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Carletti V, Yacoub V, Lopizzo P. Ultrasound-guided suction curettage followed by cervico-isthmic placement of foley three-way catheter for cesarean scar pregnancy's treatment. Retrospective study. J Gynecol Obstet Hum Reprod 2024:102746. [PMID: 38369245 DOI: 10.1016/j.jogoh.2024.102746] [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: 11/14/2023] [Revised: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES Cesarean scar pregnancy (CSP) is a rare dangerous condition with still no consensus on standard treatment. Suction curettage has been used as the first-line treatment for CSP with controversial outcomes. This study evaluates efficacy of ultrasound-guided suction curettage (UGSC) followed by cervical-isthmic placement of silicon semirigid three-way foley catheter. MATERIALS AND METHODS This study included 24 women with CSP. Preoperative ultrasound study was conducted. UGSC followed by placement of catheter was performed in all patients. The success rate and incidence of major complication, surgical time and hospital stay were recorded. RESULTS The success rate of UGSC followed by placement of foley catheter was 100%, effectively reduced major complications and none of the patients had a blood loss higher than 900 ml. Median hospital stay was 2 days and median foley stay was 1 day. Surgery had limited last with a median of 17 minutes. CONCLUSION UGSC followed by foley placement is a safe effective treatment for CSP with a clinical resolution of 100%. The catheter is easy to place under ultrasound guidance and prevents bleeding, reducing major procedures to solve the bleeding. Suction curettage in CSP treatment should be performed under ultrasound guidance and followed by cervical-isthmic placement of foley balloon.
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Affiliation(s)
- Valerio Carletti
- Department of Obstetrics and Gynecology, "Tor Vergata" University, Rome, Italy; Department of Obstetrics and Gynecology, Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy.
| | - Veronica Yacoub
- Department of Obstetrics and Gynecology, "Tor Vergata" University, Rome, Italy; Department of Obstetrics and Gynecology, Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy
| | - Paola Lopizzo
- Department of Obstetrics and Gynecology, Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy
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Timor-Tritsch IE, Kaelin Agten A, Monteagudo A, Calỉ G, D'Antonio F. The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy. Best Pract Res Clin Obstet Gynaecol 2023; 91:102409. [PMID: 37716338 DOI: 10.1016/j.bpobgyn.2023.102409] [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: 02/20/2023] [Revised: 08/02/2023] [Accepted: 08/17/2023] [Indexed: 09/18/2023]
Abstract
Cesarean scar pregnancy (CSP) is among the most severe complications of cesarean delivery. CSP refers to the abnormal implantation of the gestational sac in the area of the prior cesarean delivery (CD), potentially leading to severe hemorrhage, uterine rupture, or development of placenta accreta spectrum disorders (PAS). The management of women with CSP has not been standardized yet. In women who opted for termination, discussion about the treatments should consider maternal symptoms, gestational age at intervention, and the future reproductive risk. A multitude of treatments, either medical or surgical, for CSP has been reported in the published literature. The present review aims to provide up-to-date information on a recently introduced minimally invasive treatments for CSP, including the single and double balloon catheter. The methodology of using the single or double catheter is described in a step-by-step fashion illustrated by pictures as well as video recordings. Both catheters have their deserved place to be used as a primary method for terminating scar pregnancies as well as using them as adjuncts to other treatments. They were successfully used by multiple individual practitioners and institutions due to their simplicity and low complication rates. The rare, but possible post-procedure complications such as recurrent CSP and enhanced myometrial vascularity are also mentioned.
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Affiliation(s)
| | - Andrea Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, L8 7SS, United Kingdom
| | - Ana Monteagudo
- Icahn School of Medicine. Carnegie Maternal Fetal Associates New York, USA
| | - Giuseppe Calỉ
- Maternal Fetal Medicine Unit AO Villa Sofia-Cervello, Italy
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3
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Wu BT, Feld Z, Creinin MD. Management of cesarean scar ectopic pregnancies at an academic referral center: A case series. Contraception 2023; 123:110021. [PMID: 36940910 DOI: 10.1016/j.contraception.2023.110021] [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: 12/06/2022] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 03/22/2023]
Abstract
OBJECTIVES To describe treatment and outcomes of patients with confirmed cesarean scar ectopic pregnancy (CSEP) at a tertiary referral center. STUDY DESIGN We reviewed a deidentified family planning clinical database for patients seen by our subspecialty service for CSEP from January 2017 through December 2021 in this case series. We extracted referral information, final diagnosis, management, and outcome measures including estimated blood loss, secondary procedures, and treatment complications. RESULTS Of 57 cases referred for suspected CSEPs, 23 (40%) had confirmed diagnoses; one additional case was diagnosed during clinic evaluation for early pregnancy loss. Most (n = 50 [88%]) referrals occurred in the last 2 years of the 5-year study period. Of 24 confirmed CSEP cases, eight were pregnancy losses at the time of diagnosis. Fourteen cases were ≤50 days gestation or gestational size (7 [50%] pregnancy losses) and 10 >50 days gestation (range 39-66 days). We treated all 14 patients ≤50 days primarily with suction aspiration under ultrasound guidance in an operating room with no complications and estimated blood loss of 14 ± 10 mL. Of the 10 patients>50 days (maximum 66 days), seven were managed with primary aspiration of which five were uncomplicated. We treated one patient (57 days) had primary intrauterine double-catheter balloon with immediate hemorrhage requiring uterine artery embolization followed by an uncomplicated suction aspiration. CONCLUSIONS Patients with confirmed CSEPs at 50 days or less gestation or gestational size can likely be primarily treated with suction aspiration with low risk for significant adverse outcomes. Treatment success and complications are directly related to gestational age at treatment. IMPLICATIONS Ultrasound-guided suction aspiration monotherapy should be considered for primary CSEP treatment up to 50 days and, with continued experience, may be reasonable beyond 50 days gestation. Invasive treatments or those that require multiple days and visits, such as methotrexate or balloon catheters, are not necessary for early CSEPs.
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Affiliation(s)
- Brenda T Wu
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Zoe Feld
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA
| | - Mitchell D Creinin
- Department of Obstetrics and Gynecology, University of California, Davis, Sacramento, CA, USA.
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Nijjar S, Jauniaux E, Jurkovic D. Surgical evacuation of cesarean scar ectopic pregnancies. Best Pract Res Clin Obstet Gynaecol 2023; 89:102361. [PMID: 37356118 DOI: 10.1016/j.bpobgyn.2023.102361] [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: 04/01/2023] [Revised: 04/13/2023] [Accepted: 05/02/2023] [Indexed: 06/27/2023]
Abstract
Cesarean scar ectopic pregnancy is associated with significant maternal morbidity, including severe hemorrhage, need for the blood transfusion and hysterectomy. Early diagnosis is therefore key in ensuring timely management, with consensus being that treatment before 9 weeks of gestation leads to reduced morbidity. There is no universally adopted management protocol for cesarean scar ectopic pregnancy, but surgical management generally has a higher success rate than medical management. The primary surgical treatment modalities are suction evacuation versus resection of the pregnancy via multiple routes. Adjuncts that have been shown to successfully minimize bleeding with surgical management include cervical cerclage, balloon catheter, and uterine artery embolization. However, there remains a lack of high-quality evidence regarding what is the best surgical treatment option for cesarean scar ectopic pregnancy, and therefore it is essential that clinicians provide tailored management to patients considering the presenting symptoms and local expertise with various surgical techniques.
