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Al Naimi A. Is it the surgical intervention or was it the preoperative medical preparation? Am J Obstet Gynecol 2024; 230:272. [PMID: 37852522 DOI: 10.1016/j.ajog.2023.10.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/12/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Ammar Al Naimi
- Department of Obstetrics and Gynecology, Buergerhospital - Dr. Senckenbergische Stiftung, Nibelungenallee 37-41, D-60318 Frankfurt am Main, Hessen, Germany; Department of Obstetrics and Gynecology, Goethe University of Frankfurt, Hessen, Germany.
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Di Spiezio Sardo A, Zizolfi B, Saccone G, Ferrara C, Sglavo G, De Angelis MC, Mastantuoni E, Bifulco G. Hysteroscopic resection vs ultrasound-guided dilation and evacuation for treatment of cesarean scar ectopic pregnancy: a randomized clinical trial. Am J Obstet Gynecol 2023; 229:437.e1-437.e7. [PMID: 37142075 DOI: 10.1016/j.ajog.2023.04.038] [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: 10/27/2022] [Revised: 04/02/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Cesarean scar ectopic pregnancy is a type of ectopic pregnancy in which the fertilized egg is implanted in the muscle or fibrous tissue of the scar after a previous cesarean delivery. The condition can be catastrophic if not managed on time and can lead to significant morbidity and mortality. Several approaches have been studied for the management of cesarean scar ectopic pregnancy in women who opted for termination of pregnancy with no consensus on the best treatment modality reached so far. OBJECTIVE This study aimed to compare the success rate of hysteroscopic resection vs ultrasound-guided dilation and evacuation for the treatment of cesarean scar ectopic pregnancy. STUDY DESIGN This was a parallel group, nonblinded, randomized clinical trial conducted at a single center in Italy. Women with singleton gestations at <8 weeks and 6 days of gestation were included in the study. Inclusion criteria were women with a cesarean scar ectopic pregnancy with positive embryonic heart activity who opted for termination of pregnancy. Patients were randomized 1:1 to receive either hysteroscopic resection (ie, intervention group) or ultrasound-guided dilation and evacuation (ie, control group). Both groups received 50 mg/m2 of methotrexate intramuscularly at the time of randomization (day 1) and another dose at day 3. A third dose of methotrexate was planned in case of persistence of positive fetal heart activity at day 5. Participants received either ultrasound-guided dilation and evacuation or hysteroscopic resection from 1 to 5 days after the last dose of methotrexate. Hysteroscopic resection was performed under spinal anesthesia using a 15 Fr bipolar mini-resectoscope. Dilation and evacuation were performed by vacuum aspiration with a Karman cannula, followed by sharp curettage, if necessary, under ultrasound guidance. The primary outcome was the success rate of the treatment protocol, defined as no further treatment required until the complete resolution of the cesarean scar ectopic pregnancy. Resolution of the cesarean scar ectopic pregnancy was evaluated based on decline of beta-hCG and the absence of residual gestational material in the endometrial cavity. Treatment failure was defined as the necessity for further treatment required until the complete resolution of the cesarean scar ectopic pregnancy. A sample size calculation indicated that 54 participants were required to test the hypothesis RESULTS: A total of 54 women were enrolled and randomized. Number of previous cesarean deliveries ranged from 1 to 3. Overall, 10 women received a third dose of methotrexate with 7 of 27 (25.9%) participants in the hysteroscopic resection group and 3 of 27 (11.1%) in the dilation and evacuation group. The success rate was 100% (27/27) in the hysteroscopic resection group and 81.5% (22/27) in the dilation and evacuation group (relative risk, 1.22; 95% confidence interval, 1.01-1.48). Additional procedures were required in 5 cases of the control group, namely 3 hysterectomies, 1 laparotomic uterine segmental resection, and 1 hysteroscopic resection. The length of stay in the hospital was 9.0±2.9 days in the intervention group and 10.0±3.5 days in the control group (mean difference, -1.00 days; 95% confidence interval, -2.71 to 0.71). No cases of admission to intensive care unit or maternal death were reported. CONCLUSION Hysteroscopic resection was associated with an increased success rate in the treatment of cesarean scar ectopic pregnancy when compared with ultrasound-guided dilation and evacuation.
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Affiliation(s)
| | | | - Gabriele Saccone
- Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
| | - Cinzia Ferrara
- Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Gabriella Sglavo
- Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | | | - Enrica Mastantuoni
- Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Giuseppe Bifulco
- Neuroscience, Reproductive Science and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
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Cagli F, Dolanbay M, Gülseren V, Kütük S, Aygen EM. Is local methotrexate therapy effective in the treatment of cesarean scar pregnancy? A retrospective cohort study. J Obstet Gynaecol Res 2023; 49:122-127. [PMID: 36183741 DOI: 10.1111/jog.15453] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 01/20/2023]
Abstract
AIM To evaluate the success of local methotrexate (MTX) treatment, the side-effect profile and its fertility effect in patients diagnosed with cesarean scar pregnancy. MATERIALS This retrospective cohort study included 56 cesarean scar pregnancy patients who applied to Erciyes University Faculty of Medicine, Department of Obstetrics and Gynecology between January 2012 and January 2022 and were treated with ultrasound-guided local MTX. The results of 56 patients with cesarean scar pregnancy who underwent transvaginal ultrasound-guided single-dose local MTX treatment were evaluated. First, the contents of the sac were aspirated, and then 50 mg of MTX was injected into the gestational sac. RESULTS The median gestational age at diagnosis was 7 weeks 2 days. The mean beta human chorionic gonadotrophin level was 31 345 ± 37 838 (range: 113-233 835 mIU/mL). Fifty-four patients were successfully treated with local MTX therapy. The interval between the first MTX injection and the normalization of beta human chorionic gonadotrophin was 55.2 ± 41.0 days. None of our patients required surgical treatment. Beta human chorionic gonadotrophin values did not decrease in one patient and she was treated with systemic MTX. Local MTX therapy could not be applied to one patient for technical reasons. Only one patient needed blood transfusion after local MTX. Thirteen patients become pregnant after treatment (76%). No systemic side effects related to MTX were observed in any of the patients. CONCLUSION Transvaginal ultrasound-guided single-dose local MTX treatment is an effective, safe, and fertility-preserving treatment method for cesarean scar pregnancy.
