Risk prediction of major haemorrhage with surgical treatment of live cesarean scar pregnancies

Braud, Lucrezia V. De; Knez, Jure; Mavrelos, D.; Thanatsis, Nikolaos; Jauniaux, Eric

doi:10.1016/j.ejogrb.2021.07.030

Cited by 19 publications

(20 citation statements)

References 27 publications

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“…A CSP is typically diagnosed in the first trimester and women can either be asymptomatic or present with vaginal bleeding, abdominal pain or a combination of both. In a recent report of 62 viable CSPs from a single centre, 26% of women were asymptomatic, 23% presented with vaginal bleeding, 12% with abdominal pain and 39% with a combination of both [24 ▪ ]. In a retrospective cohort of 232 CSPs, 24.5% of women were asymptomatic, 48.5% presented with vaginal bleeding, 9% with abdominal pain and 18% with a combination of both [13].…”

Section: Clinical Presentationmentioning

confidence: 97%

“…Notably, additional haemostatic measures, such as oxytocics, cervical suture and Foley catheter were used in 80% of cases managed by D&C. The time to obtain the resolution of the CSP was also shorter after surgical management (median of 11 days) compared with 21 and 82 days for medical and expectant management, respectively. For viable CSPs terminated by D&C, the gestational age at treatment is a predictive factor for the risk of severe bleeding and/or the need for transfusion, with one-third of women requiring blood transfusion after 9 weeks versus none before 9 weeks’ gestation in a cohort of 62 women [24 ▪ ]. Monteagudo et al [30] published 48 cases treated by double balloon tamponade before 10 weeks’ gestation [31].…”

Section: Managementmentioning

confidence: 99%

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Caesarean scar pregnancy: diagnosis, natural history and treatment

Noël

Thilaganathan

2022

Current Opinion in Obstetrics &Amp; Gynecology

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Purpose of reviewThis review aims at summarizing the latest evidence on diagnosis, natural history and management of caesarean scar pregnancy (CSP).Recent findingsCSP can result in maternal morbidity from major haemorrhage, uterine rupture, placenta accreta spectrum disorders and hysterectomy. Classification of the CSP types, presence of fetal heart activity, gestational age and residual myometrial thickness seem to influence rates of ongoing pregnancy, subsequent development of placenta accreta with expectant management, as well as success and complication rates associated with various methods of pregnancy termination. Expectant management may be appropriate in certain good prognosis cases, such as absent fetal heart activity or when the myometrial layer at the implantation site is relatively thick. Surgical treatments are typically associated with higher success rates, but seem to result in severe haemorrhage more frequently than medical treatments, which have higher failure rates. Although other treatment modalities are available, in general, the size and quality of evidence to guide care provision in CSP is very poor.SummaryCSP can be associated with severe maternal morbidity but can also lead to a livebirth. There is currently a lack of good-quality evidence to predict the outcome of CSP and provide informed and evidence-based care.

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Section: Clinical Presentationmentioning

confidence: 97%

Section: Managementmentioning

confidence: 99%

Caesarean scar pregnancy: diagnosis, natural history and treatment

Noël

Thilaganathan

2022

Current Opinion in Obstetrics &Amp; Gynecology

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“…The median age was 31.0 years (range 24-38), and gravidity ranged from two to five. The median duration of gestation at diagnosis was 8.2 weeks (range [6][7][8][9][10][11]. The median interval between the current CSP and previous cesarean section was 2.5 years (range 1-7) (Table 1).…”

Section: Clinical Characteristicsmentioning

confidence: 99%

“…Type I CSP is characterized by implantation on top of a well‐healed cesarean scar, whereas type II CSP is a deep implantation within a cesarean scar defect 7 . Resection of gestational contents can be accomplished either through operative hysteroscopy or laparoscopy, and transcervical vacuum suction has been proposed as a minimally invasive treatment option 8 . Extravillous trophoblast cells (EVTs) can invade deeply into the myometrium or beyond the uterine serosa, resulting in placenta accreta spectrum disorders, including accreta, increta, and percreta, which are potentially life‐threatening because of associated massive hemorrhage events 9,10 .…”

Section: Introductionmentioning

confidence: 99%

Extravillous trophoblast invasion and decidualization in cesarean scar pregnancies

