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Kaelin Agten A, Jurkovic D, Timor-Tritsch I, Jones N, Johnson S, Monteagudo A, Huirne J, Fleisher J, Maymon R, Herrera T, Prefumo F, Contag S, Cordoba M, Manegold-Brauer G. First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry. Am J Obstet Gynecol 2024; 230:669.e1-669.e19. [PMID: 37865390 DOI: 10.1016/j.ajog.2023.10.028] [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: 07/26/2023] [Revised: 10/08/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry. OBJECTIVE This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies. STUDY DESIGN We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions. RESULTS Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9). CONCLUSION A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment.
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Affiliation(s)
| | | | | | - Nia Jones
- University of Nottingham, Nottingham, United Kingdom
| | - Susanne Johnson
- Princess Anne Hospital, University Hospitals Southampton, Southampton, United Kingdom
| | | | - Judith Huirne
- Amsterdam University Medical Centers, Amsterdam, Netherlands
| | | | - Ron Maymon
- Department of Obstetrics and Gynecology, Shamir Medical Center (Assaf Harofeh), Be'er Ya'akov, Israel
| | | | - Federico Prefumo
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Stephen Contag
- Division of Maternal Fetal Medicine, University of Minnesota, Minneapolis, MN
| | | | - Gwendolin Manegold-Brauer
- Division of Gynecologic and Prenatal Ultrasound, Department of Obstetrics and Gynecology, University of Basel, Basel, Switzerland.
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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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Timor-Tritsch IE, Monteagudo A, Calì G, Kaelin Agten A, Palacios-Jaraquemada JM, D'Antonio F. Hidden in plain sight: role of residual myometrial thickness to predict outcome of Cesarean scar pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:624-632. [PMID: 37266902 DOI: 10.1002/uog.26246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/20/2023] [Accepted: 05/01/2023] [Indexed: 06/03/2023]
Affiliation(s)
- I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Hackensack Meridian School of Medicine and Maternal Resources, Hackensack, NJ, USA
| | - A Monteagudo
- Icahn School of Medicine, Carnegie Maternal-Fetal Associates, NY, USA
| | - G Calì
- Department of Obstetrics and Gynecology, Maternal-Fetal Medicine Unit, Azienda Ospedaliera Villa Sofia-Cervello, Palermo, Italy
- Maternal-Fetal Unit, Candela Clinic, Palermo, Italy
| | - A Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, UK
| | | | - F D'Antonio
- Center for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
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4
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Lin R, DiCenzo N, Rosen T. Cesarean scar ectopic pregnancy: nuances in diagnosis and treatment. Fertil Steril 2023; 120:563-572. [PMID: 37506758 DOI: 10.1016/j.fertnstert.2023.07.018] [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: 05/02/2023] [Revised: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 07/30/2023]
Abstract
A cesarean scar ectopic pregnancy (CSEP) occurs when the embryo implants on the scar of a previous cesarean delivery. The number of births delivered by cesarean section has climbed by 50% over the last decade, from a nadir of 20.7% in 1996 to 32.1% in 2021. As a result, the incidence of CSEP has also increased. Because CSEP may cause serious morbidity such as life-threatening hemorrhage, uterine rupture, placental accreta spectrum, hysterectomy, and even mortality, accurate diagnosis and appropriate management of this condition are essential. This review focuses on the etiology, incidence, clinical diagnosis, and management of CSEPs.
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Affiliation(s)
- Ruby Lin
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.
| | - Natalie DiCenzo
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Todd Rosen
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
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Vieira de Mello P, Bruns RF, Fontoura Klas C, Raso Hammes L. Expectant management of viable cesarean scar pregnancies: a systematic review. Arch Gynecol Obstet 2022:10.1007/s00404-022-06835-3. [DOI: 10.1007/s00404-022-06835-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 10/21/2022] [Indexed: 11/18/2022]
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Loh WN, Adno AM, Reid S. A 10‐year retrospective cohort study of non‐tubal ectopic pregnancy management outcomes in an Australian tertiary centre. Australas J Ultrasound Med 2022; 25:166-175. [PMID: 36405797 PMCID: PMC9644438 DOI: 10.1002/ajum.12312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Introduction Non-tubal ectopic pregnancy (NTEP) is a rare but significant early pregnancy complication which can result in maternal morbidity and mortality. There is however a lack of evidence-based guidelines for the management of NTEP. Purpose To evaluate the success rates of expectant, medical and surgical management in the treatment of NTEP at our tertiary centre. Methods Retrospective cohort study from 2010 to 2020. All NTEP were classified by ectopic sites. Primary management was classified by expectant, medical [systemic methotrexate (Sys-MTX) and/or local ultrasound-guided injection of MTX and/or KCl intra-sac (L-MTX, L-MTX/KCl)] or surgical. Primary management was considered successful if no change in intervention was required. Treatment complications were compared. Results Twenty-four NTEP were identified, which included 14 interstitial pregnancies (IP), 9 caesarean scar pregnancies (CSP) and 1 ovarian pregnancy (OP), which gave NTEP an incidence of 7.12% among all EP (4.15% for IP, 2.67% for CSP and 0.30% for OP). The success of primary surgical management was 100% (7/7), primary medical management was 76.9% (10/13) and primary expectant management was 33.3% (1/3). Primary medical management had a non-statistically significant greater mean time to serum ß-human Chorionic Gonadotrophin <5 IU/L, mean length of hospitalisation, mean number of follow-up visits and hospital re-presentation/readmissions compared to primary surgical management. There was no other difference in complication rates between the treatment management groups. Conclusion Surgery remains the most effective way to manage NTEP. However, medical management can be a safe and effective alternative option in carefully selected cases.
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Affiliation(s)
- Wei‐Guo Nicholas Loh
- Department of Obstetrics and Gynaecology Liverpool Hospital Sydney New South Wales Australia
- South Western Sydney Clinical School University of New South Wales Sydney New South Wales Australia
| | - Alan Maurice Adno
- Department of Feto‐Maternal Unit Liverpool Hospital Sydney New South Wales Australia
| | - Shannon Reid
- Department of Obstetrics and Gynaecology Liverpool Hospital Sydney New South Wales Australia
- Faculty of Medicine Western Sydney University Sydney New South Wales Australia
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Zhu W, Zhang X, Liu C, Liu Y, Xu W. Uterine Artery Embolization on Serum β-HCG Levels, Fertility Function and Clinical Efficacy in Patients With Cesarean Uterine Scar Pregnancy. Front Surg 2022; 9:838879. [PMID: 35187063 PMCID: PMC8847222 DOI: 10.3389/fsurg.2022.838879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 01/05/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To analyze the therapeutic effect of uterine artery embolisation (UAE) in patients with cesarean section pregnancy (CSP) delivered by cesarean section and the effect on serum human chorionic gonadotrophin (β-HCG) levels and reproductive function. Methods In total 142 patients with CSP, The control group (n = 71) received Methotrexate (MTX) with ultrasound monitoring after admission and the research group (n = 71) was treated with UAE on basic of the control group. The two groups were compared in terms of treatment outcome, intraoperative bleeding, bed activity, vaginal bleeding and length of hospital stay, and serum follicle stimulating hormone (FSH), oestradiol (E2), luteinising hormone (LH) and β-HCG levels at 1 month postoperatively. The clinical symptoms (normalization of β-HCG and return of menstruation) and clinical outcomes (normal pregnancy, recurrent scar pregnancy) were compared between the two groups, as well as the occurrence of post-operative complications in both groups. Results Compared with the control group, the research group had a higher overall near-term effective rate, a lower recurrence rate of CSP in pregnancy, and a lower complication rate (P < 0.05); meanwhile, the time to get out of bed, postoperative vaginal bleeding, length of hospital stay, normalization of serum β-HCG, and return to menstruation were shorter in the research group than in the control group (P < 0.05); In addition, serum FSH, E2, LH and β-HCG levels improved better in the research group compared with the control group 1 month after surgery (P < 0.05). Conclusion The treatment of CSP patients with UAE can reduce the amount of intraoperative bleeding and the duration of vaginal bleeding, promote the improvement of patients' clinical symptoms, have less impact on the disruption of patients' sex hormone balance, reduce patients' surgical risks to a greater extent, preserve patients' normal fertility, and have better application.
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Affiliation(s)
- Wenyang Zhu
- Department of Interventional Radiolody, The Affiliated Huaian Hospital of Xuzhou Medical University, Huaian, China
| | - Xiaofang Zhang
- Department of Ultrasound, The Huaian Clinical College of Xuzhou Medical University, Huaian Maternity and Children Hospital, Huaian, China
| | - Chang Liu
- Department of Gynaecology, The Affiliated Huaian Hospital of Xuzhou Medical University, Huaian, China
| | - Yang Liu
- Department of Gynecology, The Huaian Clinical College of Xuzhou Medical University, Huaian Maternity and Children Hospital, Huaian, China
| | - Wei Xu
- Department of Interventional Radiolody, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
- *Correspondence: Wei Xu
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Shilei B, Lizi Z, Yulian L, Yingyu L, Lijun H, Minshan H, Baoying H, Jinping J, Yinli C, Shaoshuai W, Xiaoyan X, Ling F, Yangyu Z, Xianlan Z, Qiying Z, Hongbo Q, Suiwen W, Lanzhen Z, Hongtian L, Jingsi C, Zhijian W, Lili D, Dunjin C. The Risk of Postpartum Hemorrhage Following Prior Prelabor Cesarean Delivery Stratified by Abnormal Placentation: A Multicenter Historical Cohort Study. Front Med (Lausanne) 2021; 8:745080. [PMID: 34708056 PMCID: PMC8542659 DOI: 10.3389/fmed.2021.745080] [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: 07/21/2021] [Accepted: 09/03/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Prior prelabor cesarean delivery (CD) was associated with an increase in the risk of placenta previa (PP) in a second delivery, whether it may impact postpartum hemorrhage (PPH) independent of abnormal placentation. This study aimed to assess the risk of PPH stratified by abnormal placentation following a first CD before the onset of labor (prelabor) or intrapartum CD. Methods: This multicenter, historical cohort study involved singleton, pregnant women at 28 weeks of gestation or greater with a CD history between January 2017 and December 2017 in 11 public tertiary hospitals within 7 provinces of China. PPH was analyzed in the subsequent pregnancy between women with prior prelabor CD and women with intrapartum CD. Furthermore, PPH was analyzed in pregnant women stratified by complications with PP alone [without placenta accreta spectrum (PAS) disorders], complications with PP and PAS, complications with PAS alone (without PP), and normal placentation. We performed multivariate logistic regression to calculate adjusted odds ratios (aOR) and 95% CI controlling for predefined covariates. Results: Out of 10,833 pregnant women, 1,197 (11%) women had a history of intrapartum CD and 9,636 (89%) women had a history of prelabor CD. Prior prelabor CD increased the risk of PP (aOR 1.91, 95% CI 1.40–2.60), PAS (aOR 1.68, 95% CI 1.11–2.24), and PPH (aOR 1.33, 95% CI 1.02–1.75) in a subsequent pregnancy. After stratification by complications with PP alone, PP and PAS, PAS alone, and normal placentation, prior prelabor CD only increased the risk of PPH (aOR 3.34, 95% CI 1.35–8.23) in a subsequent pregnancy complicated with PP and PAS. Conclusion: Compared to intrapartum CD, prior prelabor CD increased the risk of PPH in a subsequent pregnancy only when complicated by PP and PAS.
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Affiliation(s)
- Bi Shilei
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhang Lizi
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Li Yulian
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Liang Yingyu
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Huang Lijun
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Huang Minshan
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Huang Baoying
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jia Jinping
- Department of Obstetrics and Gynecology, Guangzhou Huadu District Maternal and Child Health Hospital, Guangzhou, China
| | - Cao Yinli
- Department of Obstetrics and Gynecology, Northwest Women's and Children's Hospital, Xian, China
| | - Wang Shaoshuai
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xu Xiaoyan
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Ling
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhao Yangyu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Zhao Xianlan
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhu Qiying
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Qi Hongbo
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wen Suiwen
- Department of Obstetrics and Gynecology, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Guangzhou, China
| | - Zhang Lanzhen
- Department of Obstetrics and Gynecology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Li Hongtian
- National Health Commission Key Laboratory of Reproductive Health, Institute of Reproductive and Child Health, Peking University Health Science Center, Beijing, China
| | - Chen Jingsi
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institute, Guangzhou, China
| | - Wang Zhijian
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Du Lili
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institute, Guangzhou, China
| | - Chen Dunjin
- Key Laboratory for Major Obstetric Diseases of Guangdong Province, Department of Obstetrics and Gynecology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Key Laboratory of Reproduction and Genetics of Guangdong Higher Education Institute, Guangzhou, China
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Nohuz E, Noel L, Lepinay K, Michy T, Lamblin G, Massardier J, Chêne G. [How I do…the diagnosis of a cesarean scar pregnancy]. ACTA ACUST UNITED AC 2021; 50:194-200. [PMID: 34492378 DOI: 10.1016/j.gofs.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Indexed: 11/25/2022]
Affiliation(s)
- E Nohuz
- Service de gynécologie-obstétrique, hospices civils de Lyon, hôpital Femme-Mère-Enfant, HFME, 59, boulevard Pinel, 69000 Lyon, France.
| | - L Noel
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, Londres, Royaume-Uni; Centre de procréation médicale assistée, université de Liège, site CHR Liège, boulevard du 12(e) de Ligne 1, 4000 Liège, Belgique; Laboratoire de biologie des tumeurs et développement, université de Liège, 4000 Liège, Belgique
| | - K Lepinay
- Service de gynécologie-obstétrique, hospices civils de Lyon, hôpital Femme-Mère-Enfant, HFME, 59, boulevard Pinel, 69000 Lyon, France
| | - T Michy
- Service de gynécologie-obstétrique, hôpital Couple-Enfant, CHU de Grenoble-Alpes, avenue Maquis du Grésivaudan, 38700 La Tronche, France
| | - G Lamblin
- Service de gynécologie-obstétrique, hospices civils de Lyon, hôpital Femme-Mère-Enfant, HFME, 59, boulevard Pinel, 69000 Lyon, France
| | - J Massardier
- Service de gynécologie-obstétrique, hospices civils de Lyon, hôpital Femme-Mère-Enfant, HFME, 59, boulevard Pinel, 69000 Lyon, France
| | - G Chêne
- Service de gynécologie-obstétrique, hospices civils de Lyon, hôpital Femme-Mère-Enfant, HFME, 59, boulevard Pinel, 69000 Lyon, France; EMR 3738, université Claude-Bernard Lyon 1, 69000 Lyon, France
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10
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Timor-Tritsch IE, Horwitz G, D'Antonio F, Monteagudo A, Bornstein E, Chervenak J, Messina L, Morlando M, Cali G. Recurrent Cesarean scar pregnancy: case series and literature review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:121-126. [PMID: 33411387 DOI: 10.1002/uog.23577] [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: 06/04/2020] [Revised: 08/18/2020] [Accepted: 09/22/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES To determine the rate of recurrent Cesarean scar pregnancy (CSP) in our clinical practices and to evaluate whether the mode of treatment of a CSP is associated with the risk of recurrent CSP, as well as to review the published literature on recurrent CSP. METHODS We performed a retrospective search of our six obstetric and gynecological departmental ultrasound databases for all CSPs and recurrent CSPs between 2010 and 2019. We extracted various data, including number of CSPs with follow-up, number of cases attempting and number achieving pregnancy following treatment of CSP and number of recurrent CSPs, as well as details of the treatment of the original CSP. After analyzing the clinical data, we evaluated whether the mode of treatment terminating the previous CSP was associated with the risk of recurrent CSP. We also performed a PubMed search for: 'recurrent Cesarean scar pregnancy' and 'recurrent Cesarean scar ectopic pregnancy'. Articles were reviewed for year of publication, and extraction and analysis of the same data as those obtained from our departmental databases were performed. RESULTS Our database search identified 252 cases of CSP. The overall rate of clinical follow-up ranged between 71.4% and 100%, according to treatment site (mean, 90.9%). Among these, 105 women had another pregnancy after treatment of the previous CSP. Of these, 36 (34.3%) pregnancies were recurrent CSP, with 27 women having a single recurrence and three women having multiple recurrences, one with two, one with three and one with four. We did not find any particular single or combination treatment mode terminating the previous CSP to be associated with recurrent CSP. The literature search identified 17 articles that yielded sufficient information for us to evaluate their reported prevalence of recurrent CSP. These reported 1743 primary diagnoses of CSP, of which 944 had reliable follow-up. Data were available for 489 cases that attempted to conceive again after treatment of a previous CSP, and on the 327 pregnancies achieved. Of these, 67 (20.5%) were recurrent CSP. CONCLUSIONS On the basis of our pooled clinical data and review of the literature, recurrent CSP is apparently more common than was previously assumed based upon mostly single-case reports or series with few cases. This should be borne in mind when counseling patients undergoing treatment for CSP regarding their risk of recurrence. We found no obvious causal relationship or association between the type of treatment of the previous CSP and recurrence of CSP. Patients who become pregnant after treatment of a CSP should be encouraged to have an early (5-7-week) first-trimester transvaginal scan to determine the location of the gestation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - G Horwitz
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - F D'Antonio
- Department of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - A Monteagudo
- Carnegie Imaging for Women, Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - E Bornstein
- Department of Obstetrics and Gynecology, Division of MFM Lenox Hill Hospital, New York, NY, USA
| | - J Chervenak
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - L Messina
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - M Morlando
- Department of Woman, Child and General and Special Surgery, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - G Cali
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
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11
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Timor-Tritsch IE, McDermott WM, Monteagudo A, Calί G, Kreines F, Hernandez S, Stephenson C, Bryk H, D'Antonio F. Extreme enhanced myometrial vascularity following cesarean scar pregnancy: a new diagnostic entity. J Matern Fetal Neonatal Med 2021; 35:5846-5857. [PMID: 33730990 DOI: 10.1080/14767058.2021.1897564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To define, illustrate and to follow-up the diagnosis, pathophysiology and treatment of a subset of the known enhanced myometrial vascularity (EMV): its extreme form, associated with cesarean scar pregnancies (CSP) and with some cases pf placenta accreta spectrum being at increased risk of significant bleeding complications. We also aim to provide guidance to the management of such cases. MATERIAL AND METHODS This is an IRB-approved retrospective observational study of thirteen patients with an extreme form of EMV complicating CSPs. Patient's age, parity, number of cesarean deliveries, initial and time to negative serum hCG levels, primary and secondary diagnoses, blood flow peak systolic velocities, primary and secondary treatments, uterine artery embolization and outcomes were recorded. RESULTS Gestational ages ranged 6-11 weeks at initial presentation. Initial serum hCG was 20.0-102.48 mIU/L (mean 44.4 mIU/L). Diameter of EMV reached 20-75 mm (mean 46.8 mm). The mean peak systolic velocity (PSV) was 84.2 cm/s (range 46.7-118.0). Primary treatments were: systemic methotrexate (MTX) alone; D&C alone; MTX and D&C; local and systemic intra-gestational MTX injection; double cervical ripening balloon with systemic MTX; misoprostol and D&C; emergent UAE. UAE and hysterectomy were the two main secondary treatments in 10 women except 1 having a D&C after UAE, and in 1 the lesion regressed without secondary treatment. Mean time to nonpregnant hCG levels was 21-122 days (mean 67.2). Mean follow-up was 110.2 days (range 26-160). Ten women were treated with UAE, 6 had one, 3 had two embolizations. Two women had hysterectomies, one of these for persistent bleeding. Based upon the common denominators of the clinical and the US pictures, our definition of extreme EMV is sustained form of EMV associated with treated or untreated CSP, with peak systolic velocities of blood flow over 50 cm/s, slow return or plateauing serum hCG, with or without clinically significant vaginal bleeding, unresponsive to initial or secondary treatment requiring uterine artery embolization or hysterectomy. CONCLUSION The EMV developing in the background of retained placental tissue associated with CSP differs following the normal regression of the physiologically re-modelled, dilated vascular bed from the faulty "disrepair" of the vessel wall in in treated or untreated CSPs. The "threatening" appearance of the above EMVs warranted the term "extreme", creating their separate new sub-category." Extreme forms of CSP-related EMV pose significant diagnostic and management challenges. Prompt recognition and intervention, the proactive use of UAE, can maximize the outcome of women affected by this "extreme" form of EMV enabling to preserve reproductive potential. Obstetricians, gynecologists and interventional radiologists should be aware of this form of severe vascular complication.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU Langone Health, NYU School of Medicine, New York, NY, USA
