Surgical evacuation of cesarean scar ectopic pregnancies

Cesarean scar ectopic pregnancy is associated with significant maternal morbidity, including severe hemorrhage, need for the blood transfusion and hysterectomy. Early diagnosis is therefore key in ensuring timely management, with consensus being that treatment before 9 weeks of gestation leads to reduced morbidity. There is no universally adopted management protocol for cesarean scar ectopic pregnancy, but surgical management generally has a higher success rate than medical management. The primary surgical treatment modalities are suction evacuation versus resection of the pregnancy via multiple routes. Adjuncts that have been shown to successfully minimize bleeding with surgical management include cervical cerclage, balloon catheter, and uterine artery embolization. However, there remains a lack of high-quality evidence regarding what is the best surgical treatment option for cesarean scar ectopic pregnancy, and therefore it is essential that clinicians provide tailored management to patients considering the presenting symptoms and local expertise with various surgical techniques.     

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.     

Effect of early pregnancy on a previous lower segment cesarean section scar.

OBJECTIVE: To summarize the manifestation, diagnosis, and early management of early pregnancy on a previous cesarean section scar. METHOD: Fifteen cases of early pregnancies implanted on previous cesarean section scars were diagnosed and treated in two obstetrical centers. RESULTS: The 15 patients had light, painless vaginal bleeding and their serum beta-subunit human chorionic gonadotropin (beta-HCG) was elevated. The interval between cesarean section and admission ranged from 6 months to 12 years (7.1+/-3.6 years). Doppler and real-time ultrasonic examinations demonstrated an enlargement of the previous cesarean section scar in the lower segment, a gestational sac or a mixed mass attached to the cicatrix, and a very thin myometrium between the gestational sac and the bladder wall. Serum beta-HCG dropped to normal in 12 of the 15 patients following treatment with crystalline trichosanthin injected into the cervix followed by oral mifepristone, intramuscular injections of methotrexate, or other appropriate treatment. Two patients underwent total hysterectomy due to massive vaginal bleeding. The remaining patient was misdiagnosed with choriocarcinoma and also had total hysterectomy. CONCLUSION: Pregnancy on a previous lower segment cesarean section scar is rare but very dangerous. Early diagnosis and effective conservative drug treatment may be instrumental in decreasing the occurrence of uterine rupture.     

Suction curettage as first line treatment in cases with cesarean scar pregnancy: feasibility and effectiveness in early pregnancy

Objective: A cesarean scar pregnancy (CSP) is an extremely rare form of an ectopic pregnancy, which is defined as the localization of a fertilized ovum surrounded by uterine muscular fiber and scar tissue. The objective of this study was to discuss the management options for CSPs in a singleton center. In the current study, we discussed the current management options for CSPs based on our 6 years of experience.

Material and methods: A retrospective evaluation of diagnosed and treated 26 patients with CSPs in Istanbul Kanuni Sultan Suleyman Training and Research Hospital during a 6-year period was discussed. Suction curettage was performed as first-line treatment in patients with a gestation <8 weeks and myometrial thickness >2?mm.

Results: Twenty-two (84.6%) patients with CSPs were initially treated surgically (curettage and hysterotomy) and four (15.4%) patients were treated medically with methotrexate injections. Vacuum aspiration was performed in 19 patients as a first-line treatment, six of them needed an additional Foley balloon catheter to be inserted for tamponade because of persistent vaginal bleeding. Suction curettage was successful in 12 patients. The treatment rate for suction curettage with or without Foley balloon catheter tamponade was 16 of 19 (84.2%).

Conclusion: The early diagnosis of a CSP (7–8 weeks gestation) with a β-hCG level <17.000?mIU/ml and a myometrial thickness >2?mm can be treated with suction curettage with or without placement of a uterine Foley balloon as curative treatment.     

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.     

剖宫产瘢痕妊娠的处理

剖宫产瘢痕妊娠是一种特殊的异位妊娠,随着剖宫产率的升高,其发病率也呈上升趋势。目前剖宫产瘢痕妊娠尚无规范的统一治疗标准,目前主要的治疗方法包括期待治疗、药物治疗和手术治疗,但目前期待治疗并不被推荐。对于瘢痕妊娠的患者应尽早终止妊娠,以减小损伤、保留患者的生育能力为目的。     

Image in reproductive medicine. Cesarean scar ectopic pregnancy

Bilateral hypogastric artery ligation followed by dilatation and evacuation under laparoscopic guidance was successful in the treatment of an advanced cesarean scar ectopic pregnancy. This case presents images of ultrasound, magnetic resonance imaging, and gross anatomy unique to cesarean scar pregnancy.     

Laparoscopic management of an ectopic pregnancy within a previous caesarean section scar

Ectopic pregnancy situated in a caesarean section scar is a rare but potentially life-threatening event. Because of its rarity there are no universal guidelines to manage this condition. We report a case of laparoscopic management of an ectopic pregnancy in a previous caesarean section scar. Laparoscopy enabled the successful treatment of an ectopic pregnancy, avoided unnecessary laparotomy and made it possible to preserve the patient’s reproductive capability. We discuss the management options and review the literature.     

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。     

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.     

Reproductive outcomes of cesarean scar pregnancies treated with uterine artery embolization combined with curettage

ObjectiveThe aim of this study was to review the reproductive outcomes of women with a cesarean scar pregnancy (CSP) treated with dilation and curettage (D&C) after uterine artery embolization (UAE).Materials and methodsThis was a retrospective study to review women who received UAE followed by D&C for CSP between January 2010 and December 2019 at the Changhua Christian Hospital, Changhua in Taiwan. Data were collected from both electronic and paper medical records. Patients were contact via phone call to follow up reproductive outcomes between January 2021 and March 2021. These subsequent reproductive outcomes (including pregnancy rate, secondary infertility rate, miscarriage rate, live birth rate, and recurrent CSP rate) were recorded and analyzed.ResultsA total of 53 cases of women who received UAE followed by D&C for CSP were identified. The women's average age was 34.8 ± 5.1 years. The mean gestational age at diagnosis was 6.2 ± 1.1 weeks. The mean level for human chorionic gonadotropin was 23,407.7 ± 29,105.5 mIU/ml. The average of blood loss during D&C was 19.2 ± 43.6 ml. The average hospitalization time after D&C was 3.5 ± 1.1 days. Of the 53 cases, 10 patients were lost to follow-up and 43 patients agreed to follow-up on reproductive outcomes in 2021. Twenty-three patients who desired to conceive were analyzed. Nineteen out of these 23 women (82.6%) succeeded in conceiving again and gave birth to 15 healthy babies (78.9%). Only one woman (1/19, 5.3%) experienced recurrence of CSP. The average time interval between previous CSP treatment and subsequent conception was 10.4 ± 6.7 months.ConclusionUAE combined with curettage treatment in CSP patients results in a positive rate of subsequent pregnancy outcomes. This minimally invasive procedure may be considered as one of the treatment options for CSP, as it enables preservation of fertility after treatment.