Cesarean Scar Pregnancy: Current Understanding and Treatment Including Role of Minimally Invasive Surgical Techniques

Are the Risk Factors for Developing Type 1 and Type 2 Cesarean Scar Pregnancy Different?

OBJECTIVES

Cesarean scar pregnancy (CSP) is a life-threatening complication of pregnancy. Early termination of pregnancy is recommended because of the potential risks of uterine rupture if the pregnancy continues. CSP is clinically divided into type 1 and type 2, based on the site of embryo implantation and grow direction of the gestational sac. The clinical risk and treatment options may vary between these subtypes. Identifying the differences and potential factors impacting the development of each type could contribute to improved clinical management.

METHODS

This retrospective study included 143 women with type 1 CSP and 200 women with type 2 CSP women, diagnosed between January 2020 and July 2023. The primary objective was to analyze the differences in clinical characteristics between the 2 CSP subtypes.

RESULTS

Body mass index, the number of previous CSPs, elective abortions, gravidity, and parity were not significantly different between the 2 subtypes. Similarly, the interval between the last cesarean section and the current CSP was not associated with developing the 2 subtypes. However, women with more than 3 prior cesarean sections had an increased risk of developing type 1 CSP. In contrast, vaginal bleeding before diagnosis was more frequently associated with type 2 CSP.

CONCLUSIONS

Our study with a large sample size found that despite type 2 CSP involving deeper myometrial invasion, the 2 subtypes share many clinical characteristics. Moreover, the clinical risk factors for distinguishing between type 1 and type 2 CSP are limited. Future research to identify predictors for CSP classification is required.

Ultrasound outcomes and surgical parameters of the double-layer purse-string uterine closure technique in cesarean delivery: a systematic review and meta-analysis of randomized trials

BACKGROUND

A cesarean scar defect is a structural abnormality in the myometrium at the site of a prior cesarean incision, primarily influenced by the closure technique. Purse-string uterine suturing (PSUS) may reduce the incidence of cesarean scar defects and improve uterine integrity. However, the literature presents inconsistent findings, necessitating a systematic evaluation. This systematic review and meta-analysis of randomized controlled trials (RCTs) aims to assess the impact of PSUS on ultrasound outcomes and surgical parameters related to cesarean scars.

METHODS

This systematic review and meta-analysis involved a search for relevant publications in English and Persian across multiple databases, including PubMed, the Cochrane Library, Google Scholar, Scopus, Web of Science, and SID. The search was unrestricted by date and included all available publications up to August 8, 2024. The risk of bias in the included studies was evaluated using the Risk of Bias 2 (ROB2) tool, while the certainty of the evidence was assessed through the GRADE approach. Meta-regression was employed to investigate potential risk factors for cesarean scar defects, and trial sequential analysis was conducted to mitigate Type I and Type II errors.

RESULTS

A total of 353 studies were identified through the search strategy, with 8 studies included in the analysis. The meta-analysis demonstrated a significant reduction in the rate of cesarean scar defects in the PSUS group compared to the control group (risk ratio [RR] 0.45, 95% confidence interval [CI] 0.36 to 0.58; 8 trials, 751 participants, I² = 0%, indicating no heterogeneity). Additionally, a shorter uterine incision length was observed in the PSUS group compared to the control group (MD -3.84, 95% CI -4.97 to -2.71; 4 trials, 438 participants, I² = 80%, suggesting substantial heterogeneity). The PSUS group also exhibited greater residual myometrium thickness (RMT) than the control group (MD 1.33, 95% CI 0.72 to 1.94; 5 trials, 417 participants, I² = 92%, indicating considerable heterogeneity). However, no statistically significant differences were found between the PSUS and control groups regarding operation time (p = 0.10, I² = 67%, suggesting moderate heterogeneity), length (p = 0.14, I² = 98%, indicating considerable heterogeneity), height (p = 0.10, I² = 76%, suggesting substantial heterogeneity) of incision defects, or blood loss during the procedure (p = 0.94, I² = 0%, indicating no heterogeneity).

