Uterine conservation requires resection and reconstruction in placenta accreta spectrum and cesarean scar pregnancy (letter to the editors).

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

First-trimester prediction of uterine rupture in cesarean scar pregnancy

This article contains the academic, but more importantly clinical debate of the terminology of pregnancies after cesarean deliveries, namely cesarean scar pregnancies as well as increasingly relevant social aspects determining their management. Its main purpose is to offer a solution to the controversy created by the debate about the terminology of pregnancies implanted in, or on the uterine scar left behind by a cesarean delivery. The 2 opposing terms creating the argument are: cesarean scar pregnancy and cesarean scar ectopic pregnancy. They seem to exhibit a spectrum of different pathophysiologic properties and outcomes with different outcomes almost regardless of their expectant or surgically management. Based upon the above and modeled by the creation of the entity called "placenta accreta spectrum" which also contains clinico-pathologically slightly but different entities, we suggest unifying the terminology of cesarean scar pregnancies. By creating an all-encompassing term: cesarean scar pregnancy spectrum that includes the different presentations, various levels of their clinical severities and associated complications. Categorizing cesarean scar pregnancies as "on-scar cesarean scar pregnancy (oCSP)" and cesarean scar ectopic pregnancy (CSeP), distinguishes the clinical presentation and risk stratification. While all CSPs carry risk, this not only will make the reporting to permit some shared decision-making for expectant management of oCSP, but also will better inform the patient of the potential risk and the treatment for CSeP depending on which end of the spectrum the cesarean scar pregnancy was found.

Accumulating evidence suggests that cesarean scar implantation represents the earliest manifestation of placenta accreta spectrum (PAS) disorders, reflecting a continuous pathophysiologic process rather than distinct clinical entities. This article examines data supporting cesarean scar pregnancy as a precursor to a substantial proportion of PAS, particularly after cesarean delivery, and advocates for unified clinical approaches to these conditions. The global rise in cesarean deliveries has triggered parallel increases in PAS disorders, characterized by abnormal placental attachment at sites of myometrial scarring where regulatory decidual mechanisms are absent. Histopathologic studies demonstrate that cesarean scar implantation and PAS are often indistinguishable, likely representing different developmental stages of the same condition, with up to 70% of expectantly managed cesarean scar pregnancies progressing to PAS at delivery. First-trimester ultrasound enables early identification of high-risk pregnancies through the use of several cesarean scar pregnancy classification systems, including the crossover sign, which categorizes cesarean scar pregnancies based on the position of the gestational sac relative to the endometrial line. Additional classifications distinguish between "on-the-scar" and "in-the-niche" implantation and implantation position relative to the uterine midline in the transverse plane. These parameters predict PAS severity and outcomes. Despite compelling evidence connecting cesarean scar pregnancy and PAS, most literature focuses on them as separate entities, resulting in fragmented clinical approaches. Here, we propose framing the cesarean scar pregnancy as an early manifestation of PAS. Equipped with an appreciation of the natural history of PAS, we recommend targeted screening for women with prior cesarean delivery, uterine surgery, previous cesarean scar pregnancy, or suspected early pregnancy loss, with critical screening windows at 5-7 and 11-14 weeks of gestation. Early identification and risk stratification enable individualized management decisions through shared decision making to reduce maternal morbidity from unanticipated uterine rupture, hemorrhage, and fertility loss. Recognizing cesarean scar pregnancy as the earliest detectable manifestation of PAS transforms management from reactive to proactive risk mitigation and fertility-sparing approaches, potentially improving outcomes and reducing PAS-associated health care burdens worldwide.

