First-trimester diagnosis and management of Cesarean scar pregnancies after in vitro fertilization-embryo transfer: a retrospective clinical analysis of 12 cases

Abstract

BackgroundAlthough Caesarean scar pregnancy (CSP) is rare, it can cause life-threatening complications. The increasing rate of Cesarean delivery plus rapid development of in vitro fertilization-embryo transfer (IVF-ET) may increase the occurrence of CSP as well as the ratio of heterotopic CSP (HCSP)/CSP. Therefore, early diagnosis and management of CSP are necessary to avoid serious complications. And the purpose of this article is to evaluate the importance and feasibility of the first-trimester diagnosis and management of CSP after IVF-ET.MethodsAll the 12 cases were secondary infertility patients who had a history of Cesarean section and underwent IVF-ET in our reproductive center. All cases with CSP were diagnosed using transvaginal color Doppler sonography (TVS). Medical, surgical and expectant managements were implemented, and the management results were traced.ResultsPatients with CSP (n = 12) were diagnosed from January 2011 to April 2015, 6 (50 %) of which were HCSP. The prevalence of CSP was 1:1688 pregnancies. The gestational age ranged from 5 + 3 to 7 + 4 weeks in all CSP, and from 5 + 6 to 7 + 4 weeks in HCSP at diagnosis. Five patients received successful surgical treatment. The success rate of medical and expectant management was 50 % (1/2) and 100 % (5/5), respectively. One patient with failed medical management needed an emergency laparotomy to evacuate CSP. The uterus was preserved in all 12 patients.ConclusionsThe Caesarean section and IVF-ET may increase the ratio of HCSP/CSP. TVS is a noninvasive and effective tool for use in diagnosing CSP. CSP should be carefully excluded in patients who have had a history of Caesarean section. Early diagnosis of CSP in the first trimester may contribute towards the preservation of uterus as well as intrauterine pregnancy (IUP) in HCSP.

Successful selective reduction of a heterotopic cesarean scar pregnancy in the second trimester: a case report and review of the literature

“…High-resolution vaginal ultrasonography is the preferred diagnostic method for HCSP, and the mean gestational age at CSP diagnosis is reported to be 7.5±2.5 weeks [11]. Ouyang et al [4] showed that the gestational age ranged from 5 weeks and 3 days to 7 weeks and 4 days in CSP and from 5 weeks and 6 days to 7 weeks and 4 days in HCSP using transvaginal color Doppler sonography.…”

“…Therefore, in the present study, we conducted a search and review of the literature pertaining to HCSP. To the best of our knowledge, a total of 23 cases of HCSP have been reported in the English literature [2, 4, 10, 12–26], and the results are summarized in Additional file 1: Table S1. The reported treatments included conservative management, fetal reduction by potassium chloride, laparoscopic excision, aspiration of embryonic or ectopic gestational sac, hysteroscopy with directed evacuation, injection of a mixture of MTX and KCl, or laparotomic excision.…”

“…The literature includes seven case reports of HCSP with expectant management [4, 21, 25], only one of which was a spontaneous pregnancy; the others developed after in-vitro fertilization. Five cases exhibited vaginal bleeding and/or abdominal pain and 4 cases delivered live births at 35–37 weeks of gestation.…”

“…In Bai’s report, during the expectant management severe vaginal bleeding occurred at 8 + 4 weeks of gestation, and this resulted in blood loss anemia (Hb 68 g/L) and a blood transfusion; and subsequently, spontaneous abortion of the CSP occurred at 9 + 1 weeks [21]. Ouyang et al [4] reported that the success rate with expectant management in cases with a non-viable CSP was 100% (5/5); however, we do not know the maternal morbidity in 3 cases, as 2 cases terminated pregnancy at 14 weeks and 6 months, and 1 case was uneventful at the time of the author’s report (18 weeks of gestation). An emergency cesarean section was performed at 35 weeks in 1 patient due to massive hemorrhage caused by complete placenta previa.…”

“…The incidence of CSP has been estimated to be between 1:2216 and 1:1688 [1–4]. CSP results in life-threatening complications such as uterine rupture and catastrophic hemorrhage, which may, in turn, be associated with maternal and fetal morbidity and mortality [5].…”