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Shai D, Meyer R, Levin G, Touval O, Ben-David A, Yagel I, Mashiach R, Cohen SB. Single-dose methotrexate-based protocol for the treatment of caesarean scar pregnancy and successive pregnancy outcomes. HUM FERTIL 2023; 26:582-588. [PMID: 34459324 DOI: 10.1080/14647273.2021.1969598] [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: 12/28/2020] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
The incidence of caesarean scar pregnancy (CSP) increases in recent years. Yet, the best mode of treatment and its effects on successive pregnancies is not well established. The aim of this study was to investigate the success rate of single-dose methotrexate (MTX) in the management of CSP, and the outcomes of subsequent pregnancies in a retrospective cohort study. All women who were treated for CSPs between the years 2011 and 2019 were included. Treatment included systemic MTX and ultrasound-guided needle aspiration (UGNA) in cases with active foetal heartbeat. Overall, 34 women were diagnosed with CSP, of whom 31 were treated with systemic MTX. Twelve patients (38.7%) needed additional curettage or hysteroscopy. The only identified risk factor for failure of MTX-based treatment was time interval between the previous caesarean delivery and CSP (22 vs 34 months, p = 0.04). Twelve women had a subsequent pregnancy. Five pregnancies ended in term delivery, three in preterm delivery, three in abortion and one woman had a recurrent CSP. The study conclusion is that a single dose MTX with UGNA in cases of active heartbeat is an effective mode of treatment in cases of CSP with good sequential pregnancy outcomes. Longer time interval from the previous caesarean delivery was identified as a risk factor for failure of conservative management.
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Affiliation(s)
- Daniel Shai
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gabriel Levin
- Department of Gynecologic Oncology, Hadassah Medical Center, Jerusalem, Israel
| | - Or Touval
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Alon Ben-David
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Itai Yagel
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Roy Mashiach
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shlomo B Cohen
- Department of Obstetrics and Gynecology, The Chaim Sheba Medical Center, Tel-Aviv, and the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Hameed MSS, Wright A, Chern BSM. Scope and Suction: Hysteroscopic-guided Suction Evacuation of Cesarean Scar Pregnancy - A Safe and Efficacious Treatment for Selected Patients. Gynecol Minim Invasive Ther 2023; 12:72-76. [PMID: 37416109 PMCID: PMC10321336 DOI: 10.4103/gmit.gmit_87_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/21/2022] [Accepted: 11/22/2022] [Indexed: 07/08/2023] Open
Abstract
Objectives This study aimed to evaluate hysteroscopic-guided suction evacuation for the treatment of cesarean scar pregnancy (CSP). Materials and Methods This was a retrospective analysis of CSP over 2 years. This study was conducted at KK Women's and Children's Hospital (KKH), Singapore, thirty-seven patients with a CSP. Hysteroscopic-guided suction evacuation to treat CSP used alone or in combination with laparoscopy depending on residual myometrial thickness (RMT) and future fertility requirements. Results The majority of women (29) were diagnosed under 9-week gestation. Just over a third (13) had an RMT of more than 3 mm. Women with an RMT <3 mm had added laparoscopy. In total, 22 women had hysteroscopic-guided suction evacuation with 9 having it performed under laparoscopic guidance because the RMT was under 3 mm. The remaining patients underwent either laparoscopic repair (5 cases) or vaginal repair (1 case) done under laparoscopic guidance. Conclusion Hysteroscopic-guided suction evacuation of CSP has the potential to become part of the routine management for uncomplicated cases of CSP in women with an RMT of greater than 3 mm who do not wish for future pregnancy. Its use, in combination with other minimally invasive techniques, can be extended to more complex cases where the RMT is <3 mm and future fertility is desired.
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Affiliation(s)
- Mohamed Siraj Shahul Hameed
- Division of Obstetrics and Gynaecology, Department of Minimally Invasive Surgery, KK Women’s and Children’s Hospital, Singapore
| | - Ann Wright
- Department of Maternal Fetal Medicine, KK Women’s and Children’s Hospital, Singapore
| | - Bernard Su Min Chern
- Division of Obstetrics and Gynaecology, Department of Minimally Invasive Surgery, KK Women’s and Children’s Hospital, Singapore
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Agarwal N, Gainder S, Chopra S, Rohilla M, Prasad G, Jain V. The Management of Scar Ectopic: A Single-Center Experience. Cureus 2021; 13:e15881. [PMID: 34336408 PMCID: PMC8312794 DOI: 10.7759/cureus.15881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 11/05/2022] Open
Abstract
PURPOSE This study aimed to highlight the clinical features, diagnosis, and different modalities of the treatment of cesarean scar pregnancy (CSP). METHODS This study was done in the tertiary referral hospital of India for one year. A total of 11 cases were enrolled prospectively. In each case, the diagnostic ultrasonography and measurement of baseline beta-human chorionic gonadotropin (β-HCG) levels were done. The treatment was given based on the hemodynamic status of the patient and desire for future fertility. Various treatment modalities used were medical, surgical, or interventional digital subtraction angiography to control hemorrhage. Also, in some cases, ultrasound-guided methotrexate was injected into the scar ectopic. Medically treated cases were followed up until their β-HCG levels became normal. RESULTS Out of 11 patients, six had a history of two cesarean sections in the past, four patients had a history of one cesarean section and one patient with a previous three low segments cesarean section (LSCS). Seven out of 11 patients underwent medical management with either methotrexate with potassium chloride (KCl) or methotrexate alone. The success of the medical management was monitored by serial β- HCG values. The mean time for the resolution of these 10 patients was 86.7 ± 53.6 days. Three patients underwent emergency uterine artery embolization due to uncontrolled bleeding and one patient required laparotomy. CONCLUSION CSP is a life-threatening condition that can be diagnosed with the help of transvaginal ultrasonography. The treatment, however, depends on the hemodynamic status of the patient and desire for future fertility. Well-defined diagnostic criteria coupled with structured management and follow-up protocol can help in treating this challenging form of ectopic pregnancy.
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Affiliation(s)
- Neha Agarwal
- Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, IND.,Obstetrics and Gynecology, Maulana Azad Medical College, New Delhi, IND
| | - Shalini Gainder
- Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, IND
| | - Seema Chopra
- Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, IND
| | - Minakshi Rohilla
- Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, IND
| | - Grv Prasad
- Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, IND
| | - Vanita Jain
- Obstetrics and Gynecology, Post Graduate Institute of Medical Education and Research, Chandigarh, IND
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Hüner B, Lato K, Reister F, Janni W, Deniz M. A Scary Complication: Single-center Study on Management and Outcome of Cesarean Scar Pregnancy. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:311-316. [PMID: 33979891 PMCID: PMC10183945 DOI: 10.1055/s-0041-1728781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
A cesarean scar pregnancy (CSP) is a scary and life-threatening complication of cesarean section (CS). Nevertheless, the incidence of CS is constantly growing. The CSP incidence is 0,15% of pregnancies after CS which represents 6,1% of all ectopic pregnancies in women with condition after CS. Therefore, it should be more present in the clinical daily routine. From mild nonspecific symptoms to hypovolemic shock, diagnosis and therapy must be performed quickly. With the progressive growth of the scar pregnancy, a uterine rupture involves the risk of severe bleeding, and an emergency hysterectomy could be necessary. Prolongation of pregnancy has been successful only in a few cases. We report 11 cases from our hospital in the past 10 years. In the discussion, treatment options of this complication with an increasing incidence, which is associated with serious morbidity and mortality, are presented based on the current literature. Treatment options include drug therapy, but also surgical or combined procedures with radiological intervention.
