剖宫产瘢痕妊娠研究进展

剖宫产瘢痕妊娠（CSP）是一种特殊类型的异位妊娠,随着剖宫产率的增加,其发病率也在逐年增高。如不能对其进行及时诊治,将会出现大量出血、甚至子宫破裂等并发症,严重威胁患者生命。目前,CSP的发病机制、诊断及治疗尚无统一标准,对其发病机制的研究有助于CSP的预防,早期诊断及合理的治疗方法可以避免严重的并发症发生。     

Combination of transarterial embolization of uterine arteries and conservative surgical treatment for pregnancy in a cesarean section scar. A report of 3 cases

BACKGROUND: Pregnancy developing within a previous cesarean section scar is one of the rarest kinds of ectopic pregnancy. It can result in term pregnancy and therefore must be distinguished from cervical pregnancy. Irregular vaginal bleeding is common, but massive bleeding may lead to life-threatening situations. The treatment for postabortal or postpartal hemorrhage is total or subtotal hysterectomy. CASES: Three cases of pregnancy within scars from previous cesarean sections are reported. Two patients were transferred to our hospital due to postabortal hemorrhage for unwanted pregnancy. The third patient went to the emergency department for low abdominal pain with vaginal spotting and was mis-diagnosed as having a tubal pregnancy from the initial ultrasound examination. Exploratory laparotomy was done for evacuation of the abnormally implanted conception tissue. Transarterial embolization of bilateral uterine arteries (UAs) was performed to stop postoperative bleeding in one case and to prevent intraoperative hemorrhage in the other two. Subsequently, the postoperative bleeding case underwent cesarean delivery of a full-term infant following an uneventful pregnancy. CONCLUSION: Conservative surgical treatment following transarterial embolization of bilateral uterine arteries is an alternative method of managing the patients with early pregnancy in the scar from a cesarean section. This technique preserves the uterus and greatly reduces morbidity.     

Conservative treatment of an early ectopic pregnancy in a cesarean scar with systemic methotrexate--case report

PURPOSE OF INVESTIGATION: Pregnancy implanted in a cesarean scar is rare, and is a life-threatening condition due to high risk of uterine rupture, hemorrhage, hysterectomy, and maternal mortality. CASE REPORT: We describe a 26-year-old woman who presented with five weeks of amenorrhea and a serum hCG level of 10,440 mIU/ml. Transvaginal sonography revealed a gestational sac of 15 x 11 mm containing a yolk sac located in a previous cesarean scar. She was successfully treated conservatively with multi-dose methotrexate. No side-effects were encountered. The serum hCG levels were undetectable in 58 days. The patient had normal menstrual cycles afterwards. CONCLUSIONS: In the view of increasing cesarean rates, healthcare professionals should be aware of the possibility of a scar pregnancy and the potentially life threatening sequelae. Early diagnosis by transvaginal sonography can improve outcome and minimize the need for emergent surgery. Conservative treatment with systemic methotrexate is an effective option in selected patients.     

Three-dimensional ultrasonographic diagnosis and hysteroscopic management of a viable cesarean scar ectopic pregnancy

Implantation of conception material within a cesarean section scar is an extremely rare form of ectopic pregnancy with devastating complications, such as uterine rupture and intractable bleeding. Both 2-D and 3-D transvaginal ultrasonographic devices are used adequately for precise diagnosis, but there is still a lack of consensus concerning management strategies. No therapeutic modality is suggested to be entirely efficacious and safe for preserving uterine integrity. We present here a 29-year-old woman with vaginal bleeding and a gestational sac with a viable embryo of 6 weeks of age that was implanted in a cesarean section scar. Serum beta-hCG levels were 16 792 mIU/mL. Following an unsuccessful treatment course of systemic methotrexate, the patient underwent operative hysteroscopy. Minimally invasive hysteroscopic resection of the ectopic gestational mass without major complication appears to be an alternative therapeutic approach with minimal morbidity and preservation of future fertility.     

