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Amirkhanloo F, Haddadi M, Ebrahimi M. Paradoxical air embolism in patients undergoing hysteroscopic surgery for cesarean scar pregnancy: A case report and review of the literatures. Clin Case Rep 2024; 12:e9060. [PMID: 38947538 PMCID: PMC11211086 DOI: 10.1002/ccr3.9060] [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] [Received: 01/20/2024] [Revised: 05/10/2024] [Accepted: 05/28/2024] [Indexed: 07/02/2024] Open
Abstract
Cesarean scar pregnancy cases who undergo hysteroscopic suction aspiration could be at higher risk of air emboli due to dilated, low-resistant, high-velocity blood vessels.
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Affiliation(s)
- Fatemeh Amirkhanloo
- IVF Unit, Obstetrics and Gynecology WardYas Hospital Complex, Tehran University of Medical SciencesTehranIran
| | - Mohammad Haddadi
- Vali‐E‐Asr Reproductive Health Research Center, Family Health Research InstituteTehran University of Medical SciencesTehranIran
| | - Mahbod Ebrahimi
- IVF Unit, Obstetrics and Gynecology WardYas Hospital Complex, Tehran University of Medical SciencesTehranIran
- Vali‐E‐Asr Reproductive Health Research Center, Family Health Research InstituteTehran University of Medical SciencesTehranIran
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Fazari A, Mohammed PB, Fahad A. Outcomes of the Expectant Management of 10 Cesarean Scar Pregnancy Cases in Patients Who Refused the Termination of Pregnancy. Cureus 2023; 15:e48921. [PMID: 38106794 PMCID: PMC10725518 DOI: 10.7759/cureus.48921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVE Expectant management of cesarean scar pregnancy (CSP) in patients who refuse termination of pregnancy and continue with placenta accreta spectrum (PAS) is possible with multidisciplinary care and careful monitoring in a tertiary care center. Doctors with the relevant expertise in managing PAS use highly accurate ultrasound as a tool to diagnose, monitor, and manage this disorder, which enables them to determine appropriate surgical strategies and techniques to achieve optimum maternal and fetal outcomes with minimal blood loss and no major maternal mortality and morbidity. In this study, we aim to evaluate expectant management in such patients. MATERIALS AND METHODS This is a retrospective study of 10 patients with a previous history of a uterine scar. Diagnosed with CSP in the first trimester, they refused to terminate their pregnancy and continued with PAS. We studied them over a period of four years from 2018 to 2022 and managed them at Latifa Hospital, Dubai, UAE. RESULTS Of the 10 patients, nine delivered in the third trimester (around 34 weeks gestation), seven underwent elective surgery, and three underwent emergency surgery. Four patients were exogenous cases and six were endogenous cases at diagnosis during early gestation. Seven patients had a cesarean hysterectomy, and three (with focal placenta accreta) had uterine wall reconstruction surgery. Four patients needed blood transfusions. The average duration of surgery was between 2.5 and 5 hours. There were no miscarriages, no maternal and neonatal deaths, and no significant obstetric complications such as rupture of the uterus or major obstetric hemorrhage. CONCLUSION Even though CSP is a potentially life-threatening condition because of serious complications such as PAS if continued, expectant management is possible under multidisciplinary care where the team strictly adheres to clinical protocols and accurate surgery to reduce obstetric hemorrhage.
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Affiliation(s)
- Atif Fazari
- Faculty of Medicine, University of Medical Sciences and Technology, Khartoum, SDN
- Obstetrics and Gynecology, Latifa Hospital, Dubai Academic Health Corporation, Dubai, ARE
| | | | - Asma Fahad
- Obstetrics and Gynecology, Latifa Hospital, Dubai Academic Health Corporation, Dubai, ARE
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Silva B, Viana Pinto P, Costa MA. Cesarean Scar Pregnancy: A systematic review on expectant management. Eur J Obstet Gynecol Reprod Biol 2023; 288:36-43. [PMID: 37421745 DOI: 10.1016/j.ejogrb.2023.06.030] [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: 04/26/2023] [Revised: 06/26/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023]
Abstract
A Cesarean Scar Pregnancy (CSP) is a variant of uterine ectopic pregnancy defined by full or partial implantation of the gestational sac in the scar of a previous cesarean section. The continuous increase of Cesarean Deliveries is causing a parallel increase in CSP and its complications. Considering its high morbidity, the most usual recommendation has been termination of pregnancy in the first trimester; however, several cases progress to viable births. The aim of this systematic review is to evaluate the outcome of CSP managed expectantly and understand whether sonographic signs could correlate to the outcomes. An online-based search of PubMed and Cochrane Library Databases was used to gather studies including women diagnosed with a CSP who were managed expectantly. The description of all cases was analysed by the authors in order to obtain information for each outcome. 47 studies of different types were retrieved, and the gestational outcome was available in 194 patients. Out of these, 39 patients (20,1%) had a miscarriage and 16 (8,3%) suffered foetal death. 50 patients (25,8%) had a term delivery and 81 (41,8%) patients had a preterm birth, out of which 27 (13,9%) delivered before 34 weeks of gestation. In 102 (52,6%) patients, a hysterectomy was performed. Placenta Accreta Spectrum (PAS) was a common disorder among CSP and was linked to a higher rate of complications such as foetal death, preterm birth, hysterectomy, haemorrhagic morbidity and surgical complications. Some of the analysed articles showed that sonographic signs with specific characteristics, such as type II and III CSP classification, Crossover Sign - 1, "In the niche" implantation and lower myometrial thickness could be related to worse outcomes of CSP. This article provides a good understanding of CSP as an entity that, although rare, presents with a high rate of relevant morbidity. It is also understood that pregnancies with confirmed PAS had an even higher rate of morbidity. Some sonographic signs were shown to predict the prognosis of these pregnancies and further investigation is necessary to validate one or more signs so they can be used for a more reliable counselling of women with CSP.
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Affiliation(s)
- Beatriz Silva
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Pedro Viana Pinto
- Department of Biomedicine, Service of Anatomy, Faculty of Medicine, University of Porto, Porto, Portugal; Gynecology and Obstetrics Service, University Hospital Center São João, Porto, Portugal.
| | - Maria Antónia Costa
- Gynecology and Obstetrics Service, University Hospital Center São João, Porto, Portugal; Department of Gynecology-Obstetrics and Paediatrics, Faculty of Medicine, University of Porto, Porto, Portugal
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Zheng YJ, Chen Q, Li S, Yan XT, Zhu T, He Z. Cesarean Scar Pregnancies Treated by Uterine Artery Chemotherapy Embolization Combined With Ultrasound-Guided Dilation and Curettage: A Retrospective Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:27-33. [PMID: 35778904 DOI: 10.1002/jum.16050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 05/03/2022] [Accepted: 06/08/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES To explore the effect of cesarean scar pregnancy (CSP) treatment by comparing uterine artery chemotherapy embolization (UACE) combined with dilation and curettage (D&C) with or without ultrasound guidance. METHODS CSP patients treated with UACE combined with D&C from January 2013 to December 2020 at Shuguang Hospital, affiliated to Shanghai University of Traditional Chinese Medicine were included in this retrospective study. The patients were divided into groups A and B according to whether D&C was guided by ultrasound. RESULTS Forty-eight patients with CSP diagnosed by transvaginal ultrasound were included in this study, whose gestational age was <8 weeks. There were no significant differences in the basic clinical characteristics of the two groups. The success rates of the 2 groups were no significant difference, 100% (27/27) in group A and 85.7% (18/21) in group B. The maximal intraoperative blood loss of group A was 100 mL and that of group B was 150 mL. There was no uterine perforation during the operation. Ultrasound guidance can shorten the D&C operation time, reduce intraoperative bleeding during D&C, and decrease the residual rate of trophoblastic tissue after D&C. CONCLUSIONS Ultrasound guidance can improve the safety and efficiency of UACE combined with D&C in the treatment of CSP and reduce its complications. We believe it is an optimal treatment for CSP patients who do not plan to have children in the future.
