Cesarean Scar Research Articles

Predictive value of crossover sign for outcome of ultrasound-guided vacuum aspiration in women with Cesarean scar pregnancy.

To examine the value of the crossover sign (COS) in predicting treatment outcome in women with a Cesarean scar pregnancy (CSP) who were treated with ultrasound-guided vacuum aspiration. This was a retrospective cohort study of women with CSP who underwent ultrasound-guided vacuum aspiration. Based on the relationship between the gestational sac, Cesarean scar and anterior wall of the uterus, CSPs were classified by COS type. Analysis was conducted to investigate the association between COS type (COS-1, COS-2) and treatment outcome. The incidence of treatment failure, retained pregnancy tissue, secondary therapy and bleeding ≥ 200 mL were analyzed. In total, 181 eligible patients with CSP, including 90 (49.7%) women with COS-1 and 91 (50.3%) women with COS-2, were analyzed. COS-1 patients had a higher incidence of treatment failure compared with COS-2 patients (25.6% vs 8.8%; P = 0.003), as well as higher rates of retained pregnancy tissue (18.9% vs 6.6%; P = 0.013), secondary therapy (20.0% vs 6.6%; P = 0.002) and bleeding of ≥ 200 mL (13.3% vs 4.4%; P = 0.034). COS-1 and a large gestational sac (30.1-50.0 mm or >50.0 mm in diameter) were associated independently with increased risk of treatment failure (odds ratio, 4.57 (95% CI, 1.66-12.56); P = 0.003, 4.34 (95% CI, 1.35-13.94); P = 0.014 and 10.50 (95% CI, 2.54-43.46); P = 0.001, respectively). Ultrasound evaluation of the relationship between the gestational sac and the endometrial line (COS classification) in women with CSP may help to predict treatment outcome among those undergoing vacuum aspiration. Among COS-1 patients, especially those with a gestational sac diameter of >30.0 mm, vacuum aspiration may be discouraged. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Ultrasonography Findings in Post-Methotrexate Treatment of Cesarean Scar Pregnancy

Background: Cesarean scar pregnancy (CSP) can cause life-threatening complications for pregnant women, so early diagnosis and treatment are crucial for the prevention of maternal mortality. Transvaginal color Doppler ultrasonography, along with serum beta-human chorionic gonadotropin (β-hCG) level follow-up, can be a noninvasive and proper method for the post-treatment follow-up of a CSP. The present study investigated the Doppler resistance index (RI) changes in CSPs after medical management with methotrexate (MTX), evaluated by sac diameter and serum β-hCG level measurement. Methods: Overall, 28 patients with CSP and a history of previous cesarean delivery, a gestational age of less than 9 completed weeks at ultrasonography, the decision to medical management by the gynecologist, and having a β-hCG level before treatment were enrolled and initially examined by ultrasound and Doppler studies. The RI of the closest myometrial artery to the CSP mass and its diameter underwent measurement. After 72 hours, 1 week, and 2 weeks of medical therapy with MTX, the mentioned variables were measured again and compared with the values of the pretreatment time point. Results: RI values were significantly higher at all the follow-up time points compared with the pre-treatment time points, while serum β-hCG levels were significantly lower. Moreover, sac diameter values increased 72 hours post-treatment and then represented a decline. Conclusion: Serial Doppler ultrasound examination can be a useful method to evaluate the success or failure of the medical management of CSPs, as the increase in RI values occurs rapidly after medical treatment and correlates well with serum β-hCG levels.

Transvaginal sonographic diagnosis of caesarean scar ectopic pregnancy: A case report

We report a case of scar ectopic pregnancy which is the rarest type of all ectopic pregnancies. We need to diagnose & treat this condition in the early weeks of pregnancy to avoid the complication. This case of Caesarean scar ectopic pregnancy (CSEP) was diagnosed during an antenatal ultrasound scan, at six weeks of pregnancy. An ultrasound scan of this case revealed the gestation sac in the lower uterine segment at the previous caesarean scar.

