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Guraslan H, Akgul OK, Aydin DE, Kovalak EE, Aksoy NK, Aydin TO. Laparoscopic removal of heterotopic cesarean scar pregnancy. Fertil Steril 2024; 122:543-545. [PMID: 38636771 DOI: 10.1016/j.fertnstert.2024.04.018] [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: 11/07/2023] [Revised: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To present the laparoscopic management of heterotopic cesarean scar pregnancy and discuss other treatment options. DESIGN Surgical video article. The Institutional Ethics Committee approved the video reproduction. SETTING Tertiary referral to a university hospital. PATIENT A 29-year-old woman with spontaneous heterotopic cesarean scar pregnancy presented for vaginal spotting. Ultrasound revealed two gestational sacs at 7 weeks and 6 days of gestation with fetal cardiac activity. One sac was in a normal intrauterine (IU) location, and the other was in a previous cesarean section scar. INTERVENTIONS Scar pregnancy was excised laparoscopically, preserving IU pregnancy. No additional measures were taken to reduce bleeding. The bladder was filled with 150 cc isotonic to determine its boundaries. The peritoneum was dissected away from the cervix. After removing the ectopic pregnancy material, the myometrial defect was excised. The uterine wall was closed in three layers using 2-0 V-Loc sutures. MAIN OUTCOME MEASURES Ongoing IU pregnancy after laparoscopic removal of cesarean scar pregnancy and term delivery. RESULTS The procedure was completed in 67 minutes. Total blood loss was <100 cc. The ongoing pregnancy follow-up was uneventful. Delivery was planned for the 37th-38th weeks. Although instructed to visit immediately after experiencing pain, the patient arrived after the 38th week and reported having pain for 2 days. During the cesarean section, a rupture was observed at the previous incision site, which was fortunately incomplete. A healthy male infant (weight, 3,210 g; Apgar score, 9/10) was delivered. CONCLUSIONS The most common approach for heterotopic scar pregnancy is embryo reduction with potassium chloride injection. However, the mass persists in the scar area, resulting in complications associated with excessive bleeding during a cesarean section in approximately half of cases. Moreover, almost all published cases of embryo reduction resulted in premature births before week 36. Considering the present case, laparoscopic surgery may be appropriate for managing heterotopic cesarean scar pregnancy by preserving IU pregnancy.
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Affiliation(s)
- Hakan Guraslan
- Department of Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey.
| | - Ozlem K Akgul
- Department of Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Dogan E Aydin
- Department of Obstetrics and Gynecology, Ministry of Health Havran State Hospital, Balikesir, Turkey
| | - Evrim E Kovalak
- Department of Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Nursen K Aksoy
- Department of Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Tugba O Aydin
- Department of Obstetrics and Gynecology, Ministry of Health Edremit State Hospital, Balikesir, Turkey
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Kennedy A, Debbink M, Griffith A, Kaiser J, Woodward P. Cesarean Scar Ectopic Pregnancy: A Do-Not-Miss Diagnosis. Radiographics 2024; 44:e230199. [PMID: 38843098 DOI: 10.1148/rg.230199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
The rate of cesarean section (CS) for delivery has increased internationally, reaching 50% in some countries. Abnormal implantation of a new pregnancy at the site of the prior hysterotomy is an important complication because of the risks of hemorrhage, uterine rupture, and progression to placenta accreta spectrum (PAS), a condition with high morbidity with potential for catastrophic obstetric hemorrhage, maternal and fetal mortality, and loss of fertility. Cesarean scar ectopic pregnancy (CSEP) is the recommended term to describe these pregnancies, which are recognized on the basis of the sac implantation site, growth pattern, and associated abnormal perfusion. The true incidence of CSEP is unknown because the condition is likely underdiagnosed and underreported. The 2022 Society for Maternal-Fetal Medicine consult series notes that severe maternal morbidity and mortality are linked to difficulty in making the diagnosis of CSEP. The authors review the signs of CSEP at imaging, some pitfalls that may lead to delayed or missed diagnosis, and the consequences thereof. CSEPs must be differentiated from low implantation of a normal pregnancy, cervical ectopic pregnancy, and evolving pregnancy loss. Early recognition allows prompt and safe treatment that is usually surgical. Early treatment results in decreased health care costs, a shorter hospital stay, preservation of fertility, and prevention of iatrogenic preterm delivery, which is typical in cases that progress to PAS. Hysterectomy has serious negative psychologic consequences for patients of childbearing age; early diagnosis and prompt treatment of CSEP can prevent this often-ignored complication. ©RSNA, 2024 Supplemental material is available for this article.
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Affiliation(s)
- Anne Kennedy
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Michelle Debbink
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - April Griffith
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Jennifer Kaiser
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
| | - Paula Woodward
- From the Departments of Radiology and Imaging Sciences (A.K., A.G., P.W.) and Obstetrics and Gynecology (M.D., J.K.), University of Utah Hospital, 30 N Medical Dr, Salt Lake City, UT 84132
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Karbasi M, Aletaha R, Ahangar‐Sirous R, Alamdari AH, Gharepapagh E, Rezaei S. A rare case report of heterotopic cesarean scar pregnancy in the 8th week of gestation that was managed successfully by exploratory laparotomy with dilation and curettage. Clin Case Rep 2024; 12:e9025. [PMID: 38831983 PMCID: PMC11144611 DOI: 10.1002/ccr3.9025] [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: 03/15/2024] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 06/05/2024] Open
Abstract
Key Clinical Message Swift and precise identification of heterotopic cesarean scar pregnancy, coupled with standardized treatment approaches for handling possible serious complications, form an essential component in reaching favorable outcomes for patients experiencing this rare type of pregnancy. Abstract Heterotopic pregnancy (HP) denotes a form of multiple gestation where intrauterine and ectopic pregnancies coexist. Cesarean scar ectopic pregnancy, on the other hand, involves the implantation of a fetus over the previous cesarean scar. This condition poses a significant risk of uterine rupture, which may lead to serious health complications, and even death. We report a case of a fit 37-year-old woman with two previous cesarean deliveries who was diagnosed with a heterotopic cesarean scar pregnancy at 8 weeks gestation following symptoms of lower abdominal pain and delayed menstruation. Both pregnancies demonstrated cardiac activity and the portion of the myometrium located between the bladder wall and the gestational sac was noted to exhibit considerable thinness. The patient underwent an exploratory laparotomy coupled with dilation and curettage and recovered uneventfully. The proper management of a HCSP requires timely diagnosis through ultrasonography. Early diagnosis allows for immediate intervention to prevent complications such as uterine rupture or potentially lethal bleeding.
