Cesarean Scar Pregnancies

Abstract

Objectives To evaluate the management, clinical courses, and outcomes of cesarean scar pregnancies diagnosed in the first trimester. Methods We identified 60 cases of cesarean scar pregnancies diagnosed between 5 and 14 weeks. Group A contained 48 patients with fetal/embryonic cardiac activity; group B comprised 12 patients without cardiac activity; and group C included 11 patients with cardiac activity who chose expectant management. Results Five of the 48 patients (10.4%) in group A were successfully treated for vaginal bleeding. Thirty‐three (68.7%) received methotrexate injections, and all had full resolution. Three (6.3%) required uterine artery embolization for late‐developing arteriovenous malformations. Ten of the 12 patients (83.3%) in group B were managed expectantly and had full recovery. Two of the 10 (20.0%) had arteriovenous malformations; 1 had unsuccessful uterine artery embolization followed by a hysterectomy, and the second requested a hysterectomy. Ten of the 11 patients (90.9%) in group C continued the pregnancies. One declined local injection. Four of the 10 (40.0%) delivered live offspring by successive elective cesarean deliveries. Three (30.0%) had hysterectomies for placenta percreta, and 1 did not have a hysterectomy after delivery. Five (50%) had second‐trimester complications, all leading to hysterectomies. Of the 60 patients, 20 (33.3%) had serious complications: 5 had arteriovenous malformations; 4 had uterine artery embolization; and 11 had hysterectomies. Conclusions A cesarean scar pregnancy is a serious complication for patients who have had cesarean deliveries. Counseling, treatment, and follow‐up are challenging for patients and caregivers. However, emerging data from different management approaches confirm that a cesarean scar pregnancy may progress and result in a live neonate at the expense of further fertility. This study confirmed that expectant management of a cesarean scar pregnancy is associated with a high risk of hysterectomy due to morbidly adherent placenta.

Incidence, diagnosis and management of tubal and nontubal ectopic pregnancies: a review

“…Live births resulting from a cesarean scar ectopic implantation have been described; however, these deliveries are frequently associated with hemorrhage and emergent cesarean hysterectomy [9, 181, 182]. In a series of 10 patients with cesarean scar EPs with fetal cardiac activity who elected for expectant management, 4 patients (40 %) had live births, 3 of whom (75 %) required hysterectomies; overall, 80 % required hysterectomies [183]. …”

“…Of note, complications of medical or surgical management include formation of arterio-venous malformations, which are prone to bleeding; in one series of 60 cesarean scar EPs, this occurred at a rate of 8.5 %, requiring UAE or hysterectomy (Fig. 9) [183].

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Ectopic low-lying implantation pregnancy: analysis of outcomes depending on gestation age

“…Discharge from care (median number of days) was 82 (range 37-174) with expectant, 21 (range 10-31) with medical and 11 (range 4-49) with surgical management [19]. In a series of 10 patients with CSP with fetal cardiac activity who elected for expectant management 80% required hysterectomies [25]. Early diagnosis allows to avoid uterine rupture and haemorrhage, thus preserving the uterus and fertility.…”

“…In recent years the number of reports of livebirth delivery has increased although this situation is always connected with high risk of bleeding and hysterectomy [2,13,17,[22][23][24][25]. Unfortunately, in clinical practice the majority of clinicians have very limited experience and confidence in the differential diagnosis of this pathology and treatment is at the physicians' discretion [16].…”

Ectopic Mural Pregnancy

“…В серии из 10 пациенток с CSP с сердечной деятельностью эмбриона, выбравших выжидательную тактику, 8 (80%) потребовалась гистерэктомия [88]. Выжи-дательная тактика не может рассматриваться как приемлемый выбор в большинстве случаев и до-пустима лишь при снижении концентрации сыво-роточного ХГЧ и отсутствии сердечной деятель-ности плода [89].…”