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STUDY QUESTION
What are the important risk factors for having a caesarean scar pregnancy (CSP)?
SUMMARY ANSWER
Independent risk factors were smoking in the first trimester, higher parity, and previous caesarean section (CS) before the index caesarean delivery.
WHAT IS KNOWN ALREADY
A spectrum of risk factors for CSP has been suggested but not pro...
Context in source publication
Context 1
... is a heterogenous condition, which can be divided into two subgroups, endogenous and exogenous CSP ( Vial et al., 2000; Gonzalez and Tulandi, 2017). Endogenous CSP, also called Type 1, originates from the wound tissue (scar) but bulges into the cavity (Fig. 1). If this pregnancy proceeds it can develop into morbidly adherent placenta such as accreta/increta/percreta (Timor-Tritsch et al., 2014a, 2014b). In the exogenous subgroup, also called Type 2, the embryo is implanted deep inside the scar tissue in the myometrium and the growth of the pregnancy is through the evolving placenta directed ...
Citations
... This leads to reduced perfusion and a diminished supply of oxygen and nutrients to the cells involved in wound healing, including the uterine scar. Some new articles published in 2021 [31] and in 2018 [32] highlighted a risk of developing isthmocele in women who smoke compared to non-smokers. It was postulated that cigarette consumption may thereby compromise uterine scar healing and negatively impact the scar tissue formation process. ...
Isthmocele is a gynecological condition characterized by a disruption in the uterine scar, often associated with prior cesarean sections. This anatomical anomaly can be attributed to inadequate or insufficient healing of the uterine wall following a cesarean incision. It appears that isthmocele may impact a woman’s quality of life as well as her reproductive capacity. The incidence of isthmocele can range from 20% to 70% in women who have undergone a cesarean section. This review aims to sum up the current knowledge about the effect of isthmocele on fertility and the possible therapeutic strategies to achieve pregnancy. However, currently, there is not sufficiently robust evidence to indicate the need for surgical correction in all asymptomatic patients seeking fertility. In cases where surgical correction of isthmocele is deemed necessary, it is advisable to evaluate residual myometrial thickness (RMT). For patients with RMT >2.5–3 mm, hysteroscopy appears to be the technique of choice. In cases where the residual tissue is lower, recourse to laparotomic, laparoscopic, or vaginal approaches is warranted.
... A strong relationship has been shown between a history of uterine procedures such as dilatation and curettage, myomectomy, and caesarean section and an increased chance of developing CSP. Other risk factors include in vitro fertilization, adenomyosis, manual placenta removal, a short interval between pregnancies and multiple pregnancy [3] . Cesarean scar pregnancy's treatment should be personalized according to various criteria such as gestational age, clinical symptoms, gestational sac size, hemodynamic stability, and the patient's future reproductive aspirations. ...
Conservative management Methotrexate treatment a b s t r a c t Ectopic pregnancy in a previous caesarean scar is a rare, potentially life-threatening situation that can cause massive bleeding and uterine rupture. Clinical symptoms can range from vaginal bleeding with or without pain, to uterine rupture with hypovolemic shock. Early diagnosis is possible by ultrasound examination, and it is very important because it leads to prompt management, improving maternal morbidity and mortality as well as future fertility. The current case report refers to a G3P2 woman with a history of 2 previous caesarean deliveries, who was diagnosed with an ectopic pregnancy on the caesarean scar using ultra-sonography. The patient was treated with methotrexate both systemic and into the sac, as well as with injection into the sac of 5mEq potassium chloride. The woman was followed up until measurements of serum β-Human Chorionic Gonadotropin were within nonpregnant levels. There is no clear-cut best way to handle cesarean scar pregnancy. Pregnancy with a cesarean scar should be identified and treated as soon as possible in order to avoid serious problems and preserve fertility. However, even more advanced cesarean scar pregnancies can be managed conservatively at first, when a highly expertized team in a tertiary hospital is available.
... As a result, the prevalence of cesarean scar defect (CSD) is also higher in ART populations. Independent risk factors for having a CSD include smoking in the first trimester, higher parity, and previous cesarean section (Gull et al., 2021). Using transvaginal ultrasound, the reported prevalence of a post-cesarean niche varies between 24% and 70% (Bij de Vaate et al., 2014). ...
Background: This study investigated pregnancy outcomes after expectant management and infertility treatment in women with secondary infertility, with and without cesarean scar defect (CSD).
Methods: This retrospective cohort study was conducted at IVFMD, My Duc Hospital, Ho Chi Minh City, Vietnam. Women aged [Formula: see text] 18 years with at least one previous cesarean section were eligible. Women who had any uterine malformation, leiomyoma, adenomyosis, and myometrial surgery (except for cesarean section or previous CSD repair) were excluded. Patients were followed up for 15 months. The primary outcome was the cumulative live birth rate.
Results: A total of 340 women were included between October 2020 and March 2021. The cumulative live birth rate did not differ significantly between women with and without CSD (odds ratio 0.76; 95% confidence interval 0.47–1.22; [Formula: see text] = 0.256). In patients with CSD, only 6/117 (5%) had obstetrics complications, such as placenta previa and postpartum hemorrhage.
Conclusions: These data indicate that CSD does not appear to have a significant detrimental effect on pregnancy outcomes in our cohort of patients. This information is useful to help physicians to counsel women with secondary infertility and CSD.