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Affiliation(s)
- Simrit Nijjar
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Davor Jurkovic
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
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Management of caesarean scar pregnancy with ultrasound guided suction curettage followed by foley balloon catheter placement. J Gynecol Obstet Hum Reprod 2022; 51:102471. [DOI: 10.1016/j.jogoh.2022.102471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/05/2022] [Accepted: 09/06/2022] [Indexed: 11/20/2022]
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Miller R, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy. Am J Obstet Gynecol 2022; 227:B9-B20. [PMID: 35850938 DOI: 10.1016/j.ajog.2022.06.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cesarean scar ectopic pregnancy is a complication in which an early pregnancy implants in the scar from a previous cesarean delivery. This condition presents a substantial risk for severe maternal morbidity and mortality because of challenges in securing a prompt diagnosis. Ultrasound is the primary imaging modality for cesarean scar ectopic pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar ectopic pregnancy management, but the optimal treatment is unknown. Patients who decline treatment of a cesarean scar ectopic pregnancy should be counseled regarding the risk for severe morbidity. The following are the Society for Maternal-Fetal Medicine recommendations: we recommend against expectant management of cesarean scar ectopic pregnancy (GRADE 1B); we suggest that operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided uterine aspiration be considered for the surgical management of cesarean scar ectopic pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for the medical treatment of cesarean scar ectopic pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar ectopic pregnancy (GRADE 1C); in patients who choose expectant management and continuation of a cesarean scar ectopic pregnancy, we recommend repeated cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that patients with a cesarean scar ectopic pregnancy be advised on the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).
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Mu L, Weng H, Wang X. Evaluation of the treatment of high intensity focused ultrasound combined with suction curettage for exogenous cesarean scar pregnancy. Arch Gynecol Obstet 2022; 306:769-777. [PMID: 35303150 DOI: 10.1007/s00404-022-06487-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 02/21/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the effectiveness of high-intensity focused ultrasound (HIFU) combined with suction curettage in the treatment of exogenous cesarean scar pregnancy (CSP). METHODS A retrospective single-center observational study was conducted. A total of 41 patients diagnosed with exogenous CSP were enrolled in this study. All patients received HIFU combined with suction curettage. RESULTS Twenty-nine patients were administered one session of HIFU ablation. In addition, the other 12 patients received 2 HIFU sessions. Suction curettage was performed in all patients after HIFU, and no patient was converted to laparoscopy or hysterectomy. The mean blood loss during suction curettage was 99 ml. Three patients received two sessions of suction curettage. The success rate of our study was 92.68%. The mean time for serum β-HCG normalization was 23.18 ± 3.13 days. The average menstruation recovery time was 29.38 ± 3.34 days. Based on the blood loss during suction curettage, 41 patients were divided into a bleeding group and a control group. The size of the gestational sac in the bleeding group (3.80 ± 0.87 cm) was larger than that in the control group (3.39 ± 0.77 cm) (P < 0.05). The thickness of the myometrium between the bladder and gestational sac in the bleeding group (2.37 ± 0.89 mm) was less than that in the control group (2.75 ± 0.75 mm) (P < 0.05). CONCLUSION The results suggested that HIFU combined with suction curettage could be considered an effective treatment for exogenous CSP of < 9 weeks. The size of the gestational sac and the thickness of the myometrium between the bladder and gestational sac might be high-risk factors for blood loss during this treatment.
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Affiliation(s)
- Lin Mu
- Department of Gynecology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang, China.
| | - Huifang Weng
- Department of Ultrasound, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Xiaoyun Wang
- Department of Gynecology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang, 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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Vo TM, Dinh HT, Van TP, Nguyen CS. Value of Crossover Sign in Anticipating Under-8-week Cesarean Scar Pregnancy Treatment by Foley Insertion Combined with Suction Curettage in Vietnam. Gynecol Minim Invasive Ther 2021; 10:84-90. [PMID: 34040966 PMCID: PMC8140541 DOI: 10.4103/gmit.gmit_127_19] [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: 03/16/2020] [Revised: 08/24/2020] [Accepted: 09/14/2020] [Indexed: 11/06/2022] Open
Abstract
Objectives: An earlier study completed at TuDu Hospital presented the efficacy of Foley insertion combined with fetal suction curettage at a high rate of success in treatment of cesarean scar pregnancy (CSP) of < 8 weeks, but the efficacy of prognosticating factors for this approach has not been specifically addressed yet, especially crossover sign (COS) on ultrasound. We aimed to investigate the correlation between COS on ultrasound and the treatment results of CSP using Foley insertion combined with fetal suction. Materials and Methods: A case–control study of CSPs ≤ 8 weeks treated at TuDu Hospital during September 2017–April 2019 included 63 failures in the case group and 98 successes in the control group. Results: COS-2 + increased the likelihood of treatment success by 4.9 times (95% confidence interval: 1.8–13.5) compared with COS-1 cases. In addition, other factors favoring treatment success with statistical significance included no vascularization at cesarean scar on ultrasound (odds ratio [OR] = 7.1), gestational mass volume ≤4 cm3 (OR = 3.7), and β-human chorionic gonadotropin at hospital admission ≤ 10,000 mIU/mL (OR = 6.1). Conclusion: COS imaging played an important role in the prediction of treatment outcomes for CSP ≤ 8 weeks by the combined approach of Foley insertion and fetal suction curettage.
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Affiliation(s)
- Tuan Minh Vo
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at HCMC, Vietnam
| | - Hoang T Dinh
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at HCMC, Vietnam
| | - Thong P Van
- Department of Gynecology, Tudu Hospital at Ho Chi Minh City, Vietnam
| | - Christopher Son Nguyen
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy at HCMC, Vietnam
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Karakuş R, Karakuş SS, Güler B, Ünver G, Özkaya E. Myometrial thickness overlying cesarean scar pregnancy is significantly associated with isthmocele formation in the third month of the postoperative period. Turk J Obstet Gynecol 2021; 18:37-43. [PMID: 33715331 PMCID: PMC7962161 DOI: 10.4274/tjod.galenos.2021.65288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective: To determine some associated factors for isthmocele formation 3 months after the treatment of cesarean scar pregnancy (CSP). Materials and Methods: This is a prospective consecutive case series of CSP managed by fertility preservation modalities at a single tertiary care center from May 2016 to March 2019 (n=95). Patients with a diagnosis of CSP were identified and followed prospectively to collect data on the patients’ demographics; detailed medical, surgical, and social history; symptoms; imaging and laboratory parameters at the time of CSP diagnosis and during treatment; treatment modalities, myometrial thickness; and outcomes in terms of isthmocele formation. Results: Mean myometrial thickness overlying scar pregnancy was significantly lower in the group with isthmocele formation, and the mean gestational age of scar pregnancy was also significantly lower in the group with isthmocele formation following treatment of scar pregnancy (p<0.05). Multivariate regression analysis was conducted to determine associations between certain variables and isthmocele development, which revealed that the gestational age of scar pregnancy and myometrial thickness were significantly associated with isthmocele formation. Conclusion: Myometrial thickness and gestational age of scar pregnancy were significantly associated with isthmocele formation 3 months after treatment.
