Advances in Treating Cesarean Scar Pregnancy: A Comprehensive Review of Techniques, Clinical Outcomes, and Fertility Preservation.

Cesarean scar pregnancy (CSP) is a rare but potentially dangerous condition that occurs when an embryo implants and develops within the scar tissue from a previous cesarean section. Treatment of cesarean scar pregnancy depends on several factors, including the gestational age of the pregnancy, the presence of complications, and the individual patient's circumstances. We performed a systematic review of the published literature on management of cesarean scar pregnancy and the outcomes, complications, and effects on fertility. A systematic review of recent scientific literature published up to April 2023 in the databases PubMed, Google Scholar, and Web of Science was performed according to the PRISMA guidelines. We used the search keywords "cesarean scar pregnancy," "methotrexate," "systemic," "chemoembolization," and "uterine artery embolization." The baseline search resulted in 413 articles. After the exclusion of 342 irrelevant articles, the abstracts and titles of the remaining 71 articles were read for potential inclusion, resulting in exclusion of a further 16 articles. Therefore, the full texts of 55 articles were investigated. Finally, 42 papers were included in the study. The main finding was that chemoembolization is more successful than systemic methotrexate therapy, and is associated with less blood loss and shorter hospital stay. Transarterial chemoembolization appears to be safe and effective method of treatment in patients with CSP and should thus be considered during multidisciplinary evaluation of these patients.

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 ß-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.

Cornual Pregnancy: Results of a Single-Center Retrospective Experience and Systematic Review on Reproductive Outcomes.

Background and Objectives: Cornual pregnancies (CPs) are rare forms of ectopic pregnancy. When abortion does not occur, it can be a life-threatening condition for the mother and can also impair future fertility. We present our experience in the diagnosis and management of CPs. A systematic review was also conducted to investigate the reproductive outcomes after treatment. Materials and Methods: Between January 2010 and December 2022, we performed a retrospective, cross-sectional, single-center, and descriptive data collection and analysis (ClinicalTrial ID: NCT06165770). The search for suitable articles published in English was carried out using the following databases (PROSPERO ID: CRD42023484909): MEDLINE, EMBASE, Global Health, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Cochrane Methodology Register), Health Technology Assessment Database, Web of Science, and search register such as ClinicalTrial. Only studies describing the impact of CP treatment on fertility were selected. Results: Two studies were included in the systematic review. Seventeen patients suffering from CPs were selected. In our series, a pelvic ultrasound allowed for the diagnosis of a cornual localization in 35.30% of cases. Thirteen women (76.47%) underwent immediate surgical management. The laparoscopic approach was the most used (76.92%), with a laparotomic conversion rate of 30%. Four patients (23.52%) received medical treatment with methotrexate. After treatment, two patients managed to achieve pregnancy. Conclusions: CP is a rare form of ectopic pregnancy that can quickly become life-threatening for the mother. Ultrasound does not lead to a precise diagnosis in all cases. In the absence of complications and emergencies, laparoscopy is an approach that could be considered valid. For selected asymptomatic patients, medical treatment may be a valid alternative. The data from the studies included in the systematic review, although demonstrating a superiority of medical treatment in terms of future pregnancies, are heterogeneous and do not allow us to reach a definitive conclusion.

Successful conservative management of a large 12-week-old cervical ectopic pregnancy in a nulliparous woman: a case report.

Cervical ectopic pregnancy (CEP) accounts for less than 0.1% of all ectopic pregnancies. CEP is associated with high morbidity and mortality potential due to the associated life-threatening hemorrhage. When it is large, detected late, and occurs in a nulliparous woman, management is more challenging as it requires the need to preserve the uterus. We present a case of a 33-year-old nulliparous woman with a large live cervical ectopic pregnancy at 12 weeks + 1 day gestation and a very high serum ß-HCG of 126,750 Miu/ml. She was successfully managed with suction curettage and cervical encerclage tamponade in order to preserve the uterus. The treatment was associated with significant hemorrhage and a prolonged period of follow-up. In low-resource settings, uterine-conserving management of CEP can be challenging, and curettage with cervical encerclage tamponade can be a cost-effective treatment modality even though it is associated with significant haemorrhage and prolonged treatment period.

