Recurrent Cesarean Scar Pregnancy Research Articles

Analysis of pregnancy outcomes following surgical treatment of cesarean scar pregnancy

PurposeTo investigate the surgical treatment approaches for patients with Cesarean scar pregnancy (CSP) and the effects on subsequent pregnancy.MethodsCSP patients admitted to Shengjing Hospital of China Medical University from January 2013 to December 2018 were retrospectively analyzed to collect their clinical characteristics, and follow-up of postoperative pregnancies.ResultsA total of 1126 CSP patients were enrolled in this study, including 595 (52.84%) CSP type I, 415 (36.86%) CSP type II, and 116 (10.30%) CSP type III cases. There were significant differences between the three types of patients in terms of β-HCG levels, gestational sac diameter, clinical symptoms and presence of fetal heartbeat at diagnosis (P < 0.01). Among these, 89.90% of CSP type I, 88.90% of CSP type II and 50% of CSP type III patients were treated with hysteroscopic lesion excision, 7.9% of CSP type I and 2.2% of CSP type II patients underwent ultrasound-monitored curettage, and the remaining patients underwent lesion excision and and simultaneous repair of excised lesions by different routes (trans-laparoscopic, transabdominal or transvaginal methods). And 5.55% of CSP type I, 22.65% of CSP type II and 43.10% of CSP type III patients were treated with adjunctive uterine artery embolization (UAE). The patients were followed up for more than 2 years after surgery. Among the 166 re-pregnancies, 58 (34.94%) were normal pregnancies, 17 patients reoccurred with CSP, the recurrent rate of CSP was 10.24%. All 58 normal pregnancies were terminated by cesarean section, with a mean gestational week of delivery of (38.36 ± 2.25) weeks, a mean birth weight of (3228.45 ± 301.96)g, and the postnatal Apgar score was (9.86 ± 0.23) points at 1 min and all 5 min were 10 points. Logistic regression analysis suggested that the number of previous cesarean deliveries was a risk factor for recurrent CSP (RCSP) (OR = 10.82, 95% CI: 2.52–46.50, P = 0.001).ConclusionsThe type of CSP is related to β-HCG values, presence of fetal heartbeat, gestational sac diameter and clinical symptoms. Hysteroscopic therapy is a commonly used surgical procedure and UAE is often used as an adjuvant treatment. For subsequent pregnancies, the number of previous cesarean deliveries is a risk factor for recurrent CSP.

Reproductive outcomes of cesarean scar pregnancies treated with uterine artery embolization combined with curettage

ObjectiveThe aim of this study was to review the reproductive outcomes of women with a cesarean scar pregnancy (CSP) treated with dilation and curettage (D&C) after uterine artery embolization (UAE). Materials and methodsThis was a retrospective study to review women who received UAE followed by D&C for CSP between January 2010 and December 2019 at the Changhua Christian Hospital, Changhua in Taiwan. Data were collected from both electronic and paper medical records. Patients were contact via phone call to follow up reproductive outcomes between January 2021 and March 2021. These subsequent reproductive outcomes (including pregnancy rate, secondary infertility rate, miscarriage rate, live birth rate, and recurrent CSP rate) were recorded and analyzed. ResultsA total of 53 cases of women who received UAE followed by D&C for CSP were identified. The women's average age was 34.8 ± 5.1 years. The mean gestational age at diagnosis was 6.2 ± 1.1 weeks. The mean level for human chorionic gonadotropin was 23,407.7 ± 29,105.5 mIU/ml. The average of blood loss during D&C was 19.2 ± 43.6 ml. The average hospitalization time after D&C was 3.5 ± 1.1 days. Of the 53 cases, 10 patients were lost to follow-up and 43 patients agreed to follow-up on reproductive outcomes in 2021. Twenty-three patients who desired to conceive were analyzed. Nineteen out of these 23 women (82.6%) succeeded in conceiving again and gave birth to 15 healthy babies (78.9%). Only one woman (1/19, 5.3%) experienced recurrence of CSP. The average time interval between previous CSP treatment and subsequent conception was 10.4 ± 6.7 months. ConclusionUAE combined with curettage treatment in CSP patients results in a positive rate of subsequent pregnancy outcomes. This minimally invasive procedure may be considered as one of the treatment options for CSP, as it enables preservation of fertility after treatment.

