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Cesarean Scar Pregnancy
Aboubakr Elnashar
Benha university Hospital, Egypt
AboubakrElnashar
AboubakrElnashar
1. INTRODUCTION
Define
Prevalence
Pathogenesis
Complications
2. DIAGNOSIS;
DIFFERENTIAL DIAGNOSIS
3. MANA...
1. INTRODUCTION
Define
GS implanted in the myometrium at the site of a
previous CS scar.
The first case
1978.
Terminology
...
Prevalence
Rare
Rising
1. {increased incidence of CS}
72% of CSP occur in women who have had ≥2CS
2. {increased use of T...
AboubakrElnashar
Pathogenesis
Prior CS: fibrous scar tissue with a wedge-shaped
myometrial defect .
Pregnancy: Blastocyst implants on fib...
The myometrial defect:
Develops after:
CS
D &C
Myomectomy
Metroplasty
Hysteroscopy
Manual removal of the placenta.
Due ...
Complications
±devastating
Placenta previa/accreta
Uterine rupture
Massive hge:
increased maternal morbidity and mortal...
2. DIAGNOSIS
Time of presentation
At any time from implantation to term
More commonly in 1st T.
1. Vag bleeding and abd...
 Degrees
1. Severe:
 little or no myometrium overlying GS
 usually diagnosed in 1st T
 Hge and ut rupture if untreated...
Difficult
Missed in: 15%
D&C for “termination of an early pregnancy”
or D&C for missed abortion:
heavy bleeding
Shock...
Sonography
TA:
 Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladd...
Sonographic criteria in 1st T
1. Uterus:
 empty with a clearly visualized endometrium
2. Cervix:
Empty
3. GS:
 within ...
5. Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis: 30-40%
low-impedance (p...
Low
intrauterine
pregnancies
Miscarriage
in progress
Cervical
pregnancy
AboubakrElnashar
CSP: at 6 w
GS: in the anterior LUS at the site of the uterine scar
Uterus: empty(thin arrows
Cervix: empty(long arrows...
Transverse TVS color Doppler: flow around G S
AboubakrElnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx).
Power Doppler of blood
vessels surrounding GS.
Aboubak...
Triangular shape of GS (on
sagittal plane)
assuming shape of niche.
GS embedded in scar. Thin
(1-3 mm) or lack of
myometri...
Previous CS
Vag bleeding
Positive serum BHCG test.
Prominent, richly vascular area in site of scar highlighted
by power Do...
CSP at 9 w 5 d
Sagittal (A) and transverse (B)
TVS: GS in the anterior LUS
with thinning of the overlying
anterior myometr...
CSP at 12 W.
Sagittal (A and B) and transverse (C)
TAS: GS in the anterior LUS There is
thinning of the overlying anterior...
MRI
Indication
1. US is equivocal or inconclusive before
intervention or therapy.
2. To measure the lesion volume to hel...
Sagittal, coronal, and transverse sections of T1-
and T2-weighted sequences:
1. GS embedded in the anterior LUS
2. Pelvic...
CSP at 9 w: Sagittal T2 MRI: implantation of GS in the anterior
LUS with bulging of the anterior contour and thinning of t...
CSP at 12 w: Sagittal (Aand C) and coronal (B) T2-
weighted MRI: enlarged uterus (U) with GS within
the anterior LUS, a th...
DIFFERENTIAL DIAGNOSIS
Failed pregnancyCx ectopicCSP
within the cervical canalanterior LUS1. GS
normalthin2. Overlying ant...
Cervical ectopic pregnancy:
Sagittal TAS of the midline
uterus (A): GS centered in the
endocervical canal, normal
myometri...
Cervical ectopic pregnancy
GS is seen within the cervical canal
 myometrium is not thinned out as seen in LSCS
scar preg...
Failed pregnancy TV color Doppler: sagittal midline
cervix: avascular GS centered within the endocervical
canal AboubakrEl...
3. MANAGEMENT
Objective
 eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion:
most ef...
Timor-Tritsch et al, 2014AboubakrElnashar
 Treatment should be individualized, based on
1. Patient’s age
2. Number of children.
3. Number of previous CS
4. Anterio...
Gynecologic surgeons:
laparoscopy, and hysteroscopy or
laparotomy
Obstetricians, radiologists, and IVF specialists:
IM M...
