Evaluation of outcome of medical and surgical management in cesarean scar pregnancy in a tertiary health care institute of Northen India
DOI:
https://doi.org/10.18203/2320-1770.ijrcog20242828Keywords:
Cesarean scar, Ectopic pregnancy, Methotrexate, ß hCGAbstract
A rare form of ectopic pregnancy known as caesarean scar pregnancy (CSP) is associated with high rates of morbidity and mortality. When a growing conceptus is pathologically implanted into the site of a prior caesarean section, CSP ensues. Transvaginal ultrasonography (TVS) and transabdominal ultrasound are the main diagnostic methods for CSP. It was a series of clinical cases diagnosed over a period of 1 year. The clinical characteristics included in the study were maternal age, gravidity, number of prior caesarean sections, number of abortions, interval between CSP and caesarean sections, gestational age, mean size of the residual gestational tissue before intervention, serum β-hCG levels before and after intervention. All cases were detected timely in the first trimester itself on USG evaluation. Amongst all cases, ß hCG levels at the time of admission varied between 266 mIU/ml-56,265 mIU/ml. 30% patients were treated with medical management only with inj. methotrexate and inj. folinic acid out of which 60% of cases had failed medical management and had to undergo further surgical procedure. 30% of cases with failed medical management were planned for hysteroscopic curettage, 20% underwent dilatation and curettage (D and C) while only 1 patient who was diagnosed with early placenta accreta required hysterectomy. CSP is a rare yet life threatening obstetric condition. Medical management should be used as the first line of treatment in patients with hemodynamic stability. Laparotomy and embolization are invasive procedures that should only be used in patients with failed medical management or patients with severe bleeding.
References
Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar. Ultrasound Obstet Gynecol. 2003;21(3):220-7.
Jayaram PM, Okunoye GO, Konje J. Caesarean scar ectopic pregnancy: diagnostic challenges and management options. Obstetric Gynaecol. 2017;19(1):13-20.
Mittal S, Pardeshi S, Mayadeo N, Mane J. Trends in cesarean delivery: rate and indications. J Obstet Gynaecol India. 2014;64(4):251-4.
Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, Svarre Nielsen H. Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril. 2016;105(4):958-67.
Fobelets M, Beeckman K, Faron G, Daly D, Begley C, Putman K. Vaginal birth after caesarean versus elective repeat caesarean delivery after one previous caesarean section: a cost-effectiveness analysis in four European countries. BMC Pregnancy Childbirth. 2018;18(1):92.
Boerma T, Ronsmans C, Melesse DY, Barros AJD, Barros FC, Juan L, et al. Temmerman M. Global epidemiology of use of and disparities in caesarean sections. Lancet. 2018;392(10155):1341-8.
Simionescu AA, Marin E. Caesarean birth in Romania: safe motherhood between ethical, medical and statistical arguments. Maedica. 2017;12(1):5.
Maymon R, Halperin R, Mendlovic S, Schneider D, Vaknin Z, Herman A, et al. Ectopic pregnancies in Caesarean section scars: the 8 year experience of one medical centre. Hum Reprod. 2004;19(2):278-84.
Zhou X, Li H, Fu X. Identifying possible risk factors for cesarean scar pregnancy based on a retrospective study of 291 cases. J Obstetr Gynaecol Res. 2020;46(2):272-8.
Timor-Tritsch IE, Monteagudo A, Cali G, Palacios-Jaraquemada JM, Maymon R, Arslan AA, Patil N, et al. Cesarean scar pregnancy and early placenta accreta share common histology. Ultrasound Obstet Gynecol. 2014;43(4):383-95.
Timor‐Tritsch IE, Monteagudo A. OP25. 12: Cesarean deliveries: a mounting threat. Ultrasound Obstetr Gynecol. 2012;40(S1):132-.
Ballas J, Pretorius D, Hull AD, Resnik R, Ramos GA. Identifying sonographic markers for placenta accreta in the first trimester. J Ultrasound Med. 2012;31(11):1835-41.
