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Alameddine S, Lucidi A, Jurkovic D, Timor Tritsch I, Coutinho CM, Ranucci L, Buca D, Khalil A, Jauniaux E, Mappa I, D'Antonio F. Treatments for cesarean scar pregnancy: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2024; 37:2327569. [PMID: 39385517 DOI: 10.1080/14767058.2024.2327569] [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: 01/16/2024] [Revised: 02/21/2024] [Accepted: 02/25/2024] [Indexed: 10/12/2024]
Abstract
OBJECTIVE To report the outcome of cesarean scar pregnancy (CSP) undergoing treatment. METHODS MEDLINE, Embase and CINAHL databases were searched. Inclusion criteria were women with CSP undergoing treatment. The primary outcome was successful treatment for CSP, defined as no need for additional medical or surgical strategies. Secondary outcomes were the type of additional treatment (surgical or medical), need for blood transfusion, emergency laparotomy, hysterectomy, post-treatment complications.All these outcomes were explored in women undergoing single and compound treatments for CSP. Furthermore, we performed a separate sub-group analysis only including studies which reported on the outcomes of elective treatments. Random effects meta-analyses were used to analyze the data and results reported as pooled proportions or odd ratio (OR). RESULTS 176 studies (13431 women with CSP undergoing treatment) were included.Successful treatment after primary intervention was achieved in 86.2% (95% CI 82.3-89.7) of women with CSP undergoing treatment with ultrasound guided suction curettage, 72.4% (95% CI 64.8-79.3) with systemic MTX, 81.6% (95% CI 72.3-89.3) with local MTX, 83.9% (95% CI 66.7-95.6) with interventional radiology, 90.42% (95% CI 82.9-96.0) with hysteroscopy, 96.1% (95% CI (92.3-98.6) with laparoscopy and 92.6 with high intensity focused ultrasound (95% CI 78.2-99.6). Post-treatments complications were reported in 3.5% (95% CI 1.7-6.0) of women treated with systemic MTX, 5.9% (95% CI 0.8-15.1) with local MTX or KCl, 1.2% (95% CI 0.1-3.5) with interventional radiology, 1.4% (95% CI 0.4-2.9) with hysteroscopy, 5.5% (95% CI 0.4-25.7) with high intensity focused ultrasound and in none of the cases treated with ultrasound guided suction curettage.When considering compound treatments, successful resolution of CSP was achieved in 91.9% (95% CI 88.0-95.10) of women treated with interventional radiology followed by curettage, 83.3% (95% CI 68.8-93.8) with systemic MTX and curettage, 79.4% (95% CI 56.3-95.2) with local MTX and curettage, 96.2% (95% CI 92.3-98.7) with curettage followed by single or double balloon insertion in the uterine cavity, 98.3% (95% CI 95.9-99.7) with high intensity focused ultrasound followed by curettage, 91.1% (95% CI 3.4-97.0) with interventional radiology followed by removal of CSP with hysteroscopy, 64.3% (95% CI 13.8-99.2) with interventional radiology and systemic MTX and in 95.5% (95% CI 92.9-97.5) with curettage and hysteroscopy.When considering studies reporting a comparison between different treatments, there was no difference between systemic vs local MTX in the primary outcome. Curettage was associated with a higher chance of achieving a successful treatment. CONCLUSIONS A multitude of treatments for CSP have been reported in the published literature. All treatments described for CSP are apparently equally effective in treating this condition. The findings from this systematic review highlight the need for adopting a common definition and outcome reporting of CSP to better elucidate its natural history, estimate the magnitude of maternal complication after treatment and design appropriately powered RCT to elucidate the optimal treatment of CSP according to its ultrasound phenotype and gestational age at treatment, in terms of effective resolution of the condition and risk of post-intervention complications.
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Affiliation(s)
- Sara Alameddine
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Alessandro Lucidi
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Davor Jurkovic
- Institute for Women's Health, University College London, London, United Kingdom
| | | | - Conrado Milani Coutinho
- Department of Gynecology and Obstetrics, Hospital das Clínicas, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Ludovica Ranucci
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Danilo Buca
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
| | - Asma Khalil
- Fetal medicine Unit, St. George's University of London, UK
| | - Eric Jauniaux
- EGA Institute for Women's Health, University College London, London, UK
| | - Ilenia Mappa
- Department of Obstetrics and Gynecology, Università di Roma Tor Vergata, Rome, Italy
| | - Francesco D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, Department of Obstetrics and Gynecology, University of Chieti, Italy
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Bacila IF, Balulescu L, Dabica A, Brasoveanu S, Pirtea M, Ratiu A, Pirtea L. Laparoscopic Management of Cesarean Scar Pregnancy with Temporary Clipping of Anterior Trunk of Hypogastric Arteries: A Case Report. J Pers Med 2024; 14:469. [PMID: 38793050 PMCID: PMC11122334 DOI: 10.3390/jpm14050469] [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: 04/07/2024] [Revised: 04/25/2024] [Accepted: 04/28/2024] [Indexed: 05/26/2024] Open
Abstract
A cesarean scar ectopic pregnancy (CSP) represents an uncommon yet potentially life-threatening condition requiring immediate and efficient management. We present a case of a 32-year-old woman diagnosed with a scar pregnancy at 8 weeks of gestation. Laparoscopic surgical management was chosen due to its minimally invasive nature and potential for preserving fertility. During the procedure, temporary clipping of uterine arteries was employed to control intraoperative bleeding. The patient recovered well postoperatively with no complications. This case highlights the feasibility and effectiveness of laparoscopic intervention combined with temporary uterine artery clipping in the management of scar pregnancies, offering a valuable approach for clinicians faced with similar cases. Through this report, we aim to contribute to the existing literature on the optimal management of CSP and highlight the efficacy of laparoscopic surgery in this context.