Recurrent Cesarean Scar Pregnancy: Case Series and Literature Review

(Abstracted from Ultrasound Obstet Gynecol 2021;58:121–126) There has been an increase in the number of cesarean deliveries (CDs) over the years and, with it, the publication of more cesarean scar pregnancy (CSP) data. Several authors have reported that, even with successful CSP treatment, there is a risk of recurrence.

Safety and Efficacy of a Single Local Methotrexate Injection for Cesarean Scar Pregnancy

To investigate the safety and efficacy of a single local methotrexate (MTX) injection for the treatment of cesarean scar pregnancy (CSP), assess reproductive outcomes after treatment, and confirm clinical outcomes after the treatment of CSP patients according to the presence of fetal cardiac activity or serum human chorionic gonadotropin (hCG) levels. A retrospective cohort study. A university hospital. Women with CSP. Single local MTX injection under transvaginal ultrasound guidance. A total of 45 CSP cases were identified; the mean (standard deviation, range) estimated gestational age was 7.7 (1.7, 5.4-12.5) weeks and the mean serum hCG level was 51 801 (40 761, 2307-187 898) mIU/mL. Three cases required additional treatment with MTX, and none of the cases needed uterine artery embolization or hysterectomy. The success rate for a single dose was 93.3%, and it was 100% if additional treatments with MTX were included. The mean time required for hCG normalization in those with fetal cardiac activity or with an initial level of hCG greater than 100 000 mIU/mL was not significantly longer than that in the controls (93.4 vs 77.1 days, p=.12; 113.7 days vs 83.6 days, p=.10). Of the 23 women who desired a subsequent pregnancy, 13 delivered 14 healthy newborns after treatment, 3 had an ongoing pregnancy, and 3 experienced recurrent CSP. A single local MTX injection is safe and effective for the treatment of CSP despite the presence of fetal cardiac activity or any initial level of hCG and may allow the possibility of a subsequent uneventful pregnancy.

The Role of Transvaginal Two-Dimensional Ultrasound Combined With Color Doppler in the Evaluation of Ovarian Function and Fertility After Uterine Artery Embolization.

Our study seeks to assess the value of transvaginal two-dimensional ultrasound combined with color Doppler in evaluating ovarian function and reproductive function after uterine artery embolization (UAE). Totally 64 cases with cesarean scar pregnancy (CSP) were collected. Their information was recorded, including baseline information, intraoperative and postoperative information, preoperative and postoperative uterine receptivity, and preoperative and postoperative levels of sex hormones in serum. Finally, the patients were followed up to observe whether they were pregnant after treatment. In comparison with 24 hours after UAE, decreases were found in endometrial blood flow pulsatility index (PI), endometrial thickness, ovarian artery peak end-systolic velocity (Vs), ovarian artery resistance index (RI), and the ratio of Vs to peak end-diastolic velocity (S/D) 1 and 3 months after embolization, while Vd increased markedly 3 months after embolization. In addition, in terms of sex hormones, a significant increase was revealed in the level of follicle-stimulating hormone, while the reduction in the levels of luteinizing hormone (LH), estrogen (E2), prolactin (PRL), and progesterone (P) in the first month and the third month of menstrual resumption compared with those before treatment. From the follow-up data, there were 50 cases of pregnancy, including 45 cases of intrauterine pregnancy, 2 cases of tubal pregnancy, and 3 cases of recurrent CSP. UAE is a safe and effective method to prevent massive hemorrhage of CSP. Transvaginal two-dimensional ultrasound combined with color Doppler can more accurately evaluate its therapeutic effect and provide a basis for effective treatment.

Recurrent Cesarean scar pregnancy: case series and literature review.