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Affiliation(s)
- Mahsa Karbasi
- Department of Radiology, Medical SchoolTabriz University of Medical SciencesTabrizIran
| | - Reza Aletaha
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | | | | | - Esmaeil Gharepapagh
- Department of Nuclear Medicine, Medical SchoolTabriz University of Medical SciencesTabrizIran
| | - Sahar Rezaei
- Department of Nuclear Medicine, Medical SchoolTabriz University of Medical SciencesTabrizIran
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Wang F, Vaught A, Rosner M, Baschat A, Darwin K, Halscott T, Kush M, Miller J, Gomez E. Dichorionic diamniotic heterotopic twin gestation with cesarean section scar implantation and placenta increta. Radiol Case Rep 2023; 18:4006-4011. [PMID: 37691758 PMCID: PMC10491656 DOI: 10.1016/j.radcr.2023.08.075] [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: 07/05/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023] Open
Abstract
Heterotopic cesarean scar pregnancy is an extremely rare form of pregnancy and is defined as an intrauterine pregnancy coexisting with an ectopic pregnancy implanted in the cesarean scar. Cesarean scar ectopic pregnancy can also be a precursor for placenta accreta spectrum, a potentially life-threatening condition in which the placenta is abnormally adherent to the uterine myometrium and possibly adjacent organs. Although cesarean scar ectopic pregnancies are rare, there has been an increase in their incidence due to the rise in cesarean deliveries. We present the case of a 35-year-old patient with a heterotopic pregnancy with ectopic implantation in a cesarean scar and associated placenta increta, as well as the radiologic evaluation of placenta accreta spectrum and subsequent management.
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Affiliation(s)
- Felicia Wang
- Johns Hopkins University School of Medicine, 733 North Brdwy, Baltimore, MD 21205, USA
| | - Arthur Vaught
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Mara Rosner
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Ahmet Baschat
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Kristin Darwin
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Torre Halscott
- Division of Maternal Fetal Medicine, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Michelle Kush
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Jena Miller
- Center for Fetal Therapy, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Erin Gomez
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Dominguez JA, Pacheco LA, Moratalla E, Carugno JA, Carrera M, Perez-Milan F, Caballero M, Alcázar JL. Diagnosis and management of isthmocele (Cesarean scar defect): a SWOT analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:336-344. [PMID: 36730180 DOI: 10.1002/uog.26171] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/28/2022] [Accepted: 01/17/2023] [Indexed: 06/18/2023]
Abstract
The purpose of this State-of-the-Art Review was to provide a strategic analysis, in terms of strengths, weaknesses, opportunities and threats (SWOT analysis), of the current evidence regarding the management of uterine isthmocele (Cesarean scar defect). Strengths include the fact that isthmocele can be diagnosed on two-dimensional transvaginal ultrasound, and that surgical repair may restore natural fertility potential and prevent secondary infertility, as well as reduce the risk of miscarriage and other obstetric complications. However, there is a lack of high-quality evidence regarding the best diagnostic method and criteria, as well as the potential benefits of surgical repair with respect to fertility. There is a need for experienced surgeons skilled in the various isthmocele repair techniques. Isthmocele repair does not prevent the need for Cesarean delivery in subsequent pregnancies. There is increasing awareness regarding the accuracy of transvaginal ultrasound in diagnosing isthmocele. This may lead to surgical correction and prevention of obstetric and perinatal complications in subsequent pregnancies, including Cesarean scar pregnancy. Regarding threats, the existence of different surgical techniques means that there is a risk of selecting an inadequate approach if the type of isthmocele and the patient's characteristics are not considered. There is a risk of overtreatment when asymptomatic defects are repaired surgically. Finally, there is an absence of cost-effectiveness analyses to justify routine repair. Thus, while there are many data suggesting that isthmocele has an adverse effect on both natural fertility and the outcome of assisted reproduction techniques, high-quality evidence to support surgical isthmocele repair in all asymptomatic patients desiring future fertility are lacking. There is increasing agreement to recommend hysteroscopic repair of isthmocele as a first-line approach as long as the residual myometrial thickness is at least 2.5-3.0 mm. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J A Dominguez
- IERA (Instituto Extremeño de Reproducción Asistida), Badajoz, Spain
| | | | - E Moratalla
- Department of Obstetrics and Gynecology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J A Carugno
- Minimally Invasive Gynecology Division, University of Miami, Miami, FL, USA
| | - M Carrera
- Department Obstetrics and Gynecology, Hospital Universitario Doce de Octubre, Madrid, Spain
| | - F Perez-Milan
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - M Caballero
- Department of Obstetrics and Gynecology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - J L Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, Pamplona, Spain
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Kim H, Koh JH, Lee J, Sim Y, Lee SH, Lee SJ, Ahn JW, Roh HJ, Kim JS. Successful Full-Term Delivery via Selective Ectopic Embryo Reduction Accompanied by Uterine Cerclage in a Heterotopic Cesarean Scar Pregnancy: A Case Report and Literature Review. Diagnostics (Basel) 2022; 12:diagnostics12030762. [PMID: 35328315 PMCID: PMC8947258 DOI: 10.3390/diagnostics12030762] [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: 02/27/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 02/05/2023] Open
Abstract
Heterotopic cesarean scar pregnancy (HCSP) is a combination of cesarean scar pregnancy (CSP) and intrauterine pregnancy (IUP). Cesarean scar pregnancy is accompanied by life-threatening complications, such as uterine rupture and massive bleeding. Herein, we present a case of HCSP treated with selective potassium chloride injection into the CSP under ultrasonography in association with uterine cerclage to control vaginal bleeding; this led to a successful IUP preservation and full-term delivery. Additionally, we will review several previous reports on HCSP management, including our case.