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Affiliation(s)
- Yi-Jun Zheng
- Department of Ultrasound, Shuguang Hospital affiliated to Shanghai Universtity of Traditional Chinese Medicine, Shanghai, China
| | - Qing Chen
- Department of Ultrasound, Shuguang Hospital affiliated to Shanghai Universtity of Traditional Chinese Medicine, Shanghai, China
| | - Sheng Li
- Department of Ultrasound, Shuguang Hospital affiliated to Shanghai Universtity of Traditional Chinese Medicine, Shanghai, China
| | - Xiao-Tong Yan
- Department of Gynecology, Shuguang Hospital affiliated to Shanghai Universtity of Traditional Chinese Medicine, Shanghai, China
| | - Ting Zhu
- Department of Gynecology, Shuguang Hospital affiliated to Shanghai Universtity of Traditional Chinese Medicine, Shanghai, China
| | - Zheng He
- Department of Ultrasound, Shuguang Hospital affiliated to Shanghai Universtity of Traditional Chinese Medicine, Shanghai, China
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Vieira de Mello P, Bruns RF, Fontoura Klas C, Raso Hammes L. Expectant management of viable cesarean scar pregnancies: a systematic review. Arch Gynecol Obstet 2022:10.1007/s00404-022-06835-3. [DOI: 10.1007/s00404-022-06835-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022]
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Saleh MM, Mallmann MR, Essakly A, Drebber U, Kleinert R, Kütting F, Bratke G, Müller AM. Placental Invasion into the Small Bowel Intestine Through a Myomectomy Scar: A Case Report With Literature Review. Int J Gynecol Pathol 2022; 41:151-156. [PMID: 33782340 DOI: 10.1097/pgp.0000000000000778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Although extremely rare, uterine damage after hysteroscopic myomectomy sets the precondition for various life-threatening placental attachment disorders like placenta percreta (PP) or scar pregnancy. Due to vast clinical similarities, these terms are often used interchangeably. We report a case of a 47-yr-old patient at 27 wk + 4 d of gestation who presented with rectal bleeding. Clinical history revealed a previous uterine posterior wall myomectomy. The patient received intensive diagnostic work-up including sonography and magnetic resonance imaging. Under the suspicion of a bleeding Meckel diverticulum, an emergency laparotomy was performed. Intraoperatively it was observed that the placental tissue infiltrated the small bowel intestine at the location of the previous myomectomy. The adjacent intestine and the infiltrating placenta were surgically removed. The placenta could be easily detached from the uterus, which is why no hysterectomy was performed. Retrospectively, no radiologic or clinical hints of PP or scar pregnancy were evident before the surgery. Moreover, the pathologic work-up carried out afterwards proved no histopathologic evidence for PP. Our case underlines several clinical and pathologic difficulties. First, invasive placenta disorders including infiltration of intestinal organs have to be considered even after minor surgical interventions such as myomectomy. Second, clinical presentation is extremely variable and sometimes misleading, depending on the localization and the type of invasion. Our case underlines the importance of histopathologic work-up for distinguishing between various placenta attachment disorders such as PP and scar pregnancy. Given the large overlap in clinical presentation, pathophysiology and definition, we propose that the current definitions for PP and scar pregnancy have to be carefully reevaluated and broadened.
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Stupak A, Kondracka A, Fronczek A, Kwaśniewska A. Scar Tissue after a Cesarean Section-The Management of Different Complications in Pregnant Women. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:11998. [PMID: 34831752 PMCID: PMC8620716 DOI: 10.3390/ijerph182211998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 11/16/2022]
Abstract
The definition of a cesarean scar pregnancy (CSP) is the localization of the gestational sac (GS) in the cicatrix tissue, which is created in the front wall of the uterus after a previous cesarean section (CS). The worldwide prevalence of CSP has been growing rapidly. However, there are no general recommendations regarding prophylaxis and treatment of the abnormalities of the anterior wall of the uterus discovered in a non-pregnant myometrium, or how to deal with existing cases of CSP. We present the latest knowledge, a holistic approach to the biology, histology, imaging, and management concerning post-CS scars based on our cases, which were treated in the Department of Pregnancy and Pathology of Pregnancy in the Medical University of Lublin, Poland. In our study, we present images of tissue samples of areas with a cicatrix in the uterus, and ultrasound and MRI images of CSP. We discuss the advances in the biology of the post-CS scar tissue, the prevention techniques used to repair the scar defect (niche) before the pregnancy, and the treatment of different complications of CSP, such as the rupture of the gravid uterus or the dehiscence of the myometrium.
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Affiliation(s)
- Aleksandra Stupak
- Department of Obstetrics and Pathology of Pregnancy, Independent Public Teaching Hospital No 1 in Lublin, Medical University of Lublin, 20-081 Lublin, Poland; (A.K.); (A.K.)
| | - Adrianna Kondracka
- Department of Obstetrics and Pathology of Pregnancy, Independent Public Teaching Hospital No 1 in Lublin, Medical University of Lublin, 20-081 Lublin, Poland; (A.K.); (A.K.)
| | - Agnieszka Fronczek
- Department of Pathomorphology, Independent Public Teaching Hospital No 1 in Lublin, Medical University of Lublin, 20-081 Lublin, Poland;
| | - Anna Kwaśniewska
- Department of Obstetrics and Pathology of Pregnancy, Independent Public Teaching Hospital No 1 in Lublin, Medical University of Lublin, 20-081 Lublin, Poland; (A.K.); (A.K.)