Characterising umbilical abdominal wall endometriosis as a distinct subgroup of abdominal wall endometriosis – retrospective cohort study

Abdominal wall endometriosis (AWE) is one of the rarest forms of endometriosis. Little is known about differences between umbilical AWE (U-AWE) and non-umbilical AWE (non-U-AWE) patients. This retrospective cohort study included patients treated for AWE at tertiary endometriosis centre between 2012 and 2020. Patients were divided into two groups – umbilical AWE and non-umbilical AWE. We identified 14 U-AWE and 45 non-U-AWE patients who mostly had lesions in caesarean section scar (38, 64.4%), rarely at other locations (7, 11.9%). Infertility rates for U-AWE patients and non-U-AWE patients were 57.1% and 17.8%, respectively. Concurrent or previous peritoneal endometriosis was noted in 85.7% of U-AWE and 24.4% of non-U- AWE patients. In addition, U-AWE patients and non-UAWE patients significantly differed in following: parity, number of previous caesarean sections, lesion size, prevalence of concurrent or previous deep infiltrating endometriosis, bleeding from abdominal wall, cyclic pain, continuous pain. Infertility and pelvic endometriosis were more prevalent in U-AWE patients. Our data suggests that U-AWE may be a specific marker for a patient highly prone to pelvic endometriosis and subsequent infertility. Findings suggests that clinician should consider comprehensive evaluation of U-AWE patients.

Pouch of sorrow: Undiagnosed isthmocele – presenting as secondary infertility of 11 years in a middle age female

In the past decade, the rate of cesarean sections has doubled leading to the more frequent occurrence of cesarean-related complications. Cesarean scar site diverticulum or isthmocele is one such complication that is defined as an outpouching of the anterior uterine wall at the cesarean scar site in continuity with the endometrial cavity, creating a wedge-shaped defect of variable depth. We report a case of a middle-aged female with secondary infertility for the last 11 years with one live issue 12 years back through a cesarean section at term. She had undergone an array of investigations for infertility for the past 5 years. She was diagnosed as having an isthmocele and managed with surgical repair of the defect at our hospital with subsequent assisted conception 8-month post-surgical repair. The importance of diagnosing a cesarean scar diverticulum cannot be understated not only because it is a surgically treatable cause of infertility but also because if such patients conceive, they may land in uterine rupture, placenta accreta, or scar ectopic pregnancy which can complicate into life-threatening situations.

Determinants Of Retained Placenta At Malinau Hospital, North Kalimantan

Malinau Regency health profile data in 2018 recorded 268 deliveries, and 38 cases (14.1%) of them experienced retained placenta. Factors that cause retained placenta are placenta previa, caesarean section scar, repeated curettage, age, history of manual placenta, anemia, history of surgery and parity. Remaining placental remains in the uterus can cause weakened contractions which can cause postpartum bleeding. The aim of this study was to determine the determinants of the incidence of retained placenta in Malinau District Hospital, North Kalimantan.This research uses design correlational research with cross sectional approach. Respondents are recruited using accidental Sampling techniques with a sample of 36 people. Independent variables were parity and history of retained placenta. The dependent variable is incidence of retained placenta. Statistical test results using chi square.The research results showed that the majority of mothers giving birth at Malinau District Hospital had high parity, namely 23 (63.9%). The majority of mothers giving birth at Malinau Regional Hospital had a history of placental retention, 21 (58.3%), and the majority of mothers giving birth at Malinau Regional Hospital experienced placental retention, namely 25 (69.4%). The results of data analysis show that the significance level is 0.000 < α = 0.005 so that H0 rejected and H1 Thus, it is accepted that there is a relationship between parity and a history of placental retention with the incidence of retention at Malinau Regional Hospital, North Kalimantan.The conclusion in this research is mothers who have a history retained placenta and high parity tend to have a risk of retained placenta in the next delivery

Laparoscopic Correction of Cesarean Scar Defects by Temporary Bilateral Uterine Artery Occlusion

Laparoscopic Correction of Cesarean Scar Defects by Temporary Bilateral Uterine Artery Occlusion