Cesarean Scar Defects: An Underrecognized Cause of Abnormal Uterine Bleeding and Other Gynecologic Complications

The gynecologic sequelae due to deficient uterine scar healing after cesarean section are only recently being identified and described. These include conditions such as abnormal bleeding, pelvic pain, infertility, and cesarean scar ectopic pregnancy, as well as a potentially higher risk of complications and difficulties during gynecologic procedures such as uterine evacuation, hysterectomy, endometrial ablation, and insertion of an intrauterine device. The proposed mechanism of abnormal uterine bleeding is a pouch or “isthmocele” in the lower uterine segment that causes delayed menstrual bleeding. The prevalence of symptomatic or clinically relevant cesarean scar defects (CSDs) ranges from 19.4% to 88%. Possible risk factors for CSD include number of cesarean sections, uterine position, labor before cesarean section, and surgical technique used to close the uterine incision. There are no accepted guidelines for the diagnostic criteria of CSD. We propose that a CSD be defined on transvaginal ultrasound or saline infusion sonohysterography as a triangular hypoechoic defect in the myometrium at the site of the previous hysterotomy. We also propose a classification system to aid in standardized classification for future research. Surgical techniques for repair of CSD include laparoscopic excision, resectoscopic treatment, vaginal revision, and endometrial ablation.     

Subsequent pregnancy outcome after conservative treatment of a previous cesarean scar pregnancy

BACKGROUND: To assess pregnancy course and outcome after conservative treatment of a cesarean scar pregnancy. METHODS: During an 8-year period, 15 cases of cesarean scar pregnancies were diagnosed at our institution. Seven of the 14 patients for whom we successfully preserved the uterus became pregnant within 3 years after termination of the scar pregnancy. The year of diagnosis, conservative method and gestational age for these five patients were recorded. Delivery method, time interval between the scar pregnancy and subsequent pregnancy, and maternal and neonatal outcome were evaluated. RESULTS: Seven pregnancies (eight live and one dead baby) were noted. The mean interval between the ectopic pregnancy and subsequent pregnancy was 13.3 months (range 0-34 months). One patient, who became pregnant 3 months after the scar pregnancy was found, suffered uterine rupture at 38.3 weeks' gestational age. Two patients with placental accrete, and one of them who continued the existing intrauterine twin pregnancy after transvaginal sono-guided aspiration of the scar pregnancy received a cesarean hysterectomy at 32 weeks of gestation. The remaining four pregnancies were uneventful, followed by early cesarean sections at 36 weeks. CONCLUSION: The results of this first series of seven subsequent pregnancies after conservative treatment of scar pregnancies are promising. An early cesarean section before over-extension of the uterus and spontaneous labor can help to prevent uterine rupture. Placenta accrete is another severe morbidity of these patients in addition to uterine rupture. Thus a cesarean hysterectomy may be the choice of treatment.     

Study of Vaginal Delivery in Patients with One Previous Lower Segment Caesarean Section

This retrospective study evaluated the prospects of having a vaginal delivery following a lower segment Caesarean section in Nehru Hospital; 685 (52%) of 1,315 patients with a previous Caesarean section were given a trial of vaginal delivery with a success rate of 69%. Vaginal breech delivery was allowed in 14 patients without affecting the outcome of term babies and without maternal morbidity or mortality. There were 12 cases (1.7% incidence) of scar disruption of which 4 were of scar rupture. There was no maternal or fetal death as a result of these disruptions even though 3 mothers had subtotal hysterectomy. Pitocin was used in 144 (21%) patients. Of the 12 cases of scar disruption 5 patients had received pitocin. There was no favourable influence of prior vaginal delivery on the success of the trial, and 3 patients with scar disruption had already had a vaginal delivery in addition to a lower segment Caesarean section.     

Breech vaginal delivery after one cesarean section: a retrospective study

This retrospective study evaluates the prospects of allowing a vaginal breech to follow a previous lower segment cesarean section by examining data from Farwania Hospital, Kuwait where 33 (38.4%) of 86 patients with a previous cesarean section with fetuses in breech presentation were given a chance for vaginal delivery. The remaining 53 patients were delivered by lower segment cesarean section. Out of 53 patients, 34 patients were sectioned because of the presence of uterine scar. The other 19 patients were sectioned because of the additional presence of other obstetric complications such as diabetes, pre-eclamptic toxemia or large fetus. This group of patients was excluded from comparison.     

