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Lutfi A, Hayes-Ryan D, Cottrell E, Greene RA. Systemic methotrexate (MTX) in early pregnancy: a retrospective study of a tertiary maternity hospital. Ir J Med Sci 2024:10.1007/s11845-024-03748-9. [PMID: 38980553 DOI: 10.1007/s11845-024-03748-9] [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: 08/29/2023] [Accepted: 06/30/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Methotrexate (MTX) is used in clinical practice as a medical treatment option in patients with early pregnancy complications like ectopic pregnancy. AIMS To review systemic MTX therapy use in the first trimester of pregnancy in our hospital and to examine subsequent clinical outcomes. METHODS Retrospective review of all women treated with systemic MTX in early pregnancy identified from electronic prescription records from 1 January 2018 to 31 December 2020 at Cork University Maternity Hospital, Ireland. Relevant data was transcribed from electronic health records. RESULTS Indications for treatment were tubal ectopic pregnancy (70%, n = 51), persistent pregnancy of unknown location (22%, n = 16) and caesarean scar pregnancy (7%, n = 5). Treatment was successful in 88% (n = 44) of tubal ectopic pregnancies with 73% (n = 37) and 14% (n = 7) of women receiving a single dose and repeated doses, respectively. Only 8% (n = 4) of tubal ectopic pregnancies required emergency surgery for subsequent tubal rupture. In 93% (n = 15) of cases of persistent pregnancy of unknown location, treatment was successful with one patient requiring uterine evacuation. Women with caesarean scar pregnancy were treated with combined MTX and uterine evacuation without complication. CONCLUSIONS The efficacy of medical treatment with systemic MTX for confirmed tubal ectopic pregnancy in our hospital is in line with national and international standards. Careful consideration should be given to treating caesarean scar pregnancy and persistent pregnancy of unknown location with systemic MTX. Systemic MTX use guided by clinicians specialised in early pregnancy complications and safe medication practices may improve treatment success and reduce adverse events.
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Affiliation(s)
- Ahmed Lutfi
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland.
| | - Deirdre Hayes-Ryan
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
- Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
- Department of Obstetrics and Gynaecology, National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | | | - Richard A Greene
- Department of Obstetrics and Gynaecology, Cork University Maternity Hospital, Cork, Ireland
- Department of Obstetrics and Gynaecology, National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
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2
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Shoai BB, Gibbs L, Leonis R. Cesarean Scar Pregnancy With Surgical and Conservative Managements: A Case Report. Cureus 2024; 16:e61311. [PMID: 38947697 PMCID: PMC11212840 DOI: 10.7759/cureus.61311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 07/02/2024] Open
Abstract
A cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. Proper diagnosis and management of CSP are incredibly important secondary to the risk of uterine rupture and life-threatening hemorrhage. Various medical and surgical management have been described previously. This report looks at two cases of CSP diagnosed at an urban hospital in Atlanta, Georgia. The first woman was 30 years old with a history of five prior CS. She was referred from an abortion clinic for CSP at 6 weeks 2 days gestation. She did not desire future fertility and opted for a hysterectomy. The second woman was 38 years old with a history of three prior CS presenting with vaginal bleeding and abdominal pain and found to have a CSP with a gestation sac measuring 5 weeks 1 day. Given the patient's desires for future fertility, she was treated with a two-dose regimen of systemic intramuscular methotrexate (MTX) at 1 mg/kg with successful resolution of CSP and subsequent intrauterine pregnancy. Due to the high risk of uterine rupture and hemorrhage with CSP, it is important to have a high index of suspicion for diagnosis. Due to the rarity of CSP, and thus difficulty creating quality prospective trials, there is no consensus on the best management yet. Although conservative treatment carries high failure risk, shared decision-making incorporating future fertility desires should be considered when determining management of CSP, and when surgical management is considered a minimally invasive approach should be the standard of care in surgical management.