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Hu Q, Li C, Luo L, Li J, Zhang X, Chen S, Yang X. Clinical analysis of second-trimester pregnancy termination after previous caesarean delivery in 51 patients with placenta previa and placenta accreta spectrum: a retrospective study. BMC Pregnancy Childbirth 2021; 21:568. [PMID: 34407784 PMCID: PMC8375210 DOI: 10.1186/s12884-021-04017-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUNDS Pregnancy termination during the second trimester in patients with placenta previa and placenta accreta spectrum (PAS) is a complex and challenging clinical problem. Based on our literature review, there has been a relative increase in the number of such cases being treated by hysterotomy and/or local uterine lesion resection and repair. In the present study, a retrospective analysis was conducted to compare the clinical outcomes when different management strategies were used to terminate pregnancy in the patients with placenta previa and PAS. METHODS A total of 51 patients who underwent pregnancy termination in the second trimester in Beijing Obstetrics and Gynecology Hospital between June 2013 and December 2018 were retrospectively analyzed in this study. All patients having previous caesarean delivery (CD) were diagnosed with placenta previa status and PAS. RESULTS ① Among the 51 patients, 16 cases received mifepristone and misoprostol medical termination, 15 cases received mifepristone and Rivanol medical termination, but 1 of them was transferred to hysterotomy due to failed labor induction, another 20 cases were performed planned hysterotomy. There was no placenta percreta cases and uterine artery embolization (UAE) was all performed before surgery.② There were 31 cases who underwent medical termination and 30 cases were vaginal delivery. Dilation and evacuation (D&E) were used in 20 cases of medical abortion failure and in all 30 cases of difficult manual removal of placental tissue. ③ A statistically significant difference was found among the three different strategies in terms of gestational weeks, the type of placenta previa status, main operative success rate and β-HCG regression time (P < 0.05). ④ There were 4(7.8%) cases who were taken up for hysterectomy because of life-threatening bleeding or severe bacteremia during or after delivery and hysterotomy. The uterus was preserved with the implanted placenta partly or completely left in situ in 47(92.2%) cases. Combined medical and/or surgical management were used for the residual placenta and the time of menstrual recovery was 52(range: 33 to 86) days after pregnancy termination. CONCLUSIONS Terminating a pregnancy by vaginal delivery through medical induction of labor may be feasible if clinicians have an overall understanding of gestational age, the type of placenta previa status, the type of placenta accreta, and patients concerns about preserving fertility. A collaborative team effort in tertiary medical centers with a very experience MDT and combined application of multiple methods is required to optimize patient outcomes.
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Affiliation(s)
- Qiaofei Hu
- Department of Reproduction Regulation, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Changdong Li
- Department of Reproduction Regulation, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Lanrong Luo
- Department of Reproduction Regulation, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Jian Li
- Department of Reproduction Regulation, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Xiaofeng Zhang
- Department of Radiology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Suwen Chen
- Department of Reproduction Regulation, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China.
| | - Xiaokui Yang
- Department of Human Reproductive Medicine, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China.
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A stepwise approach to robotic assisted excision of a cesarean scar pregnancy. Obstet Gynecol Sci 2021; 64:329-331. [PMID: 33610162 PMCID: PMC8138068 DOI: 10.5468/ogs.20311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/14/2021] [Indexed: 11/29/2022] Open
Abstract
Objective To develop a stepwise approach to robotic assisted excision of cesarean scar pregnancy (CSP) with metroplasty. Methods This illustrative video presentation demonstrating CSP, the criteria for ultrasound diagnosis, and a step-by-step approach for robotic assisted excision of CSP and multi-layer hysterotomy closure at a tertiary medical center. Results Robotic assisted resection is a safe and feasible method to treat cesarean scar ectopic pregnancies. Key ultrasonographic characteristics of CSP are highlighted to facilitate its diagnosis, thus allowing for early intervention with a minimally invasive surgical treatment as necessary. Our patient was a 30-year-old gravida 2 para 1 woman with a history of 1 prior-term low transverse cesarean delivery, who presented with vaginal bleeding in the first trimester and was ultimately diagnosed with CSP. After unsuccessful methotrexate therapy, the patient underwent an uncomplicated robotic assisted excision of her CSP and metroplasty in 2 layers using a stepwise approach: Step 1-Creation of a bladder flap; Step 2-Isolation and excision of CSP; Step 3-Hysterotomy closure in 2 layers; and Step 4-Hysteroscopy. Conclusion When diagnosed late, cesarean scar ectopic pregnancy can cause a significant hemorrhage from rupture. Early radiologic diagnosis does not only indicate minimally invasive surgery as a treatment option but also assists with related surgical planning. This video demonstrates a stepwise approach to the robotic assisted excision of CSP with metroplasty. With these 4 simple steps, surgical procedure can be safe and efficient.
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Brar R, Saha PK, Bagga R. Termination of pregnancy may not be the only option for women diagnosed with live caesarean scar pregnancy at an early gestation: Lights and shadows. Aust N Z J Obstet Gynaecol 2021; 60:987-988. [PMID: 33373052 DOI: 10.1111/ajo.13251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/09/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Rinnie Brar
- Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pradip Kumar Saha
- Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rashmi Bagga
- Department of Obstetrics and Gynaecology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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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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Li H, Liu X, Xie L, Ye Z, Gan L. Diagnostic accuracy and cut-off of contrast-enhanced ultrasound in caesarean scar pregnancy. Eur J Obstet Gynecol Reprod Biol 2020; 246:117-122. [PMID: 32007793 DOI: 10.1016/j.ejogrb.2020.01.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/05/2020] [Accepted: 01/26/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To investigate the diagnostic accuracy of contrast-enhanced ultrasound (CEUS) and to search for cut-offs in caesarean scar pregnancy (CSP) patients for making quantitative diagnoses. STUDY DESIGN Thirty patients in the first trimester of pregnancy were enrolled in our study. They were suspected as being at risk of caesarean scar pregnancy by conventional ultrasound and insisted on abortions. Transvaginal ultrasonography (TVU) and CEUS were performed, and parameters were analysed on the time-intensity curve (TIC). Laparotomy, laparoscopy, hysteroscopy or curettage under the guidance of ultrasound were performed, and pathological finding of villi in the uterine scar is the gold standard for a diagnosis of CSP. The area under the receiver operating characteristic (ROC) curve (AUC) was used to estimate the probability of the correct prediction of CSP. RESULTS CSP was diagnosed in 27 patients: pathological diagnosis revealed villus tissue in the scar. The peak intensity ratios of caesarean scar to myometrium have the overall best diagnostic performances (AUC: 0.877, 95 % CI: 0.74-1.00). Using a cut-off value of 1.08 for the peak intensity ratio of caesarean scar to myometrium, the diagnosis sensitivity, specificity, PPV and NPV for CSP were 77.8, 100, 100, and 81.8 %, respectively. CONCLUSIONS CEUS offers good diagnostic performance, and the peak intensity ratio of caesarean scar to myometrium can be used as a quantitative index to diagnose CSP accurately.
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Affiliation(s)
- Haiying Li
- Department of Medical Ultrasound, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Xinxiu Liu
- Department of Medical Ultrasound, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Lijun Xie
- Department of Medical Ultrasound, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Zhen Ye
- Department of Medical Ultrasound, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China
| | - Ling Gan
- Department of Medical Ultrasound, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350005, China.
