Evaluation of the treatment of high intensity focused ultrasound combined with suction curettage for exogenous cesarean scar pregnancy

A novel scoring model to predict massive hemorrhage during dilatation and curettage following focused ultrasound ablation surgery in patients with type 2 cesarean scar pregnancy

OBJECTIVE

To develop a predictive model for assessing massive hemorrhage risk during dilatation and curettage (D&C) after focused ultrasound ablation surgery (FUAS) in Type 2 cesarean scar pregnancy (CSP) patients.

METHODS

A retrospective analysis of 405 Type 2 CSP patients treated at Hunan Maternal and Child Health Hospital (2018-2023) was conducted. Multivariable logistic regression identified independent risk factors, and a nomogram was constructed. Model performance was evaluated using AUC, calibration curves, and decision curve analysis (DCA). Ten-fold cross-validation was performed, and external validation was conducted on 327 patients.

RESULTS

Independent risk factors included gestational sac maximum diameter (OR 1.11, 95% CI: [1.07-1.15], p < 0.001), GS blood flow US grade 3 (OR 9.96, 95% CI: [2.65-40.10], p < 0.001), and FUAS-curette time >24 h (OR 17.57, 95% CI: [3.88-84.48], p < 0.001). C-scar thickness and HCG levels were also included in the model as clinically significant factors. The model showed high discriminative ability (AUC 0.910, 95% CI: 0.867-0.953) and was validated through 10-fold cross-validation (mean AUC 0.838). External validation confirmed its robustness (AUC 0.812, 95% CI: 0.742-0.881). Calibration curves and DCA confirmed its accuracy and clinical utility.

CONCLUSION

The predictive model effectively assesses hemorrhage risk in Type 2 CSP patients post-FUAS, offering valuable clinical utility.

Treatments for cesarean scar pregnancy: a systematic review and meta-analysis

OBJECTIVE

To report the outcome of cesarean scar pregnancy (CSP) undergoing treatment.

METHODS

MEDLINE, Embase and CINAHL databases were searched. Inclusion criteria were women with CSP undergoing treatment. The primary outcome was successful treatment for CSP, defined as no need for additional medical or surgical strategies. Secondary outcomes were the type of additional treatment (surgical or medical), need for blood transfusion, emergency laparotomy, hysterectomy, post-treatment complications.All these outcomes were explored in women undergoing single and compound treatments for CSP. Furthermore, we performed a separate sub-group analysis only including studies which reported on the outcomes of elective treatments. Random effects meta-analyses were used to analyze the data and results reported as pooled proportions or odd ratio (OR).

RESULTS

176 studies (13431 women with CSP undergoing treatment) were included.Successful treatment after primary intervention was achieved in 86.2% (95% CI 82.3-89.7) of women with CSP undergoing treatment with ultrasound guided suction curettage, 72.4% (95% CI 64.8-79.3) with systemic MTX, 81.6% (95% CI 72.3-89.3) with local MTX, 83.9% (95% CI 66.7-95.6) with interventional radiology, 90.42% (95% CI 82.9-96.0) with hysteroscopy, 96.1% (95% CI (92.3-98.6) with laparoscopy and 92.6 with high intensity focused ultrasound (95% CI 78.2-99.6). Post-treatments complications were reported in 3.5% (95% CI 1.7-6.0) of women treated with systemic MTX, 5.9% (95% CI 0.8-15.1) with local MTX or KCl, 1.2% (95% CI 0.1-3.5) with interventional radiology, 1.4% (95% CI 0.4-2.9) with hysteroscopy, 5.5% (95% CI 0.4-25.7) with high intensity focused ultrasound and in none of the cases treated with ultrasound guided suction curettage.When considering compound treatments, successful resolution of CSP was achieved in 91.9% (95% CI 88.0-95.10) of women treated with interventional radiology followed by curettage, 83.3% (95% CI 68.8-93.8) with systemic MTX and curettage, 79.4% (95% CI 56.3-95.2) with local MTX and curettage, 96.2% (95% CI 92.3-98.7) with curettage followed by single or double balloon insertion in the uterine cavity, 98.3% (95% CI 95.9-99.7) with high intensity focused ultrasound followed by curettage, 91.1% (95% CI 3.4-97.0) with interventional radiology followed by removal of CSP with hysteroscopy, 64.3% (95% CI 13.8-99.2) with interventional radiology and systemic MTX and in 95.5% (95% CI 92.9-97.5) with curettage and hysteroscopy.When considering studies reporting a comparison between different treatments, there was no difference between systemic vs local MTX in the primary outcome. Curettage was associated with a higher chance of achieving a successful treatment.

