Successful pregnancy located in a uterine cesarean scar: A case report

Cesarean Scar Pregnancy: A systematic review on expectant management

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

Emergency internal iliac artery temporary occlusion after massive hemorrhage during surgery of cesarean scar pregnancy: A case report

BACKGROUND

Cesarean scar pregnancy (CSP) is rare but may result in uterine rupture during pregnancy or massive hemorrhage during abortion procedures. Awareness of this condition is increasing, and most patients with CSP are now diagnosed early and can be managed safely. However, some atypical patients are misdiagnosed, and their surgical risks are underestimated, increasing the risk of fatal hemorrhage.

CASE SUMMARY

A 27-year-old Asian woman visited our institution because of abnormal pregnancy, and she was diagnosed with a hydatidiform mole through trans-vaginal ultrasound (TVS). Under hysteroscopy, a large amount of placental tissue was found in the scar of the lower uterine segment, and a sudden massive hemorrhage occurred during the removal process. The bilateral internal iliac arteries were temporarily blocked under laparoscopy, and scar resection and repair were rapidly performed. She was discharged in good condition 5 d after the operation.

CONCLUSION

Although TVS is widely used in the diagnosis of CSP, delays in the diagnosis of atypical CSP remain. Surgical treatment following internal iliac artery temporary occlusion may be an appropriate management method for unanticipated massive hemorrhage during CSP surgery.

Introduction and utility of resuscitative endovascular balloon occlusion of the aorta for cases with a potential high risk of postpartum hemorrhage: A single tertiary care center experience of two cases

Postpartum hemorrhage is an important obstetric complication and the leading cause of maternal mortality worldwide. Occasionally, we encounter unexpected massive postpartum hemorrhage diagnosed for the first time after delivery. Therefore, it is essential to pay attention to patients with a high risk of postpartum hemorrhage. The authors report two cases of patients at high risk of postpartum hemorrhage that were successfully managed by resuscitative endovascular balloon occlusion of the aorta before cesarean section. Case 1: A 32-year-old woman with a history of cesarean section and who conceived using assisted reproductive technology was diagnosed with partial placenta previa at 25 weeks of gestation. Because of tocolysis failure, emergent cesarean section with resuscitative endovascular balloon occlusion of the aorta was performed at 36 weeks of gestation. Natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage. Case 2: A 41-year-old woman with suspected placenta accreta spectrum due to a cesarean scar pregnancy was referred to our hospital at 33 weeks of gestation. A planned cesarean section with resuscitative endovascular balloon occlusion of the aorta was conducted at 37 weeks of gestation. There was no visual evidence of abnormal placental invasion of the myometrium, and natural placental resorption was observed. She was discharged at 5 days after delivery without significant hemorrhage.

Expectant management of cesarean scar pregnancy in 13 patients

OBJECTIVE

To monitor Cesarean scar pregnancy (CSP) patients preferring to continue their pregnancy and analyze their clinical characteristics as well as maternal and fetal outcomes.

METHODS

A retrospective cohort study including 13 pregnant women diagnosed with CSP (including types I, II, III) and continued their pregnancy with cautious monitoring at Peking University First Hospital between January, 2014 and December, 2018.

RESULTS

8/13 (61.5%) of them delivered after 28 weeks and finally gave birth to healthy babies with 3 term births and 5 preterm births (one of them which suspected placenta percreta received hysterectomy for massive bleeding and hemorrhagic shock at 34 weeks). 2/13 (15.4%) of them terminated their pregnancy at second trimester by Cesarean section for ultrasonic manifestation of placenta percreta with or without threatened uterine rupture. 1/13 (7.7%) of them went through induced labor due to inevitable abortion and needed dilatation and evacuation afterwards at 20 weeks. 2/13 (15.4%) of those patients with twin pregnancy chose fetal reduction to keep the non-CSP fetus at 8 weeks and 11 weeks. No maternal or fetal death was observed.

