Cesarean Scar Ectopic Pregnancy: Current Management Strategies

A combination of laparoscopy and bilateral uterine artery occlusion for the treatment of type II cesarean scar pregnancy: a retrospective analysis

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.

Scar Ectopic Pregnancy as an Uncommon Site of Ectopic Pregnancy: A Case Report and Literature Review

A cesarean scar pregnancy is a rare type of ectopic pregnancy that occurs when a fertilized egg implants in the scar from a previous cesarean section. It is a serious condition that can lead to significant morbidity and mortality if not managed promptly and appropriately. In this literature review and case report, we discuss the etiology, diagnosis, and management of cesarean scar pregnancy. We conducted a comprehensive search of relevant literature using electronic databases and included studies that reported on the diagnosis and management of cesarean scar pregnancy. We also present a case report of a patient with cesarean scar pregnancy who was managed surgically. The diagnosis of cesarean scar pregnancy is primarily done via transvaginal or transabdominal ultrasound, and medical or surgical management can be used depending on the gestational age, hemodynamic status, and patient preferences. The surgical approach, which involves hysteroscopy, laparoscopy, or laparotomy, is usually preferred, since it is associated with fast recovery and lower recurrence rates. However, it is crucial to consider the patient's plans for future fertility when selecting the management approach. In conclusion, cesarean scar pregnancy is a rare but potentially life-threatening condition that requires prompt and appropriate management. Early diagnosis and treatment can prevent significant morbidity and mortality, and surgical management is usually preferred due to its higher success rates and lower recurrence rates.

Effectiveness and safety of prophylactic abdominal aortic balloon occlusion for patients with type III caesarean scar pregnancy: a prospective cohort study

BACKGROUND

Caesarean scar pregnancy (CSP) is a special type of ectopic pregnancy with a high risk of massive haemorrhage. Few studies have focused on the efficacy of prophylactic abdominal aortic balloon occlusion as a minimally invasive method in caesarean section. This study aimed to evaluate the effectiveness and safety of prophylactic abdominal aortic balloon occlusion for patients with type III CSP.

METHODS

This was a prospective cohort study. Patients with type III CSP in the First Affiliated Hospital of Zhengzhou University from January 2020 to June 2022 were enrolled. Eligible patients received prophylactic abdominal aortic balloon occlusion (defined as the AABO group) or uterine artery embolization (defined as the UAE group) before laparoscopic surgery. Clinical outcomes included intraoperative blood loss, body surface radiation dose, hospitalization expenses, and time to serum β-hCG normalization, and safety were also assessed.

RESULTS

A total of 68 patients met the criteria for the study, of whom 34 patients were in the AABO group and 34 patients were in the UAE group. The median intraoperative blood loss in the AABO and UAE groups was 17.5 (interquartile ranges [IQR]: 10, 45) and 10 (IQR: 6.25, 20) mL, respectively (P = 0.264). The body surface radiation dose of the AABO group was much lower than that of the UAE group (5.22 ± 0.44 vs. 1441.85 ± 11.59 mGy, P < 0.001). The AABO group also had lower hospitalization expenses than the UAE group (2.42 ± 0.51 vs. 3.42 ± 0.85 *10^5 yuan, P < 0.001). The average time to serum β-hCG normalization in the AABO group was 28.9 ± 3.21 d, which was similar to that in the UAE group (30.3 ± 3.72 d, P = 0.099). In addition, the incidence of adverse events in the AABO group was lower than that in the UAE group (5.9% vs. 58.8%, P < 0.001).

CONCLUSION

Prophylactic AABO was equally as effective as UAE in patients with type III CSP but was safer than UAE during and after the operation.

Successful Non-surgical Management of Cesarean Scar Pregnancy

Ectopic pregnancy in the scar of a previous cesarean section contributes to significant maternal morbidity in the first trimester due to a significantly higher risk of uterine rupture if left undetected. The routine scans done in the first trimester serve as an important screening tool in the detection of such an ectopic pregnancy. Early detection can aid in making a paradigm shift from a surgical to a more conservative approach for the management of such pregnancies. Here, we report a case of a cesarean scar pregnancy diagnosed in the sixth week of gestation which was managed non-surgically with methotrexate and intracardiac potassium chloride injection.

Nontubal ectopic pregnancies: overview of diagnosis and treatment

Nontubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal ectopic pregnancies. Diagnostic and management options may be limited, especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for nontubal ectopic pregnancies.

Single-dose methotrexate-based protocol for the treatment of caesarean scar pregnancy and successive pregnancy outcomes

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.

The Effectiveness of Combined Local and Systemic Methotrexate Treatment in Cesarean Scar Pregnancy Weeks 8 to 14

Objectives

This study aims to identify the success rate and correlated factors of combined local and systemic methotrexate (MTX) injection treatment in cesarean scar pregnancy (CSP).

Materials and Methods

The combined local and systemic MTX administration has been used for CSP weeks 8-14 at Tu Du Maternal Hospital; however, its effectiveness and correlated factors have not been closely investigated. This is a retrospective case series of 123 CSP patients between 8 and 14 weeks of gestation who were treated at Tu Du Hospital from the year 2016 to 2020.

Results

The success rate, uterine-sparing rate, and side effects of MTX treatment are 50.4%, 95%, and 17.2%, respectively. The factors related to treatment failure with statistical significance included gestational age (odds ratio [OR] = 3.99), residual myometrial thickness >3 mm (OR = 0.37), and postprocedure gestational sac diameter (OR = 1.09).

Conclusion

Combined local and systemic MTX injection is minimally invasive and effective in CSP weeks 8-14. Therefore, it should be utilized routinely.

Methotrexate for CSPs

Expectant management of a cesarean scar pregnancy (CSP) is associated with a high risk of severe maternal morbidity. Therefore, most experts recommend immediate termination after the diagnosis of a CSP. However, there is no consensus about the optimal management of a CSP in terms of efficacy, safety, and preservation of future fertility. Methotrexate (MTX) is a folic acid antagonist that has been largely used to treat tubal ectopic pregnancies. This review summarizes the current knowledge and uncertainties about the administration of MTX as a medical or non-invasive option to terminate a CSP; the preferred injection route (systemic or local/intragestational), the comparison with other treatment modalities, and the prognostic factors for MTX success will be discussed, as well as the recommendations from scientific societies.

Caesarean scar pregnancy: is there a light in the end of the tunnel?

PURPOSE

To summarize and present a single tertiary center's 25 years of experience managing patients with caesarean scar pregnancies and their long-term reproductive and obstetric outcomes.

METHODS

A 25-year retrospective study included women diagnosed with CSP from 1996 to 2020 in one tertiary center. Data were retrieved from the medical records and through a telephone interview. Diagnosis was made by sonography and color Doppler. Treatments included methotrexate, suction curettage, hysteroscopy, embolization and wedge resection by laparoscopy or laparotomy as a function of the clinical manifestations, the physicians' decisions, patient counseling, and parental requests.

RESULTS

Analysis of the records recovered 60 cases of CSP (two of whom were recurrent). All patients had complete resolution with no indication for hysterectomy. Thirty-five patients had a long-term follow-up, of whom 24 (68.6%) attempted to conceive again and 22 (91.6%) succeeded. There were 17/22 (77.3%) patients with at least one live birth, 3/22 (13.6%) spontaneous miscarriages and 2/22 (9%) recurrent CSP. The obstetric complications included abnormal placentation 5/19 (26.3%), premature rupture of membranes 2/19 (10.5%), preterm delivery 4/19 (21%) and abnormality of the uterine scar 2/19 (10.5%). There was one case of neonatal death due to complications of prematurity 1/19 (5.2%).

CONCLUSION

CSP treatment focusing on reducing morbidity and preserving fertility has encouraging long-term reproductive and obstetric outcomes. In subsequent pregnancies, we recommend performing an early first trimester vaginal scan to map the location of the new pregnancy, followed by close monitoring given the obstetric complications mentioned above.

Cesarean Scar Pregnancies Treated by Uterine Artery Chemotherapy Embolization Combined With Ultrasound-Guided Dilation and Curettage: A Retrospective Study

OBJECTIVES

To explore the effect of cesarean scar pregnancy (CSP) treatment by comparing uterine artery chemotherapy embolization (UACE) combined with dilation and curettage (D&C) with or without ultrasound guidance.

METHODS

CSP patients treated with UACE combined with D&C from January 2013 to December 2020 at Shuguang Hospital, affiliated to Shanghai University of Traditional Chinese Medicine were included in this retrospective study. The patients were divided into groups A and B according to whether D&C was guided by ultrasound.

RESULTS

Forty-eight patients with CSP diagnosed by transvaginal ultrasound were included in this study, whose gestational age was <8 weeks. There were no significant differences in the basic clinical characteristics of the two groups. The success rates of the 2 groups were no significant difference, 100% (27/27) in group A and 85.7% (18/21) in group B. The maximal intraoperative blood loss of group A was 100 mL and that of group B was 150 mL. There was no uterine perforation during the operation. Ultrasound guidance can shorten the D&C operation time, reduce intraoperative bleeding during D&C, and decrease the residual rate of trophoblastic tissue after D&C.

CONCLUSIONS

Ultrasound guidance can improve the safety and efficiency of UACE combined with D&C in the treatment of CSP and reduce its complications. We believe it is an optimal treatment for CSP patients who do not plan to have children in the future.

Methotrexate therapy followed by laparotomy to manage a viable first-trimester cesarean scar ectopic pregnancy in a low-resource setting: A case report

Cesarean scar ectopic pregnancy (CSEP) is rare, occurring in 1:1800 to 1:2625 pregnancies. It is classified into two types: endogenous, which grows inside the uterine cavity; and exogenous, which grows outward, toward the bladder. Both types are associated with increased maternal morbidity and mortality. The case report describes a 25-year-old woman with a viable first-trimester CSEP treated with both methotrexate and operative resection. Management was in a low-resource setting.

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Cesarean scar ectopic pregnancy (CSEP) is rare.

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We report the management of a viable first-trimester CSEP in a low-resource setting.

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Management involved methotrexate followed by operative resection with laparotomy.

The efficacy of different treatments for type 2 cesarean scar pregnancy

OBJECTIVE

To study the efficacy of 3 treatment options for type 2 cesarean scar pregnancy (CSP) and establish an optimal treatment strategy for type 2 CSP.

DESIGN

Retrospective cohort study.

SETTING

A tertiary hospital.

PATIENTS

The study examined 160 women with type 2 CSP.

INTERVENTIONS

Ultrasound-guided vacuum aspiration after local injection of lauromacrogol, ultrasound-guided vacuum aspiration after uterine artery embolization (UAE), and transabdominal resection or hysteroscopy combined with laparoscopic resection.

