Management Of Cesarean Scar Pregnancy Research Articles

Manual Vacuum Aspiration Alone Versus Manual Vacuum Aspiration Preceded by Methotrexate in Management of Caesarean Scar Pregnancy

Manual Vacuum Aspiration Alone Versus Manual Vacuum Aspiration Preceded by Methotrexate in Management of Caesarean Scar Pregnancy

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

Efficacy, Safety and Outcomes of the Laparoscopic Management of Cesarean Scar Ectopic Pregnancy as a Single Therapeutic Approach: A Case Series.

A standardized consensus for the management of cesarean scar pregnancy (CSP) is lacking. The study objective is to evaluate the efficacy, safety and outcomes of the laparoscopic management of CSP as a single therapeutic surgical approach without being preceded by vascular pretreatment or vasoconstrictors injection. This is a retrospective bi-centric study, a case series. Eight patients with a future desire to conceive underwent the laparoscopic treatment of unruptured CSPs. Surgery consisted of "en bloc" excision of the deficient uterine scar with the adherent tissue of conception, followed by immediate uterine repair. The data collected for each patient was age, gestity, parity, number of previous c-sections, pre-pregnancy isthmocele-related symptoms, gestational age, fetal cardiac activity, initial β-human chorionic gonadotropin levels, intra-operative blood loss, blood transfusion, operative time and the postoperative complications, evaluated according to Clavien-Dindo classification. The CSP was successfully removed in all patients by laparoscopy. The surgical outcomes were favorable. All patients with histories of isthmocele-related symptoms reported postoperative resolution of symptoms. The median residual myometrium thickness increased significantly from 1.2 mm pre-operatively to 8 mm 3 to 6 months after surgery. The laparoscopic management seems to be an appropriate treatment of CSP when performed by skilled laparoscopic surgeons. It can be safely proposed as a single surgical therapeutic approach. Larger series and further prospective studies are needed to confirm this observation and to affirm the long-term gynecological and obstetrical outcomes of this management.

Outcomes of the Expectant Management of 10 Cesarean Scar Pregnancy Cases in Patients Who Refused the Termination of Pregnancy.

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.

9744 Hysteroscopic Management of Caesarean Scar Pregnancy

9744 Hysteroscopic Management of Caesarean Scar Pregnancy

9757 Management of Cesarean Scar Pregnancy over 8 Weeks of Gestation with Intra-Gestational MTX Followed By Surgery at Different Opportunities

9757 Management of Cesarean Scar Pregnancy over 8 Weeks of Gestation with Intra-Gestational MTX Followed By Surgery at Different Opportunities

EP27.20: Management of Caesarean scar pregnancy with combination of intragestational and systemic therapy: experience from a tertiary care centre in India

EP27.20: Management of Caesarean scar pregnancy with combination of intragestational and systemic therapy: experience from a tertiary care centre in India

Evaluation of management of Cesarean Scar Pregnancy (CSP).

Objective: To evaluate our experience in treatment of Caesarean Scar Pregnancy (CSP). Study Design: Cross Sectional Descriptive study. Setting: Department of Gynecology and Obstetrics, Independent Medical College Faisalabad. Period: Jan 2016 to Jan 2021. Material & Methods: The data for this study retrospectively obtained from outpatient department, emergency ward and labor ward registers. Data was analyzed by simple descriptive statics. Diagnosis of CSP was made by using transvaginal ultrasound and color flow Doppler ultrasound. Treatment offered was either medical management as systemic methotrexate or surgical as D&C or laparotomy. The aim was to do conservative treatment for fertility sparing. Patient age, gestational age at time of presentation, number of previous Cesarean Section and success of overall management strategy was analyzed. Results: In this study we had 12 patients diagnosed to have CSP with at least one scar on uterus of previous caesarean section. The mean age of patients was 32.5± 2 years and the gestational age range was from 5 weeks and 3 days to 10 weeks and 1 day. The diagnosis was done by using transvaginal ultrasound and color flow Doppler ultrasound. Which showed high velocity and low impedance flow in sub trophoblastic area. Out of 12 patient’s 58.33 percent were treated with systemic methotrexate and had successful outcome. These were followed by B-hCG levels till non pregnant serum level of B-hCG of <5.1IU was achieved. 16.66 percent patients underwent D&C, but due to hemorrhage they were treated with laparotomy as supplementary procedure. 41.55 percent Patients were treated by laparotomy as their primary management with aim of fertility sparing surgery. The laparotomy was found to be successful treatment in all the patients who underwent surgical management as their primary treatment. Conclusion: Prompt diagnosis has pivotal role in reducing morbidity and mortality associated with CSP. Medical management is found to be successful at early gestational age. Fertility sparing surgery is better option as gestation advances more than 8 weeks to avoid undesirable outcome like hemorrhage and hysterectomy.