Curative effect of high‐intensity focused ultrasound in management of different types of ectopic pregnancy: A systematic review

AbstractEctopic pregnancy (EP) could be defined as any embryo that got implanted in any site rather than the endometrial cavity. Lately, different types of EP were reportedly managed by high‐intensity focused ultrasound (HIFU). We aimed to pool all available data in a systematic review without meta‐analysis and investigate the efficacy and safety tendencies of HIFU among different types of EP. We applied our comprehensive terms in Google Scholar, PubMed, Scopus, Ovid, and PubMed Central databases from their inception until September 23. Retrieved references were gathered using EndNote in which we omitted the duplicates and exported the record for screening. Data regarding characteristics, safety and efficacy outcomes, and baseline information of the enrolled population were extracted. The eligible case reports were assessed using a tool by Murad and colleagues, while the quality of the included cohorts was appraised using the NIH tool. We retrieved 6637 studies, which were scrutinized by titles and abstracts. We scrutinized the full texts of 36 studies and ultimately included a total of 17 studies. All studies were conducted in China, and on different types of ectopic pregnancy including tubal, cervical, intramural, caesarian scar, and corneal ectopic pregnancy. The mean age of enrolled patients was 33.03 years, and we pooled a total sample of 853 patients. The follow‐up period varied widely among the included studies, ranging from 1.3 months to up to 69 months. Normal menstruation recurred after a mean of 35 days, as reported by nine studies. Most of the included studies reported normal β‐HCG after around 30–40 days. Twelve studies with 757 patients reported a cumulative incidence of 179 cases of abdominal pain after HIFU. Neither of the enrolled patients reportedly complained of skin burn after HIFU. We suggested managing EP patients with HIFU, especially when seeking further conceiving. High‐quality randomized controlled trials are required to draw a stronger level of evidence.

Successful Management of Cesarean Scar Pregnancy in a Tertiary Care Hospital in North India: A Case Series

Successful Management of Cesarean Scar Pregnancy in a Tertiary Care Hospital in North India: A Case Series

The degree of risk factor and accumulation effect for large niche in individuals after cesarean section

BackgroundThe risk factors associated with niche on the cesarean scar have been reported, however, the degree of these factors associated with large niche and the accumulation effects of these risk factors on the development of large niche are unclear.MethodsLarge niche was evaluated by transvaginal sonography during mid-follicular phase. Logistic regression model was used to assess 32 risk factors by univariate analysis. Then, a scoring model based on the screened risk factors was generated. The performance of this model was evaluated by area under curve (AUC). Finally, the scoring model was applied in 123 women to assess the external validation.Result(s)In the training cohort study, 163 women were diagnosed with large niche. The final scoring model involves eight risk factors with the rating scores including age at delivery (30–34 years: 1 point; ≥ 35 years: 4.5 points), retroflexed uterus (8.5 points), meconium-stained amniotic fluid (4.5 points), twice CSs (4.0 points), postpartum endometritis (4.5 points), premature rupture of membranes (2.5 points), intrahepatic cholestasis of pregnancy (mild to moderate: 3 points; severe: 6.5 points), and cervical dilatation (1-3 cm: 2.0 points; 4-10 cm: 4.5 points). The accumulation effect with a cut-off value of 8.0 in the scoring was associated with the large niche after CS.Conclusion(s)This is the first scoring model to objectively quantify the risk of a large niche after CS. Optimal risk factors control by avoiding high score factors and multiple factors accumulation may eliminate the risk of large niche development.

Cesarean Scar Pregnancy: Results of Treatment Using a Double-Balloon Cervical Ripening Catheter.

