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Shen M, Li L, Zhu L, Liu J, Lin T, Liu X. Predictive value of crossover sign for outcome of ultrasound-guided vacuum aspiration in women with Cesarean scar pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:544-550. [PMID: 37610656 DOI: 10.1002/uog.27459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 07/18/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE To examine the value of the crossover sign (COS) in predicting treatment outcome in women with a Cesarean scar pregnancy (CSP) who were treated with ultrasound-guided vacuum aspiration. METHODS This was a retrospective cohort study of women with CSP who underwent ultrasound-guided vacuum aspiration. Based on the relationship between the gestational sac, Cesarean scar and anterior wall of the uterus, CSPs were classified by COS type. Analysis was conducted to investigate the association between COS type (COS-1, COS-2) and treatment outcome. The incidence of treatment failure, retained pregnancy tissue, secondary therapy and bleeding ≥ 200 mL were analyzed. RESULTS In total, 181 eligible patients with CSP, including 90 (49.7%) women with COS-1 and 91 (50.3%) women with COS-2, were analyzed. COS-1 patients had a higher incidence of treatment failure compared with COS-2 patients (25.6% vs 8.8%; P = 0.003), as well as higher rates of retained pregnancy tissue (18.9% vs 6.6%; P = 0.013), secondary therapy (20.0% vs 6.6%; P = 0.002) and bleeding of ≥ 200 mL (13.3% vs 4.4%; P = 0.034). COS-1 and a large gestational sac (30.1-50.0 mm or >50.0 mm in diameter) were associated independently with increased risk of treatment failure (odds ratio, 4.57 (95% CI, 1.66-12.56); P = 0.003, 4.34 (95% CI, 1.35-13.94); P = 0.014 and 10.50 (95% CI, 2.54-43.46); P = 0.001, respectively). CONCLUSIONS Ultrasound evaluation of the relationship between the gestational sac and the endometrial line (COS classification) in women with CSP may help to predict treatment outcome among those undergoing vacuum aspiration. Among COS-1 patients, especially those with a gestational sac diameter of >30.0 mm, vacuum aspiration may be discouraged. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M Shen
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - L Li
- Department of Ultrasound, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - L Zhu
- Department of Ultrasound, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - J Liu
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - T Lin
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
| | - X Liu
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian Province, China
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Fu P, Sun H, Zhang L, Liu R. Efficacy and safety of treatment modalities for cesarean scar pregnancy: a systematic review and network meta-analysis. Am J Obstet Gynecol MFM 2024:101328. [PMID: 38485053 DOI: 10.1016/j.ajogmf.2024.101328] [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: 11/29/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE Cesarean scar pregnancy may lead to varying degrees of complications. There are many treatment methods for it, but there are no unified or recognized treatment strategies. This systematic review and network meta-analysis aimed to observe the efficacy and safety of treatment modalities for patients with cesarean scar pregnancy. DATA SOURCES MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched from their inception to January 31, 2024. In addition, relevant reviews and meta-analyses were manually searched for additional references. STUDY ELIGIBILITY CRITERIA Our study incorporated head-to-head trials involving a minimum of 10 women diagnosed with cesarean scar pregnancy through ultrasound imaging or magnetic resonance imaging, encompassing a detailed depiction of primary interventions and any supplementary measures. Trials with a Newcastle-Ottawa scale score <4 were excluded because of their low quality. METHODS We conducted a random-effects network meta-analysis and review for cesarean scar pregnancy. Group-level data on treatment efficacy and safety, reproductive outcomes, study design, and demographic characteristics were extracted following a predefined protocol. The quality of studies was assessed using the Cochrane risk-of-bias tools for randomized controlled trials and the Newcastle‒Ottawa scale for cohort studies and case series. The main outcomes were efficacy (initial treatment success) and safety (complications), of which summary odds ratios and the surface under the cumulative ranking curve using pairwise and network meta-analysis with random effects. RESULTS Seventy-three trials (7 randomized controlled trials) assessing a total of 8369 women and 17 treatment modalities were included. Network meta-analyses were rooted in data from 73 trials that reported success rates and 55 trials that reported complications. The findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage demonstrated the highest cure rates, as