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Affiliation(s)
- Banafsheh B Shoai
- Obstetrics and Gynecology, Morehouse School of Medicine, Atlanta, USA
| | - Lauren Gibbs
- Obstetrics and Gynecology, Morehouse School of Medicine, Atlanta, USA
| | - Regina Leonis
- Obstetrics and Gynecology, Morehouse School of Medicine, Atlanta, USA
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3
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Verma M, Chauhan M, Malhotra V, Chaudhary S, Singh P, Mahaych R. Caesarean scar ectopic pregnancy: A case series. Trop Doct 2024; 54:35-38. [PMID: 37822254 DOI: 10.1177/00494755231206417] [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] [Indexed: 10/13/2023]
Abstract
Caesarean scar ectopic pregnancy (CSEP) is a uncommon presentation of pregnancy with incidence of nearly 1 in 2000 pregnancies. We present this case series of scar pregnancy with a objective to help obstetricians in early diagnosis and appropriate management to prevent its catastrophic complications.
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Affiliation(s)
- Menka Verma
- Assistant Professor, Department of Obstetrics and Gynaecology, Pt. B. D. Sharma PGIMS, Rohtak, India
| | - Meenakshi Chauhan
- Senior Professor, Department of Obstetrics and Gynaecology, Pt. B. D. Sharma PGIMS, Rohtak, India
| | - Vani Malhotra
- Professor, Department of Obstetrics and Gynaecology, Pt. B. D. Sharma PGIMS, Rohtak, India
| | - Sushila Chaudhary
- Professor, Department of Obstetrics and Gynaecology, Pt. B. D. Sharma PGIMS, Rohtak, India
| | - Parul Singh
- Associate Professor, Department of Obstetrics and Gynaecology, Pt. B. D. Sharma PGIMS, Rohtak, India
| | - Ravi Mahaych
- Junior Resident, Department of Obstetrics and Gynaecology, Pt. B. D. Sharma PGIMS, Rohtak, India
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4
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Wu BT, Feld Z, Creinin MD. Management of cesarean scar ectopic pregnancies at an academic referral center: A case series. Contraception 2023; 123:110021. [PMID: 36940910 DOI: 10.1016/j.contraception.2023.110021] [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: 12/06/2022] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 03/22/2023]
Abstract
OBJECTIVES To describe treatment and outcomes of patients with confirmed cesarean scar ectopic pregnancy (CSEP) at a tertiary referral center. STUDY DESIGN We reviewed a deidentified family planning clinical database for patients seen by our subspecialty service for CSEP from January 2017 through December 2021 in this case series. We extracted referral information, final diagnosis, management, and outcome measures including estimated blood loss, secondary procedures, and treatment complications. RESULTS Of 57 cases referred for suspected CSEPs, 23 (40%) had confirmed diagnoses; one additional case was diagnosed during clinic evaluation for early pregnancy loss. Most (n = 50 [88%]) referrals occurred in the last 2 years of the 5-year study period. Of 24 confirmed CSEP cases, eight were pregnancy losses at the time of diagnosis. Fourteen cases were ≤50 days gestation or gestational size (7 [50%] pregnancy losses) and 10 >50 days gestation (range 39-66 days). We treated all 14 patients ≤50 days primarily with suction aspiration under ultrasound guidance in an operating room with no complications and estimated blood loss of 14 ± 10 mL. Of the 10 patients>50 days (maximum 66 days), seven were managed with primary aspiration of which five were uncomplicated. We treated one patient (57 days) had primary intrauterine double-catheter balloon with immediate hemorrhage requiring uterine artery embolization followed by an uncomplicated suction aspiration. CONCLUSIONS Patients with confirmed CSEPs at 50 days or less gestation or gestational size can likely be primarily treated with suction aspiration with low risk for significant adverse outcomes. Treatment success and complications are directly related to gestational age at treatment. IMPLICATIONS Ultrasound-guided suction aspiration monotherapy should be considered for primary CSEP treatment up to 50 days and, with continued experience, may be reasonable beyond 50 days gestation. Invasive treatments or those that require multiple days and visits, such as methotrexate or balloon catheters, are not necessary for early CSEPs.
