Cesarean scar pregnancy with expectant management

Sonographic Assessment of Isthmocele and Its Obstetric Complications in Subsequent Pregnancies: A Pictorial Review

Cesarean scar defect represents a significant pathology attributed to the rising prevalence of cesarean deliveries. While not commonplace, these lesions can give rise to severe obstetric consequences during subsequent pregnancies. Given the potential complications, it is advisable to screen for uterine niches using transvaginal ultrasound (TVUS) or contrast-enhanced TVUS for individuals planning to conceive. Surgical repair and correction of these lesions can be crucial in averting obstetric and perinatal complications in future pregnancies. Furthermore, timely sonographic evaluation and reporting of isthmocele-related obstetric complications can help avoid serious issues.

Obstetric outcomes in the expectant management of cesarean scar pregnancy with fetal heart activity: a single-center retrospective cohort study

Background

Cesarean scar pregnancy (CSP) is a high-risk complication characterized by the implantation of a pregnancy within a cesarean scar resulting from a previous delivery. Currently, clinical indicators guiding the expectant management of patients with CSP are lacking. We thus aimed to evaluate pregnancy and neonatal outcomes among women who underwent expectant CSP management and to investigate whether sonographic signs correlated with obstetric outcomes.

Methods

We retrospective reviewed the electronic medical records and first-trimester transvaginal ultrasonography reports of consecutive patients diagnosed with CSP in the first trimester at the West China Second University Hospital from January 1, 2010 to December 31, 2022. Pregnancy outcomes (emergency surgery, blood loss, and rescue) and neonatal outcomes (gestational age at delivery, neonatal weight, and Apgar scores) were examined. A binary logistic regression analysis was conducted to identify independent risk factors that could predict severe complications.

Results

The final analysis included 54 patients. The mean age of the pregnant women was 34±4 years. Among the 54 patients, 14 (25.9%) did not progress to 20 weeks of gestation. Pregnancy continued beyond 20 weeks in 40 patients, with 37 live births (92.5%) and 3 stillbirths (7.5%). Moreover, 7 (17.5%) and 33 (82.5%) patients delivered before and after 34 weeks, respectively. Placenta accreta spectrum (PAS) and placenta previa were confirmed in 29 (72.5%) and 17 (42.5%) patients, respectively. Hysterectomy, emergency cesarean section, and rescue surgery were performed in 5 (12.5%), 15 (37.5%), and 22 (55.5%) patients, respectively. Patients with a visible niche were significantly more likely to have preterm labor, PAS, placenta previa, low-birth-weight newborns, higher blood loss, intraoperative rescue, blood transfusion, and first-trimester vaginal bleeding than were those without one (all P values <0.05).

Conclusions

Our study showed that expectant management of CSP to achieve live birth might be feasible. Patients with a visible niche exhibited worse outcomes, with a higher incidence of severe delivery complications.

Treatment Outcomes of Cesarean Scar Pregnancy Under a Novel Classification System: A Retrospective Cohort Study

OBJECTIVES

To determine whether the new classification system published by Jordans et al for cesarean scar pregnancy (CSP) can guide management and treatment outcomes.

METHODS

A retrospective study of women diagnosed with CSP from October 2010 to December 2022 in a single tertiary center was performed. Sonographic records of these women were classified into three types according to the classification published by Jordans et al. Treatment outcomes were compared across each type of CSP.

RESULTS

The study included a total of 84 women, where 60 (71.4%), 17 (20.2%), and 7 (8.3%) of them were categorized into Type 1, 2, and 3 CSP, respectively. A total of 47 (55.9%) women were managed with methotrexate, 22 (26.2%) underwent surgical management of the CSP without removal of the Cesarean section (CS) niche, and 11 (13.1%) underwent surgery to remove the CSP and the CS niche. Overall treatment success rates for medical management and surgical management were 70 and 97%, respectively. Four women were managed expectantly and continued their pregnancies, among which three carried beyond 34 weeks and had good neonatal outcomes.

CONCLUSIONS

The classification as published by Jordans et al is easily replicable and readily implemented clinically. Our findings show that a higher proportion of Type 1 and Type 2 CSP were treated successfully by a less invasive medical approach with a high success rate, whereas most Type 3 CSP required surgical resection to successfully remove the CSP and the CS niche. Prospective studies are required to confirm these findings and further validate the clinical utility of this nomenclature system.

