Mid-trimester cesarean scar pregnancy: a case report

Early first-trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory?

The implantation of a pregnancy within the scar of a previous caesarean delivery is the rarest of ectopic pregnancy locations. If it is diagnosed early, treatment options are capable of preserving the uterus and subsequent fertility. Objective: Pregnancy in previous caesarean scar is the rarest form of ectopic pregnancy. We aimed to present 4 cases of caesarean scar ectopic pregnancy and assess the potential role of three dimensional ultrasonography in the diagnosis. Design: We report 4 cases of caesarean scar pregnancies; one of them was initially mistaken for a viable intrauterine pregnancy. Results: 2 cases had transcervical aspiration of the gestational sac and two by open surgery. One underwent hysterectomy and the other laparotomy and excision of the pregnancy located in the CS scar. Conclusions: We report on four cases of caesarean scar pregnancy with different modes of treatment. The three dimensional ultrasound improved visualisation of the caesarean scar pregnancy. Care should be taken in the diagnosis of caesarean scar twin pregnancy by a transvaginal ultrasonography in order to not mistake a caesarean scar pregnancy for an intrauterine pregnancy.

A cesarean scar pregnancy (CSP) is a rare type of ectopic pregnancy that does not have any obvious signs or symptoms. However, the gestational sac in CSP is often embedded in the myometrial scar from the previous cesarean section. We report two cases of CSP in women with a history of cesarean sections who experienced profuse vaginal bleeding. The patients underwent hysterectomy at their own request due to devastating bleeding. CSP is one of the complications of cesarean sections. The patient may present with devastating bleeding, and immediate management is necessary. In a woman who is early into her pregnancy and has a history of cesarean section with profuse vaginal bleeding, CSP is one of the possible diagnoses.

Objective To explore the effect of two different embolization agents polyvinyl alcohol particles (PVA) with a diameter of 560-710 μm and gelfoam particles (GP) with a diameter of 500-710 μm on the volumes of bleeding in uterine artery chemoembolization (UACE) combined with uterine curettage under ultrasound monitoring in pregnant women with caesarean scar pregnancy (CSP). Methods From July 1 of 2015 to March 1 of 2019, a total of 142 cases of CSP pregnant women who received UACE combined with uterine curettage under ultrasound monitoring in Department of Radiology, West China Second University Hospital, Sichuan University were selected as the research subjects by simple random sampling method, and there were 102 cases of CSP Ⅱ, and 40 cases of CSP Ⅲ. According to types of CSP and different embolization agents used in UACE, the 142 pregnant women with CSP were divided into type Ⅱ PVA group (n=51, CSP Ⅱ pregnant women with the use of PVA as embolization agents), type Ⅱ GP group (n=51, CSP Ⅱ pregnant women with the use of GP as embolization agents), type Ⅲ PVA group (n=20, CSP Ⅲ pregnant women with the use of PVA as embolization agents), type Ⅲ GP group (n=20, CSP Ⅲ pregnant women with the use of GP as embolization agents). The age, the maximum diameter of gestational sac, time of menopause at admission, gravidity, number of caesarean sections, levels of human chorionic gonadotropin (hCG) before operation, length of hospital stay, and volume of bleeding during uterine curettage of all pregnant women were collected by retrospective method. Wilcoxon rank sum test and independent-samples t test were used to compare the volume of bleeding during uterine curettage and length of hospital stay between type Ⅱ PVA group and type Ⅱ GP group, type Ⅲ PVA group and type Ⅲ GP group. This study was in line with the requirements of World Medical Association of Helsinki revised in 2013. Results ①There were no statistically significant differences between type Ⅱ PAV group and type Ⅱ GP group, type Ⅲ PAV group and type Ⅲ GP group in the age, time of menopause at admission, gravidity, number of caesarean sections, level of hCG before operation (P>0.05). ②The maximum diameters of gestational sac in type Ⅱ PAV group and type Ⅲ PAV group were longer than those in type Ⅱ GP group and type Ⅲ GP group, respectively, and both differences were statistically significant (t=3.377, 2.096; P=0.001, 0.043). The correlation analysis of the maximum diameter of gestational sac and volume of bleeding during uterine curettage showed that the maximum diameter of gestational sac of pregnant women with type Ⅱ CSP was weakly correlated with the volume of bleeding during uterine curettage (rs=0.235, P=0.017), and in pregnant women with type Ⅲ CSP, there was no significant correlation between these two indexes (rs=0.295, P=0.064). ③The volumes of bleeding during uterine curettage in type Ⅱ PVA group and type Ⅱ GP group were 10 mL (2-200 mL) and 10 mL (2-100 mL), respectively, and the length of hospital stay were (5.3±1.5) d and (5.2±1.7) d, respectively, and there were no statistically significant differences between these two groups in these two indexes (P>0.05). The volumes of bleeding during uterine curettage in type Ⅲ PVA group and type Ⅲ GP group were (10.7±7.5) mL and (11.7±13.9) mL, respectively, and the length of hospital stay were (5.5±1.1) d and (4.8±1.8) d, respectively, and there were no statistically significant differences between these two groups in these two indexes (P>0.05). Conclusions The effects of reducing the volume of bleeding during uterine curettage are the same with the use of PVA and GP as embolization agents to embolize bilateral uterine artery of CSP pregnant women in UACE combined with uterine curettage under ultrasound monitoring. Key words: Cesarean scar pregnancy; Pregnancy, ectopic; Uterine artery embolization; Embolization agents; Dilatation and curettage; Blood loss, surgical; Pregnant women

