Cesarean Scar Pregnancy Research Articles

The effectiveness of hysteroscopy for the treatment of cesarean scar pregnancy: a retrospective cohort study

BackgroundCesarean scar pregnancy (CSP) is a long-term complication of cesarean section characterized by the localization of a subsequent gestational sac within the scar area or niche developed as a result of a previous cesarean section. Its incidence has increased substantially because of the high global cesarean section rate in recent decades. Several surgical and drug treatments exist for this condition; however, there is currently no optimal treatment. This study compared the effectiveness of direct hysteroscopic removal of the gestational tissue and hysteroscopy combined with vacuum suction for the treatment of CSP.MethodsFrom 2017 to 2023, 521 patients were diagnosed with CSP at our hospital. Of these patients, 45 underwent hysteroscopy. Among them, 28 underwent direct hysteroscopic removal (hysteroscopic removal group) and 17 underwent hysteroscopy combined with vacuum suction (hysteroscopic suction group). The clinical characteristics and outcomes of the hysteroscopic removal group and hysteroscopic suction group were analyzed.ResultsAmong the 45 patients, the amount of bleeding and hospitalization cost were significantly higher in the hysteroscopic removal group than in the hysteroscopic suction group (33.8 mL vs. 9.9 mL, P < 0.001; and 8744.0 yuan vs. 5473.8 yuan, P < 0.001; respectively). The operation time and duration of hospitalization were significantly longer in the hysteroscopic removal group than in the hysteroscopic suction group (61.4 min vs. 28.2 min, P < 0.001; and 3.8 days vs. 2.4 days, P = 0.026; respectively). Three patients in the hysteroscopic removal group had uterine perforation and received laparoscopic repair during operation. No complications occurred in the hysteroscopic suction group. One patient in the hysteroscopic removal group received ultrasound-guided suction curettage due to postoperative moderate vaginal bleeding, and one patient in the hysteroscopic suction group received ultrasound-guided suction curettage due to postoperative gestational residue and elevated serum beta-human chorionic gonadotropin levels. Reproductive function was preserved in all patients.ConclusionsHysteroscopy is an effective method for treating CSP. Compared with direct hysteroscopic removal, hysteroscopy combined with vacuum suction is more suitable for CSP. However, multicenter prospective studies with large sample sizes are required for verification of these findings.

Surgical evacuation combined with Shirodkar cervical suture and selective uterine artery embolization: A fertility preserving treatment for 10-15 weeks' live cesarean scar ectopic pregnancies.

Cesarean scar ectopic pregnancies (CSEPs) are associated with significant maternal morbidity and termination is often recommended in the early first trimester. Management of more advanced cases is challenging due to higher risks of major intraoperative hemorrhage. Hysterectomy is currently the intervention of choice for advanced cases. This study aimed to investigate if advanced live CSEPs could be managed effectively conservatively using suction curettage and interventional radiology. A retrospective single-center cohort study was performed. A total of 371 women diagnosed with CSEP were identified between January 2008 and January 2023. A total of 6% (22/371) women had an advanced live CSEP with crown-rump length (CRL) of ≥40 mm (≥10 weeks' gestation). Of these, 77% (17/22) opted for surgical intervention, whilst the remaining five continued their pregnancies. A preoperative ultrasound was performed in each patient. All women underwent suction curettage under ultrasound guidance and insertion of Shirodkar cervical suture as a primary hemostatic measure combined with uterine artery embolization (UAE) if required. The primary outcome was rate of blood transfusion. Secondary outcomes were estimated intraoperative blood loss, UAE, intensive care unit admission, reintervention, hysterectomy, hospitalization duration and rate of retained products of conception. Descriptive statistics were used to describe these variables. Median CRL of the 17 patients included was 54.1 mm (range: 40.0-85.7) and median gestational age based on CRL was 12 + 3 weeks (range: 10 + 6-15 + 0). On preoperative ultrasound scan placental lacunae were recorded in 76% (13/17) of patients and color Doppler score was ≥3 in 67% (10/15) of patients. At surgery, Shirodkar cervical suture was used in all cases. It was successful in achieving hemostasis by tamponade in 76% (13/17) of patients. In the remaining 24% (4/17) patients tamponade failed to achieve complete hemostasis and UAE was performed to stop persistent arterial bleeding into the uterine cavity. Median intraoperative blood loss was 800 mL (range: 250-2500) and 41% (7/17) women lost >1000 mL. 35% (6/17) needed blood transfusion. No women required hysterectomy. Surgical evacuation with Shirodkar cervical suture and selective UAE is an effective treatment for advanced live CSEPs.