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Affiliation(s)
- Brenda T Wu
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Zoe Feld
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA.
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5
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Nijjar S, Jauniaux E, Jurkovic D. Surgical evacuation of cesarean scar ectopic pregnancies. Best Pract Res Clin Obstet Gynaecol 2023; 89:102361. [PMID: 37356118 DOI: 10.1016/j.bpobgyn.2023.102361] [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: 04/01/2023] [Revised: 04/13/2023] [Accepted: 05/02/2023] [Indexed: 06/27/2023]
Abstract
Cesarean scar ectopic pregnancy is associated with significant maternal morbidity, including severe hemorrhage, need for the blood transfusion and hysterectomy. Early diagnosis is therefore key in ensuring timely management, with consensus being that treatment before 9 weeks of gestation leads to reduced morbidity. There is no universally adopted management protocol for cesarean scar ectopic pregnancy, but surgical management generally has a higher success rate than medical management. The primary surgical treatment modalities are suction evacuation versus resection of the pregnancy via multiple routes. Adjuncts that have been shown to successfully minimize bleeding with surgical management include cervical cerclage, balloon catheter, and uterine artery embolization. However, there remains a lack of high-quality evidence regarding what is the best surgical treatment option for cesarean scar ectopic pregnancy, and therefore it is essential that clinicians provide tailored management to patients considering the presenting symptoms and local expertise with various surgical techniques.
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Affiliation(s)
- Simrit Nijjar
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Davor Jurkovic
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
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6
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Kusumo F, Adegoke OA, Guelfguat M. Reprint of: Twin live gestation in a cesarean section scar ectopic pregnancy. Dis Mon 2022; 68:101380. [PMID: 35483976 DOI: 10.1016/j.disamonth.2022.101380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/08/2020] [Indexed: 10/18/2022]
Affiliation(s)
- Faiz Kusumo
- Jacobi Medical Center, Department of Radiology, Albert Einstein College of Medicine, USA
| | - Oluwakemi A Adegoke
- Jacobi Medical Center, Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, USA
| | - Mark Guelfguat
- Jacobi Medical Center, Department of Radiology, Albert Einstein College of Medicine, 1400 South Pelham Parkway, Building 1, Room 4N15, Bronx, NY, 10461, USA.
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7
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Toh J, Deussen A, Yasin N, Skubisz M, Dodd J. Cesarean scar ectopic pregnancies - a retrospective case series at an Australian tertiary referral center. Int J Gynaecol Obstet 2022; 159:771-775. [PMID: 35304736 DOI: 10.1002/ijgo.14183] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/10/2022] [Accepted: 03/16/2022] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To review the management, success, and complication rates of women who presented with a cesarean scar ectopic pregnancy at an Australian tertiary referral center. METHODS A retrospective case series was undertaken. Patients were identified through the hospital's clinical information services coding system and data were collected from medical records. RESULTS A total of 38 cases were identified. Patients who were hemodynamically stable were predominantly managed according to local expertise via intramuscular, intra-sac methotrexate or a combination of these two. In some cases, surgical management was preferred. CONCLUSION Cesarean scar ectopic pregnancy may be managed both surgically and medically. At institutions where surgical expertise is unavailable, medical management would be valuable with few adverse outcomes identified, provided women have closely monitored follow-up.
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Affiliation(s)
- Justine Toh
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Andrea Deussen
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Nooraishah Yasin
- Women's and Children's Hospital, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Monika Skubisz
- Women's and Children's Hospital, Adelaide, South Australia, Australia.,Healthy Mothers, Babies and Children Theme, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Jodie Dodd
- Women's and Children's Hospital, Adelaide, South Australia, Australia
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8
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Cesarean scar pregnancy management: Different approach for different situation; A case series. Ann Med Surg (Lond) 2021; 70:102808. [PMID: 34603714 PMCID: PMC8463825 DOI: 10.1016/j.amsu.2021.102808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/23/2022] Open
Abstract
The incidence of caesaean scar pregnancy (CSP) increases since the cesarean delivery rate had increased as well. Diagnosing of CSP was also a challenge to identify the type of CSP which important things for choosing the right management. The CSP could be classified into two types, which are endogenous and exogenous. While the management was dependent into the types, such as suction curettage, resection, and also hysterectomy. This paper showed cases of cesarean scar pregnancy in Cipto Mangunkusumo General Hospital, in one year.
