Successful methotrexate treatment of a viable pregnancy within a thin uterine scar

Successful technique of manual vacuum aspiration for treatment of type 2 cesarean scar pregnancies: evaluation of 40 cases

OBJECTIVE

To demonstrate the effectiveness and safety of the defined manual vacuum aspiration (MVA) technique for treatment of type 2 cesarean scar pregnancies (CSPs).

METHODS

We treated 40 patients with CSP by MVA at the Early Pregnancy Clinic of our hospital between 1 January 2012 and 31 December 2014. The files of patients were reviewed and evaluated retrospectively. Eligibility criteria were hemodynamic stability and at least 2 mm myometrial thickness at the anterior part of the CSP. The key-point of successful MVA procedure is to keep away from entering the cesarean scar cavity directly; instead, CSP is displaced from the implantation site by applying vacuum, only while the cannula is passing near.

RESULTS

During the study period, the ratio of CSP to total pregnancies was 1/1000. The ratio of CSP to cesarean delivery (CD) was 1/372. In that time period, CSPs were constituted 4.41% of all ectopic pregnancies. Total of 40 patients were treated with dilatation and MVA. Complications such as excessive hemorrhage, persistence of CSP, and any need of extra intervention were not observed. The beta-hCG values of 21 patients (52.5%) decreased below 10 mIU/mL after the first 15 days, and the rest decreased below 10 mIU/mL after 3 weeks following MVA.

CONCLUSIONS

This MVA technique for treatment of CSP is easily applicable and effective method with high success and low complication rates. For appropriately selected patients, we think that this method can be considered as the first- line treatment.

Caesarean scar pregnancy: hysterotomy is rapid and safe management option

Caesarean scar pregnancy (CSP) is implantation of the gestational sac within the hysterotomy scar. Ultrasound is the main diagnostic tool. Early diagnosis and termination of pregnancy is crucial to avoid the risk of uterine rupture. The termination modalities available are dilatation and curettage, methotrexate therapy, hysteroscopy, uterine artery embolization and laparotomy. We present a case of undisturbed CSP which presented at 6 weeks + 6 days gestation. Our management was termination of pregnancy by exploratory laparotomy and hysterotomy for excision of the mass. The postoperative period was uneventful and there was rapid decline of beta human chorionic gonadotrophin to the normal level.

Cervicoisthmic pregnancy near cesarean scar after oocyte donation in premature ovarian failure: literature review starting from a single case

OBJECTIVE

This study aimed to identify the best management options in decision making in cases of cervicoisthmic and cesarean scar pregnancies and rare forms of ectopic pregnancies with high rates of pregnancy-related morbidity in the first trimester, more commonly associated with assisted reproductive medicine.

MATERIALS AND METHODS

We performed a literature review of the description of a case report of a cervicoisthmic pregnancy near a cesarean scar in a premature ovarian failure woman. She obtained pregnancy after ovum donation, hormonal therapy, and in vitro fertilization. The researchers focused on the MEDLINE/PubMed database articles on ectopic pregnancies, particularly on cesarean scar pregnancies, cervical pregnancies, and ectopic pregnancies after in vitro fertilization in English-language journals published from January 1996 to December 2011.

RESULTS

The conservative or nonconservative options for medical or surgical treatments are disposables. Moreover, in literature, no consensus was found about the best treatment method.

CONCLUSIONS

Obstetricians should pay great attention to a possible cesarean scar pregnancy in patients with risk factors in their medical history. Until now, the rarity of these findings does not allow the definition of a commonly accepted management, so the best personalized approach may be guided by early recognition, close surveillance, and appropriate counseling. Further investigations are necessary to recognize high-risk factors for all ectopic pregnancies and those unique to cesarean scar ectopic pregnancies.

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.

The diagnosis, treatment, and follow-up of cesarean scar pregnancy

OBJECTIVE

The diagnosis and treatment of cesarean scar pregnancy (CSP) is challenging. The objective of this study was to evaluate the diagnostic method, treatments, and long-term follow-up of CSP.

STUDY DESIGN

This is a retrospective case series of 26 patients between 6-14 postmenstrual weeks suspected to have CSP who were referred for diagnosis and treatment. The diagnosis was confirmed with transvaginal ultrasound. In 19 of the 26 patients the gestational sac was injected with 50 mg of methotrexate: 25 mg into the area of the embryo/fetus and 25 mg into the placental area; and an additional 25 mg was administered intramuscularly. Serial serum human chorionic gonadotropin determinations were obtained. Gestational sac volumes and vascularization were assessed by 3-dimensional ultrasound and used to monitor resolution of the injected site and outcome.

RESULTS

The 19 treated pregnancies were followed for 24-177 days. No complications were observed. After the treatment, typically, there was an initial increase in the human chorionic gonadotropin serum concentrations as well as in the volume of the gestational sac and their vascularization. After a variable time period mentioned elsewhere the values decreased, as expected.

CONCLUSION

Combined intramuscular and intragestational methotrexate injection treatment was successful in treating these CSP.