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus.
Options:
1. Co...
2. Termination of the pregnancy in 1st T
Substantial hge: 20%-40%
Hysterectomy: substantially lower.
Termination: Recom...
Potential complications
751 cases reviewed, 21.8% resulted in major surgery or interventional
radiology procedures (primar...
lowest complication rate:
1. Local and US directed MTX injection with or
without additional IM MTX
2. Surgical excision b...
Management approaches
I. Surgical: Excision
Laparotomy or
Hysterectomy, or
Laparoscopic or
Hysteroscopic followed by D&C
I...
 Medical
1. Systemic, single-dose MTX
1 mg/kg or 50 mg/m2 of body surface area.
complication rate: 64.6%
{second tt whe...
Systemic MTX as a single tt should be avoided.
1. Waiting days for its effect to stop the heart beats, which
may not happ...
2. Systemic, multidose, sequential MTX
Two to three IM (1 mg/kg BW or 50 mg/mm2 of surface
area) at an interval of 2 or 3...
Minimally invasive.
1. Intragestational-sac injection of MTX or Kcl,
with US guidance
 Indications
 hemodynamically sta...
Approach:
 TV approach is favored over TA
1. better visualization of the needle
2. shorter distance to reach the sac
3. ...
 Steps:
1. After confirming the placement of needle, 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2. 25 ...
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w, 4 days. The arrow points to the needle
in place. (...
Advantages
No anesthesia.
Complications: fewest :10.8%
most effective intervention
decrease the need for additional i...
Aspiration of gestational sac fluid,
injection of methotrexate in the sac,
injection of homeostatic agent and pituitrin in...
2. Use of a Foley balloon catheter
Indications:
1. Alone: (usually in gestations of 5–7 w) in the
hope of stopping the ev...
The catheter with the
balloon inflated with 5
mL of saline.
TV power Doppler image
of the inflated balloon
(B) in a case o...
Steps:
GA: not required.
TAS guidance Or TVS guidance
{allow for more precise placement and assess the
pressure, avoidi...
3. UAE, alone or in combination
 Indication:
1. As a rescue procedure in the case of significant
bleeding or an A-VM
2. C...
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to prese...
AboubakrElnashar
1. Excision by laparotomy, alone or in
combination with hysteroscopy
18 cases:
5 complications
and only when used in an em...
2. Laparoscopic excision
Complication rate: 30.6%
Laparoscopy combined with hysteroscopy:
Complication rate: 20%
Aboubakr ...
3. Hysteroscopy, alone or in combination
complication rate: 13.8%.
Hysteroscopy combined with TA US guidance:
9 cases: n...
4. Suction aspiration or D&C, alone or in
combination
Isolated D & C should be avoided.
1. Trophoblastic tissue and villi...
 MTX followed by suction curettage:
Mean blood loss: 707 mL (100–2,000 mL)
tt failure:
3 out of 45 despite insertion of...
FOLLOW-UP
{Placenta is implanted mostly within fibrous
tissue, absorption of the GS is slow after med tt}
1. 9 w to obtai...
3. SIS:
in a nonpregnant patient
uterine wall integrity
size of the cesarean scar
which may relate to the possibility of u...
5. Avoiding pregnancy
No guidelines
12 to 24 months.
6. Repair of scar before future pregnancies.
not known whether requi...
Outcomes
Uneventful viable pregnancies have been
reported after all modalities of conservative
management.
Recurrence r...
4. PREVENTION OF CSP
1. Surgical repair of the uterine dehiscence (niche)
in patients with previous CS while not pregnant....
2. Specific surgical technique
single- or double-layer closure of the incision
can minimize or avoid a CSP
Aboubakr Elnas...
SUMMARY
 CSP
 An uncommon but potentially life-threatening
 The incidence is rising as CSR is rising.
 Precursor of mo...
 If heart activity is documented: Counsel the patient:
inform the patient of the risks of pregnancy
continuation.
 If co...
Consider combination treatments: best results.
direct injection of MTX or Kcl into GS with TVS
guidance.
