In my experience, it’s helpful to proactively develop a multidisciplinary management pathway for these uncommon scenarios to prevent recreating the wheel each time they occur.
a cesarean scar ectopic pregnancy at just over 5 weeks gestational age. She was advised of the risks from this type of pregnancy and that termination was warranted. She underwent ultrasound-guided methotrexate injection into the gestational sac by her referring obstetrician with subsequent appropriate decline in the B hCG levels. Despite a successful termination procedure, she experienced intermittent heavy bleeding with symptomatic anemia and was referred for uterine artery embolization (UAE). Follow-up ultrasound was notable for a residual gestational sac only and no abnormal vascularity. Her bleeding stopped a few weeks after termination and has not recurred.
In your opinion, what role can IR play in cases of ectopic uterine scar pregnancy (primary vs. secondary intervention in conjunction with medical/ surgical treatment)? For CSP, a rare type of ectopic pregnancy, there are several ways an IR may become involved in the patient’s care. UAE can be the primary termination procedure, commonly performed using bilateral embolization with an embolic mixed with methotrexate. Or UAE may be employed as a hybrid procedure along with evacuation. In the hybrid procedure, UAE is performed to treat the abnormal vascularity associated with the ectopic implantation followed by obstetric evacuation in the following 2–3 days. As in this case, there are other opportunities to consider UAE
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whereby persistent abnormal uterine bleeding occurred despite successful pregnancy termination.
For which cases do you typically perform prophylactic UAE? Do you have experience with embolization in the setting of CSP? I don’t do much prophylactic embolization. My practice involves treating women with symptomatic fibroids, adenomyosis and rarely uterine arteriovenous malformations. I also perform UAE in cases of postpartum hemorrhage and bleeding associated with abnormal placental implantation. This was my first referral for UAE in the setting of a CSP.
What specifically prompted you to reach out regarding this case/topic? Despite practicing for over 10 years at a large academic urban medical center, I had never been approached to intervene on a patient with a CSP. Admittedly, I was completely naive to the potential roles an IR physician may play in the care of these patients.
Is there a role for collaboration with OB/Gyn in these cases? Definitely. In my experience, it’s helpful to proactively develop a multidisciplinary management pathway for these uncommon scenarios to prevent recreating the wheel each time they occur. Creating the pathway forces you to examine the published experience and learn from it, but also encourages collaboration with another specialty which is often mutually beneficial.
What post or posts were most valuable to you and why? I received a number of replies and direct messages that were helpful. First, it was clear this was uncommon in practice, as few operators had more than a few cases of experience. Second, the role of the IR physician varied from performing the primary procedure to utilizing the hybrid approach to even performing microwave ablation. This was congruent with the published literature whereby some authors favored one approach over another without a clear definitive practice guideline or role for IR procedures.
Will you or have you changed your practice patterns based off of responses on SIR Connect? Please describe any changes you are considering. I am currently working with the referring obstetrician to establish a local pathway or guideline with the goal of involving the IR team at various steps depending on what is needed for the patient. I will reach out to some of our members who responded to my inquiry to hear more about their experiences, pearls and pitfalls.
Additional comments: CSP is a rare ectopic pregnancy in which the embryo implants in a previous cesarean scar. This can lead to complications such as uterine rupture and profuse bleeding as pregnancy progresses, posing significant risk to maternal and fetal health as well as future fertility.1,2
As the number
of C-sections continues to increase worldwide, so does the incidence of CSP. CSP occurs in approximately 1 in 2,000 pregnancies and accounts for 6% of abnormally implanted pregnancies among patients with a prior cesarean birth.3
The diagnosis
The Society for Maternal-Fetal Medicine describes surgical, medical and minimally invasive therapies for CSP management, but the optimal treatment strategy is not yet known.4 Systematic reviews have suggested that overall surgical interventions have been associated with higher rates of success and pregnancy resolution (83%) when compared to medical treatment alone (60%).5
Some of the current treatment strategies established for CSP include: systemic MTX plus curettage, embryo aspiration plus local administration of MTX, uterine artery embolization (UAE) followed by curettage, UAE as primary termination procedure and surgical removal of the CSP either
of CSP is most often made on first trimester transvaginal ultrasound, which has been found to be the superior imaging modality when compared to transabdominal. Imaging findings often include an empty uterus and cervical canal with development of the gestational sac in the anterior lower uterine segment at site of cesarean scar.1
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