To determine the rate of recurrent Cesarean scar pregnancy (CSP) in our clinical practices and to evaluate whether the mode of treatment of a CSP is associated with the risk of recurrent CSP, as well as to review the published literature on recurrent CSP. We performed a retrospective search of our six obstetric and gynecological departmental ultrasound databases for all CSPs and recurrent CSPs between 2010 and 2019. We extracted various data, including number of CSPs with follow-up, number of cases attempting and number achieving pregnancy following treatment of CSP and number of recurrent CSPs, as well as details of the treatment of the original CSP. After analyzing the clinical data, we evaluated whether the mode of treatment terminating the previous CSP was associated with the risk of recurrent CSP. We also performed a PubMed search for: 'recurrent Cesarean scar pregnancy' and 'recurrent Cesarean scar ectopic pregnancy'. Articles were reviewed for year of publication, and extraction and analysis of the same data as those obtained from our departmental databases were performed. Our database search identified 252 cases of CSP. The overall rate of clinical follow-up ranged between 71.4% and 100%, according to treatment site (mean, 90.9%). Among these, 105 women had another pregnancy after treatment of the previous CSP. Of these, 36 (34.3%) pregnancies were recurrent CSP, with 27 women having a single recurrence and three women having multiple recurrences, one with two, one with three and one with four. We did not find any particular single or combination treatment mode terminating the previous CSP to be associated with recurrent CSP. The literature search identified 17 articles that yielded sufficient information for us to evaluate their reported prevalence of recurrent CSP. These reported 1743 primary diagnoses of CSP, of which 944 had reliable follow-up. Data were available for 489 cases that attempted to conceive again after treatment of a previous CSP, and on the 327 pregnancies achieved. Of these, 67 (20.5%) were recurrent CSP. On the basis of our pooled clinical data and review of the literature, recurrent CSP is apparently more common than was previously assumed based upon mostly single-case reports or series with few cases. This should be borne in mind when counseling patients undergoing treatment for CSP regarding their risk of recurrence. We found no obvious causal relationship or association between the type of treatment of the previous CSP and recurrence of CSP. Patients who become pregnant after treatment of a CSP should be encouraged to have an early (5-7-week) first-trimester transvaginal scan to determine the location of the gestation. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Recurrent cesarean scar pregnancy treated successfully with uterine artery chemoembolization.

Recurrent cesarean scar pregnancy treated successfully with uterine artery chemoembolization.

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.

Reproductive outcomes of cesarean scar pregnancies pretreated with methotrexate and uterine artery embolization prior to curettage

ObjectiveTo evaluate the reproductive outcomes of cesarean scar pregnancy (CSP) pretreated with methotrexate (MTX) and uterine artery embolization (UAE) prior to curettage. Materials and methodsThe medical records of patients with CSP who were pretreated with MTX and UAE prior to curettage in our institute from January 2013 to December 2015 were collected and retrospectively reviewed. ResultsA total of 53 patients were eligible for further analysis. Consecutive systemic MTX or a single dose of MTX was administered in 31 or 15 patients, respectively. The UAE procedure was uneventful, and no side effects occurred. The duration of the curettage operation was 21.4 ± 10.4 min, and the volume of blood loss was 23.5 ± 61.6 ml. The serum β-HCG level returned to normal 36.1 ± 10.1 days after the date of initial MTX administration. Eight of 10 patients with a desire to have children became pregnant naturally. Two (25%) patients developed recurrent CSP during the first trimester. One patient underwent emergency cesarean delivery and hysterectomy due to placental implantation and sudden massive hemorrhage during delivery. A total of 6 live newborns were delivered. ConclusionPretreatment with MTX and UAE prior to curettage is safe and effective for the management of CSP. The reproductive outcomes are encouraging.

Different treatment modalities and outcomes in cesarean scar pregnancy: a retrospective analysis of 31 cases in a unıversity hospital.