MAIN OUTCOME MEASURES

The success rates, duration of hospitalization, hospitalization cost, amount of blood loss, recovery time, and menstruation resuming after recovery.

RESULTS

The success rates of the UAE, lauromacrogol, and surgical groups were 87.1%, 92.5%, and 95.5%, respectively, with no significant differences. The cost and duration of hospitalization in the lauromacrogol group were significantly lower than those in the UAE and surgical groups. Analysis of the causes of treatment failure revealed a significant difference in the gestational age. The area under the receiver operating characteristic curve was 0.660 (95% confidence interval, 0.533-0.788). When the gestational age was 48.5 days, Youden index was the highest. Furthermore, when the diagnostic thresholds were selected as 49, 56, and 63 days of pregnancy, the corresponding areas under the receiver operating characteristic curve were 0.652, 0.541, and 0.510, respectively.

CONCLUSION

Ultrasound-guided vacuum aspiration after local injection of lauromacrogol is recommended for patients with type 2 CSP at <49 days of gestation. Laparotomy or laparoscopy combined with hysteroscopy is suitable for patients with gestation of >49 days, especially for those with >56 days of gestation.

Comparison of different treatment strategies in the management of endogenic caesarean scar pregnancy: a multicentre retrospective study

Background

The aim of this study was to evaluate the effectiveness and safety of different treatment strategies for endogenic caesarean scar pregnancy (CSP) patients.

Methods

According to Vial’s standard, we defined endogenic-type CSP as (1) the gestational sac growing towards the uterine cavity and (2) a greater than 0.3 cm thickness of myometrial tissue at the caesarean scar. A total of 447 endogenic CSP patients out of 527 patients from 4 medical centres in China were enrolled in this study. A total of 120 patients were treated with methotrexate (MTX) followed by surgery, 106 received ultrasound-guided curettage directly and 221 received curettage combined with hysteroscopy. The clinical information and clinical outcomes of these patients were reviewed. Successful treatment was defined as (1) no additional treatment needed, (2) no retained mass of conception and (3) serum β subunit of human chorionic gonadotropin (β-hCG) level returning to a normal level within 4 weeks. The success rate was analysed based on these factors.

Result

Among 447 patients, no significant difference was observed in baseline characteristics between groups except for foetal heartbeat. The success rate was significantly different (p<0.001) among the three groups. The highest success rate of 95.9% was noted in the hysteroscopy group, and the lowest success rate of 84.0% was noted in the curettage group. In addition, the MTX group reported the longest hospital stay and highest expenses, but the curettage group showed the shortest and lowest expenses, respectively. Nevertheless, no difference in blood loss was observed between the groups.

Conclusion

The combination of curettage and hysteroscopy represents the most effective strategy. Pretreatment with MTX did not result in better clinical outcomes. Ultrasound-guided curettage directly should not be considered a first-line treatment choice for endogenic CSP patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04633-y.

Cesarean scar ectopic pregnancies - a retrospective case series at an Australian tertiary referral center

OBJECTIVE

To review the management, success, and complication rates of women who presented with a cesarean scar ectopic pregnancy at an Australian tertiary referral center.

METHODS

A retrospective case series was undertaken. Patients were identified through the hospital's clinical information services coding system and data were collected from medical records.

RESULTS

A total of 38 cases were identified. Patients who were hemodynamically stable were predominantly managed according to local expertise via intramuscular, intra-sac methotrexate or a combination of these two. In some cases, surgical management was preferred.

CONCLUSION

Cesarean scar ectopic pregnancy may be managed both surgically and medically. At institutions where surgical expertise is unavailable, medical management would be valuable with few adverse outcomes identified, provided women have closely monitored follow-up.

Temporary Internal Iliac Artery Blockage versus Uterine Artery Embolization in Patients After Laparoscopic Pregnancy Tissue Removal Due to Cesarean Scar Pregnancy

Objective

This study aims to evaluate the clinical value of laparoscopic temporary internal iliac artery blockage (TIIAB) compared with uterine artery embolization (UAE) in type III cesarean scar pregnancy (CSP).

Methods

A total of 76 patients with type III CSP admitted to the Department of Gynecology the First Affiliated Hospital of Zhengzhou University between September 2017 and June 2019 were selected for this retrospective study. Thirty-six of them in the study group received TIIAB, and the rest in control group received UAE. Laparoscopic pregnancy tissue was removed from all patients, and the uterine defects were repaired. The absence of remnants was then confirmed using ultrasonography. Follow-ups were performed in the two groups for six months, and the factors of intraoperative blood loss, operation and menelipsis time, 24-h human chorionic gonadotropin decline rate, postoperative complications, hospitalization days, hospitalization costs, peri-operative hormone levels, and ovarian function indicators were compared between the two groups and within each group.

Results

There were statistically significant differences in the hospitalization cost, menelipsis time, and postoperative complication incidence between the two groups (p < 0.05). There were statistically significant differences between ovarian function at one month and three months after surgery (p < 0.05) as well as among the follicle-stimulating hormone, luteinizing hormone, and estradiol levels at one, three, and six months after surgery in the control group (p < 0.05).

Conclusion

Compared with uterine artery embolization, laparoscopic TIIAB has the advantages of a low hospitalization cost, lower postoperative complication rate, and shorter menelipsis time. Moreover, it avoids ovarian function damage. It is a safe method worthy of clinical popularization.

