Diagnostic multimodal imaging and therapeutic transcatheter arterial chemoembolization for conservative management of hemorrhagic cesarean scar pregnancy

Objective

To evaluate the value of emergency transcatheter arterial chemoembolization (TACE) for initial conservative management of hemorrhagic cesarean scar pregnancy after multimodal image diagnosis.

Study design

Five consecutive cases of hemorrhagic cesarean scar pregnancy were diagnosed for precise localization of ectopic placentation site, depth of placental invasion and uteroplacental neovascularization by imaging studies including color Doppler ultrasonography, magnetic resonance imaging (MRI) and three-dimensional computerized tomographic angiography. Emergency TACE with dactinomycin was initially performed to achieve immediate hemostasis and cytotoxic effects on chorionic villous tissue. Then, the need for either expectant management or subsequent hysteroscopic resection was individually determined. Systemic methotrexate (MTX) administration was added when delayed decline of serum hCG value was noted.

Results

On MRI, total placental invasion to the serosa of the anterior uterine wall was diagnosed in three cases, while the two remaining cases showed subtotal invasion to the anterior uterine wall. All cases were managed by emergency TACE as an initial conservative measure. Subsequently, spontaneous expulsion of gestational products occurred in one case of subtotal placental invasion. Additional MTX administration was required to achieve complete resorption of cesarean scar pregnancy in two cases of total placental invasion. In one case of subtotal placental invasion, successful hysteroscopic resection was performed under laparoscopic guidance, whereas, in one case of total placental invasion, hysteroscopic removal of gestational products was incomplete due to the risk of uterine perforation and additional systemic MTX administration was required for complete resolution. Uterine preservation was achieved in all cases without unfavorable effects of TACE or secondary hemorrhagic complications.

Conclusions

This small case series emphasizes that TACE is potentially useful as an initial emergency intervention for conservative management of hemorrhagic cesarean scar pregnancy to achieve immediate hemostasis and direct cytotoxic effects on chorionic villous tissue with minimal systemic side effects of chemotherapeutic agent.     

224例剖宫产术后子宫疤痕妊娠不同治疗方法的临床疗效分析

目的:比较剖宫产术后子宫疤痕妊娠(CSP)不同治疗方法的临床疗效。方法:回顾分析在福建省妇幼保健院妇产科诊治的224例CSP患者,按首治方案分组:药物治疗加清宫术(A组),子宫动脉栓塞(UAE)加清宫术(B组),经腹CSP病灶切除加修补术(C组),腹腔镜下CSP病灶切除加修补术(D组)。根据治疗药物不同将A组再分为:甲氨蝶呤(MTX)(局部/全身)组(A1组),天花粉组(A2组),MTX(局部/全身)加天花粉组(A3),米非司酮组(A4)。根据术前是否行UAE,将C组分为:术前未行UAE(C1组),术前行UAE(C2组)。结果:A、B、C、D组的治疗成功率分别为90.12%、95.61%、100%和100%,差异无统计学意义(P=0.255);入院时血β-HCG、CSP分型、手术出血量、手术时间、住院时间及住院费用比较,差异均有统计学意义(均P0.05)。A1~A4组的治疗成功率分别为85.37%、100%、83.33%、96.43%,差异无统计学意义(P=0.381),入院时血β-HCG、术后2~3天血β-HCG下降程度、手术出血量、手术时间差异无统计学意义(均P0.05),住院时间和住院费用差异有统计学意义(均P=0.000)。C1、C2组的治疗成功率均为100%;入院时血β-HCG、术后2~3天血β-HCG下降程度和住院费用差异有统计学意义(均P0.05);手术出血量、手术时间、住院时间差异无统计学意义(均P0.05)。结论:根据入院时血β-HCG水平、B超情况选择恰当的治疗方案,均能取得好的临床效果。药物治疗采用MTX、或天花粉、或米非司酮临床效果相似,住院时间长,费用增加。UAE后清宫术,可以减少术中出血量。经腹疤痕妊娠病灶切除加子宫修补,术前行UAE未减少术中出血量。     

Caesarean scar pregnancy: comparative efficacy and safety of treatment by uterine artery chemoembolization and systemic methotrexate injection

Objectives

The aim of this study was to investigate the efficacy and safety of uterine artery embolization (UAE) combined with intra-arterial methotrexate (MTX) infusion for the treatment of caesarean scar pregnancy (CSP), compared with systemic MTX injection combined with uterine curettage.