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Antoine C, Pimentel RN, Reece EA, Oh C. Endometrium-free uterine closure technique and abnormal placental implantation in subsequent pregnancies. J Matern Fetal Neonatal Med 2019; 34:2513-2521. [PMID: 31581865 DOI: 10.1080/14767058.2019.1670158] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Abnormal placentation can result in massive hemorrhage, which is the leading cause of severe maternal morbidities and mortality in its management. Over the past 50 years, the incidence of placenta previa (PP), abnormal implantation of the placenta, and cesarean scar pregnancy have continued to rise. This coincides with the well-documented parallel rise in the rate of cesarean deliveries, the performance of multiple repeat cesarean deliveries and the adoption of newer uterine closure techniques. However, no studies have examined the role of uterine closure techniques in abnormal placentation in women with a history of a prior cesarean delivery. OBJECTIVE To assess the practicality of one specific uterine closure technique at cesarean delivery and to evaluate the relationship between previous cesarean delivery and subsequent development of abnormal implantation of the placenta, as well as neonatal and other perioperative outcomes after receiving an endometrium-free uterine closure technique. METHODS This retrospective observational study considered cesarean deliveries (n = 727) and subsequent vaginal births after cesarean delivery (n = 109) among total deliveries (n = 4496) performed in private practice at NYU Langone Health from 1985 to 2015. All cesarean deliveries were performed using the endometrium-free uterine closure technique. The primary outcome was the incidence of abnormal implantation of the placenta in subsequent pregnancies. The secondary outcomes were neonatal and maternal complications, specifically postoperative hemoglobin and hematocrit concentration losses. The association between independent variables and outcomes were evaluated using mixed-effect regression models. RESULTS In contrast to published data, independent of the number of repeat cesarean deliveries, the presence of 26 (3.1%) PPs and of 366 (43.8%) anterior placentas, there were no patients with abnormal implantation of the placenta in a cesarean scar, neither prenatally nor at delivery. Maternal hemorrhage, postoperative and neonatal complications did not reach clinical significance. The statistical analysis revealed that, when compared with women who had fewer repeat cesarean deliveries using endometrium-free uterine closure technique, those with the most had a lesser risk of forming PP and less blood loss, as measured by both hematocrit and hemoglobin evaluation. CONCLUSION In this retrospective cohort study, the exclusion of the endometrium during the endometrium-free uterine closure technique was associated with fewer placental abnormalities in subsequent pregnancies and reduced life-threatening maternal morbidity for future cesarean deliveries.
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Affiliation(s)
- Clarel Antoine
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - Ricardo N Pimentel
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
| | - E Albert Reece
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cheongeun Oh
- Department of Population Health, Division of Biostatistics, New York University School of Medicine, New York, NY, USA
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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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15
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Sroussi J, Panchbhaya N, Boujlel S, Dautry R, Tigaizin A, Benifla JL. Cesarean scar pregnancy with deep serosal invasion at 16 weeks: Uterus-sparing surgery with posterior hysterotomy after transcatheter arterial embolization. J Obstet Gynaecol Res 2018; 44:1824-1827. [PMID: 29974587 DOI: 10.1111/jog.13707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/20/2018] [Indexed: 11/29/2022]
Abstract
We report a case of cesarean scar pregnancy at 16 weeks. Magnetic resonance imaging confirmed the isthmic ectopic location with an empty fundus and a high suspicion of placental invasion to the anterior myometrium. Because of pelvic pain, bleeding and the major risks of hysterectomy, a decision was made to terminate the pregnancy. After a preventive pelvic artery embolization, we performed an unusual posterior isthmic hysterotomy for the extraction of the fetus, followed by conservative management of the placenta. Bleeding loss was 300 mL, and no complication was reported. Successive magnetic resonance imaging was planned and 6 months later, there were no placental remnants. At 7 months, an office hysteroscopy revealed a normal uterine cavity. In case of cesarean scar pregnancy in the second trimester with an emergency need to interrupt pregnancy, posterior hysterotomy with conservative treatment of placenta may be an option to avoid massive bleeding and hysterectomy.
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Affiliation(s)
- Jérémy Sroussi
- Department of Obstetrics and Gynecology, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Nabilah Panchbhaya
- Department of Obstetrics and Gynecology, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Sihem Boujlel
- Department of Anesthesiology and Intensive Care, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Raphaël Dautry
- Department of Body and Interventional Imaging, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Bondy, France
| | - Ahmed Tigaizin
- Department of Obstetrics and Gynecology, Paris Seine Saint-Denis, site Jean-Verdier, Assistance Publique - Hôpitaux de Paris, Bondy, France
| | - Jean-Louis Benifla
- Department of Obstetrics and Gynecology, Hôpital Lariboisière, Assistance Publique - Hôpitaux de Paris, Paris, France
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16
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Pędraszewski P, Wlaźlak E, Panek W, Surkont G. Cesarean scar pregnancy - a new challenge for obstetricians. J Ultrason 2018; 18:56-62. [PMID: 29844942 PMCID: PMC5911720 DOI: 10.15557/jou.2018.0009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/09/2018] [Accepted: 01/13/2018] [Indexed: 01/25/2023] Open
Abstract
Diagnosis and treatment of ectopic cesarean scar pregnancy has become a challenge for contemporary obstetrics. With an increase in the number of pregnancies concluded with a cesarean section and with the development of transvaginal ultrasonography, the frequency of cesarean scar pregnancy diagnoses has increased as well. The aim of the study is to evaluate various diagnostic methods (ultrasonography in particular) and analyze effective treatment methods for cesarean scar pregnancy. An ultrasound scan, Doppler examination and magnetic resonance imaging are all useful in early detection of asymptomatic cesarean scar pregnancy, thus enabling effective treatment and preservation of fertility. Dilatation and curettage is not recommended as it carries significant risk of bleeding and very high risk of hysterectomy and fertility loss. Systemic methotrexate treatment should not be applied on the routine basis due to its low efficacy, high risk of fertility loss and adverse effects. Local methotrexate therapy (under ultrasound or hysteroscopy guidance) should be considered a perfect management method as it offers fertility preservation in asymptomatic pregnant patients without concomitant hemodynamic disorders. Synchronous usage of several treatment methods is an effective way to manage cesarean scar pregnancy. The combination of local methotrexate with simultaneous aspiration of gestational tissues under ultrasound or hysteroscopy guidance seems optimal. Subsequently, the remaining gestational tissues can be removed hysteroscopically in combination with vascular coagulation at the implantation site. In more advanced cases, local methotrexate treatment should be considered followed by laparoscopic or laparotomic wedge resection with subsequent surgical correction of the cesarean section scar.