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Affiliation(s)
| | - Ligia Balulescu
- Department of Obstetrics and Gynecology, Victor Babes University of Medicine and Pharmacy, 300041 Timisoara, Romania; (I.-F.B.); (A.D.); (S.B.); (M.P.); (A.R.); (L.P.)
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Hameed MSS, Wright A, Chern BSM. Cesarean Scar Pregnancy: Current Understanding and Treatment Including Role of Minimally Invasive Surgical Techniques. Gynecol Minim Invasive Ther 2023; 12:64-71. [PMID: 37416110 PMCID: PMC10321345 DOI: 10.4103/gmit.gmit_116_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 12/29/2022] [Accepted: 01/10/2023] [Indexed: 07/08/2023] Open
Abstract
The incidence of cesarean scar pregnancy (CSP) is increasing reflecting the global increase in cesarean section (CS) rate which has almost doubled since 2000. CSP differs from other types of ectopic pregnancy in its ability to progress while still carrying a significant risk of maternal morbidity. Little is known about precise etiology or natural history although current interest in the pathology of placenta accretes spectrum disorders might be enlightening. Early detection and treatment of CSP are challenging. Once diagnosed, the recommendation is to offer early termination of pregnancy because of the potential risks of continuing the pregnancy. However, as the likelihood of future pregnancy complications for any CSP varies depending on its individual characteristics, this might not always be necessary nor might it be the patient's preferred choice if she is asymptomatic, hemodynamically stable, and wants a baby. The literature supports an interventional rather than a medical approach but the safest and most efficient clinical approach to CSP in terms of treatment modality and service delivery has yet to be determined. This review aims to provide an overview of CSP etiology, natural history, and clinical implications. Treatment options and methods of CSP repair are discussed. We describe our experience in a large tertiary center in Singapore with around 16 cases/year where most treatment modalities are available as well as an "accreta service" for continuing pregnancies. We present a simple algorithm for approach to management including a method of triaging for those CSPs suitable for minimally invasive surgery.
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Affiliation(s)
- Mohamed Siraj Shahul Hameed
- Division of Obstetrics and Gynaecology, Department of Minimally Invasive Surgery, K. K. Women’s and Children’s Hospital, Singapore
| | - Ann Wright
- Division of Obstetrics and Gynaecology, Department of Maternal Fetal Medicine, K. K. Women’s and Children’s Hospital, Singapore
| | - Bernard Su Min Chern
- Division of Obstetrics and Gynaecology, Department of Minimally Invasive Surgery, K. K. Women’s and Children’s Hospital, Singapore
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Kakinuma T, Kakinuma K, Matsuda Y, Yanagida K, Ohwada M, Kaijima H. Efficacy of transvaginal ultrasound-guided local injections of absolute ethanol for ectopic pregnancies with intrauterine implantation sites. World J Clin Cases 2023; 11:788-796. [PMID: 36818618 PMCID: PMC9928688 DOI: 10.12998/wjcc.v11.i4.788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 12/27/2022] [Accepted: 01/12/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Cervical pregnancies, interstitial tubal pregnancies, and cesarean scar pregnancies, which are ectopic pregnancies with intrauterine implantation sites exhibit increasing trends with the recent widespread use of assisted reproductive technologies and increased rate of cesarean deliveries. The development of high-sensitivity human chorionic gonadotropin testing reagents and the increased precision of transvaginal ultrasonic tomography have made early diagnosis possible and have enabled treatment. Removal of ectopic pregnancies using methotrexate therapy and/or uterine artery embolization has been reported. However, delayed resumption of infertility treatments after methotrexate therapy is indicated, and negative effects on the next pregnancy after uterine artery embolization have been reported.
AIM To examine the efficacy and safety of ultrasound-guided topical absolute ethanol injection in ectopic pregnancies with an intrauterine implantation site.
METHODS In this study, we retrospectively examined the medical records of 21 patients who were diagnosed with an ectopic pregnancy with an intrauterine implantation site at our hospital, between April 2010 and December 2018, and underwent transvaginal ultrasound-guided local injections of absolute ethanol to determine the treatment outcomes. We evaluated the treatment methods, treatment outcomes, presence of bleeding requiring hemostasis measures and blood transfusion, complications, and treatment periods. Successful treatment was defined as the completion of treatment using transvaginal ultrasound-guided local injections of absolute ethanol alone.
RESULTS There were 21 total cases comprising 10 cervical pregnancies, 10 interstitial tubal pregnancies, and 1 cesarean scar pregnancy. All patients completed treatment with this method. No massive hemorrhaging or serious adverse reactions were observed during treatment. The mean gestation ages at the time of diagnosis were 5.9 wk (SD, ± 0.9 wk) for cervical and 6.9 wk (SD, ± 2.1 wk) for interstitial tubal pregnancies. The total ethanol doses were 4.8 mL (SD, ± 2.2 mL) for cervical pregnancies and 3.3 mL (SD, ± 2.2 mL) for interstitial pregnancies. The treatment period was 28.5 days (SD, ± 11.7 d) for cervical pregnancies and 30.0 ± 8.1 d for interstitial pregnancies. Positive correlations were observed between the blood β- human chorionic gonadotropin level at the beginning of treatment and the total ethanol dose (r = 0.75; P = 0.00008), as well as between the total ethanol dose and treatment period (r = 0.48; P = 0.026).
