Management of persistent caesarean scar pregnancy after curettage treatment failure

Abstract

BackgroundCaesarean scar pregnancy (CSP) is a late serious complication of caesarean section. The incidence of CSP has increased worldwide in recent years. Early diagnosis and prompt therapy are crucial to avoid catastrophic complications. There are various strategies for CSP treatment, but there is no consensus on the best management for CSP. Dilation and curettage (D&C) and hysteroscopy are common and effective treatments with their advantages and disadvantages. No in-depth study of the clinical effects of hysteroscopic management of CSP after D&C treatment failure has been conducted. The purpose of this study is to evaluate the effectiveness and safety of hysteroscopic removal of residual CSP tissue (persistent CSP) as a rescue after failed D&C management.MethodsThis is a retrospective clinical research study. Forty-five patients underwent operative hysteroscopy to remove the residual gestational tissue in the caesarean scar after failed D&C treatment. The clinical characteristics and outcomes of hysteroscopic surgeries of 45 CSP cases were investigated. All data analyses were conducted with SPSS 17.0.ResultsForty-three CSP cases after unsuccessful curettage treatment were successfully treated by operative hysteroscopy. The estimated intraoperative blood loss was 20.00 (10.00–500.00) mL, the hysteroscopic operating time was 20.00 (15.00–45.00) min, the decline of serum β-hCG the day after surgery was 71.91 ± 14.05%, the total hospitalisation time was 7.87 ± 2.26 days, the medical cost was 13,682.71 ± 3553.77 China Yuan (CNY), the time of bleeding after surgery was 7.42 ± 2.48 days, and the time of serum β-hCG resolution after surgery was 13.84 ± 9.83 days. Follow-up after discharge demonstrated that there were no severe complications for any patients.ConclusionsHysteroscopy therapy could treat persistent CSP effectively and safely after curettage treatment failure. Therapy should be individualised, and the risks and cost of the hysteroscopy procedure and anaesthesia must be considered and fully discussed with the patients before surgery.

Early first‐trimester transvaginal ultrasound is indicated in pregnancy after previous Cesarean delivery: should it be mandatory?

“…A difference of just a couple of weeks (for example, 8–10 weeks compared with 5–7 weeks) increases the complexity of a termination, usually necessitating an operating suite, an anesthesiologist and an expert gynecologic surgeon. It is clearly documented in the literature that termination of CSP at or after 9 weeks decreases the success rate of initial treatment and calls for more involved procedures, such as hysteroscopy, laparoscopy, uterine artery embolization, and/or gravid hysterectomy, all of which by their very nature carry higher risk for complications and even loss of fertility (in cases of hysterectomy).…”

Advanced 11 weeks CS scar ectopic pregnancy. A case report

“…Cesarean scar pregnancy occurs due to implantation of the gestational sac into a myometrial defect at the site of previous uterine incision. 2,3 It's a very rare form of ectopic pregnancy, with an estimated incidence ranging from 1/1800 to 1/2500 of all pregnancies. 4 The first case of CSP was described in 1978, and until 2001 only 19 cases were reported.…”

“…1 In a study published in 2017, in a tertiary hospital in the School of Medicine, Zhejiang University, People's Republic of China, a total of 1348 women were diagnosed during the study period (between March 2011 and September 2014). 3 This dramatic increase in prevalence of CSP is in part due to higher rates of CS, but it's also attributable to better ultrasound diagnosis on basis of high index of suspicion and clinical awareness. Some cases may be asymptomatic, while others may present with abdominal pain and vaginal bleeding or hemodynamic instability.…”

Different treatment modalities and outcomes in cesarean scar pregnancy: a retrospective analysis of 31 cases in a unıversity hospital

“…journals.viamedica.pl/ginekologia_polska pothesized that while D/C procedure alone is inadequate in the treatment of CSP, D/C plus systemic MTX therapy may be useful. Since the recurrent CSP is ubiquitous after the D/C procedure, a recent trial has shown that the operative hysteroscopy is useful in such cases [22].…”