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Ouyang Y, Chen H, Lin G, Xiang S, Qin J, Gong F, Li X. Heterotopic Cesarean Scar Pregnancy: An Analysis of 20 Cases Following in vitro Fertilization-Embryo Transfer. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2239-2249. [PMID: 33470465 DOI: 10.1002/jum.15610] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 11/27/2020] [Accepted: 12/12/2020] [Indexed: 06/12/2023]
Abstract
We report a series of 20 cases of heterotopic cesarean scar pregnancy in this study. The results show that transvaginal sonography offers highly accurate diagnoses of heterotopic cesarean scar pregnancy during the first trimester. Careful exclusion of cesarean scar pregnancy is of great clinical importance for patients with a history of cesarean section after in vitro fertilization-embryo transfer, even when an intrauterine pregnancy has been detected. We recommend single embryo transfer for patients with a history of cesarean section. Expectant management may provide the opportunity for a live cesarean scar pregnancy to develop, albeit at high risks of placenta accreta and hemorrhage, and this needs further verification in the future.
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Affiliation(s)
- Yan Ouyang
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- College of Life Science, Hunan Normal University, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Hui Chen
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Ge Lin
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Shuanglin Xiang
- College of Life Science, Hunan Normal University, Changsha, China
| | - Jiabi Qin
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Fei Gong
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Xihong Li
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
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An updated guide to the diagnosis and management of cesarean scar pregnancies. Curr Opin Obstet Gynecol 2021; 32:255-262. [PMID: 32618745 DOI: 10.1097/gco.0000000000000644] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW To review the current literature on the diagnosis and management of cesarean scar pregnancies RECENT FINDINGS: The incidence of cesarean scar pregnancies (CSPs) is increasing as a result of the increasing cesarean section rate, improved diagnostic capabilities, and a growing awareness. CSPs are associated with significant morbidity and early diagnosis is key. Diagnosis is best achieved with transvaginal ultrasound. Sonographic diagnostic criteria have been developed over decades and recently endorsed by the Society for Maternal-Fetal Medicine and other professional societies. The current categorization system differentiates CSPs that are endogenic or 'on the scar' from those that are exogenic or 'in the niche'. Following diagnosis, the challenge remains in determining the optimal management as multiple modalities can be considered. Studies have demonstrated the favorable outcomes with combined local and systemic methotrexate, surgical excision through multiple routes, and adjunctive therapies, such as uterine artery embolization or uterine balloons. The current evidence is insufficient to identify a single best treatment course and a combined approach to treatment is often required. SUMMARY Successful outcomes while minimizing complications can be achieved with a multidisciplinary, collaborative effort. Guidelines for cesarean scar pregnancies will continue to evolve as the published reports grow.
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Wu J, Ye J, OuYang Z, Wan Z, Zhang Q, Zhong B, Wei S. Outcomes of reproduction following cesarean scar pregnancy treatment: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2021; 262:80-92. [PMID: 33993066 DOI: 10.1016/j.ejogrb.2021.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To explore the reproductive outcomes of women with a history of cesarean scar pregnancy (CSP) and the influence of various treatments on subsequent pregnancy outcomes. STUDY DESIGN The PubMed, Embase, Medline, Cochrane Library and ClinicalTrial.gov databases were searched for studies with the outcomes of pregnancy after CSP treatment. Studies that reported reproductive outcomes after CSP with more than 5 followed cases were included. The main data collected includes the treatment methods of CSP and subsequent pregnancy outcomes. The main information includes intrauterine pregnancy, recurrent CSP (RCSP), and spontaneous miscarriage, while the secondary information includes complications during pregnancies and the outcomes of childbirths. According to different treatments (conservative treatment, surgical treatment without resection of cesarean scar, and surgical treatment with resection of cesarean scar), a stratified analysis was carried out to compare the influence of treatments on subsequent pregnancy outcomes. RESULTS A total of 32 studies including 3380 cases of CSP met the inclusion criteria, of which 583 cases conceived again after treatment (including 292 cases of unexpected pregnancy), and finally 178 cases delivered successfully. The follow-up time ranged from 3 to 72 months. Among women with fertility requirements, a total of 291 cases in 403 women were successfully conceived during the follow-up period in 15 studies. Thence the pregnancy rate of women with fertility requirements was 76.2 %. Among all of the 583 successfully conceived women, 83.4 % of them had intrauterine pregnancy, while 15.3 % of cases were RCSP. The total ectopic pregnancy rate reached 16.6 %, covering RCSP and other sites of ectopic pregnancy. 14.6 % of intrauterine pregnancy experienced spontaneous miscarriage. The intrauterine pregnancy rates of the conservative treatment group, the surgical treatment without resection of cesarean scar group, and the surgical treatment with resection of cesarean scar group were 93.1 %, 80.1 % and 86.0 % respectively; the corresponding RCSP rates were 6.9 %, 15.6 % and 14.0 % respectively; and the corresponding spontaneous miscarriage rates were 20.7 %, 13.9 % and 22.2 % respectively. CONCLUSION The outcomes of reproduction after CSP included intrauterine pregnancy, RCSP and other sites of ectopic pregnancy. Women with a history of CSP still have a high pregnancy rate, but the risk of RCSP and spontaneous miscarriage is also increased. It is impossible to clarify the effect of different treatments on subsequent pregnancy. Whether the resection and repair of cesarean scar can ameliorate reproductive outcomes needs to be further assessed. Further large-scale prospective studies, even RCTs with long-term follow-up are needed to expound the outcomes of reproduction after CSP and the effect of different treatments on subsequent reproductive outcomes.
