Treatment Of Cesarean Scar Pregnancy Research Articles

Case Series: Medical Versus Surgical Management of Cesarean Scar Pregnancy [ID 2683419

INTRODUCTION: Although cesarean scar pregnancy (CSP) is rare, it is a potentially fatal condition, and the incidence is rising. Treatment of CSP may consist of medical management with methotrexate or surgical management; however, a consensus regarding optimal treatment has not been well defined. This series reports our experience with management of CSP. METHODS: Our series included a chart review that identified 10 cases of CSP from 2020 to 2023 at a high-volume, community-based, academic hospital that serves as a surgical referral center in a metropolitan area. We obtained IRB exemption. RESULTS: At diagnosis of CSP, gestational age by ultrasound ranged from 5 6/7 weeks to 11 4/7 weeks. None of the pregnancies had ruptured. Eight cases reported symptoms including bleeding or abdominal pain. Six underwent surgical management: one dilation and evacuation (D&E), one D&E converted to laparotomy, two combined D&Es with robotic-assisted laparoscopic excisions, and two laparotomies with excision. Four received methotrexate: one intragestational, two dual-dose intramuscular, and one single-dose intramuscular. All surgical cases resulted in definitive resolution. Of those treated with methotrexate, three of four cases required additional methotrexate treatment. Time from initial dose of methotrexate to resolution ranged from 29 to 95 days. CONCLUSION: In our experience, the advancement of gynecologic surgical modalities has broadened options for CSP treatment to allow for definitive and timely management. Methotrexate remains a viable option; however, treatment failures occur and may prolong a potentially life-threatening condition. Our findings strengthen the recommendation for surgical management, consistent with SMFM guidelines. Furthermore, there is an opportunity to provide surgical training to better equip gynecologists with the ability to treat this challenging condition.

The value of ultrasound parameters in predicting the efficacy of transabdominal ultrasound-guided suction curettage alone in the treatment of cesarean scar pregnancy.

To investigate the value of ultrasound parameters in assessing the efficacy of transabdominal ultrasound (TAUS)-guided suction curettage alone for cesarean scar pregnancy (CSP). Secondary retrospective analysis of a prospective study consisted of 137 women diagnosed with CSP who were performed TAUS-guided suction curettage alone for the first time at Maternity and Child Health Care of Guangxi Zhuang Autonomous Region in China. Prior to surgery, an ultrasound examination was conducted. Based on the need for secondary intervention, the patients were categorized into failure group and success group, and the predictive factors for failure of TAUS-guided suction curettage alone were analyzed. Multivariate logistic regression showed that maximum diameter of the gestational sac>29 mm (odds ratio [OR] = 4.043, 95% CI: 1.100-14.862), residual myometrium thickness ≤1.8 mm (OR = 3.719, 95% CI: 1.148-12.048) and chorionic villi thickness at the scar >4.7 mm (OR = 15.327, 95% CI: 4.617-50.881) were independent predictors of failure in TAUS-guided suction curettage alone for CSP. Furthermore, the logistic regression model that was jointly constructed by these three predictors demonstrated an area under the curve, sensitivity, specificity, and Youden index of 0.913, 0.912, 0.864, and 0.776, respectively. The maximum diameter of the gestational sac, residual myometrium thickness, and chorionic villi thickness at the scar has certain predictive efficacy of TAUS-guided suction curettage alone for CSP. Nevertheless, it is more valuable to apply the model of this study, composed of the three ultrasound parameters, for this prediction purpose.

Dilatation and Curettage after Uterine Artery Embolization versus Methotrexate Injection for the Treatment of Cesarean Scar Pregnancy: A Single-Center Experience.