Objective: To investigate the rational choice of early diagnosis and treatment of cesarean scar pregnancy (CSP). M ethods: The clinical data, including age, gravidity, time to previous cesarean section, first symptom, auxiliary examination, regimen, and therapeutic outcomes, of 211 patients with CSP admitted to Sichuan Provincial People’s Hospital from March 2016 to February 2018 were retrospectively analyzed. Results: Of the 211 patients, 165 patients were first diagnosed with CSP in this hospital, and eight of them (4.85%) were misdiagnosed; 46 patients were referred to thus hospital by physicians in other hospitals, and 21 of them (45.65%) were misdiagnosed. After admission, transvaginal color Doppler sonography was performed with a blood β-human chorionic gonadotropin (β-hCG) study to confirm the diagnosis. According to the surgical approaches, 211 patients were divided into six groups: group A: hysteroscopy group (141 patients), group B: uterine artery embolization (UAE) plus hysteroscopy group (38 patients), group C: hysteroscopy plus laparoscopy group (seven patients), group D: UAE with hysteroscopy plus laparoscopy group (six patients), group E: laparotomy group (12 patients), and group F: uterine evacuation group (seven patients). There were no significant differences in age, number of cesarean sections, time from previous cesarean section, days of the missed period, diameter of the gestational sac, or blood β-hCG levels among the six groups (p > 0.05). However, the cure rate, complication rate, mean intraoperative blood loss, mean operative time, mean length of hospital stay, and mean medical cost were all statistically significant between the six groups (p < 0.05). Conclusions: Women who have a history of cesarean section should be vigilant and undergo a transvaginal ultrasound examination as early as possible to exclude CSP and avoid a missed diagnosis or misdiagnosis. For patients at less than or equal to eight weeks of gestation and with a gestational sac diameter less than or equal to 3.0 cm, hysteroscopy is the preferred treatment that is safe and effective. Hysteroscopy combined with laparoscopy and laparotomy are suitable for patients with a high risk of massive bleeding, for instance, patients with a thin anterior myometrium on which abundant blood flow signals are shown, or should be considered as emergency backup plans for other surgical approaches. UAE can effectively reduce intraoperative blood loss but increases the risk of postoperative complications, length of hospital stay, medical costs, and it is suitable for patients with massive bleeding during or after CSP surgery and in need of emergency hemostasis or for patients with a very high risk of bleeding confirmed by a preoperative assessment.

Clinical Characteristic and Management of Acquired Uterine Arteriovenous Malformation.

