Cesarean scar pregnancy – a new challenge for obstetricians

Abstract

Diagnosis and treatment of ectopic cesarean scar pregnancy has become a challenge for contemporary obstetrics. With an increase in the number of pregnancies concluded with a cesarean section and with the development of transvaginal ultrasonography, the frequency of cesarean scar pregnancy diagnoses has increased as well. The aim of the study is to evaluate various diagnostic methods (ultrasonography in particular) and analyze effective treatment methods for cesarean scar pregnancy. An ultrasound scan, Doppler examination and magnetic resonance imaging are all useful in early detection of asymptomatic cesarean scar pregnancy, thus enabling effective treatment and preservation of fertility. Dilatation and curettage is not recommended as it carries significant risk of bleeding and very high risk of hysterectomy and fertility loss. Systemic methotrexate treatment should not be applied on the routine basis due to its low efficacy, high risk of fertility loss and adverse effects. Local methotrexate therapy (under ultrasound or hysteroscopy guidance) should be considered a perfect management method as it offers fertility preservation in asymptomatic pregnant patients without concomitant hemodynamic disorders. Synchronous usage of several treatment methods is an effective way to manage cesarean scar pregnancy. The combination of local methotrexate with simultaneous aspiration of gestational tissues under ultrasound or hysteroscopy guidance seems optimal. Subsequently, the remaining gestational tissues can be removed hysteroscopically in combination with vascular coagulation at the implantation site. In more advanced cases, local methotrexate treatment should be considered followed by laparoscopic or laparotomic wedge resection with subsequent surgical correction of the cesarean section scar.

Identifying possible risk factors for cesarean scar pregnancy based on a retrospective study of 291 cases

“…The fertilized egg can easily implant here; if the endometrial stroma deciduates insufficiently or is unable to deciduate, the trophoblast cells of a pregnancy will invade the myometrium directly, even though the uterine wall . Cesarean scar defects have been shown to be associated with various gynecological and obstetric problems, such as uterine rupture and ectopic CSP . There have been a large number of reports about the risk factors for incomplete healing of the uterine incision after CS .…”

Cesarean scar defect: a prospective study on risk factors

“…Uterine rupture and ectopic cesarean scar pregnancy are fairly rare complications of cesarean scar defect yet with potentially catastrophic consequences. 5,6 However, postmenstrual spotting, dysmenorrhea, dyspareunia, or chronic pelvic pain are frequently described in relation to cesarean scar defect. 7e11 Additionally, cesarean scar defect may increase the risk for complications in gynecological procedures such as intrauterine device placement, evacuation, and embryo transfer.…”

Live Cesarean Scar Pregnancy: A Case Report

“…A diagnosis of caesarean scar pregnancy based on symptoms and pelvic examination alone is difficult as CSP is asymptomatic in its initial phases. Later, signs of this type of pregnancy like vaginal bleeding and abdominal pain are frequently non-specific and also often present in other obstetric conditions [2]. Early CSP is frequently misdiagnosed as normal intrauterine pregnancy, missed abortion, inevitable abortion, gestational trophoblastic disease or cervical pregnancy [9].…”

“…The overall prevalence of ectopic pregnancy is approximately 2%. In most cases (about 97%), an ectopic pregnancy is located in a fallopian tube [2]. However, an ectopic pregnancy can occur in other anatomic locations including the myometrium, cervix, ovaries, and abdomen.…”

“…However, an ectopic pregnancy can occur in other anatomic locations including the myometrium, cervix, ovaries, and abdomen. Caesarean scar pregnancy (CSP) is a type of ectopic pregnancy where the fertilized egg is implanted in the muscle or fibrous tissue of the scar after a previous caesarean section [2]. This is a lifethreatening form of pregnancy due to the increased risk of uterine rupture and haemorrhage that may require an urgent hysterectomy and blood transfusion [3].…”