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Affiliation(s)
- Piotr Pędraszewski
- Department of Gynecology and Obstetrics, Regional Polyclinical Hospital, Płock, Poland
| | - Edyta Wlaźlak
- First Department of Gynecology and Obstetrics of the Medical University of Łódź, Teaching Clinic of Operative Gynecology and Gynecologic Oncology, Łódź, Poland
| | - Wojciech Panek
- Department of Gynecology and Obstetrics, Regional Polyclinical Hospital, Płock, Poland
| | - Grzegorz Surkont
- First Department of Gynecology and Obstetrics of the Medical University of Łódź, Teaching Clinic of Operative Gynecology and Gynecologic Oncology, Łódź, Poland
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17
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Calì G, Timor-Tritsch IE, Palacios-Jaraquemada J, Monteaugudo A, Buca D, Forlani F, Familiari A, Scambia G, Acharya G, D'Antonio F. Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:169-175. [PMID: 28661021 DOI: 10.1002/uog.17568] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 06/16/2017] [Accepted: 06/22/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP). METHODS An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis. RESULTS A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case. CONCLUSIONS CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Calì
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, New York University School of Medicine, New York, NY, USA
| | - J Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - A Monteaugudo
- Department of Obstetrics and Gynaecology, Division of Maternal-Fetal Medicine, New York University School of Medicine, New York, NY, USA
| | - D Buca
- Department of Obstetrics and Gynaecology, University of Chieti, Chieti, Italy
| | - F Forlani
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - A Familiari
- Department of Maternal-Fetal Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - G Scambia
- Department of Maternal-Fetal Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - G Acharya
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
| | - F D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
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18
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Thornton P. Limitations of Vaginal Birth After Cesarean Success Prediction. J Midwifery Womens Health 2018; 63:115-120. [PMID: 29356333 DOI: 10.1111/jmwh.12724] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/02/2017] [Accepted: 12/04/2017] [Indexed: 11/27/2022]
Abstract
The Society for Maternal-Fetal Medicine endorses an algorithm for estimating the probability of successful vaginal birth for women undergoing trial of labor after cesarean (TOLAC). The algorithm is available online in the form of an easy-to-use calculator. This calculator has significant limitations that are easily overlooked by women and providers alike. The calculator has much greater positive than negative predictive power, and it cannot predict unsuccessful TOLAC or uterine rupture. Furthermore, the calculator cannot predict rare catastrophes, such as unplanned hysterectomy, permanent injury, or death. Predictions are heavily influenced by race and ethnicity, which are social and not biological constructs. Relevant variables, such as provider attitudes and institutional differences, are not accounted for. Providers should be mindful and transparent about calculator limitations when counseling women, particularly Latina and African American women. It may be appropriate to use the calculator to inform but not restrict women's options.
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19
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Abbas AM, Ali SS, Michael A, Badran SA. Caesarean Scar Ectopic Pregnancy Complicated by Uterine Rupture at 10 Weeks Gestation. J Gynecol Surg 2017. [DOI: 10.1089/gyn.2017.0034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ahmed M. Abbas
- Department of Obstetrics and Gynecology, Women's Health Hospital, and Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Shymaa S. Ali
- Department of Obstetrics and Gynecology, Women's Health Hospital, and Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Armia Michael
- Department of Obstetrics and Gynecology, Women's Health Hospital, and Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Sherif A. Badran
- Department of Obstetrics and Gynecology, Women's Health Hospital, and Faculty of Medicine, Assiut University, Assiut, Egypt
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20
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Bhide A, Sebire N, Abuhamad A, Acharya G, Silver R. Morbidly adherent placenta: the need for standardization. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 49:559-563. [PMID: 28120421 DOI: 10.1002/uog.17417] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 01/10/2017] [Accepted: 01/20/2017] [Indexed: 06/06/2023]
Affiliation(s)
- A Bhide
- Fetal Medicine Unit, Lanesborough Wing, 4th Floor, St George's, University of London & St George's University Hospitals NHS Foundation Trust, Molecular and Clinical Sciences Research Institute, London, UK
| | - N Sebire
- Perinatal Pathology, Great Ormond Street Hospital, London, UK
| | - A Abuhamad
- Eastern Virginia Medical School, Norfolk, VA, USA
| | - G Acharya
- Department of Clinical Science, Intervention and Technology, Division of Obstetrics and Gynecology, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Medicine, UiT-The Arctic University of Norway, Tromsø, Norway
| | - R Silver
- University of Utah School of Medicine, Salt Lake City, UT, USA
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21
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Kaelin Agten A, Cali G, Monteagudo A, Oviedo J, Ramos J, Timor-Tritsch I. The clinical outcome of cesarean scar pregnancies implanted "on the scar" versus "in the niche". Am J Obstet Gynecol 2017; 216:510.e1-510.e6. [PMID: 28115056 DOI: 10.1016/j.ajog.2017.01.019] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/20/2016] [Accepted: 01/13/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND The term cesarean scar pregnancy refers to placental implantation within the scar of a previous cesarean delivery. The rising numbers of cesarean deliveries in the last decades have led to an increased incidence of cesarean scar pregnancy. Complications of cesarean scar pregnancy include morbidly adherent placenta, uterine rupture, severe hemorrhage, and preterm labor. It is suspected that cesarean scar pregnancies that are implanted within a dehiscent scar ("niche") behave differently compared with those implanted on top of a well-healed scar. To date there are no studies that have compared pregnancy outcomes between cesarean scar pregnancies implanted either "on the scar" or "in the niche." OBJECTIVES The purpose of this study was to determine the pregnancy outcome of cesarean scar pregnancy implanted either "on the scar" or "in the niche." STUDY DESIGN This was a retrospective 2-center study of 17 patients with cesarean scar pregnancy that was diagnosed from 5-9 weeks gestation (median, 8 weeks). All cesarean scar pregnancies were categorized as either implanted or "on the scar" (group A) or "in the niche" (group B), based on their first-trimester transvaginal ultrasound examination. Clinical outcomes based on gestational age at delivery, mode of delivery, blood loss at delivery, neonate weight and placental histopathologic condition were compared between the groups with the use of the Mann-Whitney U test. Myometrial thickness overlying the placenta was compared among all the patients who required hysterectomy and those who did not with the use of the Mann-Whitney U test. Myometrial thickness was also correlated with gestational age at delivery with the use of Spearman's correlation. RESULTS Group A consisted of 6 patients; group B consisted of 11 patients. Gestational age at delivery was lower in group B (median, 34 weeks; range, 20-36 weeks) than in group A (median, 38 weeks; range, 37-39 weeks; P=.001). In group A, 5 patients were delivered via cesarean delivery (with normal placenta), and 1 patient underwent a cesarean-hysterectomy for placenta accreta. In group B, 10 patients had a cesarean-hysterectomy for placenta increta/percreta, and 1 patient underwent gravid-hysterectomy for vaginal bleeding at 20 weeks gestation. Blood loss was increased, but not significantly higher in group B (median, 1200 mL; range, 600-4000 mL) than in group A (median, 700 mL; range, 600-1400 mL; P=.117). Myometrium was statistically significantly thinner in the patients group that require hysterectomy (median, 1 mm; range, 0-2 mm) than in the group that did not (median, 5 mm; range, 4-9 mm; P=.001). Myometrial thickness showed a positive correlation with the gestational age (r=0.820; P<.0005). CONCLUSION Patients with cesarean scar pregnancy implanted "on the scar" had a substantially better outcome compared with patients in whom the cesarean scar pregnancy implanted "in the niche." Myometrial thickness <2 mm in the first-trimester ultrasound examination is associated with morbidly adherent placenta at delivery.