Background and Objectives: Cesarean scar pregnancy (CSP) represents a type of ectopic pregnancy in which the embryo implants inside the scar of a previous cesarean section. This condition can lead to maternal morbidity and mortality. The best therapeutic approach in terms of clinical effectiveness and patient safety for CSP has not been described yet, although different therapeutic strategies are currently available. The purpose of the present study was to analyze the success rate of two different treatments in a single institution. Materials and Methods: A retrospective study was performed among patients diagnosed with CSP at the Gynecology and Obstetrics Department of the "Cannizzaro" Hospital in Catania (University of Enna-Italy) from January 2016 to December 2022. The diagnosis was made by 2D/3D transvaginal ultrasound, following Timor-Tritsch criteria. Two treatment strategies were performed: local and systemic methotrexate (MTX) injection and uterine artery embolization (UAE) with subsequent dilatation and curettage (D&C). All treated women underwent subsequent clinical and sonographic follow-up. Complete recovery was defined as the reduction of β-HCG values until it was undetectable and the disappearance of the mass in the uterine scar on ultrasound. Results: Nineteen patients were included; nine were in the MTX group and ten were in the UAE + D&C group. No significant differences were found between the two groups in terms of clinical parameters. Treatment was successful in 4 of 10 (44%) patients in the MTX group and 10 of 10 (100%) in the UAE + D&C group (p = 0.01); the length of hospital stay was significantly shorter in the latter group (p < 0.0001). Conclusions: In our experience, administration of MTX is not recommended as the primary treatment or pre-treatment. Dilatation and curettage after uterine artery embolization are better than methotrexate injection for the treatment of cesarean scar pregnancy in a single-institution series in terms of complete recovery and length of hospital stay.

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

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

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

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

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

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

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

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

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.

Effect of Mifepristone Preconditioning on Stress Response and Sex Hormone Levels after Combined Laparoscopic Treatment for Cesarean Scar Pregnancy: A Prospective Randomized Trial

Effect of Mifepristone Preconditioning on Stress Response and Sex Hormone Levels after Combined Laparoscopic Treatment for Cesarean Scar Pregnancy: A Prospective Randomized Trial

EP27.15: Conservative treatment for Caesarean scar pregnancy: uterine artery embolisation followed by suction evacuation

EP27.15: Conservative treatment for Caesarean scar pregnancy: uterine artery embolisation followed by suction evacuation

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 &amp; 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&amp;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 &lt;5.1IU was achieved. 16.66 percent patients underwent D&amp;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.

P-496 The effect of adding letrozole to the combined treatment of caesarean scar pregnancy with methotrexate followed by hysteroscopic evacuation of products of conception

Abstract Study question Does adding letrozole to combined cesarean scar pregnancy (CSP) treatment cause a greater decrease in B-human chorionic gonadotropin (B-hCG) concentrations and less blood loss? Summary answer The addition of letrozole to the combined CSP treatment does not result in a greater decrease in B-hCG concentrations or less blood loss. What is known already There is no reference treatment for CSP as the limited number of cases precludes the extrapolation of results. In our center we successfully use two-step treatment with methotrexate followed by hysteroscopic removal of products of conception (POC). The time in between is needed to achieve a decrease in the trophoblast's vital potential (B-hCG fall) and its vascularization. The suppression of estradiol production by letrozole may interfere with the physiological effect of progesterone, which is essential for the maintenance of pregnancy. Additional administration of letrozole could further reduce the vital potential of the pregnancy, resulting in a lower rate of complications. Study design, size, duration A prospective cohort tertiary single-center study (consent no. 1072.6120.321.2020) was conducted among women with CSP from January 2021 to December 2022. Only women with increasing concentrations of B-hCG and consent of the Bioethics Committee for termination of pregnancy were included. Women with decreasing B-hCG concentrations were excluded. All enrolled women gave informed written consent to participate in the study. Participants/materials, setting, methods All women received a single dose of 100 mg MTX intravenously and 50 mg MTX in intra-amniotic injection (day 0), along with 30 mg potassium chloride in case of positive fetal heartbeat (FH). Women who consented were additionally given letrozole 5 mg orally (day 0) for 10 days. B-hCG concentration was measured on day 0,4,7. After obtaining satisfactory decrease in B-hCG and POC vascularization, women underwent hysteroscopic evacuation of POC. Blood loss parameters were measured. Main results and the role of chance The study included 28 women aged 27-41, with a gestational age of 6-12 weeks. FH was present in 17/28 (60.7%) women. Of the 28 women, 16 (57.1%) received additional letrozole (arm 1). There was no significant difference between arm 1 vs. arm 2 (without letrozole) in terms of gestational age (7.69±1.54 vs. 8.00±2.09 weeks, p = 0.85), FH positivity (10/16, 62.5% vs. 7/12, 58.33%; p = 1), BMI (25.39±5.08 vs. 26.24±6.51; p = 0.82), day 0 B-hCG (47656.89± 37747.87 vs. 51870.83± 45838.87 mIU/ml; p = 0.89) and day 0 hemoglobin (Hb) (12.98±0.74 vs. 12.74±1.26 g/dl; p = 0.57). Timing of hysteroscopy was not significantly different between arm 1 vs. arm 2 (day 22.19± 14.44 vs. 31.42± 25.83; p = 0.42). The dynamics of B-hCG decline in arm 1 vs. arm 2 between days 4-0 (-3295.67± 15133.13 vs. −6883.00± 20029.88 mIU/ml; p = 0.71) and 7-4 (-13137.82± 13765.14 vs. −19145.75± 23526.70 mIU/ml; p = 0.68) was not significantly different. There were no differences between arm 1 vs. arm 2, in decrease in Hb concentration on day 1 post-hysteroscopy (-1.79± 1.67 vs. −2.19± 1.68 g/dl, p = 0.53), blood loss volume (318.75± 437.37 vs. 591.67 ± 744.02 ml; p = 0.29) and rate of hemorrhage (4/16, 25% vs. 3/12, 25% cases, p = 1). Limitations, reasons for caution The limitations of the study are the small sample size, the single-center nature of the study, and the arbitrarily set dosing regimen of letrozole. Wider implications of the findings The results do not support the use of letrozole in the above regimen as an adjunct to combined CSP treatment. Trials with a larger sample size and with a different letrozole dosing regimen are needed to confront the results. Trial registration number 072.6120.321.2020

