Cesarean scar pregnancy combined with arteriovenous malformation successfully treated with transvaginal fertility-sparing surgery: A case report and literature review

Global variation and outcomes of expectant management of CSP

The incidence of Cesarean scar pregnancies (CSPs) is rising globally. Ultrasound criteria for the diagnosis of CSPs have been described by the International Society of Ultrasound in obstetrics and gynecology and appear to be well used in various centers around the world. There is no guidance on best practices for expectant management of CSP, and there is considerable variation in how this is offered globally. Many studies have reported significant maternal morbidity in cases of CSP with fetal cardiac activity managed expectantly, largely relating to hemorrhage and cesarean hysterectomy from placenta accreta spectrum. However, high live birth rates are also reported. Literature describing the diagnosis and expectant management of CSP in low-resource settings is lacking. Expectant management in selected cases where no fetal cardiac activity is present is a reasonable option and can be associated with good maternal outcomes. Standardization in reporting different types of CSPs and correlating these with pregnancy outcomes will be an important next step in developing guidance for expectant management of this high-risk pregnancy with a high burden of complications.

Uterine Artery Embolization on Serum β-HCG Levels, Fertility Function and Clinical Efficacy in Patients With Cesarean Uterine Scar Pregnancy

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.

Comparison of Diagnostic Efficacy among Transvaginal Sonography, Transabdominal Sonography, and 3.0 T Magnetic Resonance Imaging in Early Cesarean Scar Pregnancy

Objective

To compare the diagnostic efficacy among transvaginal sonography (TVS), transabdominal sonography (TAS), and 3.0 T magnetic resonance imaging (MRI) in early cesarean scar pregnancy (CSP).

Methods

The clinical data of 65 patients initially diagnosed with CSP in our hospital from November 2019 to November 2020 were selected for the retrospective analysis, and all patients received TVS, TAS, and 3.0 T MRI. Taking the pathological findings as the “gold standard”, the diagnostic efficacy of different diagnostic modalities in early CSP was compared.

Results

In terms of the AUC value, the result was 3.0 T MRI > TVS > TAS, and among the three diagnosis methods, 3.0 T MRI had the highest diagnostic specificity, and TVS and 3.0 T MRI had the highest sensitivity; other than intragestational hemorrhage, the detection rates of other signs of disease by TVS and TAS were significantly higher than 3.0 T MRI (P < 0.05).

Conclusion

3.0 T MRI has better diagnostic efficacy in early CSP than TVS and TAS, while TVS and TAS work better in diagnosing uterine bleeding, plumule, yolk sac, and fetal heartbeat than 3.0 T MRI. The results are more beneficial to the guidance on selecting treatment modalities.

Laparoscopic management of cesarean scar pregnancy after medical treatment failure using laparoscopic bulldog clamps

Cesarean scar pregnancies are a rare complication of pregnancy, with an incidence rate of approximately 1 in 2000 pregnancies. Numerous treatment alternatives have been proposed and published for cesarean scar pregnancies (CSPs), including medical management with local or systemic methotrexate injection, resection through hysteroscopic, vaginal, abdominal or laparoscopic approach, and dilation and curettage. Concomitant strategies for achieving hemostasis/bleeding control have been attempted, including uterine artery embolization, the placement of a Foley balloon catheter, injection of vasopressin, and less commonly reported, the use of vascular clamps. We describe a case of failed medical management of a CSP, followed by laparoscopic resection with the use of vascular clamps to minimize bleeding. This approach can be considered for minimizing blood loss in the laparoscopic management of cesarean ectopic pregnancies.

Arteriovenous Malformation Complicating Cesarean Scar Pregnancy: A Rare Case of Vaginal Bleeding Managed Successfully by Uterine Artery Embolization

Objective: Arteriovenous malformation (AVM) can occur in cesarean scar ectopic pregnancy. The presence of retained product of conception can pose a diagnostic dilemma and clinical presentation could be similar.

Case report: A 27 year old female presented with continuous vaginal bleeding for two and half months following dilatation and evacuation (D&E) done for cesarean scar pregnancy (CSP) of 10 weeks 4days period of gestation. Sonography with color Doppler revealed dilated tortuous vessels around the mass in lower uterine segment suggesting CSP with AVM. Digital subtraction angiography confirmed the diagnosis. Bilateral uterine artery embolization achieved complete devascularisation as confirmed on post intervention angiogram. Patient became symptom free since then.

Conclusion: Uterine artery embolization is an effective mode of treatment of AVM complicating CSP if future fertility is desired.