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9
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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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10
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Daram NR, Berry L, Fakih M, Alhousseini A. Successful Use of Myosure in the Management of Cesarean Scar Ectopic Pregnancy. Cureus 2021; 13:e17500. [PMID: 34603879 PMCID: PMC8476203 DOI: 10.7759/cureus.17500] [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] [Accepted: 08/02/2021] [Indexed: 11/27/2022] Open
Abstract
Cesarean scar pregnancy (CSP) is a very serious complication of a prior cesarean delivery. The major risks associated with CSP are uncontrolled hemorrhage and uterine rupture, potentially leading to future infertility. Management of CSP remains a major obstetric challenge without a well-defined therapeutic procedure. Dilation & curettage is a commonly used procedure for the treatment of CSP. However, it can be ineffective and often leads to definite infertility. Therefore, we present a case of the successful use of an alternative procedure, Myosure® hysteroscopy, in the treatment of CSP. We herein report the case of a 32-year-old G5P3013 woman who presented with vaginal bleeding and past history of three cesarean sections. She was found to have a CSP with fetal pole and cardiac activity at 6 weeks 2 days. The patient was initially treated with a systemic methotrexate injection, but there was persistence of cardiac activity. A second course of methotrexate was administered into the gestational sac, which systemically led to successful fetal cardiac arrest and downtrend of beta-human chorionic gonadotropin (HCG) level. A dilation & curettage procedure was not successful in removing products of conception. A Myosure hysteroscopy procedure, however, was successful in removing products of conception. The patient was discharged after a negative ultrasound and beta-HCG level. In our review of the literature, we found that there is no general consensus on the management of cesarean scar ectopic pregnancies. To date, there is no literature cited about the use of Myosure for cesarean scar ectopic pregnancies. However, our case suggests that Myosure can be effective for CSP and this warrants a larger-scale controlled study to better evaluate this as a treatment for this condition.
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Affiliation(s)
- Naveena R Daram
- Obstetrics and Gynecology, Oakland University William Beaumont School of Medicine, Rochester, USA
| | - Lawrence Berry
- Radiology, Wayne State University School of Medicine, Detroit, USA
| | - Mona Fakih
- Obstetrics and Gynecology, Beaumont Health, Royal Oak, USA
| | - Ali Alhousseini
- Maternal and Fetal Medicine, Beaumont Health, Royal Oak, USA
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11
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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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12
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Kumari V, Kumar H, Datta MR. The Importance of Ectopic Mindedness: Scar Ectopic Pregnancy, a Diagnostic Dilemma. Cureus 2021; 13:e13089. [PMID: 33728112 PMCID: PMC7933601 DOI: 10.7759/cureus.13089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
There has been a consistent rise in ectopic pregnancies due to increase in maternal age, infertility treatment, cesarean sections, smoking among women, and use of contraceptives. With the extratubal ectopic pregnancies accounting for only 4% of the total ectopic pregnancies, scar pregnancies are even more of a rare entity with their incidence being less than 1%. We hereby present two cases of ectopic pregnancies, which though managed successfully presented a huge diagnostic challenge in the first case while the diagnosis was completely missed in the second case, hence, emphasizing the need for ectopic mindedness when dealing with early pregnancies.
