern management algorithm

A 20 year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital - a retrospective review

BACKGROUND

Non-tubal ectopic pregnancies account for < 10% of all ectopic pregnancies. Due to its rarity and wide variation in clinical practice, there is no guideline or consensus for its management. We reported our 20-year experience in the management of non-tubal ectopic pregnancies in a tertiary hospital.

METHODS

This is a retrospective review of all women admitted for non-tubal ectopic pregnancies from January 2003 to December 2022 in a tertiary hospital. Women with non-tubal ectopic pregnancies diagnosed by ultrasound or operation were included for analysis.

RESULTS

Within the study period, 180 women were diagnosed to have non-tubal ectopic pregnancies at a mean gestation of 6.8 weeks. 16.7% (30/180) were conceived via assisted reproduction. Medical treatment was the first-line management option for 81 women, of which 75 (92.1%) women received intralesional methotrexate administered under transvaginal ultrasound guidance. The success rate of intralesional methotrexate ranges from 76.5% to 92.3%. Intralesional methotrexate was successful even in cases with a positive fetal pulsation or with high human chorionic gonadotrophin levels up to 252605U/L. Twenty seven women were managed expectantly and 40 underwent surgery. Nine (11.1%), two (6.1%), and one (2.3%) women required surgery due to massive or recurrent bleeding following medical, expectant, or surgical treatment. Hysterotomy and uterine artery embolization were necessary to control bleeding in one Caesarean scar and one cervical pregnancy.

CONCLUSIONS

Intralesional methotrexate is more effective than systemic methotrexate and should be considered as first line medical treatment for non-tubal ectopic pregnancies. It has a high success rate in the management of unruptured non-tubal ectopic pregnancies even in the presence of fetal pulsations or high human chorionic gonadotrophin levels, but patients may require a prolonged period of monitoring. Close surveillance and readily available surgery were required due to the risk of heavy post-procedural intra-abdominal bleeding.

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

OBJECTIVE

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

DESIGN

Retrospective study from 2013 to 2018.

SETTING

Inpatient samples.

PATIENT(S)

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

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

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

RESULT(S)

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

CONCLUSIONS

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

Successful management of cervical ectopic pregnancy with embryo reduction: report of three cases

If methotrexate (MTX) fails to resolve cervical ectopic pregnancies (CEP), the remaining surgical options result in the potential loss of the patient’s fertility. Therefore, we examined if the embryo reduction technique can resolve the CEP without any complications while conserving the patient’s fertility. We report three cases in which CEP didn’t respond to MTX but was successfully solved by embryo reduction. Each patient underwent a standard in vitro fertilization (IVF) protocol. Once CEP was confirmed, the pregnancy’s location, the fetus’s size and gestational sac and heartbeat were determined. Afterward, embryo reduction was performed under general anesthesia (operative time: ~30 min). All patients had successful procedures without any postoperative complications. Since the procedure, one woman was pregnant and delivered, the second has registered a positive β-human chorionic gonadotropin test and the last is waiting for IVF preparation. In summary, embryo reduction is a feasible approach in the management of CEP with favorable fertility outcomes.

Potential risk factors for caesarean scar pregnancy: a retrospective case-control study

STUDY QUESTION

What are the important risk factors for having a caesarean scar pregnancy (CSP)?

SUMMARY ANSWER

Independent risk factors were smoking in the first trimester, higher parity, and previous caesarean section (CS) before the index caesarean delivery.

WHAT IS KNOWN ALREADY

A spectrum of risk factors for CSP has been suggested but not proven: parity, number of previous caesarean section, elective as opposed to emergency CS, IVF-pregnancy, breech presentation, previous gynaecological surgery as well as suture technique.

STUDY DESIGN SIZE DURATION

This retrospective case-control study included 31 women with a CSP during the period 2003-2018 treated at a tertiary care centre for gynaecology and reproduction. A control cohort of 8300 women with a history of a CS and a subsequent delivery during the same time period was formed.

PARTICIPANTS/MATERIALS SETTING METHODS

Variables describing demography, lifestyle factors, and reproductive and obstetric history were retrieved from medical records and the obstetric hospital database. Logistic regression analyses were applied to identify potential risk factors.

MAIN RESULTS AND THE ROLE OF CHANCE

In a multivariable analysis, smoking in first trimester (adjusted odds ratio (OR) 3.03, 95% CI 1.01-9.07), higher parity (adjusted OR 1.30, 95% CI 1.03-1.64) and previous CS in addition to the preceding CS (adjusted OR 3.43, 95% CI 1.35-8.66) were independently predictive of a CSP. An elective CS at the index pregnancy was associated with an increased risk of CSP but did not remain significant in the multivariable analysis.

LIMITATIONS REASONS FOR CAUTION

CSP is a very rare phenomenon and several of the risk factor estimates are imprecise. Nevertheless, significant risk factors could be identified. Another limitation is the lack of electronically recorded details on suture techniques.

WIDER IMPLICATIONS OF THE FINDINGS

The identified factors, namely higher parity and previous CS before the index caesarean section, are in accordance with previously suggested risk factors. Whether there is a true risk association between elective CS and future CSP needs to be investigated further. Smoking in the first trimester is a new finding, which has a plausible rationale. These factors should be recognised when counselling women after a caesarean delivery, particularly in a subsequent pregnancy with early complications.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by a grant from the Swedish state under the agreement between the Swedish government and the county councils the ALF-agreement (ALFGBG-720291). None of the authors has any conflict of interest to declare.