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Affiliation(s)
- Fulya Cagli
- Department of Obstetrics and Gynecology, Erciyes University, Kayseri, Turkey
| | - Mehmet Dolanbay
- Department of Obstetrics and Gynecology, Erciyes University, Kayseri, Turkey
| | - Varol Gülseren
- Department of Obstetrics and Gynecology, Erciyes University, Kayseri, Turkey
| | - Serhan Kütük
- Department of Obstetrics and Gynecology, Develi Public Hospital, Kayseri, Turkey
| | - Ercan M Aygen
- Department of Obstetrics and Gynecology, Erciyes University, Kayseri, Turkey
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Verberkt C, Lemmers M, de Leeuw RA, van Mello NM, Groenman FA, Hehenkamp WJ, Huirne JA. Effectiveness, complications, and reproductive outcomes after cesarean scar pregnancy management: a retrospective cohort study. AJOG GLOBAL REPORTS 2022; 3:100143. [PMID: 36691399 PMCID: PMC9860491 DOI: 10.1016/j.xagr.2022.100143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There is a dramatic rise in cesarean deliveries worldwide, leading to higher complication rates in subsequent pregnancies. One of these complications is a cesarean scar pregnancy. During the last decades, treatment options for cesarean scar pregnancies have changed, and less invasive interventions have been employed to preserve fertility and reduce morbidity. However, the optimal treatment approach and the influence of various treatments on reproductive outcomes have to be determined. OBJECTIVE This study aimed to evaluate the short- and long-term outcomes after cesarean scar pregnancy management. STUDY DESIGN We conducted a retrospective cohort study of women determined to have a cesarean scar pregnancy from 2010 to 2021 at a tertiary referral center, the Amsterdam University Medical Center, in the Netherlands. Outcomes of the following management strategies were compared: expectant management, methotrexate, curettage with temporary cervical cerclage, or a laparoscopic niche resection. We performed a curettage if the cesarean scar pregnancy did not cross the serosal line of the uterus, and a laparoscopic niche resection was performed if the cesarean scar pregnancy crossed the serosal line. The main outcomes were treatment efficacy and time to subsequent ongoing pregnancy or pregnancy leading to a live birth. RESULTS Of the 60 included women, 5 (8.3%) were managed expectantly, 8 (13.3%) were treated with methotrexate, 31 (51.8%) were treated with a curettage, and 16 (26.7%) with a laparoscopic niche resection. The groups were not comparable. The gestational age and human chorionic gonadotropin levels were generally higher in women who received methotrexate or a laparoscopic niche resection. Additional treatment in the conservative group was needed for 4 (80%) women after expectant management and for 7 (87.5%) women after methotrexate treatment. In the surgical group, all 31 women treated with a curettage and all 16 treated with a laparoscopic niche resection did not require additional treatment. The subsequent ongoing pregnancy rate after cesarean scar pregnancy management was 81.1% (30/37) among women who wished to conceive, with a live birth rate of 78.4% (29/37); 1 woman was in her third trimester of pregnancy at the time of analyses. The time between cesarean scar pregnancy management and subsequent ongoing pregnancy was 4 months (interquartile range, 3-6; P=.02) after expectant management, 18 months (interquartile range, 13-22) after initial methotrexate treatment, 5 months (interquartile range, 3-14; P=.01) after a curettage, and 6 months (interquartile range, 4-15; P=.03) after a laparoscopic niche resection. CONCLUSION Surgical treatment of a cesarean scar pregnancy led to a high success rate without additional interventions, high pregnancy rates with a short time interval between treatment, and subsequent pregnancy leading to an ongoing pregnancy or live birth. Conservative management, both with expectant management and methotrexate treatment, led to high (re)intervention rates. Different management approaches are indicated for different types of cesarean scar pregnancies.