Being considered a life-threatening condition, cesarean scar pregnancy (CSP) leads to loss of fertility, severe bleeding, and even maternal mortality. We intended to assess the effect of double-balloon cervical ripening catheter insertion on CSP termination before nine weeks of gestation. All participants were diagnosed CSP by abdominal and transvaginal ultrasound. The cases were treated with a sterile, double-balloon cervical ripening catheter inserted with real-time transabdominal ultrasound guidance and removed three days later. The control group consisted of patients treated with systemic methotrexate with or without fetal reduction. Thirty-five patients were eligible for double-balloon ripening and 32 for MTX therapy; the treatment in cases failed in five of the patients. Success rate difference between two methods was insignificant (Pearson Chi-square: 0.383, p-value: 0.536). There were significant differences regarding the time to normal menstruation (OR: 1.303) and the thickness of the myometrium after surgery (OR: 4.721), but there was no significant difference in the time resolve of either β-HCG or residue of pregnancy. Double-balloon cervical ripening insertion yields acceptable results for terminating CSP. This strategy does not cause bleeding and even prevents it with its tamponade properties. Additionally, this treatment is minimally invasive simple with low morbidity.

Advanced repair of recurrent and low-large hysterotomy defects using a myometrial glide flap

Background The resolution of factors linked to the recurrence of cesarean section defects can be accomplished through a comprehensive technique that effectively addresses the dehiscent area, eliminates associated intraluminal fibrosis, and establishes a vascularized anterior wall by creating a sliding myometrial flap. Objective Propose a comprehensive surgical repair for recurrent and large low hysterotomy defects in women seeking pregnancy or recurrent spotting. Study design A retrospective cohort analysis included 54 patients aged 25–41 with recurrent large cesarean scar defects treated at Otamendi, CEMIC, and Valle de Lili hospitals. Comprehensive surgical repair was performed by suprapubic laparotomy, involving a wide opening of the vesicouterine space, removal of the dehiscent cesarean scar and all intrauterine abnormal fibrous tissues, using a glide myometrial flap, and intramyometrial injection of autologous platelet-rich plasma. Qualitative variables were determined, and descriptive statistics were employed to analyze the data in absolute frequencies or percentages. The data obtained were processed using the InfostatTM statistic program. Results Following the repair, all women experienced normal menstrual cycles and demonstrated an adequate lower uterine segment thickness, with no evidence of healing defects. All patients experienced early ambulation and were discharged within 24 h. Uterine hemostasis was achieved at specific points, minimizing the use of electrocautery. The standard duration of the procedure was 60 min (skin-to-skin), and the average bleeding was 80–100 ml. No perioperative complications were recorded. A control T2-weighted MRI was performed six months after surgery. All patients displayed a clean, unobstructed endometrial cavity with a thick anterior wall (Median: 14.98 mm, IQR 13–17). Twelve patients became pregnant again, all delivered by cesarean between 36.1 and 38.0 weeks, with a mean of 37.17 weeks. The thickness of the uterine segment before cesarean ranged between 3 and 7 mm, with a mean of 3.91 mm. No cases of placenta previa, dehiscence, placenta accreta spectrum (PAS), or postpartum hemorrhage were reported. Conclusions The comprehensive repair of recurrent low-large defects offers a holistic solution for addressing recurrent hysterotomy defects. Innovative repair concepts effectively address the wound defect and associated fibrosis, ensuring an appropriate myometrial thickness through a gliding myometrial flap.

Differential Diagnostic Value of Two-dimensional Ultrasound Combined with Three-dimensional Ultrasound Imaging Technology for Cesarean Scar Pregnancy.

Cesarean scar pregnancy (CSP) refers to the phenomenon in which a fertilized egg implants and develops in the scar of the uterus in a woman with a history of cesarean section. The study aimed to explore the differential diagnostic value of two-dimensional ultrasound (2D US) combined with three-dimensional ultrasound (3D US) for CSP. Clinical data of 89 patients with CSP admitted to our hospital from January 2022 to January 2023 were retrospectively analyzed. Of them, 65 patients met the inclusion criteria. Patients underwent 2D US, 3D US, and combined 2D and 3D US imaging. Using the clinical pathological diagnosis as the "gold standard", the differential diagnostic value of 2D US, 3D US, and 2D US combined with 3D US for CSP was compared. The detection rate of CSP using a combined 2D US and 3D US was 98.46%, which was higher than 84.62% and 89.23% achieved with 2D US and 3D US alone, respectively (P<0.05). The pathological results showed that among 65 patients, CSP type I accounted for 24.62%, type II accounted for 55.38%, and type III accounted for 20.00%. The coincidence rate of 2D US combined with 3D US was 98.46%, which was higher than that of 2D US (83.08%) and 3D US 89.23%) alone (P<0.05). The accuracy, specificity, and sensitivity of 2D US combined with 3D US in diagnosing CSP were higher compared to the two methods alone (P<0.05). The combination of 2D US and 3D US can accurately detect and classify CSP, further improving diagnostic efficiency.