There is no standardized treatment modality or a generally accepted guideline in cesarean scar pregnancy (CSP) treatment. The aim of this study is to retrospectively evaluate the outcomes of the different treatment modalities used in CSP treatment. 31 CSP patients retrospectively evaluated between May 2011 and February at Uludag University Hospital in Bursa, Turkey included in the study. A graphical flowchart according to the treatment modalities and timeline graphics of the patients were used. Main outcome measures were recurrent CSPs and healthy pregnancies in clinical follow-up after a successful CSP treatment. 31 CSP patients were treated with six different treatment modalities in our series. Recurrent CSP was diagnosed in three patients after a successful CSP treatment. All of these recurrent CSPs were treated with D/C procedure in their first CSP. Six patients conceived again in clinical follow-up after successful treatment of CSP. CSP is a serious maternal complication that risks the mother's life, and this problem is growing because of the increased cesarean rates. Invasive procedures applied to the uterus in CSP treatment may cause recurrent CSP in the next pregnancy of the patient. When considering the treatment options of the CSP, minimally invasive treatment modalities and the subsequent gestation of the patient should be taken into account.

Outcomes of subsequent pregnancies in patients following treatment of cesarean scar pregnancy with high intensity focused ultrasound followed by ultrasound-guided dilation and curettage

Objective: To evaluate the outcomes of subsequent pregnancies in patients with a history of cesarean scar pregnancy (CSP) treated with high intensity focused ultrasound (HIFU) followed by ultrasound-guided dilation and curettage (USg-D&C).Methods: A retrospective analysis was performed on data collected from 154 patients with CSP who were treated by HIFU followed by USg-D&C in Suining Central Hospital between January 2015 and January 2018. Among them, 28 patients wanted to conceive following treatment. Baseline characteristics, treatment results, intraoperative hemorrhages during USg-D&C, post-curettage serum beta human chorionic gonadotropin (β-hCG) levels and vaginal bleeding were investigated. Subsequent pregnancy outcomes, including intervals between pregnancy and treatment of CSP, complications during pregnancy, and outcomes of newborns were evaluated.Results: All patients with CSP were successfully treated by HIFU combined with USg-D&C. Of the 28 CSP patients who intended to conceive after the treatment, 23 patients (82.14%) successfully conceived. The average interval between conception and HIFU treatment was 18.38 ± 10.04 months. Eighteen patients (78.26%) had an intrauterine pregnancy, in which 12 had delivery by cesarean section, 1 had an ongoing pregnancy, and 5 had an abortion in the first trimester. Among the other 5 women, 3 had tubal ectopic pregnancy and 2 had recurrent CSP. These five patients underwent laparoscopy within the first trimester.Conclusion: HIFU followed by USg-D&C is an effective and safe treatment for patients with CSP who wish to conceive. Prospective multi-center studies with larger sample sizes and longer follow-up periods are needed to compare this treatment with others.

Analysis of the Reproductive Outcome of Patients with Cesarean Scar Pregnancy Treated by High-Intensity Focused Ultrasound and Uterine Artery Embolization: A Retrospective Cohort Study

To investigate risk factors for infertility and recurrent cesarean scar pregnancy (CSP) after previous CSP. A retrospective cohort study (Canadian Task Force classification II-1). University hospital. Between January 2007 and April 2016, a total of 650 patients were included, all diagnosed with CSP and treated by high-intensity focused ultrasound (HIFU) and uterine artery embolization (UAE), followed by suction curettage under hysteroscopic guidance. None. Follow-up of the reproductive outcomes ended in June 2017. A total of 135 of the 650 patients with CSP were involved in the study, among whom 32 became infertile, 78 had an intrauterine pregnancy, and 25 had recurrent CSP after previous CSP. Age (≥35 years; odds ratio [OR], 4.252; p = .002), β-human chorionic gonadotropin (≤5000 mIU/mL; OR, 3.778; p = .011), and longer duration of amenorrhea (>56 days; OR, 2.507; p = .05) were risk factors for infertility. Treatment with UAE (OR, 5.796; p = .003), more abortions (≥4; OR, 2.851; p = .022), and being asymptomatic (OR, 4.175; p = .039) were risk factors for recurrent CSP. There was no statistically significant difference in the subsequent outcomes of pregnant women in the HIFU and UAE groups (p >.05). More attention should be given to subsequent reproductive outcomes after CSP, not only for intrauterine pregnancy, but also for infertility and recurrent CSP. Early diagnosis and treatment of CSP could reduce the risk of infertility and recurrent CSP. HIFU seemed to be superior to UAE in reducing the risk of recurrent CSP. Patients with CSP should adhere to strict contraception if they do not desire more children.