High-intensity focused ultrasound compared with uterine artery chemoembolization with methotrexate for the management of cesarean scar pregnancy

OBJECTIVE

To compare the effectiveness and safety of high-intensity focused ultrasound (HIFU) versus uterine artery chemoembolization with methotrexate for the management of cesarean scar pregnancy (CSP).

METHODS

A total of 170 women with CSP were enrolled in the retrospective cohort study from April 2016 to September 2020. One hundred women received HIFU followed by suction curettage, and 70 women were treated with uterine artery chemoembolization followed by suction curettage.

RESULTS

The median blood loss during suction curettage was 20 ml (range 2-800 ml) in the HIFU group versus 20 ml (range 5-200 ml) in the chemoembolization group (P = 0.837). The mean time for β-human chorionic gonadotropin normalization was 28.52 ± 10.82 days versus 26.69 ± 8.97 days (P = 0.246), respectively. The mean time of menstruation recovery was 34.36 ± 10.63 days versus 31.93 ± 8.53 days (P = 0.114), respectively. The incidence of adverse effects in the HIFU group was lower than that in the chemoembolization group (P = 0.028). The median hospitalization time in the HIFU group was longer than that in the chemoembolization group (P = 0.000).

CONCLUSION

HIFU was as effective and safe as uterine artery chemoembolization in the management of CSP, and the incidence of adverse effects was lower.

The effect of ultrasound-guided high-intensity focused ultrasound treatment for cesarean scar pregnancy on ovarian reserve

OBJECTIVE

The aim of this study was to evaluate changes in anti-Müllerian hormone (AMH) levels after ultrasound-guided high-intensity focused ultrasound (USgHIFU) treatment of cesarean scar pregnancy (CSP).

METHODS

A retrospective case series study was conducted in the Affiliated Hospital of North Sichuan Medical College. Thirty-two women with cesarean scar pregnancy who met the inclusion criteria were enrolled in the study between January 2018 and December 2019. All patients underwent USgHIFU treatment with or without suction curettage. Intraoperative blood loss in suction curettage and hysteroscopy procedures, time to return of β-human chorionic gonadotropin (β-hCG) to normal levels, and time to recovery of normal menstruation were recorded. AMH levels before and 3 months after HIFU treatment were compared to determine whether USgHIFU treatment affected ovarian reserve.

RESULTS

AMH levels before and 3 months after HIFU ablation were 1.87 ± 1.19 ng/ml and 1.90 ± 1.17 ng/ml, respectively. There was no significant difference in AMH levels between the two-time points (p > .05). The median volume of intraoperative blood loss was 20 ml, the median time for the serum β-hCG level to return to normal was 35.5 days, and the median time of menstruation recovery was 39 days.

CONCLUSIONS

USgHIFU treatment for CSP was effective and safe without affecting ovarian reserve.

Repair of the myometrial scar defect at repeat caesarean section: a modified surgical technique

Background

To investigate whether the existing surgical technique for uterine closure at repeat lower segment Caesarean section (LSCS) can be modified to achieve adequate residual myometrial thickness (RMT) to ensure scar integrity and reduce complications in future pregnancy.

Methods

Women with a significant scar defect at repeat LSCS had the anterior uterine wall closed by a single experienced obstetrician with a technique focused on recognition, mobilisation and apposition of the retracted myometrial edges at the boundary of the defect. This was aimed at anatomical restoration of the lower segment. The RMT at the scar area was assessed by postnatal pelvic ultrasound scan at three months.

Results

Thirty women with a history of at least one previous CS, incidentally found to have a large defect at operation underwent the technique with prior consent. A postnatal scan showed a mean residual myometrial thickness of 8.4 mm (SD ±1.3 mm; range 5.6–11.0 mm). The average operating time was 91 mins and the average blood loss 728 ml. Two women who underwent the repair have gone on to have a further uneventful CS.

Conclusion

This modified technique resulted in scan evidence of an RMT indicative of uterine wall stability postnatally and offers the potential for reducing the risk of rupture and placenta accreta spectrum (PAS) in future pregnancy.

An updated guide to the diagnosis and management of cesarean scar pregnancies

PURPOSE OF REVIEW

To review the current literature on the diagnosis and management of cesarean scar pregnancies RECENT FINDINGS: The incidence of cesarean scar pregnancies (CSPs) is increasing as a result of the increasing cesarean section rate, improved diagnostic capabilities, and a growing awareness. CSPs are associated with significant morbidity and early diagnosis is key. Diagnosis is best achieved with transvaginal ultrasound. Sonographic diagnostic criteria have been developed over decades and recently endorsed by the Society for Maternal-Fetal Medicine and other professional societies. The current categorization system differentiates CSPs that are endogenic or 'on the scar' from those that are exogenic or 'in the niche'. Following diagnosis, the challenge remains in determining the optimal management as multiple modalities can be considered. Studies have demonstrated the favorable outcomes with combined local and systemic methotrexate, surgical excision through multiple routes, and adjunctive therapies, such as uterine artery embolization or uterine balloons. The current evidence is insufficient to identify a single best treatment course and a combined approach to treatment is often required.

SUMMARY

Successful outcomes while minimizing complications can be achieved with a multidisciplinary, collaborative effort. Guidelines for cesarean scar pregnancies will continue to evolve as the published reports grow.

Cesarean section scar pregnancy: Challenges in choosing treatment approach

Choosing a treatment approach of Cesarean section scar pregnancy is challenging and requires making women aware of material risks inherent in the different approaches that they perceive as having potential impact on their live or quality of life.