Ultrasound-guided suction curettage followed by cervico-isthmic placement of foley threeway catheter for cesarean scar pregnancy's treatment. Retrospective study

ObjectivesCesarean scar pregnancy (CSP) is a rare dangerous condition with still no consensus on standard treatment. Suction curettage has been used as the first-line treatment for CSP with controversial outcomes. This study evaluates efficacy of ultrasound-guided suction curettage (UGSC) followed by cervical-isthmic placement of silicon semirigid three-way foley catheter. Materials and methodsThis study included 24 women with CSP. Preoperative ultrasound study was conducted. UGSC followed by placement of catheter was performed in all patients. The success rate and incidence of major complication, surgical time and hospital stay were recorded. ResultsThe success rate of UGSC followed by placement of foley catheter was 100 %, effectively reduced major complications and none of the patients had a blood loss higher than 900 ml. Median hospital stay was 2 days and median foley stay was 1 day. Surgery had limited last with a median of 17 min. ConclusionUGSC followed by foley placement is a safe effective treatment for CSP with a clinical resolution of 100 %. The catheter is easy to place under ultrasound guidance and prevents bleeding, reducing major procedures to solve the bleeding. Suction curettage in CSP treatment should be performed under ultrasound guidance and followed by cervical-isthmic placement of foley balloon.

A skillful approach in a case of caesarean scar ectopic pregnancy

Key to a successful outcome in a rare life threatening condition like cesarean scar ectopic pregnancy is early diagnosis and treatment. The risk of massive haemorrhage can lead inevitably to a hysterectomy in past. The most effective method of treatment is not yet found. We report a case of a previous LCSC and one D&amp; E of 35-year-old female (G3P1A1L1) with 7 weeks of amenorrhea and vaginal bleeding. A gestational sac with an embryo in the cesarean scar canal was seen on ultrasonography. The fertility-sparing therapeutic strategy involved cesarean scar curettage to remove the trophoblastic under ultrasound.

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 &amp; 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.

Clinical and historical features of cesarean scar pregnancies in a tertiary hospital with a high rate of cesarean section: A case-control survey.

Cesarean scar pregnancy (CSP) is a rare medical condition accounting for 1:2000 of all pregnancies with prior history of cesarean deliveries (CS). As the rate of CS is increasing worldwide, it is important to know the nature of CSP and its complications. In this retrospective case-control study, we evaluated 264 pregnant women; 86 cases with ultra-sonographic findings of CSP and 178 controls: normal pregnancies with gestational age less than 12 weeks. The variables consisted of demographic characteristics, the features and causes of the prior CS, the time distance to the current pregnancy, sonographic features, and the final management. All data analyzed using SPSS version 21. There was a significant difference between the two study groups regarding to parity, abortions and D&Cs (p < 0.001). In the case group, 19.8% of patients had positive results for STDs versus 16.3% in the control group (p > 0.990). The mean average of intervals between the last CS and current pregnancies were 48.22 ± 37.03 in the case group versus 61.25 ± 36.25 months in the control group (p < 0.001). Regression Logistic analysis showed advanced maternal age (p < 0.001), positive history of abortions and D&C (p < 0.001), elective type of prior c/s (p < 0.001) and the short time interval between prior CS and current pregnancy (p < 0.001) could significantly predict the patients at higher risk of presenting CSP in the case group. Based on our findings, advanced maternal age, positive history of abortion, the elective type of the former CS, and short time intervals between previous CS and current pregnancy are the main risk factors of CSP.

Factors affecting blood loss during hysteroscopy due to cesarean scar pregnancy

Factors affecting blood loss during hysteroscopy due to cesarean scar pregnancy

Non-tubal ectopic pregnancy treatment experiences of a tertiary care center.

