Management Of Cesarean Scar Pregnancy Research Articles

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.

VP02.04: Management of Caesarean scar pregnancy

VP02.04: Management of Caesarean scar pregnancy

Cesarean scar pregnancy management: Different approach for different situation; A case series

The incidence of caesaean scar pregnancy (CSP) increases since the cesarean delivery rate had increased as well. Diagnosing of CSP was also a challenge to identify the type of CSP which important things for choosing the right management. The CSP could be classified into two types, which are endogenous and exogenous. While the management was dependent into the types, such as suction curettage, resection, and also hysterectomy. This paper showed cases of cesarean scar pregnancy in Cipto Mangunkusumo General Hospital, in one year.

Clinical Course of 60 Cesarean Scar Pregnancies.

Early diagnosis and therapy are important in a cesarean scar pregnancy (CSP), which can cause uterine rupture with resultant massive bleeding. However, there are some reports of CSPs continued to term. The optimal management of CSPs remains unclear; therefore, we investigated the clinical courses of CSPs diagnosed and treated at perinatal institutions in the Chugoku and Shikoku regions of Japan. We enrolled 60 women diag-nosed with CSP at 21 institutions from January 2006 to December 2015. Of the 60 women diagnosed with CSP, 57 were treated. Pregnancy was terminated in 48 women and continued in 9. Thirteen women underwent transabdominal hysterectomy; they experienced no postoperative complications or allogeneic blood transfu-sion. Nine women received therapies such as dilation and curettage, and 26 received non-surgical therapies such as methotrexate and topical administration of potassium chloride. Among 9 women who chose to con-tinue with their CSP, 7 successfully delivered newborns, 2 had uterine ruptures in the second trimester, and all women required transabdominal hysterectomy. Diagnosis and therapy in the first trimester of pregnancy are important in the management strategy of a CSP. When continuing a CSP, the risk of uterine rupture and trans-abdominal hysterectomy must be considered.

A review on management of caesarean scar pregnancy.

To review the current literature on management of cesarean scar pregnancy. Caesarean scar pregnancy (CSP) is a complex pathologic condition, which is strictly related to a previous caesarean section. It is an iatrogenic disorder, that has had an exponential increase over the last few years linked to the parallel increase in the number of caesarean sections. The Society for Maternal-Fetal Medicine (SMFM) confirmed the presence of surgical, medical, and minimally invasive therapies for caesarean scar pregnancy management but the optimal treatment is not known; the main recommendation is to avoid expectant management of CSP (GRADE 1B). The treatments for Caesarean scar pregnancy are multiple, and they include a surgical management, a medical management and a combination between these two types of treatments. Despite the recommendation of SMFM in this review, we also included some cases of conservative management published in the last months. Considering all the different approaches on CSP, the management has to be individualized mainly on gestational age and it has to be discussed by a multidisciplinary team, to choose the safest clinical option.

Computed tomography-guided injection for management of caesarean scar pregnancy

Caesarean scar pregnancy (CSP), defined as a pregnancy that implants in the scar from a previous caesarean birth, has a rising incidence and is associated with a significant risk for maternal morbidity and mortality.1–6 Prompt diagnosis, based on a high degree of clinical suspicion, and subsequent treatment is required to reduce such risks.1 Although a variety of medical and surgical interventions have been described for the management of CSP, the optimal treatment is unknown.1,5,6 We describe a novel method of methotrexate administration utilising a multidisciplinary approach with interventional radiology and computed tomography (CT) for the treatment of three CSPs that resulted in favourable maternal outcomes.

A Comparison of Treatment Options for Type 1 and Type 2 Caesarean Scar Pregnancy: A Retrospective Case Series Study.