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Affiliation(s)
- Vina Kumari
- Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, IND
| | | | - Mamta R Datta
- Obstetrics and Gynaecology, Tata Main Hospital, Jamshedpur, IND
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13
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Different treatment modalities for cesarean scar pregnancies: a single-center experience and literature review. Arch Gynecol Obstet 2020; 303:1143-1151. [PMID: 33048187 DOI: 10.1007/s00404-020-05831-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/03/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Cesarean scar pregnancy (CSP) remains a sporadic form of ectopic pregnancy associated with a severe life-threatening condition. There is no consensus on the treatment modality or a generally accepted guideline in CSP. This study aims to evaluate the outcomes of the different treatment modalities used in CSP treatment at a single center, as well as a literature review. METHODS This is a retrospective case series study that was conducted; all women who diagnosed with CSP between January 2013 and November 2019 at Women's Specialized Hospital, King Fahad Medical City. The clinical characteristics, diagnosis, different treatment modalities, and clinical outcomes were analyzed. RESULTS Twenty-seven cases of CSP identified during the study period. The median maternal age was 38 years (range 23-47 years). The gestational age at diagnosis ranged between 5 weeks and 5 days to 13 weeks and 6 days. All diagnoses were made by ultrasound. The absence of embryonic cardiac activity was seen in 10 cases (37.03%). The most commonly used method for first-line treatment was medical treatment. A total of 14 patients (51.85%) were treated with systemic methotrexate (MTX), three (11.1%) intra-sac and systemic MTX, and two (7.4%) intra-cardiac potassium chloride (KCl) along with systemic MTX, five (18.51%) cases had expectant management, one case initially treated with Laparotomy Wedge resection, and one case treated with uterine artery embolization (UAE) and systemic MTX. A total of 20 (74.07%) patients were treated successfully with first-line treatment. Seven (25.92%) patients needed additional second-line treatment. Among them, only one case had surgical intervention. None of the women in the medical treatment group experienced any side effects. Based on ANOVA results, there is no considerable relationship between the mean time of resolution of β-hCG and four treatment modalities for CSP (p = 0.2406). There was no statistical significance when the fetal viability at the time of diagnosis was compared to the need for second-line treatment of CSP (p = 0.58). CONCLUSION The treatment of CSP should be individualized based on risk factors. Diagnosis and management of CSP need expertise and a multidisciplinary approach to prevent complications. Early diagnosis and management of cesarean scar ectopic pregnancy remains the mainstay for a successful outcome.
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14
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Diagnostic and Management Challenges of Caesarean Scar Ectopic Pregnancy in a Lower Middle Income Country. Case Rep Obstet Gynecol 2019; 2019:4257696. [PMID: 31815027 PMCID: PMC6878799 DOI: 10.1155/2019/4257696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 08/19/2019] [Indexed: 11/17/2022] Open
Abstract
Caesarean scar ectopic pregnancy is defined as the implantation of the blastocyst in a previous Caesarean scar. It is a rare type of ectopic pregnancy. The incidence is however rising due to the increasing rates of Caesarean sections as well as in-vitro fertilization embryo-transfer. It can be diagnosed early by ultrasound. This remains a challenge in lower middle income countries where the availability of high resolution ultrasound and the skill for such sonography may be lacking. Misdiagnosis or a delay in diagnosis often leads to poor treatment outcomes. We present a case of a gravida 3 para 2 + 0 who had laparotomy for a caesarean scar pregnancy and highlight the challenges associated with diagnosis and management of this rare ectopic pregnancy in a lower middle income country.