The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy.

Cesarean scar pregnancy (CSP) is among the most severe complications of cesarean delivery. CSP refers to the abnormal implantation of the gestational sac in the area of the prior cesarean delivery (CD), potentially leading to severe hemorrhage, uterine rupture, or development of placenta accreta spectrum disorders (PAS). The management of women with CSP has not been standardized yet. In women who opted for termination, discussion about the treatments should consider maternal symptoms, gestational age at intervention, and the future reproductive risk. A multitude of treatments, either medical or surgical, for CSP has been reported in the published literature. The present review aims to provide up-to-date information on a recently introduced minimally invasive treatments for CSP, including the single and double balloon catheter. The methodology of using the single or double catheter is described in a step-by-step fashion illustrated by pictures as well as video recordings. Both catheters have their deserved place to be used as a primary method for terminating scar pregnancies as well as using them as adjuncts to other treatments. They were successfully used by multiple individual practitioners and institutions due to their simplicity and low complication rates. The rare, but possible post-procedure complications such as recurrent CSP and enhanced myometrial vascularity are also mentioned.

Retroperitoneal ectopic pregnancy: successful expectant management in condition of early pregnancy failure.

BACKGROUND: Retroperitoneal ectopic pregnancy (REP) refers to abnormal implantation of the fertilized egg in the retroperitoneal cavity. REP can be divided into pelvic and abdominal positions. Extremely rare, the incidence of REP is less than 1% of ectopic pregnancy (EP). Herein, we report the first case of paraaortic-located REP in association with successful expectant management, thus raising awareness among healthcare providers, particularly in low-resource settings. CASE PRESENTATION: A reproductive-age woman presented at our tertiary referral hospital because of amenorrhea and a positive pregnancy test. Based on serial serum ß-hCG levels and imaging modalities including transabdominal ultrasound, transvaginal sonography, and magnetic resonance imaging (MRI), a REP of 7-9 weeks of gestational age adherent to abdominal paraaortic region was detected. Since the pregnancy was spontaneously arrested without clinical symptoms, expectant management was first indicated following careful evaluation. After a 1-month follow-up, the ectopic mass naturally degenerated without complications and her ß-hCG concentration returned to a negative value. Therefore, the patient recovered completely and avoided unnecessary surgery as well as toxicity of medical treatment when using systemic methotrexate. CONCLUSIONS: In addition to transvaginal and transabdominal ultrasound, MRI is necessary for the diagnosis of nonviable REP. Alongside the great vessels in the abdominal cavity should be taken into consideration in all suspected cases relating to this rare entity. Expectant management may be carefully indicated in conditions of nonviable REP and unruptured REP, where applicable.

The feasibility of introducing early pregnancy assessment unit in Nigerian hospitals: A pilot study from a private hospital in Enugu, Southeast Nigeria.

Background: Early pregnancy assessment unit (EPAU) is a dedicated unit that provides specialist care such as definitive ultrasonographic and biochemical assessment to women who have or have had vaginal bleeding or pain before 16 weeks of pregnancy. Such patients usually have a positive pregnancy test with a scan showing pregnancy of an unknown location, previous ectopic pregnancy, recurrent miscarriages, or previous molar pregnancy. Such a holistic and prompt approach leads to better outcome in the management of women with early pregnancy and other complications. Aim: This study aimed to describe the diagnosis and outcome of early pregnancy pain and bleeding, managed by rapid ultrasonographic and biochemical assessments by a dedicated gynecological team in a private hospital to determine the feasibility of establishing early pregnancy assessment units (EPAUs) in Nigeria. Materials and Methods: This is a cross-sectional study of eligible cases of early pregnancy bleeding and pain in a private gynecological hospital in Enugu, Nigeria. Results: During the 9-year study period, 160 women with early pregnancy pain or bleeding were analyzed. The mean age of the participants was 32.3 ± 7.2 years, and they were mostly multipara (68.7%) and Christians and of the Igbo tribe (91.3%). The final diagnosis after clinical and radiological evaluations showed that the majority had miscarriages (82.5%), while 17.5% had ectopic gestations. All the participants had their definitive diagnosis and treatment within 24 hours of presentation. There was no recorded case of maternal death. Conclusion: EPAUs are feasible in a Nigerian setting provided that trained, dedicated staff and equipment are provided.