The Management of Scar Ectopic: A Single-Center Experience

PURPOSE

This study aimed to highlight the clinical features, diagnosis, and different modalities of the treatment of cesarean scar pregnancy (CSP).

METHODS

 This study was done in the tertiary referral hospital of India for one year. A total of 11 cases were enrolled prospectively. In each case, the diagnostic ultrasonography and measurement of baseline beta-human chorionic gonadotropin (β-HCG) levels were done. The treatment was given based on the hemodynamic status of the patient and desire for future fertility. Various treatment modalities used were medical, surgical, or interventional digital subtraction angiography to control hemorrhage. Also, in some cases, ultrasound-guided methotrexate was injected into the scar ectopic. Medically treated cases were followed up until their β-HCG levels became normal.

RESULTS

Out of 11 patients, six had a history of two cesarean sections in the past, four patients had a history of one cesarean section and one patient with a previous three low segments cesarean section (LSCS). Seven out of 11 patients underwent medical management with either methotrexate with potassium chloride (KCl) or methotrexate alone. The success of the medical management was monitored by serial β- HCG values. The mean time for the resolution of these 10 patients was 86.7 ± 53.6 days. Three patients underwent emergency uterine artery embolization due to uncontrolled bleeding and one patient required laparotomy.

CONCLUSION

CSP is a life-threatening condition that can be diagnosed with the help of transvaginal ultrasonography. The treatment, however, depends on the hemodynamic status of the patient and desire for future fertility. Well-defined diagnostic criteria coupled with structured management and follow-up protocol can help in treating this challenging form of ectopic pregnancy.

When to perform curettage after uterine artery embolization for cesarean scar pregnancy: a clinical study

Background

Prophylactic uterine artery embolization (UAE) combined with subsequent curettage is suggested as an effective and minimally invasive treatment strategy for cesarean scar pregnancy (CSP) with a high bleeding risk. However, the timing of curettage after UAE remains to be studied. Thus, we aimed to identify the optimal time interval to perform curettage after UAE in patients with CSP.

Methods

We conducted a retrospective cohort study in a large medical center for women and children in Southwest China. CSP patients treated by UAE combined with subsequent curettage were included and grouped by the treatment time interval between these two procedures. The clinical outcomes among arms were compared by univariate and multivariable analysis.

Results

Our study included 314 CSP patients who received this combination treatment in our department from January 2014 to December 2019. The median time interval between UAE and curettage was 48 h, with a range of 12-168 h among all participants. Thirty-two patients (10.2%) experienced intraoperative hemorrhage (blood loss ≥200 mL). Intrauterine balloon tamponade was used in 17 cases (5.4%). In 14 cases (4.5%), the procedure was converted to laparoscopy (or laparotomy). In the cohort study, patients with longer treatment intervals had more intraoperative blood loss and a higher incidence of complications than those with shorter intervals (P < 0.05). The rates of intraoperative bleeding were 5.0% for patients who received curettage within 24 h after UAE (Arm 1) and 19.4% for those who had a treatment interval longer than 72 h (Arm 4). In the multivariable logistic regression model of bleeding, a treatment interval > 72 h had an adjusted odds ratio of 3.37 (95% confidence interval: 1.40-8.09).

Conclusion

We suggest that curettage not be delayed longer than 72 h after UAE in this combined treatment of CSP.

Successful hysteroscopy and curettage of a caesarean scar ectopic pregnancy

Caesarean scar ectopic pregnancies are the rarest type of ectopic pregnancy. The optimum management regime is not yet established. We report the case of a 39-year-old woman who presented at 11 weeks gestation with painless vaginal bleeding, having had 2 previous caesarean sections. Ultrasound revealed a gestational sac within the caesarean scar niche. On follow-up, her serial ß human chorionic gonadotropin (ßHCG) measurements fell significantly. The woman initially opted for conservative management but subsequently required surgical management. Hysteroscopy demonstrated a sac within the caesarean scar which was successfully evacuated by ultrasound-guided suction curettage, with no complications. Caesarean scar ectopic pregnancies are becoming increasingly common. Diagnosis is primarily through ultrasound using specified criteria. Management may be conservative, medical or surgical excision depending on the clinical circumstances. Hysteroscopy and suction curettage is an effective therapeutic option for caesarean scar ectopic management.

Cesarean Scar Ectopic Pregnancy: A Diagnostic and Management Challenge

Cesarean section scar pregnancy is the rarest form of ectopic pregnancy. Cesarean scar ectopic pregnancy poses a diagnostic and management challenge, and if not diagnosed and adequately treated in early pregnancy, it may lead to considerable maternal morbidity or mortality. We describe the presentation, workup including radiology studies, and subsequent management plan of a cesarean scar ectopic pregnancy in a 34-year-old female with a history of four previous cesarean sections. We were successful in treating this rare form of ectopic pregnancy without any maternal morbidity with a combination of medical and surgical management.

Pituitrin local injection versus uterine artery embolization in the management of cesarean scar pregnancy: A retrospective cohort study

AIM

To compare the effect of pituitrin local injection (PIT) and uterine artery embolization (UAE) as pretreatment before surgery during the management of cesarean scar pregnancy (CSP).

