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Elawad M, Alyousef SZH, Alkhaldi NK, Alamri FA, Bakhsh H. Scar Ectopic Pregnancy as an Uncommon Site of Ectopic Pregnancy: A Case Report and Literature Review. Life (Basel) 2023; 13:2151. [PMID: 38004291 PMCID: PMC10672687 DOI: 10.3390/life13112151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/03/2023] [Accepted: 10/31/2023] [Indexed: 11/26/2023] Open
Abstract
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.
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Affiliation(s)
- Mamoun Elawad
- Obstetrics & Gynecology Department, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia;
| | | | - Njoud Khaled Alkhaldi
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; (N.K.A.); (F.A.A.)
| | - Fayza Ahmed Alamri
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; (N.K.A.); (F.A.A.)
| | - Hanadi Bakhsh
- Clinical Sciences Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia; (N.K.A.); (F.A.A.)
- Department of Obstetrics and Gynecology, King Abdullah Bin Abdulaziz University Hospital, Princess Nourah bint Abdulrahman University, Riyadh 11671, Saudi Arabia
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Rouvalis A, Vlastarakos P, Daskalakis G, Pouliakis A, Stavrou S, Tsiriva M, Giourga M, Gerede A, Pappa K, Gregoriadis T, Vlachos DE, Rodolakis A, Domali E. Caesarean Scar Pregnancy: Single Dose of Intrasac Ultrasound-Guided Methotrexate Injection Seems to be a Safe Option for Treatment. Ultrasound Int Open 2023; 9:E18-E25. [PMID: 37727679 PMCID: PMC10506866 DOI: 10.1055/a-2137-8318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/15/2023] [Indexed: 09/21/2023] Open
Abstract
Objective The purpose of the study was to assess the efficacy of local ultrasound-guided methotrexate injection in patients with caesarean section scar pregnancy, to chart the course of beta-human chorionic gonadotropin levels (HCG) after treatment, and to see if HCG levels are correlated with clinical presentation. Methods Between May 2018 and January 2021, data were collected retrospectively from the Early Pregnancy Unit of a tertiary hospital. Results Our clinic assessed 20 patients; one disputed terminating the pregnancy and was not included in the research. The remaining 19 patients, with a median age of 34 years, received intragestational sac methotrexate injection under ultrasound guidance. 7w3d was the median gestational age. These women had one to four previous caesarean sections, with a mean of 1.60±9. Patients with caesarean scar pregnancy most typically presented with spotting (42.1%), whereas 26.3% were asymptomatic. Except in cases of pain, the symptomatic women's HCG levels were lower than in the non-symptomatic women. The level of HCG in patients with pain was approximately double that of non-pain patients (p=0.2557). In our series, intragestational sac methotrexate injection was effective in 17/19 women, or 89.5% (95%CI: 75.7-100%). HCG levels were undetectable in 97.6±30 days on average (minimum: 42 days, maximum: 147 days). Conclusion Caesarean scar pregnancy is a rare possibly fatal condition with no consensus on the optimal treatment. An experienced Early Pregnancy Unit member performing local methotrexate injections under ultrasound guidance is a feasible and successful strategy in clinically stable patients.
