Heterotopic Cesarean Scar Pregnancy Research Articles

First-trimester ultrasound diagnosis and risk factor analysis of cesarean scar pregnancy after in vitro fertilization-embryo transfer.

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.

Combined hysteroscopic Bigatti shaver (IBS) and resectoscope removal of a heterotopic cesarean scar pregnancy in the first trimester

To report a case of heterotopic cesarean scar pregnancy reduction using a combined hysteroscopic integrated Bigatti shaver (IBS) and resectoscope with the preservation of a normal gestational sac in the uterine cavity under simultaneous transabdominal ultrasound guidance. Video article. University-affiliated hospital. A 30-year-old woman, G5P2A2L2, with two previous cesarean deliveries and a history of fertility problems, was admitted with a heterotopic cesarean scar pregnancy at 7+2 gestational weeks. Ultrasound examination showed a dichorionic diamniotic pregnancy. The first gestational sac (1.7 × 1.7 × 0.6 cm) was located in the previous hysterotomy scars, with a thin layer of myometriummeasuring 0.2 cm in thickness and a rich blood supply. The second chorionic sac (2.8 × 2.4 × 1.8 cm) was observed at the uterine fundus. Normal cardiac activity and yolk sacs were observed in both gestational sacs. The couple strongly desired to preserve the intrauterine pregnancy. After Institutional Review Board approval was obtained, a hysteroscopic IBS combined with a bipolar resectoscope was used to remove the heterotopic cesarean scar pregnancy while preserving the intrauterine gestational sac under simultaneous transabdominal ultrasound guidance. The heterotopic cesarean scar pregnancy was completely resected using hysteroscopy, and the gestational sac in the uterine cavity was successfully preserved. Trophoblastic tissue was confirmed using histopathological examination. The patient had an unremarkable postoperative recovery. Subsequent serial ultrasonography confirmed a single ongoing pregnancy with normal growth parameters and a normal placental site. The inability of an IBS to perform coagulation can be offset by its combination with the bipolar resectoscope. Hysteroscopic IBS combined with resectoscope to remove a heterotopic cesarean scar pregnancy offers a short operation time and minimum blood loss. It could be an optimized approach for the management of heterotopic cesarean scar pregnancy in the first trimester when an intrauterine pregnancy needs to be preserved.

Laparoscopic removal of heterotopic cesarean scar pregnancy

ObjectiveTo present the laparoscopic management of heterotopic cesarean scar pregnancy and discuss other treatment options. DesignSurgical video article. The Institutional Ethics Committee approved the video reproduction. SettingTertiary referral university hospital PatientA 29-year-old woman with spontaneous heterotopic cesarean scar pregnancy presented for vaginal spotting. Ultrasound revealed two gestational sacs at 7 weeks and 6 days of gestation with fetal cardiac activity. One sac was in a normal intrauterine location and the other in a previous cesarean section scar. InterventionsScar pregnancy was excised laparoscopically while preserving intrauterine pregnancy. No additional measures were taken to reduce bleeding. The bladder was filled with 150 cc isotonic to determine its boundaries. The peritoneum was dissected away from the cervix. After removing the ectopic pregnancy material, the myometrial defect was excised. The uterine wall was closed in three layers using 2-0 V-LocTM sutures. Main outcome measuresOngoing intrauterine pregnancy after laparoscopic removal of cesarean scar pregnancy and term delivery. ResultsThe procedure was completed in 67 min. Total blood loss was <100 cc. Ongoing pregnancy follow-up was uneventful. Delivery was planned for the 37th-38th weeks. Although instructed to visit immediately after experiencing pain, the patient arrived after the 38th week and reported having pain for 2 days. During cesarean section, a rupture was observed at the previous incision site, which was fortunately incomplete. A healthy male baby (weight, 3210 g; Apgar score, 9/10) was delivered. ConclusionsThe most common approach for heterotopic scar pregnancy is embryo reduction with potassium chloride injection. However, the mass persists in the scar area, resulting in complications associated with excessive bleeding during cesarean section in approximately half cases. Moreover, almost all published cases of embryo reduction resulted in premature births before week 36. Considering the present case, laparoscopic surgery may be appropriate for managing heterotopic cesarean scar pregnancy by preserving intrauterine pregnancy.