We present a rare case of Caesarean scar pregnancy (CSP) in which the embryo implants within the myometrium at the site of a previous caesarean scar with complete scar dehiscence and its distinctive management. A 38-year-old G8P1 woman presented with vaginal bleeding following 6 weeks of amenorrhoea following IVF. Serum b-human chorionic gonadotropin (HCG) level was 9166 mIU/mL and transvaginal ultrasound (TVS) revealed (Fig. 1) an inhomogeneous fixed mass, 5 cm in size within the myometrium at her previous caesarean scar site extending outside the uterus through the caesarean scar and adjacent to the bladder; on the basis of this diagnosis CSP was made. Systemic methotrexate (MTX) was administered, (1 mg/kg intramuscular) and b-HCG level fell to 18.0 mIU/mL over 3 months follow-up. However, the patient continued to have lower abdominal pain and a repeat TVS showed the mass had reduced in size to 3.5 cm. Because of drawn out recovery period and as she wanted to go for another IVF cycle, laparoscopy was undertaken. After reflection of the bladder peritoneum, it was noted that the previous caesarean section scar had dehisced completely (Fig. 2a, b). The CSP mass was thus excised and the edges of the defect approximated in two layers. Postoperative course was unremarkable, and her b-hCG levels were \5 mIU/mL. The histopathology report confirmed diagnosis of CSP with evidence of placenta percreta. The first ever case of CSP was reported in 1978, and since then only 19 cases were reported until 2001 [1, 2], followed by sudden increase to 751 cases by 2011 [3]. With no evident mechanism for CSP yet understood, the finding in most of the cases reflect that implantation occurs at the site of a micro or macroscopic defect in the scar [4]. Commonest presentation of CSP is abdominal pain and bleeding [5]. CSP is a diagnosis on ultrasound visualisation of gestational sac at the level of internal os, penetrating the anterior uterine wall approaching the bladder [6]. CSP is more challenging to diagnose if only inhomogeneous mass of products of conception is present such as in this case, where use of Doppler helps [3, 4]. Possibility of CSP should be considered in women who have had a previous caesarean [7], as delay in diagnosis can lead to uterine rupture causing serious maternal morbidity and loss of future fertility. There is no consensus on the preferred mode of treatment [3, 8]. After discussing the various treatment modalities in the literature [2, 3, 5], as per patients choice our management started with a single dose of systemic MTX. But later laparoscopy showed a silent complete scar dehiscence, which could have possibly resulted in rupture and intraperitoneal bleeding. There are no other published case reports of concomitant CSP and silent scar dehiscence. Our case brings to light the possibility of dehiscence after MTX therapy that could have implications for future fertility. It highlights the importance of post treatment long term surveillance following MTX and in cases where there is slow resolution of the CSP mass. The incidence of CSP is likely to rise substantially in the near future as caesarean delivery rates continue to increase. Setting up multicentre collaboration would encourage robust evidence-based studies essential for making recommendations for practice. Until then, one has to rely on N. Agarwal A. Shahid (&) F. Odejinmi Whipps Cross University Hospital, Barts Health NHS Trust, London, UK e-mail: anupamashahid@gmail.com; anupamashahid@yahoo.com

Cesarean scar pregnancy (CSP) is one of the rarest ectopic pregnancies which may be associated with life-threatening complications. Owing to the rarity of CSP, little is known about it. This study aimed to evaluate the value of the first-trimester transvaginal sonography (TVS) diagnosis and the risk factors of CSP after in vitro fertilization-embryo transfer (IVF-ET). This was a retrospective study of women undergoing IVF-ET between January 2013 and December 2018. Women who were diagnosed with a CSP using TVS and confirmed by surgery and histological examination were included. The clinical data and ultrasound findings were collected and analyzed. Univariate and multivariate logistic regression analyses were performed for evaluation of possible influence factors. Diagnostic parameters including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TVS were calculated for the diagnosis of CSP. Overall, 75,438 consecutive women who underwent IVF-ET had received TVS during this period. Of these, 4,817 women (6.4%) had a history of cesarean section and 83 cases were found to have a CSP. Due to the absence of histological data, 19 cases treated conservatively were excluded. Finally, 64 cases were included, among whom 63 cases were correctly diagnosed [including 17 cases of heterotopic CSP (HCSP)] and 1 case was missed using TVS. Another 1 case of inevitable miscarriage was misdiagnosed as a CSP. The maternal age at the initial scan [34.0 (range, 26.0-44.0) years], the infertility duration [4.0 (range, 1-12) years], and the initial diagnostic time after ET [27 (range, 20-50) days] were recorded. A gestational sac (GS) was observed in all 63 cases during ultrasound examinations, including 28 with fetal pole, 25 with a yolk sac only, and 10 with an empty sac. The sensitivity and specificity of first-trimester TVS in diagnosing CSP were 98.44% and 99.98%, respectively; the PPV and NPV were 98.44% and 99.98%, respectively. Multivariate logistic regression analysis showed thinner endometrial thickness (ET) on transfer day [adjusted odds ratio (aOR): 0.83; 95% confidence interval (CI): 0.76-0.93, P<0.001] and multiple ET (aOR 53.60, 95% CI: 5.31-1,736.00, P=0.008) were independent risk factors for CSP and HCSP, respectively. First-trimester TVS performed by an experienced sonographer has a high sensitivity for making the correct diagnosis of CSP after IVF-ET, which is helpful for clinical intervention and avoiding severe complications. For patients with a history of cesarean section, thinner ET on the transfer day and bigger body mass index (BMI) seem to be risk factors for CSP; single blastocyst transfer should be recommended to decrease the possibility of HCSP. The clinical significance of this study still needs to be considered.