CONCLUSIONS

The use of PSUS during cesarean sections significantly reduces the occurrence of cesarean scar defects, indicating a clear clinical benefit with moderate certainty. However, the evidence for other ultrasound evaluation outcomes and surgical parameters remains of low to very low certainty. Therefore, further research is essential to validate these findings and assess the long-term clinical implications of integrating PSUS into cesarean procedures.

Vesicouterine Cutaneous Fistula Post-cesarean Section - A Case Report

This case report presents the diagnosis and management of a 41-year-old woman who developed a vesicouterine cutaneous fistula after a cesarean section. She initially presented with pus discharge from the cesarean wound site, and later exhibited cyclical hematuria and fluid leakage from the skin incision, prompting further investigation. Diagnostic modalities, including computed tomography with contrast, confirmed the presence of a complex fistula involving the bladder, uterus, and skin. Conservative management with gonadotropin-releasing hormone therapy was attempted but discontinued due to worsening symptoms. Surgical intervention was performed successfully, leading to the resolution of symptoms. This case underscores the importance of prompt recognition and appropriate management of rare postcesarean complications, emphasizing adherence to anatomical principles.

Minimally invasive management of intramural pregnancy using ultrasound combined with laparoscopy -based learning experience from a low-middle income country: a case report and review of the literature

BACKGROUND

Intramural pregnancy is a very rare type of ectopic pregnancy, which is surrounded by uterine myometrium layer and separates from endometrium. To our knowledge, this abnormal location site of ectopic pregnancy remains likely under-recognized and under-reported. Through this paper, we aim to underscore the role of minimally invasive surgery in this uncommon condition where applicable, especially in low-middle income countries.

CASE PRESENTATION

A 34-year-old Vietnamese female patient (gravida 3 parity 1) was hospitalized due to a diagnosis of intramural pregnancy. Rapidly, the patient underwent laparoscopy for a removal of ectopic pregnancy mass corresponding to 5-6 weeks of gestation, taking into consideration the possibility of conservative surgery. This surgical intervention was carefully performed under ultrasound guidance at operating room. The surgical management resulted in a favorable outcome, though a hysterectomy and laparotomy could be avoided intentionally in this case.

CONCLUSION

This case report emphasizes the timely detection of intramural pregnancy involving the successful outcome. Moreover, in an early term of intramural pregnancy, uterine conservative management under laparoscopic surgery combined with ultrasound could be a reliable management for this extreme rarity at tertiary center. Further data is required to strengthen this finding.

Enhancing precision in hysteroscopic surgery: The role of intraoperative ultrasound

Hysteroscopy stands as the gold-standard approach for managing intrauterine pathology. However, in complex clinical cases, hysteroscopic evaluation alone may prove insufficient for the safest and successful patient management. Intraoperative ultrasound (IOUS) has emerged as a valuable adjunct to hysteroscopic surgery, offering real-time visualization of endometrial cavity, uterine walls and instruments within the uterine cavity, enabling precise delineation of anatomical structures, and helping to assess the extent of pathology during intricate interventions. This review aims to comprehensively assess the applications, efficacy and utility of IOUS in hysteroscopic surgery. Available evidence indicates that in hysteroscopic myomectomy, IOUS significantly reduces the risk of uterine perforation, particularly in submucosal FIGO 2 myomas, and enhances the likelihood of a single-step procedure. During hysteroscopic metroplasty, ultrasound guidance decreases the chance of incomplete uterine septum resection. In the hysteroscopic management of severe Asherman syndrome, IOUS reduces the risk of uterine perforation or false passage. For cesarean scar pregnancy (CSP), ultrasound is crucial in defining the most appropriate surgical approach and is effective in guiding the hysteroscopic treatment of endogenic CSP. The use of IOUS in hysteroscopy proves valuable in complex cases where the risk of uterine perforation or incomplete procedure is increased.