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Affiliation(s)
- Andrea Kaelin Agten
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY.
| | - Giuseppe Cali
- Department of Obstetrics and Gynecology, ARNAS Civico, Palermo, Italy
| | - Ana Monteagudo
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY; Maternal Fetal Medicine Associates, Carnegie Hill Imaging for Women, New York, NY
| | - Johana Oviedo
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY
| | - Joanne Ramos
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY
| | - Ilan Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY
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22
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Tamada S, Masuyama H, Maki J, Eguchi T, Mitsui T, Eto E, Hayata K, Hiramatsu Y. Successful pregnancy located in a uterine cesarean scar: A case report. Case Rep Womens Health 2017; 14:8-10. [PMID: 29593990 DOI: 10.1016/j.crwh.2017.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 11/22/2016] [Accepted: 03/13/2017] [Indexed: 11/18/2022] Open
Abstract
Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. Because CSP carries a high risk of uterine rupture and life-threatening bleeding, the pregnancy should be terminated upon confirmation of diagnosis. There have been few reports of CSP with successful delivery. We present a case of CSP under expectant management, with delivery via planned cesarean section at 35 weeks of gestation. This report suggests that successful pregnancy outcome can be achieved in some women with uterine cesarean scar, but further analysis and additional studies are required in order to describe the optimal protocol of expectant management in CSP.
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Affiliation(s)
- Shoko Tamada
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kita-ku, Okayama 700-8558, Japan
| | - Hisashi Masuyama
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kita-ku, Okayama 700-8558, Japan
| | - Jota Maki
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kita-ku, Okayama 700-8558, Japan
| | - Takeshi Eguchi
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kita-ku, Okayama 700-8558, Japan
| | - Takashi Mitsui
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kita-ku, Okayama 700-8558, Japan
| | - Eriko Eto
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kita-ku, Okayama 700-8558, Japan
| | - Kei Hayata
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kita-ku, Okayama 700-8558, Japan
| | - Yuji Hiramatsu
- Department of Obstetrics and Gynecology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata, Kita-ku, Okayama 700-8558, Japan
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23
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Pitfalls in Ultrasound Diagnosis of Cesarean Scar Pregnancy. J Obstet Gynaecol India 2017; 68:164-172. [PMID: 29895994 DOI: 10.1007/s13224-016-0956-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 11/25/2016] [Indexed: 12/16/2022] Open
Abstract
Cesarean scar pregnancy (CSP) is a rare kind of ectopic pregnancy implanted in the previous cesarean scar and has an increasing incidence over the past 30 years. As the suspicion is low, the diagnosis may be delayed or misinterpreted in ultrasound, leading to treatment strategies that might end up in uterine rupture or hysterectomy. The objective here is to review the ultrasound findings in CSP with varied presentations. Transabdominal and transvaginal sonography combined with color Doppler is a reliable tool for the diagnosis of CSP. When the gestational sac is seen in lower part of the uterine cavity, differentiation between threatened miscarriage, cervical pregnancy and CSP could be difficult. Not all cases of CSP present with typical ultrasound findings and a high index of suspicion is needed for diagnosis in these cases. An attempted curettage or MTP pill taken in an undiagnosed CSP often alters the typical findings. The possibility of CSP should also be considered in cases presenting with abnormal uterine bleeding and have a prior history of cesarean section. With lack of awareness about this condition, the diagnosis can often be missed either with MRI or in ultrasound. Correct interpretation and timely diagnosis save the mother from life-threatening complications and also preserves future fertility.
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24
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Chen MJ, Huang EC, Hou MY. Abnormal placentation in caesarean scar ectopic pregnancy. BMJ Case Rep 2016; 2016:bcr-2016-217311. [PMID: 27789549 DOI: 10.1136/bcr-2016-217311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Melissa J Chen
- Department of Obstetrics and Gynecology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Eric C Huang
- Department of Pathology, University of California, Davis, Sacramento, California, USA
| | - Melody Y Hou
- Department of Obstetrics and Gynecology, University of California, Davis School of Medicine, Sacramento, California, USA
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25
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Pinto PV, Machado AP, Montenegro N. Risk of hemorrhage in abnormally invasive placenta according to its management. J Matern Fetal Neonatal Med 2016; 30:2139-2145. [DOI: 10.1080/14767058.2016.1240163] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Pedro Viana Pinto
- Serviço de Ginecologia e Obstetrícia, Alameda do Professor Hernâni Monteiro, Centro Hospitalar São João, Porto, Portugal and
| | - Ana Paula Machado
- Serviço de Ginecologia e Obstetrícia, Alameda do Professor Hernâni Monteiro, Centro Hospitalar São João, Porto, Portugal and
| | - Nuno Montenegro
- Serviço de Ginecologia e Obstetrícia, Alameda do Professor Hernâni Monteiro, Centro Hospitalar São João, Porto, Portugal and
- Serviço de Ginecologia e Obstetrícia, Faculdade de Medicina da Universidade do Porto, Alameda do Professor Hernâni Monteiro, Centro Hospitalar São João, Porto, Portugal
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26
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Morbidly Adherent Placenta at 19 Weeks' Gestation. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:611. [PMID: 27591341 DOI: 10.1016/j.jogc.2016.04.089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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27
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Placenta Increta Complicating Persistent Cesarean Scar Ectopic Pregnancy following Failed Excision with Subsequent Preterm Cesarean Hysterectomy. Case Rep Obstet Gynecol 2016; 2016:4071840. [PMID: 27375911 PMCID: PMC4914722 DOI: 10.1155/2016/4071840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/08/2016] [Indexed: 12/03/2022] Open
Abstract
Introduction. Cesarean scar pregnancies (CSPs) are one of the rarest forms of ectopic pregnancy. Given their rarity, there is lack of consensus regarding the management and natural course of CSPs. Case. A 37-year-old G10 P3063 female with a history of two prior cesarean deliveries was diagnosed with her second CSP at 6 weeks and 5 days in her tenth pregnancy. The patient underwent vertical hysterotomy, excision of a gestational sac implanted in the cesarean sac, and bilateral salpingectomy via a laparotomy incision. The histopathology report confirmed immature chorionic villi. The patient returned 10 weeks later and was found to be still pregnant. Obstetric ultrasound confirmed a viable fetus of 19 weeks and 4 days of gestational age with a thin endometrium and an anteroposterior and right lateral placenta with multiple placental lakes. The patient ruptured her membranes at 31 weeks of gestation and pelvic MRI revealed an anterior placenta invading the myometrium and extending to the external serosal surface consistent with placenta increta. Following obstetric interventions, a live female infant was delivered by cesarean hysterectomy (because of placenta increta) at 32 weeks of gestation. Conclusion. Development of standardized guidelines for management of CSPs, as well as heightened vigilance for possible complications, is required for proper care and avoidance of potential morbidity and mortality.