Cesarean scar pregnancy: a practical overview and our series of combined double step procedure management.

Cesarean scar pregnancy (CSP), a rare iatrogenic form of ectopic pregnancy (EP), cause of severe maternal morbidity. Each subtype of CSP needs different treatment and there is no consensus about this topic. Despite improvements, the lack of universally accepted therapeutic management and discordance present in literature indicates that treatment has been mainly based on experiences reported. A case series of our double combined approach with methotrexate (MTX) administration followed by vacuum aspiration or resectoscopic approach was reported, with an overview of literature. Eleven patients with CSP underwent a double-step treatment: systemic MTX therapy followed by vacuum aspiration or by resectoscopy, if the gestational sac was embedded deeply in myometrium. For CSP type 1, according to Delphi sonographic classification, with minor potentially risk of complications with a myometrial thickness >3.5 mm, we preferred to adopt vacuum aspiration, while type 2-3 of CSP and myometrial thickness ≤3.5mm were managed with resectoscopy. The average gestational age was 59.1±7.22 days. On the seventh day after MTX administration, the serum β hCG levels decreased in 80% of all patients. After the MTX injection, the CSP mass did not disappear in any patient. MTX therapy was followed by vacuum aspiration in six and by resectoscopy in five cases. In one case bleeding was controlled by Foley balloon treated with vacuum. In type II-III, CSP was performed UAE (uterine artery embolization) followed by resectoscopy procedure. Compared with the results in previous studies, MTX administration followed by suction curettage was more effective than dilatation and curettage and systemic MTX in treatment of CSP. We consider very useful this procedure in case of slow absorption and when the camera was embedded deeply in myometrium (CSP2-3), because that hysteroscopy evaluation of uterine cavity under direct vision is highly accurate in identifying the real cleavage of the gestational camera. We have only used vacuum aspiration in CSP type 1 for minor risk of bleeding.

Analysis of risk factors for patients with cesarean scar pregnancy treated with methotrexate combined with suction curettage.

To analyze the predictive value of clinical and ultrasound parameters for treatment failure after administration of methotrexate (MTX) in combination with suction curettage (SC) in treatment of cesarean scar pregnancy (CSP) in the early first trimester. In this retrospective cohort study, electronic medical records of patients diagnosed with CSP and initially treated between 2015 and 2022 with MTX combined with SC were reviewed and outcome data were collected. 127 patients met inclusion criteria. 25 (19.69%) required additional treatment. Logistic regression analysis indicated that factors independently associated with the need for additional treatment included progesterone level > 25mIU/mL (OR: 1.97; 95% CI: 0.98-2.87, P = 0.039), abundant blood flow (OR: 5.19; 95% CI: 2.44-16.31, P = 0.011), gestational sac size > 3cm (OR: 2.54; 95% CI: 1.12-6.87, P = 0.029), and the myometrial thickness between the bladder and gestational sac < 2.5mm (OR: 3.48; 95% CI: 1.91-6.98, P = 0.015). Our study identified several factors which increase the need for additional treatment following the initial treatment of CSP with MTX and SC. Alternative therapy should be considered if these factors are present.

Risk factors associated with the failure of initial treatment for cesarean scar pregnancy.