Postcesarean disasters – Isthmocele, ventrofixed uterus, and cesarean scar pregnancy: A case series

Abstract Isthmocele is a niche defect in the area of previous cesarean scar. It is any indention representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity at the site of the previous cesarean section (CS) scar. Ventrofixed uterus is an adhesion between anterior surface of uterus and anterior abdominal wall secondary to Caesarean section. Cesarean scar pregnancy (CSP) pregnancy at a scar site is trouble either causing scar rupture or placenta accreta syndrome. Here are the seven cases of having a problem of isthmocele or ventrofixed uterus or both. All these cases had previous CS done at peripheral hospitals. The intension of this case series is to study preoperative symptoms, clinical and investigation findings, intraoperative presentation, and challenges with postoperative recovery in cases of previous CS-related problems. All these cases presented with us post-CS either lower abdominal pain, intermenstrual spotting, menorrhagia, or secondary infertility, and one had emergency abdominal pain with pregnancy. On hysteroscopy, a large niche at CS scar with trenches was detected in five cases, and on laparoscopy, ventrofixed uterus in five cases, and four cases have both. One has multiple fibroids, one has associated ventrofixed ovarian endometrioma. One case has ruptured CSP. After corrective hysterolaparoscopy surgery, all patients recovered well. Hysterolaparoscopic corrective surgery is a real need and challenge in cases of symptomatic ventrofixed uterus and isthmocele. The incidence and prevalence of isthmocele are greater than most gynecologists realize. It is imperative to understand the etiology and adopt preventive measures during CS to reduce its incidence and also to reduce the incidence of CSP.

Clinical Application of a New Cesarean Scar Pregnancy Classification and Evaluation System and a Risk Scoring System.

Cesarean scar pregnancy (CSP) is an uncommon form of ectopic pregnancy that carries the risk of severe bleeding. To date, there has not been a universally accepted classification and treatment strategy. We performed this study to establish a risk scoring system and new CSP classification system for CSP and evaluate its efficacy. A total of five groups were generated based on different methods of treatment, and the factors that increase the risk of intraoperative bleeding were examined in our center from 2013 to 2018. The construction of a risk scoring system in this study was based on the use of the chi-square test and multivariate logistic regression analysis. To determine the appropriate cutoff scores, receiver operating characteristic (ROC) curves and the area under the curve (AUC) were generated. We identified the main high-risk factors for excessive intraoperative hemorrhage during CSP surgery through univariate and multivariate analyses. Within this investigation, the risk factors included gestational sac location and gestational sac diameter. Through analysis, an optimal cutoff score of 3 was determined, and the area under the ROC curve was calculated to be 0.8113 (95% CI=0.7696-0.8531). A score ranging from 0-3 was classified as low risk, while a score ranging from 5-7 was classified as high risk. Additionally, a new classification system for CSP has been established based on sonographic parameters. We also established a diagnostic and treatment process for CSP patients according to the risk scoring method and new CSP classification. We identified the high-risk factors associated with bleeding during CSP surgery and developed a scoring system incorporating these factors. The utilization of this novel CSP typing method, in conjunction with the risk scoring system, can effectively inform doctors in their decision-making process concerning treatment strategies for patients with CSP.