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Ramadan EF, Cardoso-Medinillia R. Adhérence anormale du placenta à 19 semaines de grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:612. [DOI: 10.1016/j.jogc.2016.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zosmer N, Fuller J, Shaikh H, Johns J, Ross JA. Natural history of early first-trimester pregnancies implanted in Cesarean scars. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:367-375. [PMID: 25586877 DOI: 10.1002/uog.14775] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 12/18/2014] [Accepted: 12/23/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To describe the ultrasound findings and natural history of pregnancies implanted within or on Cesarean section scars in the first trimester of pregnancy. METHODS This was a prospective observational study of 10 women diagnosed with a pregnancy implanted in or on a Cesarean section scar in the first trimester, who declined medical intervention because of their desire to continue the pregnancy. The study population comprised women at < 12 weeks' gestation who were seen in our early pregnancy unit between January 2011 and September 2013. Nine women were followed up by serial ultrasound examinations and had detailed care plans for delivery at King's College Hospital (KCH). One woman was followed up and delivered at another teaching hospital. The first-trimester ultrasound findings were compared with the clinical outcome of the pregnancy. RESULTS The nine patients who were followed up at KCH developed ultrasound findings of morbidly adherent placenta (MAP) in the second and third trimesters. All 10 patients were diagnosed with MAP at the time of delivery by Cesarean section. The gestational age at delivery ranged from 26 to 38 weeks. The uterus was conserved in five patients, and Cesarean hysterectomy was performed in the remaining five. All three women with complete implantation of the gestational sac within the scar and two of three cases with placental lakes in the first trimester had hysterectomies. The two cases with bulging of the gestational sac out of the uterine contour had a preterm emergency hysterectomy due to placenta percreta. Histology confirmed placenta accreta in the five hysterectomy specimens. There were no fetal or neonatal complications. CONCLUSIONS Implantation of a pregnancy on or in a Cesarean section scar is a precursor of MAP; however, the degree of morbidity associated with this implantation is variable and difficult to predict based on first-trimester ultrasound findings only. The assessment of ongoing pregnancies implanted in Cesarean scars is most beneficial when performed between 7 and 9 weeks' gestation. Complete implantation within the myometrial defect, bulging of the trophoblast from the uterine contour and large placental lakes in the first trimester are ultrasound findings that may predict severe placenta accreta or percreta and consequently a poor outcome.
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Affiliation(s)
- N Zosmer
- Early Pregnancy Unit, Kings College Hospital, London, UK
| | - J Fuller
- Early Pregnancy Unit, Kings College Hospital, London, UK
| | - H Shaikh
- Department of Histopathology, Kings College Hospital, London, UK
| | - J Johns
- Early Pregnancy Unit, Kings College Hospital, London, UK
| | - J A Ross
- Early Pregnancy Unit, Kings College Hospital, London, UK
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Timor-Tritsch IE, Khatib N, Monteagudo A, Ramos J, Berg R, Kovács S. Cesarean scar pregnancies: experience of 60 cases. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2015; 34:601-10. [PMID: 25792575 DOI: 10.7863/ultra.34.4.601] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To evaluate the management, clinical courses, and outcomes of cesarean scar pregnancies diagnosed in the first trimester. METHODS We identified 60 cases of cesarean scar pregnancies diagnosed between 5 and 14 weeks. Group A contained 48 patients with fetal/embryonic cardiac activity; group B comprised 12 patients without cardiac activity; and group C included 11 patients with cardiac activity who chose expectant management. RESULTS Five of the 48 patients (10.4%) in group A were successfully treated for vaginal bleeding. Thirty-three (68.7%) received methotrexate injections, and all had full resolution. Three (6.3%) required uterine artery embolization for late-developing arteriovenous malformations. Ten of the 12 patients (83.3%) in group B were managed expectantly and had full recovery. Two of the 10 (20.0%) had arteriovenous malformations; 1 had unsuccessful uterine artery embolization followed by a hysterectomy, and the second requested a hysterectomy. Ten of the 11 patients (90.9%) in group C continued the pregnancies. One declined local injection. Four of the 10 (40.0%) delivered live offspring by successive elective cesarean deliveries. Three (30.0%) had hysterectomies for placenta percreta, and 1 did not have a hysterectomy after delivery. Five (50%) had second-trimester complications, all leading to hysterectomies. Of the 60 patients, 20 (33.3%) had serious complications: 5 had arteriovenous malformations; 4 had uterine artery embolization; and 11 had hysterectomies. CONCLUSIONS A cesarean scar pregnancy is a serious complication for patients who have had cesarean deliveries. Counseling, treatment, and follow-up are challenging for patients and caregivers. However, emerging data from different management approaches confirm that a cesarean scar pregnancy may progress and result in a live neonate at the expense of further fertility. This study confirmed that expectant management of a cesarean scar pregnancy is associated with a high risk of hysterectomy due to morbidly adherent placenta.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Departments of Obstetrics and Gynecology (I.E.T.-T., N.K., A.M., J.R., R.B.) and Radiology (S.K.), New York University School of Medicine, New York, New York USA.
| | - Nizar Khatib
- Departments of Obstetrics and Gynecology (I.E.T.-T., N.K., A.M., J.R., R.B.) and Radiology (S.K.), New York University School of Medicine, New York, New York USA
| | - Ana Monteagudo
- Departments of Obstetrics and Gynecology (I.E.T.-T., N.K., A.M., J.R., R.B.) and Radiology (S.K.), New York University School of Medicine, New York, New York USA
| | - Joanne Ramos
- Departments of Obstetrics and Gynecology (I.E.T.-T., N.K., A.M., J.R., R.B.) and Radiology (S.K.), New York University School of Medicine, New York, New York USA
| | - Robert Berg
- Departments of Obstetrics and Gynecology (I.E.T.-T., N.K., A.M., J.R., R.B.) and Radiology (S.K.), New York University School of Medicine, New York, New York USA
| | - Sándor Kovács
- Departments of Obstetrics and Gynecology (I.E.T.-T., N.K., A.M., J.R., R.B.) and Radiology (S.K.), New York University School of Medicine, New York, New York USA
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Armbrust R, Krätschell R, Henrich W, David M. Operative Therapy for Heterotopic Scar Pregnancy and Successful Birth of the Intrauterine Foetus - Case Report and Review of the Literature. Geburtshilfe Frauenheilkd 2015; 75:384-388. [PMID: 26028696 PMCID: PMC4437755 DOI: 10.1055/s-0035-1545918] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/06/2015] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
A heterotopic pregnancy in the vicinity of a previous Caesarean section scar (HSP) occurs frequently after fertility treatment. In spite of the low incidence to date, the increasing numbers of Caesarean sections as well as IVF treatment will probably lead to a higher prevalence in the future. Up to now the literature contains only isolated case reports on therapeutic options. These range from conservative management through selective termination of the HSP by injections of methotrexate or potassium chloride into the amniotic sac to invasive methods such as resectoscopic removal or laparoscopy. In the case presented here we describe the successful excision of the HSP by laparotomy with a subsequent uncomplicated Caesarean section and delivery of a healthy baby at the 37 + 0 week of pregnancy.