Michaels AY, Washburn EE, Pocius KD, Benson CB, Doubilet PM, Carusi DA. Outcome of cesarean scar pregnancies diagnosed sonographically in the first trimester. J Ultrasound Med. 2015;34(4):595-9.
Zosmer N, Fuller J, Shaikh H, Johns J, Ross JA. Natural history of early first-trimester pregnancies implanted in Cesarean scars. Ultrasound Obstet Gynecol. 2015;46(3):367-75.
Rac MW, Moschos E, Wells CE, McIntire DD, Dashe JS, Twickler DM. Sonographic Findings of Morbidly Adherent Placenta in the First Trimester. J Ultrasound Med. 2016;35(2):263-9.
Glenn TL, Bembry J, Findley AD, Yaklic JL, Bhagavath B, Gagneux P, et al. Cesarean Scar Ectopic Pregnancy: Current Management Strategies. Obstet Gynecol Surv. 2018;73(5):293-302.
Jabeen K, Karuppaswamy J. Non-surgical management of caesarean scar ectopic pregnancy-a five-year experience. J Obstet Gynaecol. 2018;38(8):1121-7.
Bodur S, Özdamar Ö, Kılıç S, Gün I. The efficacy of the systemic methotrexate treatment in caesarean scar ectopic pregnancy: A quantitative review of English literature. J Obstet Gynaecol. 2015;35(3):290-6.
Kalampokas E, Boutas I, Panoulis K, Kalampokas T. Novel Medical Therapy of Cesarean Scar Pregnancy with a Viable Embryo Combining Multidose Methotrexate and Mifepristone: A Case Report. Medicine (Baltimore). 2015;94(41):e1697.
Kapp N, Baldwin MK, Rodriguez MI. Efficacy of medical abortion prior to 6 gestational weeks: a systematic review. Contraception. 2018;97(2):90-99.
Raymond EG, Harrison MS, Weaver MA. Efficacy of Misoprostol Alone for First-Trimester Medical Abortion: A Systematic Review. Obstet Gynecol. 2019;133(1):137-7.
Gómez García MT, Ruiz Sánchez E, Aguarón Benítez G, Nogueira García J, Callejón Rodríguez C, González Merlo G. Caesarean scar ectopic pregnancy successfully treated with methotrexate and mifepristone. J Obstet Gynaecol. 2015;35(1):105-6.
Ma Y, Shao M, Shao X. Analysis of risk factors for intraoperative hemorrhage of cesarean scar pregnancy. Medicine (Baltimore). 2017;96(25):e7327.
Wang JH, Xu KH, Lin J, Xu JY, Wu RJ. Methotrexate therapy for cesarean section scar pregnancy with and without suction curettage. Fertil Steril. 2009;92(4):1208-13.
Timor-Tritsch IE, Cali G, Monteagudo A, Khatib N, Berg RE, Forlani F, et al. Foley balloon catheter to prevent or manage bleeding during treatment for cervical and Cesarean scar pregnancy. Ultrasound Obstet Gynecol. 2015;46(1):118-23.
Sadeghi H, Rutherford T, Rackow BW, Campbell KH, Duzyj CM, Guess MK, et al. Cesarean scar ectopic pregnancy: case series and review of the literature. Am J Perinatol. 2010;27(2):111-20.
Jurkovic D, Knez J, Appiah A, Farahani L, Mavrelos D, Ross JA. Surgical treatment of Cesarean scar ectopic pregnancy: efficacy and safety of ultrasound-guided suction curettage. Ultrasound Obstet Gynecol. 2016;47(4):511-7.
Deans R, Abbott J. Hysteroscopic management of cesarean scar ectopic pregnancy. Fertil Steril. 2010;93(6):1735-40.
Chou YM, Wu D, Wu KY, Lee CL. Hysteroscopic removal of cesarean scar pregnancy after methotrexate treatment failure. Gynecol Minimally Invasive Therapy. 2013;2(2):70-2.
Chao A, Wang TH, Wang CJ, Lee CL, Chao AS. Hysteroscopic management of cesarean scar pregnancy after unsuccessful methotrexate treatment. J Minim Invasive Gynecol. 2005;12(4):374-6.