Keep a catheter...
ThankYou
https://www.facebook.com/groups/
227744884091351/
AboubakrElnashar
(Timor-Tritsch et al, 2012).
Timor-Tritsch et al (2012.)
AboubakrElnashar
Management
31 primary approaches:
systemic therapy
local injection
surgical aspiration of GS
hysteroscopic, laparosco...
 Intracervical vasopressin should also be
considered.
AboubakrElnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS. There is mi...
AboubakrElnashar
ArchGynecol Obstet. 2014 Dec 23. [Epub ahead of print]
Ultrasonography-guided multidrug stratification in...
AboubakrElnashar
Ultrasound Med. 2014 Sep;33(9):1533-7. doi: 10.7863/ultra.33.9.1533.
Heterotopic cesarean scar pregnancy:...
AboubakrElnashar
Fertil Steril. 2014 Oct;102(4):1085-1090.e2. doi:
10.1016/j.fertnstert.2014.07.003. Epub 2014 Aug 11.
Out...
I. All are correct regarding CS scar
pregnancy (CSP) except:
1.Incidence is rising
2.Asymptomatic: in 1/3 of cases
3.Time ...
II. Sonographic criteria of CSP include
all except
1. Empty uterus with a clearly visualized
endometrium
2. Empty cervical...
III. For treatment of CSP, all are correct
except
1.Anterior uterine wall thickness is important
2.With pregnancy continua...
IV. All are correct regarding CSP treatment
except:
1. Complications are most often when single
IM Methotrexate or D&C
2. ...
V. For follow up after treatment of CSP
all are correct except
1. 5 w are required to obtain clearance of
βHCG
2. TVS is d...
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Cesarean Scar Pregnancy

  1. 1. Cesarean Scar Pregnancy Aboubakr Elnashar Benha university Hospital, Egypt AboubakrElnashar
  2. 2. AboubakrElnashar 1. INTRODUCTION Define Prevalence Pathogenesis Complications 2. DIAGNOSIS; DIFFERENTIAL DIAGNOSIS 3. MANAGEMENT FOLLOW-UP 4. PREVENTION SUMMARY
  3. 3. 1. INTRODUCTION Define GS implanted in the myometrium at the site of a previous CS scar. The first case 1978. Terminology cesarean scar pregnancy Ectopic pregnancy in a Caesarean scar cesarean ectopic pregnancy cesarean scar ectopic. : MXT as in tubal ectopic pregnancies: failed but disastrous AboubakrElnashar
  4. 4. Prevalence Rare Rising 1. {increased incidence of CS} 72% of CSP occur in women who have had ≥2CS 2. {increased use of TVS} AboubakrElnashar
  5. 5. AboubakrElnashar
  6. 6. Pathogenesis Prior CS: fibrous scar tissue with a wedge-shaped myometrial defect . Pregnancy: Blastocyst implants on fibrous scar Multiple CS: increase scar surface area: increase the risk of implantation on the scar AboubakrElnashar
  7. 7. The myometrial defect: Develops after: CS D &C Myomectomy Metroplasty Hysteroscopy Manual removal of the placenta. Due to: 1. incomplete healing 2. increased fibrosis Aboubakr Elnashar
  8. 8. Complications ±devastating Placenta previa/accreta Uterine rupture Massive hge: increased maternal morbidity and mortality. AboubakrElnashar
  9. 9. 2. DIAGNOSIS Time of presentation At any time from implantation to term More commonly in 1st T. 1. Vag bleeding and abd pain: common 2. Asymptomatic: 1/3 AboubakrElnashar
  10. 10.  Degrees 1. Severe:  little or no myometrium overlying GS  usually diagnosed in 1st T  Hge and ut rupture if untreated. 2. Less severe: often diagnosed in 2nd and 3rd T as PA ±: normal live births but with increased maternal morbidity. AboubakrElnashar
  11. 11. Difficult Missed in: 15% D&C for “termination of an early pregnancy” or D&C for missed abortion: heavy bleeding Shock hemoperitoneum AboubakrElnashar
  12. 12. Sonography TA:  Panoramic view of the pelvis and uterus Inspection of the interface between the anterior LUS and bladder. then TV: Reference standard in 1st T Sensitivity: 86.4% Sagittal view along the long axis of the uterus through the plane of GS: localize GS within the anterior LUS. AboubakrElnashar
  13. 13. 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. AboubakrElnashar
  14. 14. 5. Doppler Marked peritrophoblastic color Doppler flow around GS Avoid false positive diagnosis: 30-40% low-impedance (pulsatility <1) high-velocity flow (>20 cm/s) Resistive index: < 0.5 Peak systolic to diastolic blood flow ratio: < 3.1 AboubakrElnashar
  15. 15. Low intrauterine pregnancies Miscarriage in progress Cervical pregnancy AboubakrElnashar
  16. 16. CSP: at 6 w GS: in the anterior LUS at the site of the uterine scar Uterus: empty(thin arrows Cervix: empty(long arrows) canals  myometrium between GS and bladder (short arrows): thin. AboubakrElnashar