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Affiliation(s)
- Jiawen Wu
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Jianbin Ye
- Department of Intensive Care Unit, Puning People's Hospital, Puning, China
| | - Zhenbo OuYang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China.
| | - Zixian Wan
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Qiushi Zhang
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Biting Zhong
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Shiyuan Wei
- Department of Gynecology, Guangdong Second Provincial General Hospital, Guangzhou, China
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Wu Y, Sun LF, Si YN, Luan XL, Gao YM. Clinical efficacy analysis of different therapeutic methods in patients with cesarean scar pregnancy. Taiwan J Obstet Gynecol 2021; 60:498-502. [PMID: 33966735 DOI: 10.1016/j.tjog.2021.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2020] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The purpose of this study was to analyze the clinical efficacy of five therapeutic strategies in patients with CSP. MATERIALS AND METHODS A total of 135 CSP patients were included and divided into five groups based on the treatment they received, including transvaginal resection (Group A), laparoscopic resection (Group B), uterine arterial embolization (UAE) combined with hysteroscopic curettage (Group C), UAE combined with uterine curettage (Group D), and hysteroscopic curettage (Group E). To investigate the clinical efficacy of these strategies, intraoperative bleeding, serum β-hCG levels and recovery time, menstruation recovery time, hormone levels at 1 month after treatment. RESULTS Patients in group A had the lowest postoperative serum β-hCG levels, and the shortest recovery times of both serum β-hCG and menstruation, followed by patients in group B. Group C and D had small amount of blood loss. The hospital stays and costs were low in group E. In addition, the sex hormone levels showed no significant difference among the five groups. CONCLUSION Our results indicated that resection surgery and UAE have good curative effects, but high hospital costs in CSP treatment. The selection of an optimal treatment regimen for CSP should be carried out based on specific conditions of the patients.
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Affiliation(s)
- Yan Wu
- Department of Obstetrics and Gynecology, The Affiliated Qingdao Hiser Hospital of Qingdao University (Qingdao Hospital of Traditional Chinese Medicine), Qingdao, 266033, Shandong, China
| | - Lei-Fang Sun
- Department of Obstetrics and Gynecology, The Affiliated Qingdao Hiser Hospital of Qingdao University (Qingdao Hospital of Traditional Chinese Medicine), Qingdao, 266033, Shandong, China
| | - Ya-Nan Si
- Department of Obstetrics and Gynecology, The Affiliated Qingdao Hiser Hospital of Qingdao University (Qingdao Hospital of Traditional Chinese Medicine), Qingdao, 266033, Shandong, China
| | - Xiao-Li Luan
- Department of Obstetrics and Gynecology, The Affiliated Qingdao Hiser Hospital of Qingdao University (Qingdao Hospital of Traditional Chinese Medicine), Qingdao, 266033, Shandong, China
| | - Yong-Mei Gao
- Department of Obstetrics and Gynecology, The Affiliated Qingdao Hiser Hospital of Qingdao University (Qingdao Hospital of Traditional Chinese Medicine), Qingdao, 266033, Shandong, China.
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Deng K, Liu W, Chen Y, Lin S, Huang X, Wu C, Wang H, Wang J, Chen L, Liu X, Zheng Y. Obstetric and Gynecologic Outcomes after the Transvaginal Repair of Cesarean Scar Defect in a Series of 183 Women. J Minim Invasive Gynecol 2020; 28:1051-1059. [PMID: 33326862 DOI: 10.1016/j.jmig.2020.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 01/23/2023]
Abstract
STUDY OBJECTIVE To analyze retrospectively the effect of hysteroscopy combined with transvaginal repair on the cesarean section diverticulum (CSD) and explore the clinical significance of this procedure. DESIGN Retrospective study. SETTING University-affiliated hospital and a gynecology hospital. PATIENTS A total of 183 patients with scar diverticulum after cesarean section were recruited from the Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan and Shenzhen In Vitro Fertilization Gynecological Hospital. INTERVENTIONS In this study, we reported a surgical method for repairing uterine scar through uterine therapy and explored its clinical efficacy and pregnancy outcome. MEASUREMENTS AND MAIN RESULTS The time of operation, volume of bleeding, and duration of hospitalization were recorded. The size of the scar diverticulum and the remaining myometrium were examined by B-mode ultrasonography before and after the operation. The length of the menstrual cycle and pelvic pain were recorded during follow-up to check the recovery of patients after surgery. The pregnancy of patients with pregnancy needs was recorded to check the pregnancy outcome. All 183 patients successfully completed the repair of the transvaginal uterus scar diverticulum with the help of a hysteroscopy examination. The mean (± standard deviation) operation time was 58.61 ± 18.56 minutes. The mean blood loss was 36.97 ± 22.32 mL. The mean hospital stay was 6.08 ± 1.89 days. In 57.14% of patients, the CSD completely disappeared, whereas the volume of CSD shrank by at least 50% in 88.95% of patients. The mean menstrual period of patients after surgery was 7.72 ± 2.68 days, which was significantly shorter than that recorded preoperatively (13.45 ± 3.69 days) (t = 19.62, p = .00). The pelvic pain disappeared in 81.08% of the patients. The mean postoperative thickness of the remaining muscular layer was 5.30 ± 1.27-mm, which was significantly higher than the preoperative value of 2.25 ± 0.92-mm (t = 28.21, p = .00). The mean postoperative thickness of the remaining muscular layer of patients with improved menstrual cycle was 5.40 ± 1.27-mm, which was significantly higher than the thickness of 4.88 ± 1.11-mm in patients without improved menstrual cycle (t = 2.31, p = .025). A total of 124 patients attempted to become pregnant, 83 of whom were successful. The pregnancy rate was as high as 66.95%, which included 2 scar pregnancies, 4 ectopic pregnancies, and 87 intrauterine pregnancies. No uterine rupture occurred. CONCLUSION The transvaginal repair of the uterine diverticulum improved the symptoms and probability of a successful pregnancy effectively. This process is a surgical procedure to increase the thickness of the residual uterine muscle wall effectively.