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Affiliation(s)
- Resul Karakuş
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Sultan Seren Karakuş
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Burak Güler
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Gökhan Ünver
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
| | - Enis Özkaya
- University of Health Sciences Turkey, Zeynep Kamil Women and Children's Diseases Training and Research Hospital, Clinic of Obstetrics and Gynecology, İstanbul, Turkey
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Pristavu A, Vinturache A, Mihalceanu E, Pintilie R, Onofriescu M, Socolov D. Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series. BMC Pregnancy Childbirth 2020; 20:617. [PMID: 33050911 PMCID: PMC7557042 DOI: 10.1186/s12884-020-03237-8] [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: 01/28/2020] [Accepted: 09/07/2020] [Indexed: 12/12/2022] Open
Abstract
Background There is no clear consensus on the management of caesarean scar pregnancy (CSP), a complex and life-threatening condition. The objective of this study was to present a novel approach to management of CSP that combines medical therapy of multidose methotrexate and mifepristone with active surgical management by uterine curettage and consecutive local haemostasis. Case presentation We report on a prospective case series of six women with first trimester pregnancy, in whom the diagnosis of CSP was confirmed by 2D and color Doppler transvaginal ultrasound and serial hormone chorionic gonadotropin (hCG) testing. Women were between 23 and 36 years old and had at least one previous delivery by caesarean. At admission, gestational age ranged between 6 to 14 weeks, and serum hCG levels between 397 and 23,000 mUI/ml. Upon decision of pregnancy termination, medical management was undertaken in all cases and 1 mg/kg systemic Methotrexate was administered between 1 and 5 daily doses. Mifepristone was part of the treatment in cases with live pregnancy. Surgical management was employed for the cases were an embryo was seen by ultrasound, being prompted by inadequate response to Methotrexate and/or signs of miscarriage with vaginal bleeding. Curettage combined with local isthmic balloon or vaginal pack tamponade prevented further complications. High treatment rates with preservation of fertility was achieved in all patients except one who underwent hysterectomy for invasive placentation. Ultrasound and hCG levels surveillance ensured that the resolution of pregnancy was achieved. Conclusion Women with history of delivery by caesarean section should be carefully monitored in future pregnancies for prompt diagnosis of CSP. Early diagnosis of CSP allows selection of successful conservative therapy. Through this case series we contribute with our experience to the body of knowledge about the management of this serious complication of early pregnancy.
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Affiliation(s)
- Anda Pristavu
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Angela Vinturache
- Department of Obstetrics & Gynaecology, Women's Centre, John Radcliffe University Hospital, Oxford University Hospitals NHS Foundation Trust, Headley Way, Oxford, OX3 9DU, UK.
| | - Elena Mihalceanu
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Radu Pintilie
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Mircea Onofriescu
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
| | - Demetra Socolov
- Cuza-Voda Obstetrics and Gynecology University Hospital, Grigore T.Popa University of Medicine and Pharmacy, Iasi, Romania
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Tan KL, Jiang L, Chen YM, Meng Y, Lv BQ, Wei LF, Peng XZ, Ling YY, Lan J, Wei JY. Local intra-gestational sac methotrexate injection followed by dilation and curettage in treating cesarean scar pregnancy. Arch Gynecol Obstet 2020; 302:439-445. [DOI: 10.1007/s00404-020-05619-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 05/26/2020] [Indexed: 12/14/2022]
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13
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Abstract
Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).
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Timor-Tritsch IE, Monteagudo A, Calì G, D'Antonio F, Agten AK. Cesarean Scar Pregnancy: Patient Counseling and Management. Obstet Gynecol Clin North Am 2020; 46:813-828. [PMID: 31677756 DOI: 10.1016/j.ogc.2019.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
There is no universally agreed upon and adopted management protocol supported by professional societies in the United States or around the world for the treatment of cesarean scar pregnancy. There is a wide range of management options in the literature, and many of them can to lead to severe bleeding complications, which can result in loss of fertility or even maternal death. If inadequately managed, it can lead to untoward complications throughout all 3 trimesters of the pregnancy. Early detection of CSP has a paramount clinical importance.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Health, 550 1st Avenue, New York, NY 10016, USA.
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calì
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - Francesco D'Antonio
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Andrea Kaelin Agten
- Nottingham University Hospitals NHS, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
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Cohen A, Jersey A, Nelson M. Use of Point-of-Care Ultrasound to Facilitate Guidance and Intrauterine Placement of a Foley Urinary Catheter to Tamponade Life-Threatening Postprocedure Hemorrhage Caused by Disseminated Intravascular Coagulation. J Emerg Med 2020; 58:e75-e78. [PMID: 31982201 DOI: 10.1016/j.jemermed.2019.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 09/19/2019] [Accepted: 11/23/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Severe vaginal hemorrhage caused by disseminated intravascular coagulation (DIC) after dilation and evacuation is a rare but life-threatening situation that can be difficult to manage. Obtaining hemostasis in such a patient with heavy vaginal bleeding secondary to DIC can be difficult. One technique involves the use of a urinary bladder catheter inserted into the uterus that is inflated to apply pressure on the endometrium, allowing for tamponade of the bleeding. CASE REPORT A 36-year-old female gravida 2 para 0 at 21 weeks' gestation presented to the emergency department after being transferred from another facility for a higher level of care available at our facility, after a dilation and evacuation procedure that was indicated because of intrauterine fetal demise. The physical examination was significant for an ill-appearing female with active heavy vaginal bleeding. Resuscitation was initiated with packed red blood cells, cryoprecipitate, and platelets. Because of her thrombocytopenia, the development of DIC was suspected. Point-of-care ultrasound (POCUS) was performed and showed a thickened endometrial stripe with evidence of multiple anechoic foci, which were thought to represent intrauterine clots. To tamponade the bleeding, a 30-cc standard Foley urinary bladder catheter was placed into the uterus, using POCUS for guidance, to attempt to induce hemostasis via tamponade of the bleeding after inflation of the catheter balloon. Placement of an intrauterine urinary catheter to enable tamponade can be useful for the management of uncontrolled hemorrhage, but can be difficult to accomplish without use of POCUS for guidance. POCUS enabled us to accomplish accurate intrauterine placement of the urinary catheter and confirmation of a properly placed catheter balloon within the uterus. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Menorrhagia in the emergency department can be difficult to manage, especially in the setting of DIC. Placement of an intrauterine urinary catheter can be useful in management but may be difficult for the inexperienced provider. POCUS can be used to guide the catheter into place and confirm the location once the balloon is inflated.
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Affiliation(s)
- Allison Cohen
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Andrew Jersey
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
| | - Mathew Nelson
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, New York
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Lian ZQ, Yu HY, Zhang AQ, Xie SM, Wang Q. Use of urinary balloon catheter to prevent postoperative bleeding after ultrasound-guided vacuum-assisted breast biopsy. Breast J 2019; 26:144-148. [PMID: 31650650 DOI: 10.1111/tbj.13484] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 04/14/2019] [Accepted: 04/15/2019] [Indexed: 11/30/2022]
Abstract
Postoperative bleeding is the most frequent serious complications after vacuum-assisted breast biopsy (VABB). The aim of this study was to evaluate the clinical effect of using urinary balloon catheter to prevent postoperative bleeding after ultrasound-guided VABB. From May 2016 to June 2018, 324 patients who underwent ultrasound-guided VABB were randomized into the study group and control group. In the study group, an urinary balloon catheter was inserted into the excision cavity to prevent bleeding and hematoma. In the control group, compression with thorax pressure bandage was used for hemostasis. Postoperative subcutaneous ecchymosis and hematoma were recorded and compared between the two groups. The rates of postoperative ecchymosis and hematoma in the study group were significantly lower than that in the control group (5.6% vs 13.0%, P < .05; 8.0% vs 20.4%, P < .05). Among patients with lesions ≤1.5 cm, the rates of postoperative ecchymosis and hematoma were 2.9% and 4.3% in the study group, 6.5% and 11.7% in the control group, but there was no statistically significant difference between the two groups (P > .05). Among patients with lesions >1.5 cm, the rates of postoperative ecchymosis and hematoma in the study group were significantly lower than that in the control group (7.6% vs 18.8%, P < .05; 10.9% vs 28.2%, P < .05). Hemostasis with balloon urinary catheter is a safe and effective method to prevent postoperative bleeding after VABB.