CONCLUSION Transvaginal ultrasound-guided local injections of absolute ethanol could become a new option for intrauterine ectopic pregnancies when fertility preservation is desired.
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Affiliation(s)
- Toshiyuki Kakinuma
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Kaoru Kakinuma
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Yoshio Matsuda
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Kaoru Yanagida
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
| | - Michitaka Ohwada
- Department of Obstetrics and Gynecology, International University of Health and Welfare Hospital, Nasushiobara 329-2763, Japan
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Tan KL, Chen YM, Zeng W, Meng Y, Jiang L. Local Methotrexate Injection Followed by Dilation and Curettage for Cesarean Scar Pregnancy: A Prospective Non-randomized Study. Front Med (Lausanne) 2022; 8:800610. [PMID: 35127758 PMCID: PMC8815728 DOI: 10.3389/fmed.2021.800610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/29/2021] [Indexed: 11/13/2022] Open
Abstract
PurposeTo evaluate the clinical effects and outcomes of local intra-gestational sac methotrexate injection followed by dilation and curettage for treatment of cesarean scar pregnancies (CSP).MethodThis prospective non-randomized study was conducted on patients diagnosed with CSP between 2018 and 2020 at the Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region. Patients were categorized into two groups according to the treatments, i.e., local intra-gestational sac methotrexate injection followed by dilation and curettage (group A), and uterine artery embolization in combination with dilation and curettage (group B). The choices of treatment reflect the patients' decision after they thoroughly understood the benefits and risks of the two therapies. Clinical data were then collected and compared between these two alternatives.ResultsSeventy-seven patients with CSP were enrolled in the study. Of this total, 41 vs. 36 were respectively categorized into group A and group B. Similar success rates were observed between these two groups (92.7 vs. 97.2%; RR = 27.362, 95% CI: 0.496–1.51E3, p = 0.106). However, the overall occurrence of complications in group A was significant lower when compared with group B (17.1 vs. 52.8%; RR = 0.236, 95% CI: 0.077–0.728, p = 0.012). Lower abdominal pain (unrelated to infection) and intrauterine adhesions were the two primary complications exhibited in group B of the present study, with rates of 38.9 and 22.2% respectively.ConclusionsLocal intra-gestational sac methotrexate injection followed by dilation and curettage is an effective and safe treatment for CSP that also drastically reduces the risks of complications. Further multiple center randomized trials with large series are warranted to confirm these findings.
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Herondelle C, Spiers A, Nyangoh-Timoh K, Thubert T, Fauconnier A, Moquet PY, Bouet PE, Legendre G. Efficacy of In Situ Methotrexate Injection in the Treatment of Nontubal Ectopic Pregnancies: A Retrospective Multicenter Study. J Minim Invasive Gynecol 2021; 29:243-249. [PMID: 34400353 DOI: 10.1016/j.jmig.2021.08.007] [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: 03/25/2021] [Revised: 08/03/2021] [Accepted: 08/09/2021] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE Evaluation of the efficacy of different injection sites of methotrexate in the treatment of nontubal ectopic pregnancies. DESIGN Retrospective multicenter study. SETTING Multicenter, including 3 teaching hospitals, an intercommunal hospital, and a clinic. PATIENTS A total of 106 patients with nontubal ectopic pregnancies, including 59 interstitial, 39 cesarean scar, and 8 cervical or isthmic. INTERVENTIONS Overall, 58 patients received methotrexate via intramuscular injection (IM group), 35 received methotrexate via in situ injection (IS group), and 13 received a combination of both in situ and intramuscular injections of methotrexate (IS + IM group). MEASUREMENTS AND MAIN RESULTS The main end point of this study was measured via the primary success rate (defined as a negative β-human chorionic gonadotropin level without recourse to any additional treatment) of treatment with methotrexate according to injection site. The primary success rate was 46.55% in the IM group, 60% in the IS group, and 61.54% in the IS + IM group, respectively. In the multivariate analysis, the primary success rate of treatment was significantly correlated to the in situ injection of methotrexate, either solely or in conjunction with an intramuscular injection of methotrexate administered the following day, (odds ratio = 2.7; 95% confidence interval, 1.03-7.14). CONCLUSION Solely an intramuscular injection of methotrexate is a less efficient first-line treatment strategy for the conservative management of nontubular ectopic pregnancy. The use of an in situ injection of methotrexate should therefore be preferred.