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Affiliation(s)
- Angeliki Rouvalis
- Obstetrics and Gynecology, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
| | - Panagiotis Vlastarakos
- Obstetrics and Gynecology, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
| | - Georgios Daskalakis
- Obstetrics and Gynecology, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
| | - Abraham Pouliakis
- 2nd Department of Pathology, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Sofoklis Stavrou
- First Department of Obstetrics and Gynecology, University of Athens, Greece, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
| | - Maria Tsiriva
- First Department of Obstetrics and Gynecology, University of Athens, Greece, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
| | - Maria Giourga
- First Department of Obstetrics and Gynecology, University of Athens, Greece, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
| | - Angeliki Gerede
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Kalliopi Pappa
- First Department of Obstetrics and Gynecology, University of Athens, Greece, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
| | - Themos Gregoriadis
- First Department of Obstetrics and Gynecology, University of Athens, Greece, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
| | - Dimitrios-Efthymios Vlachos
- First Department of Obstetrics and Gynecology, University of Athens, Greece, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
| | - Alexandros Rodolakis
- First Department of Obstetrics and Gynecology, University of Athens, Greece, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
| | - Ekaterini Domali
- First Department of Obstetrics and Gynecology, University of Athens, Greece, National and Kapodistrian University of Athens - 1st Obstetrics and Gynecology Clinic, Athens, Greece
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Tan KL, Chen YM, Zeng W, Meng Y, Jiang L. Local Methotrexate Injection Followed by Dilation and Curettage for Cesarean Scar Pregnancy: A Prospective Non-randomized Study. Front Med (Lausanne) 2022; 8:800610. [PMID: 35127758 PMCID: PMC8815728 DOI: 10.3389/fmed.2021.800610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 12/29/2021] [Indexed: 11/13/2022] Open
Abstract
PurposeTo evaluate the clinical effects and outcomes of local intra-gestational sac methotrexate injection followed by dilation and curettage for treatment of cesarean scar pregnancies (CSP).MethodThis prospective non-randomized study was conducted on patients diagnosed with CSP between 2018 and 2020 at the Maternal and Child Health Hospital of Guangxi Zhuang Autonomous Region. Patients were categorized into two groups according to the treatments, i.e., local intra-gestational sac methotrexate injection followed by dilation and curettage (group A), and uterine artery embolization in combination with dilation and curettage (group B). The choices of treatment reflect the patients' decision after they thoroughly understood the benefits and risks of the two therapies. Clinical data were then collected and compared between these two alternatives.ResultsSeventy-seven patients with CSP were enrolled in the study. Of this total, 41 vs. 36 were respectively categorized into group A and group B. Similar success rates were observed between these two groups (92.7 vs. 97.2%; RR = 27.362, 95% CI: 0.496–1.51E3, p = 0.106). However, the overall occurrence of complications in group A was significant lower when compared with group B (17.1 vs. 52.8%; RR = 0.236, 95% CI: 0.077–0.728, p = 0.012). Lower abdominal pain (unrelated to infection) and intrauterine adhesions were the two primary complications exhibited in group B of the present study, with rates of 38.9 and 22.2% respectively.ConclusionsLocal intra-gestational sac methotrexate injection followed by dilation and curettage is an effective and safe treatment for CSP that also drastically reduces the risks of complications. Further multiple center randomized trials with large series are warranted to confirm these findings.
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Yu L, Yang B, Xu Q, Teng Y, Xue Z. A study on the timing of uterine artery embolization followed by pregnancy excision for cesarean scar pregnancy: a prospective study in China. BMC Pregnancy Childbirth 2021; 21:697. [PMID: 34654394 PMCID: PMC8518328 DOI: 10.1186/s12884-021-04180-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/05/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cesarean scar pregnancy (CSP) remains a sporadic and special form of ectopic pregnancy in which the fertilized ovum is implanted on a previous cesarean scar within 12 weeks. This study aims to evaluate the optimal time interval between uterine artery embolization (UAE) and curettage modalities in order to provide the best clinical outcomes. METHODS From January 2018 to December 2020, we recruited 61 patients with CSP. They were randomly divided into two groups depending on whether the time interval between UAE and dilatation and curettage (D&C) requires additional hospitalization: 31 patients received prophylactic UAE followed by D&C on the same day (0-12 h; group A) and 30 patients need hospitalization (12-72 h; group B). The clinical characteristics, diagnostic data, and outcomes of the two groups were compared and analyzed. RESULTS A total of 59 (96.72%) cases had responded well to the first treatment. One patient in each arm undergone retreatment, but none of the 61 patients needed additional hysterectomy. There was no considerable relationship between the two groups with respect to the intraoperative hemorrhage during D&C, serum index (containing β-hCG, hemoglobin, CRP, and D-dimer) on the first day after D&C, side effects (containing fever and abdominal pain), renal, hepatic, and coagulation function, time of CSP residual mass disappearance, and hospitalization cost. The time of serum β-hCG resolution after surgery was 41.22 ± 14.97 days in group A and 66.67 ± 36.64 days in group B (P = 0.027), and group A treatment resulted in a shorten hospital stay as compared with group B (4.81 ± 2.74 days vs. 6.80 ± 2.14 days, P < 0.001). However, the average hourly serum β-hCG decrease rate within 24 h and the leukocytes on the first day after D&C in group B were superior than in group A (P < 0.050). CONCLUSION For patients with CSP, UAE followed by D&C on the same day (0-12 h) appears to have more advantages in hospitalization and recovery time, while the long time interval (12-72 h) may have a lower risk of inflammation and a more rapid decrease in serum β-hCG level within 24 h after D&C surgery. The treatment of CSP should be individualized based on the conditions of patients.