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Affiliation(s)
- Beate Hüner
- Department of Obstetrics and Gynecology, Ulm University, Ulm, Germany
| | - Krisztian Lato
- Department of Obstetrics and Gynecology, Ulm University, Ulm, Germany
| | - Frank Reister
- Department of Obstetrics and Gynecology, Ulm University, Ulm, Germany
| | - Wolfgang Janni
- Department of Obstetrics and Gynecology, Ulm University, Ulm, Germany
| | - Miriam Deniz
- Department of Obstetrics and Gynecology, Ulm University, Ulm, Germany
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Mo X, Tang S, Li C. Management for delayed diagnosis in cesarean scar pregnancy with hemorrhage intra- or postuterine dilation and curettage. J Obstet Gynaecol Res 2021; 47:2014-2020. [PMID: 33779116 PMCID: PMC8252716 DOI: 10.1111/jog.14771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/27/2021] [Accepted: 03/10/2021] [Indexed: 12/01/2022]
Abstract
Aim This study aimed to examine the characteristics, management, and outcomes of delayed diagnosis of cesarean scar pregnancy (CSP) with hemorrhage intra‐ or postuterine curettage for early pregnancy termination. Methods The retrospective study, cases were identified from the interrogation of the hospital database and clinical data including the success rate of different treatments, vaginal bleeding time, abnormal beta‐human chorionic gonadotropin (β‐hCG) time, and menstrual recovery time, preservation of uterus were analyzed. Results Medical records of 80 confirmed CSP cases with dilation and curettage (D&C) as primary treatment were analyzed; among them, 22 were treated with uterine arterial embolization (UAE) + methotrexate (MTX); 32 with UAE + surgery; 26 with only surgery or resection and repair. Treatment with UAE had less intraoperative blood loss (p < 0.05). UAE + surgery treatment had the highest success rate (96.8%, p < 0.05), the least vaginal bleeding duration after treatment (11.9 ± 9.6 days, p < 0.05), and least β‐hCG normalization time (17.4 ± 7.8 days, p < 0.05). Conclusion UAE + surgery treatment is a favorable and effective option to control massive hemorrhage intra‐ or post‐uterine curettage for early CSP termination.
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Affiliation(s)
- Xuetang Mo
- The Third Affiliated Hospital of Guangzhou Medical University and Key Laboratory for Major Obstetric Diseases, Guangzhou, China.,Gynaecological Laboratory, University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Shiyan Tang
- The Third Affiliated Hospital of Guangzhou Medical University and Key Laboratory for Major Obstetric Diseases, Guangzhou, China.,Department of Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - Cuilan Li
- The Third Affiliated Hospital of Guangzhou Medical University and Key Laboratory for Major Obstetric Diseases, Guangzhou, China.,OB-GYN Associate of Advantia Health, Silver Spring, Maryland, USA
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6
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Different treatment modalities for cesarean scar pregnancies: a single-center experience and literature review. Arch Gynecol Obstet 2020; 303:1143-1151. [PMID: 33048187 DOI: 10.1007/s00404-020-05831-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/03/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Cesarean scar pregnancy (CSP) remains a sporadic form of ectopic pregnancy associated with a severe life-threatening condition. There is no consensus on the treatment modality or a generally accepted guideline in CSP. This study aims to evaluate the outcomes of the different treatment modalities used in CSP treatment at a single center, as well as a literature review. METHODS This is a retrospective case series study that was conducted; all women who diagnosed with CSP between January 2013 and November 2019 at Women's Specialized Hospital, King Fahad Medical City. The clinical characteristics, diagnosis, different treatment modalities, and clinical outcomes were analyzed. RESULTS Twenty-seven cases of CSP identified during the study period. The median maternal age was 38 years (range 23-47 years). The gestational age at diagnosis ranged between 5 weeks and 5 days to 13 weeks and 6 days. All diagnoses were made by ultrasound. The absence of embryonic cardiac activity was seen in 10 cases (37.03%). The most commonly used method for first-line treatment was medical treatment. A total of 14 patients (51.85%) were treated with systemic methotrexate (MTX), three (11.1%) intra-sac and systemic MTX, and two (7.4%) intra-cardiac potassium chloride (KCl) along with systemic MTX, five (18.51%) cases had expectant management, one case initially treated with Laparotomy Wedge resection, and one case treated with uterine artery embolization (UAE) and systemic MTX. A total of 20 (74.07%) patients were treated successfully with first-line treatment. Seven (25.92%) patients needed additional second-line treatment. Among them, only one case had surgical intervention. None of the women in the medical treatment group experienced any side effects. Based on ANOVA results, there is no considerable relationship between the mean time of resolution of β-hCG and four treatment modalities for CSP (p = 0.2406). There was no statistical significance when the fetal viability at the time of diagnosis was compared to the need for second-line treatment of CSP (p = 0.58). CONCLUSION The treatment of CSP should be individualized based on risk factors. Diagnosis and management of CSP need expertise and a multidisciplinary approach to prevent complications. Early diagnosis and management of cesarean scar ectopic pregnancy remains the mainstay for a successful outcome.
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Delayed diagnosis of a cesarean scar pregnancy: a case report. J Med Case Rep 2019; 13:53. [PMID: 30841899 PMCID: PMC6404313 DOI: 10.1186/s13256-019-1983-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 01/16/2019] [Indexed: 11/16/2022] Open
Abstract
Background Cesarean scar pregnancy is rare but may be related to early uterine rupture and may result in massive hemorrhage. Nowadays, most cesarean scar pregnancies are diagnosed early and can be managed properly. However, diagnoses of cesarean scar pregnancies that develop in the obstetrical area are sometimes delayed. Case presentation A 28-year-old Asian woman visited our institution because of suspected cesarean scar pregnancy. Ultrasonography and computed tomography confirmed a cesarean scar pregnancy with a live fetus with a crown-rump length of 4.83 cm, corresponding to 11 weeks 6 days of gestation. Initially, we injected 50 mg of methotrexate in the amniotic sac under transabdominal ultrasonographic guidance. However, fetal cardiac activity was still observed 2 days later. We decided to perform open laparotomy because of the possibility of massive bleeding. The gestational sac was removed, as well as most of the trophoblastic tissues that were adherent and invading the wall of the lower uterine segment. She was discharged in good condition 5 days after the operation. Conclusions Despite the popular use of ultrasonography in prenatal care, diagnosis of cesarean scar pregnancy is still delayed. Surgical treatment with local methotrexate injection could be an option for the management of advanced cesarean scar pregnancy.