To explore the factors related to cesarean scar pregnancy (CSP) treatment failure under different treatment strategies. This is a cohort study that consecutively included 1637 patients with CSP. Characteristics including age, gravidity, parity, previous uterine curettages, time since the last cesarean section, gestational age, mean sac diameter, initial serum β-human chorionic gonadotropin, distance between gestational sac and serosal layer, CSP subtype, classification of blood flow abundance, fetal heartbeat presence, and intraoperative bleeding were recorded. Four strategies were performed separately on these patients. Binary logistic regression analysis was used to analyze the risk factors for initial treatment failure (ITF) under the different treatment strategies. The treatment methods failed in 75 CSP patients, and succeeded in 1298 patients. The analysis found that the presence of a fetal heartbeat was significantly associated with ITF of strategy 1, 2 and 4 (P < 0.05); sac diameter was associated with ITF of strategy 1 and 2 (P < 0.05); gestational age was associated with initial treatment failure of strategy 2 (P < 0.05). There was no difference of the failure rate between ultrasound-guided evacuation and hysteroscopy-guided evacuation for CSP treatment with or without uterine artery embolization pretreatment. Sac diameter, fetal heartbeat presence, and gestational age were all associated with CSP initial treatment failure.

Comparison of clinical safety and efficacy of ultrasound-guided local lauromacrogol injection versus uterine artery embolization in the treatment of caesarean scar pregnancy: a systematic review and meta-analysis

BackgroundThe aim of this systematic review and meta-analysis was to introduce the relatively novel method of ultrasound-guided local lauromacrogol injection (USG-LLI) followed by dilatation and curettage for caesarean scar pregnancy (CSP) and to investigate the clinical safety and efficacy between uterine artery embolization (UAE) and USG-LLI in the treatment of CSP.MethodsThe relevant literature and articles about USG-LLI, UAE and CSP published in eight electronic databases were searched to extract the primary outcomes for the selected articles. Review Manager Software(RevMan) V.5.2 was used for quantitative data synthesis and data analysis. Forest plots, sensitivity analysis and bias analysis were also performed on the included articles.ResultsOf 10 studies included in our search, 623 patients were in the USG-LLI group and 627 patients were in the UAE groups. There were no significant differences between the two groups in terms of success rate, blood loss and time to human chorionic gonadotropin (hCG) normalization. However, USG-LLI group patients than UAE group patients had a shorter duration of hospital stay (mean difference [MD] = -1.97; 95% confidence intervals [CI] -2.63 to -1.31; P < 0.05; I2 = 95%), shorter restored menses (MD = -4.84; 95%CI -5.78 to -3.90; P < 0.05; I2 = 95%), and lower complication rates [odds ratio(OR) = 0.21; 95%CI:0.15 to 0.30; P < 0.05]; and cheaper on expenses of hospitalization (MD = -8028.29; 95%CI -10,311.18 to -5745.40; P < 0.05; I2 = 100%).ConclusionsThe results demonstrate that USG-LLI is comparable in curative effect and success rates with UAE in the therapy of CSP, but patients in the USG-LLI group seem to have fewer complications rates, shorter duration of hospital stays and lower costs.

Predictive factors analysis of cesarean scar pregnancy treated by local injection of Lauromacrogol combined with curettage.

To explore factors related to local injection of Lauromacrogol combined with curettage in the treatment of cesarean scar pregnancy. A total of 24 successful and 8 unsuccessful cases were included. The age, gravidity, parity, times of cesarean section, interval from the last cesarean section, preoperative human chorionic gonadotropin (HCG), HCG on the first day after operation, decreasing rate of HCG on the first day after operation, average diameter of gestational sac, and preoperative vaginal bleeding days were analyzed. There were no significant differences of age, gravidity, parity, previous cesarean section times between groups. The differences of preoperative HCG, HCG on the first day after operation, the decreasing rate of HCG, gestational sac diameter, preoperative vaginal bleeding days were statistically significant between groups. The interval from the last cesarean section and the decreasing rate of HCG were protective factors, while the mean diameter of gestational sac and period of vaginal bleeding before operation were risk factors for the success of the treatment. The mean diameter of gestational sac owned the best predictive value.