  17. 17. Transverse TVS color Doppler: flow around G S AboubakrElnashar
  18. 18. Empty uterine cavity with GS(arrow) between cavity and cervix (Cx). Power Doppler of blood vessels surrounding GS. AboubakrElnashar
  19. 19. Triangular shape of GS (on sagittal plane) assuming shape of niche. GS embedded in scar. Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder. Aboubakr Elnashar
  20. 20. Previous CS Vag bleeding Positive serum BHCG test. Prominent, richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation.Aboubakr Elnashar
  21. 21. CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS: GS in the anterior LUS with thinning of the overlying anterior myometrium (A, arrow). The fundus (f) and cervical canals are empty. Aboubakr Elnashar
  22. 22. CSP at 12 W. Sagittal (A and B) and transverse (C) TAS: GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows). The endometrial (thin arrow) and cervical (long arrow) canals are empty. Aboubakr Elnashar
  23. 23. MRI Indication 1. US is equivocal or inconclusive before intervention or therapy. 2. To measure the lesion volume to help assess the indication for and success of local MTX tt. Aboubakr Elnashar
  24. 24. Sagittal, coronal, and transverse sections of T1- and T2-weighted sequences: 1. GS embedded in the anterior LUS 2. Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1: fat: bright . fluid: dark T2: fat: intermediate-bright. fluid: bright AboubakrElnashar
  25. 25. CSP at 9 w: Sagittal T2 MRI: implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows). The endometrial and cervical canals are empty (A and B). CS scar is shown in the anterior lower abdominal wall (short arrows). The patient was successfully treated with systemic MTX and TVS guided injection of Kcl. B indicates bladder; and U, uterus.Aboubakr Elnashar
  26. 26. CSP at 12 w: Sagittal (Aand C) and coronal (B) T2- weighted MRI: enlarged uterus (U) with GS within the anterior LUS, a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows). The endometrial and cervical canals are empty (A). The cesarean scar is shown in the anterior lower abdominal wall (short arrows). The patient went on to have a hysterectomy, which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly, adherent to the bladder (B).Aboubakr Elnashar
  27. 27. DIFFERENTIAL DIAGNOSIS Failed pregnancyCx ectopicCSP within the cervical canalanterior LUS1. GS normalthin2. Overlying anterior myometrium positivenegative3. Sliding organ sign* lack color flowvascular flow around and within the GS marked peritrophoblastic color Doppler flow around GS 4. Doppler Not fixed in location, not growing ±growing5. Short follow up US *Gentle pressure with the TV probe: displace GS from its position within the endocervical canal
  28. 28. Cervical ectopic pregnancy: Sagittal TAS of the midline uterus (A): GS centered in the endocervical canal, normal myometrial thickness between GS and bladder (arrow). Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C).Aboubakr Elnashar
  29. 29. Cervical ectopic pregnancy GS is seen within the cervical canal  myometrium is not thinned out as seen in LSCS scar pregnancy. Aboubakr Elnashar
  30. 30. Failed pregnancy TV color Doppler: sagittal midline cervix: avascular GS centered within the endocervical canal AboubakrElnashar
  31. 31. 3. MANAGEMENT Objective  eliminating GS preserving fertility No universal tt guidelines No clear conclusion: most effective  least or no complications. AboubakrElnashar
  32. 32. Timor-Tritsch et al, 2014AboubakrElnashar
  33. 33.  Treatment should be individualized, based on 1. Patient’s age 2. Number of children. 3. Number of previous CS 4. Anterior uterine wall thickness {when the trophoblast reaches the bladder- uterine space: Non surgical tt} 5. Expertise of the clinicians AboubakrElnashar
  34. 34. Gynecologic surgeons: laparoscopy, and hysteroscopy or laparotomy Obstetricians, radiologists, and IVF specialists: IM MTX or US local MTX (or Kcl) UAE: occasionally Aboubakr Elnashar
  35. 35. Counseling of the patient Immediate and decisive action to prevent further growth of the embryo or fetus. Options: 1. Continuation of the pregnancy Successful births uneventful term pregnancy: poor. Hysterectomy rate: 71% {increased risk of placenta previa/accreta and massive hge} AboubakrElnashar