To evaluate the incidence, the risk factors, and the treatment outcomes of Non-tubal ectopic pregnancies (NTEP) treated in a tertiary care center. A total of 110 NTEP cases treated between 2014 and 2019 were included in the retrospective study. The study cohort was divided into 6 groups according to the pregnancy localization: 87 cesarean scar pregnancies (CSPs), 7 ovarian pregnancies, 6 interstitial pregnancies, 4 rudimentary horn pregnancies, 4 abdominal pregnancies, and 2 cervical pregnancies. One woman rejected all treatment modalities. Demographic characteristics, treatment modalities, and outcomes of each group were evaluated. In the study cohort, expectant management was performed in one (0.9%) woman. The methotrexate (MTX) treatment was administered in 29 (26.3%) women. Seventeen (15.4%) women underwent surgery, and 63 (57.2%) women underwent manual vacuum aspiration (MVA). A woman rejected all treatment modalities. Although 70.1% (n = 61) of CSPs were cured with MVA, 24.1% (n = 21) of them were treated with a single-dose MTX regimen in addition to MVA. The higher mean gestational sac size (33,9 ± 12,96mm vs. 17,34 ± 9,87mm), the higher mean gestational week (8,43 ± 1,16w vs. 6,66 ± 1,49w), the presence of fetal heartbeat (FHB) (90.5% vs. 26,2%) and the history of pelvic ınflammatory disease (PID) (38.1% vs. 6,6%) were found in the CSPs with MVA treatment failure (p < 0.05). The management of NTEPs should be individualized according to the clinical and ultrasonographic findings. The size of the ectopic pregnancy mass, the gestational week, the presence of FHB, and the PID history were the predictive factors for the failure of MVA in CSP cases.

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

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.

Predicting intraoperative hemorrhage during curettage treatment of cesarean scar pregnancy using free-breathing GRASP DCE-MRI

ObjectiveTo explore the feasibility of the golden-angle radial sparse parallel (GRASP) dynamic magnetic resonance imaging (MRI) technique in predicting the intraoperative bleeding risk of scar pregnancy.MethodsA total of 49 patients with cesarean scar pregnancy (CSP) who underwent curettage and GRASP-MRI imaging were retrospectively selected between January 2021 and July 2022. The pharmacokinetic parameters, including Wash-in, Wash-out, time to peck (TTP), initial area under the curve (iAUC), the transfer rate constant (Ktrans), constant flow rate (Kep), and volume of extracellular space (Ve), were calculated. The amount of intraoperative bleeding was recorded by a gynecologist who performed surgery, after which patients were divided into non-hemorrhage (blood loss ≤ 200 mL) and hemorrhage (blood loss > 200 mL) groups. The measured pharmacokinetic parameters were statistically compared using the t-test or Mann–Whitney U test with a significant level set to be p < 0.05. The receiver operating characteristic (ROC) curve was constructed, and the area under the curve (AUC) was calculated to evaluate each parameter’s capability in intraoperative hemorrhage subgroup classification.ResultsTwenty patients had intraoperative hemorrhage (blood loss > 200 mL) during curettage. The hemorrhage group had larger Wash-in, iAUC, Ktrans, Ve, and shorter TTP than the non-hemorrhage group (all P > 0.05). Wash-in had the highest AUC value (0.90), while Ktrans had the lowest value (0.67). Wash-out and Kep were not significantly different between the two groups.ConclusionGRASP DCE-MRI has the potential to forecast intraoperative hemorrhage during curettage treatment of CSP, with Wash-in exhibiting the highest predictive performance. This data holds promise for advancing personalized treatment. However, further study is required to compare its effectiveness with other risk factors identified through anatomical MRI and ultrasound.

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.

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.

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.

Analysis of Risk Factors for Intraoperative Bleeding in the Surgical Treatment of Cesarean Scar Pregnancy and Development of Predictive Models.