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Successful Treatment of Cesarean Scar Pregnancy With Suction Curettage: Our Experiences in Early Pregnancy. Ochsner J 2018; 18:222-225. [PMID: 30275785 DOI: 10.31486/toj.17.0118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background Cesarean scar pregnancy is an ectopic pregnancy embedded in the myometrium of a cesarean scar. Several types of conservative treatment have been used to treat cesarean scar pregnancy, but no management protocol has been established for this rare, life-threatening condition. The purpose of this study was to evaluate the feasibility of suction curettage as a first-line treatment in early cesarean scar pregnancy. Methods During a 4-year period, 19 cases of cesarean scar pregnancy were diagnosed at Süleymaniye Maternity Hospital in Istanbul, Turkey. Suction curettage and Foley balloon tamponade were performed as a first-line treatment in 13 patients. Medical records and treatment results of the patients were evaluated. Results The mean maternal age was 32.5 years (range, 24-39 years). The mean gestational sac diameter was 13.65 mm (range, 7.6-27 mm), and mean endometrial thickness was 10.7 mm (range, 6.7-14.6 mm). A measurable fetal pole for crown-rump length was available for 6 (46.1%) patients. None of the fetuses had cardiac activity. Suction curettage under ultrasound guidance and Foley balloon tamponade were successful as the primary treatment in 13 of 13 patients. No major complications occurred during or after the procedure. Conclusion Our data suggest that surgical evacuation under ultrasound guidance with Foley balloon tamponade is a safe and successful treatment modality in carefully selected patients with early cesarean scar pregnancy.
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Baradwan S, Khan F, Al-Jaroudi D. Successful management of a spontaneous viable monochorionic diamniotic twin pregnancy on cesarean scar with systemic methotrexate: A case report. Medicine (Baltimore) 2018; 97:e12343. [PMID: 30212987 PMCID: PMC6155970 DOI: 10.1097/md.0000000000012343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Cesarean scar twin pregnancy is exceedingly rare and it remains to be a life-threatening condition even in the early weeks of gestation. Because of its rare occurrence, there is no consensus on the treatment modality of cesarean ectopic pregnancy. PATIENT CONCERNS A 41-year-old, woman, gravida 7, para 6, with a history of low transverse cesarean section 2 years back presented with an estimated 6 weeks gestational age and viable spontaneous twin, monochorionic diamniotic gestation. The patient presented to the Emergency Department with complaints of vaginal bleeding and mild lower abdominal pain for 5 days. DIAGNOSES An ultrasound examination was performed demonstrating a single intrauterine gestational sac with 2 viable embryos (monochorionic diamniotic) implanted in the lower uterine segment at the level of the prior cesarean section scar. A diagnosis of viable cesarean scar twin pregnancy was made. INTERVENTIONS A 2 doses of 50 mg/m methotrexate (MTX) was given intramuscularly. The response to the treatment was monitored by serial beta-human chorionic gonadotropin (β-hCG) and ultrasound. OUTCOMES Patient was followed up with β-hCG weekly levels which became 0 after 68 days of treatment. During the follow-up, the patient was asymptomatic, no side effects of MTX were noticed. LESSONS We reported a rare case of viable monochorionic diamniotic twin pregnancy on a cesarean scar that was successfully treated with systemic MTX without any additional therapy. Additionally, the decline of β-hCG in twin ectopic cesarean scar pregnancy appears to be similar to a singleton ectopic pregnancy.
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Affiliation(s)
| | | | - Dania Al-Jaroudi
- Reproductive Endocrine and Infertility Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
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Takashima A, Takeshita N, Kinoshita T. A case of scarred uterine rupture at 11 weeks of gestation having a uterine scar places induced by in vitro fertilization-embryo transfer. Clin Pract 2018; 8:1038. [PMID: 30069297 PMCID: PMC6047476 DOI: 10.4081/cp.2018.1038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 04/03/2018] [Indexed: 12/01/2022] Open
Abstract
Having a uterine scar places a woman at increased risk of complications, such as Cesarean scar pregnancy (CSP), uterine rupture, placenta previa, and placenta accreta, in subsequent pregnancies. We report a case of uterine rupture at 11 weeks of gestation in a woman with a previous Cesarean section. A 43-year-old woman with a history of abdominal myomectomy and Cesarean section had her pregnancy induced by in vitro fertilization with donor eggs. The exact location of the gestational sac was identified on her first day of hospitalization, and her pregnancy was suspected to be a CSP. The following day, the patient complained of sudden lower abdominal pain. A uterine scar rupture was diagnosed, and an emergency surgery was required. It may be that first-trimester screening could allow the early recognition of patients at risk for these perinatal complications.
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Affiliation(s)
- Akiko Takashima
- Department of Obstetrics and Gynecology, Toho University Medical Center, Sakura Hospital, Japan
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Ying X, Zheng W, Zhao L, Zhou M, Chen Z. Clinical characteristics and salvage management of persistent cesarean scar pregnancy. J Obstet Gynaecol Res 2017; 43:1293-1298. [PMID: 28612958 PMCID: PMC5575528 DOI: 10.1111/jog.13367] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 01/28/2017] [Accepted: 03/27/2017] [Indexed: 11/28/2022]
Abstract
Aim The study was conducted to illustrate the clinical characteristics and treatment outcomes of patients with persistent cesarean scar pregnancy (PCSP). Methods During a six‐year period, 38 cases of PCSP were diagnosed and treated conservatively to preserve fertility. The clinical presentations, imaging findings and treatment outcomes of these patients were reviewed. Results Fourteen out of 38 women (37%) presenting with PCSP suffered heavy vaginal bleeding. Gestational age at diagnosis was 73.1 ± 21.7 days. The maximum diameter of the PCSP mass was 3.6 ± 1.6 cm. The presence of a rich vascular pattern in the area of the PCSP mass was detected by ultrasound in 33/38 (87%) patients. Six patients with a PCSP gestational age of 64.2 ± 6.2 days and a mass diameter of 2.5 ± 0.6 cm were successfully treated with medical treatment alone and 32 patients with a gestational age of 74.8 ± 23.1 days and a mass diameter of 3.8 ± 1.6 cm were successfully treated with surgical or combined treatment. Conclusions Patients with PCSP are diagnosed at advanced gestational age and are more prone to heavy bleeding. Surgery is the main treatment for PCSP. Medical treatment of PCSP has become an attractive alternative, especially for hemodynamically stable patients with a PCSP mass with a maximum diameter of < 3.5 cm.
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Affiliation(s)
- Xue Ying
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wei Zheng
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Li Zhao
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Mi Zhou
- Department of Obstetrics and Gynecology, Maternal and Child Health Hospital of Hainan Province, Haikou, China
| | - Zhengyun Chen
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Abstract
The incidence of cesarean scar pregnancy (CSP), which was extremely rare till recent times, has been rising steadily. We have more of such cases being published in medical literature now. A 38-year-old woman with a past history of previous three cesarean sections presented with five weeks pregnancy and complaints of bleeding per vaginum associated with mild lower abdominal discomfort. The diagnosis of CSP with a live fetus within the gestational sac was made on a transvaginal ultrasound examination and later confirmed with a magnetic resonance imaging (MRI). The management involved injecting potassium chloride into the gestational sac and a combination of local and systemic methotrexate administration. The patient was followed-up by monitoring the beta human chorionic gonadotropin level until it reached non pregnant level and followed-up with scan and MRI until complete resolution of the pregnancy sac. Due to the rarity of this condition, there are no specific guidelines available for its management.