Background: There is currently no agreement on the optimal management of caesarean scar pregnancy. Caesarean scar pregnancy is currently categorised into two subtypes according to the site of implantation. This may consequently result in the difference in treatment options. However, the comparison of the success rate of each treatment option according to the subtypes has not been fully investigated.Methods: 71 patients who were treated by uterine curettage (D and C), or uterine artery embolization with curettage (UAE) or hysteroscopy in conjunction with laparoscopy between January 2016 and March 2020 were included. Data on maternal age, gestational sac age, the sac diameter, the interval between two pregnancies, the number of previous caesarean sections, amount of bleeding and β-hCG levels were collected and analysed dependent on the subtypes.Results: There was no difference in the clinical parameters of the cases who received different options of treatment, as well as no difference in the clinical parameters between type 1 and type 2 caesarean scar pregnancy. The primary success rate for type 1 caesarean scar pregnancy by D and C, or UAE, or hysteroscopy in conjunction with laparoscopy was 95, or 100 or 100%, respectively. The primary success rate for type 2 caesarean scar pregnancy by D and C, or UAE, or hysteroscopy in conjunction with laparoscopy was 27, or 67, or 95% respectively.Conclusion: Our data demonstrates that hysteroscopy in conjunction with laparoscopy for type 2 caesarean scar pregnancy was the most successful compared to other options, but for type 1 caesarean scar pregnancy, D and C could be the cost-effective option.

Pituitrin local injection versus uterine artery embolization in the management of cesarean scar pregnancy: A retrospective cohort study.

To compare the effect of pituitrin local injection (PIT) and uterine artery embolization (UAE) as pretreatment before surgery during the management of cesarean scar pregnancy (CSP). Forty-nine CSP patients diagnosed in our department of Suzhou Ninth People's Hospital from October 2017 to October 2019. All patients underwent hysteroscopy and negative pressure aspiration (for type I CSP) or laparoscopic wedge-resection (for type II and III CSP) following one of the preoperative treatments: PIT group (n = 26) and UAE group (n = 23). The baseline clinical data, intraoperative blood loss, blood transfusion rate, postoperative hospital stay, hospitalization expenses, postoperative pain, postoperative fever, postoperative serum β-human chorionic gonadotropin (β-hCG) level, and pregnancy outcome were reviewed and analyzed. There was no significant difference (p ≥ 0.05) between two groups in baseline characteristics including age, gravidity, previous cesarean section times, interval since last cesarean delivery, menolipsis time, maximum diameter of gestational sac or mass under ultrasound, fetal cardiac activity and preoperative β-hCG level. There was no significant difference in blood loss, transfusion rate, and postoperative β-hCG reduction percentage (p ≥ 0.05) either. The postoperative hospital stay, hospitalization expenses, postoperative pain, and postoperative fever rate in PIT group were significantly lower than those in UAE group (p < 0.05). Moreover, β-hCG level of all patients turned negative 1 month after surgery successfully. PIT pretreatment seems to be a same effective, more economical, and with fewer side effects pretreatment method compared to traditional UAE pretreatment in the management of CSP.

Laparoscopic management of cesarean scar pregnancy: Report of two cases with video-presentation of different operative techniques and literature review

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. We present two different techniques of laparoscopic management of CSP, with the concomitant repair of the coexisting uterine isthmocele. The first case is a combination of diagnostic hysteroscopy and laparoscopic extraction of conception products, and the second technique is a combination of laparoscopy and guided Dilation & Curettage. We also conducted a thorough review of the literature to present all cases of laparoscopic treatment of CSP, focusing on the surgical technique, the operation outcome, and the future pregnancies. Laparoscopy is a potential effective treatment of CSP.