Study design

A retrospective cohort study. An analysis of CSP patients was performed using records from the Department of Obstetrics and Gynecology in Renji Hospital for the period between January 1, 2000 and December 30, 2010. Twenty-two patients received UAE combined with intra-arterial MTX infusion and in this group 16 patients received uterine curettage after UAE, whereas 25 patients received intramuscular MTX injection and subsequent uterine curettage. The clinical information on these patients and clinical outcomes were reviewed.

Results

All patients in the UAE group were treated successfully and 2 patients in the non-UAE group had to undergo hysterectomy or uterine repair. No patients in the UAE group had recurrent vaginal bleeding of more than 100 ml/day after treatment, while 8 patients in the non-UAE group did, and this difference was significant. The blood loss during uterine curettage in the UAE group was much less than in non-UAE group. The serum β-hCG level in the UAE group recovered more quickly than in the non-UAE group, and hospital stay was significantly shorter in the UAE group.

Conclusions

UAE combined with intraarterial MTX infusion turned out to be an effective and safe treatment for CSP.     

Risk factors for intraoperative hemorrhage at evacuation of a cesarean scar pregnancy following uterine artery embolization

Objective

To determine risk factors associated with massive uterine bleeding during dilation and suction curettage (D&C) after uterine artery embolization (UAE) for the treatment of cesarean scar pregnancy (CSP).

Methods

Data from 128 CSP patients treated with D&C after UAE were analyzed to assess risk factors associated with massive uterine bleeding (blood loss 500 mL or more) during D&C after UAE.

Results

In total, 15 CSP patients had massive bleeding during D&C after UAE. Univariate analysis showed that a greater gestational age (GA), a larger CSP mass size, a thinner myometrium at the implantation site, a GA of 8 weeks or more, a CSP mass diameter of 6 cm or more, and evidence of fetal heartbeat were risk factors for massive bleeding (P < 0.05). In a binary logistic regression analysis, GA of 8 weeks or more and CSP mass diameter of 6 cm or more remained as the only significant risk factors for massive bleeding (OR 11.49 [95% CI 1.08–122.13] and OR 96.59 [95% CI 6.20–150.57], respectively; P < 0.05).

Conclusion

For CSP masses with a GA of 8 weeks or more and a diameter of 6 cm or more, the outcome of surgical evacuation after UAE tends to be unsatisfactory.     

hCG values and gestational sac size as indicators of successful systemic methotrexate treatment in cesarean scar pregnancy

ObjectiveTo retrospectively investigate cesarean scar pregnancy (CSP) patients who received systemic methotrexate (MTX) and to clarify the criteria for administering systemic MTX to CSP patients.Materials and methodsFifteen CSP patients who were initially treated with systemic MTX (50 mg/m²/week) were included. Nine patients, who needed a uterine artery embolization (UAE) or a laparotomy, including a transabdominal hysterectomy (TAH), were defined as the unsuccessful MTX group. Six patients who did not require UAE or a laparotomy were defined as the successful MTX group. Furthermore, the hCG cut-off value and the GS cut-off size at the time of CSP diagnosis, which differentiated successful and unsuccessful patients, were defined. MTX success rates were investigated by combining the hCG and gestational sac (GS) size cut-off values.ResultsThe hCG cut-off value was 17757.0 mIU/mL, and the GS cut-off size was 10.4 mm. In patients with hCG values less than 17757.0 mIU/mL, the MTX success rate was 75.0%. Fewer patients needed UAE or a laparotomy compared to patients with hCG values higher than 17757.0 mIU/mL (P = 0.007). In patients with a GS size less than 10.4 mm, the MTX success rate was 80.0%. Fewer patients among them needed UAE or a laparotomy compared to those among patients with a GS size greater than 10.4 mm (P = 0.089). In patients with hCG values and GS sizes lower than the cut-off values, the MTX success rate was 80.0%. Fewer patients among them needed UAE or a laparotomy compared to those among patients with hCG values and/or GS sizes higher than the cut-off values, respectively (P = 0.010).ConclusionPatients with hCG values less than 17757.0 mIU/mL and GS sizes less than 10.4 mm may have a greater chance of successful systemic MTX treatment when it is used as the first line of treatment for CSP.     