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Affiliation(s)
- Carry Verberkt
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development Research Institute, Amsterdam University Medical Center, VU Medical Center, Amsterdam, The Netherlands (Dr Verberkt)
| | - Marike Lemmers
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
| | - Robert A. de Leeuw
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
| | - Norah M. van Mello
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
| | - Freek A. Groenman
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
| | - Wouter J.K. Hehenkamp
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
| | - Judith A.F. Huirne
- Department of Obstetrics and Gynecology, Amsterdam University Medical Center, Amsterdam, The Netherlands (Drs Lemmers, de Leeuw, van Mello, Groenman, Hehenkamp, and Huirne)
- Corresponding author:
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Shao M, Tang F, Ji L, Hu M, Zhang K, Pan J. The management of caesarean scar pregnancy with or without a combination of methods prior to hysteroscopy: ovarian reserve trends and patient outcomes. J Gynecol Obstet Hum Reprod 2022; 51:102417. [PMID: 35667588 DOI: 10.1016/j.jogoh.2022.102417] [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: 09/03/2021] [Revised: 05/15/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE This study compared the efficacy and safety of a combination of uterine artery embolization or methotrexate before hysteroscopy in the treatment of cesarean scar pregnancy. METHODS We divided 276 cesarean scar pregnancy patients into three groups. Group A underwent direct hysteroscopy; Group B received uterine artery embolization plus hysteroscopy; Group C received the systemic administration of methotrexate prior to hysteroscopy. RESULTS The patients in Group A lost significantly more blood than those in Groups B (P < 0.05). There were no significant differences between the three groups with regards to massive hemorrhage and transfusion (P > 0.05). None of the patients required hysterectomy. Group A was also associated with a significantly shorter period of hospitalization, reduced medical costs, and fewer adverse events than either Group B or C (P < 0.05). Moreover, among women of advanced age (≥35y), the levels of serum anti-Mullerian hormone in Group B were significantly lower than those of the baseline group (P<0.05), which were significantly lower than those in Group A after surgery (4.22 ± 2.35 vs 2.78± 1.89 ng/ml, P < 0.05). CONCLUSION Direct hysteroscopy is a reliable treatment option for most early type I cesarean scar pregnancy patients with a gestational sac. A combination of methotrexate and uterine artery embolization before hysteroscopy in these patients has limited remedial effects. uterine artery embolization may reduce ovarian reserve in patients aged ≥35y.
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Affiliation(s)
- Mingjun Shao
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Fei Tang
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Limei Ji
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Min Hu
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Keke Zhang
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China
| | - Jiangfeng Pan
- Department of Obstetrics and Gynecology, Jinhua Municipal Central Hospital, Jinhua, China.
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Saccone G, Mastantuoni E, Ferrara C, Sglavo G, Zizolfi B, De Angelis M, Di Spiezio Sardo A. Hysteroscopic resection vs dilation and evacuation for treatment of caesarean scar pregnancy: study protocol for a randomised controlled trial. Facts Views Vis Obgyn 2022; 14:83-86. [PMID: 35373552 PMCID: PMC9612857 DOI: 10.52054/fvvo.14.1.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background Caesarean scar pregnancy (CSP) is a type of ectopic pregnancy where the fertilised egg is implanted in the muscle or fibrous tissue of the scar after a previous caesarean section. Management options for women who opted for termination of CSP include sharp curettage, dilation and evacuation (D&E), excision of trophoblastic tissues, local or systemic administration of methotrexate, bilateral hypogastric artery ligation, and selective uterine artery embolisation with curettage and/or methotrexate administration. Recently hysteroscopic resection has also been proposed as an alternative option. Objective To compare the surgical outcome of hysteroscopic resection with dilation and evacuation (D&E) for the treatment of caesarean scar pregnancy (CSP). Methods Parallel-group, non-blinded, randomised clinical trial conducted at a single centre in Italy. Eligible women are those with singleton gestations at less than 9 weeks of gestation, and with thickness of myometrial layer ≥1 mm at the level of the ectopic. Inclusion criteria are women with CSP with positive embryonic/fetal heart activity who opted for termination of pregnancy. Patients will be randomised 1:1 to receive either hysteroscopic resection (i.e. intervention group) or D&E (i.e. control group). In both groups, 50 mg/m2 (based on DuBois formula for body surface area) of methotrexate (MTX) will be injected intramuscularly at the time of randomisation (day 1) and another dose at day 3. A third dose of MTX is planned in case of persistence of fetal heart activity on day 5. Participants will receive either D&E or hysteroscopic resection from 3 to 7 days after the last dose of MTX. A sample size of 54 women is planned. Main Outcome Measures The primary outcome is the success rate of the treatment protocol, defined as no requirement for further treatment until complete resolution of the CSP as demonstrated by negative beta hCG levels and absence of residual gestational material on ultrasound examination.. Study hypothesis Hysteroscopic surgery is superior to D&E for the treatment of CSP. What is new? The results of the trial will provide information on the best treatment for CSP.
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Mitsui T, Mishima S, Ohira A, Tani K, Maki J, Eto E, Hayata K, Masuyama H. hCG values and gestational sac size as indicators of successful systemic methotrexate treatment in cesarean scar pregnancy. Taiwan J Obstet Gynecol 2021; 60:454-457. [DOI: 10.1016/j.tjog.2021.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 12/26/2022] Open
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Mo R, Kalburgi S, Thakur Y, Jadhav J. Successful hysteroscopy and curettage of a caesarean scar ectopic pregnancy. BMJ Case Rep 2021; 14:14/4/e241183. [PMID: 33858897 PMCID: PMC8055137 DOI: 10.1136/bcr-2020-241183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Roxana Mo
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Sujatha Kalburgi
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Yatin Thakur
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Jitendra Jadhav
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
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Single- versus multiple-dose methotrexate in cesarean scar pregnancies management: treatment and reproductive outcomes. Arch Gynecol Obstet 2021; 303:1255-1261. [PMID: 33389098 DOI: 10.1007/s00404-020-05914-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
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.