Conservative Laparoscopic Approach for the Management of a 14-Week Viable Ectopic Cesarean Scar Ectopic Pregnancy

Introduction: Cesarean scar ectopic pregnancy (CSEP) is a rare gynecological disorder that occurs at a rate of approximately 0.05% of pregnancies and less than 0.2% of cesarean scars. The ultimate goal in the management of CSEP cases is to remove pregnancy and reduce morbidity while preserving fertility. This case report highlights the successful application of a conservative laparoscopic approach in managing a 14-week viable CSEP. Case Presentation: A 35-year-old multiparous woman (G8P5A2L5) with five previous cesarean sections and five normal healthy children presented to the clinic with a viable CSEP of 14 weeks of gestation as revealed by abdominal and transvaginal ultrasound examination. The decision for a conservative laparoscopic approach was made in light of the patient's desire to preserve fertility. Intervention and outcome: The laparoscopic procedure included the following steps: extensive dissection of adhesions between the bladder and the uterus; identification of the ectopic pregnancy at the level of the lower segment; extraction of the product of conception in an endobag; and suturing of the lower segment defect. The successful execution of these steps resulted in the removal of the ectopic pregnancy while addressing associated structural concerns. This approach allowed for mitigating morbidity and, importantly, preserving the patient's fertility. Conclusion: This case highlights the importance of a conservative laparoscopic approach for CSEP in the second trimester. Imaging techniques play a pivotal role in accurate diagnosis, with minimally invasive technologies offering effective solutions. Individualized, patient-centered approaches are necessary to prioritize clinical outcomes and patient preferences.

Comparing Cesarean Scar Defect Incidence After Locked and Unlocked Repair Methods Among Primiparous Patients: A Randomized Double-Blinded Trial

Objective

To compare residual myometrial thickness (RMT) and cesarean scar defect (CSD) development after cesarean section using double-layer locked and unlocked closure techniques.

Materials and methods

We conducted a randomized double-blinded trial comparing double-layer locked and unlocked uterine closure techniques following cesarean section in primiparous women. The locked technique involved continuous suturing of the full myometrial thickness in the first layer, followed by back-and-forth needle maneuvering on both sides of the incision for the second layer. The unlocked method included running suturing of two-thirds of the myometrial thickness in the first layer, followed by suturing the upper half of the myometrial thickness in the second layer. Transvaginal ultrasonography was performed one year post-cesarean section, with RMT as the primary outcome and scar depth and width as secondary outcomes. Independent t-test and Chi-square test were utilized for statistical analysis.

Results

All 30 patients from the locked and 26 from the unlocked group in the follow-up were diagnosed with CSD (scar depth>2mm). The mean RMT for the unlocked and locked groups were 4.44±1.07mm and 4.12±0.48mm, respectively, showing no significant difference (p =0.14). There was also no significant difference in mean scar width between the locked and unlocked groups (3.68±1.44mm vs. 3.95±1.00mm, p =0.42). However, the mean scar depth was higher in the unlocked group (3.77±1.11 mm vs. 3.16±1.1mm, p =0.04).

Conclusion

We have found no significant differences in the RMT and CSD prevalence between two-layered locked and unlocked uterine closure techniques, while the scar depth was greater in the unlocked group. Nonetheless, future randomized trials implementing larger sample sizes are required to precisely compare the outcomes of the double-layer locked and unlocked uterine suturing techniques.

Laparoscopic Management of Cesarean Scar Pregnancy with Temporary Clipping of Anterior Trunk of Hypogastric Arteries: A Case Report

A cesarean scar ectopic pregnancy (CSP) represents an uncommon yet potentially life-threatening condition requiring immediate and efficient management. We present a case of a 32-year-old woman diagnosed with a scar pregnancy at 8 weeks of gestation. Laparoscopic surgical management was chosen due to its minimally invasive nature and potential for preserving fertility. During the procedure, temporary clipping of uterine arteries was employed to control intraoperative bleeding. The patient recovered well postoperatively with no complications. This case highlights the feasibility and effectiveness of laparoscopic intervention combined with temporary uterine artery clipping in the management of scar pregnancies, offering a valuable approach for clinicians faced with similar cases. Through this report, we aim to contribute to the existing literature on the optimal management of CSP and highlight the efficacy of laparoscopic surgery in this context.