METHODS

Forty-nine CSP patients diagnosed in our department of Suzhou Ninth People's Hospital from October 2017 to October 2019. All patients underwent hysteroscopy and negative pressure aspiration (for type I CSP) or laparoscopic wedge-resection (for type II and III CSP) following one of the preoperative treatments: PIT group (n = 26) and UAE group (n = 23). The baseline clinical data, intraoperative blood loss, blood transfusion rate, postoperative hospital stay, hospitalization expenses, postoperative pain, postoperative fever, postoperative serum β-human chorionic gonadotropin (β-hCG) level, and pregnancy outcome were reviewed and analyzed.

RESULTS

There was no significant difference (p ≥ 0.05) between two groups in baseline characteristics including age, gravidity, previous cesarean section times, interval since last cesarean delivery, menolipsis time, maximum diameter of gestational sac or mass under ultrasound, fetal cardiac activity and preoperative β-hCG level. There was no significant difference in blood loss, transfusion rate, and postoperative β-hCG reduction percentage (p ≥ 0.05) either. The postoperative hospital stay, hospitalization expenses, postoperative pain, and postoperative fever rate in PIT group were significantly lower than those in UAE group (p < 0.05). Moreover, β-hCG level of all patients turned negative 1 month after surgery successfully.

CONCLUSIONS

PIT pretreatment seems to be a same effective, more economical, and with fewer side effects pretreatment method compared to traditional UAE pretreatment in the management of CSP.

Outcome of cesarean scar pregnancy treated with local methotrexate injection

Local injection of methotrexate (MTX) has been widely used for caesarean scar pregnancy (CSP), but the optimal candidate remains undetermined. The aim of this study is to determine the risk factors associated with treatment failure among patients who received a single dose of local MTX. This is a retrospective cohort study. Clinical information was compared between treatment success vs. failure groups. Risk factors related to treatment failure were also investigated with multivariate analysis. Of 47 patients diagnosed with CSP, 30 received local MTX injection. The initial serum ß- human chorionic gonadotropin (hCG) level in the failure group was significantly higher than in the success group (p = 0.048), and the cut-off value was 47,000 mIU/ml. The rate of type 2 position of the gestational sac in the failure group was significantly higher than in the treatment success group (p = 0.031). A high initial serum ß-hCG level (≥ 47,000 mIU/ml) was identified as the independent risk factor for treatment failure (adjusted odds ratio = 21.9; 95% confidence interval = 1.3-383.1). Type 2 gestational sac position and a higher level of ß-hCG at diagnosis appear to be associated with poor outcomes after local injection of a single dose of MTX.

Laparoscopic management of cesarean scar pregnancy: Report of two cases with video-presentation of different operative techniques and literature review

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. We present two different techniques of laparoscopic management of CSP, with the concomitant repair of the coexisting uterine isthmocele. The first case is a combination of diagnostic hysteroscopy and laparoscopic extraction of conception products, and the second technique is a combination of laparoscopy and guided Dilation & Curettage. We also conducted a thorough review of the literature to present all cases of laparoscopic treatment of CSP, focusing on the surgical technique, the operation outcome, and the future pregnancies. Laparoscopy is a potential effective treatment of CSP.

Single- versus multiple-dose methotrexate in cesarean scar pregnancies management: treatment and reproductive outcomes

PURPOSE

We aim to assess the outcome of the treatment of cesarean scar pregnancy (CSP) with single-dose methotrexate (MTX) versus multiple-dose MTX protocols.

METHODS

A retrospective cohort study including two tertiary medical centers was conducted. All women diagnosed with CSPs between the years 2011 and 2019 that were initially managed with systemic MTX were included. Single-dose MTX practiced in one medical center was compared to multiple-dose MTX, practiced in the other medical center.

RESULTS

The study cohort included 31 women in the single dose and 32 women in the multiple-dose MTX groups. Baseline characteristics did not differ between groups. The primary outcome occurred in 12 (38.7%) of the cases in the single-dose group and in 6 (18.8%) in the multiple-dose group (p = 0.083). The rate of conversion to surgical treatment was similar in both groups (4 vs. 5 in the single vs. multiple-dose groups, respectively, p = 0.758). There was no significant difference between the single- and the multiple-dose groups in the administration of blood products (16.1% vs. 3.1%, respectively, p = 0.104), total days of admission (18 ± 9.3 vs. 17 ± 12.8 days, respectively, p = 0.850), and readmission rate (32.3% vs. 21.9%, respectively, p = 0.353). Data regarding sequential pregnancies were available for 11 women in the single and 13 women in the multiple-dose MTX groups. There were no differences between the groups in rates of term deliveries, CSP recurrence, and abortions.

CONCLUSION

Both single- and multiple-dose MTX treatment protocols offer high success rate with a relatively low complication rate in the treatment of CSP.

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

OBJECTIVES

To investigate the risk factors of persistent cesarean scar pregnancy (PCSP) after dilation and curettage (D&C).

MATERIALS AND METHODS

A retrospective, age-matched case-control study including 45 cases of PCSP patients after D&C was conducted between January 2013 and April 2018. For each case, 4 women who had been diagnosed with CSP and had the same age and same hospitalization period as the case group but no residual CSP tissue after D&C were selected as the controls (Control group, n = 180). Conditional logistic regression analysis was used to assess the risk factors of PCSP after D&C.

