Analysis of pregnancy outcomes following surgical treatment of cesarean scar pregnancy

Outcomes of local vasopressin injection and vaginal evacuation for cesarean scar pregnancy: A retrospective review of 11 cases

AIM

Vaginal removal of cesarean scar pregnancy (CSP) carries the risk of massive bleeding and residual gestational tissue. To address these complications, we administered local injections of diluted vasopressin surrounding the gestational tissue before vaginal evacuation. In this study, we investigated the surgical and subsequent reproductive outcomes of patients with CSP treated using this technique.

METHODS

We retrospectively analyzed 11 patients between January 2014 and December 2023, for whom the above technique was used to manage cases in which gestational tissue did not bulge on the bladder side. We injected 5-10 mL of vasopressin diluted 100 times with saline surrounding the gestational sac under transvaginal ultrasound guidance and performed vaginal evacuation either electronically or manually.

RESULTS

The median (range) age, body mass index, and gestational week at surgery were 35 (27-43) years, 26.0 (21.5-33.0) kg/m2, and 6 (5-8) weeks of gestation, respectively. The longest diameter of the gestational sac was 9.7 (6.5-19.4) mm, and serum human chorionic gonadotropin level at vaginal evacuation was 6327 (1284-14 446) mIU/mL. Surgeries were completed in 17 (10-18) min with minimal blood loss and no residual tissue. Five of the 10 patients who wished for a subsequent pregnancy conceived successfully, and three patients had term deliveries. One patient with a T-shaped uterine cavity experienced recurrent CSP.

CONCLUSION

Local injection of diluted vasopressin and vaginal evacuation is safe and easy without critical adverse events in patients with CSP, where the gestational tissue is not bulging toward the bladder.

Reproductive outcomes in women with prior cesarean scar pregnancies over six years

To explore the impact of two surgical methods, ultrasound-guided vacuum aspiration and laparoscopic scar resection with repair on the reproductive outcomes of patients with caesarean scar pregnancy. We systematically selected 562 women who had undergone surgical treatment for caesarean scar pregnancies at a tertiary hospital in China between May 2017 and July 2022. After 6 years of follow-up, the reproductive outcomes of 100 women who desired future pregnancies were ultimately tracked. We retrospectively analysed the clinical data and follow-up records of these women to explore the impact of the two surgical methods on their reproductive outcomes. Among those 100 patients, 43(43%) live births, 19(19%) miscarriages, 15(15%) RCSP, and 38 (38%) cases of secondary infertility. Comparison of the clinical data between the ultrasound-guided vacuum aspiration and laparoscopic scar resection with repair groups showed that patients in the latter had longer hospital stays, higher gestational age at treatment, greater maximum GS diameter, and lower BMI (P < 0.05). Women with thicker myometrial layers at the caesarean scar site were more likely to have live births in subsequent pregnancies (P = 0.044; HR 1.207; 95% CI 1.001-1.909). Older women were at higher risk of miscarriage and recurrent caesarean scar pregnancies (P = 0.028; HR 1.868; 95% CI 1.765-1.985).The reproductive outcomes of women with caesarean scar pregnancies after surgical treatment are optimistic.The reproductive outcomes were not dependent on the type of surgical methods used, either ultrasound-guided vacuum aspiration or laparoscopic scar resection with repair for the treatment of caesarean scar pregnancy. Advancing maternal age in subsequent pregnancies is a risk factor for adverse reproductive outcomes and warrants attention.

Predictive nomogram of ultrasound indicators for the termination outcome of caesarean scar pregnancy

To develop and validate a nomogram for predicting the risk of adverse events (intraoperative massive haemorrhage or retained products of conception) associated with the termination of Caesarean scar pregnancy (CSP). Data were retrospectively collected from patients diagnosed with CSP who underwent Dilation and Curettage (D&C) at two hospitals. This data was divided into internal and external cohorts for analysis. The internal cohort was randomly split, with 70% of the data designated for a training set and 30% for an internal validation set. The external cohort served exclusively as the external validation set. LASSO and logistic regression techniques were employed to select variables and construct the nomogram. The performance of the nomogram was evaluated using various methods, including C-index, calibration curve, decision curve analysis (DCA), and clinical impact curve analysis (CICA), to assess its identification, calibration, and clinical effectiveness. The prediction nomogram included several predictors, such as scar thickness, type of CSP, gestational sac diameter, and blood flow. It demonstrated strong discrimination, with a C-index of 0.83 (95% confidence interval: 0.77-0.89). Furthermore, in the internal validation set, a high C-index of 0.78 was achieved, while in the external validation set, it reached 0.83. Additional assessments using calibration curve analysis, DCA, and CICA indicated robust agreement between the nomogram's predictions and actual observations, highlighting its utility and reliability. The developed nomogram shows excellent discriminative ability and calibration, with the potential for effective local prediction of adverse events in CSP.

Global variation and outcomes of expectant management of CSP

The incidence of Cesarean scar pregnancies (CSPs) is rising globally. Ultrasound criteria for the diagnosis of CSPs have been described by the International Society of Ultrasound in obstetrics and gynecology and appear to be well used in various centers around the world. There is no guidance on best practices for expectant management of CSP, and there is considerable variation in how this is offered globally. Many studies have reported significant maternal morbidity in cases of CSP with fetal cardiac activity managed expectantly, largely relating to hemorrhage and cesarean hysterectomy from placenta accreta spectrum. However, high live birth rates are also reported. Literature describing the diagnosis and expectant management of CSP in low-resource settings is lacking. Expectant management in selected cases where no fetal cardiac activity is present is a reasonable option and can be associated with good maternal outcomes. Standardization in reporting different types of CSPs and correlating these with pregnancy outcomes will be an important next step in developing guidance for expectant management of this high-risk pregnancy with a high burden of complications.