Conservative surgical management of a heterotopic scar pregnancy: A case report

Introduction: The cesarean scar pregnancy is on rise and the objective of this case study is to highlight a different, bold but conservative approach to an unusual challenging case of eight weeks heterotopic cesarean scar pregnancy, which was threatening to rupture. Case Report: A 31-year-old G3P2L1 previous two cesarean sections presented with lower abdominal pain and bleeding. She was hemodynamically stable, and ultrasonography (USG) and magnetic resonance imaging (MRI) revealed heterotopic pregnancy, eight weeks (gestational sacs &gt; 32 mm) intrauterine and caesarean scar pregnancy, which was threatening to rupture. Since the scar pregnancy was large, BHcG was &gt; 200,000 iu, there was evidence of imminent scar dehiscence; and she was stable and had good blood parameters. The authors decided to take cautious but bold decision of suction evacuation under USG guidance, following the uterine artery embolism. The procedure was smooth and lower segment scar sacculus bleeding was controlled by compression with help of Foley’s balloons inside uterine cavity as well as in bladder. There was no evidence of extrauterine bleeding. She made a good post-operative recovery. Follow-ups consisted of serial BHcG and USG to monitor the regress. Conclusion: This case study implies that cesarean scar pregnancy, even with imminent scar dehiscence can be managed by USG-guided suction evacuation by experienced hands. Prior uterine artery embolization (UAE) added the safety of bleeding control. This case also emphasizes the importance of a patient monitoring and relying on failing BHcG, and a symptom free patient; and not on mass in CS scar alone which was slow to resolve.

Ultrasound for monitoring twin cesarean scar pregnancy following feticide.

ObjectiveImplantation of the conceptus in a twin cesarean scar pregnancy (CSP) is considered the rarest type of ectopic pregnancy. Preserving the fetus in utero and effectively dealing with CSP can be challenging. This study aimed to determine the clinical value of ultrasonography by monitoring imaging changes in twin CSP following selective feticide.MethodsUltrasonographic and clinical data were collected from four patients with twin CSP who were treated between December 2017 and December 2018 at our hospital.ResultsAll patients had a history of cesarean section, followed by a heterotopic CSP, with one embryo implanted into the uterine cavity and the other located in the anterior isthmus. All of the patients were pregnant with twins with double chorionic and amniotic sacs, and all gave birth in our hospital. The patients underwent feticide at 8 to 9 weeks of gestation, after which we focused on monitoring the implantation. Delivery was performed by cesarean section according to scores of an ultrasonic scoring system and clinical manifestations. The patients’ uterus was preserved and they recovered.ConclusionsThis study shows that ultrasound is useful for determining the timing of clinical termination of CSP by selective feticide.

Ultrasound-guided procedures in the management of heterotopic caesarean scar pregnancy - A review of case reports and case series.

Heterotopic caesarean scar pregnancy (HCSP) is where one gestational sac implants in the previous caesarean section (CS) scar and another sac implants in the uterine cavity. There is limited evidence on the management of this rare condition. Here, we present a case of HCSP in which US-guided selective reduction of the CS pregnancy (CSP) was performed using potassium chloride (KCl) to salvage the intrauterine pregnancy. We also conducted a review of published case reports to understand the determinants of outcome. After a MEDLINE search, 23 case reports were found eligible based on quality assessment and were included in the analysis. A composite-score indicating overall obstetric morbidity was computed, and mixed-effects linear regression was implemented to identify its predictors. US-guided local treatment was the most common mode of intervention for HCSP. The regression analyses revealed that the poor obstetric outcomes, especially antepartum haemorrhage (APH) and postpartum haemorrhage (PPH), were significantly predicted by advanced gestational age at treatment and a higher number of previous CS, irrespective of the mode of treatment. These results indicate that a high index of suspicion for an early ultrasound diagnosis and treatment is critical. US-guided techniques are useful in salvaging the intrauterine pregnancy with decreased maternal morbidity. The results are preliminary due to the rarity and a small number of published reports. Every CSP should be recorded in a central international registry to obtain reliable data on the diagnosis and management of women with CSP. Given the rising rates of CS, future systematic studies are warranted.

Early intervention for heterotopic caesarean scar pregnancy to preserve intrauterine pregnancy may improve outcomes: a retrospective cohort study.