Placenta percreta diagnosed after first-trimester pregnancy termination: a case report

BACKGROUND: Placenta percreta in early pregnancy has been documented in only a few cases. This is the first report of placenta percreta diagnosed after an extended period from pregnancy termination. CASE: A woman with a history of a previous cesarean section presented with heavy and irregular vaginal bleeding beginning immediately after pregnancy termination at 7 weeks' gestation. Failed response to hormonal treatment and curettage necessitated hysterectomy. Histologic examination revealed a placenta percreta. CONCLUSION: Although placenta percreta is an uncommon occurrence, clinicians should consider it in patients who have a uterotomy scar and complain of long-term metrorrhagia following pregnancy termination.     

Pitfalls in Ultrasound Diagnosis of Cesarean Scar Pregnancy

Cesarean scar pregnancy (CSP) is a rare kind of ectopic pregnancy implanted in the previous cesarean scar and has an increasing incidence over the past 30 years. As the suspicion is low, the diagnosis may be delayed or misinterpreted in ultrasound, leading to treatment strategies that might end up in uterine rupture or hysterectomy. The objective here is to review the ultrasound findings in CSP with varied presentations. Transabdominal and transvaginal sonography combined with color Doppler is a reliable tool for the diagnosis of CSP. When the gestational sac is seen in lower part of the uterine cavity, differentiation between threatened miscarriage, cervical pregnancy and CSP could be difficult. Not all cases of CSP present with typical ultrasound findings and a high index of suspicion is needed for diagnosis in these cases. An attempted curettage or MTP pill taken in an undiagnosed CSP often alters the typical findings. The possibility of CSP should also be considered in cases presenting with abnormal uterine bleeding and have a prior history of cesarean section. With lack of awareness about this condition, the diagnosis can often be missed either with MRI or in ultrasound. Correct interpretation and timely diagnosis save the mother from life-threatening complications and also preserves future fertility.     

Uterine rupture of cesarean scar related to spontaneous abortion in the first trimester

We report the case of a 31-year-old Japanese female diagnosed by transvaginal ultrasonography to have a spontaneous uterine rupture in the first trimester. Her condition was complicated by diabetes mellitus type 1. Her previous pregnancy had resulted in an emergency cesarean section by transverse incision of the lower uterine segment with single-layer suture at 37(+4) weeks of gestation. Transvaginal ultrasonography displayed both a gestational sac located in the anterior lower uterine segment and a defect in the uterine wall located at the site of the previous cesarean delivery scar. Pelvic magnetic resonance imaging showed that the uterine muscle layer was discontinuous and the gestational sac was almost outside the uterine cavity, accompanied by mild hemorrhaging within the endometrial cavity. The defect in the lower uterine wall was round in shape and was 3 cm in diameter. Since uterine ruptures can occur during all gestational periods, it is important to pay attention to the uterine wall where any cesarean incision was previously made.     

剖宫产手术史对体外受精-胚胎移植患者临床结局的影响

目的探讨剖宫产手术史对体外受精-胚胎移植(IVF-ET)患者临床结局的影响。方法回顾性分析2013年1月—2015年12月行IVF-ET且有剖宫产手术史的144例患者的助孕情况、妊娠及分娩结局,对照组为同期行IVF-ET且既往仅有阴道分娩史的166例患者。结果与对照组比较,剖宫产史组基础卵泡刺激素水平(b FSH)、人绒毛膜促性腺激素(h CG)注射日雌二醇(E2)水平、子宫内膜厚度、促性腺激素(Gn)用量、G n刺激时间,获卵率、受精率、卵裂率、优质胚胎率、胚胎移植数、多胎妊娠率、流产率、异位妊娠率差异均无统计学意义(P0.05);但剖宫产手术史组胚胎移植困难比例(6.25%)高于阴道分娩史组(0.00%),胚胎种植率(24.01%)及临床妊娠率(40.28%)明显低于阴道分娩史组(分别为34.98%和54.82%),差异均有统计学意义(P0.05);剖宫产史组双胎妊娠者较对照组双胎妊娠发生前置胎盘、产后出血比例增加(P0.05);无论是剖宫产手术史组还是阴道分娩史组,双胎分娩较单胎分娩新生儿出生孕周、体质量明显降低(P0.01)。结论剖宫产手术史可能降低IVF-ET患者的胚胎种植率和临床妊娠率,增加胚胎移植难度。对疤痕子宫妇女应严格控制移植胚胎数目,妊娠后加强孕期监管。     