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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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Gulino FA, Pappalardo E, Ettore C, Laganà AS, Capriglione S, Ettore G. Caesarean scar pregnancy: descriptive paper of three different types of management on a series of clinical cases. PRZEGLAD MENOPAUZALNY = MENOPAUSE REVIEW 2020; 19:61-65. [PMID: 32802015 PMCID: PMC7422283 DOI: 10.5114/pm.2020.97836] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/09/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION A caesarean scar pregnancy is a complex iatrogenic pathology, which represents a consequence of a previous caesarean section. It increased in recent years due to parallel increase of cesarean sections. MATERIAL AND METHODS We present a retrospective study on patients with caesarean scar pregnancy diagnosed in our department from June 2016 to June 2019. Stable women with an embryo (with or without cardiac activity) who accepted our experimental protocol were treated with single dose of methotrexate (50 mg administered locally intracavitary + 50 mg administered intramuscularly) and folinic acid (15 mg/day orally for 30 days). Clinically stable women with embryo (without cardiac activity) who decided to wait, were monitored by serial assays of b-hCG and clinical and ultrasonographic follow up. Women who were clinically unstable with embryo (without cardiac activity), were referred for urgent surgical treatment with dilation and curettage. RESULTS Caesarean scar pregnancy was diagnosed in sixteen women. Among these women, seven were treated according to our experimental protocol with methotrexate and folinic acid and only one had profuse bleeding, which required a laparotomic hysterectomy. Four women were treated urgently with dilatation and curettage. Five women chose to wait: they were monitored and all spontaneously had a miscarriage. CONCLUSIONS In our preliminary study, we highlighted how our experimental protocol gave encouraging results in the first 10 weeks of caesarean scar pregnancy. However, caution is needed in patients with advanced gestational age, a gestational sac with large diameter, higher CRL and presence of embryonic cardiac activity.
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Affiliation(s)
- Ferdinando Antonio Gulino
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Elisa Pappalardo
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Carla Ettore
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Stella Capriglione
- Department of Obstetrics and Gynaecology, Campus Bio-Medico University, Rome, Italy
| | - Giuseppe Ettore
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
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Gundewar T, Pandurangi M, Reddy NS, Vembu R, Andrews C, Nagireddy S, Soni A, Kakkad V. Exclusive use of intrasac potassium chloride and methotrexate for treating cesarean scar pregnancy: effectiveness and subsequent fecundity. Hum Reprod Open 2020; 2020:hoaa025. [PMID: 32685702 PMCID: PMC7359909 DOI: 10.1093/hropen/hoaa025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/25/2020] [Accepted: 04/06/2020] [Indexed: 12/27/2022] Open
Abstract
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
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Affiliation(s)
- Tejas Gundewar
- Department of Reproductive Medicine & Surgery, Sri Ramachandra Medical College & Research Institute, Chennai 600116, India
| | - Monna Pandurangi
- Department of Reproductive Medicine & Surgery, Sri Ramachandra Medical College & Research Institute, Chennai 600116, India
| | - N Sanjeeva Reddy
- Department of Reproductive Medicine & Surgery, Sri Ramachandra Medical College & Research Institute, Chennai 600116, India
| | - Radha Vembu
- Department of Reproductive Medicine & Surgery, Sri Ramachandra Medical College & Research Institute, Chennai 600116, India
| | - Chitra Andrews
- Department of Obstetrics & Gynecology, Sri Ramachandra Medical College & Research Institute, Chennai 600116, India
| | - Siddharth Nagireddy
- Department of Reproductive Medicine & Surgery, Sri Ramachandra Medical College & Research Institute, Chennai 600116, India
| | - Ashish Soni
- Department of Reproductive Medicine & Surgery, Sri Ramachandra Medical College & Research Institute, Chennai 600116, India
| | - Vivek Kakkad
- Department of Reproductive Medicine & Surgery, Sri Ramachandra Medical College & Research Institute, Chennai 600116, India
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Timor-Tritsch IE, Monteagudo A, Calì G, D'Antonio F, Agten AK. Cesarean Scar Pregnancy: Patient Counseling and Management. Obstet Gynecol Clin North Am 2020; 46:813-828. [PMID: 31677756 DOI: 10.1016/j.ogc.2019.07.010] [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] [Indexed: 12/29/2022]
Abstract
There is no universally agreed upon and adopted management protocol supported by professional societies in the United States or around the world for the treatment of cesarean scar pregnancy. There is a wide range of management options in the literature, and many of them can to lead to severe bleeding complications, which can result in loss of fertility or even maternal death. If inadequately managed, it can lead to untoward complications throughout all 3 trimesters of the pregnancy. Early detection of CSP has a paramount clinical importance.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Health, 550 1st Avenue, New York, NY 10016, USA.
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calì
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - Francesco D'Antonio
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Andrea Kaelin Agten
- Nottingham University Hospitals NHS, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
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Abdelazim IA, Abu-Faza M, Zhurabekova G, Shikanova S, Kanshaiym S, Karimova B, Sarsembayev M, Starchenko T. Successful Pregnancy Outcome Immediately after Methotrexate Treatment for Cesarean Section Scar Pregnancy. Gynecol Minim Invasive Ther 2019; 8:185-187. [PMID: 31741846 PMCID: PMC6849100 DOI: 10.4103/gmit.gmit_134_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/21/2019] [Accepted: 03/07/2019] [Indexed: 11/04/2022] Open
Abstract
A 27-year-old cesarean section scar pregnancy (CSSP) case diagnosed by the vaginal ultrasound which showed gestational sac located in the lower uterine anterior quadrant close to the site of the previous scars (with yolk sac inside) with β-hCG 15,373 mIU/ml in September 2017 was managed by intramuscular (IM) multidose methotrexate (MTX). The studied woman discharged home when the β-hCG decreased to 11,630 mIU/ml on the 1st week after the first MTX dose. On the 5th week after the first dose of IM-MTX, the β-hCG dropped to zero and the gestational sac completely disappeared. She was counseled about the risk of pregnancy in the first 6 months after the MTX and the possibility of the CSSP recurrence. She presented on December 16, 2018, with preterm delivery at 35 weeks' gestation. After delivery, her neonate admitted to the neonatal intensive care unit (NICU) due to mild respiratory distress and discharged from the NICU on the 4th day in good condition. Multi-dose MTX regimen for the treatment of CSSP supported by many authors with follow-up by β-hCG and vaginal ultrasound. This report highlights the successful outcome immediately after the proper management of CSSP cases.