Pregnancy implantation within previous caesarean scar is one of the rarest locations for an ectopic pregnancy. Incidence of caesarean section is increasing worldwide and with more liberal use of transvaginal sonography, more cases of caesarean scar pregnancy are being diagnosed in early pregnancy thus allowing preservation of uterus and fertility. However, a delay in either diagnosis or treatment can lead to uterine rupture, hysterectomy, and significant maternal morbidity. We are reporting a rare case of first trimester caesarean scar pregnancy with viable fetus in the process of rupture, where uterine repair could be done, thus preserving the future fertility.

Clinical Analysis of 45 Cases of Caesarean Scar Pregnancy

Objective: To investigate the efficacy of uterine artery embolization (UAE) in preventing acute massive hemorrhage caused by uterine curettage with cesarean scar pregnancies (CSP). Methods: 20 cases of cesarean scar pregnancy admitted into our hospitals from January 2013 to December 2015 were selected in this study. All the 20 patients were treated by UAE. Then the therapeutic effect of UAE on cesarean scar pregnancy was observed. Results: 20 patients were all successfully treated with UAE, and the curettage procedures were performed in next 48~72 h. Intraoperative blood loss was about 30~150 ml. Pathological examinations detected villi tissue after curettage. The β-HCG value resumed to normal levels in 10~29 d, with an average of (16.7±4.5)d. There were no hemorrhage observed in the follow-up of 3~6 months later. Conclusions: UAE is an effective therapeutic method in preventing acute massive hemorrhage caused by uterine curettage with CSP. It is easy to manipulate with evident benefit to patients, thus is worthy of clinical application. Key words: Uterine arterial embolization; Cesarean section; Cesarean scar pregnancy

A retrospective study was conducted in women with history of a caesarean scar pregnancy (CSP) to explore the possible causative mechanisms. Over a period of 40 months, a total of 16,926 deliveries and 3554 caesarean sections (CS) occurred in our hospital. Nine cases of CSP were identified at an incidence of 1:1880 births and 0.25% of all CS. Analysis of the indications of the previous CS revealed that 88.8% of women with known indication had undergone CS without labour. Out of them, 75% underwent CS at preterm gestation and 25% had term elective procedure for breech presentation. Of the patients, 77.7% had multiple CS. Conservation of the uterus was possible in 77.7% of patients utilising non-radical forms of treatment. As most of the women underwent CS with a non-contractile uterus without labour, we believe that the risk of CSP may be related to the indications of the previous CS as the number of CS alone could not explain the occurrence of CSP. It is time to explore this area so that screening strategies can be developed to detect CSP at the earliest possible gestation and to prevent life-threatening complications such as uterine rupture and severe hemorrhage. Impact statement What is already known on this subject? A caesarean scar pregnancy (CSP) is a life-threatening condition that can result in uterine rupture and in severe haemorrhage. Although the diagnostic criteria for the CSP have been established, the risk factors that favour the condition are not well understood. We know that the incomplete healing of the lower uterine segment (LUS) from poor vascularisation can create a microscopic dehiscent tract through which the blastocyst enters the myometrium. Some have postulated that the healing processes following the elective procedures, such as for breech deliveries performed in a non-developed LUS, might facilitate this process. What do the results of this study add? In this study, analysis of the indications of the previous CS revealed that majority of women with a known indication had undergone CS without labour, either at preterm gestation or term elective procedure for breech presentation. We have postulated the possible causative mechanisms in relation to the physiology of LUS development. To the best of our knowledge, this is the first study that has looked specifically at the relationship between the indications of previous CS and CSP. What are the implications of these findings for clinical practice and/or further research? Further studies exploring the indications of the previous CS are recommended so that early first-trimester screening strategies can be generated towards this subgroup of patients to detect CSP at the earliest possible gestation.