evidenced by surface under the cumulative ranking curve rankings of 91.2, 88.2, 86.9, and 75.3, respectively. When compared with suction curettage, the odds ratios (95% confidence intervals) for efficacy were as follows: 6.76 (1.99-23.01) for laparoscopy, 5.92 (1.47-23.78) for transvaginal resection, 5.00 (1.99-23.78) for hysteroscopic curettage, and 3.27 (1.08-9.89) for high-intensity focused ultrasound combined with suction curettage. Complications were more likely to occur after receiving uterine artery chemoembolization, suction curettage, methotrexate+hysteroscopic curettage, and systemic methotrexate; hysteroscopic curettage, high-intensity focused ultrasound combined with suction curettage, and Lap were safer than the other options derived from finite evidence; and the confidence intervals of all the data were wide. CONCLUSION Our findings indicate that laparoscopy, transvaginal resection, hysteroscopic curettage, and high-intensity focused ultrasound combined with suction curettage procedures exhibit superior efficacy with reduced complications. The utilization of methotrexate (both locally guided injection and systemic administration) as a standalone medical treatment is not recommended.
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Affiliation(s)
- Peiying Fu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haiying Sun
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Long Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ronghua Liu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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You X, Ruan Y, Weng S, Lin C, Gan M, Qi F. The effectiveness of hysteroscopy for the treatment of cesarean scar pregnancy: a retrospective cohort study. BMC Pregnancy Childbirth 2024; 24:151. [PMID: 38383385 PMCID: PMC10880367 DOI: 10.1186/s12884-024-06344-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/12/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Cesarean scar pregnancy (CSP) is a long-term complication of cesarean section characterized by the localization of a subsequent gestational sac within the scar area or niche developed as a result of a previous cesarean section. Its incidence has increased substantially because of the high global cesarean section rate in recent decades. Several surgical and drug treatments exist for this condition; however, there is currently no optimal treatment. This study compared the effectiveness of direct hysteroscopic removal of the gestational tissue and hysteroscopy combined with vacuum suction for the treatment of CSP. METHODS From 2017 to 2023, 521 patients were diagnosed with CSP at our hospital. Of these patients, 45 underwent hysteroscopy. Among them, 28 underwent direct hysteroscopic removal (hysteroscopic removal group) and 17 underwent hysteroscopy combined with vacuum suction (hysteroscopic suction group). The clinical characteristics and outcomes of the hysteroscopic removal group and hysteroscopic suction group were analyzed. RESULTS Among the 45 patients, the amount of bleeding and hospitalization cost were significantly higher in the hysteroscopic removal group than in the hysteroscopic suction group (33.8 mL vs. 9.9 mL, P < 0.001; and 8744.0 yuan vs. 5473.8 yuan, P < 0.001; respectively). The operation time and duration of hospitalization were significantly longer in the hysteroscopic removal group than in the hysteroscopic suction group (61.4 min vs. 28.2 min, P < 0.001; and 3.8 days vs. 2.4 days, P = 0.026; respectively). Three patients in the hysteroscopic removal group had uterine perforation and received laparoscopic repair during operation. No complications occurred in the hysteroscopic suction group. One patient in the hysteroscopic removal group received ultrasound-guided suction curettage due to postoperative moderate vaginal bleeding, and one patient in the hysteroscopic suction group received ultrasound-guided suction curettage due to postoperative gestational residue and elevated serum beta-human chorionic gonadotropin levels. Reproductive function was preserved in all patients. CONCLUSIONS Hysteroscopy is an effective method for treating CSP. Compared with direct hysteroscopic removal, hysteroscopy combined with vacuum suction is more suitable for CSP. However, multicenter prospective studies with large sample sizes are required for verification of these findings.
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Affiliation(s)
- Xinxin You
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, Zhejiang Province, China
| | - Yan Ruan
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, Zhejiang Province, China
| | - Shouxiang Weng
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, Zhejiang Province, China
| | - Chenya Lin
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, Zhejiang Province, China
| | - Meifu Gan
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, Zhejiang Province, China.
| | - Feng Qi
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, Linhai, Zhejiang Province, China.