Ectopic pregnancy not within the (distal) fallopian tube: etiology, diagnosis, and treatment

Ectopic pregnancy is a very common diagnosis (2% of pregnancies), and implantation location varies. Although 97% of ectopics are implanted within the fallopian tube, associated with commonly recognized risk factors, ectopic implantation can occur in other pelvic and abdominal locations that may not have such predisposing risk factors. After an extensive review of the literature, along with the author's personal experience, implantation frequency, etiologic possibilities, and treatment options for each ectopic pregnancy location are presented. When ectopic pregnancy is diagnosed early, before rupture, regardless of location, conservative, fertility-sparing treatment options can be successful in terminating the pregnancy. Predisposing risk factors and treatment options can vary and can be ectopic-location specific.

Caesarean scar pregnancy: a review of management options

PURPOSE OF REVIEW

The current review aims to provide an overview of the already available and emerging treatment modalities for caesarean scar pregnancy (CSP).

RECENT FINDINGS

CSP is a type of ectopic gestation associated with a high risk of serious complications. The cause of this condition and the best management are still unclear. However, some medical and surgical treatment modalities have been suggested. The main objectives in the clinical management of CSP should be the prevention of massive blood loss and the conservation of the uterus to maintain further fertility, women's health and quality of life. Current data suggest that expectant management should not be recommended, whereas there are accumulating data suggesting that early diagnosis offers single or combined medical and surgical treatment options avoiding uterine rupture and haemorrhage, thus preserving the uterus and fertility.

SUMMARY

No universal treatment guidelines for the management of CSP have been published up to now. The lack of data on the best evidence should encourage any individual case report and further multicentre studies for recommendations establishment.

Therapeutic options of caesarean scar pregnancy: case series and literature review

We describe our experience with the treatment of 4 caesarean scar pregnancies and provide an overview of current literature. Four women diagnosed with a caesarean scar pregnancy in our hospital between 1996 and 2007 were treated with local or systemic methotrexate and had a steady decline of the serum beta-hCG level. The uterus was preserved in all women and 3 of them had an uneventful subsequent pregnancy and delivery. We suggest that transcervical needle aspiration of amniotic fluid followed by intra-amniotic injection of methotrexate should be the treatment of choice, followed by surgical treatment only if methotrexate fails.

Caesarean scar pregnancy

Caesarean scar pregnancy is one of the rarest forms of ectopic pregnancy. Little is known about its incidence and natural history. With increasing incidence of caesarean section worldwide, more and more cases are diagnosed and reported. Transvaginal ultrasound and colour flow Doppler provides a high diagnostic accuracy with very few false positives. A delay in diagnosis and/or treatment can lead to uterine rupture, major haemorrhage, hysterectomy and serious maternal morbidity. Early diagnosis can offer treatment options of avoiding uterine rupture and haemorrhage, thus preserving the uterus and future fertility. Management plan should be individually tailored. Available data suggest that termination of pregnancy is the treatment of choice in the first trimester soon after the diagnosis. Expectant treatment has a poor prognosis because of risk of rupture. There are no reliable scientific data on the risk of recurrence of the condition in future pregnancy, role of the interval between the previous caesarean delivery and occurrence of caesarean scar pregnancy, and effect of caesarean wound closure technique on caesarean scar pregnancy. In this article, we aim to find the demography, pathophysiology, clinical presentation, most appropriate methods of diagnosis and management, with their implications in clinical practice for this condition.

Treatment of viable cesarean scar ectopic pregnancy with suction curettage

OBJECTIVE

Pregnancy in previous cesarean scar is the rarest form of ectopic pregnancy. All reported cases in the literature that were treated with uterine curettage either become unsuccessful or complicated. We aimed to present a case of cesarean scar ectopic pregnancy that was successfully treated with suction curettage without any additional therapy.

CASE

A 32-year-old asymptomatic woman, gravida 2, para 1 was referred to our hospital with the possible diagnosis of cervical ectopic pregnancy. Transvaginal and transabdominal sonographic examination revealed the diagnosis of viable ectopic pregnancy in a previous cesarean scar. Suction curettage with carman canulles was performed under transabdominal ultrasonographic guidance. beta-hCG decreased progressively postoperatively.

CONCLUSION

Suction curettage under ultrasonography guidance can be used in termination of selected cases (early diagnosed, without symptoms that necessitates emergency intervention) of cesarean scar pregnancy.

Ectopic pregnancy within a cesarean scar: a review

Implantation of a pregnancy within the scar of a previous cesarean delivery is the rarest of ectopic pregnancy locations. Only 19 cases have been reported in the English medical literature since 1966. If diagnosed early, treatment options are capable of preserving the uterus and subsequent fertility. However, a delay in either diagnosis or treatment can lead to uterine rupture, hysterectomy, and significant maternal morbidity. Although expectant and medical managements have been reported, termination of a cesarean scar pregnancy by laparotomy and hysterotomy, with repair of the accompanying uterine scar dehiscence, may be the best treatment option.