  36. 36. 2. Termination of the pregnancy in 1st T Substantial hge: 20%-40% Hysterectomy: substantially lower. Termination: Recommended particularly when Early evidence of progression toward the abdominal cavity or bladder {increased risk of life-threatening complications and loss of fertility}. AboubakrElnashar
  37. 37. Potential complications 751 cases reviewed, 21.8% resulted in major surgery or interventional radiology procedures (primary or emergency). The total planned primary (nonemergency) interventions performed were 66 (8.7%), which included 3 hysterectomies, 14 laparotomies, and 49 uterine artery embolizations or ligations. There were 98 (13.0%) emergency interventions, which included 36 hysterectomies, 40 laparotomies, and 22 uterine artery embolizations or ligations. (Timor-Tritsch et al, 2014). (Immediate or delayed): Need secondary tt for blood loss ≥200 mL or blood transfusion. Complications are most often when the following tt used alone: • Single IM MTX • D&C • UAE AboubakrElnashar
  38. 38. lowest complication rate: 1. Local and US directed MTX injection with or without additional IM MTX 2. Surgical excision by hysteroscopic guidance AboubakrElnashar
  39. 39. Management approaches I. Surgical: Excision Laparotomy or Hysterectomy, or Laparoscopic or Hysteroscopic followed by D&C II. Minimally invasive local injection of MTX or Kcl or UAE in combination with IM. MTX Medical tt alone: not recommended Aboubakr Elnashar
  40. 40.  Medical 1. Systemic, single-dose MTX 1 mg/kg or 50 mg/m2 of body surface area. complication rate: 64.6% {second tt when the fetal heart beat did not cease after several days} High failure rate {slow action and questionable ability to stop cardiac activity and placental expansion}. The expected result can take days, and all the while GS, the embryo or fetus, and its vascularity are growing. Secondary tt has to address a larger gestation with more abundant vascularization. Aboubakr Elnashar
  41. 41. Systemic MTX as a single tt should be avoided. 1. Waiting days for its effect to stop the heart beats, which may not happen. 2. It also led to the additional growth of the embryo/fetus as well as the vascularization of GS 3. Wastes precious time Aboubakr Elnashar
  42. 42. 2. Systemic, multidose, sequential MTX Two to three IM (1 mg/kg BW or 50 mg/mm2 of surface area) at an interval of 2 or 3 days over the course of a week. Cumulative adverse effects on the liver and bone marrow Success rate: 75%  Hysterectomy: 6% Best results: βHCG ≤ 5000 mU/mL. Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS. Aboubakr Elnashar
  43. 43. Minimally invasive. 1. Intragestational-sac injection of MTX or Kcl, with US guidance  Indications  hemodynamically stable  unruptured CSP  ≤8w gestation  myometrial thickness between GS and bladder.: ≤ 2 mm AboubakrElnashar
  44. 44. Approach:  TV approach is favored over TA 1. better visualization of the needle 2. shorter distance to reach the sac 3. decreased risk of bladder injury  TAS guidance: slighter higher complication rate (15%) than those using TVS guidance. AboubakrElnashar
  45. 45.  Steps: 1. After confirming the placement of needle, 25 mg of MTX in 1 mL of solution is injected slowly in the GS 2. 25 mg is injected outside GS as the needle is withdrawn, preferably the placental site 3. TVS: 60-90 m after the procedure {confirm cessation of FH and to identify local bleeding}. 4. IM of 25 mg MTX (for a total, combined dose of 75 mg) before discharge from our unit. 5. 24-48 h: follow-up scan. Close monitoring {hge may still occur} AboubakrElnashar
  46. 46. TVS -guided intragestational-sac injection of MTX in a live CSP at 6 w, 4 days. The arrow points to the needle in place. (F = fetus.) AboubakrElnashar
  47. 47. Advantages No anesthesia. Complications: fewest :10.8% most effective intervention decrease the need for additional interventions provides a higher concentration of the embryocide locally avoidance of systemic side effects more rapid interruption of the pregnancy. AboubakrElnashar
  48. 48. Aspiration of gestational sac fluid, injection of methotrexate in the sac, injection of homeostatic agent and pituitrin in the uterine muscle layer, and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP. (Kong et al, 2014) Ultrasonography-guided multidrug interventional therapy for CSP is a new, safe, effective, minimally invasive method.