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Affiliation(s)
- Mini Mammen Roy
- Department of Obstetrics and Gynecology, Khoula Hospital, Mina Al Fahal, Oman
| | - Forough Radfar
- Department of Obstetrics and Gynecology, Khoula Hospital, Mina Al Fahal, Oman
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Yu H, Luo H, Zhao F, Liu X, Wang X. Successful selective reduction of a heterotopic cesarean scar pregnancy in the second trimester: a case report and review of the literature. BMC Pregnancy Childbirth 2016; 16:380. [PMID: 27894281 PMCID: PMC5126867 DOI: 10.1186/s12884-016-1171-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 11/17/2016] [Indexed: 02/07/2023] Open
Abstract
Background Heterotopic cesarean scar pregnancy is a cesarean scar pregnancy combined with an intrauterine pregnancy that predisposes a woman to life-threatening complications such as uterine rupture and massive bleeding. Preservation of the intrauterine pregnancy in heterotopic cesarean scar pregnancy is a great challenge. Case presentation We report a case of a 33-year-old woman with heterotopic cesarean scar pregnancy after IVF-embryo transfer (ET). Expectant management was carried out with early diagnosis of heterotopic cesarean scar pregnancy (HCSP), and selective fetal reduction of cesarean scar pregnancy (CSP) was performed by ultrasound-guided intrathoracic injection of potassium chloride (KCl) at 16 + 4 weeks of gestation due to aggravation of CSP. Preservation of the intrauterine pregnancy was successful and a healthy baby was delivered by cesarean section at 37 + 6 weeks of gestation. Conclusions Heterotopic cesarean scar pregnancy is an extremely rare form of heterotopic pregnancy. Patients should be appropriately counseled regarding the different treatment options available. An ultrasound-guided injection of potassium chloride may constitute a safe, minimally invasive and reliable way to terminate the heterotopic gestation and preserve the intrauterine pregnancy. Intensive management should be performed during the ongoing pregnancy and cesarean section. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1171-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Haiyan Yu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Hong Luo
- Department of Ultrasonic Medicine, West China Second University Hospital, Sichuan University, Chengdu, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China.
| | - Fumin Zhao
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Xinghui Liu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China.
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Reproductive outcomes following cesarean scar pregnancy – a case series and review of the literature. Eur J Obstet Gynecol Reprod Biol 2016; 200:102-7. [DOI: 10.1016/j.ejogrb.2016.02.039] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/25/2016] [Accepted: 02/29/2016] [Indexed: 11/18/2022]
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Ng BK, Lim PS, Ahmad S, Kampan NC, Abdul Karim AK, Omar MH. Cesarean scar pregnancy: What can we offer? Taiwan J Obstet Gynecol 2016; 54:208-10. [PMID: 25951734 DOI: 10.1016/j.tjog.2014.11.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2014] [Indexed: 11/26/2022] Open
Affiliation(s)
- Beng Kwang Ng
- Department of Obstetrics and Gynaecology, UKM Medical Centre, Kuala Lumpur, Malaysia.
| | - Pei Shan Lim
- Department of Obstetrics and Gynaecology, UKM Medical Centre, Kuala Lumpur, Malaysia
| | - Shuhaila Ahmad
- Department of Obstetrics and Gynaecology, UKM Medical Centre, Kuala Lumpur, Malaysia
| | | | | | - Mohd Hashim Omar
- Department of Obstetrics and Gynaecology, UKM Medical Centre, Kuala Lumpur, Malaysia
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Ouyang Y, Li X, Yi Y, Gong F, Lin G, Lu G. First-trimester diagnosis and management of Cesarean scar pregnancies after in vitro fertilization-embryo transfer: a retrospective clinical analysis of 12 cases. Reprod Biol Endocrinol 2015; 13:126. [PMID: 26589452 PMCID: PMC4654878 DOI: 10.1186/s12958-015-0120-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 11/02/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Although Caesarean scar pregnancy (CSP) is rare, it can cause life-threatening complications. The increasing rate of Cesarean delivery plus rapid development of in vitro fertilization-embryo transfer (IVF-ET) may increase the occurrence of CSP as well as the ratio of heterotopic CSP (HCSP)/CSP. Therefore, early diagnosis and management of CSP are necessary to avoid serious complications. And the purpose of this article is to evaluate the importance and feasibility of the first-trimester diagnosis and management of CSP after IVF-ET. METHODS All the 12 cases were secondary infertility patients who had a history of Cesarean section and underwent IVF-ET in our reproductive center. All cases with CSP were diagnosed using transvaginal color Doppler sonography (TVS). Medical, surgical and expectant managements were implemented, and the management results were traced. RESULTS Patients with CSP (n = 12) were diagnosed from January 2011 to April 2015, 6 (50 %) of which were HCSP. The prevalence of CSP was 1:1688 pregnancies. The gestational age ranged from 5 + 3 to 7 + 4 weeks in all CSP, and from 5 + 6 to 7 + 4 weeks in HCSP at diagnosis. Five patients received successful surgical treatment. The success rate of medical and expectant management was 50 % (1/2) and 100 % (5/5), respectively. One patient with failed medical management needed an emergency laparotomy to evacuate CSP. The uterus was preserved in all 12 patients. CONCLUSIONS The Caesarean section and IVF-ET may increase the ratio of HCSP/CSP. TVS is a noninvasive and effective tool for use in diagnosing CSP. CSP should be carefully excluded in patients who have had a history of Caesarean section. Early diagnosis of CSP in the first trimester may contribute towards the preservation of uterus as well as intrauterine pregnancy (IUP) in HCSP.
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Affiliation(s)
- Yan Ouyang
- Institute of Reproductive and stem cell Engineering, Central South University, Xiangya Road, Changsha, Hunan, 410008, P.R. China.
- Reproductive and Genetic Hospital of Citic-Xiangya, Xiangya Road, Changsha, Hunan, 410078, P.R. China.
| | - Xihong Li
- Reproductive and Genetic Hospital of Citic-Xiangya, Xiangya Road, Changsha, Hunan, 410078, P.R. China.
| | - Yan Yi
- Institute of Reproductive and stem cell Engineering, Central South University, Xiangya Road, Changsha, Hunan, 410008, P.R. China.
| | - Fei Gong
- Institute of Reproductive and stem cell Engineering, Central South University, Xiangya Road, Changsha, Hunan, 410008, P.R. China.
- Reproductive and Genetic Hospital of Citic-Xiangya, Xiangya Road, Changsha, Hunan, 410078, P.R. China.
| | - Ge Lin
- Institute of Reproductive and stem cell Engineering, Central South University, Xiangya Road, Changsha, Hunan, 410008, P.R. China.
- Reproductive and Genetic Hospital of Citic-Xiangya, Xiangya Road, Changsha, Hunan, 410078, P.R. China.
| | - Guangxiu Lu
- Institute of Reproductive and stem cell Engineering, Central South University, Xiangya Road, Changsha, Hunan, 410008, P.R. China.
