(usually in gestations of 7–8 w) to
provide pressure on the GS during US-guided
injection of MTX or Kcl into the GS.
AboubakrElnashar
3. Uterine artery embolization (UAE)
Indications:
1. Failed medical tt
2. Hemodynamically unstable
3. Ruptured CSP
4. