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

Early first-trimester transvaginal ultrasound screening for cesarean scar pregnancy in patients with previous cesarean delivery: analysis of the evidence

Obstetric hemorrhage is a leading cause of maternal morbidity and mortality. An important etiology of obstetric hemorrhage is placenta accreta spectrum. In the last 2 decades, there has been increased clinical experience of the devastating effect of undiagnosed, as well as late diagnosed, cases of cesarean scar pregnancy. There is a growing body of evidence suggesting that cesarean scar pregnancy is an early precursor of second- and third-trimester placenta accreta spectrum. As such, cesarean scar pregnancy should be diagnosed in the early first trimester. This early diagnosis could be achieved by introducing regimented sonographic screening in pregnancies of patients with previous cesarean delivery. This opinion article evaluates the scientific and clinical basis of whether cesarean scar pregnancy, with special focus on its early first-trimester discovery, complies with the accepted requirements of a screening test. Each of the 10 classical screening criteria of Wilson and Jungner were systematically applied to evaluate if the criteria were met by cesarean scar pregnancy, to analyze if it is possible and realistic to carry out screening in a population-wide fashion.

Ruptured Caesarean Scar Ectopic Pregnancy: A Rare Case of Obstetric Hemorrhage

Caesarean scar ectopic pregnancy is the rarest form of ectopic pregnancy. Nowadays, with the rise in caesarean deliveries, along with better awareness and improvement in ultrasound diagnosis, there is an increase in the number and detection of caesarean scar ectopic pregnancy. A 28-year-old female patient with one previous caesarean delivery and a spontaneous abortion at three months visited the obstetrics emergency department due to three months of amenorrhea, abdominal pain, and vaginal bleeding on and off for two days. The patient was noticed to have severe anemia. After stabilizing the patient with blood transfusion, a laparotomy was performed with the presentation of hemoperitoneum and caesarean scar rupture. Fetus and soft vascular mass seen protruding from the previous scar were extracted. The caesarean scar site was repaired in layers.

Caesarean scar ectopic pregnancy: A case series

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.

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

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

Factors affecting gastrointestinal function recovery after cesarean section among Chinese mothers: A cross-sectional study

This study was conducted to explore the influencing factors of gastrointestinal function recovery after cesarean section (CS), which could provide a reference for the enhanced recovery after surgery in obstetrics. This is a cross-sectional survey on Chinese mothers receiving CS. The participants's socio-demographic characteristics, perioperative diet, medical condition and gastrointestinal function after surgery were collected by a self-designed questionnaire. Binary logistic regression analysis was employed to explore the influencing factors of gastrointestinal function recovery after CS. A total of 1501 (94.76%) valid questionnaires were collected. The first borborygmus was 2.21 ± 0.63 hours, and the first anal exhaust was 35.73 ± 14.85 hours after the CS. The incidence of abdominal distension and intestinal obstruction were 15.1% and 0.7%, respectively. The parity, type of CS, 2-hours bleeding after surgery, time of first meal after surgery, whether taking peppermint water after surgery were the independent influencing factors for gastrointestinal function recovery after CS. We should pay more attention to the mothers with scarred uterus, manage the labor process strictly, and reduce 2-hours bleeding after surgery. The mothers with CS should also be encouraged to eat early and take peppermint water to promote intestinal peristalsis actively.

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.

Comparison of efficacies between ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin and hysteroscopic electro-resection after methotrexate chemotherapy in the treatment of cesarean scar pregnancy

To compare the efficacies between ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin and hysteroscopic electro-resection after methotrexate chemotherapy in the treatment of caesarean scar pregnancy (CSP). 60 patients with CSP admitted to our hospital were selected as the study subjects, and divided into observation group (n = 35) and control group (n = 25) in accordance with the therapeutic options. The observation group was treated with ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, while the control group was treated with hysteroscopic electro-resection after methotrexate chemotherapy. The observation group was superior to the control group in the amount of intraoperative haemorrhage, in-hospital costs, and postoperative time to control vaginal haemorrhage, time to return to a normal serum human chorionic gonadotropin (HCG) level. The observation group had a lower incidence rate of adverse reactions (5.71% vs. 28.00%, p < .05) and a higher first-attempt success rate for treatment (85.71% vs. 84.00%, p > .05) compared with the control group. Ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, exhibiting a higher efficacy, can more effectively shorten the postoperative recovery, reduce adverse reactions, and improve the postoperative quality of life in patients with CSP. IMPACT STATEMENTWhat is already known on this subject? Caesarean scar pregnancy (CSP), a rare form of ectopic pregnancy where the fertilised egg is implanted in the muscle or fibrous tissue of the scar after a previous caesarean section (CS), is a long-term complication of CS that may be life-threatening for parturients. Some therapies have been used to treat CSP, such as uterine artery embolisation and uterine artery embolisation chemotherapy combined with curettage, but the potential adverse effects may affect the ovarian reserve and even affecting the fertility of patients.What do the results of this study add? This study showed that ultrasound-guided curettage combined with hysteroscopic electro-resection after injection of pituitrin, exhibiting a higher efficacy, can more effectively shorten the postoperative recovery, reduce adverse reactions, and improve the postoperative quality of life in patients with CSP.What are the implications of these findings for clinical practice and/or further research? The findings of this study may provide some references for the clinical practitioners and further research and may contribute to the treatment of CSP.