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Affiliation(s)
- Ibrahim A Abdelazim
- Department of Obstetrics and Gynecology, Ahmadi Hospital, Kuwait Oil Company, Ahmadi, Kuwait.,Department of Obstetrics and Gynecology, Ain Shams University, Cairo, Egypt
| | - Mohannad Abu-Faza
- Department of Obstetrics and Gynecology, Ahmadi Hospital, Kuwait Oil Company, Ahmadi, Kuwait
| | - Gulmira Zhurabekova
- Department of Normal and Topographical Anatomy, West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
| | - Svetlana Shikanova
- Department of Obstetrics and Gynecology No. 1, West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
| | - Sakiyeva Kanshaiym
- Department of Obstetrics and Gynecology No. 1, West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
| | - Bakyt Karimova
- Department of Obstetrics and Gynecology No. 1, West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
| | - Mukhit Sarsembayev
- Department of Obstetrics and Gynecology No. 1, West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
| | - Tatyana Starchenko
- Department of Obstetrics and Gynecology No. 1, West Kazakhstan Marat Ospanov State Medical University, Aktobe, Kazakhstan
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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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Tanaka K, Coghill E, Ballard E, Sekar R, Amoako A, Khalil A, Baartz D. Management of caesarean scar pregnancy with high dose intravenous methotrexate infusion therapy: 10-year experience at a single tertiary centre. Eur J Obstet Gynecol Reprod Biol 2019; 237:28-32. [DOI: 10.1016/j.ejogrb.2019.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/01/2019] [Accepted: 04/08/2019] [Indexed: 10/27/2022]
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Management of Caesarean scar pregnancy with or without methotrexate before curettage: human chorionic gonadotropin trends and patient outcomes. BMC Pregnancy Childbirth 2018; 18:289. [PMID: 29973177 PMCID: PMC6032533 DOI: 10.1186/s12884-018-1923-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 06/27/2018] [Indexed: 02/08/2023] Open
Abstract
Background To evaluate the effects of systemic methotrexate in cesarean scar pregnancy (CSP) patients treated with ultrasound-guided suction curettage. Methods A retrospective review of all women presenting with CSP treated with ultrasound-guided suction curettage at Tongji Hospital, Wuhan, China, between January 1, 2013 and December 31, 2015, was conducted. Patients were grouped into those not treated with methotrexate before curettage (group 1), treated with methotrexate by intramuscular injection (group 2) and treated with methotrexate by intravenous injection (group 3). The clinical characteristics and outcomes were analyzed. Results Among 107 patients, 47 patients were not treated with methotrexate before curettage, 46 patients had methotrexate administered by intramuscular injection and 14 patients had methotrexate injected intravenously. There were no significant differences among the groups in basic and clinical characteristics, such as age, gravity, parity, positive fetal heart beat and gestational age at diagnosis. Patients presented similar initial human chorionic gonadotropin (hCG) levels in all groups. After treatment with methotrexate or curettage, the percentage changes and varied ranges of the hCG levels were also similar in all groups. There were no significant differences in intraoperative blood loss and retained products of conception among the three groups. However group 1 had significantly shorter hospital stays than the two groups that were treated with methotrexate (p<0.001). Conclusion By grouping CSP patients who shared similar age, gravity, parity, fetal heart beat positive and gestational age at diagnosis, we found that the presence or absence of methotrexate treatment before curettage resulted in comparable outcomes and hCG levels, although patients who were not treated with methotrexate had significantly shorter stays in the hospital.
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18
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Ultrasound-guided local injection of methotrexate and systemic intramuscular methotrexate in the treatment of cesarean scar pregnancy. Obstet Gynecol Sci 2017; 61:147-153. [PMID: 29372162 PMCID: PMC5780311 DOI: 10.5468/ogs.2018.61.1.147] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 08/03/2017] [Accepted: 08/04/2017] [Indexed: 11/08/2022] Open
Abstract
Objective To assess the efficacy and safety of ultrasound-guided intragestational injection of methotrexate (MTX) and systemic intramuscular MTX in the management of cesarean scar pregnancies. Methods This was a retrospective case-control study that included women diagnosed with cesarean scar pregnancy at CHA Bundang Medical Center unit between 2009 and 2015. The 26 cases were managed with local injection of MTX under ultrasound guidance and 15 cases were treated with systemic intramuscular of MTX. After the procedure, serial follow-up sonographic examination and serum beta-human chorionic gonadotropin (β-hCG) measurement were performed. Results The mean initial β-hCG level was 20,610.73 mIU/mL and ranged from 263.00-71,316.50 mIU/mL. Mean gestational age was 6.3 weeks and ranged from 4.8 to 8.5 weeks. The majority of ectopic cases were treated successfully and follow-up β-hCG level declined abruptly following the first dose of MTX. The rate of success of local MTX treatment was significantly higher than that of systemic MTX treatment. It was 93.75% vs. 73.33%, respectively (P<0.05). Conclusion Ultrasound-guided intragestational injection of MTX is an effective method for the management of cesarean scar pregnancies and is associated with minimal side effects and high treatment success.