- Reproductive and Genetic Hospital of Citic-Xiangya, Xiangya Road, Changsha, Hunan, 410078, P.R. China.
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Lachiri B, Zazi A, Benkerroum Z, Hafidi MR, Kouach J, Rahali DM, Dehayni M. [Caesarean scar pregnancies: about a case report and review of literature]. Pan Afr Med J 2015. [PMID: 26213603 PMCID: PMC4508329 DOI: 10.11604/pamj.2015.20.122.6054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
La grossesse sur cicatrice de césarienne est une forme rare de grossesse ectopique qui engage le pronostic vital et fonctionnel utérin par hémorragie ou par rupture utérine précoce. Nous rapportons le cas d'une grossesse ectopique sur cicatrice de césarienne diagnostiquée à 11 semaines d'aménorrhée suite à une aspiration blanche pour grossesse arrêtée chez une patiente de 43 ans porteuse d'un utérus bi-cicatriciel. A travers cette observation ainsi qu'une revue de la littérature les auteurs vont essayer de mettre le point sur les méthodes diagnostiques et thérapeutiques de cette entité rare afin d'améliorer la prise en charge.
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Affiliation(s)
- Boutaina Lachiri
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction Med V, Maroc
| | - Abdelgheni Zazi
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction Med V, Maroc
| | - Zineb Benkerroum
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction Med V, Maroc
| | - Moulay Rachid Hafidi
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction Med V, Maroc
| | - Jaouad Kouach
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction Med V, Maroc
| | | | - Mohamed Dehayni
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction Med V, Maroc
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Cheung VY. Local Methotrexate Injection as the First-line Treatment for Cesarean Scar Pregnancy: Review of the Literature. J Minim Invasive Gynecol 2015; 22:753-8. [DOI: 10.1016/j.jmig.2015.04.008] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/08/2015] [Accepted: 04/09/2015] [Indexed: 11/28/2022]
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Le Gall J, Fichez A, Lamblin G, Philip CA, Huissoud C. [Cesarean scar ectopic pregnancies: combined modality therapies with uterine artery embolization before surgical procedure]. ACTA ACUST UNITED AC 2015; 43:191-9. [PMID: 25724449 DOI: 10.1016/j.gyobfe.2015.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 01/29/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To offer a therapeutic management of cesarean scar pregnancies (GSC) in the first trimester of pregnancy with a first approach by uterine artery embolization (UAE) PATIENTS AND METHODS: This study describes seven cases of GSC diagnosed between 2009 and 2013 in the clinic of the University Hospital of the Hospital of Croix-Rousse. We present the symptoms and how imagery has led to the diagnosis and the therapeutic management conducted. RESULTS The mean gestational age at diagnosis was 9 weeks gestation. There were ongoing pregnancies with cardiac activity present for each patient. An additional MRI was performed in five patients. Five patients were treated with methotrexate injection, two patients received the Mifegyne. All patients then received a selective uterine artery embolization. Finally within 48hours, suction curettage was performed in 6 patients. A patient at 13 WA+1 required a subtotal hysterectomy for placenta accreta. Intra-operative complications were represented by a bladder injury, two bleeding of 1000mL in patients at 13 WA+1 and 12 WA. For the 6 cases of GSC with a gestational age less than 10 WA, average blood loss was less than 500mL. Three patients underwent resection of scar isthmocele confirmed by EVAC. An intrauterine pregnancy was carried to term after care. DISCUSSION AND CONCLUSION Cesarean scar pregnancies is a diagnostic and therapeutic challenge, which should be diagnosed as early as soon as possible with care in a medical facility with a uterine artery embolization technical platform. Our protocol combining Mifegyne and methotrexate for termination of pregnancy and uterine artery embolization (UAE) followed by curettage for evacuation of pregnancy allows conservative treatment while minimizing the risk of bleeding (for GSC diagnosed before 10 WA).
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Affiliation(s)
- J Le Gall
- Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France.
| | - A Fichez
- Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - G Lamblin
- Service de gynécologie-obstétrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69500 Bron, France
| | - C A Philip
- Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - C Huissoud
- Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France; Inserm U846, Stem Cell and Brain Research Institute, université de Lyon-1, 18, avenue Doyen-Lepine, 69500 Bron, France; UMR-S 846, 69003 Lyon, France
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20
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Gozdemir E, Yilmaz Dogru H, Gokce E, Uslu Yuvacı H. Rapid management with hysterotomy for caesarean scar pregnancy. J OBSTET GYNAECOL 2015; 35:764-5. [PMID: 25671371 DOI: 10.3109/01443615.2015.1007340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- E Gozdemir
- a Department of Obstetric and Gynecology , Gazıosmanpasa University School of Medicine , Tokat , Turkey
| | - H Yilmaz Dogru
- a Department of Obstetric and Gynecology , Gazıosmanpasa University School of Medicine , Tokat , Turkey
| | - E Gokce
- b Department of Radiology , Gazıosmanpasa University School of Medicine , Tokat , Turkey
| | - H Uslu Yuvacı
- c Department of Obstetric and Gynecology , Sakarya University School of Medicine , Sakarya , Turkey
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21
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Timor-Tritsch IE, Monteagudo A, Cali G, Palacios-Jaraquemada JM, Maymon R, Arslan AA, Patil N, Popiolek D, Mittal KR. Cesarean scar pregnancy and early placenta accreta share common histology. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 43:383-395. [PMID: 24357257 DOI: 10.1002/uog.13282] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Revised: 11/28/2013] [Accepted: 12/11/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To determine, by evaluation of histological slides, images and descriptions of early (second-trimester) placenta accreta (EPA) and placental implantation in cases of Cesarean scar pregnancy (CSP), whether these are pathologically indistinguishable and whether they both represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester. METHODS The database of a previously published review of CSP and EPA was used to identify articles with histopathological descriptions and electronic images for pathological review. When possible, microscopic slides and/or paraffin blocks were obtained from the original researchers. We also included from our own institutions cases of CSP and EPA for which pathology specimens were available. Two pathologists examined all the material independently and, blinded to each other's findings, provided a pathological diagnosis based on microscopic appearance. Interobserver agreement in diagnosis was determined. RESULTS Forty articles were identified, which included 31 cases of CSP and 13 cases of EPA containing histopathological descriptions and/or images of the pathology. We additionally included six cases of CSP and eight cases of EPA from our own institutions, giving a total of 58 cases available for histological evaluation (37 CSP and 21 EPA) containing clear definitions of morbidly adherent placenta. In the 29 cases for which images/slides were available for histopathological evaluation, both pathologists attested to the various degrees of myometrial and/or scar tissue invasion by placental villi with scant or no intervening decidua, consistent with the classic definition of morbidly adherent placenta. Based on the reviewed material, cases with a diagnosis of EPA and those with a diagnosis of CSP showed identical histopathological features. Interobserver correlation was high (kappa = 0.93). CONCLUSIONS EPA and placental implantation in CSP are histopathologically indistinguishable and may represent different stages in the disease continuum leading to morbidly adherent placenta in the third trimester.