Comparison of systemic and local methotrexate treatments in cesarean scar pregnancies: time to change conventional treatment and follow-up protocols

ObjectiveThe aim of this study was to compare the use of systemic and local methotrexate in the treatment of cesarean scar pregnancy. Study designIn this retrospective cohort study, we collected the data of 44 patients with cesarean scar pregnancy. The patients were grouped according to treatment modality: Group 1, local methotrexate injection (n=17) and Group 2, systemic methotrexate (n=27). The groups were compared with respect to side effects, recovery time, reproductive outcome, and treatment cost. ResultsThe mean gestational age at diagnosis (6.4±0.93 vs. 5.4±0.80 weeks, p=0.001), pretreatment serum β-human chorionic gonadotrophin level [27,970 (11,010–39,421) vs. 7606 (4725–16,996) mIU/mL, p=0.001], and lesion size (2.74±1.36 and 1.28±0.55cm, p=0.001) were higher in Group 1. All patients were cured by primary therapy without additional surgery. The mean times for β-human chorionic gonadotrophin normalization, the uterine-mass disappearance, were significantly shorter in Group 1 than in Group 2 (6.17±1.55 vs. 8.11±2.0 weeks, p=0.001 and 10.47±4.14 vs. 13.40±4.44 weeks, p=0.002, respectively). The cost of treatment was similar between groups (281.133±112.123$ vs. 551.134±131.792$, p=0.76). The total pregnancy rates were not different between groups (5/16, 31.4% vs. 6/11, 54.6%, p=0.301). One recurrent cesarean scar pregnancy occurred after systemic methotrexate. Oral ulcers, the most common side effect, were seen in seven patients in Group 2. ConclusionEven though treatment success and reproductive outcomes are similar, local methotrexate is superior to systemic methotrexate with regard to recovery time, side effects, and treatment costs, even in patients with unfavorable pretreatment prognostic predictors.

Reproductive outcomes following cesarean scar pregnancy – a case series and review of the literature

ObjectiveTo assess the reproductive outcomes following cesarean scar pregnancy (CSP) in our center and review of published literature on CSP and subsequent reproductive issues. MethodsOver a 3-year period, 28 cases of CSPs were diagnosed in our hospital. Follow up data of 22 cases were available which included the gestational age at diagnosis of CSP, treatments employed and outcomes of previous cesarean scar pregnancy. We also had details on subsequent fertility outcomes in these women, which included intervals between the previous CSP and subsequent pregnancy, maternal and neonatal outcomes of these subsequent pregnancies and mode of delivery. ResultsEight women desired to conceive and amongst them, seven women manage to conceive spontaneously. There were five pregnancies delivered at term, two miscarriages and one recurrent CSP. One patient had placenta accreta diagnosed at cesarean section at term and had massive hemorrhage. The remaining 4 term pregnancies were delivered uneventfully by elective cesarean sections. The mean interval between the cesarean scar pregnancy and subsequent pregnancy was 24.6 months (range 9–48 months). One patient experienced secondary infertility and despite thorough investigations, no abnormalities were detected. One of the women who did not desire future fertility conceived spontaneously at 9 and 18 months respectively after one CSP and had induced abortions twice. There were 3 women who had uterine scar defect repaired, only 1 resulted in a live birth but had placenta accreta with a lower uterine segment defect and suffered from massive hemorrhage, one woman had a subsequent miscarriage with a diverticulum in the lower uterine segment, and one woman had unexplained secondary infertility. ConclusionMost women were able to conceive following CSPs. Reproductive outcomes included normal intrauterine term pregnancy, miscarriage, recurrent CSP, and infertility. Placenta accreta, which could be misdiagnosed antenatally, was a serious complication in subsequent pregnancies. Diverticulum or defect in the lower uterine segment could happen after CSP. Repair of the uterine defect, following a CSP neither guaranteed the healing of the scar, nor the ability to ensure a safe pregnancy outcome. Appropriate counseling to women desiring fertility with a history of CSP is essential and once they conceive early referral to tertiary centers for follow up is pertinent.