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Maheux-Lacroix S, Li F, Bujold E, Nesbitt-Hawes E, Deans R, Abbott J. Cesarean Scar Pregnancies: A Systematic Review of Treatment Options. J Minim Invasive Gynecol 2017; 24:915-925. [DOI: 10.1016/j.jmig.2017.05.019] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/29/2017] [Accepted: 05/31/2017] [Indexed: 10/19/2022]
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Ying X, Zheng W, Zhao L, Zhou M, Chen Z. Clinical characteristics and salvage management of persistent cesarean scar pregnancy. J Obstet Gynaecol Res 2017; 43:1293-1298. [PMID: 28612958 PMCID: PMC5575528 DOI: 10.1111/jog.13367] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 01/28/2017] [Accepted: 03/27/2017] [Indexed: 11/28/2022]
Abstract
Aim The study was conducted to illustrate the clinical characteristics and treatment outcomes of patients with persistent cesarean scar pregnancy (PCSP). Methods During a six‐year period, 38 cases of PCSP were diagnosed and treated conservatively to preserve fertility. The clinical presentations, imaging findings and treatment outcomes of these patients were reviewed. Results Fourteen out of 38 women (37%) presenting with PCSP suffered heavy vaginal bleeding. Gestational age at diagnosis was 73.1 ± 21.7 days. The maximum diameter of the PCSP mass was 3.6 ± 1.6 cm. The presence of a rich vascular pattern in the area of the PCSP mass was detected by ultrasound in 33/38 (87%) patients. Six patients with a PCSP gestational age of 64.2 ± 6.2 days and a mass diameter of 2.5 ± 0.6 cm were successfully treated with medical treatment alone and 32 patients with a gestational age of 74.8 ± 23.1 days and a mass diameter of 3.8 ± 1.6 cm were successfully treated with surgical or combined treatment. Conclusions Patients with PCSP are diagnosed at advanced gestational age and are more prone to heavy bleeding. Surgery is the main treatment for PCSP. Medical treatment of PCSP has become an attractive alternative, especially for hemodynamically stable patients with a PCSP mass with a maximum diameter of < 3.5 cm.
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Affiliation(s)
- Xue Ying
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Zheng
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Li Zhao
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Mi Zhou
- Department of Obstetrics and Gynecology, Maternal and Child Health Hospital of Hainan Province, Haikou, China
| | - Zhengyun Chen
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Uludag SZ, Kutuk MS, Aygen EM, Sahin Y. Conservative management of cervical ectopic pregnancy: Single-center experience. J Obstet Gynaecol Res 2017; 43:1299-1304. [PMID: 28586112 DOI: 10.1111/jog.13362] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 03/29/2017] [Indexed: 12/13/2022]
Abstract
AIM The aim of this study was to assess the results of conservative treatment of cervical ectopic pregnancy (CEP). METHODS We retrospectively reviewed all cervical ectopic pregnancies diagnosed at the present department between January 2010 and July 2015. Patients with CEP who were treated with either systemic or intra-amniotic methotrexate (MTX) injection were included in the study. RESULTS Ten CEP patients were identified. Median maternal age was 33 years (range, 23-40 years). Median gestational age at diagnosis was 47 days (range, 44-58 days). Before treatment, overall mean serum beta-human chorionic gonadotrophin (β-hCG) was 29 706.9 ± 19 695.2 mIU/mL. Mean gestational sac size was 29.0 ± 6.24 mm. Eight patients had viable fetuses with detected cardiac activity. Six patients were treated primarily with systemic MTX, and four were treated with local MTX injection. One patient in the systemic MTX injection group was switched to local MTX treatment due to severe oral ulceration and increasing β-hCG titers after the fourth dose. One patient in the local treatment group had severe hemorrhage 7 days after local MTX. Three of six women achieved spontaneous pregnancy and gave birth to term, healthy infants after treatment. CONCLUSION Conservative treatment of CEP with both systemic and local MTX is generally successful with regard to maternal morbidity and reproductive function, but these patients must be closely followed due to the small but real risk of late hemorrhage.
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Affiliation(s)
- Semih Zeki Uludag
- Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Turkey
| | - Mehmet Serdar Kutuk
- Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Turkey
| | - Ercan Mustafa Aygen
- Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Turkey
| | - Yılmaz Sahin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Erciyes University, Turkey
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Successful Treatment of Caesarean Scar Pregnancies by Local Treatment Only. Obstet Gynecol Int 2017; 2017:9543570. [PMID: 28396687 PMCID: PMC5371214 DOI: 10.1155/2017/9543570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Accepted: 03/05/2017] [Indexed: 12/02/2022] Open
Abstract
Background. Caesarean scar pregnancy (CSP) is a rare ectopic pregnancy associated with life-threatening complications. To date, no therapeutic protocols have been established. Sono-guided local methotrexate (MTX) injection is a relatively easy and low-invasive treatment. Additional systemic MTX is sometimes needed for CSP cases, especially when β-subunit human chorionic gonadotropin (β-hCG) levels are >20,000 mIU/ml at diagnosis. We report on six cases of CSP treated with local MTX injection, five of which received combined local treatment. Methods. Under intravenous anesthesia, six CSPs including a case with β-hCG levels >20,000 mIU/ml received MTX injection to the gestational sac. Five cases received gestational sac aspiration. Three cases had additional local potassium chloride injection and one case had a saline injection aiming at the fetal heart beat concurrent with MTX injection. MTX was administered weekly if β-hCG levels stayed beyond the expected values. Outcomes. All cases achieved β-hCG normalization without additional systemic MTX, with one case having a successful pregnancy after treatment. Conclusion. Sono-guided local MTX injection with concurrent local treatment might be a potentially effective approach for CSP cases. The accumulation of further cases is necessary to confirm this.