剖宫产瘢痕妊娠的诊断及处理

目的:探讨剖宫产瘢痕妊娠的发病机制、早期诊断以及恰当的治疗方法。方法:回顾分析1994年1月至2006年5月北京协和医院收治的25例剖宫产瘢痕妊娠患者的临床资料,包括:患者的发病年龄,孕产次,发病至剖宫产术的间隔时间,首发症状,发病部位,诊断过程,辅助检查、治疗方法,经过及结局。结果:剖宫产瘢痕妊娠占同期异位妊娠的1.1%,与同期正常妊娠数之比为1:1368。25例患者的平均年龄31.4岁,92%的患者仅有一次剖宫产手术史,发病至末次剖宫产术的间隔时间为4月至15年,最常见的临床表现为停经和阴道流血,其中11例发生阴道大出血。16例(64%)患者分别误诊为宫内早孕(14例)和滋养细胞肿瘤(2例)而给予相应处理,仅9例治疗前确诊。通过剖宫产病史,妇科检查和超声、磁共振等辅助检查综合分析可作出诊断。治疗方法包括全子宫切除和保守性治疗(全身或孕囊内甲氨蝶呤注射和保守性手术)。25例患者均治愈出院。结论:剖宫产瘢痕妊娠较少见,临床易误诊,对有剖宫产手术史的患者应结合妇科检查及辅助检查以早期诊断,强调根据患者情况予以个体化治疗,可获得较好疗效。     

Multiple-dose methotrexate for pregnancy in a cesarean section scar. A case report

BACKGROUND: Pregnancy developing in a cesarean section scar is a very rare but possibly life-threatening condition because of the risk of rupture and excessive hemorrhage. CASE: A woman with previous cesarean section had transvaginal sonography performed at 7 weeks of gestation that showed a gestational sac implanted in the anterior isthmus wall of the uterus with 3 mm of myometrium between the sac and bladder wall. A diagnosis of pregnancy in the cesarean section scar was made. The patient was asymptomatic, and her hemodynamic condition was stable. Two courses of multiple-dose systemic methotrexate-folinic acid (1 mg/kg methotrexate intramuscularly on days 1, 3, 5 and 7 with 0.1 mg/kg folinic acid intramuscularly on days 2, 4, 6 and 8) were given. The patient tolerated it and remained stable during treatment. The serum hCG dropped to < 5 IU/L on day 56. CONCLUSION: Treatment with methotrexate is a non-surgical option that can improve preservation of the uterus in patients who desire fertility. A multiple-dose regimen causes rapid interruption of the pregnancy. This is very important because the risk of rupture and hemorrhage directly correlates with the duration of the pregnancy.     

Ectopic Pregnancy in Lower Segment Uterine Scar

Summary: A case of ectopic pregnancy in a lower uterine segment scar following previous Caesarean section is reported. A significant scar defect may result in deep implantation within the myometrium with the risk of persistent pain and bleeding followed inevitably by uterine rupture. In this report we discuss a number of management options. Except in the special situation of superficial implantation in a shallow scar defect where there is ultrasound evidence of continuity of the gestational sac with the uterine cavity we would strongly advise termination of the pregnancy.     

Ectopic Pregnancy in Lower Segment Uterine Scar

Summary: A case of ectopic pregnancy in a lower uterine segment scar following previous Caesarean section is reported. A significant scar defect may result in deep implantation within the myometrium with the risk of persistent pain and bleeding followed inevitably by uterine rupture. In this report we discuss a number of management options. Except in the special situation of superficial implantation in a shallow scar defect where there is ultrasound evidence of continuity of the gestational sac with the uterine cavity we would strongly advise termination of the pregnancy.     

Methotrexate for cesarean scar pregnancy after in vitro fertilization and embryo transfer. A case report

BACKGROUND: Cesarean scar pregnancy is an exceedingly rare occurrence. We present the first case of cesarean scar pregnancy following in vitro fertilization-embryo transfer (IVF-ET). CASE: A 40-year-old woman with a history of a previous cesarean section presented with five years of unexplained infertility. The patient complained of abdominal pain 16 days after embryo transfer. Ultrasonography revealed a gestational sac with cardiac activity located outside the lower segment of the uterus. Dilatation and curettage was performed due to misdiagnosis of inevitable abortion. Two weeks later, repeated sonography demonstrated a sacculus, 4.07 x 4.07 cm, within the uterine isthmus with only 7.1 mm of thickness separating the sac from the urinary bladder. Normal cervical length without ballooning was noted. Cesarean scar pregnancy was diagnosed. Local injection of methotrexate (MTX) under ultrasound guidance was performed. Plasma beta-hCG levels declined from 23,328 to 8 mlU/mL within two months. CONCLUSION: For women with cesarean scar pregnancy who desire fertility, conservative treatment using MTX is an excellent choice.     