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Affiliation(s)
- Kaixian Deng
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng); Department of Gynecology, Shunde Hospital, Southern Medical University (The First People's Hospital of Shunde) (Dr. Deng), Foshan
| | - Wujiang Liu
- Department of Gynecology, Shenzhen In Vitro Fertilization Gynecological Hospital (Drs. W. Liu, Wu, H. Wang, J. Wang, and Chen), Shenzhen, Guangdong, China
| | - Yonglian Chen
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng)
| | - Shaoying Lin
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng)
| | - Xiaomin Huang
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng)
| | - Congbo Wu
- Department of Gynecology, Shenzhen In Vitro Fertilization Gynecological Hospital (Drs. W. Liu, Wu, H. Wang, J. Wang, and Chen), Shenzhen, Guangdong, China
| | - Hualing Wang
- Department of Gynecology, Shenzhen In Vitro Fertilization Gynecological Hospital (Drs. W. Liu, Wu, H. Wang, J. Wang, and Chen), Shenzhen, Guangdong, China
| | - Jiao Wang
- Department of Gynecology, Shenzhen In Vitro Fertilization Gynecological Hospital (Drs. W. Liu, Wu, H. Wang, J. Wang, and Chen), Shenzhen, Guangdong, China
| | - Lingyou Chen
- Department of Gynecology, Shenzhen In Vitro Fertilization Gynecological Hospital (Drs. W. Liu, Wu, H. Wang, J. Wang, and Chen), Shenzhen, Guangdong, China
| | - Xiaochun Liu
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng)
| | - Yuhua Zheng
- Department of Gynecology, Southern Medical University Affiliated Maternal & Child Health Hospital of Foshan (Drs. Deng, Chen, Lin, Huang, X. Liu, Zheng).
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Wang Y, Niu Z, Tao L, Yang Y, Ma C, Li R. Early intervention for heterotopic caesarean scar pregnancy to preserve intrauterine pregnancy may improve outcomes: a retrospective cohort study. Reprod Biomed Online 2020; 41:290-299. [PMID: 32553465 DOI: 10.1016/j.rbmo.2020.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Abstract
RESEARCH QUESTION What is the best intervention time and method for patients who are diagnosed with heterotopic caesarean scar pregnancy (HCSP) wishing to preserve intrauterine pregnancy. DESIGN Four patients diagnosed with HCSP from January 2014 to May 2019 were enrolled. Because HCSP is rare, data on 27 published cases were extracted to augment the analysis. Clinical characteristics and medical documents related to fetal reduction and subsequent maternal-neonate outcomes were analysed. RESULTS The intervention time was significantly earlier in the full-term birth group (6.76 ± 1.05 weeks) compared with pre-term birth group (8.02 ± 1.55 weeks; P = 0.042). The cumulative full-term delivery rate was 91.48% when the intervention was at 6 weeks' gestation and decreased to 42.02% at 8 weeks. The maternal-neonate outcome was similar among the selective fetal reduction and surgical removal groups as was delivery time (34.68 ± 3.12 versus 34.80 ± 6.64 weeks; P = 0.955). In the four cases undergoing selective fetal reduction, the residual mass grew by 1.16-7.07 times compared with the area before reduction. The maximum size of the residual mass was observed at 12-13 weeks and 22-25 weeks. CONCLUSIONS Most patients with HCSP who choose to keep intrauterine pregnancy will be able to carry the fetus to term. Selective fetal reduction would be the first intervention of choice and should take place immediately after diagnosis. The residual mass after reduction could continue to grow throughout the whole pregnancy, although this should not be considered as an indication for termination. With good supervision and careful management, the pregnancy could be maintained and carried to term.
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Affiliation(s)
- Yang Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Ziru Niu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Liyuan Tao
- Research Center of Clinical Epidemiology, Peking University Third hospital, Beijing 100191, China
| | - Yan Yang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Caihong Ma
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Rong Li
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China.
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Surgical management of first-trimester bleeding in a heterotopic caesarean scar pregnancy: A case report and review of literature. Case Rep Womens Health 2020; 27:e00209. [PMID: 32420043 PMCID: PMC7217994 DOI: 10.1016/j.crwh.2020.e00209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 02/07/2023] Open
Abstract
Heterotopic caesarean scar pregnancy (HCSP) is very rare, with only 24 cases reported in the literature. Optimal management is yet to be determined. We describe a 38-year-old woman, G2P1, who presented with vaginal bleeding and haemodynamic instability at 9 weeks of gestation in a HCSP. She was managed with ultrasound-guided lower-segment curettage and bilateral uterine artery ligation. The patient's pregnancy was complicated by preterm rupture of membranes and shortened cervix at 27 weeks of gestation. This necessitated preterm delivery, with subsequent neonatal death attributed to extreme prematurity. The patient later had a spontaneously conceived pregnancy, which was complicated by placenta percreta requiring elective caesarean hysterectomy at 34 weeks of gestation. This is, to our knowledge, the first case report describing preservation of the intrauterine pregnancy and future fertility in a patient with a HCSP and significant first-trimester bleeding. We suggest that ultrasound-guided lower-segment curettage may be a suitable management option for carefully selected patients with HCSP in a tertiary centre. All patients with HCSP require judicious counselling regarding the risk of morbidly adherent placenta and need for tertiary-level obstetric management in future pregnancies. First trimester bleeding in heterotopic caesarean scar pregnancy Surgical management of heterotopic caesarean scar pregnancy Ultrasound guided curettage with preservation of concurrent intrauterine pregnancy
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Dumont S, Jansen J, Bronselaer B, Cornelissen SA, Timmerman D, Deprest J. Uterine Arterial Embolization Combined with Laparoscopic Resection in the Management of Caesarean Scar Pregnancy. J Gynecol Surg 2019. [DOI: 10.1089/gyn.2019.0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sander Dumont
- Department of Gynaecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Jolien Jansen
- Department of Gynaecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Bart Bronselaer
- Department of Gynaecology and Obstetrics, AZ Sint-Lucas Gent, Gent, Belgium
| | - Sandra Adriana Cornelissen
- Department of Radiology, Section of Interventional Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Dirk Timmerman
- Department of Gynaecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
| | - Jan Deprest
- Department of Gynaecology and Obstetrics, University Hospitals Leuven, Leuven, Belgium
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15