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Affiliation(s)
- Charlyne Herondelle
- Department of Obstetrics and Gynecology, Angers University Hospital (Drs. Herondelle, Bouet, and Legendre and Mr. Spiers), Angers; Department of Obstetrics and Gynecology, Nantes University Hospital (Drs. Herondelle and Thubert), Nantes
| | - Andrew Spiers
- Department of Obstetrics and Gynecology, Angers University Hospital (Drs. Herondelle, Bouet, and Legendre and Mr. Spiers), Angers
| | - Krystel Nyangoh-Timoh
- Department of Obstetrics and Gynecology, Rennes University Hospital (Dr. Nyangoh-Timoh)
| | - Thibault Thubert
- Department of Obstetrics and Gynecology, Nantes University Hospital (Drs. Herondelle and Thubert), Nantes
| | - Arnaud Fauconnier
- Department of Obstetrics and Gynecology, Intercommunal Hospital of Poissy/Saint-Germain-en-Laye (Dr. Fauconnier), Poissy
| | - Pierre-Yves Moquet
- Department of Obstetrics and Gynecology, La Sagesse Clinic (Dr. Moquet), Rennes
| | - Pierre-Emmanuel Bouet
- Department of Obstetrics and Gynecology, Angers University Hospital (Drs. Herondelle, Bouet, and Legendre and Mr. Spiers), Angers
| | - Guillaume Legendre
- Department of Obstetrics and Gynecology, Angers University Hospital (Drs. Herondelle, Bouet, and Legendre and Mr. Spiers), Angers; CESP UMR Inserm 1018 - Center for Research in Epidemiology and Public Health (Dr. Legendre), Villejuif, France.
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Yüksel Şimşek S, Şimşek E, Alkaş Yağınç D, Baran ŞY, Çok T, Bulgan Kılıçdağ E. Outcomes of cesarean scar pregnancy treatment: Do we have options? Turk J Obstet Gynecol 2021; 18:85-91. [PMID: 34082520 PMCID: PMC8191324 DOI: 10.4274/tjod.galenos.2021.77535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: To investigate the success and complications of medical and surgical modalities used in the treatment of cesarean scar pregnancies. Materials and Methods: Medical and surgical approaches that have been used to treat cesarean scar pregnancies were evaluated retrospectively, Local, systemic, and combined methotrexate treatments were grouped as the medical approach, and dilatation and evacuation, hysteroscopic resection, laparoscopic and laparotomic approaches were grouped as the surgical approach. Fifty-three patients were diagnosed as having cesarean scar pregnancy during the study period, 48 of whom were included in the final analysis. Eighteen patients were treated with medical interventions and 30 patients were treated surgically. Results: The success rate of surgical modalities was 96.6% and the medical treatment success was 33% (p<0.001). The complication rate was higher with medical approaches compared with surgical methods (66% vs 3.3%, respectively; p<0.001). Conclusion: Surgical intervention seems safer and more successful than medical treatment.
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Affiliation(s)
- Seda Yüksel Şimşek
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Erhan Şimşek
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Didem Alkaş Yağınç
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Şafak Yılmaz Baran
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Tayfun Çok
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
| | - Esra Bulgan Kılıçdağ
- Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Research and Application Center, Clinic of Obstetrics and Gynecology, Adana, Turkey
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Po L, Thomas J, Mills K, Zakhari A, Tulandi T, Shuman M, Page A. Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:614-630.e1. [PMID: 33453378 DOI: 10.1016/j.jogc.2021.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. TARGET POPULATION All patients of reproductive age. BENEFITS, HARMS, AND COSTS The implementation of this guideline aims to benefit patients with positive β-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. EVIDENCE The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE Obstetrician-gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES) RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
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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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Dong Y, Ni H, Shen J, Fang Y. Investigation of the clinical efficacy of transvaginal and laparoscopic surgery in the treatment of type II cesarean section scar pregnancy and its effect on postoperative rehabilitation. Minerva Surg 2021; 76:482-483. [PMID: 33890446 DOI: 10.23736/s2724-5691.21.08867-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Yujun Dong
- Department of Gynecology, Shaoxing Central Hospital, Shaoxing, China -
| | - Huijuan Ni
- Department of Gynecology, Shaoxing Central Hospital, Shaoxing, China
| | - Jiali Shen
- Department of Gynecology, Shaoxing Central Hospital, Shaoxing, China
| | - Yaqin Fang
- Department of Gynecology, Shaoxing Central Hospital, Shaoxing, China
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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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Mosconi C, Crocetti L, Bruno A, Candita G, Cappelli A, Perrone O, Golfieri R, Cioni R. Scar Pregnancy and Extrauterine Implants. Semin Ultrasound CT MR 2021; 42:46-55. [PMID: 33541589 DOI: 10.1053/j.sult.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cesarean scar pregnancy (CSP) is a rare occurrence consisting in the implantation of the embryo within the myometrium of a prior cesarean delivery scar. The CSP could be a dangerous condition for women because of the related complications such as placenta previa or accreta, uterine rupture, and hemorrhage. Therefore, early diagnosis and rapid treatment are crucial. Extrauterine implants or ectopic pregnancy (EP) consists in the implantation of an embryo in a site other than the endometrium of the uterine cavity. It occurs in 1%-2% of all reported pregnancies. The most common extrauterine location is the fallopian tube, which represents 96% of cases. The diagnosis of CSP and EP is based on history, clinical examination, levels of serum β-human chorionic gonadotropin (β-hCG), and ultrasonography findings. In last 20 years, new treatments were developed, varying from medical management, minimally invasive surgical approach and local treatment including systemic or local infusion of metotrexate (MTX), and uterine artery embolization (UAE). UAE has been used widely to control hemorrhage and preserve the uterus and it is considered an affective adjuvant treatment of CSP and EP, especially associated with other therapies.