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Affiliation(s)
- I E Timor-Tritsch
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, New York University SOM, New York, NY, USA
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22
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Dubuisson JB, Ben Ali N, Bouquet de Jolinière J, Haggenjos M, Feki A. Laparoscopic treatment of placenta percreta retention in a cesarean scar: a case report. Front Surg 2014; 1:6. [PMID: 25593931 PMCID: PMC4287010 DOI: 10.3389/fsurg.2014.00006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 03/05/2014] [Indexed: 11/21/2022] Open
Abstract
Placenta percreta retention within the scar of a previous cesarean section is rare. We report here one of these cases treated successfully by laparoscopy, with uterine repair. Different therapeutic options are described.
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Affiliation(s)
| | | | | | | | - Anis Feki
- Hôpital Cantonal de Fribourg, Fribourg, Switzerland
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23
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Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012; 207:14-29. [PMID: 22516620 DOI: 10.1016/j.ajog.2012.03.007] [Citation(s) in RCA: 360] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 01/28/2012] [Accepted: 03/09/2012] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY 10016, USA.
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24
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Abstract
AIM To discuss the early diagnosis and effective treatment strategy of cesarean scar pregnancy (CSP). MATERIAL AND METHODS We reviewed 17 patients in our department diagnosed with CSP between 2005 and 2010, including clinical characteristics, early diagnosis, treatment methods, side-effects and prognosis. RESULTS The average duration of gestation at diagnosis was 46 days (range 37-82) and the interval between CSP and last cesarean scar was 6 years (range 2-15). Fourteen (82%) patients presented with slight vaginal bleeding and two (12%) complained of abdominal discomfort. Fourteen patients were diagnosed with CSP by transvaginal color Doppler ultrasonography (TVCDUS). Magnetic resonance imaging (MRI) was performed in two cases of CSP when the diagnosis by TVCDUS was difficult. One patient was diagnosed by histological examination of hysterectomy specimens due to life-threatening bleeding during curettage. Seven patients initially diagnosed with CSP before pregnancy termination were treated conservatively to preserve the uterus without causing maternal complications, ten patients underwent curettage due to incorrect diagnosis, eight patients had excessive vaginal bleeding during curettage and three patients underwent emergency hysterectomy due to hypovolemic shock. CONCLUSION CSP does not have any specific symptoms and can be easily diagnosed incorrectly. Confirmation of a portion of gestational sac in the uterus is important and TVCDUS is the first-line tool for early diagnosis of CSP. Physicians never perform curettage at diagnosis with CSP, but curettage after uterine artery embolism or methotrexate are better treatments of choice to terminate CSP.
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Affiliation(s)
- Yu Zhang
- Department of Obstetrics and Gynecology, Second Hospital of Tianjin Medical University, Tianjin, China
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25
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Fylstra DL. Ectopic pregnancy not within the (distal) fallopian tube: etiology, diagnosis, and treatment. Am J Obstet Gynecol 2012; 206:289-99. [PMID: 22177188 DOI: 10.1016/j.ajog.2011.10.857] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2011] [Revised: 09/29/2011] [Accepted: 10/16/2011] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Donald L Fylstra
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
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26
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Uterine Artery Embolization Combined with Local Methotrexate and Systemic Methotrexate for Treatment of Cesarean Scar Pregnancy with Different Ultrasonographic Pattern. Cardiovasc Intervent Radiol 2011; 35:286-91. [DOI: 10.1007/s00270-011-0097-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Accepted: 12/31/2010] [Indexed: 11/27/2022]
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Ficicioglu C, Attar R, Yildirim G, Cetinkaya N. Fertility Preserving Surgical Management of Methotrexate-Resistant Cesarean Scar Pregnancy. Taiwan J Obstet Gynecol 2010; 49:211-3. [DOI: 10.1016/s1028-4559(10)60045-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2009] [Indexed: 10/19/2022] Open
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28
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Hysteroscopic management of cesarean scar ectopic pregnancy. Fertil Steril 2010; 93:1735-40. [DOI: 10.1016/j.fertnstert.2008.12.099] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 12/18/2008] [Accepted: 12/18/2008] [Indexed: 11/30/2022]
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29
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de Vaate AJMB, Brölmann HAM, van der Slikke JW, Wouters MGAJ, Schats R, Huirne JAF. Therapeutic options of caesarean scar pregnancy: case series and literature review. JOURNAL OF CLINICAL ULTRASOUND : JCU 2010; 38:75-84. [PMID: 19902518 DOI: 10.1002/jcu.20648] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
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.
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30
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Jiao LZ, Zhao J, Wan XR, Liu XY, Feng FZ, Ren T, Xiang Y. Diagnosis and Treatment of Cesarean Scar Pregnancy. ACTA ACUST UNITED AC 2008; 23:10-5. [DOI: 10.1016/s1001-9294(09)60002-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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31
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Hois EL, Hibbeln JF, Alonzo MJ, Chen ME, Freimanis MG. Ectopic pregnancy in a cesarean section scar treated with intramuscular methotrexate and bilateral uterine artery embolization. JOURNAL OF CLINICAL ULTRASOUND : JCU 2008; 36:123-7. [PMID: 17763455 DOI: 10.1002/jcu.20374] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
We report a case of an ectopic pregnancy implanted in the myometrium at the site of a scar from a previous cesarean section that presented with vaginal bleeding and was successfully treated with bilateral uterine artery embolization and intramuscular administration of methotrexate. The combination of minimally invasive interventional techniques and medical therapies can preserve fertility.
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MESH Headings
- Adult
- Angiography
- Antimetabolites, Antineoplastic/administration & dosage
- Cesarean Section/adverse effects
- Cicatrix/complications
- Cicatrix/pathology
- Diagnosis, Differential
- Embolization, Therapeutic/methods
- Endosonography/methods
- Female
- Follow-Up Studies
- Humans
- Injections, Intramuscular
- Methotrexate/administration & dosage
- Pregnancy
- Pregnancy Complications, Neoplastic/diagnosis
- Pregnancy Complications, Neoplastic/therapy
- Pregnancy, Ectopic/diagnosis
- Pregnancy, Ectopic/etiology
- Pregnancy, Ectopic/therapy
- Ultrasonography, Prenatal
- Uterus/blood supply
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Affiliation(s)
- Erin L Hois
- Department of Radiology, Rush University Medical Center, 1653 West Congress Parkway, Chicago, IL 60612-3833, USA
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Jurkovic D, Ben-Nagi J, Ofilli-Yebovi D, Sawyer E, Helmy S, Yazbek J. Efficacy of Shirodkar cervical suture in securing hemostasis following surgical evacuation of Cesarean scar ectopic pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:95-100. [PMID: 17559184 DOI: 10.1002/uog.4058] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVES To assess the efficacy of a Shirodkar cervical suture in arresting hemorrhage following surgical removal of a Cesarean scar ectopic pregnancy. METHODS The study included women with an ultrasound diagnosis of Cesarean scar ectopic pregnancy who were scheduled for surgical evacuation. After administration of general anesthetic, a Shirodkar cervical suture was inserted using the standard surgical technique. The suture was left untied and the Cesarean scar pregnancy was evacuated under ultrasound guidance using suction curettage. Once the pregnancy had been successfully removed, the suture was tied and 500 microg ergometrine was administered intravenously to ensure uterine contraction. The patients were prescribed prophylactic antibiotics and the suture was removed 7 days later in the outpatient setting, under local anesthetic. RESULTS Over a 4-year period a total of 33 Cesarean scar pregnancies were diagnosed, and 28 (85%) had surgical evacuation. A cervical suture was necessary to achieve hemostasis in 22/28 (79%; 95% CI, 64-94) cases. In the remaining 6/28 (21%; 95% CI, 6-36) cases, the bleeding was minimal and the suture was not tied. The median estimated intraoperative blood loss was 50 (range, 50-1500) mL. Six of 28 (21%; 95% CI, 6-36) women suffered blood loss > or = 300 mL and two (7%; 95% CI, 0-17) required blood transfusion. One woman (5%; 95% CI, 0-14) required repeat surgery because of retained products of conception. There were no other significant complications and the uterus was preserved successfully in all cases. CONCLUSIONS Insertion of a Shirodkar cervical suture during the evacuation of a Cesarean scar pregnancy is an effective method for securing hemostasis; it minimizes the need for blood transfusion and ensures preservation of fertility.