Management of cesarean scar pregnancy: Importance of gestational age at diagnosis and disease type-A single center's 5 years of experience involving 223 cases.

This study aims to evaluate the importance of the gestational age at diagnosis and the types of cesarean scar pregnancy (CSP) for treatment outcomes and to identify the optimal treatment based on both the gestational age at diagnosis and the CSP type. A retrospective cohort study included 223 pregnant women diagnosed with CSP at Peking University First Hospital, Beijing, China, between 2014 and 2018. All CSP cases underwent ultrasound-guided vacuum aspiration followed by supplementary curettage. Adjuvant treatment modalities included intramuscular injection of systemic methotrexate, uterine artery embolization, and hysteroscopy before ultrasound-guided vacuum aspiration. Linear regression was used to determine the relationship between intraoperative blood loss and gestational age at diagnosis, CSP type, highest β-human chorionic gonadotropin level, and management procedures. None of the patients required blood transfusions or hysterectomies. Patients presenting at <8, 8-10, and >10 weeks had median estimated blood loss of 5, 10, and 35 ml, respectively. Patients with type I CSP, type II CSP, and type III CSP had median blood loss of 5, 5 and 10 ml, respectively. Multivariate linear regression analysis demonstrated that the gestational age at diagnosis (p < 0.001) and type of CSP (p = 0.023) were independent predictors of intraoperative estimated blood loss. For type I CSP patients, ultrasound-guided vacuum aspiration followed by supplementary curettage alone was performed in 15 of 34 (44.1%) patients, including 12/27 (44.4%) diagnosed at <8 weeks, 2/6 (33.3%) at 8-10 weeks, and 1/1 for >10 weeks. In type II CSP patients, fewer cases were managed by ultrasound-guided vacuum aspiration followed by supplementary curettage alone as the gestational age at diagnosis increased [18/96 (18.8%) for <8 weeks, 7/41 (17.1%) for 8-10 weeks, none for >10 weeks]. Most type III CSP patients (41/45, 91.1%) needed treatments in addition to the ultrasound-guided vacuum aspiration regardless of the gestational age at diagnosis. All CSP patients were treated successfully and did not require readmission or further medical interventions. Gestational age at diagnosis of CSP and its type show a strong correlation with estimated blood loss during ultrasound-guided vacuum aspiration. With careful management, CSPs may be treated at any gestational week, regardless of their type, with minimal intraoperative bleeding.

Successful Medical Management of Cesarean Scar Pregnancy with High β-hCG Levels

Successful Medical Management of Cesarean Scar Pregnancy with High β-hCG Levels

The Effect of Using Local Injection of Methotrexate in Management of Cesarean Scar Pregnancy in Minia University Maternity Hospital

The Effect of Using Local Injection of Methotrexate in Management of Cesarean Scar Pregnancy in Minia University Maternity Hospital

Effectiveness, complications, and reproductive outcomes after cesarean scar pregnancy management: a retrospective cohort study

There is a dramatic rise in cesarean deliveries worldwide, leading to higher complication rates in subsequent pregnancies. One of these complications is a cesarean scar pregnancy. During the last decades, treatment options for cesarean scar pregnancies have changed, and less invasive interventions have been employed to preserve fertility and reduce morbidity. However, the optimal treatment approach and the influence of various treatments on reproductive outcomes have to be determined. This study aimed to evaluate the short- and long-term outcomes after cesarean scar pregnancy management. We conducted a retrospective cohort study of women determined to have a cesarean scar pregnancy from 2010 to 2021 at a tertiary referral center, the Amsterdam University Medical Center, in the Netherlands. Outcomes of the following management strategies were compared: expectant management, methotrexate, curettage with temporary cervical cerclage, or a laparoscopic niche resection. We performed a curettage if the cesarean scar pregnancy did not cross the serosal line of the uterus, and a laparoscopic niche resection was performed if the cesarean scar pregnancy crossed the serosal line. The main outcomes were treatment efficacy and time to subsequent ongoing pregnancy or pregnancy leading to a live birth. Of the 60 included women, 5 (8.3%) were managed expectantly, 8 (13.3%) were treated with methotrexate, 31 (51.8%) were treated with a curettage, and 16 (26.7%) with a laparoscopic niche resection. The groups were not comparable. The gestational age and human chorionic gonadotropin levels were generally higher in women who received methotrexate or a laparoscopic niche resection. Additional treatment in the conservative group was needed for 4 (80%) women after expectant management and for 7 (87.5%) women after methotrexate treatment. In the surgical group, all 31 women treated with a curettage and all 16 treated with a laparoscopic niche resection did not require additional treatment. The subsequent ongoing pregnancy rate after cesarean scar pregnancy management was 81.1% (30/37) among women who wished to conceive, with a live birth rate of 78.4% (29/37); 1 woman was in her third trimester of pregnancy at the time of analyses. The time between cesarean scar pregnancy management and subsequent ongoing pregnancy was 4 months (interquartile range, 3-6; P=.02) after expectant management, 18 months (interquartile range, 13-22) after initial methotrexate treatment, 5 months (interquartile range, 3-14; P=.01) after a curettage, and 6 months (interquartile range, 4-15; P=.03) after a laparoscopic niche resection. Surgical treatment of a cesarean scar pregnancy led to a high success rate without additional interventions, high pregnancy rates with a short time interval between treatment, and subsequent pregnancy leading to an ongoing pregnancy or live birth. Conservative management, both with expectant management and methotrexate treatment, led to high (re)intervention rates. Different management approaches are indicated for different types of cesarean scar pregnancies.