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Affiliation(s)
- Cristina Mosconi
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Laura Crocetti
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy.
| | - Antonio Bruno
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Gianvito Candita
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Alberta Cappelli
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Orsola Perrone
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - Rita Golfieri
- Radiology Unit, Department of Specialized, Diagnostic and Experimental Medicine - DIMES, Alma Mater Studiorum - University of Bologna, University Hospital of Bologna Sant'Orsola-Malpighi Polyclinic, Bologna, Italy
| | - Roberto Cioni
- Diagnostic and Interventional Radiology, Imaging Department, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
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Po L, Thomas J, Mills K, Zakhari A, Tulandi T, Shuman M, Page A. Directive clinique n o 414 : Prise en charge des grossesses de localisation indéterminée et des grossesses ectopiques tubaires et non tubaires. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 43:631-649.e1. [PMID: 33453377 DOI: 10.1016/j.jogc.2021.01.001] [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: 10/22/2022]
Abstract
OBJECTIF Fournir un algorithme fondé sur des données probantes pour orienter le diagnostic et la prise en charge de la grossesse de localisation indéterminée et de la grossesse ectopique tubaire ou non tubaire. POPULATION CIBLE Toutes les patientes en âge de procréer. BéNéFICES, RISQUES ET COûTS: La mise en œuvre de la présente directive a pour objectif de bénéficier aux patientes ayant obtenu un résultat positif pour la sous-unité bêta de la gonadotrophine chorionique et de fournir aux médecins un algorithme normalisé pour l'expectative et le traitement pharmacologique ou chirurgical en cas de grossesse de localisation indéterminée et de grossesse ectopique tubaire ou non tubaire. DONNéES PROBANTES: Les termes de recherche suivants ont été entrés dans les bases de données PubMed-Medline et Cochrane en 2018 : cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography et prenatal. Les articles retenus sont des essais cliniques randomisés, des méta-analyses, des revues systématiques, des études observationnelles et des études de cas. Des publications supplémentaires ont été sélectionnées à partir des notices bibliographiques de ces articles. Seuls les articles en anglais ont été examinés. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la solidité des recommandations en utilisant la méthodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PUBLIC VISé: Obstétriciens-gynécologues, médecins de famille, urgentologues, sages-femmes, infirmières autorisées, infirmières praticiennes, étudiants en médecine, résidents et moniteurs cliniques. DÉCLARATIONS SOMMAIRES (CLASSEMENT GRADE ENTRE PARENTHèSES): RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).
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Salari N, Kazeminia M, Shohaimi S, Nankali AAD, Mohammadi M. Evaluation of treatment of previous cesarean scar pregnancy with methotrexate: a systematic review and meta-analysis. Reprod Biol Endocrinol 2020; 18:108. [PMID: 33168010 PMCID: PMC7650162 DOI: 10.1186/s12958-020-00666-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 10/30/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Previous caesarean scar pregnancy is one type of ectopic pregnancy in myometrium and fibrous tissue of previous caesarean scar. One of the therapeutic methods of this type of ectopic pregnancy is treatment with methotrexate. Given various findings on the treatment of caesarean scar pregnancy with methotrexate and lack of global report in this regard, we aimed to achieve a global report on the treatment of CSP with methotrexate through related literature review and analysis of the results of the studies, to enable more precise planning to reduce complications of CSP. METHOD This review study extracted information through searching national and international databases of SID،, Embase, ScienceDirect, ، Scopus, ، PubMed, Web of Science (ISI) between 2003 and January 2020. To perform the meta-analysis, random-effects model and heterogeneity of the studies with I2 index were investigated. Data were sanalysed using Comprehensive Meta-Analysis version 2. RESULTS In total, 26 articles with a sample size of 600 individuals were enrolled in the meta-analysis. According to the results of the study, the mean level of β-hCG was 28,744.98 ± 4425.1 mIU/ml before the intervention and was 23,836.78 ± 4533.1 mIU/ml after the intervention. The mean intraoperative blood loss (ml) was 4.8 ± 3.76 ml, mean hospital stay (days) was 11.7 ± 1.2 days, mean time for serum-hCG normalization (days) was 41.6 ± 3.2 days, success was 90.7% (95% CI: 86.7-93.5%), and complication was 9% (95% CI: 6.3-12.8%). CONCLUSION The results of the current study show methotrexate significantly reduces β-hCG levels and can be effective in treating caesarean scar pregnancy and its complications.