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Affiliation(s)
- Zhen-Qiang Lian
- The First Clinical Medical College of Jinan University, Jinan University, Guangzhou, Guangdong, China.,Breast disease center, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Hai-Yun Yu
- Breast disease center, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - An-Qin Zhang
- Breast disease center, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Si-Mei Xie
- Breast disease center, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Qi Wang
- The First Clinical Medical College of Jinan University, Jinan University, Guangzhou, Guangdong, China.,Breast disease center, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
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Hanacek J, Vojtech J, Urbankova I, Krcmar M, Křepelka P, Feyereisl J, Krofta L. Ultrasound cesarean scar assessment one year postpartum in relation to one- or two-layer uterine suture closure. Acta Obstet Gynecol Scand 2019; 99:69-78. [PMID: 31441500 PMCID: PMC6973250 DOI: 10.1111/aogs.13714] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/19/2019] [Accepted: 08/09/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION This study compared healing of the scars after cesarean section during the first postpartum year using a single- or double-layer suturing technique. Scarring was assessed by a transvaginal ultrasound. We explored the appearance and localization of uterine scars with regard to the obstetric history. Our aim was to compare the position of the scar or defect, if present, its dimensions, and any residual myometrium with respect to the suturing technique during the cesarean section. MATERIAL AND METHODS Women with uncomplicated singleton pregnancies indicated for elective or acute cesarean section were randomly allocated to the uterine closure technique group. During the first postpartum year, their lower uterine segment was examined with a transvaginal ultrasound in three consecutive visits at 6 weeks, 6 months and 12 months. RESULTS 324 women attended the 12-month visit; of these, 149 underwent single-layer closure of the uterine incision and 175 double-layer technique. A higher proportion of the defects is seen in the single-layer closure technique of suturing. Defects in the single-layer group were wider (0.002) and the residual myometrial thickness in the single-layer group were thinner (0.019). Women who underwent cesarean section at the stage of full cervical dilation had scars that were closer to the external cervical os (0.000). The position of the uterus varies greatly between controls (0.000). The combination of uterine position and scar defect presence changed significantly between controls (0.001), and was significantly dependent on the suturing method (0.003). Defects with or without contact with the uterine cavity changed statistically between controls (0.017). Both types of defects were more common in the single-layer closure technique group. CONCLUSIONS The findings of this study demonstrate that double-layer technique with the first continuous nonlocking suture followed by a second continuous nonlocking suture is associated with better suture healing and greater residual myometrial thickness. No difference was observed between single- and double-layer closure for the presence of maternal infectious morbidity, wound infection or blood transfusion.
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Affiliation(s)
- Jiri Hanacek
- Institute for the Care of Mother and Child, Prague, Czech Republic.,3rd Medical Faculty, Charles University, Prague, Czech Republic
| | - Jiri Vojtech
- Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Iva Urbankova
- Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Michal Krcmar
- Institute for the Care of Mother and Child, Prague, Czech Republic.,3rd Medical Faculty, Charles University, Prague, Czech Republic
| | - Petr Křepelka
- Institute for the Care of Mother and Child, Prague, Czech Republic.,3rd Medical Faculty, Charles University, Prague, Czech Republic
| | - Jaroslav Feyereisl
- Institute for the Care of Mother and Child, Prague, Czech Republic.,3rd Medical Faculty, Charles University, Prague, Czech Republic
| | - Ladislav Krofta
- Institute for the Care of Mother and Child, Prague, Czech Republic.,3rd Medical Faculty, Charles University, Prague, Czech Republic
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18
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Intrauterine Foley Balloon Catheter to Manage Acute Heavy Menstrual Bleeding in a Perimenarchal 10-Year-Old Girl. Obstet Gynecol 2019; 134:77-80. [PMID: 31188323 DOI: 10.1097/aog.0000000000003330] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Lu YM, Guo YR, Zhou MY, Wang Y. Indwelling Intrauterine Foley Balloon Catheter for Intraoperative and Postoperative Bleeding in Cesarean Scar Pregnancy. J Minim Invasive Gynecol 2019; 27:94-99. [PMID: 31212071 DOI: 10.1016/j.jmig.2019.02.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/01/2019] [Accepted: 02/20/2019] [Indexed: 12/31/2022]
Abstract
STUDY OBJECTIVE Cesarean scar pregnancy (CSP) is a rare type of ectopic pregnancy, and a significant concern in the management of this condition is the control and prevention of bleeding. We aimed to determine the efficacy and value of an indwelling, intrauterine Foley balloon catheter in controlling and preventing intraoperative and postoperative bleeding in patients with CSP. DESIGN Retrospective case series. SETTING University-affiliated hospital. PATIENTS Between January 1, 2015 and May 31, 2017, 70 patients presented with CSP. INTERVENTIONS All patients underwent uterine curettage under hysteroscopic guidance and ultrasound monitoring. Patients were then assigned to 2 groups: the study group, with an indwelling Foley balloon catheter placed in the uterine cavity during surgery and retained for 24 to 48 hours, and the control group, without catheter placement. Data were collected to compare the 2 groups in terms of intraoperative and postoperative complications, surgical time, and status of menstruation resumption. MEASUREMENTS AND MAIN RESULTS The average daily volume of postoperative blood loss during the first 3 postoperative days in the study group was 23.1 mL compared with 31.5 mL observed in the control group (p = .041). Moreover, the study group had significantly shorter average duration of bleeding (p = .027) and fewer menstruation abnormalities than the control group. Uterine ultrasonography performed after resumption of menstruation showed that none of the enrolled patients had any intrauterine abnormalities. CONCLUSIONS The use of an indwelling, intrauterine Foley balloon catheter has positive results in the management of CSP.