Cesarean scar pregnancy; Diagnosis and management between 2003 and 2015 in a single center

Objectives

We aimed to evaluate diagnosis and management of an ectopic pregnancy developing in a previous cesarean scar.

Uterine artery embolization followed by dilation and curettage within 24 hours compared with systemic methotrexate for cesarean scar pregnancy

Objective

To assess the efficacy of uterine artery embolization (UAE) combined with dilation and curettage (D&C) within 24 hours for the treatment of a cesarean scar pregnancy (CSP), compared with methotrexate and D&C.

Methods

A retrospective cohort study of 119 women with CSP was conducted at two tertiary hospitals in Guangzhou and Shenzhen, China, during 2009–2012. Twenty-six women received systemic methotrexate followed by D&C, and 93 women were treated with UAE followed by D&C within 24 hours.

Results

Mean blood loss was 261.0 ± 357.4 mL in the methotrexate group versus 14.1 ± 40.6 mL in the UAE group (P < 0.001). The time to resolution of the level of β-human chorionic gonadotropin was 40.5 ± 17.2 days versus 15.4 ± 7.7 days (P < 0.001), respectively. The duration of hospitalization was 14.6 ± 9.2 days versus 6.2 ± 3.7 days (P < 0.001), respectively. An additional intervention was needed in 9 (35%) women in the methotrexate group and in 5 (5%) in the UAE group (P < 0.001).

Conclusion

UAE combined with D&C within 24 hours was an effective uterine preservation treatment for CSP, and was associated with less blood loss and a shorter hospital stay than administration of methotrexate followed by D&C.     

剖宫产瘢痕妊娠127例临床分析

目的:探讨剖宫产瘢痕妊娠(CSP)的有效治疗方法。方法:回顾分析2013年1月至2015年3月复旦大学附属妇产科医院收治的127例CSP患者的临床资料,按治疗方法分组:单纯超声引导下清宫术组(A组)38例,行双侧子宫动脉化疗栓塞后超声引导下清宫术组(B组)72例,宫腹腔镜联合治疗组(C组)17例。比较3组的临床资料和社会经济学指标;分析CSP预后的相关因素。结果:A组患者的病灶体积为(9.76±2.30)cm3,治疗前血β-HCG为(40983±11132.40)m IU/ml,术中出血(48.55±16.07)ml,住院天数(4.63±0.29)天,住院费用(5171.57±730.41)元。B组患者的病灶体积为(27.33±6.47)cm3,治疗前血β-HCG为(76771.23±7582.95)m IU/m L,术中出血(42.32±15.15)ml,住院天数(6.42±0.28)天,住院费用(11113.41±405.94)元。C组患者的病灶体积为(65.82±29.61)cm3,治疗前血β-HCG为(47010.10±112106.42)m IU/m L,术中出血(267.65±113.41)ml,住院天数(6.82±0.52)天,住院费用为(18018.40±1209.61)元。3组的病灶体积比较,差异有统计学意义(P0.05)。C组的术中出血量高于A、B组,差异有统计学意义(P均=0.003);A、B组比较,差异无统计学意义(P0.05);3组的治疗成功率比较,差异无统计学意义(P0.05),而住院费用比较,差异均有统计学意义(P0.05)。A组的住院时间与B、C组比较,差异有统计学意义(P=0.0001、0.0009);B、C组比较差异则无统计学意义(P=0.4936)。多因素回归分析提示,停经天数、CSP超声分型、病灶体积、血β-HCG水平与CSP预后相关。结论:临床工作中可根据超声分型、病灶体积、血β-HCG水平等综合考虑给予个体化治疗,但早期发现、正确诊断是合理治疗的关键。     