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Affiliation(s)
- R. Armbrust
- Dept. of Gynecology, Charité Berlin – Campus Virchow Klinikum, Berlin
| | - R. Krätschell
- Obstetrics, Charité Berlin – Campus Virchow Klinikum, Berlin
| | - W. Henrich
- Dept. of Gynecology, Charité Berlin – Campus Virchow Klinikum, Berlin
| | - M. David
- Obstetrics, Charité Berlin – Campus Virchow Klinikum, Berlin
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Nukaga S, Aoki S, Kurasawa K, Takahashi T, Hirahara F. A case of misdiagnosed cesarean scar pregnancy with a viable birth at 28 weeks. Case Rep Obstet Gynecol 2014; 2014:375685. [PMID: 25371837 PMCID: PMC4211178 DOI: 10.1155/2014/375685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 10/01/2014] [Indexed: 11/17/2022] Open
Abstract
We report our experience with a case of presumptive cesarean scar pregnancy, based on detection of a gestational sac (GS) in early pregnancy at the site of a previous cesarean scar. The GS grew into the uterine cavity as the pregnancy progressed, showing an ultrasound image similar to that of a normal pregnancy. Thus, the pregnancy continued, resulting in a viable birth at 28 weeks of gestation. Cesarean scar pregnancy is classified as myometrial implantation or implantation growth into the uterine cavity. In the latter type, the gestational sac moves upward with increasing gestational weeks and it shows the same ultrasound image as a normal pregnancy. Therefore, the diagnosis must be made in the early pregnancy.
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Affiliation(s)
- Sakiko Nukaga
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, 4-57 Urafunecyou, Minami-ku, Yokohama, Kanagawa 232-0024, Japan
| | - Shigeru Aoki
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, 4-57 Urafunecyou, Minami-ku, Yokohama, Kanagawa 232-0024, Japan
| | - Kentaro Kurasawa
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, 4-57 Urafunecyou, Minami-ku, Yokohama, Kanagawa 232-0024, Japan
| | - Tsuneo Takahashi
- Perinatal Center for Maternity and Neonate, Yokohama City University Medical Center, 4-57 Urafunecyou, Minami-ku, Yokohama, Kanagawa 232-0024, Japan
| | - Fumiki Hirahara
- Department of Obstetrics and Gynecology, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004, Japan
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Moshiri M, Osman S, Bhargava P, Maximin S, Robinson TJ, Katz DS. Imaging Evaluation of Maternal Complications Associated with Repeat Cesarean Deliveries. Radiol Clin North Am 2014; 52:1117-35. [DOI: 10.1016/j.rcl.2014.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Timor-Tritsch IE, Monteagudo A, Cali G, Vintzileos A, Viscarello R, Al-Khan A, Zamudio S, Mayberry P, Cordoba MM, Dar P. Cesarean scar pregnancy is a precursor of morbidly adherent placenta. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:346-353. [PMID: 24890256 DOI: 10.1002/uog.13426] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 05/06/2014] [Accepted: 05/23/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To provide further sonographic, clinical and histological evidence that Cesarean scar pregnancy (CSP) is a precursor to and an early form of second- and third-trimester morbidly adherent placenta (MAP). METHODS This is a report of 10 cases of CSP identified early, in which the patients decided to continue the pregnancy, following counseling that emphasized the possibility of both significant pregnancy complications and a need for hysterectomy. Pregnancies were followed at 2-4-week intervals with ultrasound scans and customary monitoring. The aim was for patients to reach near term or term and then undergo elective Cesarean delivery and, if necessary, hysterectomy. Charts, ultrasound images, operative reports and histopathological examinations of the placentae were reviewed. RESULTS The ultrasound diagnosis of CSP was made before 10 weeks. By the second trimester, all patients exhibited sonographic signs of MAP. Nine of the 10 patients delivered liveborn neonates between 32 and 37 weeks. In the tenth pregnancy, progressive shortening of the cervix and intractable vaginal bleeding prompted termination, with hysterectomy, at 20 weeks. Two other patients in the cohort had antepartum complications (bleeding at 33 weeks in one case and contractions at 32 weeks in the other). All patients underwent hysterectomy at the time of Cesarean delivery, with total blood loss ranging from 300 to 6000 mL. Placenta percreta was the histopathological diagnosis in all 10 cases. CONCLUSION The cases in this series validate the hypothesis that CSP is a precursor of MAP, both sharing the same histopathology. Our findings provide evidence that can be used to counsel patients with CSP, to enable them to make an informed choice between first-trimester termination and continuation of the pregnancy, with its risk of premature delivery and loss of uterus and fertility.
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Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, New York, NY, USA
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Kim ML, Jun HS, Kim JY, Seong SJ, Cha DH. Successful full-term twin deliveries in heterotopic cesarean scar pregnancy in a spontaneous cycle with expectant management. J Obstet Gynaecol Res 2014; 40:1415-9. [DOI: 10.1111/jog.12326] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 10/15/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Mi-La Kim
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Hye Sun Jun
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Joo Young Kim
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Dong Hyun Cha
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
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Timor-Tritsch IE, Monteagudo A, Cali G, Palacios-Jaraquemada JM, Maymon R, Arslan AA, Patil N, Popiolek D, Mittal KR. Cesarean scar pregnancy and early placenta accreta share common histology. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:383-395. [PMID: 24357257 DOI: 10.1002/uog.13282] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 11/28/2013] [Accepted: 12/11/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester. METHODS The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined. RESULTS Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93). CONCLUSIONS EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.
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Affiliation(s)
- I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
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Chuong EB, Hannibal RL, Green SL, Baker JC. Evolutionary perspectives into placental biology and disease. Appl Transl Genom 2013; 2:64-69. [PMID: 27896057 PMCID: PMC5121266 DOI: 10.1016/j.atg.2013.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 07/27/2013] [Indexed: 12/29/2022]
Abstract
In all mammals including humans, development takes place within the protective environment of the maternal womb. Throughout gestation, nutrients and waste products are continuously exchanged between mother and fetus through the placenta. Despite the clear importance of the placenta to successful pregnancy and the health of both mother and offspring, relatively little is understood about the biology of the placenta and its role in pregnancy-related diseases. Given that pre- and peri-natal diseases involving the placenta affect millions of women and their newborns worldwide, there is an urgent need to understand placenta biology and development. Here, we suggest that the placenta is an organ under unique selective pressures that have driven its rapid diversification throughout mammalian evolution. The high divergence of the placenta complicates the use of non-human animal models and necessitates an evolutionary perspective when studying its biology and role in disease. We suggest that diversifying evolution of the placenta is primarily driven by intraspecies evolutionary conflict between mother and fetus, and that many pregnancy diseases are a consequence of this evolutionary force. Understanding how maternal-fetal conflict shapes both basic placental and reproductive biology - in all species - will provide key insights into diseases of pregnancy.
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Affiliation(s)
- Edward B Chuong
- Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Roberta L Hannibal
- Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Sherril L Green
- Department of Comparative Medicine, Stanford University Medical Center, Stanford, CA 94305, USA
| | - Julie C Baker
- Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA
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