Cesarean scar pregnancy (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.


transvaginally, laparoscopically or assisted by hysteroscopy.6,7


The role


of IRs in treatment is not clearly defined by clinical guidelines. However, treatment most commonly involves UAE as adjuvant to treat abnormal uterine vascularity in combination with an evacuation procedure (i.e., UAE plus dilatation and curettage [D&C]), UAE as primary termination procedure or for persistent bleeding after primary termination procedure such as described in the case above.7


In a 2009 prospective controlled trial published in the American Journal of Obstetrics and Gynecology, 72 women with CSP were randomized to UAE or systemic methotrexate (MTX) group, all of which underwent suction curettage 24 hours later. Results of the study showed that, compared to MTX, patients who underwent UAE showed a significant decrease in bleeding volumes (P < .001), shorter hospitalization stay, lower hysterectomy rate and no differences in severe side effects.8 Furthermore, a recent retrospective study demonstrated that shorter interval treatments between UAE with gelfoam and suction aspiration were found to decrease hemorrhage. Rates of intraoperative bleeding were 5% for patients who received curettage within 24 hours after UAE and 19.4% for those who had a treatment interval longer than 72 hours with an adjusted odds ratio of 3.37 (95% confidence interval: 1.40–8.09).9


In a study of 66 women


with CSP who were given the choice of treatment, 38 elected to receive bilateral UAE with gelatin sponge particles and


local MTX administration, 11 chose D&C and 17 chose systemic MTX. Successful outcomes were measured and defined as a complete recovery with no severe complications and with the preservation of fertility. The success rate was significantly higher in the UAE group (89.5%) compared to the systemic MTX (27.3%) or D&C groups (58.8%; P < 0.001). Additionally, the mean blood loss, time for B-HCG decline and hospital stay were all significantly lower in the UAE group. Authors concluded that UAE combined with local MTX is a safe and effective primary treatment strategy for CSP. It should be noted, however, that 63% of patients in the UAE group required additional curettage due to persistent embryo mass or persistent bleeding on an average of five days post procedure. Unsurprisingly, the rate of massive bleeding after curettage was reduced in the women previously treated with UAE (16.7%) compared to those who received only curettage as the primary treatment (72.7%).10


In summary, it is clear that UAE has a role in the treatment of CSP with the main clinical objective to prevent massive blood loss and maintain the patient’s fertility and quality of life. Due to relatively low incidence of CSP, there are currently no universal management guidelines. The choice of treatment modality is often guided by the type of CSP, gestational age, vascularity, hemodynamic stability, medical expertise, patient preference and equipment/personnel availability.


Please note: Due to recent law changes, certain procedures detailed within this article may not be legally permitted in your state. Please be sure to confer with your institution’s legal advisers.


References


1. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol. 2006 Jun;107(6):1373-81. doi: 10.1097/01. AOG.0000218690.24494.ce. PMID: 16738166.


2. Silver RM. Implications of the first cesarean: perinatal and future reproductive health and subsequent cesareans, placentation issues, uterine rupture risk, morbidity, and mortality. Semin Perinatol 2012;36:315–23. VOL. 105 NO. 4/ APRIL 2016: 965.


3. Liou N, Mallick R, Odejinmi F. From laparotomy to laparoscopy for all. Current trends in the surgical management of ectopic pregnancies: a prospective analysis of over 1000 cases. BJOG An Int J Obstet Gynaecol 2018; 3:175–177.


4. Society for Maternal-Fetal Medicine (SMFM). Electronic address: pubs@smfm.org. Miller R, Timor-Tritsch IE, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy. Am J Obstet Gynecol 2020; 222:B2–B14.


5. Maheux-Lacroix S, Li F, Bujold E, Nesbitt- Hawes E, Deans R, Abbott J. Cesarean Scar Pregnancies: A Systematic Review of Treatment Options. J Minim Invasive Gynecol. 2017 Sep- Oct;24(6):915-925. doi: 10.1016/j.jmig.2017.05.019. Epub 2017 Jul 18. PMID: 28599886.


6. Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, Svarre Nielsen H. Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril. 2016 Apr;105(4):958-67. doi: 10.1016/j. fertnstert.2015.12.130. Epub 2016 Jan 18. PMID: 26794422.


7. Litwicka K, Greco E. Caesarean scar pregnancy: a review of management options. Curr Opin Obstet Gynecol. 2011 Dec;23(6):415-21. doi: 10.1097/GCO.0b013e32834cef0c. PMID: 22011956.


8. Zhuang Y, Huang L. Uterine artery embolization compared with methotrexate for the management of pregnancy implanted within a cesarean scar. Am J Obstet Gynecol. 2009 Aug;201(2):152.e1-3. doi: 10.1016/j. ajog.2009.04.038. Epub 2009 Jun 13. PMID: 19527897.


9. Wang Q, Peng H, Zhao X, Qi X. When to perform curettage after uterine artery embolization for cesarean scar pregnancy: a clinical study. BMC Pregnancy Childbirth. 2021 May 10;21(1):367. doi: 10.1186/s12884-021-03846-x. PMID: 33971838; PMCID: PMC8108320.


10. Yang XY, Yu H, Li KM, Chu YX, Zheng A. Uterine artery embolisation combined with local methotrexate for treatment of caesarean scar pregnancy. BJOG. 2010 Jul;117(8):990-6. doi: 10.1111/j.1471-0528.2010.02578.x. PMID: 20536432.


Disclaimer: This column represents the work and opinions of the contributing authors and do not necessarily reflect the views or policies of SIR. SIR assumes no liability, legal, financial or otherwise, for the accuracy of information in this article or the manner in which it is used. The statements made in the column are not intended to set a standard of care and should not be treated as medical advice nor as a substitute for independent, professional judgment.


irq.sirweb.org | 17


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40