CONCLUSIONS

A multitude of treatments for CSP have been reported in the published literature. All treatments described for CSP are apparently equally effective in treating this condition. The findings from this systematic review highlight the need for adopting a common definition and outcome reporting of CSP to better elucidate its natural history, estimate the magnitude of maternal complication after treatment and design appropriately powered RCT to elucidate the optimal treatment of CSP according to its ultrasound phenotype and gestational age at treatment, in terms of effective resolution of the condition and risk of post-intervention complications.

Efficacy and safety of high-intensity focused ultrasound combined with suction curettage for the treatment of caesarean scar pregnancy: a systematic review and single-arm meta-analysis

PURPOSE

Caesarean scar pregnancy (CSP) presents a significant clinical challenge owing to the associated risks of uterine scar rupture, severe haemorrhage and adverse maternal outcomes. This study aimed to assess the safety and efficacy of combining high-intensity focused ultrasound (HIFU) with suction curettage for treating CSP.

METHODS

We conducted a comprehensive search in four databases, namely PubMed, Web of Science, Embase and Cochrane Library, to identify published studies evaluating the use of HIFU combined with suction curettage to treat CSP. Intraoperative blood loss, treatment success rate, and reproductive results were the primary outcomes assessed.

RESULTS

A total of 18 studies involving 1251 patients with CSP, all of whom received preoperative HIFU therapy were included. The average hospital stay was 6.22 days, the intraoperative blood loss was 26.29 ml and the incidence of adverse events was 15.60%, including abdominal or lower limb pain, fever, vaginal bleeding, haematuria and vomiting. Furthermore, post-treatment follow-up showed that serum β-human chorionic gonadotropin levels were rapidly normalized (average of 25.48 days) and menstruation returned (average of 33.03 days). The treatment had a remarkable success rate of 97.60% and a subsequent pregnancy rate of 68.70%.

CONCLUSION

While the combination of HIFU and suction-curettage may induce common adverse effects such as lower abdominal or limb pain, these reactions typically do not necessitate therapeutic intervention. Additionally, the size of the gestational sac is a determinant of the procedure's success. In conclusion, HIFU combined with suction curettage demonstrates promising clinical efficacy, safety and favourable reproductive outcomes in managing CSP.

MRI-based scoring model to predict massive hemorrhage during dilatation and curettage in patients with cesarean scar pregnancy

OBJECTIVE

To construct a scoring model based on MRI signs to predict massive hemorrhage during dilatation and curettage in cesarean scar pregnancy (CSP) patients.

MATERIALS AND METHODS

The MRIs of CSP patients admitted to a tertiary referral hospital between February 2020 and July 2022 were retrospectively reviewed. The included patients were randomly assigned to the training and validation cohorts. The univariate and multivariate logistic regression analyses were adopted to identify the independent risk factors for massive hemorrhage (the amount of bleeding ≥ 200 ml) during the dilatation and curettage. A scoring model predicting intraoperative massive hemorrhage was established where each positive independent risk factor was assigned 1 point, and the predictive power of this model was evaluated both in the training and validation cohorts via the receiver operating characteristic curve.

