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Cesarean scar pregnancy (CSP) in a 35-year-old woman at 7þ weeks' gestation. The sagittal T1 (a)-and T2 (b)-weighted images show that a gestational sac (blue arrow) within the lower segment of the anterior uterine wall, the cesarean scar is shown (red arrow).
Source publication
Objective
To evaluate the reproductive outcomes of cesarean scar pregnancy (CSP) pretreated with methotrexate (MTX) and uterine artery embolization (UAE) prior to curettage.
Materials and methods
The 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...
Context in source publication
Context 1
... by abdominal pain (17 cases). Eleven patients were asymptomatic. CSP was identified in all patients through ultrasound scanning, and the diameter of the gestational mass was 2.75 ± 1.6 cm. A fetal heartbeat was detected in 17 (32.1%) patients. MRI was performed for 47 (88.7%) patients, and the diameter of the gestational mass was 2.8 ± 1.26 cm (Fig. 2). According to the presentations on MRI and ultrasound, type I CSP was diagnosed in 22 (41.5%) patients and type II CSP in 31 (58.5%). None of the gestational sacs penetrated the uterine scar or invaded the ...
Similar publications
Purpose
To evaluate the clinical effects and outcomes of local intra-gestational sac methotrexate injection followed by dilation and curettage for treatment of cesarean scar pregnancies (CSP).
Method
This prospective non-randomized study was conducted on patients diagnosed with CSP between 2018 and 2020 at the Maternal and Child Health Hospital of...
Citations
... UAE is typically performed as an adjunct to other medical or surgical procedures either prophylactically or therapeutically when hemorrhage occurs [14]. Several studies have reported that use of UAE prior to curettage for the treatment of CSP was helpful in controlling massive bleeding [15]. UAE should be combined with other treatments for women who want to conceive again considering it required a long follow-up period [16]. ...
To investigate the efficacy and safety of laparoscopic internal iliac artery temporary occlusion and uterine repair combined with hysteroscopic aspiration in type III cesarean scar pregnancy. 135 cases of cesarean scar pregnancy in Guangzhou Women and Children's Hospital from November 2017 to November 2020 were collected and 32 cases of type III patients were retrospectively analyzed. They were divided into internal iliac artery temporary occlusion (IIATO) group (21 cases), and bilateral uterine artery embolization (UAE) group (11 cases). The general condition, intraoperative bleeding, postoperative complications, and prognosis of the two groups were analyzed. In the IIATO group, the bilateral internal iliac arteries were temporarily blocked with No. 10 silk thread under laparoscopy. The scar pregnancy clearance and repair of the scar were performed after incision. Subsequently, we performed hysteroscopic aspiration. After the operation, the internal iliac artery ligation thread was removed. In the UAE group, the patients were treated with bilateral uterine artery embolization. Laparoscopic uterine scar repair and hysteroscopy aspiration were performed within 24 hours after embolization. There was no significant difference in age, times of pregnancy, times of cesarean section and gestational weeks between the two groups (P>0.05). No significant differences were observed in the diameter of gestational sac or gestational mass and serum human chorionic gonadotropin (β-hCG) level between the two groups before operation (P>0.05). The operations were successfully completed in 32 patients, and intraoperative blood loss was 67.14±32.78 ml and 71.35±31.56 ml, respectively (P<0.05). The length of hospital stay was 5.14±0.32 day and 4.97±0.21 day, respectively. No peri-procedural bleeding occurred and no secondary surgeries were required. Laparoscopic internal iliac artery temporary occlusion and uterine repair combined with hysteroscopic aspiration is an effective and safe treatment for type III cesarean scar pregnancy, with less postoperative complications and better protection of fertility function for patients.
... However, MTX may induce hepatic and renal dysfunction and myelosuppression (9). UAE combined with curettage may be a favorable choice for CSP in decreasing menstrual blood volume (1), and curettage following combined UAE and MTX pretreatment is also effective in treating CSP (10). The procedures of UAE with or without MTX injection before curettage require catheterization of the uterine artery before injection of MTX (for UAE plus MTX injection) and embolic materials to block the uterine artery for UAE (1,4,10). ...
... UAE combined with curettage may be a favorable choice for CSP in decreasing menstrual blood volume (1), and curettage following combined UAE and MTX pretreatment is also effective in treating CSP (10). The procedures of UAE with or without MTX injection before curettage require catheterization of the uterine artery before injection of MTX (for UAE plus MTX injection) and embolic materials to block the uterine artery for UAE (1,4,10). As such, these methods are not good for women who want to conceive in the future because of the adverse effects, including ovarian dysfunction and quick establishment of collateral circulation (1,4,10). ...