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Affiliation(s)
- Liping Yu
- The Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Bikang Yang
- The Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Qinyang Xu
- The Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China
| | - Yincheng Teng
- The Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
| | - Zhuowei Xue
- The Department of Obstetrics and Gynecology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Shanghai, 200233, China.
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Abstract
PURPOSE OF REVIEW To review the current literature on management of cesarean scar pregnancy. RECENT FINDINGS Caesarean scar pregnancy (CSP) is a complex pathologic condition, which is strictly related to a previous caesarean section. It is an iatrogenic disorder, that has had an exponential increase over the last few years linked to the parallel increase in the number of caesarean sections. The Society for Maternal-Fetal Medicine (SMFM) confirmed the presence of surgical, medical, and minimally invasive therapies for caesarean scar pregnancy management but the optimal treatment is not known; the main recommendation is to avoid expectant management of CSP (GRADE 1B). The treatments for Caesarean scar pregnancy are multiple, and they include a surgical management, a medical management and a combination between these two types of treatments. Despite the recommendation of SMFM in this review, we also included some cases of conservative management published in the last months. SUMMARY Considering all the different approaches on CSP, the management has to be individualized mainly on gestational age and it has to be discussed by a multidisciplinary team, to choose the safest clinical option.
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Affiliation(s)
| | | | - Giuseppe Ettore
- Professor of Obstetrics and Gynaecology, Department of Obstetrics and Gynaecology, Azienda di Rilievo Nazionale e di Alta Specializzazione (ARNAS) Garibaldi Nesima, Catania, Italy
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Mo R, Kalburgi S, Thakur Y, Jadhav J. Successful hysteroscopy and curettage of a caesarean scar ectopic pregnancy. BMJ Case Rep 2021; 14:14/4/e241183. [PMID: 33858897 PMCID: PMC8055137 DOI: 10.1136/bcr-2020-241183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Caesarean scar ectopic pregnancies are the rarest type of ectopic pregnancy. The optimum management regime is not yet established. We report the case of a 39-year-old woman who presented at 11 weeks gestation with painless vaginal bleeding, having had 2 previous caesarean sections. Ultrasound revealed a gestational sac within the caesarean scar niche. On follow-up, her serial ß human chorionic gonadotropin (ßHCG) measurements fell significantly. The woman initially opted for conservative management but subsequently required surgical management. Hysteroscopy demonstrated a sac within the caesarean scar which was successfully evacuated by ultrasound-guided suction curettage, with no complications. Caesarean scar ectopic pregnancies are becoming increasingly common. Diagnosis is primarily through ultrasound using specified criteria. Management may be conservative, medical or surgical excision depending on the clinical circumstances. Hysteroscopy and suction curettage is an effective therapeutic option for caesarean scar ectopic management.
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Affiliation(s)
- Roxana Mo
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Sujatha Kalburgi
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Yatin Thakur
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Jitendra Jadhav
- Department of Obstetrics and Gynaecology, Basildon University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
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