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Affiliation(s)
- Yan-Ming Lu
- Department of Gynecology and Obstetrics, The Affiliated Shengjing Hospital, China Medical University, Shenyang, China (all authors)..
| | - Ya-Ru Guo
- Department of Gynecology and Obstetrics, The Affiliated Shengjing Hospital, China Medical University, Shenyang, China (all authors)
| | - Meng-Ya Zhou
- Department of Gynecology and Obstetrics, The Affiliated Shengjing Hospital, China Medical University, Shenyang, China (all authors)
| | - Yue Wang
- Department of Gynecology and Obstetrics, The Affiliated Shengjing Hospital, China Medical University, Shenyang, China (all authors)
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20
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Monteagudo A, Calì G, Rebarber A, Cordoba M, Fox NS, Bornstein E, Dar P, Johnson A, Rebolos M, Timor-Tritsch IE. Minimally Invasive Treatment of Cesarean Scar and Cervical Pregnancies Using a Cervical Ripening Double Balloon Catheter: Expanding the Clinical Series. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:785-793. [PMID: 30099757 DOI: 10.1002/jum.14736] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/06/2018] [Accepted: 06/03/2018] [Indexed: 06/08/2023]
Abstract
The efficacy of treating cesarean scar pregnancies and cervical pregnancies with the Cook® cervical ripening balloon catheter, in a multicenter office-based setting is reported. Thirty-eight women were treated. Insertion of the catheter was performed under real-time ultrasound guidance. Patients received adjuvant systemic methotrexate, prophylactic oral antibiotics, and oral pain medication. Serum human chorionic gonadotropin and ultrasound scans were followed serially until resolution. Thirty-seven patients were successfully treated, requiring no further procedures. We found that the Cook cervical ripening balloon technique is a simple, effective, outpatient, minimally invasive treatment with few complications noted in this expanded series.
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Affiliation(s)
- Ana Monteagudo
- Carnegie Imaging for Women, PLLC, New York, New York, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Giuseppe Calì
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Andrei Rebarber
- Carnegie Imaging for Women, PLLC, New York, New York, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Marcos Cordoba
- Department of Obstetrics and Gynecology, Michigan State University, East Lansing, Michigan, USA
| | - Nathan S Fox
- Carnegie Imaging for Women, PLLC, New York, New York, USA
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eran Bornstein
- Lenox Hill Hospital (Northwell Health)/NYU Medical Center, New York, New York, USA
| | - Peer Dar
- Albert Einstein College of Medicine, Bronx, New York, USA
| | - Anthony Johnson
- Texas Fetal Center, Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Mark Rebolos
- New York University Langone Health, New York, New York, USA
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21
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Vo TM, Van T, Nguyen L, Tran Q. Management of Cesarean Scar Pregnancy among Vietnamese Women. Gynecol Minim Invasive Ther 2019; 8:12-18. [PMID: 30783583 PMCID: PMC6367916 DOI: 10.4103/gmit.gmit_8_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 08/15/2018] [Accepted: 10/01/2018] [Indexed: 11/21/2022] Open
Abstract
Objective: To demonstrate the efficacy of management for cesarean scar ectopic pregnancies up to 8 weeks’ gestation using ultrasound-guided Foley balloon catheter placement combined with dilation and curettage (D and C) at TuDu Hospital. Subjects and Methods: A quasi-experimental study was conducted from March 2015 to March 2016. Patients with imaging-confirmed cesarean ectopic pregnancies were admitted to an inpatient unit at Tu Du Hospital. A Foley balloon catheter was placed inside the uterus under ultrasound guidance and was left in place for 24 h. Afterward, the patient underwent ultrasound-guided D and C. Follow-up to confirm success included serial blood draws to measure beta-human chorionic gonadotropin (β-hCG) levels until a value of 0, and routine ultrasounds to confirm absence of a gestational sac and no evidence of vascularity at the site of the cesarean section scar. Results: A total of 311 patients were enrolled over 3 months. Overall, 90.7% (95% confidence interval [CI]: 86.8%–93.9%) patients were successfully treated with this regimen. Several factors that were significantly associated with successful management included gestational age <6 weeks (odds ratio [OR] 3.1, 95% CI: 1.03%–8.76%), β-hCG level <11,000 mUI/mL before discharge from the hospital (OR 6.5, 95% CI: 1.42%–30.6%), gestational sac volume 2 weeks after treatment measuring <5 cm3 (OR 9.1, 95% CI: 1.96%–50.1%). Conclusions: This is an easily applicable method with a short follow-up period and reduction in treatment costs compared to standard treatment with methotrexate injection.
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Affiliation(s)
- Tuan Minh Vo
- Department of Obstetrics and Gynecology, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Thong Van
- Department of Gynecology, Tudu Hospital, Ho Chi Minh City, Vietnam
| | - Long Nguyen
- Department of Gynecology, Tudu Hospital, Ho Chi Minh City, Vietnam
| | - Quynh Tran
- Department of Gynecology, Tudu Hospital, Ho Chi Minh City, Vietnam
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22
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23
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Sel G, Sucu S, Harma M, Harma Mİ. Successful management of cesarean scar pregnancy with vacuum extraction under ultrasound guidance. Acute Med Surg 2018; 5:358-361. [PMID: 30338082 PMCID: PMC6167402 DOI: 10.1002/ams2.362] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 07/02/2018] [Indexed: 01/10/2023] Open
Abstract
Aim Cesarean scar pregnancy (CSP) is a rare type of ectopic pregnancy. The gestational sac is implanted in the myometrium at the site of a previous cesarean section. Mothers with CSP are faced with risks of unpredictable massive bleeding or more fatal complications. The purpose of this retrospective study was to assess the feasibility, efficacy, and reliability of the intraoperative ultrasound‐guided vacuum aspiration method as an effective treatment option for CSP. Methods We undertook a retrospective analysis of CSP patients who had undergone the vacuum aspiration method, by reviewing patient records from the period October 2015 to January 2018. All of the operations were carried out under general anesthesia, with patients in the lithotomy position, using suprapubic ultrasonography guidance. A vacuum aspirator was used to aspirate the whole pregnancy material without perforating the previous cesarean section scar. Results Ten women with CSP were managed successfully by ultrasound‐guided vacuum extraction without complications or further interventions, such as reoperation or methotrexate administration. Three of the 10 patients needed uterine Foley catheter tampon (50 cc) for 4 h after vacuum extraction alone was applied. During the study period, two additional patients who did not meet the criteria for the vacuum extraction method alone were managed with methotrexate plus vacuum application. Because of the rarity of the condition, the majority of CSPs are case reports or small case series reported in published works, with no consensus on the preferred course of treatment. Conclusion The vacuum extraction method seems to be a good and practical way of treating CSP. Comparisons of efficacy should be undertaken but large sample sizes are required. We hope this study brings a new perspective for larger sample‐sized studies, considering the technique is feasible and applicable.
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Affiliation(s)
- Görker Sel
- Zonguldak Bulent Ecevit University Health Application and Research Center Zonguldak Turkey
| | - Sadun Sucu
- Zonguldak Bulent Ecevit University Health Application and Research Center Zonguldak Turkey
| | - Müge Harma
- Zonguldak Bulent Ecevit University Health Application and Research Center Zonguldak Turkey
| | - Mehmet İbrahim Harma
- Zonguldak Bulent Ecevit University Health Application and Research Center Zonguldak Turkey
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24
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Docheva N, Slutsky ED, Borella N, Mason R, Van Hook JW, Seo-Patel S. The Rising Triad of Cesarean Scar Pregnancy, Placenta Percreta, and Uterine Rupture: A Case Report and Comprehensive Review of the Literature. Case Rep Obstet Gynecol 2018; 2018:8797643. [PMID: 29984018 PMCID: PMC6011134 DOI: 10.1155/2018/8797643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 04/26/2018] [Indexed: 11/23/2022] Open
Abstract
As the rate of cesarean sections continues to rapidly rise, knowledge of diagnosis and management of cesarean scar pregnancies (CSPs) is becoming increasingly more relevant. CSPs rest on the continuum of placental abnormalities which include morbidly adherent placenta (accreta, increta, and percreta). A CSP poses a clinical challenge which may have significant fetal and maternal morbidity. At this point, no clear management guidelines and recommendations exist. Herein we describe the case of a second trimester CSP with rapid diagnosis and management in a tertiary care center. The case underscores the need for well-coordinated mobilization of resources and a multidisciplinary approach. A review of the literature is performed and deficits in universal management principles are underscored.