7763 Hysteroscopic Morcellation (with Bigatti Shaver) Under Laparoscopic Guidance: A Novel Approach to Management of Caesarean Scar Pregnancy

<h3>Study Objective</h3> To present our experience in treating cases with caesarean scar pregnancy by hysteroscopic morcellation using Bigatti Shaver over a period of 1 year. <h3>Design</h3> Longitudinal prospective study for 1 year & follow up done till beta HCG level comes to normal. <h3>Setting</h3> Patients positioning in the OT table: Lithotomy position, 45-degree angle between OT table & patients elevated legs. 2 Endomat Select: one for irrigation & other for suction, RPM-2100, Irrigation: 200-250 ml/min, Pressure: 150mm of Hg <h3>Patients or Participants</h3> 10 women between age 22-35years presented to us in the OPD with caesarean scar pregnancy confirmed on their dating ultrasound. <h3>Interventions</h3> Pre operative investigations were done prior to surgery and under laparoscopy they were posted for surgical intervention - removal of scar pregnancy by Bigatti Shaver. <h3>Measurements and Main Results</h3> • No fertility desired by the patient further, so patient should be tubectomised • It should be done till 7 weeks of period of gestation • Myometrial thickness should be between 2 to 4 mm <h3>Results</h3> 1. None had any intra or post operative complications. 2. Average duration of procedure: less than half an hour & blood loss less than 100ml. 3. Serial Beta HCG from the day of discharge and weekly therefore done, which returned to non-pregnant levels by end of 4 weeks. <h3>Conclusion</h3> Hysteroscopic morcellation is a convenient and effective mode of management of caesarean scar pregnancy with excellent safety profile and patient satisfaction rates.

8801 Safe Hysteroscopic Management of Caesarean Scar Pregnancy

<h3>Study Objective</h3> Role of Hysteroscopy in the management of Caesarean Scar Pregnancy. <h3>Design</h3> Prospective. <h3>Setting</h3> Private clinic. <h3>Patients or Participants</h3> Patients with previous caesarean section and now presenting with amenorrhea and sonography confirmation of implantation in scar area with period of gestation not greater than 7 weeks. <h3>Interventions</h3> Operative Hysteroscopy under general anaesthesia with or without resectoscope. <h3>Measurements and Main Results</h3> Complete evacuation of pregancy-100%, Minor complications-1%. (Haemorrrhage). <h3>Conclusion</h3> Hysteroscopy is safe and effective in the management of complete evacuation of CSP as it allows: Identification of scar site pregnancy. Complete evacuation and confirmation. Control of Haemostatsis.

Caesarean Scar Pregnancy: Surgical Obstacles

As a rare phenomenon, caesarean scar pregnancy has been found to be managed in many ways in literature. However, to date there lacks a general consensus on the management of caesarean scar pregnancy. In modern obstetrics nowadays, the incidence of caesarean deliveries has been rising. Due to the increase in caesarean section rates, the incidence of caesarean scar pregnancies is also on the rise. Even though the optimal management of caesarean scar pregnancy is unclear, the basic management is tailored according to the clinical presentation and fertility concerns of the individual. Herein, we report a case of a ruptured caesarean scar pregnancy which was managed surgically via emergency laparotomy and hysterectomy.