Nontubal ectopic pregnancies: overview of diagnosis and treatment.

Nontubal 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. Nontubal pregnancies are uncommon. Nonspecific signs and symptoms of nontubal ectopic pregnancies make diagnosis challenging and, in many cases, significantly delayed, resulting in a high rate of morbidity. Although surgical management remains the mainstay of treatment, there is growing evidence that some of these can be managed medically or with the use of a combination of medical and surgical approaches with good outcome. This review summarizes the current diagnostic modalities, therapeutic options, and outcomes for nontubal 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 nontubal ectopic pregnancies.

An update and review of nontubal ectopic pregnancy management.

PURPOSE OF REVIEW: Nontubal ectopic pregnancies appear to be increasing in prevalence. Increasingly, minimally invasive methods for management are being utilized. A current literature review and recommendations for management of nontubal ectopic pregnancy is presented in this review. RECENT FINDINGS: Nontubal ectopic pregnancies are less common than tubal ectopic pregnancies but present a unique and significant threat to patient's health and are optimally managed by specialists familiar with the condition. Early diagnosis, prompt treatment and close follow-up to resolution are critical. Recent publications focus on fertility-sparing and conservative management through the use of medications both systemic and local; as well as minimally invasive surgical techniques. The Society of Maternal Fetal Medicine recommends against expectant management of cesarean scar pregnancies; however, optimal treatment is unknown and this holds true for management of other nontubal ectopic pregnancies. SUMMARY: Minimally invasive and fertility sparing management should be the mainstay in treatment of stable patients with nontubal ectopic pregnancy.

Ectopic Pregnancy and Lifesaving Care.

This JAMA Insights Clinical Update discusses the management of ectopic pregnancy and the urgency of prompt intervention.

Reproductive outcome after cesarean scar pregnancy.

Cesarean scar pregnancy (CSP) rate is rising worldwide, in parallel with the rising rates of cesarean delivery. Multiple therapeutic strategies and a timely diagnosis have led to a successful management in most cases, with many women preserving fertility after treatment. Despite this, still little is known regarding pregnancy outcomes after a CSP. The main adverse outcomes reported after CSP are recurrence of CSP, miscarriage, preterm birth, placenta accreta spectrum (PAS) disorders and uterine rupture. In addition, little is known about the influence of the different treatments on subsequent pregnancy outcomes after a CSP. Being aware of the impact of the different management strategies on the fertility outcomes is highly relevant to counsel pregnant women after a CSP. The aim of this manuscript is to provide an up-to-date review of the reproductive outcomes of women with a history of CSP and of the influence of various treatments on subsequent pregnancy outcomes.

Management of ectopic pregnancy in a tertiary hospital: a retrospective cohort study.

OBJECTIVE: The goal of this study was to manage the treatment modalities of ectopic pregnancy. PATIENTS AND METHODS: This retrospective study included 1,103 women diagnosed and treated for ectopic pregnancy at Kanuni Sultan Suleyman Training and Research Hospital between January 1, 2017, and December 31, 2020. Serial beta-human chorionic gonadotropin (ß-Hcg) measurements and transvaginal ultrasound (TV USG) findings were used to establish the diagnosis of an ectopic pregnancy. They were divided into four groups: expectant treatment, single-dose methotrexate, multidose methotrexate, and surgical treatment. All data analyses were performed using SPSS version 24.0. A receiver operating characteristic (ROC) analysis was used to determine the cut-off for change in beta-human chorionic gonadotropin (ß-hCG) levels between the first and fourth day. RESULTS: There were significant differences between groups in terms of gestational age and ß-hCG changes (p < 0.001). In patients receiving expectant treatment, the decrease in ß-hCG values on the fourth day was 35.19%, while patients receiving single-dose methotrexate treatment showed a decrease of 24%. The most common risk factor for ectopic pregnancy was the absence of risk factors. Comparison of the surgical treatment group with the other groups revealed significant differences in terms of the presence of free fluid in the abdomen, the average diameter of the ectopic pregnancy mass, and the presence of fetal cardiac activity. A single dose of methotrexate was effective in patients with ß-hCG levels lower than 1,227.5 mIU/ml, with a 68.5% sensitivity and 69.1% specificity. CONCLUSIONS: An increase in gestational age also leads to an increase in ß-hCG values and the diameter of the ectopic focus. As the diagnosis period progresses, the need for surgical intervention increases.