Focused Ultrasound Ablation Surgery combined with ultrasound-guided suction curettage in the treatment and management of Cesarean Scar Pregnancy

ObjectiveTo evaluate the feasibility, safety, and effectiveness of Focused Ultrasound Ablation Surgery (FUAS) combined with ultrasound-guided suction curettage in the management of Cesarean Scar Pregnancy (CSP). Study designWe retrospectively analyzed 52 patients with CSP from April, 2017, to December, 2019. All the patients received one session of FUAS, and suction curettage under ultrasound guidance was performed 1–3 days after FUAS. The intraoperative blood loss in suction curettage, duration of vaginal bleeding after curettage, reproductive outcomes, and adverse effects were recorded and analyzed. ResultsAll the 52 patients completed one session of FUAS combined with suction curettage without serious adverse effects. The mean intraoperative blood loss was 32.81 ± 53.83 mL. 47 (90.38 %) patients had a successful suction curettage with a blood loss of less than 80 mL. 5 (9.62 %) patients had an active bleeding of ≥80 mL; however, the bleeding was stopped effectively by Foley's urinary catheter and no evident bleeding presented when the catheter was removed 24 h later. The mean duration of vaginal bleeding was 7.88 ± 4.24 days. 48 (92.30 %) patients recovered with little vaginal bleeding after curettage. 4 (7.69 %) type III CSP patients experienced late-onset severe bleeding and required UAE or surgery. During 6–36 months of the follow-up period, 12 patients expressed reproductive plan, in which 4 patients delivered by cesarean section, 3 patients had an ongoing pregnancy and 1 patient had an abortion in the early pregnancy. ConclusionsFUAS combined with ultrasound-guided suction curettage is a safe and effective treatment strategy in the management of CSP type I and CSP type II and is particularly advantageous for CSP patients with reproductive requirements. However, further studies are warranted to determine the meticulous inclusion criteria for patients with type III CSP.

A Preliminary Study to Propose an Algorithm for Management of Cesarean Scar Pregnancy

Objectives: There is no consensus on the management of cesarean scar pregnancy (CSP). In this regard, this study proposed an algorithm for CSP management with consecutive outcomes. Materials and Methods: In this randomized clinical trial study, the data of 44 patients with CSP were collected, and the diagnosis was confirmed by transvaginal ultrasonography (TVS). Unstable patients underwent uterine artery embolization (UAE), and the fetal reduction was done for patients with the fetal heart rate (FHR). In addition, patients received systemic methotrexate (MTX) injections according to their beta-human chorionic gonadotropin (β-hCG) levels and then were followed on a predetermined schedule by β-hCG levels and TVS. Finally, prophylactic UAE was considered for patients with ongoing bleeding, placental hypervascularity, and the prospect of limited access to care. Results: Patients were within the age range of 33.9±4.9 years and the gestational age of 7.37±1.57 weeks. Twenty-two patients (50%) had vaginal bleeding, 3 of whom were unstable and underwent UAE. Five patients underwent a total abdominal hysterectomy, and fourteen patients with FHR underwent a fetal reduction. Based on β-hCG levels and changes, and placental vascularity, 4 patients received no treatment. In general, 11, 2, and 9 patients received single, double, and multiple MTX injections. A total of 10 patients underwent both multi-doses of MTX and prophylactic UAE. The median period to reach undetectable β-hCG levels was 7.3 weeks and the median interval to start menstruation was 2.8 weeks. In addition, the pregnancy remnant was resolved 3.6 months after the treatment. On the follow-up, no curettage or hysterectomy was needed and seven patients became pregnant (15.9%), 2 of whom presented recurrent CSP (28.6%). Conclusions: The proposed stepwise algorithm could be employed for CSP management with accountable outcomes, low hysterectomy rates, and fertility preservation.

Combination of medical and surgical management in successful treatment of caesarean scar pregnancy: a case report series