RESULTS

A total of 187 CSP patients were enrolled, who were divided into the training cohort (31 in 131 patients had massive hemorrhage) and validation cohort (10 in 56 patients had massive hemorrhage). The independent risk factors for intraoperative massive hemorrhage included cesarean section diverticulum area (OR = 6.957, 95% CI 1.993-21.887; P = 0.001), uterine scar thickness (OR = 5.113, 95% CI 2.086-23.829; P = 0.025) and gestational sac diameter (OR = 3.853, 95% CI 1.103-13.530; P = 0.025). A scoring model with a total point of 3 was developed and the CSP patients were divided into low-risk (Total points < 2) and high-risk groups (Total points ≥ 2) for intraoperative massive hemorrhage accordingly. This model possessed high prediction performance both in the training cohort (area under the curve [AUC] = 0.896, 95% CI 0.830-0.942) and validation cohort (AUC = 0.915, 95% CI 0.785-1.000).

CONCLUSION

We first constructed a MRI-based scoring model for predicting intraoperative massive hemorrhage in CSP patients, which could help the decision-making of the patients' therapy strategies. Low-risk patients can be cured by D&C alone to reduce the financial burden, while high-risk patients require more adequate preoperative preparation or consideration of changing surgical approaches to reduce bleeding risk.

Efficacy and Safety of High-intensity Focused Ultrasound Compared with Uterine Artery Embolization in Cesarean Section Pregnancy: A Meta-analysis

OBJECTIVE

To investigate the efficacy and safety of high-intensity focused ultrasound (HIFU) compared with uterine artery embolization (UAE) in cesarean section pregnancy (CSP) and to calculate the success rate of HIFU.

DATA SOURCES

We searched PubMed, Cochrane, Scopus, Web of Science, and Embase on September 30, 2022, and the related studies were independently reviewed by 2 researchers.

METHODS OF STUDY SELECTION

Medical subject headings and relevant terms from other articles were used for the database search. Patients with CSP who underwent HIFU were included in this analysis. The following results were recorded: success rate, intraoperative blood loss, time for serum beta-human chorionic gonadotropin (beta-HCG) normalization and menstruation recovery, adverse events, hospitalization time, and hospitalization expenses. We used the Newcastle-Ottawa Scale scoring system and the methodological index for nonrandomized studies system to evaluate the quality of the studies.

TABULATION, INTEGRATION, AND RESULTS

Data from 6 studies were used to compare the efficacy and safety of UAE and HIFU. We pooled the success rate of HIFU by including 10 studies. No data overlap between the 10 studies. Success rate was higher in the HIFU group (odds ratio [OR] = 1.90; 95% confidence interval [CI] 1.06-3.41; p = .03; I2 = 0). We performed the meta-analysis of single rate in R 4.2.0 software, and the success rate of HIFU group was 0.94 (95% CI 0.92-0.96; p = .04; I2 = 48%). Intraoperative blood loss (mean difference [MD]= -21.94 mL; 95% CI -67.34 to 23.47; p = .34; I2 = 99%) and time for serum beta-HCG normalization (MD = 3.13 days; 95% CI 0.02-6.25; p = .05; I2 = 70%) were not significantly different. Time to menstruation recovery (MD = 2.72 days; 95% CI 1.32-4.12; p = .0001; I2 = 0) in the UAE group was shorter than that in the HIFU group. Adverse events were not significantly different between the 2 groups (OR = 0.53; 95% CI 0.22-1.29; p = .16; I2 = 81%). Hospitalization time was not significantly different between the HIFU and UAE groups (MD = -0.41 days; 95% CI -1.14 to 0.31; p = .26; I2 = 55%). Hospitalization expenses of the HIFU group were lower than those of the UAE group (MD = -7488.49 yuan; 95% CI -8460.13 to -6516.84; p <.000; I2 = 0). Heterogeneity of the time for beta-HCG normalization, adverse events, and hospitalization time were improved after excluding one study, and HIFU showed better results in the sensitivity analysis of adverse events and hospitalization time.