Identifying risk factors for recurrent cesarean scar pregnancy: a case-control study

To investigate risk factors for recurrent cesarean scar pregnancies. Case-control study. University hospital. Twenty-one women with recurrent cesarean scar pregnancies and 42 women with single cesarean scar pregnancies. None. Risk factors and historical factors that might be predisposing factors in recurrent cesarean scar pregnancy. The risk factors of recurrent cesarean scar pregnancy were cesarean delivery history in rural community hospitals (odds ratio [OR] 4.75), thinner lower uterine segment (≤5mm; OR 7.10), gestational sac bulging into the uterovesical fold (OR 6.25), history ofirregular vaginal bleeding or lower abdominal pain in an earlier cesarean scar pregnancy (OR 3.52), and early termination (≤56days) of the first cesarean scar pregnancy (OR 5.85). These findings provide evidence for the prevention of recurrent cesarean scar pregnancy and early diagnosis of the disease. Early recognition and diagnosis of this disease might be feasible because of the identifiable risk factors. Clinicians should be aware of the possible existence of recurrence. An accurate and prompt diagnosis is crucial to avoid catastrophic complications such as uterine rupture, massive vaginal bleeding and placenta previa/accreta, which might lead to hysterectomy.

Transvaginal Methotrexate Injection for the Treatment of Cesarean Scar Pregnancy: Efficacy and Subsequent Fecundity

Study ObjectiveTo investigate the efficacy of local methotrexate (MTX) injections under transvaginal ultrasound guidance for treatment of cesarean scar pregnancy (CSP) and to assess fecundity after treatment. DesignRetrospective review (Canadian Task Force classification II-3). SettingUniversity hospital. PatientsEight women with CSP. InterventionTransvaginal MTX injection. Measurements and Main ResultsWe retrospectively reviewed 8 CSP cases treated with local MTX injection under transvaginal ultrasonographic guidance. In all cases, the serum human chorionic gonadotropin concentration was monitored and the gestational sac was evaluated using ultrasonography after treatment. Magnetic resonance imaging was performed as necessary. Patient clinical characteristics, clinical course after treatment, treatment efficacy, and fecundity after treatment in patients desiring subsequent pregnancies were evaluated. All 8 women were successfully treated without the need for blood transfusions or surgical procedures, although 2 required additional MTX therapy via local injection or systemic administration. The mean (SD) time to human chorionic gonadotropin normalization was 78.5 (37.7) days (range, 42–166 days). Four of 5 patients desiring subsequent pregnancies after the treatment had uneventful parturition, and recurrent CSP was diagnosed in 1 patient. ConclusionsTransvaginal MTX injection was effective and safe as sole treatment of CSP. Although the treatment course tended to be long, this method can be considered the first choice of treatment in patients desiring future pregnancies. However, careful attention should be paid to the possibility of CSP recurrence.

