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Update on
Treatment of
Cesarean Scar
Pregnancy
Prof. Aboubakr ElnasharBenha university Hospital,
Egypt
1. INTRODUCTION
Define
GS implanted at the site of a previous CS scar.
Terminologycesarean scar pregnancyEctopic pregnancy in a Caesarean scar cesarean ectopic pregnancycesarean scar ectopic.: MXT as in tubal ectopic pregnancies: failed but disastrous
Rising
1. Increased incidence of CS
72% of CSP occur in women who have had ≥2CS
2. Increased use of TVS
3. Change in Techniques of uterine surgery
Today the uterus is often closed in one layer, compared with the previous two-layer technique
Complications
1. Morbidly adherent placenta
2. Uterine rupture
3. Severe hemorrhage
4. Preterm labor.
5. Increased maternal morbidity and mortality.
Types(Vial et al, 2000)
1. Endogenic, superficially implanted (Type 1):
o grow toward uterine cavity
o±progress into IU pregnancyo birth of a live fetus
o morbidly adherent placenta
2. Exogenic, deeply implanted (Type2):
o deeply implanted into the defect of a scaro grow toward the bladder or abdominal
cavity:
o uterine rupture and severe hge[Singh et al, 2012 Jacquemyn et al, 2012].
Superficially implanted CSP
(A) GS surrounding the myometrial
defect with a bulging toward the
endometrial cavity.
(B) A dumbbell-shaped GS 5 ws in a low-segment uterine scar defect.(C) Hysteroscopy with the use of fluid medium, showing an ectopic gestation hanging from the anterior uterine defect.
Deeply implanted CSP
A. invasion of gestational trophoblasts through a
microdehiscence, well circumscribed by the myometrial tissues
of the uterus.
B. Color Doppler: extensive neovascularization encircling GS
Implanted on
1. Scar
2. Niche(Agten et al, 2017)
CSP implanted "on the scar" had a better
outcome than that implanted "in the niche".
Myometrial thickness ≤2 mm in 1st T:
morbidly adherent placenta at delivery.
Sonographic criteria in 1st T
1. Uterus:
empty with a clearly visualized
endometrium
2. Cervix:
Empty
3. GS:
within the anterior portion of LUS
at site of the cesarean scar
4.Myometrium between GS and bladder:
Thin or absent: <5 mm in 2/3 of cases.
5. Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis: 30-40%
3. DIFFERENTIAL DIAGNOSISFailed pregnancyCx ectopicCSP
within the cervical canal anterior LUS1. GS
normalthin2. Overlying anterior
myometrium
positivenegative3. Sliding organ sign*
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4. Doppler
Not fixed in location, notgrowing
±growing5. Short follow up US
*Gentle pressure with the TV probe: displace GS from its
position within the endocervical canal
The location of the center of GS relative to the midpoint axis of the uterus
differentiated between IUP and CSP (mean 17.8 vs -10.6 mm, respectively, P =
.0001), indicating that most CSPs are located proximally to the midpoint axis of
the uterus whereas most normal IUPs are located distally from the midpoint of
the uterus.
IUP & SCP
5 -10 W(Timor-Tritsch et al, 2016)
4. TREATMENTObjective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion:
most effective
least complications.
Timor-Tritsch et al, 2014
Treatment should be individualized, based on I. Center
1. Availability
2. Expertise of the clinicians
II. Patient
1. Age
2. Number of children.
3. Number of previous CS
4. Severity of symptoms
III. CSP
1. Gestational age
2. Level of HCG
3. Thickness of covering
myometrium
Treatment approaches(Timor-Tritsch, 2015)
1. Major Surgery
require general anesthesia
(a) Excision:
Laparotomy
Laparoscopy
Hysteroscopy
Transvaginal
(b) D&C
(c) Suction aspiration without dilatation of
the cervix
2. Minimally invasive surgery
No general anesthesia
(a) Local injection of MTX or KCl
(b) Local injection of Vasopressin
(c) UAE
3. Medical treatment
MTX: Single or repeated doses
Combination of the above treatments.
Rare to find a patients managed only by one
single treatment agent or protocol.
± Planned: simultaneous or Sequential fashion.
Changed, after failure of 1st line therapy
Adjuvant measures.
1. Foley balloon placement
At the site of the CSP, blocked with 5 to 30
mL
extremely useful
can be kept in situ for 3–4 days with antibiotic
coverage.
2. Shirodkar Suture
during the evacuation of CSP
Referral centers:
Experience
Operating rooms
Interventional radiology
Ready for emergencies.
Available immediate blood transfusion/
blood products.
Jain et al (2014)
CSP
Haemodinamicly stable Haemodinamicaly unstable
HCG ≤10000IU/ml HCG≥10000IU/ml
MXT: local and Sys Hysteroscopic Hysteroscopic
+
Kcl or
vasopressin
injection
Scar resection
Shao et al (2013): 1. GS
2. Myometrial Thickness
3. HCG
LUAO=Laparoscopic uterine a occlusion
Timor-Tritsch (2015) SR of 1223 CSP
Complication(%)
No
6536MXT: Sys
11200MXT: Local+Sys
28309UAE
60577D&C
10119TV excision
2594Laparoscopy
1113Hysteroscopy
050UAE+Hysteroscopy
2515Laparotomy
020HIFU
1223Total
{No single best treatment} :procedure with the least complicationsperformed without delay.
Single-dose systemic MTX injection:
Lengthy
usually ineffective 1st line therapy
delaying the final treatment.
MTXan adjuvant to other treatments
MXT: US guided local, plus sys MTX:
25mg in GS, 25mg in F placenta, 25mg IM
Simple
low complication rates.
Petersen et al (2016): SR of 2037 CSPLaparotomyBleeding
≥1LHysterectomyComplication
(%)Success
(%)No
0517544141Expectant
925101375339MTX IM
30046574MTX local
2991485148MTX local+Asp
00127734MTX Local+IM
282369427UAE+MTX
046394295UAE+D&C
337112148243D&C
00119585UAE+D&C+Hysteroscopy
011199118TV excision
20138395Hysteroscopy
00009769Laparoscopy
000010016HIFU
000010035HIFU+Hysteroscopy
2188592037Total
5 treatment modalities are recommended depending on
1. availability2. severity of patient symptoms3. surgical skills
An interventional rather than medical approach.
1. Resection through a TV approach
2. Laparoscopy
3. Hysteroscopy
4. UAE plus D&C and hysteroscopy
5. UAE combined with D&C without MTX
Hysteroscopy:
most frequently adopted 1st line approaches.
Hysteroscopy and laparoscopic hysterotomy:
safe and efficient surgical procedures
Systemic methotrexate and D&C:
not recommended as 1st line tt
{high complication and hysterectomy rates}.
Hysterectomy(%)
Success rate (%)
Resolution time (D)
Bleeding(%)
496014Systemic MTX
1185933UAE
0.039207Hysteroscopy
7624651D&C
2922028Hysterotomy
Pektas et al, 2016: 1674 CSP
SUMMARY1. CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising.
Precursor of morbidly adherent placenta
2. Early diagnosis
important.
At the time of discharging after a CS:
in a future pregnancy, an early visit for TVS is
important.
3. DD
Failed pregnancy
Cx ectopic
4. Management:
Counseling
Termination:
Reliable tt that stops fetal heart beat without
delay.
Avoid single tts unlikely to be effective:
D&C
Suction curettage
Single-dose IM MTX
UAE
Each center should have protocol :
Availability
Skills
Severity
if not: Referral
ABOUBAKR ELNASHAR
You can get this lecture from:1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
4.My clinic: Elthwra St. Mansura, Egypt