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Affiliation(s)
- Nikolina Docheva
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Emily D. Slutsky
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Nicolette Borella
- Mercyhurst University, Department of Biology, Eerie, Pennsylvania, USA
| | - Renee Mason
- Promedica Physicians Obstetrics-Gynecology, Maumee, Ohio, USA
| | - James W. Van Hook
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Sonyoung Seo-Patel
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
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Papanikolaou IG, Domali E, Daskalakis G, Theodora M, Telaki E, Drakakis P, Loutradis D. Abnormal placentation: Current evidence and review of the literature. Eur J Obstet Gynecol Reprod Biol 2018; 228:98-105. [PMID: 29913334 DOI: 10.1016/j.ejogrb.2018.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/30/2018] [Accepted: 06/04/2018] [Indexed: 01/05/2023]
Abstract
Abnormal placentation often requires the involvement of a multidisciplinary team of medical caregivers. Practicing Obstetrics is a challenging and skillful duty. This is more obvious in cases of abnormal placentation, which represents one of the most dangerous and complex clinical conditions in materno-fetal medicine. Pathological placentation involves position and invasion abnormalities and represents a serious and potentially life-threatening condition for both the pregnant woman and the fetus. The dramatic increase in cesarean section rates is an important factor which could explain the rapid raise in abnormal placentation cases, which were considered rare a few years ago. Nevertheless, the scientific armamentarium sometimes seems to be poor and this could be explained by the fact that treatment options are offered too late, since this condition is often detected late, entailing higher patients' risks. In fact, the later the diagnosis is made the poorer the prognosis is for cases of abnormal placentation. Given that abnormal placentation is constantly increasing, the scientific community should aim at early diagnosis and appropriate management of such cases based on the best evidence available. Future improvement of knowledge and practice lies in perspective, preferably randomized studies so that we obtain high quality of evidence which is still needed. The purpose of this study is to review the current literature and to update the available scientific knowledge on the topic of abnormal placentation which is an emerging issue which clinicians should learn to deal with, considering its continuous increase in the last years.
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Affiliation(s)
- Ioannis G Papanikolaou
- 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, University of Athens, Medical School, Greece(1).
| | - Ekaterini Domali
- 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, University of Athens, Medical School, Greece(1)
| | - George Daskalakis
- 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, University of Athens, Medical School, Greece(1)
| | - Marianna Theodora
- 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, University of Athens, Medical School, Greece(1)
| | - Eirini Telaki
- 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, University of Athens, Medical School, Greece(1)
| | - Petros Drakakis
- 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, University of Athens, Medical School, Greece(1)
| | - Dimitrios Loutradis
- 1(st) Department of Obstetrics & Gynecology, "Alexandra" Hospital, University of Athens, Medical School, Greece(1)
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26
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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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Yorifuji T, Takeda J, Makino S, Tanaka T, Itakura A, Takeda S. Evaluation of the effectiveness of metreurynters for balloon tamponade. HYPERTENSION RESEARCH IN PREGNANCY 2018. [DOI: 10.14390/jsshp.hrp2018-001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Takashi Yorifuji
- Department of Obstetrics and Gynecology, Juntendo University, Faculty of Medicine
| | - Jun Takeda
- Department of Obstetrics and Gynecology, Juntendo University, Faculty of Medicine
| | - Shintaro Makino
- Department of Obstetrics and Gynecology, Juntendo University, Faculty of Medicine
| | - Toshitaka Tanaka
- Department of Obstetrics and Gynecology, Juntendo University, Faculty of Medicine
| | - Atsuo Itakura
- Department of Obstetrics and Gynecology, Juntendo University, Faculty of Medicine
| | - Satoru Takeda
- Department of Obstetrics and Gynecology, Juntendo University, Faculty of Medicine
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Calì G, Forlani F, Minneci G, Foti F, Di Liberto S, Familiari A, Scambia G, D'Antonio F. First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:184-188. [PMID: 28233462 DOI: 10.1002/uog.17440] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/09/2017] [Accepted: 02/14/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Ultrasound assessment of the relationship between the ectopic gestational sac and the endometrial line (cross-over sign; COS) in Cesarean scar pregnancy (CSP) has been shown to be useful in predicting the evolution of CSP towards different types of abnormally invasive placenta (AIP). The aim of this study was to ascertain whether the COS can be used to predict surgical outcome in women with AIP. METHODS A retrospective analysis was performed of early first-trimester (6-8 weeks' gestation) ultrasound images of women with AIP managed in the third trimester of pregnancy. We hypothesized that assessment of COS may identify cases of AIP at higher risk of intra- or postsurgical morbidity. Outcomes explored were estimated blood loss during surgery, need for and amount of packed red blood cells and fresh frozen plasma units required either during or after surgery, operative time, intrasurgical complications, gestational age at birth, delivery < 34 weeks of gestation, length of hospital stay and admission to intensive care unit. Differences in the explored outcomes were assessed among women with different types of COS variant (COS-1, COS-2+ or COS-2-) as observed on first-trimester ultrasound examination. RESULTS Sixty-eight pregnancies were included in the study. Mean estimated blood loss was higher in AIP pregnancies with COS-1 than in those with COS-2+ (P = 0.039) or COS-2- (P = 0.01). Mean number of packed red blood cell units required during or after the operation was higher in women with COS-1 compared with those with COS-2+ (P = 0.001) and COS-2- (P = 0.029), while there was no difference between pregnancies with COS-2+ and those with COS-2- (P = 0.797). Mean operative time was longer in AIP pregnancies with COS-1 than in those with COS-2+ (P = 0.039) or COS-2- (P = 0.017). Finally, pregnancies with COS-1 were delivered earlier than those with COS-2+ (P = 0.0001) or COS-2- (P = 0.0001). CONCLUSION First-trimester ultrasound assessment of the relationship between the ectopic gestational sac and the endometrial line (COS) may identify women with AIP who are at higher risk of intra- or postsurgical morbidity. 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
| | - F Forlani
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - G Minneci
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - F Foti
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - S Di Liberto
- 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
- Department of Women's and Children's Health, Catholic University of the Sacred Heart, Rome, Italy
| | - F D'Antonio
- Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
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Calì G, Timor-Trisch IE, Palacios-Jaraquemada J, Monteaugudo A, Forlani F, Minneci G, Foti F, Buca D, Familiari A, Scambia G, Liberati M, D'Antonio F. Changes in ultrasonography indicators of abnormally invasive placenta during pregnancy. Int J Gynaecol Obstet 2018; 140:319-325. [DOI: 10.1002/ijgo.12413] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 10/11/2017] [Accepted: 11/30/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Giuseppe Calì
- Department of Obstetrics and Gynaecology; Arnas Civico Hospital; Palermo Italy
| | - Ilan E. Timor-Trisch
- Department of Obstetrics and Gynaecology; Division of Maternal-Fetal Medicine; New York University SOM; New York NY USA
| | - Josè Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC); University Hospital; Buenos Aires Argentina
| | - Ana Monteaugudo
- Department of Obstetrics and Gynaecology; Division of Maternal-Fetal Medicine; New York University SOM; New York NY USA
| | - Francesco Forlani
- Department of Obstetrics and Gynaecology; Arnas Civico Hospital; Palermo Italy
| | - Gabriella Minneci
- Department of Obstetrics and Gynaecology; Arnas Civico Hospital; Palermo Italy
| | - Francesca Foti
- Department of Obstetrics and Gynaecology; Arnas Civico Hospital; Palermo Italy
| | - Danilo Buca
- Department of Obstetrics and Gynaecology; University of Chieti; Chieti Italy
| | - Alessandra Familiari
- Department of Maternal-Fetal medicine; Catholic University of the Sacred Heart; Rome Italy