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Affiliation(s)
- D Jurkovic
- Early Pregnancy and Gynaecology Assessment Unit, King's College Hospital, London, UK.
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Abstract
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.
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Affiliation(s)
- A Ash
- Guy's and St Thomas' NHS Foundation Trust, London, UK.
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35
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Persadie RJ, Fortier A, Stopps RG. Ectopic Pregnancy in a Caesarean Scar: A Case Report. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2005; 27:1102-6. [PMID: 16524528 DOI: 10.1016/s1701-2163(16)30392-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND An ectopic pregnancy developing in a Caesarean section scar is extremely rare. This type of ectopic pregnancy carries with it a high risk of morbidity related to uterine rupture and extensive hemorrhage. Conservative treatment in the form of local or systemic injection of methotrexate or local injection of potassium chloride is preferable to surgical management, as the former is fertility sparing. CASE A 36-year-old multigravid woman was found to have an ectopic pregnancy in a Caesarean scar at seven weeks' gestation with a significantly elevated beta-human chorionic gonadotrophin (Beta-hCG) level. Systemic methotrexate therapy was unsuccessful; subsequently, a local injection of methotrexate was used with resolution of the pregnancy. CONCLUSION An ectopic pregnancy in a Caesarean scar can be managed effectively with local injection of methotrexate.
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Affiliation(s)
- Richard J Persadie
- Department of Obstetrics and Gynecology, McMaster University, Hamilton, ON
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Chao A, Wang TH, Wang CJ, Lee CL, Chao AS. Hysteroscopic management of cesarean scar pregnancy after unsuccessful methotrexate treatment. J Minim Invasive Gynecol 2005; 12:374-6. [PMID: 16036203 DOI: 10.1016/j.jmig.2005.05.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2004] [Accepted: 01/31/2005] [Indexed: 11/25/2022]
Abstract
Current management of cesarean scar pregnancy is conservative and consists of medical treatment with methotrexate (MTX). We present a report on a woman with this type of pregnancy who had continuous vaginal bleeding and persistent serum levels of beta human chorionic gonadotropin after undergoing curettage and MTX. Eventually, the remaining ectopic gestational tissue was removed by operative hysteroscopy.
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Affiliation(s)
- Angel Chao
- Department of Obstetrics and Gynecology, Chang Gung University, Tao-Yuan, Taiwan.
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37
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Lim YY, Hsu CY, Chen CP. Methotrexate Followed by Suctional Curettage: A Successful Treatment for Cesarean Scar Pregnancy. Taiwan J Obstet Gynecol 2005. [DOI: 10.1016/s1028-4559(09)60132-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Graesslin O, Dedecker F, Quereux C, Gabriel R. Conservative Treatment of Ectopic Pregnancy in a Cesarean Scar. Obstet Gynecol 2005; 105:869-71. [PMID: 15802418 DOI: 10.1097/01.aog.0000141569.75297.44] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pregnancy developing in a cesarean scar is a very rare but possibly life-threatening condition because of the risk of rupture and excessive hemorrhage. CASE A 34-year-old woman presented with lower abdominal pain at 6 weeks of gestation. A cesarean delivery had been performed 3 years earlier. Transvaginal ultrasound examination revealed a viable pregnancy developing in the anterior wall of the uterus. The patient was treated successfully with systemic methotrexate and curettage. CONCLUSION Conservative management with methotrexate and curettage can be considered in the treatment of ectopic cesarean scar pregnancy.
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Affiliation(s)
- Olivier Graesslin
- Institut Mère Enfant Alix de Champagne, Service de Gynécologie-Obstétrique, CHRU, Reims, France.
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Arslan M, Pata O, Dilek TUK, Aktas A, Aban M, Dilek S. Treatment of viable cesarean scar ectopic pregnancy with suction curettage. Int J Gynaecol Obstet 2005; 89:163-6. [PMID: 15847889 DOI: 10.1016/j.ijgo.2004.12.038] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2004] [Accepted: 12/15/2004] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- M Arslan
- Department of Obstetrics and Gynecology, Mersin University, School of Medicine, Mersin 33070, Turkey.
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40
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Wang YL, Su TH, Chen HS. Laparoscopic management of an ectopic pregnancy in a lower segment cesarean section scar: A review and case report. J Minim Invasive Gynecol 2005; 12:73-9. [PMID: 15904604 DOI: 10.1016/j.jmig.2004.12.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Implantation of a pregnancy within the scar of a previous cesarean delivery is the rarest of ectopic pregnancy locations, with only 32 cases reported in the English-language medical literature. A 28-year-old woman was admitted to our institution with a suspected ectopic pregnancy located in the scar from a previous cesarean section. Ultrasound revealed a well-encapsulated, bulging mass with a gestational sac within the anterior uterine isthmus in the site of an old cesarean delivery scar. Laparoscopy was performed to confirm the diagnosis, and the gestational products also were removed laparoscopically. The defect in the uterus was then repaired by suturing. Total operative time was 120 minutes, blood loss was limited, and no transfusion was needed. Laparoscopy may be a reasonable alternative to laparotomy for an unruptured ectopic pregnancy in a cesarean scar.
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Affiliation(s)
- Yeou-Lih Wang
- Department of Obstetrics and Gynecology, Mackay Memorial Hospital, and Mackay Medicine, Nursing and Management College, Taipei, Taiwan
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41
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Sugawara J, Senoo M, Chisaka H, Yaegashi N, Okamura K. Successful Conservative Treatment of a Cesarean Scar Pregnancy with Uterine Artery Embolization. TOHOKU J EXP MED 2005; 206:261-5. [PMID: 15942155 DOI: 10.1620/tjem.206.261] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Ectopic pregnancy developing in a previous Cesarean section scar is rare and is associated with catastrophic complications, such as uterine rupture and uncontrollable bleeding, which may lead to loss of the uterus. The operative treatments that have been reported for cesarean scar pregnancy are dilatation and curettage and excision of trophoblastic tissues using either laparotomy or laparoscopy. Recently, conservative treatment of scar pregnancy with locally and/or systemically administered methotrexate (MTX) has been reported. However, recent reports demonstrated that cases treated with MTX sometimes required laparotomy later because of excessive bleeding. In this series of cases we have demonstrated that viable cesarean scar pregnancies can be treated safely by selective transarterial embolization in combination with subsequent dilatation and curettage and local or systemic injections of MTX. In these three cases, uterine artery embolization proved to be a useful procedure for preventing uncontrollable bleeding and unnecessary uterine loss.