Caesarean scar pregnancy is a rare type of ectopic pregnancy with the potential for catastrophic outcomes. A high index of suspicion is required for prompt diagnosis and intervention to improve outcomes. This report describes a rare case of Caesarean scar pregnancy, which was initially misdiagnosed as a threatened miscarriage and cervical ectopic pregnancy. A 35-year-old multiparous lady with two previous caesarean sections presented to the Gynaecology Unit of the Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nigeria, at an estimated gestational age of 10 weeks, with recurrent vaginal bleeding of eight weeks' duration. She was referred to our facility from a private hospital, where she had first been managed as a case of threatened miscarriage and later as a cervical ectopic pregnancy. The transvaginal ultrasound in our facility was in keeping with a viable Caesarean scar pregnancy. The urine pregnancy test was positive, and the quantitative serum beta human chorionic gonadotropin was 75.6 mIU/ml. She had initial medical treatment with a combination of systemic multidose and intrauterine sac methotrexate and, subsequently, hysterotomy. Following systemic and local methotrexate, there was the demise of the foetus, which was evacuated at hysterotomy, and the uterine scar defect was repaired. She was discharged home in stable clinical condition one week after surgery. Her serum beta human chorionic gonadotropin dropped to 51.6 mIU/mL two weeks post-hysterotomy, and her urine pregnancy test became negative three weeks later. Though rare, caesarean scar pregnancy should be considered a differential diagnosis in reproductive-aged women with a previous caesarean section who present with vaginal bleeding in the first trimester.

Cesarean scar pregnancy (CSP) occurs in 0.2%-0.5% of women with a previous cesarean section globally. Multiple factors influence the development of CSP; however, to date, the critical factors contributing to the development of CSP have not been fully explored due to its relatively low incidence. Moreover, CSP can be clinically categorized into type 1 and type 2 CSP. In this retrospective study with a large sample size, we investigated potential risk factors that could contribute to CSP development. Two hundred-one women diagnosed with CSP, either type 1 or type 2 CSP, and 1700 pregnant women with a history of cesarean section but without CSP diagnosis in subsequent pregnancy were included. Gravidity, previous live birth(s), consecutive cesarean section(s), surgical abortion(s), the interval between the pregnancies, and maternal age were compared between the 2 groups. Gravidity, the number of previous live births, the number of previous consecutive cesarean sections, and the number of surgical abortions were significantly associated with CSP development in women with a past cesarean section. This association was regardless of the subtypes of CSP. Notably, the interval between 2 pregnancies was also significantly associated with CSP development, but this association was only seen in type 2 CSP. However, maternal age was not an independent risk factor for CSP development. Additionally, a higher incidence of CSP was observed in China compared to that reported in the literature. In addition to a previous cesarean section, our study highlights at the number of surgical abortions also contributes to the development of CSP.

Cesarean scar pregnancy is an ectopic pregnancy embedded in the myometrium of a cesarean scar. Several types of conservative treatment have been used to treat cesarean scar pregnancy, but no management protocol has been established for this rare, life-threatening condition. The purpose of this study was to evaluate the feasibility of suction curettage as a first-line treatment in early cesarean scar pregnancy. During a 4-year period, 19 cases of cesarean scar pregnancy were diagnosed at Süleymaniye Maternity Hospital in Istanbul, Turkey. Suction curettage and Foley balloon tamponade were performed as a first-line treatment in 13 patients. Medical records and treatment results of the patients were evaluated. The mean maternal age was 32.5 years (range, 24-39 years). The mean gestational sac diameter was 13.65 mm (range, 7.6-27 mm), and mean endometrial thickness was 10.7 mm (range, 6.7-14.6 mm). A measurable fetal pole for crown-rump length was available for 6 (46.1%) patients. None of the fetuses had cardiac activity. Suction curettage under ultrasound guidance and Foley balloon tamponade were successful as the primary treatment in 13 of 13 patients. No major complications occurred during or after the procedure. Our data suggest that surgical evacuation under ultrasound guidance with Foley balloon tamponade is a safe and successful treatment modality in carefully selected patients with early cesarean scar pregnancy.