CONCLUSIONS

During expectant management, type I CSP patients were at little risk for developing into placenta percreta and rather save for continue pregnancy to having babies. Type II and type III CSP patients usually ended up with placenta percreta and better terminated their pregnancy immediately.

Experience With Medical Treatment of Cesarean Scar Ectopic Pregnancy (CSEP) With Local Ultrasound-Guided Injection of Methotrexate

Objective: Ectopic pregnancy within Cesarean section scars is a rare condition. Late diagnosis carries significant risk of bleeding with poor prognosis for survival. There is no consensus on the management of this type of pregnancy. Historically, our facility offered an intra-muscular injection of methotrexate that resulted in a significant failure rate and later need for surgery. We hypothesized that injecting methotrexate directly into the gestational sac would improve the success rate of the treatment.

Patients and Methods: This retrospective, uni-centric study examined nine patients aged between 33 and 42 years (mean age = 36.5 years) with Cesarean scar ectopic pregnancy (CSEP) between 2010 and 2018. CSEP was diagnosed by transvaginal ultrasound at a mean gestational age of 8w0/7. CSEP was treated under general anesthetic by ultrasound-guided methotrexate injection directly into the gestational sac. HCG levels and subsequent childbearing were monitored post-treatment.

Results: Half of the patients were asymptomatic at the time of diagnosis. All patients tolerated treatment well and all ectopic pregnancies were successfully removed. HCG levels returned to negative within 3 months without additional medical or surgical intervention. The post-treatment pregnancy rate was 50%.

Discussions/Conclusions: Our findings indicate that local ultrasound-guided injection of methotrexate into the gestational sac is a safe and effective therapeutic approach when performed by a trained team on a hemodynamically stable patient in the early stages of CSEP.

Late-diagnosed cesarean scar pregnancy resulting in unexpected placenta accreta spectrum necessitating hysterectomy

Cesarean scar pregnancy (CSP) is a rare complication involving the implantation of the gestational sac in a cesarean delivery scar. The authors report a case of unexpected placenta accreta spectrum (PAS) caused by late diagnosed CSP, necessitating emergent hysterectomy. A 28-year-old Japanese woman with two previous cesarean deliveries presented to our hospital at 11 weeks of gestation with abnormal transvaginal ultrasound findings obtained at another hospital;however, transabdominal ultrasound revealed that the fetus was already present in the uterine cavity at this time. At 28 weeks, there was no evidence of placenta previa. The woman developed preeclampsia at 29 weeks, and a cesarean section was conducted. Intraoperative findings confirmed PAS, and hysterectomy was conducted immediately.

Cesarean Scar - Unusual Site of Ectopic Pregnancy: A Case Report

Ectopic pregnancy is a leading cause of maternal mortality in the first trimester. It may occur in different anatomic locations with fallopian tube being the most frequent. Cesarean-scar ectopic pregnancy is one of the rarest ectopic pregnancies. We report the case of a 44-year-old woman, gravida 5 para 4, who attended the antenatal clinic after her pregnancy was confirmed by positive urine testing. She underwent transvaginal ultrasound examination which identified the gestational sac with fetal pole and cardiac activity located in the anterior part of the lower uterine segment with empty uterine cavity. Magnetic resonance imaging (MRI) scan had confirmed the diagnosis of cesarean scar ectopic pregnancy. After through discussion on the management options, the patient was treated with intra-gestational sac injection of methotrexate. Four days after the procedure, she developed profuse vaginal bleeding and her hemoglobin showed a drop of 4.9 g/dL. She underwent emergency laparotomy with excision of the ectopic pregnancy. The patient tolerated the procedure well without complications. The serum β-human chorionic gonadotropin level was undetectable on the 35^th day after the methotrexate injection. Caesarean scar pregnancy is an unusual form of ectopic pregnancy. However, clinicians should have a high index of suspicion for this condition as it may result in serious complications, unless promptly managed. MRI is recommended particularly when transvaginal ultrasound scan is inconclusive.

Delayed diagnosis of a cesarean scar pregnancy: a case report

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.