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Uludag SZ, Kutuk MS, Ak M, Ozgun MT, Dolanbay M, Aygen EM, Sahin Y. Comparison of systemic and local methotrexate treatments in cesarean scar pregnancies: time to change conventional treatment and follow-up protocols. Eur J Obstet Gynecol Reprod Biol 2016; 206:131-135. [DOI: 10.1016/j.ejogrb.2016.09.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 07/21/2016] [Accepted: 09/13/2016] [Indexed: 12/28/2022]
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Kutuk MS, Subasioglu A, Uludag S, Tascioglu N, Ozgun MT, Dundar M. The effect of parental 5,10-methylenetetrahydrofolate reductase 677C/T and 1298A/C gene polymorphisms on response to single-dose methotrexate in tubal ectopic pregnancy. J Matern Fetal Neonatal Med 2016; 30:1232-1237. [PMID: 27379466 DOI: 10.1080/14767058.2016.1209652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECT The aim of this study was to assess the effect of parental 5,10-methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms (677C/T and 1298A/C) on response to single-dose methotrexate (MTX) treatment in tubal ectopic pregnancy (TEP). MATERIALS AND METHODS In this prospective cohort study, cases with unruptured TEPs were grouped into two according to their response to single-dose MTX treatment (Group 1: responsive, n:88; Group 2: unresponsive, n:21). The groups were compared with regard to baseline demographic and clinical parameters. As a main outcome measure, the independent effects of parental MTHFR gene polymorphisms on response to single dose MTX treatment were evaluated. RESULTS One hundred and nine unruptured TEP were included in the final analysis. The mean maternal age was 29.30 ± 5.21 years, gravity 2 (min-max: 1-5), parity 1 (min-max: 0-4). The median serum beta-human chorionic gonadotropin (β-hCG) was 1403.35 MI/I (Q1-Q3: 517-2564). The overall response rate was 81% (88/109). The groups were similar with respect to basic baseline demographic data and serum β-hCG level. Binary logistic regression analysis showed that the presence of parental MTHFR677C/T and 1298A/C polymorphism were not independent factor predicting treatment success (p > 0.05). The only independent factor for resistance to single dose MTX was the previous TEP (OR: 4.47 (1.18-16.9)). CONCLUSION Parental MTHFR 677C/T and 1298A/C mutations do not predict the outcome of single dose intramuscular MTX treatment in unruptured TEP.
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Affiliation(s)
- Mehmet Serdar Kutuk
- a Department of Obstetrics and Gynecology , Erciyes University , Kayseri , Turkey and
| | - Asli Subasioglu
- b Department of Medical Genetics , Faculty of Medicine, Erciyes University , Kayseri , Turkey
| | - Semih Uludag
- a Department of Obstetrics and Gynecology , Erciyes University , Kayseri , Turkey and
| | - Nazife Tascioglu
- b Department of Medical Genetics , Faculty of Medicine, Erciyes University , Kayseri , Turkey
| | - Mahmut Tuncay Ozgun
- a Department of Obstetrics and Gynecology , Erciyes University , Kayseri , Turkey and
| | - Munis Dundar
- b Department of Medical Genetics , Faculty of Medicine, Erciyes University , Kayseri , Turkey
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Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, Svarre Nielsen H. Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril 2016; 105:958-67. [PMID: 26794422 DOI: 10.1016/j.fertnstert.2015.12.130] [Citation(s) in RCA: 242] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 11/30/2015] [Accepted: 12/22/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To study treatment modalities for cesarean scar pregnancies (CSPs), focusing on efficacy and complications in relation to study quality. DESIGN Systematic review. SETTING Not applicable. PATIENT(S) A total of 2,037 women with CSP. INTERVENTION(S) Review of MEDLINE, EMBASE, and Cochrane Library to find studies including five or more women. Data were extracted on primary treatment modality/efficacy, complications, and future fertility. The level of evidence was categorized according to Oxford Centre for Evidence-based Medicine guidelines. Quality was assessed using The Cochrane Collaboration's Risk of Bias Tools for Randomized Controlled Trials and the modified Delphi techniques for case series. Meta-analysis was impossible owing to multifarious treatments. MAIN OUTCOME MEASURE(S) Successful first-line treatment. Complications were hysterectomy, laparotomy, bleeding >1,000 mL, or blood transfusion. RESULT(S) Fifty-two studies were included: four randomized, controlled trials and 48 case series. Fifteen of the 52 analyzed studies were scored as high quality. Treatment modalities were condensed to 14 different approaches. Combining study quality, level of evidence, efficacy, and safety, five approaches for treating CSP are recommended, depending on availability, severity of patient symptoms, and surgical skills: [1] resection through a transvaginal approach, [2] laparoscopy, [3] uterine artery embolization in combination with dilatation and curettage and hysteroscopy, [4] uterine artery embolization in combination with dilatation and curettage, and [5] hysteroscopy. CONCLUSION(S) This review recommends treatment options for CSP in clinical practice, based on efficacy and safety. The literature supports an interventional rather than medical approach. Present recommendations are primarily based on case series. Multicenter, well-designed studies are needed to draw definite conclusions on how to treat CSP.