| | - Giovanni Scambia
- Department of Maternal-Fetal medicine; Catholic University of the Sacred Heart; Rome Italy
| | - Marco Liberati
- Department of Obstetrics and Gynaecology; University of Chieti; Chieti Italy
| | - Francesco 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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30
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Bennett TA, Morgan J, Timor-Tritsch IE, Dolin C, Dziadosz M, Tsai M. Fifth recurrent Cesarean scar pregnancy: observations of a case and historical perspective. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:658-660. [PMID: 28295733 DOI: 10.1002/uog.17461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/31/2017] [Accepted: 03/03/2017] [Indexed: 06/06/2023]
Affiliation(s)
- T-A Bennett
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University Langone Medical Center, New York, NY, USA
| | - J Morgan
- New York University School of Medicine, New York, NY, USA
| | - I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University Langone Medical Center, New York, NY, USA
| | - C Dolin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University Langone Medical Center, New York, NY, USA
| | - M Dziadosz
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - M Tsai
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY, USA
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31
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Fang Q, Sun L, Tang Y, Qian C, Yao X. Quantitative risk assessment to guide the treatment of cesarean scar pregnancy. Int J Gynaecol Obstet 2017. [PMID: 28631355 DOI: 10.1002/ijgo.12240] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To develop a risk-factor scoring system for the prediction of bleeding during ultrasound-guided dilation and curettage (D&C) for cesarean scar pregnancy (CSP). METHODS The retrospective study included patients with a CSP of 31-67 days who underwent transabdominal ultrasonography-guided D&C in 2010-2014. Binary logistic regression analysis was used to identify risk factors for the need of Foley catheter hemostasis. The predictive accuracy of a risk-scoring system based on significant factors was evaluated by receiver operating curve analysis. RESULTS Among 82 included patients, 66 (80%) were successfully treated without any complications, whereas 16 (20%) required Foley catheter compression hemostasis. Four patients who received the Foley catheter needed further treatment. A longer pregnancy duration (odds ratio 1.171, 95% confidence interval 1.050-1.305; P=0.004) and a rich blood supply on ultrasonography (odds ratio 3.282, 95% confidence interval 1.441-4.742; P=0.005) were significant risk factors for the need of compression hemostasis. A scoring system based on these two risk factors would have identified 93.8% of patients requiring compression hemostasis if the optimum cutoff score was used. CONCLUSION Heavy bleeding during transabdominal ultrasound-guided D&C for CSP is associated with a longer pregnancy duration and a rich blood supply on ultrasonography. The new risk-scoring system can be used to predict bleeding during surgery.
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Affiliation(s)
- Qingxian Fang
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Li Sun
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Yunhui Tang
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Cuifeng Qian
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China
| | - Xiaoying Yao
- Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China.,Department of Obstetrics and Gynecology of Shanghai Medical College, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai, China.,Key Laboratory of Reproduction Regulation of National Population and Family Planning Commission, The Shanghai Institute of Planned Parenthood Research, Institute of Reproduction and Development, Shanghai, China
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Cali G, Forlani F, Timor-Tritsch IE, Palacios-Jaraquemada J, Minneci G, D'Antonio F. Natural history of Cesarean scar pregnancy on prenatal ultrasound: the crossover sign. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2017; 50:100-104. [PMID: 27420402 DOI: 10.1002/uog.16216] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/04/2016] [Accepted: 07/08/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE Advances in prenatal imaging techniques have led to an increase in the diagnosis of Cesarean scar pregnancy (CSP). However, antenatal counseling when CSP is diagnosed is challenging, and current evidence is derived mainly from small series reporting high rates of adverse maternal outcomes. The aim of this study was to ascertain the performance of prenatal ultrasound in predicting the natural history of CSP using a new sonographic sign, the crossover sign (COS). METHODS This was a retrospective analysis of early first-trimester (6-8 weeks' gestation) ultrasound images in women with morbidly adherent placenta (MAP) managed in the third trimester of pregnancy. The relationship between the gestational sac of the CSP, anterior uterine wall and Cesarean scar, defined as the COS, was analyzed to determine whether it could predict evolution in these cases. Odds ratios (ORs) were calculated and logistic regression analysis was performed to investigate the association between different types of COS (COS-1, COS-2+ or COS-2-) and the occurrence of MAP. RESULTS Sixty-eight pregnancies with MAP were included. The risk of placenta percreta was significantly higher in pregnancies with COS-1 than in those with COS-2 (OR, 6.67 (95% CI, 1.3-33.3)). When evaluating the two variants of COS-2 separately, the risk of placenta percreta was significantly higher in pregnancies with COS-1 vs COS-2+ (OR, 5.83 (95% CI, 1.1-30.2)) and this risk was even higher when comparing cases with COS-1 vs COS-2- (OR, 12.0 (95% CI, 1.9-75.7)). Logistic regression analysis showed that COS-1 was associated independently with severe forms of MAP, such as placenta percreta and increta (OR, 12.85 (95% CI, 2.0-84.0)), while COS-2+ was associated independently with placenta accreta (OR, 4.37 (95% CI, 1.1-17.0)). CONCLUSIONS Ultrasound assessment of the relationship between the gestational sac of a CSP and the endometrial line (the COS) may help to determine whether a CSP will progress towards a less severe form of MAP, amenable to postnatal treatment, and successful pregnancy outcome. Large prospective studies are needed to confirm our findings and elucidate the natural history of this condition. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- G Cali
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - F Forlani
- 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 SOM, New York, NY, USA
| | - J Palacios-Jaraquemada
- Centre for Medical Education and Clinical Research (CEMIC), University Hospital, Buenos Aires, Argentina
| | - G Minneci
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - F D'Antonio
- Department of Clinical Medicine, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
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Wu C, Li Y, Ye W, Ma W, Zhao D. Cook Cervical Ripening Balloon successfully prevents excessive hemorrhage combined with ultrasound-guided suction curettage in the treatment of cesarean scar pregnancy. J Obstet Gynaecol Res 2017; 43:1043-1047. [PMID: 28498646 DOI: 10.1111/jog.13318] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 12/14/2016] [Accepted: 01/14/2017] [Indexed: 11/28/2022]
Abstract
AIM Cesarean scar pregnancy (CSP) is a rare occurrence of ectopic pregnancy. CSP incidence has increased significantly as a result of the increase in cesarean section rates. At present, there are no standard treatment guidelines for CSP; therefore, we report a minimally invasive treatment method for patients diagnosed with CSP. METHODS This study included 15 women who were diagnosed with CSP. Ultrasound-guided suction curettage was performed on all patients. The Cook Cervical Ripening Balloon was used to tamponade and prevent hemorrhage during the procedure. In 12 patients, the balloon was placed immediately following ultrasound-guided suction curettage; in two patients, the balloon was placed when excessive bleeding occurred post-curettage; and in one patient, the balloon was placed after the gestational sac evacuated by itself, and then suction aspiration was performed on day 5, following the evacuation. Human chorionic gonadotropin levels were evaluated three days after the procedure. RESULTS Placement and inflation of the Cook Cervical Ripening Balloon was well tolerated by all patients. The balloon tamponade effectively reduced or prevented vaginal bleeding in all patients, and none of the patients had an estimated blood loss higher than 1000 ml. CONCLUSIONS Ultrasound-guided suction curettage is effective in the treatment of CSP. The Cook Cervical Ripening Balloon is easy to place and inflate and successfully prevented bleeding or assisted in the management of bleeding complications. We recommend the Cook Cervical Ripening Balloon as an adjuvant method for ultrasound-guided suction curettage for the treatment of CSP.