BackgroundThere is no clear consensus on the management of caesarean scar pregnancy (CSP), a complex and life-threatening condition. The objective of this study was to present a novel approach to management of CSP that combines medical therapy of multidose methotrexate and mifepristone with active surgical management by uterine curettage and consecutive local haemostasis.Case presentationWe report on a prospective case series of six women with first trimester pregnancy, in whom the diagnosis of CSP was confirmed by 2D and color Doppler transvaginal ultrasound and serial hormone chorionic gonadotropin (hCG) testing. Women were between 23 and 36 years old and had at least one previous delivery by caesarean. At admission, gestational age ranged between 6 to 14 weeks, and serum hCG levels between 397 and 23,000 mUI/ml. Upon decision of pregnancy termination, medical management was undertaken in all cases and 1 mg/kg systemic Methotrexate was administered between 1 and 5 daily doses. Mifepristone was part of the treatment in cases with live pregnancy. Surgical management was employed for the cases were an embryo was seen by ultrasound, being prompted by inadequate response to Methotrexate and/or signs of miscarriage with vaginal bleeding. Curettage combined with local isthmic balloon or vaginal pack tamponade prevented further complications. High treatment rates with preservation of fertility was achieved in all patients except one who underwent hysterectomy for invasive placentation. Ultrasound and hCG levels surveillance ensured that the resolution of pregnancy was achieved.ConclusionWomen with history of delivery by caesarean section should be carefully monitored in future pregnancies for prompt diagnosis of CSP. Early diagnosis of CSP allows selection of successful conservative therapy. Through this case series we contribute with our experience to the body of knowledge about the management of this serious complication of early pregnancy.

Cesarean scar pregnancy management: medical or surgical? When and which? A literature review

Cesarean scar pregnancy management: medical or surgical? When and which? A literature review

An updated guide to the diagnosis and management of cesarean scar pregnancies.

To review the current literature on the diagnosis and management of cesarean scar pregnancies RECENT FINDINGS: The incidence of cesarean scar pregnancies (CSPs) is increasing as a result of the increasing cesarean section rate, improved diagnostic capabilities, and a growing awareness. CSPs are associated with significant morbidity and early diagnosis is key. Diagnosis is best achieved with transvaginal ultrasound. Sonographic diagnostic criteria have been developed over decades and recently endorsed by the Society for Maternal-Fetal Medicine and other professional societies. The current categorization system differentiates CSPs that are endogenic or 'on the scar' from those that are exogenic or 'in the niche'. Following diagnosis, the challenge remains in determining the optimal management as multiple modalities can be considered. Studies have demonstrated the favorable outcomes with combined local and systemic methotrexate, surgical excision through multiple routes, and adjunctive therapies, such as uterine artery embolization or uterine balloons. The current evidence is insufficient to identify a single best treatment course and a combined approach to treatment is often required. Successful outcomes while minimizing complications can be achieved with a multidisciplinary, collaborative effort. Guidelines for cesarean scar pregnancies will continue to evolve as the published reports grow.

Clinical outcome of high-intensity focused ultrasound as the preoperative management of cesarean scar pregnancy

ObjectiveThe aim of this study was to retrospectively evaluate the feasibility and safety of high-intensity focused ultrasound (HIFU) treatment as the preoperative management of cesarean scar pregnancy (CSP). Materials and methods225 patients with definite Type I CSP were treated with suction curettage under hysteroscopic guidance. Among them, 103 patients chose HIFU treatment before hysteroscopy (assign to the HIFU group), and the other 122 patients without any pretreatment before hysteroscopy to the control group. The successful rate, volume of intraoperative blood loss, time for serum β-human chorionic gonadotropin (β-hCG) level returned to normal, gestational sac disappeared, normal menstrual recovery, and adverse effects were collected and analyzed to compare the two approaches. ResultsThe successful rate (98.06%) in the HIFU group was higher than that (91.80%) in the contrast group. The median ablation time was 39 min and the median HIFU sonication time was 106.6 s. The median volume of intraoperative blood loss in the HIFU group was lower than that in the contrast group (P < 0.001), and the median time of gestational sac disappeared in the HIFU group was shorter than that in the contrast group. There were no statistically significant differences in the time of serum β-hCG returned to normal and days of menstrual recovery between the 2 groups. ConclusionBased on our results, it appears that HIFU ablation is a safe and effective modality as pre-treatment before hysteroscopy in the management of CSP.

Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy

Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).