The objective of this study was to investigate the risk factors associated with cesarean scar pregnancy (CSP) and to develop a model for predicting intraoperative bleeding risk. We retrospectively analyzed the clinical data of 208 patients with CSP who were admitted to the People's Hospital of Leshan between January 2018 and December 2022. Based on whether intraoperative bleeding was ≥ 200 mL, we categorized them into two groups for comparative analysis: the excessive bleeding group (n = 27) and the control group (n = 181). Identifying relevant factors, we constructed a prediction model and created a nomogram. We observed that there were significant differences between the two groups in several parameters. These included the time of menstrual cessation (P = 0.002), maximum diameter of the gestational sac (P < 0.001), thickness of the myometrium at the uterine scar (P = 0.001), pre-treatment blood HCG levels (P = 0.016), and the grade of blood flow signals (P < 0.001). We consolidated the above data and constructed a clinical prediction model. The model exhibited favorable results in terms of predictive efficacy, discriminative ability (C-index = 0.894, specificity = 0.834, sensitivity = 0.852), calibration precision (mean absolute error = 0.018), and clinical decision-making utility, indicating its effectiveness. The clinical prediction model related to the risk of hemorrhage that we developed in this experiment can assist in the development of appropriate interventions and effectively improve patient prognosis.

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

146 A novel first-trimester ultrasound marker for cesarean scar pregnancy: the tadpole sign

146 A novel first-trimester ultrasound marker for cesarean scar pregnancy: the tadpole sign

Early diagnosis of caesarean scar pregnancy by ultrasound - a novel, simple and rapid clinical classification scoring system.

In the recent years, with the increase in the caesarean section rate, the incidence of caesarean scar pregnancy (CSP) has shown a significant upwards trend. We propose a novel, simple and rapid clinical and ultrasound (US) classification scoring system to assist in the early diagnosis of CSP. A total of 385 patients with CSP were included in the study. All patients were given a comprehensive score, iincluding clinical data (whether HCG is consistent with gestational age and vaginal bleeding) and US findings (linea a and b, gestational sac morphology, the presence of primitive cardiac tube beat, and color Doppler aspect). The scores were analysed by ROC curve analysis, and sensitivity and specificity were calculated. A score of 4 has a specificity of 91.7% and a sensitivity of 95.6% in diagnose CSP. The area under the ROC curve was 0.973. This scoring system may be a reliable tool for the early diagnosis of CSP and has the characteristics of being simple and rapid. For patients with a total score of ≥4 points, CSP is suggested, and early clinical treatment can be carried out, while patients with a score of less than 4 points can temporarily retain pregnancy and be closely followed up.

Cesarean Scar Ectopic Pregnancy: Experience From Benghazi Medical Center, 2022

Background: Cesarean scar pregnancy (CSP) is a rare consequence of a previous cesarean delivery and a new type of ectopic pregnancy, but it is life-threatening if unrecognized and inadequately managed. Despite the rising incidence of CSP, there are no consensus or evidence-based guidelines for management. Aims: To review risk factors, clinical features, diagnostic methods, and management of women with CSP at Benghazi Medical Center. Materials and methods: A descriptive-case series study of CSP cases between the Ist of March 2018 and Ist of April 2022.. Data collected retrospectively. The data included demographics, presenting symptoms and signs, ultrasound findings, treatment used, and any complications. Results: The total number of ectopic pregnancies in period between 1st March 2018 and 1st April 2022 was 262, ten women (3.82%) were diagnosed as scar ectopic, The women's ages ranged from 28 to 47 years, about 60% had three or four previous cesarean scars, abdominal pain with vaginal bleeding was in 30% of the cases, while 60% of patients were asymptomatic and all patients were stable during the diagnosis, except for one case that had signs of shock. ultrasound finding was 80% presence of gestational sac implanted low near the previous scar; initial diagnosis was delayed by 50%. The management was laparotomy and gestational sac excision in four cases that did not require further treatment, dilatation and uterine evacuation were done in two cases that required use of uterine balloon to control bleeding and further use of methotrexate In one case (10%), systemic methotrexate alone was effective. Severe bleeding was seen among 60% of women, and 20% underwent hysterectomy. The complications were significantly (P&lt; 0.05) more common among women with high parity and also in cases where there was no intervention during the diagnosis. Conclusion: A previous uterine scar is the main risk factor for CSP; there is no specific clinical feature for CSP; ultrasound is used for the diagnosis; surgical management appears to be a better option, serious complications were seen mainly when no intervention was done during the diagnosis.