  49. 49. 2. Use of a Foley balloon catheter Indications: 1. Alone: (usually in gestations of 5–7 w) in the hope of stopping the evolution of the pregnancy by placing pressure on a small GS. 2. In conjunction with another tt 3. Backup if bleeding occurs. French-12 size 10-mL silicone balloon catheter, or French-14 catheter with a 30-mL balloon AboubakrElnashar
  50. 50. The catheter with the balloon inflated with 5 mL of saline. TV power Doppler image of the inflated balloon (B) in a case of a CSP at 6 w, 4 days, after injection of MXT AboubakrElnashar
  51. 51. Steps: GA: not required. TAS guidance Or TVS guidance {allow for more precise placement and assess the pressure, avoiding over inflation of the balloon} Catheter is kept 24 to 48 h, with the outer end of the catheter fastened to the patient’s thigh. Antibiotics Reevaluate after 48H Aboubakr Elnashar
  52. 52. 3. UAE, alone or in combination  Indication: 1. As a rescue procedure in the case of significant bleeding or an A-VM 2. Concurrent with MTH Not as a primary tt {delay between tt and effect allows the gestation to grow and vascularity to increase} Disadvantages: 1. GA 2. Complication rate: 47% 3. Not the best 1st -line tt Aboubakr Elnashar
  53. 53. Surgical excision laparoscopy or laparotomy may be best tt No response to conservative medical tt Patient late to present. Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence. Risks postoperative adhesions: impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previa/accreta. AboubakrElnashar
  54. 54. AboubakrElnashar
  55. 55. 1. Excision by laparotomy, alone or in combination with hysteroscopy 18 cases: 5 complications and only when used in an emergency situation. Aboubakr Elnashar
  56. 56. 2. Laparoscopic excision Complication rate: 30.6% Laparoscopy combined with hysteroscopy: Complication rate: 20% Aboubakr Elnashar
  57. 57. 3. Hysteroscopy, alone or in combination complication rate: 13.8%. Hysteroscopy combined with TA US guidance: 9 cases: no complications. reasonable operative solution Hysteroscopy combined with mifepristone: complication rate:17%. Aboubakr Elnashar
  58. 58. 4. Suction aspiration or D&C, alone or in combination Isolated D & C should be avoided. 1. Trophoblastic tissue and villi are implanted within the myometrium: D &C is unlikely to expel the GS without rupturing the uterine wall or damaging the bladder 2. : massive bleeding: emergency laparotomies: loss of the uterus. 3. {exposed vessels in the cervical scar tissue bleed {no muscle grid to contract and contain the profuse bleeding}. 4. Complication rate: 62% (29%–86%). bleeding complications, necessitating 3rd -line tt that almost always was surgical. AboubakrElnashar
  59. 59.  MTX followed by suction curettage: Mean blood loss: 707 mL (100–2,000 mL) tt failure: 3 out of 45 despite insertion of a Foley balloon catheter. If D&C is still the preferred tt of choice, blood products should be available balloon catheter should be inserted in the cervix Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment. Primary single-step surgical evacuation was successful in most patients with superficial implantation, but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et al, 2014). Aboubakr Elnashar
  60. 60. FOLLOW-UP {Placenta is implanted mostly within fibrous tissue, absorption of the GS is slow after med tt} 1. 9 w to obtain clearance of βHCG 2. 3 months for clearance of GS on TVS  1. βHCG: weekly until it is undetectable 2. TVS: Monthly to evaluate the size of retained products of conception AboubakrElnashar
  61. 61. 3. SIS: in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies. 4. Early TVS After CSP After CS to confirm an intrauterine location of the new gestation. Aboubakr Elnashar