| | | | - Ana Monteagudo
- Department of Obstetrics, Gynecology and Reproductive Science, Carnegie Imaging for Women, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calί
- Department of Obstetrics and Gynaecology, Arnas Civico Hospital, Palermo, Italy
| | - Fabiana Kreines
- Department of Obstetrics and Gynecology, NYU Langone Health, NYU School of Medicine, New York, NY, USA
| | - Sasha Hernandez
- Department of Obstetrics and Gynecology, NYU Langone Health, NYU School of Medicine, New York, NY, USA
| | | | - Hillel Bryk
- Department of Radiology, NYU School of Medicine, New York, NY, USA
| | - Francesco D'Antonio
- Department of Obstetrics and Gynaecology, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
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Kamel R, Eissa T, Sharaf M, Negm S, Thilaganathan B. Position and integrity of uterine scar are determined by degree of cervical dilatation at time of Cesarean section. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:466-470. [PMID: 32330331 DOI: 10.1002/uog.22053] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/02/2020] [Accepted: 04/11/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Abnormal placental invasion is more common after an elective Cesarean delivery, suggesting that prelabor Cesarean section (CS) increases the likelihood of the CS scar being above the internal cervical os and predisposing to a scar pregnancy in the future. The aim of this study was to assess the location and integrity of the CS scar in postpartum women delivered by CS at different stages of labor. METHODS This was a prospective cohort study of women at term who underwent a CS for the first time. In all women, cervical dilatation was determined by digital examination at the time of the CS. All patients had a transvaginal ultrasound examination to assess the location of the CS scar in relation to the internal cervical os, as well as the presence of a scar niche. RESULTS A total of 407 pregnant women were recruited into the study: 103 with cervical dilatation ≤ 2 cm, 261 with cervical dilatation 3-7 cm and 43 with cervical dilatation ≥ 8 cm at the time of the CS. A statistically significant correlation was observed between cervical dilatation at the time of the CS and the position of the CS scar. The scar was positioned in the uterus above the internal cervical os in 97.1% (100/103) of women delivered at a cervical dilatation of 0-2 cm, whereas the scar was located at or below the internal cervical os in 97.7% (42/43) of cases delivered at a cervical dilatation of 8-10 cm (P < 0.001). A uterine-scar defect (niche) was observed in 38.1% (64/168) of women with the scar located above, compared with 18.0% (43/239) of those with the scar situated at or below, the internal cervical os (P < 0.001). CONCLUSIONS Prelabor and early-labor Cesarean delivery are associated with an increased prevalence of a scar in the uterine cavity as well as a scar niche. CS in late labor is associated with the uterine scar being situated in the endocervical canal and with a lower incidence of a niche. The position and integrity of the CS scar after prelabor and early-labor Cesarean delivery explain the predisposition to abnormal placental invasion in subsequent pregnancy. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Kamel
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University, Kasr Al-Ainy University Hospital, Egypt
| | - T Eissa
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University, Kasr Al-Ainy University Hospital, Egypt
| | - M Sharaf
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University, Kasr Al-Ainy University Hospital, Egypt
| | - S Negm
- Maternal-Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University, Kasr Al-Ainy University Hospital, Egypt
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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13
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Timor-Tritsch IE. Cesarean scar pregnancy: a therapeutic dilemma. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:32-33. [PMID: 33387410 DOI: 10.1002/uog.23549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 06/12/2023]
Affiliation(s)
- I E Timor-Tritsch
- NYU School of Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
- Department of Obstetrics and Gynecology, Division of Ob/Gyn Ultrasound, New York University Langone Health, New York, NY, USA
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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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