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Transvaginal hysterotomy: A novel approach for the treatment of cesarean scar pregnancy. Taiwan J Obstet Gynecol 2019; 58:460-464. [DOI: 10.1016/j.tjog.2019.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2019] [Indexed: 11/22/2022] Open
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16
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Ciebiera M, Słabuszewska-Jóźwiak A, Zaręba K, Jakiel G. Heterotopic pregnancy - how easily you can go wrong in diagnosing? A case study. J Ultrason 2019; 18:355-358. [PMID: 30763022 PMCID: PMC6444310 DOI: 10.15557/jou.2018.0052] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction: Heterotopic pregnancy is a rare, but potentially life-threatening pathology. The diagnosis of heterotopic pregnancy is still one of the biggest challenges in modern gynecology. The incidence of those pregnancies in natural conception is about 1:30000. Case presentation: We present an unusual case of a heterotopic pregnancy which was misdiagnosed in the first trimester as a dichorionic twin pregnancy. At 13 weeks of gestation, the patient presented with an acute abdomen, she was diagnosed with a heterotopic pregnancy, and therefore was operated on, with the excision of the ruptured fallopian tube and the ectopic pregnancy performed. Discussion: The presence of an intrauterine pregnancy does not rule out the presence of a coexisting ectopic pregnancy. Clinicians should always keep in mind that a heterotopic pregnancy may occur in a woman of reproductive age. Careful ultrasound scan of the uterus and appendages is a must in all women of reproductive age with clinical symptoms. Introduction: Heterotopic pregnancy is a rare, but potentially life-threatening pathology. The diagnosis of heterotopic pregnancy is still one of the biggest challenges in modern gynecology. The incidence of those pregnancies in natural conception is about 1:30000. Case presentation: We present an unusual case of a heterotopic pregnancy which was misdiagnosed in the first trimester as a dichorionic twin pregnancy. At 13 weeks of gestation, the patient presented with an acute abdomen, she was diagnosed with a heterotopic pregnancy, and therefore was operated on, with the excision of the ruptured fallopian tube and the ectopic pregnancy performed. Discussion: The presence of an intrauterine pregnancy does not rule out the presence of a coexisting ectopic pregnancy. Clinicians should always keep in mind that a heterotopic pregnancy may occur in a woman of reproductive age. Careful ultrasound scan of the uterus and appendages is a must in all women of reproductive age with clinical symptoms.
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Affiliation(s)
- Michał Ciebiera
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education , Warsaw , Poland
| | | | - Kornelia Zaręba
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education , Warsaw , Poland
| | - Grzegorz Jakiel
- 1st Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education , Warsaw , Poland
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Qiu J, Fu Y, Xu J, Huang X, Yao G, Lu W. Analysis on clinical effects of dilation and curettage guided by ultrasonography versus hysteroscopy after uterine artery embolization in the treatment of cesarean scar pregnancy. Ther Clin Risk Manag 2019; 15:83-89. [PMID: 30662266 PMCID: PMC6327891 DOI: 10.2147/tcrm.s184387] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of this study was to investigate the efficiency, complications, and subsequent fertility outcomes of two methods in treating patients with cesarean scar pregnancy (CSP) after receiving uterine artery embolization (UAE) treatment. Patients and methods A total of 62 CSP patients who visited our hospital and underwent UAE from January 2013 to January 2018 were retrospectively analyzed. Patients were either treated by dilation and curettage (D&C) guided by ultrasonography or hysteroscopy. The differences of related clinical indicators, clinical efficacy, complications, and subsequent fertility outcomes between the two groups were analyzed. Results The rates of therapeutic success of the ultrasonography group and hysteroscopy group were 84.6% and 95.7%, respectively, the difference was not statistically significant (P=0.243). However, the intraoperative blood loss, duration of hospitalization, and overall complications were significantly lower in hysteroscopy group compared with D&C guided by ultrasonography group (P<0.05 for all). Meanwhile, hysteroscopy had the advantage of discovering potential diverticulum in the lower segment of anterior wall of uterus (P<0.001). Conclusion D&C guided by ultrasonography or hysteroscopy for the treatment of CSP after UAE resulted in similarly good clinical outcomes. Compared with treatment of D&C guided by ultrasonography, hysteroscopy had less complications and had the advantages of discovering diverticulum. It can be used as an effective way for the treatment of CSP.
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Affiliation(s)
- Jian Qiu
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, China, .,Department of Obstetrics and Gynaecology, Huzhou Central Hospital, Huzhou, Zhejiang 313000, China
| | - Yunfeng Fu
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, China,
| | - Jiewei Xu
- Department of General Surgery, Huzhou Central Hospital, Huzhou, Zhejiang 313000, China
| | - Xiaohong Huang
- Department of Obstetrics and Gynaecology, Huzhou Central Hospital, Huzhou, Zhejiang 313000, China
| | - Guorong Yao
- Department of Obstetrics and Gynaecology, Huzhou Central Hospital, Huzhou, Zhejiang 313000, China
| | - Weiguo Lu
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310006, China,
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Selective Reduction of a Heterotopic Cesarean Scar Pregnancy Complicated by Septic Abortion. Case Rep Obstet Gynecol 2018; 2018:6478589. [PMID: 30420929 PMCID: PMC6215580 DOI: 10.1155/2018/6478589] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 09/10/2018] [Accepted: 09/20/2018] [Indexed: 01/19/2023] Open
Abstract
Background Heterotopic pregnancy involving the implantation of an ectopic pregnancy into a prior cesarean scar with a concurrent intrauterine pregnancy is a rare and potentially life-threatening condition with minimal information in the literature to guide treatment and management options. Case A 40-year-old G5P3103 at 12 weeks and 3 days with a history of two cesarean deliveries was diagnosed with a live heterotopic pregnancy containing a cesarean scar ectopic and an intrauterine pregnancy. After selective reduction of the cesarean scar gestation with potassium chloride (KCl), the patient presented ten days later to the emergency department with septic abortion and sepsis. The patient underwent bilateral uterine artery embolization followed by ultrasound guided uterine evacuation with dilation and curettage, which was complicated by intraoperative hemorrhage and persistent bacteremia. The patient had resolution of her bacteremia after total abdominal hysterectomy. Conclusion Conservative management of uterine infection resulting from selective reduction of a heterotopic pregnancy cesarean scar pregnancy may be considered; however, severe septicemia and persistent bacteremia may necessitate definitive surgical management.