... Themes include folic acid use, diet and exercise with an aim of normalising BMI, and smoking cessation. Smoking is specifically harmful to pregnancy and is known to be associated with miscarriage [13], preterm birth [14], CSP [15], and other placental disorders of pregnancy [16] which underlies widespread international and national recommendation to reduce maternal smoking [17]. ...
Caesarean Scar Pregnancy (CSP) is an ectopic pregnancy with implantation into the niche of the uterine scar. We aimed to describe the local management of consecutive cases of CSP to develop a standard operating procedure (SOP). Between December 2019 and June 2022, there were 19,100 maternities. Of these, 23 were CSPs in 19 patients. Median BMI was 29 (range 20.5–52), median number of Caesarean deliveries (CS) was 2 (range 1–4) and 7/23 (30%) were cigarette smokers. At diagnosis, 9/23 were live pregnancies, 3/23 were retained products of conception (RPOC), 9/23 were pregnancies of uncertain viability (PUV), and 2/23 were non-viable. In six, the initial management was expectant, surgical suction evacuation with transrectal ultrasound guidance in 16, and one had a hysterectomy. The median blood loss was 100 mL (range 50–2000 mL). Two patients (9%) required a blood transfusion. Median hospital stay was 1 day (range 0–4). At follow-up after 10 weeks, no patients had an ongoing haematoma, and one had significant RPOC electing hysterectomy. Eight women were known to have 9 subsequent pregnancies (recurrent CSP n = 4, livebirth n = 2, miscarriage n = 2, tubal ectopic n = 1). Outcomes as rated by low blood loss, short hospital stay, and rare need for further intervention were favorable. Factors associated included prompt ultrasonographic diagnosis, availability of transrectal ultrasound guided surgery, and specialist follow-up, which form the basis of the SOP.
... and more than 1 previous cesarean section (adjusted OR 3.43, 95% CI 1.35-8.66) were independently predictive of CSP [13]. An elective cesarean section in the index pregnancy was associated with an increased risk of CSP, but it did not remain significant in the multivariate analysis. ...
... It is unknown whether the surgical technique of cesarean section affects the risk of a subsequent CSP [13]. ...
... In the early stages of pregnancy, most patients are asymptomatic. As the pregnancy progresses, vaginal bleeding can occur with or without pain [13]. The uterus can rupture and cause hemoperitoneum and hypovolemic shock. ...
Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy located in the lower uterine segment. The current increase in the percentage of cesarean sections is accompanied by significant growth in the incidence of CSP, while advances in ultrasound diagnostic techniques have led to a greater number of CSP diagnoses. A misdiagnosed CSP, or one that is diagnosed too late, is life-threatening to the pregnant patient and predisposes her to complications such as uterine bleeding or rupture, which often require hysterectomy and thus result in the irreversible loss of fertility. We present the case of a 50-year-old woman with a history of undiagnosed CSP after multiple consultations for intermittent bleeding and hemorrhage. She was diagnosed by ultrasound and the diagnosis was confirmed by hysteroscopy. She underwent conservative medical treatment that was successful.
... Our ndings also con rm previous studies by Gull's team. By logistic regression analysis they concluded that the risk of CSP increases threefold if a woman has had at least one CD 22 . The results may also be underestimated because of the limited clinical sample. ...
Background
Cesarean scar pregnancy (CSP) is life-threatening, and the number of patients with CSP is rapidly increasing in China. However, the pathogenesis of CSP is still unclear due to the lack of macroscopic data due to spatial and temporal constraints. Therefore, the aim of this study was to explore the key regulatory molecules and mechanisms of CSP through a multi-omics approach.
Methods
Proteomics was used to detect proteins expression in deciduas and villus from six clinical patients clinical patients. Gene expression datasets were downloaded using the GEO and SRA databases. Bioinformatics analysis was performed in a series of databases and software such as DAVID, Metascape and STRING. Data analysis was performed using SPSS 27, and P < 0.05 was statistically significant.
Results
The occurrence of CSP has common DEGs with cesarean delivery (CD) and embryo implantation (EI). Enrichment analysis revealed that Biological Process and the KEGG pathway are associated with the adhesion process, with the involvement of ITGB3, ITGA2B and VTN. ITGB3 expression was significantly downregulated after CD compared to spontaneous delivery, and then increased after another pregnancy compared to normal pregnancy.
Conclusions
The occurrence of CSP is inevitably associated with CD and EI. ITGB3, ITGA2B, and VTN may act as key molecules for CSP by activating the focal adhesion signaling pathway. The rebound effect of ITGB3 is a key regulatory mechanism for CSP formation.
Non-tubal ectopic pregnancies occur as a result of embryo implantation outside the uterine cavity and fallopian tubes. Sites include ovary, cervix, abdominal cavity, interstitial portion of fallopian tube, and cesarean scar. Non-tubal pregnancies are uncommon. Nonspecific signs and symptoms of non-tubal ectopic pregnancies make diagnosis challenging and in many cases significantly delayed, resulting in a high rate of morbidity. While surgical management remains the mainstay of treatment there is growing evidence that some of these can be managed medically or with the utilization of a combined medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for non-tubal ectopic pregnancies. Diagnostic and management options may be limited especially in resource-restricted settings. Therefore, an understanding of the available options is critical. It needs to be emphasized that the rarity of cases and the difficulties in organizing ethically justified randomized trials result in the lack of well-established management guidelines for non-tubal ectopic pregnancies.
