Cesarean scar pregnancy (CSP) is a rare kind of ectopic pregnancy implanted in the previous cesarean scar and has an increasing incidence over the past 30 years. As the suspicion is low, the diagnosis may be delayed or misinterpreted in ultrasound, leading to treatment strategies that might end up in uterine rupture or hysterectomy. The objective here is to review the ultrasound findings in CSP with varied presentations. Transabdominal and transvaginal sonography combined with color Doppler is a reliable tool for the diagnosis of CSP. When the gestational sac is seen in lower part of the uterine cavity, differentiation between threatened miscarriage, cervical pregnancy and CSP could be difficult. Not all cases of CSP present with typical ultrasound findings and a high index of suspicion is needed for diagnosis in these cases. An attempted curettage or MTP pill taken in an undiagnosed CSP often alters the typical findings. The possibility of CSP should also be considered in cases presenting with abnormal uterine bleeding and have a prior history of cesarean section. With lack of awareness about this condition, the diagnosis can often be missed either with MRI or in ultrasound. Correct interpretation and timely diagnosis save the mother from life-threatening complications and also preserves future fertility.
This paper is an analysis of the effectiveness of various first trimester markers in detecting uteroplacental insufficiency. The various parameters used for screening in 3373 women were uterine artery pulsatility index (PI) [90th percentile, maternal characteristics, mean arterial pressure (MAP), PAPP-A lower than 0.5 MoM, and PlGF test. Adverse pregnancy outcomes related to uteroplacental insufficiency, namely low birth weight, fetal loss, delivery before 36 weeks (due to abnormal fetal Doppler or oligohydramnios), and hypertension were assessed. Adverse outcomes were found in 37 % of patients who had high uterine PI, in 52 % of cases that had a positive risk after inclusion of maternal characteristics, MAP, and uterine artery Doppler, 55 % of women with low PAPP-A values, 85 % in cases that had both low PAPP-A values and high uterine artery PI, in all the cases positive for early onset pre-eclampsia (PE), and in 65 % of cases positive for late onset PE after inclusion of all parameters mentioned above with PlGF testing. Hence, PlGF test had the maximum detection rate for early onset PE. However, the predictive efficacy for detection of PE and fetal growth restriction (FGR) is quite good when PAPP-A is combined along with first trimester risk prediction using maternal characteristics, MAP, and uterine artery PI. The adverse outcomes were very minimal in the screen negative group, thus first trimester screening for PE and FGR definitely helps in triaging patients earlier in pregnancy giving the advantage of adding low-dose aspirin and increasing surveillance in screen positive group which would help us in minimizing adverse perinatal outcomes.
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