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Wu T, Wang Q, Liu W, Zhang J, Wang W, Wang J, Ji C, Liu H, Tang C, Mi X. Clinical efficacy and risk factors for suction curettage and hysteroscopy in patients with type I and II cesarean scar pregnancy. Int J Gynaecol Obstet 2024; 164:270-276. [PMID: 37537977 DOI: 10.1002/ijgo.15020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/30/2023] [Accepted: 07/10/2023] [Indexed: 08/05/2023]
Abstract
OBJECTIVE To investigate the clinical efficacy and evaluate risk factors for suction curettage (SC) and hysteroscopy in the treatment of type I and II cesarean scar pregnancy (CSP). METHODS This was a retrospective study including 100 women diagnosed with type I/II CSP. Patients were treated with either ultrasound-guided SC (SC group) or hysteroscopy resection (surgery group). The success rates, mean operation time, hospitalization duration, hospitalization cost, risk factors, adverse events, and complications were analyzed. RESULTS The success rate of the SC and surgery groups were 85% and 100%, respectively, and the difference was statistically significant (P = 0.032). There was one case of type I CSP and eight cases of type II CSP that failed SC treatment. No failed cases were found in the surgery group. Analysis of the causes of treatment failure revealed that diameter of the gestational sac was a risk factor for SC failure (odds ratio, 19.66 [95% confidence interval {CI}, 1.70-227.72], P = 0.017). Comparing the clinical outcomes between the SC and surgery groups, although the mean operation time of the SC group was significantly shorter than the surgery group (15 [CI, 15-20] vs. 30 [CI, 27-40], P = 0.001), the cost and duration of hospitalization were significantly lower in the surgery group than that in the SC group. No significant differences were observed for adverse events and complications between the two groups (P > 0.05). CONCLUSION Hysteroscopy is an effective and economical method for treating type I/II CSP. Moreover, SC is not recommended for patients with type I/II CSP with a gestation age ≥8 weeks.
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Affiliation(s)
- Tong Wu
- Department of Gynecology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Qingxuan Wang
- Department of Gynecology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Wei Liu
- Department of Gynecology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Jing Zhang
- Department of Ultrasonography, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Wenhui Wang
- Department of Gynecology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Jun Wang
- Department of Gynecology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Cuihong Ji
- Department of Gynecology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Honghui Liu
- Department of Gynecology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Chunyan Tang
- Department of Gynecology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
| | - Xin Mi
- Department of Gynecology, Shunyi Maternal and Children's Hospital of Beijing Children's Hospital, Beijing, China
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Knapman BL, Forgues MAS, Abbott JA, Maheux-Lacroix S. Other treatments for CSP. Best Pract Res Clin Obstet Gynaecol 2023; 90:102367. [PMID: 37379723 DOI: 10.1016/j.bpobgyn.2023.102367] [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: 04/01/2023] [Revised: 05/20/2023] [Accepted: 05/30/2023] [Indexed: 06/30/2023]
Abstract
Caesarean scar pregnancy (CSP) is an increasingly common clinical conundrum. The non-curettage surgical management of CSP can be categorised into hysteroscopic, vaginal, laparoscopic, and open removal modalities and the choice of treatment is surgeon-dependent. A systematic review of original studies reporting surgical treatment outcomes of CSP until March 2023 was conducted to evaluate the non-curettage surgical management of this highly morbid condition. A total of 60 studies of mostly weak methodological quality were identified involving 6720 CSP cases. Success rates were generally high across all treatment modalities although highest in vaginal and laparoscopic excisional approaches. Morbidity was most associated with haemorrhage although unplanned hysterectomy rates remained low across all treatment groups. Subsequent pregnancies are associated with morbidity despite being underreported and the impact of CSP treatment on future pregnancy is poorly understood. Substantive study heterogeneity precludes meta-analyses of pooled data and treatment superiority has not been demonstrated.