Advances in Treating Cesarean Scar Pregnancy: A Comprehensive Review of Techniques, Clinical Outcomes, and Fertility Preservation

Cesarean scar pregnancy (CSP) is a rare but potentially dangerous condition that occurs when an embryo implants and develops within the scar tissue from a previous cesarean section. Treatment of cesarean scar pregnancy depends on several factors, including the gestational age of the pregnancy, the presence of complications, and the individual patient's circumstances. We performed a systematic review of the published literature on management of cesarean scar pregnancy and the outcomes, complications, and effects on fertility. A systematic review of recent scientific literature published up to April 2023 in the databases PubMed, Google Scholar, and Web of Science was performed according to the PRISMA guidelines. We used the search keywords "cesarean scar pregnancy," "methotrexate," "systemic," "chemoembolization," and "uterine artery embolization." The baseline search resulted in 413 articles. After the exclusion of 342 irrelevant articles, the abstracts and titles of the remaining 71 articles were read for potential inclusion, resulting in exclusion of a further 16 articles. Therefore, the full texts of 55 articles were investigated. Finally, 42 papers were included in the study. The main finding was that chemoembolization is more successful than systemic methotrexate therapy, and is associated with less blood loss and shorter hospital stay. Transarterial chemoembolization appears to be safe and effective method of treatment in patients with CSP and should thus be considered during multidisciplinary evaluation of these patients.

Laparoscopic Excision of Cesarean Scar Ectopic Pregnancy: An Optimum Management Option

Cesarean scar ectopic pregnancy is a leading cause of life-threatening complications in the first trimester. It poses a diagnostic and management challenge; if not diagnosed and adequately treated in early pregnancy, it may lead to considerable maternal morbidity and mortality. We report a case series of cesarean scar ectopic pregnancies managed successfully by laparoscopy. Laparoscopic excision is the gold standard management approach for cesarean scar ectopic pregnancy.

Outcomes of the Expectant Management of 10 Cesarean Scar Pregnancy Cases in Patients Who Refused the Termination of Pregnancy

OBJECTIVE

Expectant management of cesarean scar pregnancy (CSP) in patients who refuse termination of pregnancy and continue with placenta accreta spectrum (PAS) is possible with multidisciplinary care and careful monitoring in a tertiary care center. Doctors with the relevant expertise in managing PAS use highly accurate ultrasound as a tool to diagnose, monitor, and manage this disorder, which enables them to determine appropriate surgical strategies and techniques to achieve optimum maternal and fetal outcomes with minimal blood loss and no major maternal mortality and morbidity. In this study, we aim to evaluate expectant management in such patients.

MATERIALS AND METHODS

This is a retrospective study of 10 patients with a previous history of a uterine scar. Diagnosed with CSP in the first trimester, they refused to terminate their pregnancy and continued with PAS. We studied them over a period of four years from 2018 to 2022 and managed them at Latifa Hospital, Dubai, UAE.

RESULTS

Of the 10 patients, nine delivered in the third trimester (around 34 weeks gestation), seven underwent elective surgery, and three underwent emergency surgery. Four patients were exogenous cases and six were endogenous cases at diagnosis during early gestation. Seven patients had a cesarean hysterectomy, and three (with focal placenta accreta) had uterine wall reconstruction surgery. Four patients needed blood transfusions. The average duration of surgery was between 2.5 and 5 hours. There were no miscarriages, no maternal and neonatal deaths, and no significant obstetric complications such as rupture of the uterus or major obstetric hemorrhage.

CONCLUSION

Even though CSP is a potentially life-threatening condition because of serious complications such as PAS if continued, expectant management is possible under multidisciplinary care where the team strictly adheres to clinical protocols and accurate surgery to reduce obstetric hemorrhage.