... The procedures of UAE with or without MTX injection before curettage require catheterization of the uterine artery before injection of MTX (for UAE plus MTX injection) and embolic materials to block the uterine artery for UAE (1,4,10). As such, these methods are not good for women who want to conceive in the future because of the adverse effects, including ovarian dysfunction and quick establishment of collateral circulation (1,4,10). ...
Background:
Compared with the current commonly used pretreatment approaches, the therapeutic effect of contrast-enhanced ultrasound-guided sclerotherapy with lauromacrogol injection (CEUSL) on cesarean scar pregnancy (CSP) is not clear. This study aimed to investigate the clinical efficacy and safety of CEUSL compared with gelatin sponge uterine artery embolization (UAE) and UAE combined with methotrexate (UAEM) in the pretreatment of CSP to prevent massive bleeding during subsequent curettage.
Methods:
Sixty-four patients were divided into the CEUSL (n=20), UAE (n=22), and UAEM (n=22) groups. All patients with CSP underwent curettage and hysteroscopy after CEUSL, UAE, or UAEM pretreatment. The efficacy and safety indicators after pretreatment were analyzed.
Results:
Time for pretreatment [95% confidence interval (CI): 31.92-39.28] and hospitalization cost (95% CI: 7,852.32-9,063.23) were significantly decreased in the CEUSL group compared with that in the UAE (95% CI: 53.55-59.99% and 95% CI: 12,901.42-15,166.63, respectively) and the UAEM group (95% CI: 52.90-58.83 and 95% CI: 11,324.66-13,302.69, respectively; P<0.001). The beta human chorionic gonadotropin (β-hCG) percentage decrease 24 hours later and the hospital stay were significantly decreased in the CEUSL group (95% CI: 0.65-0.70 and 95% CI: 3.32-4.58 days, respectively) compared with those in the UAE (95% CI: 0.67-0.74 and 95% CI: 4.06-5.84, respectively) or UAEM (95% CI: 0.62-0.68 and 95% CI: 4.12-5.88, respectively) groups (P<0.05). After pretreatment, there were significantly fewer patients (P<0.05) with fever (95% CI: -0.52 to -0.093), pelvic pain (95% CI: -0.427 to -0.018), increased white blood cell count (95% CI: -0.359 to 0.040), and hypersensitive C-reactive protein (hs-CRP) elevation (95% CI: -0.572 to -0.118) in the CEUSL group than in the UAE or UAEM groups. At follow-up, all patients resumed normal menstruation, with no residual gestational sac on ultrasound imaging or sequel.
Conclusions:
The pretreatment procedures were all technically successful, with good outcomes in different pretreatment procedures. Compared with UAE with or without methotrexate, CEUSL may be as effective and safe for pretreatment of CSP, with fewer adverse effects and shorter pretreatment time and hospital stay.
... Diagnosis of the CSP is performed by ultrasound means, following well-established criteria [30,31]; however, there is not a standardized protocol for the treatment of CSP. Some authors associated uterine artery embolization (UAE) with dilatation and curet-tage [32][33][34][35][36], and the procedure was uneventful in most of the cases, with minimal blood loss (≈23 mL). Curettage could be the common intervention but patients have a high risk of developing massive hemorrhage, which might lead to open surgery. ...
... However, the administration of methotrexate alone and/or combined with curettage causes uncontrollable bleeding (4 cases out of 15 were misdiagnosed and treated by bling curettage, which induced heavy bleeding and required emergency UAE). This is supported by Lou et al. [35], who studied 53 women treated with methotrexate and UAE, followed by curettage. Their results showed that the blood volume lost during curettage was 23-61 mL and hemorrhage occurred in two women. ...
Objective:
The aim of this study is to propose a standardized management of care for patients diagnosed with cesarean scar pregnancy (CSP). There are two types of CSP: Type 1 (on the scar) vs. type 2 (in the niche). To date there is no international standard to predict the extent of invasion or the optimal management of CSP.
Materials and methods:
We used intramuscular methotrexate injection followed by uterine artery embolization combined with suction evacuation as a conservative approach for the treatment of seven patients diagnosed with CSP. Our inclusion criteria, to be satisfied simultaneously, were established as follows: (1) patients with CSP; (2) early gestational age ≤ 9 weeks, and (3) written consent of the proposed treatment of the patient.
Results:
This course of treatment produced a positive outcome in all cases. We did not have any complications (e.g., emergency hysterectomy, perforation of the uterine cavity, severe hemorrhage, or endometritis) during the procedures or in the follow-up. The most important predictors of successful management are early diagnosis of CSP and orientation of the invasive trophoblast opposite to the scar.
Conclusions:
The main finding from this series of cases is that associating systemic methotrexate and uterine artery embolization provides efficient and low-risk management of CSP. This treatment regime is adequate for both types of CSPs. We consider that early localization diagnosis of pregnancy following a cesarean delivery is mandatory for CSP morbidity prevention.