Treatments for cesarean scar pregnancy: 11-year experience at a medical center

Background Cesarean scar pregnancy (CSP) is a long-term complication after cesarean section that can cause severe maternal morbidity and mortality. Although a variety of treatments have been described, there is no consensus as to the optimal management approach. Many grading systems for CSP have been proposed, among which the classification made by the consensus of Chinese experts in 2016 was shown to provide improved treatment guidance for clinical practice. The purpose of the present study was to analyze the success rate of different treatments for each type of CSP as classified according to the Chinese Expert’s Consensus (2016), and to develop a management strategy for CSP. Methods A retrospective study was performed among patients diagnosed with CSP at Shandong Provincial Hospital between January 2009 and December 2019. We reviewed clinical characteristics, treatment methods, and subsequent outcomes; and analyzed these endpoints using the statistical software package SPSS 22.0 (SPSS, Inc., Chicago, IL). Results For type I CSP, systemic methotrexate (MTX) administration exhibited a success rate of 79.2% for type Ia and 14.3% for type Ib. Local and systemic MTX administration success rates were 88.9% for type Ia and 66.7% for type Ib. Dilation and curettage (D&C), curettage after uterine artery embolization (UAE + C), and hysteroscopic curettage (H + C) were 100% successful. For type II, UAE + C, H + C, and laparoscopy combined with hysteroscopic curettage (L + H+C) were 100% successful. D&C had a success rate of 97.0% for type IIa and 88.9% for type IIb. The success rate of systemic MTX administration was 52.0% for type IIa and 62.5% for type IIb. Both UAE + C and L + H+C had 100% success rates for type IIIa CSPs, while for type IIIb, the success rate was 87.9% for UAE + C vs. 96.6% for L + H+C. Conclusions For type I CSPs, D&C was quick, easy, and safe; for type II, H + C was more suitable. For type III and some type II patients who wished to undergo simultaneous repair of the cesarean defect, L + H+C was the optimal method. UAE can be used as a complementary option instead of a prophylactic measure, and when difficulties with endoscopic surgeries were encountered, conversion to laparotomy was the ultimate treatment.

Scope and Suction: Hysteroscopic-guided Suction Evacuation of Cesarean Scar Pregnancy - A Safe and Efficacious Treatment for Selected Patients.

This study aimed to evaluate hysteroscopic-guided suction evacuation for the treatment of cesarean scar pregnancy (CSP). This was a retrospective analysis of CSP over 2 years. This study was conducted at KK Women's and Children's Hospital (KKH), Singapore, thirty-seven patients with a CSP. Hysteroscopic-guided suction evacuation to treat CSP used alone or in combination with laparoscopy depending on residual myometrial thickness (RMT) and future fertility requirements. The majority of women (29) were diagnosed under 9-week gestation. Just over a third (13) had an RMT of more than 3 mm. Women with an RMT <3 mm had added laparoscopy. In total, 22 women had hysteroscopic-guided suction evacuation with 9 having it performed under laparoscopic guidance because the RMT was under 3 mm. The remaining patients underwent either laparoscopic repair (5 cases) or vaginal repair (1 case) done under laparoscopic guidance. Hysteroscopic-guided suction evacuation of CSP has the potential to become part of the routine management for uncomplicated cases of CSP in women with an RMT of greater than 3 mm who do not wish for future pregnancy. Its use, in combination with other minimally invasive techniques, can be extended to more complex cases where the RMT is <3 mm and future fertility is desired.

Cesarean Scar Pregnancies and Reproductive Outcomes: A Single Center Experience

Objective: The rising rate of cesarean delivery increases the occurrence of cesarean scar pregnancies (CSP). Early diagnosis and treatment of CSP have become the subject of considerable interest in recent years because of the risk of life-threatening uterine bleeding and rupture. The aim of this study was to share the results of ultrasonography (USG)-guided dilation and curettage (D&C) and hysterotomy in treating early CSP and the long-term reproductive results in these cases. Material and Methods: Patients diagnosed with CSP admitted to the perinatology clinic between January 2016 and April 2020 were included in this study. USG-guided D&C was recommended for all patients diagnosed with CSP in the first trimester (≤12 gestational weeks). Hysterotomy was recommended for patients who could not undergo D&C. All patients' demographic data and procedure results were retrieved retrospectively from electronic records, and reproductive anamneses after the procedure were obtained from patient files and telephone calls. Results: Sixty-three patients who underwent USG-guided D&C and hysterotomy were included in the study. While D&C was successful in 93.65% (n=59) of these patients, 6.35% (n=4) underwent hysterotomy. In the USG-guided D&C group, the infertility rate was 15.78% (n=6), the rate of the recurrent scars was 9.3% (n=3), and the rate of placenta accreta spectrum was 6.25% (n=2). The term healthy pregnancy rate was 64%. Conclusion: In experienced hands, USG-guided D&C can be considered the first choice in early scar pregnancies. We believe that similar reproductive results would be obtained when D&C and other treatment modalities were compared in CSP treatment.