Ectopic pregnancy in a cesarean section scar

A combination of systemic chemotherapy, feticide with intrachest and intra-abdominal injection with methotrexate, and hysteroscopy with dilation and curettage to remove the gestational tissue was successful in the treatment of a cesarean scar ectopic pregnancy. This case presents images of the ultrasound, magnetic resonance imaging, and pathologic features unique to a cesarean scar pregnancy.     

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。     

Clinical efficacy analysis of different therapeutic methods in patients with cesarean scar pregnancy

ObjectiveThe purpose of this study was to analyze the clinical efficacy of five therapeutic strategies in patients with CSP.Materials and methodsA total of 135 CSP patients were included and divided into five groups based on the treatment they received, including transvaginal resection (Group A), laparoscopic resection (Group B), uterine arterial embolization (UAE) combined with hysteroscopic curettage (Group C), UAE combined with uterine curettage (Group D), and hysteroscopic curettage (Group E). To investigate the clinical efficacy of these strategies, intraoperative bleeding, serum β-hCG levels and recovery time, menstruation recovery time, hormone levels at 1 month after treatment.ResultsPatients in group A had the lowest postoperative serum β-hCG levels, and the shortest recovery times of both serum β-hCG and menstruation, followed by patients in group B. Group C and D had small amount of blood loss. The hospital stays and costs were low in group E. In addition, the sex hormone levels showed no significant difference among the five groups.ConclusionOur results indicated that resection surgery and UAE have good curative effects, but high hospital costs in CSP treatment. The selection of an optimal treatment regimen for CSP should be carried out based on specific conditions of the patients.     

剖宫产瘢痕妊娠经阴道手术治疗

经阴道手术是治疗剖宫产瘢痕妊娠安全、有效的治疗方法之一,适用于孕＜10周、妊娠包块最大径线＜6cm的患者,其术前无需预处理。经阴道手术治疗剖宫产瘢痕妊娠对未来妊娠的影响、失败的相关因素及与其他一线治疗方法之间的比较,还需要多中心、大样本的临床研究进行总结。     

剖宫产后子宫瘢痕妊娠合并宫内妊娠的诊断及治疗

目的:通过回顾分析相关文献,总结剖宫产后子宫瘢痕妊娠合并宫内妊娠(HCSP)的临床表现、诊断、治疗及预后等,从而为临床诊疗提供参考。方法:检索PubMed、万方及中国期刊全文数据库中的HCSP相关文献。通过阅读文献全文,总结分析HCSP的临床表现及诊断方法,并重点探讨其治疗方法及治疗方法与预后的关系。结果:共收集HCSP患者15例,其中自然妊娠6例,体外受精-胚胎移植(IVF-ET)9例。诊断时间为孕5周至8+4周,其中6例患者有阴道流血,其余均无特殊不适;患者均通过阴道超声得以确诊。1例患者因无生育要求而选择甲氨蝶呤直接终止妊娠;14例患者中,期待治疗、宫腔镜及腹腔镜手术治疗各1例,超声监测下原位减胎术[抽吸和(或)药物注射)]11例,患者均成功减胎并继续妊娠。1例因孕12周超声提示胎儿畸形而终止妊娠;13例通过剖宫产而获得活婴,其中3例为足月择期剖宫产,10例因急诊手术指证而行剖宫产终止妊娠,4例出现术中大出血需抢救治疗。结论:剖宫产术后的再次妊娠,尤其是通过辅助生殖技术而受孕者需考虑到HCSP的可能。阴道超声是HCSP诊断及治疗的重要工具。目前超声监测下原位减胎术是治疗HCSP的主要方法,并可获得成功的宫内继续妊娠,但继续妊娠者孕期及围产期并发症多,需严格按高危妊娠积极处理。