Caesarean scar pregnancy presenting at 17 weeks with a journey involving an exploratory laparotomy, continuing pregnancy and delivery at 34 weeks: A case report

Caesarean scar pregnancy (CSP) occurs when the gestational sac implants in the region of a scar from a previous caesarean delivery. CSP can lead to life-threatening complications, including severe haemorrhage, uterine rupture, placenta accreta spectrum (PAS) and hysterectomy. A 40-year-old woman with one previous caesarean was referred to the specialist centre at 17+1 weeks of gestation with concerns about CSP. At 19 weeks, she was admitted with abdominal pain. Due to raised body habitus, accurate ultrasound assessment was challenging, necessitating reliance on magnetic resonance imaging (MRI). The patient desired to continue the pregnancy, but due to pain and concerns about uterine rupture she consented to a laparotomy to potentially terminate the pregnancy. Findings during the laparotomy were reassuring, leading to the decision not to terminate the pregnancy. The patient remained hospitalised until delivery by caesarean-hysterectomy at 33+6 weeks. Histopathology confirmed the PAS diagnosis. This case highlights the importance of achieving early diagnosis and obtaining clear sonographic findings. It emphasises the pitfalls of relying on MRI due to its tendency to over-diagnose severity. It emphasises the urgency for improved training in this domain. Early sonographic diagnosis allows safer performance of termination of pregnancy. It also provides women who continue with the pregnancy useful prognostic signs to facilitate decisions on the optimal gestation for delivery. Determining optimal conservative management for CSP remains an ongoing challenge. This case emphasises the importance of multidisciplinary discussion, comprehensive patient counselling and involving patients in their care planning, to create an individualised and adaptable treatment plan.

Scar Ectopic Pregnancy as an Uncommon Site of Ectopic Pregnancy: A Case Report and Literature Review

A cesarean scar pregnancy is a rare type of ectopic pregnancy that occurs when a fertilized egg implants in the scar from a previous cesarean section. It is a serious condition that can lead to significant morbidity and mortality if not managed promptly and appropriately. In this literature review and case report, we discuss the etiology, diagnosis, and management of cesarean scar pregnancy. We conducted a comprehensive search of relevant literature using electronic databases and included studies that reported on the diagnosis and management of cesarean scar pregnancy. We also present a case report of a patient with cesarean scar pregnancy who was managed surgically. The diagnosis of cesarean scar pregnancy is primarily done via transvaginal or transabdominal ultrasound, and medical or surgical management can be used depending on the gestational age, hemodynamic status, and patient preferences. The surgical approach, which involves hysteroscopy, laparoscopy, or laparotomy, is usually preferred, since it is associated with fast recovery and lower recurrence rates. However, it is crucial to consider the patient's plans for future fertility when selecting the management approach. In conclusion, cesarean scar pregnancy is a rare but potentially life-threatening condition that requires prompt and appropriate management. Early diagnosis and treatment can prevent significant morbidity and mortality, and surgical management is usually preferred due to its higher success rates and lower recurrence rates.

Cesarean Scar Pregnancy: A systematic review on expectant management

A Cesarean Scar Pregnancy (CSP) is a variant of uterine ectopic pregnancy defined by full or partial implantation of the gestational sac in the scar of a previous cesarean section. The continuous increase of Cesarean Deliveries is causing a parallel increase in CSP and its complications. Considering its high morbidity, the most usual recommendation has been termination of pregnancy in the first trimester; however, several cases progress to viable births. The aim of this systematic review is to evaluate the outcome of CSP managed expectantly and understand whether sonographic signs could correlate to the outcomes. An online-based search of PubMed and Cochrane Library Databases was used to gather studies including women diagnosed with a CSP who were managed expectantly. The description of all cases was analysed by the authors in order to obtain information for each outcome. 47 studies of different types were retrieved, and the gestational outcome was available in 194 patients. Out of these, 39 patients (20,1%) had a miscarriage and 16 (8,3%) suffered foetal death. 50 patients (25,8%) had a term delivery and 81 (41,8%) patients had a preterm birth, out of which 27 (13,9%) delivered before 34 weeks of gestation. In 102 (52,6%) patients, a hysterectomy was performed. Placenta Accreta Spectrum (PAS) was a common disorder among CSP and was linked to a higher rate of complications such as foetal death, preterm birth, hysterectomy, haemorrhagic morbidity and surgical complications. Some of the analysed articles showed that sonographic signs with specific characteristics, such as type II and III CSP classification, Crossover Sign - 1, "In the niche" implantation and lower myometrial thickness could be related to worse outcomes of CSP. This article provides a good understanding of CSP as an entity that, although rare, presents with a high rate of relevant morbidity. It is also understood that pregnancies with confirmed PAS had an even higher rate of morbidity. Some sonographic signs were shown to predict the prognosis of these pregnancies and further investigation is necessary to validate one or more signs so they can be used for a more reliable counselling of women with CSP.

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.