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15
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Sangwan VG, Lakra P, Patil B, Siwach S, Sangwan MK, Mahendru R. Learning Experience with Management of Caesarean-Scar Pregnancy. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2019.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Vijayata G. Sangwan
- Department of Obstetrics and Gynaecology, B.P.S. Government Medical College for Women, Sonepat, Haryana, India
| | - Pinkey Lakra
- Department of Obstetrics and Gynaecology, B.P.S. Government Medical College for Women, Sonepat, Haryana, India
| | - Bhagyashri Patil
- Department of Obstetrics and Gynaecology, B.P.S. Government Medical College for Women, Sonepat, Haryana, India
| | - Sunita Siwach
- Department of Obstetrics and Gynaecology, B.P.S. Government Medical College for Women, Sonepat, Haryana, India
| | - Mukesh Kumar Sangwan
- Department of General Surgery, B.P.S. Government Medical College for Women, Sonepat, Haryana, India
| | - Rajiv Mahendru
- Department of Obstetrics and Gynaecology, B.P.S. Government Medical College for Women, Sonepat, Haryana, India
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Ultrasound guidance in reproductive surgery. Best Pract Res Clin Obstet Gynaecol 2019; 59:12-24. [PMID: 31279764 DOI: 10.1016/j.bpobgyn.2019.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/24/2019] [Accepted: 05/24/2019] [Indexed: 11/22/2022]
Abstract
Ultrasound plays a key role in diagnosis and guidance in reproductive medicine and surgery. In the field of reproductive surgery, some of the interventions, especially intrauterine procedures, are regularly conducted without imaging guidance but instead performed based on clinical skills and experience alone. Operative real-time US provides concurrent visualisation of the structures, contents and planes and operating instruments and, therefore, has the potential to improve efficacy and safety of the operative interventions. Ultrasound should be used in our operating theatres more often to guide various intrauterine procedures to reduce the intra-operative risks and complications including uterine perforations and visceral injury. The use of ultrasound necessitates an additional assistant experienced in ultrasound in the theatre, but regular use of ultrasound improves the training opportunities of the trainees and clinicians.
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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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Majangara R, Madziyire MG, Verenga C, Manase M. Cesarean section scar ectopic pregnancy - a management conundrum: a case report. J Med Case Rep 2019; 13:137. [PMID: 31072411 PMCID: PMC6509785 DOI: 10.1186/s13256-019-2069-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 04/02/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Cesarean section scar ectopic pregnancies are a rare complication of pregnancy that may follow previous hysterotomy for any cause, uterine manipulation, and in vitro fertilization. It has become more common with the increasing number of cesarean sections worldwide. Fortunately, the use of first-trimester ultrasound imaging has led to a significant number of these pregnancies being diagnosed and managed early. CASE PRESENTATION We report a case of a 36-year-old black African patient who had two previous cesarean sections and one previous surgical evacuation. She presented with a type 2 cesarean section scar ectopic pregnancy that was suspected on the basis of transvaginal ultrasound imaging, but not at laparoscopy/hysteroscopy. A bladder adherent to the upper segment of the anterior uterine wall obscured the gestational mass at laparoscopy. There were extensive intracavitary adhesions that interfered with hysteroscopic visualization. This resulted in the original operative procedure being postponed until magnetic resonance imaging confirmed the ectopic location of the pregnancy. The ectopic gestation was subsequently excised, and the uterus was repaired via laparotomy. CONCLUSIONS It is important for clinicians and radiologists managing women with risk factors for a scar ectopic pregnancy to maintain a high index of suspicion during follow-up. Failure to diagnose and initiate prompt management may lead to uterine rupture, massive hemorrhage, and maternal death.