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Affiliation(s)
- Junichi Sugawara
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan.
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Wang CJ, Yuen LT, Yen CF, Lee CL, Soong YK. Three-Dimensional Power Doppler Ultrasound Diagnosis and Laparoscopic Management of a Pregancy in a Previous Cesarean Scar. J Laparoendosc Adv Surg Tech A 2004; 14:399-402. [PMID: 15684790 DOI: 10.1089/lap.2004.14.399] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
An ectopic pregnancy developing in a previous Cesarean section scar is a rare event, and there is still a lack of information concerning the adequacy of management strategies. So far, no modality can guarantee the integrity of the uterus. We report the case of a 29-year-old woman with three Cesarean deliveries who was transferred to our hospital with a diagnosis of cervical pregnancy. Transvaginal three-dimensional power Doppler ultrasound revealed a well-encapsulated bulging mass displacing anteriorly over the lower anterior uterine wall sounding with an irregular course and branching vessels. The diagnosis of pregnancy in a previous Cesarean scar was made. Laparoscopic ligation of bilateral uterine arteries followed by excision of the ectopic pregnant mass was undertaken, and the patient's uterus was successfully preserved. Conservative management with the laparoscopic approach may be a safe and effective alternative to hysterectomy in patients with a pregnacy in a previous Cesarean scar.
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Affiliation(s)
- Chin-Jung Wang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Kwei-Shan Tao-Yuan, Taiwan
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Shih JC. Cesarean scar pregnancy: diagnosis with three-dimensional (3D) ultrasound and 3D power Doppler. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2004; 23:306-307. [PMID: 15027025 DOI: 10.1002/uog.1000] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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44
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Marchiolé P, Gorlero F, de Caro G, Podestà M, Valenzano M. Intramural pregnancy embedded in a previous Cesarean section scar treated conservatively. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2004; 23:307-309. [PMID: 15027026 DOI: 10.1002/uog.981] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
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45
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Chen FY, Torng PL, Huang SC, Chow SN. Ectopic Pregnancy Within a Cesarean Section Scar: Report of Two Cases. Taiwan J Obstet Gynecol 2004. [DOI: 10.1016/s1028-4559(09)60053-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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46
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Seow KM, Huang LW, Lin YH, Lin MYS, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2004; 23:247-53. [PMID: 15027012 DOI: 10.1002/uog.974] [Citation(s) in RCA: 367] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To evaluate our experience with the diagnosis and treatment of Cesarean scar pregnancy. METHODS During a 6-year period, 12 cases of Cesarean scar pregnancy were diagnosed using transvaginal color Doppler sonography and treated conservatively to preserve fertility. Incidence, gestational age, sonographic findings, beta-human chorionic gonadotropin ( beta-hCG) levels, flow profiles of transvaginal color Doppler ultrasound, and methods of treatment were recorded. RESULTS The incidence of Cesarean scar pregnancy was 1:2216 and its rate was 6.1% in women with an ectopic pregnancy and at least one previous Cesarean section. Gestational age at diagnosis ranged from 5 + 0 to 12 + 4 weeks. The time interval from the last Cesarean section to the diagnosis of Cesarean scar pregnancy ranged from 6 months to 12 years. High-velocity and low-impedance subtrophoblastic flow (resistance index, 0.38) persisted until beta-hCG declined to normal. Patients were treated as follows: transvaginal ultrasound-guided injection of methotrexate into the embryo or gestational sac (n = 3), transabdominal ultrasound-guided injection of methotrexate (n = 2), transabdominal ultrasound-guided injection of methotrexate followed by systemic methotrexate administration (n = 2), systemic methotrexate administration alone (n = 2), dilatation and curettage (n = 2), or local resection of the gestation mass (n = 1). Eleven of the 12 patients preserved their reproductive capacity; the remaining patient, treated by dilatation and curettage, underwent a hysterectomy because of profuse vaginal bleeding. The Cesarean scar mass regressed from 2 months to as long as 1 year after treatment. Uterine rupture occurred in one patient during the following pregnancy at 38 + 3 weeks' gestational age. CONCLUSION Ultrasound-guided methotrexate injection emerges as the treatment of choice to terminate Cesarean scar pregnancy. Surgical or invasive techniques, including dilatation and curettage are not recommended for Cesarean scar pregnancy due to high morbidity and poor prognosis.
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Affiliation(s)
- K-M Seow
- Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, and School of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
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Lam PM, Lo KWK, Lau TK. Unsuccessful medical treatment of cesarean scar ectopic pregnancy with systemic methotrexate: a report of two cases. Acta Obstet Gynecol Scand 2003; 83:108-11. [PMID: 14678094 DOI: 10.1111/j.1600-0412.2004.0033a.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Po Mui Lam
- Department of Obstetrics and Gynecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, ROC.
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Imbar T, Bloom A, Ushakov F, Yagel S. Uterine artery embolization to control hemorrhage after termination of pregnancy implanted in a cesarean delivery scar. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2003; 22:1111-1115. [PMID: 14606570 DOI: 10.7863/jum.2003.22.10.1111] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- Tal Imbar
- Department of Obstetrics and Gynecology, Hadassah University Hospital, Mt Scopus, Jerusalem, Israel
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49
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Chuang J, Seow KM, Cheng WC, Tsai YL, Hwang JL. Conservative treatment of ectopic pregnancy in a caesarean section scar. BJOG 2003. [DOI: 10.1111/j.1471-0528.2003.02117.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2003; 21:220-7. [PMID: 12666214 DOI: 10.1002/uog.56] [Citation(s) in RCA: 451] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To describe first-trimester ultrasound diagnosis and management of pregnancies implanted into uterine Cesarean section scars. METHODS All women referred for an ultrasound scan because of suspected early pregnancy complications were screened for pregnancies implanted into a previous Cesarean section scar. The management of Cesarean section scar pregnancies included transvaginal surgical evacuation, medical treatment with local injection of 25 mg methotrexate into the exocelomic cavity and expectant management. RESULTS Eighteen Cesarean section scar pregnancies were diagnosed in a 4-year period. The prevalence in the local population was 1 : 1800 pregnancies. Surgical treatment was used in eight women and it was successful in all cases. The respective success rates of medical treatment and expectant management were 5/7 (71%) and 1/3 (33%). Five women (28%) required blood transfusion and one woman (6%) had a hysterectomy. CONCLUSIONS Cesarean section scar pregnancies are more common than previously thought. When the diagnosis is made in the first trimester the prognosis is good and the risk of hysterectomy is relatively low.
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Affiliation(s)
- D Jurkovic
- Early Pregnancy and Gynaecology Assessment Unit, Department of Obstetrics and Gynaecology, King's College Hospital, London, UK.
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