What is the best intervention time and method for patients who are diagnosed with heterotopic caesarean scar pregnancy (HCSP) wishing to preserve intrauterine pregnancy. Four patients diagnosed with HCSP from January 2014 to May 2019 were enrolled. Because HCSP is rare, data on 27 published cases were extracted to augment the analysis. Clinical characteristics and medical documents related to fetal reduction and subsequent maternal-neonate outcomes were analysed. The intervention time was significantly earlier in the full-term birth group (6.76 ± 1.05 weeks) compared with pre-term birth group (8.02 ± 1.55 weeks; P = 0.042). The cumulative full-term delivery rate was 91.48% when the intervention was at 6 weeks' gestation and decreased to 42.02% at 8 weeks. The maternal-neonate outcome was similar among the selective fetal reduction and surgical removal groups as was delivery time (34.68 ± 3.12 versus 34.80 ± 6.64 weeks; P = 0.955). In the four cases undergoing selective fetal reduction, the residual mass grew by 1.16-7.07 times compared with the area before reduction. The maximum size of the residual mass was observed at 12-13 weeks and 22-25 weeks. Most patients with HCSP who choose to keep intrauterine pregnancy will be able to carry the fetus to term. Selective fetal reduction would be the first intervention of choice and should take place immediately after diagnosis. The residual mass after reduction could continue to grow throughout the whole pregnancy, although this should not be considered as an indication for termination. With good supervision and careful management, the pregnancy could be maintained and carried to term.

Heterotopic caesarean section scar pregnancy after embryo transfer: a case report successfully treated with aspiration

Heterotopic caesarean section scar pregnancy after embryo transfer: a case report successfully treated with aspiration

EP22.09: Expectant management of heterotopic Caesarean scar pregnancy: two case reports and review of clinical courses

EP22.09: Expectant management of heterotopic Caesarean scar pregnancy: two case reports and review of clinical courses

EP02.07: Normal vaginal delivery at term after expectant management of heterotopic Caesarean scar pregnancy: case report

EP02.07: Normal vaginal delivery at term after expectant management of heterotopic Caesarean scar pregnancy: case report

Normal vaginal delivery at term after expectant management of heterotopic caesarean scar pregnancy: a case report

BackgroundHeterotopic pregnancy with a combination of a caesarean scar pregnancy and an intrauterine pregnancy is rare and has potentially life-threatening complications.Case presentationWe describe the case of a 27-year-old white woman who had experienced an emergency caesarean delivery at 39 weeks for fetal distress with no postpartum complications. This is a report of the successful expectant management of a heterotopic scar pregnancy. The gestational sac implanted into the scar area was non-viable. The woman was treated expectantly and had a normal vaginal delivery at 37 weeks of gestation.ConclusionExpectant management under close monitoring can be appropriate in small non-viable heterotopic caesarean scar pregnancies.

Heterotopic Cesarean Scar Pregnancy in a Non-assisted Fertility: A Case Report

Introduction: Cesarean rate increased in recent decades worldwide. One of the consequences of the increased cesarean rate and repeat cesarean is the significant increase in cesarean scar pregnancies (CSPs). Diagnosis of a CSP is more difficult when there is a heterotopic pregnancy in a non-assisted pregnancy. Case Presentation: The patient was a 34-year-old G5P2L2Ab2 referred for spotting in Shahidan Mobini hospital, Sabzevar, Iran in 2016. She had a history of 2 cesareans and 2 abortions. Three ultrasounds were performed showing a gestational sac in the lower segment of the uterus with different diagnoses: 1) with hemorrhage over it, 2) with the 2nd gestational sac over it, which was diagnosed as missed abortion, and 3) with an echo-free and irregularly region supporting the 2nd sac or a clot in the lower part of the uterus. The increased local vascularity suggested a level of placenta accreta, partial mole, or trophoblastic reaction. Since the first diagnosis was missed abortion, curettage was performed. Due to the continuation of severe bleeding, abdominal hysterectomy was performed. The patient was discharged in good condition after 3 days. Conclusions: Heterotopic CSP does not have any specific symptoms, which caused it to be easily misdiagnosed. Physicians should use precise diagnostic tests in case of controversial test results.

Successful treatment of spontaneous heterotopic caesarean scar pregnancy by local potassium chloride injection with preservation of the intrauterine pregnancy.

Successful treatment of spontaneous heterotopic caesarean scar pregnancy by local potassium chloride injection with preservation of the intrauterine pregnancy.

First-trimester diagnosis and management of Cesarean scar pregnancies after in vitro fertilization-embryo transfer: a retrospective clinical analysis of 12 cases.