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Affiliation(s)
- Rumbidzai Majangara
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, PO Box A178, Avondale, Harare Zimbabwe
| | - Mugove Gerald Madziyire
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, PO Box A178, Avondale, Harare Zimbabwe
| | - Cladious Verenga
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, PO Box A178, Avondale, Harare Zimbabwe
| | - Marshall Manase
- Department of Obstetrics and Gynaecology, University of Zimbabwe College of Health Sciences, PO Box A178, Avondale, Harare Zimbabwe
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Odgers HL, Taylor RAM, Balendran J, Benness C, Ludlow J. Rupture of a caesarean scar ectopic pregnancy: A case report. Case Rep Womens Health 2019; 22:e00120. [PMID: 31193006 PMCID: PMC6510699 DOI: 10.1016/j.crwh.2019.e00120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 04/24/2019] [Accepted: 04/26/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Caesarean scar pregnancy is an uncommon form of ectopic pregnancy characterized by implantation into the site of a caesarean scar. Common clinical features include vaginal bleeding and abdominal pain; however, a significant proportion of cases are asymptomatic. The primary diagnostic modality is transvaginal ultrasound. There is no current consensus on best-practice management. CASE PRESENTATION A 36-year-old woman, G7P2, presented to an early-pregnancy service with vaginal spotting and an ultrasound scan demonstrating a live caesarean scar ectopic pregnancy at 8 + 5 weeks' gestation. On examination she was hemodynamically stable with a soft abdomen. She was advised to have dilation and curettage (D&C) under ultrasound guidance; however, she was concerned that she might require more extensive surgery, such as a hysterectomy and so requested non-surgical management. On day 1 she underwent ultrasound-guided embryocide with lignocaine followed by inpatient multi-dose systemic methotrexate. Her beta-human gonadotrophic hormone level decreased. Repeat ultrasound on day 18 demonstrated a persistent caesarean scar ectopic pregnancy with increased vascularity, and so uterine artery embolization (UAE) was performed with a view to D&C the following day. This plan was altered to expectant management with ongoing follow-up by a different clinician who had had previous success with UAE alone. On day 35 the patient presented with life-threatening vaginal bleeding that required an emergency total abdominal hysterectomy. CONCLUSIONS Caesarean scar pregnancies are uncommon. Multiple treatment strategies have been employed, with variable degrees of success. Further research into risk stratification and management are needed to guide clinician and patient decision making.
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Affiliation(s)
| | | | | | - Christopher Benness
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
| | - Joanne Ludlow
- Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
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Jayaram P, Okunoye G, Al Ibrahim AA, Ghani R, Kalache K. Expectant management of caesarean scar ectopic pregnancy: a systematic review. J Perinat Med 2018; 46:365-372. [PMID: 29116934 DOI: 10.1515/jpm-2017-0189] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/02/2017] [Indexed: 12/12/2022]
Abstract
AIM The purpose of this review is to systematically review all the reported cases and case series of caesarean scar pregnancy (CSP) managed expectantly without any intervention in order to understand the outcomes of pregnancy which will guide clinicians and patients in making treatment choices. METHODS An electronic search on PubMed, EMBASE and Cochrane databases and a manual search from references of the articles were performed. Studies were selected based on inclusion and exclusion criteria. Data were extracted for various outcomes of pregnancy and the quality of the reports was assessed using a modified Delphi technique. RESULTS A total of 56 cases of CSP from 11 reports were included in the review, including 44 cases with foetal cardiac activity. Live births were achieved in 73% of cases with a quarter of them born before 34 weeks. Hysterectomy rates were 70%. In 12/44 (27%) of cases pregnancies were lost due to complications before 24 weeks. Most (67%) of the CSPs with no foetal cardiac activities resolved on expectant management and the remaining required intervention for bleeding. CONCLUSIONS Caution should be exercised when choosing expectant management in cases of viable CSPs, and if chosen, the patient should be counselled adequately for possible outcomes including loss of pregnancy and hysterectomy. Expectant management is acceptable in CSPs with no foetal cardiac activity. There is a need for prospective research on this topic with adequate reporting on possible prognostic markers, as well as a need to improve on the techniques to prevent loss of fertility during delivery.
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Affiliation(s)
- Pradeep Jayaram
- Obstetrician and Gynaecologist, Sidra Medical and Research Centre, Weill Cornell Medical College-Qatar, Doha, Qatar
| | - Gbemisola Okunoye
- Obstetrician and Gynaecologist, Sidra Medical and Research Centre, Weill Cornell Medical College-Qatar, Doha, Qatar
| | | | - Rauf Ghani
- Obstetrician and Gynaecologist, Sidra Medical and Research Centre, Weill Cornell Medical College-Qatar, Doha, Qatar
| | - Karim Kalache
- Division of Maternal-Fetal Medicine, Sidra Medical and Research Centre, Weill Cornell Medical College-Qatar, Doha, Qatar
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