  62. 62. 5. Avoiding pregnancy No guidelines 12 to 24 months. 6. Repair of scar before future pregnancies. not known whether required or not Severely deficient uterine scars: 10% of women who have had prior CS, but CSP are much more rare. Aboubakr Elnashar
  63. 63. Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management. Recurrence rate: 5% IU pregnancy: 95% spontaneous pregnancy: 88% Normal pregnancy: 65% Spontaneous abortion: 35% higher than expected AboubakrElnashar
  64. 64. 4. PREVENTION OF CSP 1. Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant. Ben Nagi et al reported on a successful surgical repair Donnez et al: hysteroscopic repair Klemm et al: laparoscopic-assisted vaginal repair Yalcinkaya et al: robotic-assisted laparoscopic repair  More research is necessary before making recommendations for such surgical tt to prevent CSP. Aboubakr Elnashar
  65. 65. 2. Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP Aboubakr Elnashar
  66. 66. SUMMARY  CSP  An uncommon but potentially life-threatening  The incidence is rising as CSR is rising.  Precursor of morbidly adherent placenta  Do not confuse CSP with ectopic pregnancy  Early diagnosis is important. TVS is the most effective and preferred diagnostic tool.  A key first step: Determine whether heart activity is present? AboubakrElnashar
  67. 67.  If heart activity is documented: Counsel the patient: inform the patient of the risks of pregnancy continuation.  If continuation: an additional counseling session: risks  If termination: a reliable tt that stops fetal heart beat without delay.  Avoid single tts unlikely to be effective:  D&C  suction curettage  single-dose IM MTX, and  UAE AboubakrElnashar
  68. 68. Consider combination treatments: best results. direct injection of MTX or Kcl into GS with TVS guidance. Keep a catheter at hand. At the time of discharging after a CS: in a future pregnancy, an early visit for TVS is important. AboubakrElnashar
  69. 69. ThankYou https://www.facebook.com/groups/ 227744884091351/ AboubakrElnashar
  70. 70. (Timor-Tritsch et al, 2012). Timor-Tritsch et al (2012.) AboubakrElnashar
  71. 71. Management 31 primary approaches: systemic therapy local injection surgical aspiration of GS hysteroscopic, laparoscopic, and open removal. AboubakrElnashar
  72. 72.  Intracervical vasopressin should also be considered. AboubakrElnashar
  73. 73. CSP 4 w after 2 doses of systemic MTX Sagittal TVS (Aand B) through the midline uterus GS in the anterior LUS. There is minimal peripheral flow around GS on color Doppler imaging (C), but no heart beat activity was detected via M-mode analysis. Incidentally, a large ovarian cyst (CY) is partially visualized in B. AboubakrElnashar
  74. 74. AboubakrElnashar ArchGynecol Obstet. 2014 Dec 23. [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy. Kong D1, Dong X, QiY. Author information Abstract PURPOSE: To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP). METHODS: Aspiration of gestational sac fluid, injection of methotrexate in the sac, injection of homeostatic agent and pituitrin in the uterine muscle layer, and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP.The lesion volume, serum β-hCG level, and blood flow were observed. RESULTS: The mean β-hCG level continued to decrease posttreatment, and the greatest reduction occurred in week 1.The mean number of days needed for serum β-hCG values to decrease to normal level was 39.1 ± 10.1 days. Mass volumes reduced and the mean number of days for the masses to disappear was 24.6 ± 14.1 days.The blood flow around the lesions continued to decrease. CONCLUSIONS: Ultrasonography-guided multidrug interventional therapy for CSP is a new, safe, effective, minimally invasive method.