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Guo J, Yu J, Zhang Q, Song X. Clinical Efficacy and Safety of Uterine Artery Embolization (UAE) versus Laparoscopic Cesarean Scar Pregnancy Debridement Surgery (LCSPDS) in Treatment of Cesarean Scar Pregnancy. Med Sci Monit 2018; 24:4659-4666. [PMID: 29978852 PMCID: PMC6069508 DOI: 10.12659/msm.907404] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The present study aimed to compare the clinical efficacy and safety of uterine artery embolization (UAE) vs. laparoscopic cesarean scar pregnancy debridement surgery (LCSPDS) in the treatment of patients with cesarean scar pregnancy (CSP). Material/Methods A retrospective analysis was performed on 87 CSP patients from March 2012 to February 2017. For the included 87 cases, 51 were treated with UAE and 36 were treated with LCSPDS. The operation success rate, intraoperative blood loss, operation time, length of hospital stay, perioperative complications, and β-HCG level were compared. Results For the UAE group, 41 patients underwent successful surgeries (80.4% success rate), and 36 cases in the LCSPDS group were successfully treated, with no case of perioperative death. In the UAE group, the operation time, intraoperative blood loss, and length of hospital stay were 82.23±45.21 min, 112.58±68.54 mL, and 12.56±3.03 days, respectively. In the LCSPDS group, the operation time, intraoperative blood loss, and length of hospital stay were 85.45±30.02 min, 108.56±54.12 mL and 7.65±2.48 days, respectively. The length of hospital stay for the UAE group was significantly longer than in the LCSPDS group (P<0.05). Conclusions UAE and LCSPDS each have their own advantages and disadvantages in treating CSP. Thus, appropriate individualized surgical programs based on specific patient circumstances are needed to avoid indiscriminately performing complete uterine cavity curettage.
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Affiliation(s)
- Junhong Guo
- Department of Obstetrics and Gynecology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Jiangtao Yu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Qing Zhang
- Department of Obstetrics and Gynecology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
| | - Xiaojie Song
- Department of Obstetrics and Gynecology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China (mainland)
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20
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Miyague AH, Chrisostomo AP, Costa SL, Nakatani ET, Kondo W, Gomes CC. Treatment of heterotopic caesarean scar pregnancy complicated with post termination increase in size of residual mass and morbidly adherent placenta. JOURNAL OF CLINICAL ULTRASOUND : JCU 2018; 46:227-230. [PMID: 28590029 DOI: 10.1002/jcu.22507] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 04/20/2017] [Accepted: 05/05/2017] [Indexed: 06/07/2023]
Abstract
We report a case of a secundipara with heterotopic cesarean scar pregnancy (HCSP) treated with potassium chloride injection into the ectopic embryo followed by sac aspiration. The remaining "mass" increased in size threefold and was surrounded by a rich vascular network. An arteriovenous malformation was suspected; however, appropriate treatment was precluded because of the viability of the ectopic gestation. Sonographic examination revealed a morbidly adherent placenta, and attempt to resect the mass laparoscopically was complicated by bleeding that required hysterectomy. This case illustrates a complication of the intervention performed to preserve the intrauterine gestation in case of HCSP. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:227-230, 2018.
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Affiliation(s)
- Andre Hadyme Miyague
- Department of Gynecology and Obstetrics, Clinical Hospital of Federal University of Paraná-UFPR, Curitiba, Brazil
- Woman and Fetal Medicine Institute-IMMEF, Curitiba, Brazil
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Cheng XY, Cheng L, Li WJ, Qian LH, Zhang YQ. The effect of surgery on subsequent pregnancy outcomes among patients with cesarean scar diverticulum. Int J Gynaecol Obstet 2018; 141:212-216. [PMID: 29341106 DOI: 10.1002/ijgo.12444] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/28/2017] [Accepted: 01/15/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Xian-Ying Cheng
- Department of Gynecology and Obstetrics; Zhejiang Hospital; Hangzhou China
- Department of Gynecology and Obstetrics; Women's Hospital School of Medicine; Zhejiang University; Hangzhou China
| | - Li Cheng
- Department of Obstetrics and Gynecology; Hangzhou Xixi Hospital; Hangzhou China
| | - Wen-Juan Li
- Department of Gynecology and Obstetrics; Zhejiang Hospital; Hangzhou China
| | - Lin-Hua Qian
- Department of Gynecology and Obstetrics; Zhejiang Hospital; Hangzhou China
| | - Yong-Qin Zhang
- Department of Gynecology and Obstetrics; Zhejiang Hospital; Hangzhou China
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Cesarean Scar Pregnancy: A Systematic Review. J Minim Invasive Gynecol 2017; 24:731-738. [DOI: 10.1016/j.jmig.2017.02.020] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/22/2017] [Accepted: 02/24/2017] [Indexed: 12/24/2022]
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Liu G, Wu J, Cao J, Xue Y, Dai C, Xu J, Jia X. Comparison of three treatment strategies for cesarean scar pregnancy. Arch Gynecol Obstet 2017. [PMID: 28634752 DOI: 10.1007/s00404-017-4426-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To explore the optimal treatment for cesarean scar pregnancy. METHOD In total, 86 women diagnosed with a cesarean scar pregnancy were divided into three groups according to treatment. The human chorionic gonadotrophin (hCG) decline percentage, intraoperative blood loss and success rate were analyzed in Group A [combination of uterine arterial embolization (UAE), local methotrexate (MTX) injection and dilation & curettage (D&C)], Group B (combination of UAE and local MTX injection) and Group C (D&C). Then, the best treatment was carefully analyzed, and recommendations were provided. RESULTS The success rate was highest in Group A (97.5%) compared with Group B (76%) and Group C (63.15%). The reduction in hCG was greatest in Group A (86.62%, 44.0-99.97%) compared with group B (67.83%, 18.0-98.03%) and Group C (68.21%, 27.0-93.24%). The intraoperative blood loss was lowest in Group A (44.881, 5-200 ml) compared with Group C (224.737, 10-1000 ml). Additionally, we found that the best time to perform D&C in group A depended on the hCG reduction percentage, and a 35% reduction after UAE and local MTX injection could be used as the indicator to perform D&C. CONCLUSIONS The combination of UAE, local MTX injection and D&C for CSP patients is the optimal treatment strategy. A 35% reduction in hCG after UAE and local MTX injection can be recommended as the indicator to perform D&C.