... Previous tubal damage is associated with a reduced likelihood of future pregnancy. The pregnancy rates of women with tubal damage and those with tubes of normal appearance have been reported to be 42% and 79%, respectively [24]. Ipsilateral peri-adnexal adhesions reflect the poor condition of the tube [25]. ...
Purpose of Review
The purpose of this review is to update readers on recent surgical treatment modalities of ectopic pregnancies (EP) and their advantages vs disadvantages.
Recent Findings
EP was generally managed with surgical treatment, and of the available applications, methotrexate (MTX) may be preferred for selected patients. “Wait-and-see” can be another treatment method, depending on preference or need. Surgical treatment indications are haemodynamic instability, suspected or risk of rupture, contraindications for MTX, or failure of medical treatment.
Summary
Salpingostomy or salpingectomy is generally the first surgical choice in tubal EPs. The selection of salpingostomy or salpingectomy is based on several factors and the decision should be made by the surgeon and patient together. For women who have completed fertility, bilateral salpingectomy can be applied for permanent sterilisation. The sterilisation method of salpingectomy has the additional potential benefit of reducing the risk of tubal neoplasia and ovarian cancer. The advantage of salpingostomy is the potential to preserve the tube to meet the patient’s wishes for potential future fertility. The selection of surgical approach (laparoscopy vs laparotomy) should be made by the surgeon in consultation with the anaesthetist and taking the clinical condition of the patient into account.
... In the May issue of the Taiwanese Journal of Obstetrics and Gynecology (TJOG), two articles addressing an important but often neglected issue-cesarean scar pregnancy (CSP) have been published simultaneously [1,2]. As shown by authors, CSP is one of the unusual locations of ectopic pregnancies, and its importance is a life-threatening situation due to uterine rupture or heavy bleeding and sometimes it may need a total hysterectomy to save life, with resultant a total loss of the reproductive performance of women. ...
Unlabelled:
Cesarean scar ectopic pregnancy (CSP) is a rare form of ectopic pregnancy, and treatment of CSP with uterine artery embolization (UAE) is a novel approach. With increasing numbers of cesarean sections being performed annually, the incidence of this condition is likely to increase. The authors became aware of an unusually high number of published studies originating in mainland China regarding this unusual treatment and sought to perform a meta-analysis to provide comprehensive evidence on this novel practice.
Methods:
We performed a thorough search and included all forms of quality studies on this topic that reported UAE as a part of first-line management of CSP. We included only studies originating in China. Ultimately, 37 studies were included for qualitative and quantitative synthesis of evidence. After screening retrieved records and extracting data from eligible studies, we pooled continuous data as a mean estimate and 95% confidence interval (CI), and dichotomous data as proportion and 95% CI.
Results:
CSP patients treated with protocols including UAE had a mean time of 30 days for serum β-hCG normalization, 95% CI [26.816, 33.881]. They had a mean estimated intraprocedural blood loss of 4.19 ± 3.76 mL, a mean hospital stay of nine days, 95%CI [7.914, 9.876], and a success rate of 93.4%, 95%CI [0.918, 0.951]. The severe complication rate was 1.2%, 95%CI [0.008, 0.017].
Conclusion:
UAE, in combination with other procedures is being used effectively for the treatment of CSP in China. Protocols including UAE have a success rate of approximately 93.4%, and a severe complication rate of approximately 1.2%. This data's utility is limited by vast differences in the studied protocols and questionable feasibility outside of China.
Objective:
To determine the characteristics and subsequent pregnancy outcomes in patients with a previous ectopic pregnancy (EP).
Study design:
Descriptive-cross sectional study.
Place and duration of study:
Department of Obstetrics-Gynaecology, Etlik Zubeyde Hanim Maternity and Women's Health Teaching and Research Hospital, Ankara, Turkey, between January 2014 and December December 2018.
Methodology:
The data of nulliparous patients diagnosed with tubal ectopic pregnancy (EP) was analysed retrospectively. Reproductive outcomes within the first two years after ectopic pregnancy diagnosis were used as "short-term" reproductive outcomes. Their EP treatment and pregnancy outcome were determined.
Results:
Expectant management was chosen in 5.8% of the patients, while the surgical intervention was 32.3%. Medical therapy involving methotrexate (MTX) was given to the remaining patients (61.9%). The tubal rupture was confirmed in 12% of the cases that received MTX. In the 2-year follow-up period after the ectopic event, the most common outcome of the subsequent pregnancies was a live birth (47.7%). Recurrent EP occurred in 4.6%.
Conclusion:
The subsequent short-term pregnancy outcomes in this study were not related to the chosen treatment modality.
Key words:
Ectopic pregnancy, Nulliparity, Reproductive outcomes, Treatment modalities, Expectant management.