Background Cesarean scar pregnancy (CSP) is a form of abnormal implantation in which the gestational sac embeds within the myometrial defect of a previous cesarean incision. Its incidence is rising in parallel with increasing cesarean delivery rates. Emerging evidence indicates that CSP and placenta accreta spectrum (PAS) share common histopathological and sonographic characteristics, supporting the concept that CSP represents an early phenotype within the PAS. Objective To synthesize current evidence on the diagnosis, classification and management of CSP and to clarify the biological and clinical continuum linking CSP with PAS, with emphasis on early prediction and reproductive implications. Results Early first-trimester targeted transvaginal ultrasonography, including assessment of residual myometrial thickness, implantation site, vascularity and standardized classification systems, remains central to diagnosis and risk stratification. Surgical approaches that incorporate scar resection via laparoscopy, laparotomy or transvaginal techniques demonstrate the highest success and lowest recurrence rates, as excision of scar tissue restores myometrial integrity. Other modalities such as suction curettage, hysteroscopy, local methotrexate, uterine artery embolization, balloon tamponade and high-intensity focused ultrasound show variable effectiveness depending on gestational age and CSP subtype. Expectant management may result in live birth, but it carries substantial risk because PAS develops in up to 80% of ongoing pregnancies and severe hemorrhage and hysterectomy are common. Shared pathological findings such as deficient decidualization, myometrial disruption and abnormal uteroplacental vascular remodeling support the concept that CSP and PAS represent a unified pathological spectrum rather than distinct entities. Conclusion CSP may represent an early phenotype within the PAS. Standardized terminology, early first-trimester screening and risk-based management strategies are essential to reduce maternal morbidity and optimize reproductive outcomes. Multicenter prospective studies are needed to guide evidence-based prevention and treatment strategies.

Development of the utero-placental circulation in cesarean scar pregnancies: a case-control study

Cesarean scar pregnancy: a therapeutic dilemma.

Abstract: Placenta accreta spectrum (PAS) disorders, also known as morbidly adherent placenta (MAP) include anomalous adherence of the placenta to implantation location. : PAS could be classified into 3 categories based on the penetration distance of trophoblasts via the myometrium and serosa of the uterus into placenta accreta, increta, and percreta. : A recent study in 2020 showed that using the introduced model based on 3 parameters; uterovesical vascularity, unusual lacunae (grades 2 and 3), and bladder wall interruption, has 100% accuracy in the diagnosis of PAS. : Accurate diagnosis of morbidly adherent placenta (MAP), helps in multidisciplinary team management at delivery, with better maternal and neonatal outcomes. : PAS could be suspected early in pregnancy by recognizing women with doubted Cesarean scar pregnancy (CSP) because CSP in the first trimester and PAS in the second and third trimesters might denote various stages of a similar pathology. : Gray scale US with or without adding color Doppler and made by transabdominal or trans vaginal route are commonly utilized for prenatal screening and diagnosis of PAS. : In a recent study made by Alalfy et al. in 2021 they revealed the systematic combined approach with the use of Alalfy Simple Criteria for assessment of placenta previa and PAS using 3D TUI (Tomographic Ultrasound Imaging and 3D power Doppler has a high diagnostic value in the diagnosis of PAS from the non-adherent placenta, the estimation of the myometrial thickness and the depth of placental invasion with the determination of different PAS subgroup plus defining diffuse from focal invasion (Figs. 1 and 2).

Subsequent pregnancy outcomes and risk factors following conservative treatment for placenta accreta spectrum: a retrospective cohort study

To summarize the current knowledge on pregnancy in a cesarean scar. A literature review on the topic using the PubMed database. Gravidity in a cesarean scar is a relatively new type of ectopic pregnancy that will be an increasingly common problem in an era of increasing cesarean section rates. It is still a relatively rare event, occurring in about 6% of the population. Diagnosis is based primarily on ultrasound examination and is essential early on in pregnancy. The pathogenesis of the disease is due to a disorder of the basal layer of the endometrium and can lead to conditions that we refer to as placenta accreta spectrum. The management is completely individualized and depends on hCG values, ultrasound findings, fetal viability, the wishes of the pregnant woman and the experience of the gynecologist concerned. This is still a rare occurrence of ectopic pregnancy but with increasing potential. The solution is completely individualized based on a precise and early ultrasound diagnosis.

Expectant management of cesarean scar pregnancy (CSP) in patients who refuse termination of pregnancy and continue with placenta accreta spectrum (PAS) is possible with multidisciplinary care and careful monitoring in a tertiary care center. Doctors with the relevant expertise in managing PAS use highly accurate ultrasound as a tool to diagnose, monitor, and manage this disorder, which enables them to determine appropriate surgical strategies and techniques to achieve optimum maternal and fetal outcomes with minimal blood loss and no major maternal mortality and morbidity. In this study, we aim to evaluate expectant management in such patients. This is a retrospective study of 10 patients with a previous history of a uterine scar. Diagnosed with CSP in the first trimester, they refused to terminate their pregnancy and continued with PAS. We studied them over a period of four years from 2018 to 2022 and managed them at Latifa Hospital, Dubai, UAE. Of the 10 patients, nine delivered in the third trimester (around 34 weeks gestation), seven underwent elective surgery, and three underwent emergency surgery. Four patients were exogenous cases and six were endogenous cases at diagnosis during early gestation. Seven patients had a cesarean hysterectomy, and three (with focal placenta accreta) had uterine wall reconstruction surgery. Four patients needed blood transfusions. The average duration of surgery was between 2.5 and 5 hours. There were no miscarriages, no maternal and neonatal deaths, and no significant obstetric complications such as rupture of the uterus or major obstetric hemorrhage. Even though CSP is a potentially life-threatening condition because of serious complications such as PAS if continued, expectant management is possible under multidisciplinary care where the team strictly adheres to clinical protocols and accurate surgery to reduce obstetric hemorrhage.