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Affiliation(s)
- Guangquan Liu
- Department of Obstetrics and Gynecology, Nanjing Maternity and Child Health Care Hospital, Obstetrics and Gynecology Hospital Affiliated to Nanjing Medical University, 123 MoChou Road, Nanjing, 210004, Jiangsu, China
| | - Jiacong Wu
- Nantong Maternity and Child Health Care Hospital, Nantong, 226081, Jiangsu, China
| | - Jian Cao
- Department of Obstetrics and Gynecology, Nanjing Maternity and Child Health Care Hospital, Obstetrics and Gynecology Hospital Affiliated to Nanjing Medical University, 123 MoChou Road, Nanjing, 210004, Jiangsu, China
| | - Yunping Xue
- Department of Obstetrics and Gynecology, Nanjing Maternity and Child Health Care Hospital, Obstetrics and Gynecology Hospital Affiliated to Nanjing Medical University, 123 MoChou Road, Nanjing, 210004, Jiangsu, China
| | - Chencheng Dai
- Department of Obstetrics and Gynecology, Nanjing Maternity and Child Health Care Hospital, Obstetrics and Gynecology Hospital Affiliated to Nanjing Medical University, 123 MoChou Road, Nanjing, 210004, Jiangsu, China
| | - Juan Xu
- Department of Obstetrics and Gynecology, Nanjing Maternity and Child Health Care Hospital, Obstetrics and Gynecology Hospital Affiliated to Nanjing Medical University, 123 MoChou Road, Nanjing, 210004, Jiangsu, China.
| | - Xuemei Jia
- Department of Obstetrics and Gynecology, Nanjing Maternity and Child Health Care Hospital, Obstetrics and Gynecology Hospital Affiliated to Nanjing Medical University, 123 MoChou Road, Nanjing, 210004, Jiangsu, China.
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Surgical Management of a Heterotopic Cesarean Scar Pregnancy With Preservation of an Intrauterine Pregnancy. Obstet Gynecol 2017; 128:613-616. [PMID: 27500331 DOI: 10.1097/aog.0000000000001514] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spontaneously conceived heterotopic pregnancies are rare. A heterotopic cesarean scar pregnancy involves an intrauterine pregnancy and a second pregnancy in the cesarean scar. Treatment approaches include both medical and surgical management. We present a surgical approach to the treatment of a heterotopic cesarean scar pregnancy with preservation of an intrauterine gestation. CASE A 29-year-old woman, gravida 4 para 1021, presented at 5 weeks of gestation with spotting. Ultrasonography revealed a heterotopic cesarean scar pregnancy. The patient underwent resection of the ectopic pregnancy through minilaparotomy in an attempt to conserve the intrauterine pregnancy. She subsequently delivered an early-term neonate. CONCLUSION Laparotomy with resection of the ectopic pregnancy is an option for treatment of an early heterotopic cesarean scar pregnancy when the patient desires conservation of the intrauterine pregnancy. Excision was not associated with pregnancy complications.
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Masuda H, Uchida H, Maruyama T, Sato K, Sato S, Tanaka M. Successful treatment of atypical cesarean scar defect using endoscopic surgery. BMC Pregnancy Childbirth 2015; 15:342. [PMID: 26696492 PMCID: PMC4687144 DOI: 10.1186/s12884-015-0730-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 11/04/2015] [Indexed: 11/23/2022] Open
Abstract
Background Cesarean scar syndrome results from a postoperative defect of the uterine isthmus, also known as an isthmocele. Patients present with gynecological symptoms, such as abnormal genital bleeding or infertility, after cesarean delivery. Although the cesarean rate is increasing worldwide, this syndrome is not widely known. Case presentation A 43-year-old G2P1 Japanese woman with atypical cesarean scar syndrome had a 3-year history of secondary infertility and postmenstrual brown discharge. Laparoscopic and hysteroscopic exploration revealed a cesarean scar defect connected to a small cavity in the myometrium: this was not an endometrial cavity or a uterine diverticulum. After endoscopic excision of the cavity, the brown discharge resolved, and the patient achieved ongoing pregnancy on her third attempt at intrauterine insemination. Conclusion Consensus is still lacking regarding the diagnosis and treatment of cesarean scar defect. However, the gynecologists should be aware that cesarean scar syndrome can have scar defects forming cavities of unusual shapes and features. Surgical correction of these defects will often improve postmenstrual bleeding and subfertility in these cases.
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Affiliation(s)
- Hirotaka Masuda
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Hiroshi Uchida
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Tetsuo Maruyama
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Kenji Sato
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Suguru Sato
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Mamoru Tanaka
- Department of Obstetrics and Gynecology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
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Refaat B, Dalton E, Ledger WL. Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies. Reprod Biol Endocrinol 2015; 13:30. [PMID: 25884617 PMCID: PMC4403912 DOI: 10.1186/s12958-015-0025-0] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/03/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Ectopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment. METHODS The scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected. RESULTS A history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence. CONCLUSIONS EP/HP are tragic events in a couple's reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.
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Affiliation(s)
- Bassem Refaat
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-Abdiyah Campus, PO Box 7607, Makkah, KSA.
| | - Elizabeth Dalton
- School of Women's & Children's Health, University of New South Wales, Sydney, NSW, 2031, Australia.
| | - William L Ledger
- School of Women's & Children's Health, University of New South Wales, Sydney, NSW, 2031, Australia.
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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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