RESULTS

After conditional logistic regression, the 3 factors associated with PCSP after D&C were maximum diameter of CSP mass (or gestational sac) ≥4.5 cm (adjusted odds ratio [aOR] 6.51, 95% CI 1.39-30.47), myometrial thickness at the implantation site <2 mm (aOR 3.58, 95% CI 1.37-9.38) and a ≤66.42% decrease rate in β-hCG levels on the first day after D&C (aOR 18.58, 95% CI 5.80-59.57). ROC analysis showed that the indicator [(hCG₀-hCG₁)/hCG₀*100%] has a good predictive value for PCSP, and the area under the curve (AUC) is 0.745; when the cut-off value is equal to 66.42%, the indicator has the best predictive value, with a sensitivity of 82.2% and a specificity of 67.7%.

CONCLUSIONS

For these high-risk patients with PCSP, choosing individualized treatment options and proper management could reduce the incidence of PCSP.

Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series

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.

Exclusive use of intrasac potassium chloride and methotrexate for treating cesarean scar pregnancy: effectiveness and subsequent fecundity

STUDY QUESTION

Is exclusive use of intragestational sac potassium chloride (KCl) and methotrexate (MTX) effective in the management of viable cesarean scar pregnancy (CSP)?

SUMMARY ANSWER

Exclusive use of intragestational sac KCl and MTX was effective in the management of viable CSP.

WHAT IS KNOWN ALREADY

Owing to a paucity of randomized studies on management of CSP, evidence-based management remains unclear. Intragestational sac KCl or MTX along with either systemic MTX or surgical intervention, such as uterine artery embolization or dilation and curettage, has proved to be effective in the management of CSP. Furthermore, there are limited data in the literature on the use of exclusive intragestational sac KCl and MTX for management of CSP and subsequent fecundity.

STUDY DESIGN, SIZE, DURATION

A prospective cohort study was conducted from June 2017 to September 2019. We recruited nine CSP patients referred to our unit. There was no lost to follow-up noted.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Patients with an ultrasound diagnosis of CSP who fulfilled the inclusion criteria were recruited. The study was conducted in a tertiary care center. Clinical symptoms, pregnancy viability, gestational age and human chorionic gonadotrophin (HCG) values determined the management in each individual case. Accordingly, patients were grouped into the expectant management (Group I, n = 3) and intragestational sac KCl with MTX (Group II, n = 6) groups. Demographic details, clinical characteristics, ultrasound details at diagnosis, post-treatment HCG normalization time, menses resumption, mass resolution and subsequent fecundity were noted. Descriptive statistics were used for analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the nine patients with CSP, six patients had viable CSP and required intervention. Out of these, four patients expressed a desire for future fertility. Mean gestational age at treatment among patients in Group II was 54.33 ± 7.51 days (range 46–65). Mean HCG value at the time of diagnosis was 84 110 ± 38 679.39 IU/l in Group II patients as compared with 2512 ± 709.36 in Group I. HCG had decreased by 92.7 ± 3.78% 2 weeks after intervention and normalized (<5 IU/l) by 53.5 ± 14.97 days. No major complications occurred and additional treatment was not required in these patients. Menstruation had resumed by 26 ± 6.6 days after treatment in Group II. On follow up, a small unresolved mass was present in two patients and the cesarean scar niche was visible in the remaining four patients. Out of the four patients desirous of future conception, three conceived naturally and one delivered a term baby via repeat lower segment cesarean section.

LIMITATIONS, REASONS FOR CAUTION

The main limitation of our study was small sample size. All the patients were asymptomatic at presentation and hence we cannot comment on use of this method in those presenting with active vaginal bleeding.

WIDER IMPLICATIONS OF THE FINDINGS

Intragestational sac KCl plus MTX may be a highly effective approach for the management of viable CSP despite high initial HCG values. There seems to be no need for any further intervention. It can be considered as the first line minimally invasive treatment option in patients desirous of future fertility. Nevertheless, accumulation of further cases is required to validate this treatment modality.

STUDY FUNDING/COMPETING INTERESTS

No specific funding was received to undertake this study. The authors report no conflict of interest.

TRIAL REGISTRATION NUMBER

N/A

Anesthetic efficacy of propofol combined butorphanol in laparoscopic surgery for ectopic pregnancy: A protocol of systematic review and meta-analysis

BACKGROUND

Recent studies have suggested that propofol combined butorphanol (PB) has anesthetic effect in laparoscopic surgery (LS) for ectopic pregnancy (EP). But investigations of its potential effects are inconsistent. We will explore the current literature examining PB in LS for EP.

METHODS

We will perform a comprehensive search from MEDLINE, Embase, Cochrane Library, PsycINFO, Global Health, Web of Science, Allied and Complementary Medicine Database, and China National Knowledge Infrastructure from inception to the present. Other literatures, such as conference abstracts, references to the relevant reviews will also be checked. Two authors will check the titles, abstracts, and full texts independently. They will also independently carry out data collection and study quality assessment. We will conduct statistical analysis using RevMan 5.3 software.

RESULTS

This study will provide accurate results on the anesthetic effect and safety of PB in LS for EP.

CONCLUSION

This study will establish high-quality evidence of the anesthetic effect and safety of PB in LS for EP to facilitate the clinical practice and guideline development.

STUDY REGISTRATION NUMBER

INPLASY202040044.