CONCLUSION

According to our analysis, HIFU demonstrated satisfactory treatment success, accompanied by similar intraoperative blood loss, slower normalization of beta-HCG levels, and menstruation recovery, but potentially shorter hospitalization time, lower adverse events and lower costs than UAE. Therefore, HIFU is an effective, safe, and economical treatment for patients with CSP. These conclusions should be interpreted with caution because of the significant heterogeneity. However, large and strictly designed clinical trials are required to verify these conclusions.

Caesarean scar pregnancy: is there a light in the end of the tunnel?

PURPOSE

To summarize and present a single tertiary center's 25 years of experience managing patients with caesarean scar pregnancies and their long-term reproductive and obstetric outcomes.

METHODS

A 25-year retrospective study included women diagnosed with CSP from 1996 to 2020 in one tertiary center. Data were retrieved from the medical records and through a telephone interview. Diagnosis was made by sonography and color Doppler. Treatments included methotrexate, suction curettage, hysteroscopy, embolization and wedge resection by laparoscopy or laparotomy as a function of the clinical manifestations, the physicians' decisions, patient counseling, and parental requests.

RESULTS

Analysis of the records recovered 60 cases of CSP (two of whom were recurrent). All patients had complete resolution with no indication for hysterectomy. Thirty-five patients had a long-term follow-up, of whom 24 (68.6%) attempted to conceive again and 22 (91.6%) succeeded. There were 17/22 (77.3%) patients with at least one live birth, 3/22 (13.6%) spontaneous miscarriages and 2/22 (9%) recurrent CSP. The obstetric complications included abnormal placentation 5/19 (26.3%), premature rupture of membranes 2/19 (10.5%), preterm delivery 4/19 (21%) and abnormality of the uterine scar 2/19 (10.5%). There was one case of neonatal death due to complications of prematurity 1/19 (5.2%).

CONCLUSION

CSP treatment focusing on reducing morbidity and preserving fertility has encouraging long-term reproductive and obstetric outcomes. In subsequent pregnancies, we recommend performing an early first trimester vaginal scan to map the location of the new pregnancy, followed by close monitoring given the obstetric complications mentioned above.

Clinical efficacy and safety analysis of different treatment options for Cervical pregnancy

OBJECTIVE

To compare the efficacy and safety of different treatment options for cervical pregnancy (CP).

MATERIALS AND METHODS

A total of 74 patients diagnosed with CP at Hunan Provincial Maternal and Child Health Care Hospital between January 2016 and September 2022 were retrospectively analyzed. Among them, 31 were treated with uterine artery embolization (UAE) followed by hysteroscopic curettage, 34 were treated with hysteroscopic curettage alone, and nine were treated with high-intensity focused ultrasound (HIFU) followed by hysteroscopic curettage. Medical records and pregnancy outcomes were analyzed.

RESULTS

There were no significant differences in age, gravidity, parity, abortion, or preoperative hemoglobin levels among the patients in the three groups; however, significant differences in gestational age, gestational sac diameter, preoperative β-hCG, and presence of cardiac pulsation were observed (p < 0.05). After treatment, there was no conversion to laparotomy, and the uterus was preserved in all patients. Significant differences in blood loss during curettage, hospitalization costs, hospital days, menstrual recovery interval, β-hCG decline rates, retained products of conception, and intrauterine adhesions rate among the three groups were observed (p < 0.05). There were no significant differences in the placement of the uterine Foley balloon, effective curettage rate, pre-and postoperative hemoglobin decline, live birth rate, or proportion of subsequent pregnancies among the three groups.

CONCLUSION

Our results showed that hysteroscopic curettage, HIFU, and UAE followed by hysteroscopic curettage are safe and effective for treating patients with CP. Compared with the UAE, HIFU has the advantages of lower hospitalization costs, shorter hospital stays, and shorter menstrual recovery intervals.