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Affiliation(s)
| | - Elise Hoffmann
- Department of Obstetrics and Gynaecology, Copenhagen University Hospital, Roskilde Sygehus, Roskilde, Denmark
| | - Christian Rifbjerg Larsen
- Centre for Minimal Invasive and Robotic Surgery Research, Departments of Gynecology, General Surgery, and Urology, Copenhagen University Hospital, Herlev Hospital, Herlev, Denmark
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Kalampokas E, Boutas I, Panoulis K, Kalampokas T. Novel Medical Therapy of Cesarean Scar Pregnancy With a Viable Embryo Combining Multidose Methotrexate and Mifepristone: A Case Report. Medicine (Baltimore) 2015; 94:e1697. [PMID: 26469907 PMCID: PMC4616779 DOI: 10.1097/md.0000000000001697] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
An ectopic pregnancy is defined as cesarean scar pregnancy (CSP) when the products of conception are implanted within the myometrium in the area of a cesarean section scar. CSP can be a life-threatening condition and to date there is no clear consensus for CSP management. A medical approach joining high treatment rates with fertility preservation could be a safer and less invasive method of therapy.We present a case of CSP with a viable embryo that was successfully treated with a novel medical therapy combining multidose methotrexate (MTX) and mifepristone.No further additional invasive procedure was required since pregnancy products were dissolved and no major complications were experienced.Multidose MTX and mifepristone can be considered a safe and effective treatment for CSP.
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Affiliation(s)
- Emmanouil Kalampokas
- From the Second Department of Obstetrics and Gynecology, Aretaieion Hospital, University of Athens Medical School, Athens, Greece
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Tsuji S, Murakami T, Kimura F, Tanimura S, Kudo M, Shozu M, Narahara H, Sugino N. Management of secondary infertility following cesarean section: Report from the Subcommittee of the Reproductive Endocrinology Committee of the Japan Society of Obstetrics and Gynecology. J Obstet Gynaecol Res 2015; 41:1305-12. [DOI: 10.1111/jog.12750] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/07/2015] [Accepted: 04/08/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Shunichiro Tsuji
- Department of Obstetrics and Gynecology; Shiga University of Medical Science; Shiga Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology; Shiga University of Medical Science; Shiga Japan
| | - Fuminori Kimura
- Department of Obstetrics and Gynecology; Shiga University of Medical Science; Shiga Japan
| | - Satoshi Tanimura
- Department of Obstetrics and Gynecology; Toyama Prefectural Central Hospital; Toyama Japan
| | - Masataka Kudo
- Department of Obstetrics and Gynecology; Hokkaido University; Hokkaido Japan
| | - Makio Shozu
- Department of Obstetrics and Gynecology; Chiba University; Chiba Japan
| | - Hisashi Narahara
- Department of Obstetrics and Gynecology; Oita University Faculty of Medicine; Oita Japan
| | - Norihiro Sugino
- Department of Obstetrics and Gynecology; Yamaguchi University Hospital; Yamaguchi Japan
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28
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Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes. ACTA ACUST UNITED AC 2015; 40:2589-99. [DOI: 10.1007/s00261-015-0472-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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29
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Peng P, Gui T, Liu X, Chen W, Liu Z. Comparative efficacy and safety of local and systemic methotrexate injection in cesarean scar pregnancy. Ther Clin Risk Manag 2015; 11:137-42. [PMID: 25670903 PMCID: PMC4315462 DOI: 10.2147/tcrm.s76050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To investigate the efficacy of methotrexate (MTX) injection in treatment of cesarean scar pregnancy (CSP). Method A randomized controlled study was performed in 104 CSP patients receiving either local or systemic MTX injection at the Peking Union Medical College Hospital from the year 2008 to 2013. Results Complete cure was defined as regression of ultrasonographic findings and normalization of serum β-hCG within 60 days. It was regarded as delayed cure if additional dilation and curettage (D&C) was needed. The overall cure rate (complete cure plus delayed cure) was 69.2% versus 67.3% for local injection versus systemic administration (P>0.05). The median time for serum β-hCG remission and uterine mass disappearance after systemic administration (42 [21–69] days and 40 [20–67] days) were significantly lower than those receiving local injection (56 [24–92] days and 53 [23–88] days), with P=0.029 and 0.046, respectively. The mean pretreatment serum β-hCG (human chorionic gonadotropin) level and lesion size in cured group (21,941±18,351 mIU/mL and 2.9±1.3 cm, respectively) were significantly lower than those in the failed group (37,047±30,864 mIU/mL and 3.6±1.3) with P=0.038 and 0.044, respectively. Conclusion MTX injection is effective in CSP treatment. Systemic administration shows similar overall cure rate compared to local injection, but requires shorter time for serum β-hCG remission and uterine mass disappearance.
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Affiliation(s)
- Ping Peng
- Department of Obstetrics and Gynecology, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Ting Gui
- Department of Obstetrics and Gynecology, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xinyan Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Weilin Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Zhenzhen Liu
- Department of Ultrasonography, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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