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Affiliation(s)
- Nader Salari
- grid.412112.50000 0001 2012 5829Department of Biostatistics, School of Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
- grid.412112.50000 0001 2012 5829Sleep Disorders Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Mohsen Kazeminia
- grid.412112.50000 0001 2012 5829Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shamarina Shohaimi
- grid.11142.370000 0001 2231 800XDepartment of Biology, Faculty of Science, Universiti Putra Malaysia, Serdang, Selangor Malaysia
| | - Anis al-Dawlah Nankali
- grid.412112.50000 0001 2012 5829Department of Obstetrics and Gynecology, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Masoud Mohammadi
- grid.412112.50000 0001 2012 5829Department of Nursing, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Huang L, Zhao L, Shi H. Clinical Efficacy of Combined Hysteroscopic and Laparoscopic Surgery and Reversible Ligation of the Uterine Artery for Excision and Repair of Uterine Scar in Patients with Type II and III Cesarean Scar Pregnancy. Med Sci Monit 2020; 26:e924076. [PMID: 32595205 PMCID: PMC7341695 DOI: 10.12659/msm.924076] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background With the changes in China’s family planning policy, the incidence of cesarean scar pregnancy (CSP) significantly increased in recent years. The present study aimed to investigate the clinical efficacy of combined hysteroscopic and laparoscopic surgery and reversible ligation of the uterine artery for cesarean scar excision and repair in patients with type II and III CSP. Material/Methods This was a retrospective study of 173 patients with type II and III CSP. They were assigned to the hysteroscopy and laparoscopy group (group A), hysteroscopy group (group B), and curettage group (group C) according to the surgery they underwent. The surgical indicators (intraoperative bleeding volume and hospital stay), postoperative recovery (time of serum β-hCG returning to the normal, postoperative residual lesion, the thickness of the uterine scar, and recovery time of menstruation), and the postoperative complications were compared among the 3 groups. Results In patients with type II and III CSP, significant differences (P<0.05) were observed between group A vs. groups B and C in terms of the time of serum β-HCG returning to normal, postoperative residual lesions, the thickness of the uterine scar, and recovery time of menstruation, while there were no significant differences in intraoperative bleeding volume and postoperative hospital stay (P>0.05). Conclusions For patients with type II and III CSP, hysteroscopy and laparoscopy surgery and reversible ligation of the uterine artery achieved better clinical outcomes than hysteroscopy or curettage with respect to postoperative recovery. This could be suitable for patients with CSP and desire for fertility.
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Affiliation(s)
- Lina Huang
- Department of Obstetrics and Gynecology, Ningbo Women's and Children's Hospital, Ningbo, Zhejiang, China (mainland)
| | - Lingjun Zhao
- Department of Obstetrics and Gynecology, Ningbo Women's and Children's Hospital, Ningbo, Zhejiang, China (mainland)
| | - Huiwei Shi
- Department of Obstetrics and Gynecology, Ningbo Women's and Children's Hospital, Ningbo, Zhejiang, China (mainland)
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Tan KL, Jiang L, Chen YM, Meng Y, Lv BQ, Wei LF, Peng XZ, Ling YY, Lan J, Wei JY. Local intra-gestational sac methotrexate injection followed by dilation and curettage in treating cesarean scar pregnancy. Arch Gynecol Obstet 2020; 302:439-445. [DOI: 10.1007/s00404-020-05619-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/26/2020] [Indexed: 12/14/2022]
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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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Li Q, Xu H, Wang Y, Liu Q, He P, Wang L. Ultrasound-guided local methotrexate treatment for cesarean scar pregnancy in the first trimester: 12 years of single-center experience in China. Eur J Obstet Gynecol Reprod Biol 2019; 243:162-167. [DOI: 10.1016/j.ejogrb.2019.10.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 09/28/2019] [Accepted: 10/20/2019] [Indexed: 01/06/2023]
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Cesarean scar pregnancy managed with local and systemic methotrexate: A single center case series. Eur J Obstet Gynecol Reprod Biol 2019; 238:138-142. [DOI: 10.1016/j.ejogrb.2019.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 05/11/2019] [Accepted: 05/13/2019] [Indexed: 11/19/2022]
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Fatusic J, Hudic I, Zildzic-Moralic A, Hadziefendic B. Cesarean Scar Pregnancy Complicated with Placenta Percreta. Med Arch 2019; 73:58-60. [PMID: 31097863 PMCID: PMC6445621 DOI: 10.5455/medarh.2019.73.58-60] [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] [Indexed: 12/02/2022] Open
Abstract
Introduction: Cesarean scar pregnancy is potentially life-threatening condition because of heavy complications and includes adherent placenta: accreta, increta or percreta as a result of deep placental invasion. Aim: To present a rare case of ectopic cesarean scar pregnancy combined with placenta percreta in 38-year old woman who undergone previous cesarean section delivery. Case report: A multiparous woman aged 38 years with prior cesarean section delivery, admitted first time to the Clinic in 7th week of gestation, due to her medical record (light bleeding). Diagnosis was: graviditas hbd 7, gemellar pregnancy, blighted ovum gemellus I, graviditas isthmico-cervicalis gemellus II. Due to diagnosis it was performed vacuum aspiration et curettage and woman leaved hospital same day. One month later same woman was admitted again to the Clinic due to bleeding and ultrasound finding suspicious to residual trophoblastic tissue. Beta human chorionic gonadotropin serum concentration at the day of admittance was 8,419 IU/ml. Ultrasound finding showed inhomogeneous supracervical formation with dimension 2,73x1,89 cm with increased vascularity and resistant index 0.36 and suspicious placenta increta. We made decision to surgery, and performed hysterectomy in view of heavy intraoperative haemorrhage. Woman was discharged at fifth day after surgery in good condition. Histological finding showed cervical pregnancy complicated with placenta percreta parietis isthmicocervicalis of the uterus. Conclusion: We showed the importance of early and opportune diagnosis of cervical pregnancy specially complicated with one of kind of throphoblastic disease, to prevent life-threatening complication.