Gao

Chen

Liu

et al. 2022

Acta Obstet Gynecol Scand

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Introduction:The increasing cesarean section rate has led to an increase in the number of subsequent pregnancies resulting in a cesarean scar pregnancy. There appears to be preferential attachment of the blastocyst to the scar site, which may be associated with defective decidua in that region, resulting in abnormal implantation, which can in turn negatively affect the success of the pregnancy. The aim of the current study was to evaluate the extravillous trophoblast, decidua, and myometrium in scar and adjacent non-scar regions of the implantation site of a cesarean scar pregnancy.Material and Methods: Samples containing a gestational mass were obtained by laparoscopic excision from patients with a cesarean scar pregnancy at 6-11 weeks of gestation as diagnosed by transvaginal or transabdominal ultrasound (n = 8 type II cesarean scar pregnancy). Cesarean scar pregnancy tissues were separated into scar and non-scar regions, and the scar regions were sub-separated into non-implantation and implantation sites. Serial sections were histologically examined after hematoxylin and eosin, Masson's trichrome and immunochemical staining, and changes in the myometrium, extravillous trophoblast, and decidua were evaluated. Results:In cesarean scar pregnancy, compared with scars not in the implantation site, scars in the implantation site displayed increased fibrosis, and had disrupted myometrium, which was related to varying patterns of E-cadherin expression as a response to extravillous trophoblast invasion. In addition, local decidua was found at the non-scar implantation sites, with multinucleated trophoblast giant cell accumulation and shallow invasion. These features were not evident in the scar implantation sites. Conclusions:This study emphasizes that the decidua drives multinucleated trophoblast giant cell differentiation, limiting the degree of invasion. Better characterization of this differentiation process may be helpful for better management and avoidance of the consequences of cesarean scar pregnancy.

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“…The manner in which the termination is performed has a direct impact on the future of the reproductive capacity. The recommendations from the Society for Maternal–Fetal Medicine suggest two types of management for this situation: surgical treatment (resection) or medical (Methotrexate) followed by surgical treatment [ 1 , 6 ]. Curettage alone or systemic methotrexate administration, as well as expectant management, are strongly considered unsuitable because of the high morbidity and mortality maternal risks (hemorrhage, perforation, development of uterine arteriovenous malformation, etc.…”

Section: Introductionmentioning

confidence: 99%

Uterine Artery Embolization Combined with Subsequent Suction Evacuation as Low-Risk Treatment for Cesarean Scar Pregnancy

Bohîlțea

Ducu

Mihai³

et al. 2021

Diagnostics

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Objective: The aim of this study is to propose a standardized management of care for patients diagnosed with cesarean scar pregnancy (CSP). There are two types of CSP: Type 1 (on the scar) vs. type 2 (in the niche). To date there is no international standard to predict the extent of invasion or the optimal management of CSP. Materials and methods: We used intramuscular methotrexate injection followed by uterine artery embolization combined with suction evacuation as a conservative approach for the treatment of seven patients diagnosed with CSP. Our inclusion criteria, to be satisfied simultaneously, were established as follows: (1) patients with CSP; (2) early gestational age ≤ 9 weeks, and (3) written consent of the proposed treatment of the patient. Results: This course of treatment produced a positive outcome in all cases. We did not have any complications (e.g., emergency hysterectomy, perforation of the uterine cavity, severe hemorrhage, or endometritis) during the procedures or in the follow-up. The most important predictors of successful management are early diagnosis of CSP and orientation of the invasive trophoblast opposite to the scar. Conclusions: The main finding from this series of cases is that associating systemic methotrexate and uterine artery embolization provides efficient and low-risk management of CSP. This treatment regime is adequate for both types of CSPs. We consider that early localization diagnosis of pregnancy following a cesarean delivery is mandatory for CSP morbidity prevention.

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Risk prediction of major haemorrhage with surgical treatment of live cesarean scar pregnancies

Cited by 19 publications

References 27 publications

Caesarean scar pregnancy: diagnosis, natural history and treatment

Caesarean scar pregnancy: diagnosis, natural history and treatment

Extravillous trophoblast invasion and decidualization in cesarean scar pregnancies

Uterine Artery Embolization Combined with Subsequent Suction Evacuation as Low-Risk Treatment for Cesarean Scar Pregnancy

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