Cesarean scar pregnancy, the importance of immediate treatment

Introduction: Cesarean scar pregnancy (CSP) is an uncommon entity, with high morbidity. Its diagnosis is difficult and delays in management are frequent. We report a series of cases of CSP and analysis of the differences in the outcomes depending on the moment of pregnancy in which they are treated.Case report: Twelve patients with a diagnosis of CSP. Seven of them were diagnosed and treated in the first trimester, often required more than one type of management, but were not transfused or presented complications. The five patients diagnosed lately in the pregnancy, always required cesarean section and emergency hysterectomy, with massive bleeding, transfusions, urinary or vascular complications.Discussion: CSP can be complicated by abnormal placental invasion when pregnancy continuity is allowed. The ideal management is the termination of pregnancy shortly after the diagnosis is made. Our series highlights the diagnostic difficulties that lead to late treatment with frequent complications.Conclusion: It is essential to perform routine analysis of the site of implantation of the gestational sac in the first-trimester ultrasonography and the CSP suspected cases should be handled by interdisciplinary teams in experienced centers.

Successful treatment of cesarean scar pregnancy with transvaginal injection of absolute ethanol around the gestation sac via ultrasound

Background

This study aims to evaluate the curative effect and complications in cesarean scar pregnancy (CSP) patients treated with a transvaginal injection of absolute ethanol (AE) around the gestation sac (GS) under ultrasound guidance.

Methods

This retrospective clinical investigation analyzed 26 CSP patients treated at the Affiliated Hospital of Guilin Medical University in Guilin, Guangxi, China, between January 1, 2018 and January 30, 2019. Outcomes and complications were analyzed following treatment with AE.

Results

Out of the entire group, 20 patients were successfully treated with a single AE injection, while the remaining six patients required two or three repeat injections. In 21 patients, the serum beta-human chorionic gonadotropin (β-hCG) level was reduced to > 50% 1 day after a single AE injection; in 19 patients, the serum β-hCG level was reduced to > 80% 4 days after a single AE injection. In all patients, the average time for serum β-hCG to reduce to normal levels (< 3.0 mIU/mL) was 36.50 ± 12.54 days. The overall cure rate of CSP by AE injection was 100%. Average length of hospitalization was 6.73 ± 3.66 days, with Patient 2 having the longest hospitalization at 17 days, and Patient 3 the shortest at 2 days. No adverse effects on hematopoietic, hepatic or renal function were observed in the short term.

Conclusion

The study demonstrated that transvaginal injection of AE around the gestation sac under ultrasound guidance had good clinical effects, fewer complications, and merit as a novel treatment for CSP. However, larger multi-center trials are needed to confirm the safety and effectiveness of this treatment.

Cesarean section scar ectopic pregnancy - a management conundrum: a case report

BACKGROUND

Cesarean section scar ectopic pregnancies are a rare complication of pregnancy that may follow previous hysterotomy for any cause, uterine manipulation, and in vitro fertilization. It has become more common with the increasing number of cesarean sections worldwide. Fortunately, the use of first-trimester ultrasound imaging has led to a significant number of these pregnancies being diagnosed and managed early.

CASE PRESENTATION

We report a case of a 36-year-old black African patient who had two previous cesarean sections and one previous surgical evacuation. She presented with a type 2 cesarean section scar ectopic pregnancy that was suspected on the basis of transvaginal ultrasound imaging, but not at laparoscopy/hysteroscopy. A bladder adherent to the upper segment of the anterior uterine wall obscured the gestational mass at laparoscopy. There were extensive intracavitary adhesions that interfered with hysteroscopic visualization. This resulted in the original operative procedure being postponed until magnetic resonance imaging confirmed the ectopic location of the pregnancy. The ectopic gestation was subsequently excised, and the uterus was repaired via laparotomy.

CONCLUSIONS

It is important for clinicians and radiologists managing women with risk factors for a scar ectopic pregnancy to maintain a high index of suspicion during follow-up. Failure to diagnose and initiate prompt management may lead to uterine rupture, massive hemorrhage, and maternal death.

Cesarean Scar Pregnancies: Incidence and Factors Associated with Conversion to Surgery from Medical Management

STUDY OBJECTIVE

To describe the incidence, management, and complications of cesarean scar pregnancy (CSP) and define risk factors for conversion from medical to surgical treatment of CSP.

DESIGN

Retrospective clinical study (Canadian Task Force classification II-3).

SETTING

Tertiary medical center.

PATIENTS

All patients who were admitted and treated for CSP between 2008 and 2016.

INTERVENTIONS

The cohort was divided according to management, and demographic, clinical, and sonographic data were collected. Rates of conversion were compared between groups, and risk factors necessitating conversion were sought.

MEASUREMENTS AND MAIN RESULTS

Forty-six cases of CSP were identified. The incidence of CSP has increased from 0.05% to 0.09% of all deliveries. A regression model for absolute numbers of CSP predicted an additional 0.47 CSP each year (p = .03). The most common treatment modalities were systemic treatment with methotrexate (28.2%) and ultrasound-guided intrasac injection of KCl with systemic treatment of methotrexate (58.7%). The mean sac diameter (MSD) of cases that were converted was 11.2 mm larger than in cases that were not converted (p < .001). No patients with an MSD <10 mm or a trophoblastic mass <20 mm³ were converted to surgical management. Maximal levels of beta human chorionic gonadotropin (β-hCG) were significantly associated with the risk of conversion. Only 6.3% of patients with a β-hCG level <10,000 IU at presentation were converted from medical to surgical management. There was no significant association between fetal cardiac activity and conversion from medical to surgical management.

CONCLUSIONS

CSP has emerged as an important phenomenon in modern obstetrics and gynecology, and its frequency appears to be on the rise. The preferred method of treatment remains unclear; however, it is possible that a large MSD and trophoblastic mass at presentation should prompt surgical treatment.