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Affiliation(s)
- Jasenko Fatusic
- Department of Gynecology, Clinic for Gynecology and Obstetrics, University Clinical Center, Tuzla, Bosnia and Herzegovina
| | - Igor Hudic
- Department of Gynecology, Clinic for Gynecology and Obstetrics, University Clinical Center, Tuzla, Bosnia and Herzegovina
| | - Alma Zildzic-Moralic
- Department of Obstetrics and Gynecology, Health Care Center, Doboj, Bosnia and Herzegovina
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Tahaoglu AE, Dogan Y, Bakir MS, Baglı I, Peker N, Cavus Y, Togrul C, Tahaoglu Z. A single centre’s experience of caesarean scar pregnancy and proposal of a management algorithm. J OBSTET GYNAECOL 2018; 39:259-264. [DOI: 10.1080/01443615.2018.1499714] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Ali Emre Tahaoglu
- Department of Obstetrics and Gynecology, University of Health Sciences Gazi Yasargil Research and Training Hospital, Diyarbakir, Turkey
| | - Yasemin Dogan
- Department of Obstetrics and Gynecology, University of Health Sciences Gazi Yasargil Research and Training Hospital, Diyarbakir, Turkey
| | - Mehmet Sait Bakir
- Department of Obstetrics and Gynecology, University of Health Sciences Gazi Yasargil Research and Training Hospital, Diyarbakir, Turkey
| | - Ihsan Baglı
- Department of Obstetrics and Gynecology, University of Health Sciences Gazi Yasargil Research and Training Hospital, Diyarbakir, Turkey
| | - Nurullah Peker
- Department of Obstetrics and Gynecology, University of Health Sciences Gazi Yasargil Research and Training Hospital, Diyarbakir, Turkey
| | - Yunus Cavus
- Department of Obstetrics and Gynecology, University of Health Sciences Gazi Yasargil Research and Training Hospital, Diyarbakir, Turkey
| | - Cihan Togrul
- Department of Obstetrics and Gynecology, University of Health Sciences Gazi Yasargil Research and Training Hospital, Diyarbakir, Turkey
| | - Zelal Tahaoglu
- Department of Obstetrics and Gynecology, University of Health Sciences Gazi Yasargil Research and Training Hospital, Diyarbakir, Turkey
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Liu D, Yang M, Wu Q. Application of ultrasonography in the diagnosis and treatment of cesarean scar pregnancy. Clin Chim Acta 2018; 486:291-297. [PMID: 30102898 DOI: 10.1016/j.cca.2018.08.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 12/21/2022]
Abstract
The morbidity of cesarean scar pregnancy (CSP) has shown an obvious ascending tendency with the increase of cesarean delivery in China and other countries. The timely diagnosis and treatment of CSP currently relies on medical imaging technology. In this article, we analyzed and compare the imaging methods in diagnosis of CSP. The imaging methods to diagnose CSP include traditional two-dimensional color/power Doppler ultrasound (2D-US), three-dimensional color/power Doppler ultrasound (3D-US), contrast-enhanced ultrasound (CEUS), and Magnetic Resonance Imaging (MRI). 2D-US provides important information including the location and size of gestational sac (GS), embryo with or without heart activity, and the relationship between the GS and scar. It can also divide CSP into different types, which are convenient for the choice of clinical treatment. CEUS can observe the perfusion of CSP in real-time, the arrival time of GS in CSP is earlier than that of the myometrium. It provides reliable evidence for diagnosis and evaluation of the treatment of CSP, which is helpful for making treatment plans and post-treatment follow-up. Combined use of ultrasound and CEUS could be a problem-solving method for CSP when conventional ultrasound is often inconclusive. Ultrasound has been accepted as the first-line imaging method and an important guiding method for CSP, supervising local methotrexate injection and curettage.
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Affiliation(s)
- Dongmei Liu
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China
| | - Min Yang
- Department of Ultrasound, Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, China
| | - Qingqing Wu
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China.
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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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Docheva N, Slutsky ED, Borella N, Mason R, Van Hook JW, Seo-Patel S. The Rising Triad of Cesarean Scar Pregnancy, Placenta Percreta, and Uterine Rupture: A Case Report and Comprehensive Review of the Literature. Case Rep Obstet Gynecol 2018; 2018:8797643. [PMID: 29984018 PMCID: PMC6011134 DOI: 10.1155/2018/8797643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 04/26/2018] [Indexed: 11/23/2022] Open
Abstract
As the rate of cesarean sections continues to rapidly rise, knowledge of diagnosis and management of cesarean scar pregnancies (CSPs) is becoming increasingly more relevant. CSPs rest on the continuum of placental abnormalities which include morbidly adherent placenta (accreta, increta, and percreta). A CSP poses a clinical challenge which may have significant fetal and maternal morbidity. At this point, no clear management guidelines and recommendations exist. Herein we describe the case of a second trimester CSP with rapid diagnosis and management in a tertiary care center. The case underscores the need for well-coordinated mobilization of resources and a multidisciplinary approach. A review of the literature is performed and deficits in universal management principles are underscored.