Caesarean Scar Pregnancy: A Case Report and a Literature Review

Background and Objectives: Caesarean scar pregnancy (CSP) refers to placental implantation on or in the scar of a previous caesarean section and represents a potentially life-threatening condition. CSP is considered a diagnostic challenge in obstetrics, with the diagnosis relying mainly on transvaginal ultrasound (TVS) and the management depending upon case presentation and available healthcare infrastructures. Case Presentation: We present a case of 34-year-old G3P2 with a history of two-previous caesarean sections referred to the outpatient gynaecology clinic of our Department at the 7th week (7/40) of gestation with abnormal early pregnancy TVS findings, illustrating the gestational sac attached to the caesarean scar and a foetal pole with evidence of foetal cardiac activity. We discuss the outcome of an alternative combined medical and surgical approach we followed as well as an updated review of the current literature. Conclusions: The ideal management of CSP requires tertiary centers, equipment availability and experienced healthcare professionals capable of dealing with any possible complication, as well as individualized treatment based on each case presentation.

Effect of Low-Frequency Electric Pulse Technique Combined with Carboprost Methylate Suppositories on Recovery of Gastrointestinal Function and Postoperative Complications of Patients with Scarred Uterus Undergoing Secondary Cesarean Section

The study aims to explore the effect of low-frequency electric pulse technique combined with carboprost methylate suppositories on recovery of gastrointestinal function and postoperative complications of patients with scarred uterus undergoing secondary cesarean section (C-section). The clinical data of 120 patients with scarred uterus undergoing secondary C-section treated in our hospital from February 2019 to February 2020 were retrospectively analyzed, and the patients were equally divided into experimental and control groups according to their admission order, where each group included 60 patients. After the operation, patients in the control group received routine nursing and conducted breastfeeding, and carboprost methylate suppositories were used for postoperative hemostasis. Those in the experimental group received low-frequency electric pulse technique for comprehensive treatment to compare their coagulation function indicators, recovery of gastrointestinal function, incidence rates of postoperative complications, and involution of uterus. No significant between-group differences in patients' general information such as gestational weeks, gravidity, and number of times receiving C-section were observed (P > 0.05). Compared with the control group after the operation, patients in the experimental group obtained significantly better coagulation function indicators (P < 0.001) and presented better gastrointestinal function recovery (P < 0.001), significantly lower incidence rates of postpartum hemorrhage, retention of urine, deep venous thrombosis of lower limb, rupture of uterus, and endometrial cavity fluid (P < 0.05), and significantly better involution of uterus (P < 0.001). In conclusion, combining low-frequency electric pulse technique with carboprost methylate suppositories can lower the incidence rates of postoperative complications for patients with scarred uterus undergoing secondary C-section, improve their coagulation function, promote the recovery of gastrointestinal function, and present the desirable involution of uterus, which should be promoted in practice.

Successful Use of Myosure in the Management of Cesarean Scar Ectopic Pregnancy

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.

Cesarean Scar Ectopic Pregnancy: A Case Report

BACKGROUND

A cesarean scar pregnancy is a rare, life-threatening obstetric emergency. Early recognition and prompt treatment of cesarean scar pregnancy is essential because of the risk for long-term reproductive complications associated with this condition.

CASE PRESENTATION

A 33-year-old gravida 6 para 5 female presented to the emergency department with pain to the suprapubic area. Following assessment and diagnostic testing, she was diagnosed with a cesarean scar pregnancy. The patient was admitted to the women's services department where she received a multidose regimen of methotrexate. The patient was discharged home, and no further surgical interventions were necessary. Two months after her visit to the emergency department, the patient has not had any complications related to the cesarean scar pregnancy.

CONCLUSION

This manuscript outlines the case of a patient presenting to the emergency department with a cesarean scar pregnancy that was promptly recognized and treated. It is important for emergency nurses to quickly recognize the risk factors and clinical presentation of a cesarean scar pregnancy to reduce maternal morbidity and mortality.

Successful hysteroscopy and curettage of a caesarean scar ectopic pregnancy

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

Cesarean Scar - Unusual Site of Ectopic Pregnancy: A Case Report

Ectopic pregnancy is a leading cause of maternal mortality in the first trimester. It may occur in different anatomic locations with fallopian tube being the most frequent. Cesarean-scar ectopic pregnancy is one of the rarest ectopic pregnancies. We report the case of a 44-year-old woman, gravida 5 para 4, who attended the antenatal clinic after her pregnancy was confirmed by positive urine testing. She underwent transvaginal ultrasound examination which identified the gestational sac with fetal pole and cardiac activity located in the anterior part of the lower uterine segment with empty uterine cavity. Magnetic resonance imaging (MRI) scan had confirmed the diagnosis of cesarean scar ectopic pregnancy. After through discussion on the management options, the patient was treated with intra-gestational sac injection of methotrexate. Four days after the procedure, she developed profuse vaginal bleeding and her hemoglobin showed a drop of 4.9 g/dL. She underwent emergency laparotomy with excision of the ectopic pregnancy. The patient tolerated the procedure well without complications. The serum β-human chorionic gonadotropin level was undetectable on the 35^th day after the methotrexate injection. Caesarean scar pregnancy is an unusual form of ectopic pregnancy. However, clinicians should have a high index of suspicion for this condition as it may result in serious complications, unless promptly managed. MRI is recommended particularly when transvaginal ultrasound scan is inconclusive.