Management of caesarean scar pregnancy with ultrasound guided suction curettage followed by foley balloon catheter placement

ObjectiveCaesarean scar pregnancy (CSP), which is a direct consequence of caesarean delivery, can lead to serious complications such as placenta acreta spectrum (PAS). The aim of this study is to assess the effectiveness of ultrasound-guided suction curettage followed by foley balloon tamponade for the management of CSP in the first trimester of pregnancy. Study designA retrospective evaluation of 32 women who were managed with ultrasound-guided suction curettage and foley balloon catheter insertion to the CSP region was performed. The primary outcome of the study was the rate of successful termination of CSP without need of additional surgical intervention. Secondary outcomes were the rate of haematocrit decrease, duration of hospitalization and need for transfusion. ResultsThe described procedure was performed successfully without need for additional interventions for all patients. Median decrease in the haematocrit level post-operatively was 4% (2.25–5). Median hospitalization time was 1 day (1–2). ConclusionsUltrasound-guided suction curettage followed by foley balloon tamponade is an effective and safe method for the management of CSP. Direct comparative studies with other methods are required for a more precise conclusion.

Intra-gestational agents for management of cesarean scar pregnancy: Is the long wait and stress worth it?

Intra-gestational agents for management of cesarean scar pregnancy: Is the long wait and stress worth it?

Caesarean scar pregnancy: diagnosis, natural history and treatment.

This review aims at summarizing the latest evidence on diagnosis, natural history and management of caesarean scar pregnancy (CSP). CSP can result in maternal morbidity from major haemorrhage, uterine rupture, placenta accreta spectrum disorders and hysterectomy. Classification of the CSP types, presence of fetal heart activity, gestational age and residual myometrial thickness seem to influence rates of ongoing pregnancy, subsequent development of placenta accreta with expectant management, as well as success and complication rates associated with various methods of pregnancy termination. Expectant management may be appropriate in certain good prognosis cases, such as absent fetal heart activity or when the myometrial layer at the implantation site is relatively thick. Surgical treatments are typically associated with higher success rates, but seem to result in severe haemorrhage more frequently than medical treatments, which have higher failure rates. Although other treatment modalities are available, in general, the size and quality of evidence to guide care provision in CSP is very poor. CSP can be associated with severe maternal morbidity but can also lead to a livebirth. There is currently a lack of good-quality evidence to predict the outcome of CSP and provide informed and evidence-based care.

High-intensity focused ultrasound compared with uterine artery chemoembolization with methotrexate for the management of cesarean scar pregnancy.

To compare the effectiveness and safety of high-intensity focused ultrasound (HIFU) versus uterine artery chemoembolization with methotrexate for the management of cesarean scar pregnancy (CSP). A total of 170 women with CSP were enrolled in the retrospective cohort study from April 2016 to September 2020. One hundred women received HIFU followed by suction curettage, and 70 women were treated with uterine artery chemoembolization followed by suction curettage. The median blood loss during suction curettage was 20ml (range 2-800ml) in the HIFU group versus 20ml (range 5-200ml) in the chemoembolization group (P=0.837). The mean time for β-human chorionic gonadotropin normalization was 28.52±10.82days versus 26.69±8.97days (P=0.246), respectively. The mean time of menstruation recovery was 34.36±10.63days versus 31.93±8.53days (P=0.114), respectively. The incidence of adverse effects in the HIFU group was lower than that in the chemoembolization group (P=0.028). The median hospitalization time in the HIFU group was longer than that in the chemoembolization group (P=0.000). HIFU was as effective and safe as uterine artery chemoembolization in the management of CSP, and the incidence of adverse effects was lower.

Laparoscopic Management of Cesarean Scar Pregnancy

<h3>Study Objective</h3> To present a case and surgical video of a laparoscopic excision of a cesarean scar pregnancy at 12 weeks and review the literature regarding cesarean scar pregnancy management. <h3>Design</h3> Case report and surgical video. <h3>Setting</h3> Tertiary care hospital. <h3>Patients or Participants</h3> One patient. <h3>Interventions</h3> 23 y/o G5P0131 at 7 weeks 1 day with history of obesity and a 31-week low transverse cesarean delivery presented for initial prenatal care to an outside OB. Cesarean scar pregnancy diagnosis was not recognized until patient presented for a nucal translucency to maternal fetal medicine at 11 weeks and 3 days where suspicion for scar pregnancy was raised. Patient was referred to our institution where cesarean scar pregnancy was confirmed at 11 weeks and 6 days and laparoscopic excision was recommended, as it was felt that pregnancy was too large and advanced in gestational age for medical management to be successful. Patient underwent uterine artery embolization and fetal intra-cardiac KCl injection the day prior to procedure to prevent hemorrhage during surgery, then patient underwent laparoscopic excision of cesarean scar pregnancy. <h3>Measurements and Main Results</h3> Laparoscopic excision of cesarean scar pregnancy was completed successfully with no intra or post-operative complications. Surgical techniques are reviewed in the surgical video. Patient had a good surgical recovery. <h3>Conclusion</h3> Laparoscopic excision of a cesarean scar pregnancy can be accomplished successfully with good outcomes when preventative measures to achieve good hemostasis such as pre-operative uterine artery embolization and fetal intra-cardiac KCl injection are used.