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Affiliation(s)
- Blake L Knapman
- School of Clinical Medicine, UNSW Sydney, NSW, 2031, Australia; Gynaecological Research and Clinical Evaluation (GRACE) Unit, The Royal Hospital for Women, Barker Street, Randwick, NSW, 2031, Australia.
| | | | - Jason A Abbott
- School of Clinical Medicine, UNSW Sydney, NSW, 2031, Australia; Gynaecological Research and Clinical Evaluation (GRACE) Unit, The Royal Hospital for Women, Barker Street, Randwick, NSW, 2031, Australia.
| | - Sarah Maheux-Lacroix
- Gynaecological Research and Clinical Evaluation (GRACE) Unit, The Royal Hospital for Women, Barker Street, Randwick, NSW, 2031, Australia; CHU de Quebec, Université Laval, 2705 Boul. Laurier, Quebec, QC, G1V 0A6, Canada.
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Jin X, Liu M, Zhang P, Zheng L, Qi F. Subsequent fertility after cesarean scar pregnancy: a retrospective analysis. BMC Pregnancy Childbirth 2023; 23:337. [PMID: 37170216 PMCID: PMC10173584 DOI: 10.1186/s12884-023-05584-8] [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: 11/29/2022] [Accepted: 04/08/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Cesarean scar pregnancy (CSP) refers to the implantation and growth of the gestational sac at a uterine scarring site due to a previous cesarean section. The effects of CSP on subsequent fertility have emerged as a clinical issue of importance in gynecology and obstetrics in China owing to the increasing rate of cesarean section over the past 30 years in combination with the abolition of the national family planning policy, allowing for subsequent pregnancies. Therefore, we aimed to investigate the effects of CSP treatment on subsequent fertility and pregnancy outcomes. METHODS The study consecutively enrolled 499 women treated for CSP at Taizhou Hospital between January 2009 and December 2018. The study outcomes were the rate of secondary infertility and pregnancy outcomes. Clinical information was collected at the time of admission for CSP treatment. Information on subsequent fertility and pregnancy outcomes was collected via telephonic follow-up. RESULTS Among the 499 women who met the inclusion criteria for CSP, 48 were lost to follow-up. Most women (74.9%, 338/451) did not express the desire for a subsequent pregnancy after CSP treatment. Among the 113 women who initially desired a subsequent pregnancy, 62 finally abandoned fertility plans. Among the 51 women who pursued pregnancy, 48 pregnancies were recorded in 43 women, infertility secondary to CSP treatment was identified in 15.7% (8/51) of women, and 60.8% (31/51) of women achieved full-term pregnancy, with placenta accreta spectrum identified in two women, one requiring a hysterectomy during cesarean section due to massive bleeding. Among the 16 women treated with uterine artery embolization combined with uterine aspiration and 18 women treated by ultrasound-guided local lauromacrogol injection combined with uterine aspiration, a successful full-term pregnancy rate of 68.8% (11/16) and 88.9% (16/18), respectively, was achieved. There were five cases of recurrent CSP among all 76 pregnancies (6.6%). CONCLUSION Over a long-term follow-up of women after CSP treatment, a high successful fertility rate was identified, with also an increased CSP recurrence rate. Uterine artery embolization combined with uterine aspiration and ultrasound-guided local lauromacrogol injection combined with uterine aspiration showed high rates of successful post-treatment fertility and pregnancy.
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Affiliation(s)
- Xiaoxiao Jin
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, No. 150, Ximen St, Linhai, Zhejiang Province, 317000, China
| | - Manman Liu
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, No. 150, Ximen St, Linhai, Zhejiang Province, 317000, China
| | - Panxi Zhang
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, No. 150, Ximen St, Linhai, Zhejiang Province, 317000, China
| | - Lingzhi Zheng
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, No. 150, Ximen St, Linhai, Zhejiang Province, 317000, China.
| | - Feng Qi
- Department of Gynecology and Obstetrics, Taizhou Hospital of Zhejiang Province, Zhejiang University, No. 150, Ximen St, Linhai, Zhejiang Province, 317000, China.
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