体外受精-胚胎移植后宫内妊娠合并瘢痕妊娠一例

报道1例体外受精-胚胎移植（IVF-ET）后宫内妊娠合并子宫瘢痕妊娠（CSP）的病例。该患者取卵3枚,成功配成3枚胚胎,移植胚胎3枚,成功着床2枚,但1枚在宫内正常位置上,1枚着床在前次剖宫产切口上。该患者对瘢痕处的妊娠囊行减胎术后,因持续不规则阴道出血来医院就诊,妇科超声检查提示,宫腔内可见2个胎囊,其一可见胎芽,胎心（+）,其二位于前次剖宫产切口处,仅见胎囊,其内未见卵黄囊及胎芽,形态不规则。最终行经腹宫腔内胎盘胎儿清除术+CSP病灶切除术+剖宫产瘢痕憩室修补术,终止妊娠。报道此特殊病例,将CSP的超声和磁共振成像（MRI）诊断技术的优缺点进行比较,并对CSP的治疗和预防提出一些思考。     

Cesarean scar ectopic pregnancies: etiology, diagnosis, and management

OBJECTIVE: To clarify the appropriate way to diagnose and treat an ectopic pregnancy in the uterine scar of a prior cesarean delivery. DATA SOURCES: Articles written in English that were published from January 1966 to August 2005 and quoted in the computerized database MEDLINE/PubMed retrieved by using the words "cesarean section," "cesarean delivery," "cesarean section scar pregnancy," and "ectopic pregnancy." Additional articles were obtained from reference lists of pertinent case reports and reviews. METHODS OF STUDY SELECTION: Fifty-nine articles that met the inclusion criteria provided data on the clinical presentation, diagnosis, and treatment modalities of 112 cases of cesarean delivery scar pregnancies. TABULATION, INTEGRATION, AND RESULTS: Review of the 112 cases revealed a considerable increase in the incidence of this condition over the last decade, with a current range of 1:1,800 to 1:2,216 normal pregnancies. More than half (52%) of the reported cases had only one prior cesarean delivery. The mean gestational age was 7.5 +/- 2.5 weeks, and the most frequent symptom was painless vaginal bleeding. Endovaginal ultrasonography was the diagnostic method in most cases, with a sensitivity of 84.6% (95% confidence interval 0.763-0.905). Expectant management of 6 patients resulted in uterine rupture that required hysterectomy in 3 patients. Dilation and curettage was associated with severe maternal morbidity. Wedge resection and repair of the implantation site via laparotomy or laparoscopy were successful in 11 of 12 patients. Simultaneous administration of systemic and intragestational methotrexate to 5 women, all with beta-hCG exceeding 10,000 milli-International Units/mL required no further treatment. CONCLUSION: Surgical treatment or combined systemic and intragestational methotrexate were both successful in the management of cesarean delivery scar pregnancy. Because subsequent pregnancies may be complicated by uterine rupture, the uterine scar should be evaluated before, as well as during, these pregnancies.     

超声波诊断妊娠子宫瘢痕缺陷

应用Ｂ超对７１例初产妇（初产妇组）和３１例有剖宫产史的孕妇（剖宫产史组），自妊娠３３～４１周连续进行子宫下段形成状况及子宫下段瘢痕缺陷的观察。结果：１０２例孕妇的子宫下段在妊娠３３周以后均已形成，妊娠３７周以后，剖宫产史组较同期初产妇组子宫下段的长、宽、厚径均缩短。剖宫产史组中７例经Ｂ超诊断存在子宫下段瘢痕缺陷，其中２例诊断为先兆子宫破裂，并均经手术证实。提示：应用Ｂ超可进行妊娠期子宫下段变化的动态观察，并预测先兆子宫破裂。