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Affiliation(s)
- Nikolina Docheva
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Emily D. Slutsky
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Nicolette Borella
- Mercyhurst University, Department of Biology, Eerie, Pennsylvania, USA
| | - Renee Mason
- Promedica Physicians Obstetrics-Gynecology, Maumee, Ohio, USA
| | - James W. Van Hook
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Sonyoung Seo-Patel
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
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Uludag SZ, Kutuk MS, Dolanbay M, Ozgun MT, Eliyeva G, Altun O. Conservative management of interstitial pregnancies: experience of a single centre. J OBSTET GYNAECOL 2018. [DOI: 10.1080/01443615.2017.1417979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Semih Zeki Uludag
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Mehmet Serdar Kutuk
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Mehmet Dolanbay
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Mahmut Tuncay Ozgun
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Gunel Eliyeva
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Ozguc Altun
- Departments of Obstetrics & Gynecology, Kayseri Education & Research Hospital, Kayseri, Turkey
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Song JW, Ju DH, Yi SW, Lee JH, Sohn WS, Lee SS. A large intrauterine vascular lesion developing after the successful treatment of a cesarean scar pregnancy with methotrexate injection. JOURNAL OF CLINICAL ULTRASOUND : JCU 2018; 46:222-226. [PMID: 28440862 DOI: 10.1002/jcu.22490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 02/27/2017] [Accepted: 03/22/2017] [Indexed: 06/07/2023]
Abstract
A cesarean scar pregnancy is a rare type of ectopic pregnancy. Induced abortion by local methotrexate (MTX) injection is an effective management approach. We describe a case in which a large intrauterine vascular lesion appeared after the sonographic-guided local injection of MTX, which successfully induced the abortion of the cesarean scar pregnancy. Although a cesarean scar pregnancy may be safely treated with a local MTX injection, close follow-up, including serum β-human chorionic gonadotropin level measurement and Doppler sonography, is needed because an intrauterine vascular lesion could develop even after a successfully induced abortion. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:222-226, 2018.
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Affiliation(s)
- Ji Won Song
- Department of Obstetrics and Gynecology, Seoul Asan Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Da Hye Ju
- Department of Obstetrics and Gynecology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sang Wook Yi
- Department of Obstetrics and Gynecology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Joo Hee Lee
- Department of Obstetrics and Gynecology, Seoul Asan Hospital, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Seok Sohn
- Department of Obstetrics and Gynecology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Sang Soo Lee
- Department of Obstetrics and Gynecology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
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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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Cesarean Scar Pregnancy: A Systematic Review. J Minim Invasive Gynecol 2017; 24:731-738. [DOI: 10.1016/j.jmig.2017.02.020] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/22/2017] [Accepted: 02/24/2017] [Indexed: 12/24/2022]
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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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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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Zhang H, Shi J, Yang Y, Liang Y, Gao X, Wang J, Liu H, Wu B, Zhao J. Transvaginal Surgical Management of Cesarean Scar Pregnancy II (CSP-II): An Analysis of 25 Cases. Med Sci Monit 2015; 21:3320-6. [PMID: 26520674 PMCID: PMC4634161 DOI: 10.12659/msm.893776] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the feasibility and clinical value of transvaginal surgical treatment for cesarean scar pregnancy (CSP-II). MATERIAL AND METHODS This study was a retrospective analysis of 25 CSP-II patients who received transvaginal surgical treatments. These patients were admitted in our hospital between January 2010 and June 2012. RESULTS All surgical treatments were successful without overt complications. The average operation time was 61.5 minutes, the average intraoperative blood loss was 60.5 ml, the average hospital stay was 9.4 days and the average time that blood β-human chorionic gonadotropin (β-HCG) returned to normal range was 15 days. In all 25 patients, the cesarean scar mass located at the anterior wall of the lower uterine segment disappeared by B-ultrasound examination within 1 or 2 weeks after surgery. Postoperatively, the normal menstrual period started again with an average time of 28.9 days. No menstruation-related abnormalities, such as menstrual dripping or an abnormal amount of blood, were reported after surgery. CONCLUSIONS Transvaginal surgery for CSP-II is a novel surgical approach. It has several advantages, including a thorough one-time treatment lesion clearance, short operation time, minimized trauma, minimal intraoperative blood loss, quick reduction of blood β-HCG, and rapid menstruation recovery. It is a simple and feasible surgical approach of great clinical value and few treatment-related complications.
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Affiliation(s)
- Hui Zhang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Hebei University, Baoding, Hebei, China (mainland)
| | - Junrong Shi
- Department of Obstetrics and Gynecology, Affiliated Hospital of Hebei University, Baoding, Hebei, China (mainland)
| | - Yong'An Yang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Hebei University, Baoding, Hebei, China (mainland)
| | - Yijuan Liang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Hebei University, Baoding, Hebei, China (mainland)
| | - Xinping Gao
- Department of Obstetrics and Gynecology, Affiliated Hospital of Hebei University, Baoding, Hebei, China (mainland)
| | - Jing Wang
- Department of Obstetrics and Gynecology, Affiliated Hospital of Hebei University, Baoding, Hebei, China (mainland)
| | - Hui Liu
- Department of Obstetrics and Gynecology, Affiliated Hospital of Hebei University, Baoding, Hebei, China (mainland)
| | - Bingge Wu
- Department of Ophthalmology, Baotou Eighth Hospital, Baotou, Inner Mongolia, China (mainland)
| | - Jinhui Zhao
- Department of Obstetrics and Gynecology, Affiliated Hospital of Hebei University, Baoding, Hebei, China (mainland)
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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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Shokeir T. Methotrexate Treatment for Cesarean Scar Ectopic Pregnancy: Learning Lessons. J Minim Invasive Gynecol 2015; 22:1116. [PMID: 25989280 DOI: 10.1016/j.jmig.2015.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
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