Approximately two-thirds of the patients with a cesarean scar pregnancy (CSP) will develop placenta accreta spectrum (PAS). PAS occurs when the placenta attaches too deeply to the uterine wall, and sometimes, the placenta can extend beyond the uterus, invading surrounding organs. PAS is commonly managed with a cesarean hysterectomy, and these deliveries are often complicated by maternal and fetal morbidity and mortality. However, delaying hysterectomy and using chemotherapeutic agents may be a safe and beneficial alternative. We describe the case of a 32 -year-old G3P2002 with a history of two prior cesarean sections (CS) who was referred to our Maternal Fetal Medicine department due to the concern of a gestational sac embedded in the anterior uterine wall in the cesarean scar. Magnetic resonance imaging (MRI) findings at 33 weeks confirmed that the patient had developed placenta percreta extending into the sigmoid colon. We also describe the case of a 30-year-old G6P4104 with a history of four prior CS who was referred to our department for concern of a pregnancy complicated by CSP. This patient had an MRI performed at 23 weeks that showed placenta percreta invading the bladder. Patients one and two were managed with a staged procedure, with CS followed by a delayed laparoscopic and abdominal hysterectomy, respectively, to minimize bowel and bladder injury. After the CS, the patients subsequently received a five-day course of intravenous (IV) etoposide 100mg/m2, and at six weeks postpartum, the patients had a hysterectomy, both showing resolution of the placenta invasion into the surrounding organs on postpartum MRI and confirmed by tissue pathology reports. Our cases present the challenge in diagnosis and management of the most severe presentation of PAS that varies from the generally accepted management recommendations. Delayed hysterectomy with chemotherapy can be a reasonable, conservative surgical approach in the most severe types of PAS. As in our cases, this management could improve maternal and fetal morbidity and mortality.

How to Reduce the Incidence of Placenta Accreta Spectrum Independently of the Number of Cesarean?

Successful management of cesarean scar pregnancy progressive to placenta accreta spectrum: An uncommon condition in Vietnam and mini-review of the literature.

To evaluate subsequent reproductive among women with a prior cesarean scar pregnancy (CSP). MEDLINE, Embase and ClinicalTrials.gov databases were searched. Inclusion criteria were women with a prior CSP, defined as the gestational sac or trophoblast within the dehiscence/niche of the previous cesarean section scar or implanted on top of it. The primary outcome was the recurrence of CSP; secondary outcomes were the chance of achieving a pregnancy after CSP, miscarriage, preterm birth, uterine rupture and the occurrence of placenta accreta spectrum disorders. Subgroup analysis according to the management of CSP (surgical vs non-surgical) was also performed. Random effect meta-analyses of proportions were used to analyze the data. Forty-four studies (3598 women with CSP) were included. CSP recurred in 17.6% of women. Miscarriage, preterm birth and placenta accreta spectrum disorders complicated 19.1% (65/341), 10.3% (25/243) and 4.0% of pregnancies, and 67.0% were uncomplicated. When stratifying the analysis according to the type of management, CSP recurred in 21% of women undergoing surgical and in 15.2% of those undergoing non-surgical management. Placenta accreta spectrum disorders complicated 4.0% and 12.0% of cases, respectively. Women with a prior CSP are at high risk of recurrence, miscarriage, preterm birth and placenta accreta spectrum. There is still insufficient evidence to elucidate whether the type of management adopted (surgical vs non-surgical) can impact reproductive outcome after CSP. Further large, prospective studies sharing an objective protocol of prenatal management and long-term follow up are needed to establish the optimal management of CSP and to elucidate whether it may affect its risk of recurrence and pregnancy outcome in subsequent gestations.