Cesarean scar pregnancy: an analysis of 100 cases

To explore the clinical diagnosis and treatment of cesarean scar pregnancy (CSP). The clinical data of 100 CSP patients during the period of January 2003 to March 2011 were collected for a retrospective analysis. Among 100 cases of CSP, there were cases of asymptomatic (45%, n = 45), vaginal hemorrhage (55%, n = 55) and lower abdominal pain (7%, n = 7); among first diagnosed (n = 81), the cases were diagnosed (n = 75) or misdiagnosed (n = 6); among 19 hospital referrals, 18 were confirmed and 1 case was misdiagnosed as choriocarcinoma. Treatments included ultrasound monitoring curettage after UAE (uterine artery embolism) (n = 56), pure ultrasound monitoring curettage (n = 30), laparoscopic lumpectomy after UAE (n = 2), laparoscopic lumpectomy (n = 2), methotrexate only (n = 3), hysterectomy (n = 2), UAE hemostasis (n = 3) and Foley catheter balloon compression hemostasis (n = 2). No significant difference was found in the average duration of pregnancy, average operative hemorrhage volume and operative duration between 2 management groups of curettage after UAE or pure curettage (P > 0.05). But sac diameter and serum level of β-HCG were obviously less in the pure curettage group than those in the UAE group. And the distance between gestation sac and bladder significantly was greater than that in the UAE group; in the pure curettage group, 96.7% existed as an endogenous type and only 36.7% yielded small flow signals. One hundred patients recovered before discharge. A follow-up of patients with curettage after UAE (n = 43) and pure curettage (n = 26) had similar recovery of menstruation. Eight cases (4 in each) were pregnant again during the follow-up. One case of recurrent CSP was treated with curettage after methotrexate. Early diagnosis and early treatment remain the key for a successful treatment of CSP. Color Doppler ultrasound is important in its early diagnosis and treatment. Different therapeutic modalities may be selected according to specific patient conditions.

Fertility Performance and Obstetric Outcomes Among Women With Previous Cesarean Scar Pregnancy

The purpose of this study was to assess fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy. We conducted a retrospective study in a large tertiary hospital in Israel. The study included 18 women with a diagnosis of cesarean scar pregnancy between 2000 and 2009. The incidence of cesarean scar pregnancy among our parturient patients was 1 per 3000 for the general obstetric population and 1 per 531 among those with at least 1 cesarean delivery. Sixteen were treated primarily with methotrexate. Two were treated primarily by surgery, and 2 more were treated by surgery after failed methotrexate treatment. After cesarean scar pregnancy treatment, 7 women conceived spontaneously, and 1 conceived by in vitro fertilization-intracytoplasmic sperm injection. The remaining 10 (55%) did not wish to conceive again. Two of the women who became pregnant (25%) had recurrent cesarean scar pregnancy. This study shows encouraging results for fertility performance and obstetric outcomes after treatment of cesarean scar pregnancy. Nevertheless, the risk of recurrent cesarean scar pregnancy is not negligible.

Management of cesarean scar pregnancy by hysteroscopy combined with uterine artery embolism

To investigate safety and efficacy of hysteroscopy in treatment of cesarean scar pregnancy (CSP). From Aug. 2003 to Dec. 2011, 33 cases with CSP treated by hysteroscopy guided by transabdominal ultrasound or laparoscopy were studied retrospectively in Women's Hospital, School of Medicine, Zhejiang University. The clinical characteristics including gestational age, myometrial thickness anterior to the CSP, β-hCG level before treatment, success rate, cure rate, operative time, blood loss, time of serum β-hCG resolution and CSP mass clearance, and complication were collected and analyzed. Median gestational age was 54 days (range, 37 - 140 days). Median level of β-hCG before treatment was 15 000 U/L (range, 3.3 - 151 747 U/L). Mean thickness of anterior myometrium was 3.3 mm. Twenty-nine cases underwent uterine artery embolism (UAE) before hysteroscopy. Pouch in the anterior uterine isthmus with gestation masses implanted were observed in 30 cases (91%, 30/33). CSP masses progressed toward the pouch or uterine cavity in all cases was removed by cutting wire loop electrode combined with curettage. The mean operative time was (34 ± 10) minutes. Both success rate and cure rate were 94% (31/33). Salvage methotrexate (MTX) therapy was administrated in one case. Complication occurred in three cases (9%, 3/33). Both massive hemorrhage rate and hysterectomy rate were performed in two cases (6%, 2/33). No uterine perforation occurred. The mean time of hCG resolution was (22 ± 10) days. The mean time of CSP mass clearance was (21 ± 12) days. Four pregnancies were achieved in four cases: one term pregnancy and three abortions. No recurrent CSP occurred. Management of CSP by hysteroscopy combined with UAE is safe and effective.