BackgroundAlthough Caesarean scar pregnancy (CSP) is rare, it can cause life-threatening complications. The increasing rate of Cesarean delivery plus rapid development of in vitro fertilization-embryo transfer (IVF-ET) may increase the occurrence of CSP as well as the ratio of heterotopic CSP (HCSP)/CSP. Therefore, early diagnosis and management of CSP are necessary to avoid serious complications. And the purpose of this article is to evaluate the importance and feasibility of the first-trimester diagnosis and management of CSP after IVF-ET.MethodsAll the 12 cases were secondary infertility patients who had a history of Cesarean section and underwent IVF-ET in our reproductive center. All cases with CSP were diagnosed using transvaginal color Doppler sonography (TVS). Medical, surgical and expectant managements were implemented, and the management results were traced.ResultsPatients with CSP (n = 12) were diagnosed from January 2011 to April 2015, 6 (50 %) of which were HCSP. The prevalence of CSP was 1:1688 pregnancies. The gestational age ranged from 5 + 3 to 7 + 4 weeks in all CSP, and from 5 + 6 to 7 + 4 weeks in HCSP at diagnosis. Five patients received successful surgical treatment. The success rate of medical and expectant management was 50 % (1/2) and 100 % (5/5), respectively. One patient with failed medical management needed an emergency laparotomy to evacuate CSP. The uterus was preserved in all 12 patients.ConclusionsThe Caesarean section and IVF-ET may increase the ratio of HCSP/CSP. TVS is a noninvasive and effective tool for use in diagnosing CSP. CSP should be carefully excluded in patients who have had a history of Caesarean section. Early diagnosis of CSP in the first trimester may contribute towards the preservation of uterus as well as intrauterine pregnancy (IUP) in HCSP.

Heterotopic Cesarean Scar Pregnancy in a Spontaneous Cycle

Heterotopic Cesarean Scar Pregnancy in a Spontaneous Cycle

Heterotopic cesarean scar pregnancy: diagnosis, treatment, and prognosis.

Heterotopic cesarean scar pregnancy is a rare, life-threatening form of ectopic pregnancy. To provide information regarding the clinical manifestations, diagnosis, management, and prognosis of this condition, we reviewed all cases reported in the English literature. All literature on heterotopic cesarean scar pregnancy was retrieved by searching the PubMed database and tracking references of the relevant literature. Full texts were reviewed, and clinical manifestations, diagnostic methods, and the relationship between the treatment and prognosis were summarized. A total of 14 patients with heterotopic cesarean scar pregnancies were identified, including 6 spontaneous pregnancies and 8 following in vitro fertilization-embryo transfer. Gestational ages at diagnosis ranged from 5 weeks to 8 weeks 4 days. Only 5 cases presented with vaginal bleeding, and the others were asymptomatic. All 14 cases were diagnosed by transvaginal sonography. One patient with no future fertility requirements underwent pregnancy termination by methotrexate. Of the remaining 13 patients who desired to preserve their intrauterine gestations, 10 were treated by sonographically guided selective embryo reduction in situ (by embryo aspiration, drug injection, or both); 2 underwent laparoscopic and hysteroscopic excision of the ectopic pregnancy masses; and 1 was treated by expectant management. All operations were successful and maintained a living intrauterine gestation. Twelve cases resulted in live births by cesarean delivery (3 at term and 9 preterm). One patient underwent pregnancy termination at 12 weeks because of a fetal malformation confirmed by sonography. The possibility of heterotopic cesarean scar pregnancy after cesarean delivery should be considered, especially when pregnancy follows assisted reproductive technology. Transvaginal sonography is an important tool for diagnosis and management. Despite the many options, the best treatment for this condition remains unclear. Selective embryo reduction in situ with sonographic guidance is the main treatment modality and can result in a successful intrauterine gestation, albeit at high risk.

Successful full‐term twin deliveries in heterotopic cesarean scar pregnancy in a spontaneous cycle with expectant management

Heterotopic cesarean scar pregnancy (CSP) usually follows assisted reproductive technologies (ART) in women who have already delivered by cesarean section. It is extremely rare: thus far, there have been only 12 individual case reports. However, over the last 20 years, the rate of cesarean delivery has increased and ART have become more common; hence, heterotopic CSP will be more prevalent in the future. Currently available data suggest that the early selective termination of CSP by medical or surgical methods is the most reliable treatment in the hemodynamically stable heterotopic CSP women because of the serious complications of continuing the CSP. We present the first case report of heterotopic CSP in a spontaneous cycle with expectant management that resulted in full-term twin deliveries.

Successful embryo aspiration and preservation of intrauterine pregnancy in a heterotopic cesarean scar pregnancy: a case report

Successful embryo aspiration and preservation of intrauterine pregnancy in a heterotopic cesarean scar pregnancy: a case report

Spontaneous Heterotopic Cesarean Scar Pregnancy: Conservative Management by Transvaginal Sonographic Guidance and Successful Pregnancy Outcome

Spontaneous Heterotopic Cesarean Scar Pregnancy: Conservative Management by Transvaginal Sonographic Guidance and Successful Pregnancy Outcome

Heterotopic cesarean scar pregnancy associated with a levonorgestrel-releasing intrauterine device

Heterotopic cesarean scar pregnancy associated with a levonorgestrel-releasing intrauterine device