Report and Literature Review on Type III Cesarean Scar Pregnancy Tissue Resection and Scar Defect Repair Surgery

Report and Literature Review on Type III Cesarean Scar Pregnancy Tissue Resection and Scar Defect Repair Surgery

Endometriosis at the level of uterine isthmocele: Case report

An isthmocele is a reservoir-type defect in the fornix of the cul-de-sac in the anterior wall of the isthmus at the site of the previous cesarean scar. It’s appearance is related to the accumulation of menstrual blood flow through the cervix and with the presence of fibrotic tissue and pelvic pain. We present the case of a 33-year-old patient, with a history of a cesarean section 2 years ago, who presents for preconceptional counseling complaining of abnormal uterine bleeding and dysmenorrhea since surgery. In imaging studies, she was diagnosed with uterine isthmocele, with minimal remaining tissue, a combined hysteroscopic and laparoscopic repair was performed. Endometriosis was identified in the istmocele scar tissue.

Scar Endometriosis After Cesarean Section; Our Clinical Experiences, 32 Cases of Cesarean Scar Endometriosis

Scar Endometriosis After Cesarean Section; Our Clinical Experiences, 32 Cases of Cesarean Scar Endometriosis

Emergency Bilateral Internal Iliac Artery Ligation in Antepartum Haemorrhage with Complete Placenta Previa and Placenta Accreta at Previous Caesarean Scar Site: A Case Report

Implantation and placentation at the normal site are critical for a successful pregnancy. Many complications associated with pregnancy, which manifest late in pregnancy, such as preeclampsia and preterm labour, have been reported to have origins early during pregnancy with abnormalities in implantation and placental development. Placental abnormalities result from impaired embedding of the placenta in the endometrium, encompassing a wide range of placental pathologies associated with high maternal morbidity and mortality. Pregnancy-related complications such as Postpartum Haemorrhage (PPH) and hysterectomy have been closely linked to the Placenta Accreta Spectrum (PAS). PAS refers to the aberrant and invasive implantation of the placenta into the myometrium. Invasiveness in placenta accreta is marginal, followed by placenta increta (partial), placenta percreta (total), and placenta previa (covering the cervix). Here, the authors present a unique case report of an antenatal woman with antepartum haemorrhage, placenta previa, and placenta accreta at the previous Lower Segment Caesarean Section (LSCS) scar site, with massive PPH at 35 weeks, who benefited from an emergency LSCS with bilateral uterine and internal iliac artery ligation procedure, resulting in a life-saving outcome. The most common risk factors for PAS include prior caesarean section and curettage. The adhered placenta can lead to pelvic bleeding and necessitate an emergency hysterectomy. Therefore, it poses unique diagnostic and treatment issues, with the majority of cases requiring preterm termination of pregnancy.

Outcomes of Laparoscopic Approach to Cesarean Scar Pregnancy (CSP).

Cesarean scar pregnancy (CSP) is a rare long-term complication after cesarean delivery. In clinical practice, its diagnosis and management is very important because it may be associated with serious consequences. Although a wide range of treatment options have been reported, the best treatment is unrecognized yet. This study aimed to evaluate the outcomes of laparoscopy in CSP. This non-randomized single-arm clinical trial was conducted on 43 CSP patients who were referred to the educational and medical centers of Isfahan University of Medical Science from 2021 to 2022. All the patients were treated by laparoscopy, and during follow-up, the pregnancy test was measured weekly until the test was negative, and an ultrasound was performed 6 months later. Myometrial thickness and occurrence of isthmocele were checked and recorded. Abnormal uterine bleeding or pelvic pain were also evaluated 6 months later. Mean time of surgery was 55.12 ± 10.61 minutes, and the rate of intraoperative bleeding was 62.93 ± 24.00 cc. Four cases had excess intraoperative bleeding: two of them received packed cells, and two led to laparotomy. After surgery, the time to negative pregnancy test was 19.21 ± 5.50 days and 4 (10.3%) patients had isthmocele in follow-up sonography. Human chorionic gonadotropin hormone (BHCG) decreased significantly after surgery (percentage reduction: 97.71 ± 3.80; P value < 0.001) and myometrial thickness increased significantly (percentage increase: 46.94 ± 28.66; P value < 0.001). Laparoscopic excision of a CSP is an effective and feasible technique with the advantage of an immediate myometrial reconstruction.