  75. 75. AboubakrElnashar Ultrasound Med. 2014 Sep;33(9):1533-7. doi: 10.7863/ultra.33.9.1533. Heterotopic cesarean scar pregnancy: diagnosis, treatment, and prognosis. OuYang Z1, Yin Q2, Xu Y2, Ma Y2, Zhang Q2, Yu Y2. Author information Abstract Heterotopic cesarean scar pregnancy is a rare, life-threatening form of ectopic pregnancy. To provide information regarding the clinical manifestations, diagnosis, management, and prognosis of this condition, we reviewed all cases reported in the English literature. All literature on heterotopic cesarean scar pregnancy was retrieved by searching the PubMed database and tracking references of the relevant literature. Full texts were reviewed, and clinical manifestations, diagnostic methods, and the relationship between the treatment and prognosis were summarized. A total of 14 patients with heterotopic cesarean scar pregnancies were identified, including 6 spontaneous pregnancies and 8 following in vitro fertilization-embryo transfer. Gestational ages at diagnosis ranged from 5 weeks to 8 weeks 4 days. Only 5 cases presented with vaginal bleeding, and the others were asymptomatic. All 14 cases were diagnosed by transvaginal sonography. One patient with no future fertility requirements underwent pregnancy termination by methotrexate. Of the remaining 13 patients who desired to preserve their intrauterine gestations, 10 were
  76. 76. AboubakrElnashar Fertil Steril. 2014 Oct;102(4):1085-1090.e2. doi: 10.1016/j.fertnstert.2014.07.003. Epub 2014 Aug 11. Outcomes of primary surgical evacuation during the first trimester in different types of implantation in women with cesarean scar pregnancy. Cheng LY1, Wang CB1, Chu LC1, Tseng CW1, Kung FT2. Author information Abstract OBJECTIVE: To assess the efficacy and safety of primary surgical evacuation therapy for cesarean scarpregnancy (CSP) of the first trimester, and to evaluate its possible prognostic factors. DESIGN: Retrospective consecutive cohort study. SETTING: Tertiary care university hospital. SUBJECT(S): A cohort of patients with CSP and clear ultrasound images who underwent primary surgical evacuation from January 2000 to December 2012. INTERVENTION(S): Patients fulfilling the ultrasound criteria of CSP were further classified into superficial and deep groups according to their implantation locations and extents. The final decision on the method of treatment, including methotrexate chemotherapy, surgical evacuation, and others, was made by
  77. 77. I. All are correct regarding CS scar pregnancy (CSP) except: 1.Incidence is rising 2.Asymptomatic: in 1/3 of cases 3.Time of presentation is commonly 2nd trimester 4.Diagnosis is missed in 14% of cases AboubakrElnashar
  78. 78. II. Sonographic criteria of CSP include all except 1. Empty uterus with a clearly visualized endometrium 2. Empty cervical canal 3. Gestational sac:  within the anterior portion of lower uterine segment at site of the cesarean scar 4. Sliding organ sign is positive AboubakrElnashar
  79. 79. III. For treatment of CSP, all are correct except 1.Anterior uterine wall thickness is important 2.With pregnancy continuation, hysterectomy rate is 17% 3.Termination of the pregnancy in first trimester is recommended 4.Immediate and decisive action is recommended AboubakrElnashar
  80. 80. IV. All are correct regarding CSP treatment except: 1. Complications are most often when single IM Methotrexate or D&C 2. Complications are at lowest rate with Local and US directed MTX injection with or without additional IM MTX 3. Use of a Foley balloon catheter is not recommended 4. laparoscopy or laparotomy with excision of the pregnancy may be best treatment AboubakrElnashar
  81. 81. V. For follow up after treatment of CSP all are correct except 1. 5 w are required to obtain clearance of βHCG 2. TVS is done monthly to evaluate the size of retained products of conception 3. Avoiding pregnancy for 12 to 24 months. 4. In a future pregnancy, an early visit for TVS is important. AboubakrElnashar
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Cesarean Scar Pregnancy

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