Successful treatment of a recurrent Cesarean scar ectopic pregnancy by surgical repair of the uterine defect

Cesarean-scar pregnancy—which is defined as the implantation of a gestational sac into deficient myometrium at the site of a uterine incision—is a late serious complication of Cesarean section1. There is currently no consensus as to the most effective management of Cesarean-scar ectopic pregnancy, and little is known about the outcome of subsequent pregnancies2. In this report, we present a case of a woman diagnosed with three consecutive Cesarean-scar ectopic pregnancies. She underwent a successful repair of the uterine defect, resulting in normal intrauterine implantation of her subsequent pregnancies. A 39-year-old woman, gravida 3 para 2, attended for an early pregnancy ultrasound scan with a history of vaginal bleeding. Her two children had both been delivered by Cesarean section. On ultrasound scan a diagnosis of a viable 12-week Cesarean-scar ectopic pregnancy was made. The placenta was implanted low within the anterior uterine wall. The myometrium at the implantation site appeared severely deficient, with only a thin layer of tissue separating the pregnancy from the urinary bladder. After discussion she opted for a laparoscopy and suction evacuation of the pregnancy under ultrasound-scan guidance. The procedure was complicated by profuse vaginal bleeding, which was eventually controlled by the insertion of a Shirodkar suture. Five units of blood were transfused peri-operatively. The postoperative recovery was uneventful and she attended for the removal of the cervical suture 5 days later. Ten months later she attended for another scan, which showed a 7-week viable recurrent Cesarean-scar pregnancy. The pregnancy was removed by suction curettage without complications. Six months later she attended again with a 4-week Cesarean-scar ectopic, which was also removed surgically without complications. Three months following her third Cesarean-scar ectopic a laparotomy was performed to repair the uterine-scar defect. The deficient scar was completely excised and the uterine wall was then closed in three layers including the visceral peritoneum. Her postoperative recovery was uneventful and she was discharged a week later. On histological examination, the excised uterine scar tissue contained an old suture remnant and it showed evidence of chronic inflammation and fibrosis. A follow-up scan 2 months after laparotomy revealed a well-healed uterine scar with no evidence of residual myometrial defect (Figures 1 and 2). Transvaginal ultrasound scan showing deficient myometrium at the site of a previous Cesarean scar. Transvaginal ultrasound scan showing a repaired Cesarean-scar defect after laparotomy. Eight months after the operation she had a biochemical pregnancy, which was not detectable on the scan. Following this she had two pregnancies, which were both located normally within the uterine cavity. Although the pregnancies initially contained embryos with evidence of cardiac activity, they both miscarried spontaneously at 7 and 8 weeks' gestation, respectively. Until this case, there have been only two previous reports of recurrent Cesarean-scar pregnancies in the world literature3, 4. This low prevalence of recurrent scar pregnancies indicates that implantation into the scar is more likely to be a chance event, rather than the result of a particular affinity of a pregnancy for implanting into the scar. It is possible that the risk of scar implantation may be proportional to the size of the anterior uterine wall defect. The patient described in this report had a particularly large defect on the scan, which supports this hypothesis. Our case report also shows that laparotomy and repair of a uterine defect may be successful in preventing recurrent Cesarean-scar ectopics. Major open surgery and uterine repair may be complicated by poor scar healing and postoperative intra-abdominal adhesions, both of which may have a detrimental effect on the patient's future fertility. Therefore, we suggest that repair should only be considered in recurrent cases or in women with unusually large uterine defects. J. Ben Nagi*, D. Ofili-Yebovi*, E. Sawyer*, J. Aplin*, D. Jurkovic*, * Early Pregnancy and Gynaecology Assessment Unit, King's College Hospital, Denmark Hill, London SE5 8RX, UK