Subsequent fertility after cesarean scar pregnancy: a retrospective analysis.

BACKGROUND: Cesarean scar pregnancy (CSP) refers to the implantation and growth of the gestational sac at a uterine scarring site due to a previous cesarean section. The effects of CSP on subsequent fertility have emerged as a clinical issue of importance in gynecology and obstetrics in China owing to the increasing rate of cesarean section over the past 30 years in combination with the abolition of the national family planning policy, allowing for subsequent pregnancies. Therefore, we aimed to investigate the effects of CSP treatment on subsequent fertility and pregnancy outcomes. METHODS: The study consecutively enrolled 499 women treated for CSP at Taizhou Hospital between January 2009 and December 2018. The study outcomes were the rate of secondary infertility and pregnancy outcomes. Clinical information was collected at the time of admission for CSP treatment. Information on subsequent fertility and pregnancy outcomes was collected via telephonic follow-up. RESULTS: Among the 499 women who met the inclusion criteria for CSP, 48 were lost to follow-up. Most women (74.9%, 338/451) did not express the desire for a subsequent pregnancy after CSP treatment. Among the 113 women who initially desired a subsequent pregnancy, 62 finally abandoned fertility plans. Among the 51 women who pursued pregnancy, 48 pregnancies were recorded in 43 women, infertility secondary to CSP treatment was identified in 15.7% (8/51) of women, and 60.8% (31/51) of women achieved full-term pregnancy, with placenta accreta spectrum identified in two women, one requiring a hysterectomy during cesarean section due to massive bleeding. Among the 16 women treated with uterine artery embolization combined with uterine aspiration and 18 women treated by ultrasound-guided local lauromacrogol injection combined with uterine aspiration, a successful full-term pregnancy rate of 68.8% (11/16) and 88.9% (16/18), respectively, was achieved. There were five cases of recurrent CSP among all 76 pregnancies (6.6%). CONCLUSION: Over a long-term follow-up of women after CSP treatment, a high successful fertility rate was identified, with also an increased CSP recurrence rate. Uterine artery embolization combined with uterine aspiration and ultrasound-guided local lauromacrogol injection combined with uterine aspiration showed high rates of successful post-treatment fertility and pregnancy.

Different management strategies for cesarean scar pregnancy: Short-term outcomes and reproductive prognosis.

PURPOSE: To investigate the impact on future reproductive potential of systemic methotrexate (MTX) administration, uterine artery embolization (UAE) and expectant management as treatments of caesarean scar pregnancy (CSP) and to assess their efficacy and safety. BASIC PROCEDURES: We retrospectively analysed patients with a diagnosis of CSP treated in a five years' period (2014-2018). Hospitalization, hCG normalization, menstrual cycle recovery, ultrasound restitutio ad integrum times, reproductive desire accomplishment after the resolution of the picture, and outcomes of subsequent pregnancies were considered. Only patients for whom complete diagnosis, treatment and follow-up data were available could be considered for study entry. MAIN FINDINGS: A total of 21 patients were included. Three of them were managed expectantly. In two cases spontaneous abortion occurred and one case underwent caesarean delivery at 35 weeks of gestation for complete placenta previa with hysterectomy for post partum haemorrhage. Seven patients were treated with systemic MTX. Median [IQR] times of hospitalization, hCG normalization, menstrual cycle recovery and ultrasound restitutio ad integrum were 21 days [10-26 days], 52 days [18-64 days], 8 weeks [6-10 weeks] and 8 weeks [6-11 weeks] respectively. At the end of follow up, 80% (95%CI [38-96%]) of patients with reproductive desire achieved at least one live birth. Eleven patients were treated with UAE combined with MTX. Median [IQR] times of hospitalization, hCG normalization, menstrual cycle recovery and ultrasound restitutio ad integrum were 14 days [12-20 days], 43 days [30-52 days], 8 weeks [4-12 weeks] and 8 weeks [8-10 weeks], respectively. Of those who expressed a reproductive desire after treatment, 80% (95%CI [49-94%]) achieved at least one live birth. In all included patients, the menstrual cycle was restored. PRINCIPAL CONCLUSIONS: Reproductive potential of women treated for CSP was preserved after both systemic MTX administration and systemic MTX combined with UAE. Both strategies proved to be safe.