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Affiliation(s)
- Chaoying Wu
- Department of Gynecology, Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, China
| | - Yong Li
- Department of Gynecology, Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, China
| | - Wenfeng Ye
- Department of Gynecology, Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, China
| | - Wenqin Ma
- Department of Gynecology, Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, China
| | - Danmei Zhao
- Department of Gynecology, Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, China
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Double Balloon Cervical Ripening Catheter for Control of Massive Hemorrhage in a Cervical Ectopic Pregnancy. Case Rep Obstet Gynecol 2017; 2017:9396075. [PMID: 28261511 PMCID: PMC5312454 DOI: 10.1155/2017/9396075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/02/2017] [Accepted: 01/09/2017] [Indexed: 01/11/2023] Open
Abstract
Cervical pregnancy can be complicated by perfuse vaginal bleeding. Mechanical compression directed at tamponing the cervical vessels can control hemostasis. There are several types of balloon catheters that have been described for cervical compression. However use of a double balloon catheter is a novel approach for cervical tamponade, as one balloon is positioned below the external cervical os and the second balloon is situated above in the internal cervical os. This compresses the cervix from internal os to external os between the two balloons, forming a “cervical sandwich.” We describe this method of cervical tamponade using a silicone double balloon cervical ripening catheter that rapidly controlled hemorrhage in a patient that failed conservative management with methotrexate.
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A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy. Am J Obstet Gynecol 2016; 215:351.e1-8. [PMID: 26979630 DOI: 10.1016/j.ajog.2016.03.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 03/02/2016] [Accepted: 03/07/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Cesarean scar pregnancy and cervical pregnancy are unrelated forms of pathological pregnancies carrying significant diagnostic and treatment challenges, with a wide range of treatment effectiveness and complication rates ranging from 10% to 62%. At times, life-saving hysterectomy and uterine artery embolization are required to treat complications. Based on our previous success with using a single-balloon catheter for the treatment of cesarean scar pregnancy after local injection of methotrexate, we evaluated the use of a double-balloon catheter to terminate the pregnancy while preventing bleeding without any additive treatment. This was a retrospective study. OBJECTIVES The objective of the study was to describe the placement of a cervical ripening double-balloon catheter as a novel, minimally invasive treatment in patients with cesarean scar and cervical pregnancies to terminate the pregnancy and at the same time prevent bleeding by compressing the blood supply of the gestational sac. STUDY DESIGN Patients with diagnosed, live cervical pregnancy and cesarean scar pregnancy between 6 and 8 weeks' gestation were considered for the office-based treatment. Paracervical block with 1% lidocaine was administered in 3 patients for pain control. Insertion of the catheter and inflation of the upper balloon were done under transabdominal ultrasound guidance. The lower (pressure) balloon was inflated opposite the gestational sac under transvaginal ultrasound guidance. After an hour, the area of the sac was scanned. When fetal cardiac activity was absent and no bleeding was noted, patients were discharged. After 2-3 days, a follow-up appointment was scheduled for possible catheter removal. Serial ultrasound (US) and serum human chorionic gonadotropin were followed weekly or as needed. RESULTS Three live cervical pregnancies and 7 live cesarean scar pregnancies were successfully treated. Median gestational age at treatment was 6 6/7 weeks (range 6 1/7 through 7 4/7 weeks). Patients' acceptance for the double-balloon treatment was high in spite of the initial low abdominal pressure felt at the inflation of the balloons. All but 1 patient noted vaginal spotting at the follow-up appointment. Only 1 patient experienced bleeding of dark blood. The balloons were in place for a median of 3 days (range, 1-5 days). Median time from treatment to the total drop of human chorionic gonadotropin was 49 days (range, 28-97 days). CONCLUSION The double balloon is a successful, minimally invasive and well-tolerated single treatment for cervical pregnancy and cesarean scar pregnancy. This simple treatment method has 4 main advantages: it effectively stops embryonic cardiac activity, prevents bleeding complications, does not require any additional invasive therapies, and is familiar to obstetricians-gynecologists who use the same cervical ripening catheters for labor induction. Its wider application, however, has to be validated on a larger patient population.
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Jurkovic D, Knez J, Appiah A, Farahani L, Mavrelos D, Ross JA. Surgical treatment of Cesarean scar ectopic pregnancy: efficacy and safety of ultrasound-guided suction curettage. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:511-7. [PMID: 26764166 DOI: 10.1002/uog.15857] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/12/2015] [Accepted: 12/04/2015] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To assess the efficacy of ultrasound-guided suction curettage for management of pregnancies implanted into the lower uterine segment Cesarean section scar. METHODS This was a retrospective study including women diagnosed with Cesarean section scar pregnancy at two large tertiary referral early pregnancy units between 1997 and 2014. Surgical evacuation was offered to selected women presenting in the first trimester ≤ 14 weeks' gestation. All procedures were performed transcervically under ultrasound guidance using suction curettage. A modified Shirodkar cervical suture was used in women who required additional measures to secure hemostasis. RESULTS A total of 232 women with Cesarean section scar pregnancy were seen at the referral units; 191/232 (82.3%) women were treated surgically. The median intraoperative blood loss was 100 mL (range, 10-3000 mL); 9/191 (4.7% (95% CI, 1.7-7.7%)) women required blood transfusion and, in one (0.5% (95% CI, 0-1.5%)), life-saving hysterectomy had to be performed because of uncontrollable intraoperative bleeding. Of the women who attended for follow-up, 7/116 (6.0% (95% CI, 1.7-10.3%)) required a repeat surgical procedure because of retained products of conception. Multivariable analysis showed that the gestational sac diameter (odds ratio (OR), 1.10 (95% CI, 1.03-1.17)) and pregnancy vascularity on Doppler examination (OR, 3.41 (95% CI, 1.39-8.33)) were significant predictors of heavy intraoperative blood loss (> 1000 mL). CONCLUSIONS Ultrasound-guided suction curettage is an effective method for the treatment of pregnancies implanted into a lower uterine segment Cesarean section scar and is associated with a low risk of blood transfusion and hysterectomy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Jurkovic
- Institute of Women's Health, University College Hospital, London, UK
| | - J Knez
- Institute of Women's Health, University College Hospital, London, UK
| | - A Appiah
- Early Pregnancy Unit, King's College Hospital, London, UK
| | - L Farahani
- Early Pregnancy Unit, King's College Hospital, London, UK
| | - D Mavrelos
- Institute of Women's Health, University College Hospital, London, UK
| | - J A Ross
- Early Pregnancy Unit, King's College Hospital, London, UK
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