Scarred for life: a review of cesarean section scar pregnancy and potential pitfalls in diagnosis.

Cesarean section scar pregnancy (CSSP) is defined as abnormal implantation of a gestational sac on or in a previous cesarean section scar. There is an increasing incidence of detection of CSSP, likely in part due to the growing rates of cesarean deliveries and the improved rates of detection with advancing ultrasound technology. Diagnosis of CSSP is critical due to the potentially life-threatening complications to the mother if left untreated. Pelvic ultrasound is the imaging modality of choice in the initial evaluation of suspected CSSP, with MRI potentially useful if ultrasound findings are equivocal, or if confirmation is requested prior to definitive intervention. Early and accurate diagnosis of CSSP allows for prompt management to avoid severe complications and the potential to preserve the uterus and future fertility. A combination of medical and surgical treatment strategies may be needed with specific therapy tailored to each patient. Follow-up after treatment should include serial beta-hCG levels and possible repeat imaging if there is clinical concern for complications or treatment failure. This article will provide a comprehensive review of this uncommon but important phenomenon, detailing the pathophysiology and types of CSSP, imaging presentations, potential pitfalls in diagnosis, and management options.

Management of cesarean scar ectopic pregnancies at an academic referral center: A case series.

OBJECTIVES: To describe treatment and outcomes of patients with confirmed cesarean scar ectopic pregnancy (CSEP) at a tertiary referral center. STUDY DESIGN: We reviewed a deidentified family planning clinical database for patients seen by our subspecialty service for CSEP from January 2017 through December 2021 in this case series. We extracted referral information, final diagnosis, management, and outcome measures including estimated blood loss, secondary procedures, and treatment complications. RESULTS: Of 57 cases referred for suspected CSEPs, 23 (40%) had confirmed diagnoses; one additional case was diagnosed during clinic evaluation for early pregnancy loss. Most (n = 50 [88%]) referrals occurred in the last 2 years of the 5-year study period. Of 24 confirmed CSEP cases, eight were pregnancy losses at the time of diagnosis. Fourteen cases were ≤50 days gestation or gestational size (7 [50%] pregnancy losses) and 10 >50 days gestation (range 39-66 days). We treated all 14 patients ≤50 days primarily with suction aspiration under ultrasound guidance in an operating room with no complications and estimated blood loss of 14 ± 10 mL. Of the 10 patients>50 days (maximum 66 days), seven were managed with primary aspiration of which five were uncomplicated. We treated one patient (57 days) had primary intrauterine double-catheter balloon with immediate hemorrhage requiring uterine artery embolization followed by an uncomplicated suction aspiration. CONCLUSIONS: Patients with confirmed CSEPs at 50 days or less gestation or gestational size can likely be primarily treated with suction aspiration with low risk for significant adverse outcomes. Treatment success and complications are directly related to gestational age at treatment. IMPLICATIONS: Ultrasound-guided suction aspiration monotherapy should be considered for primary CSEP treatment up to 50 days and, with continued experience, may be reasonable beyond 50 days gestation. Invasive treatments or those that require multiple days and visits, such as methotrexate or balloon catheters, are not necessary for early CSEPs.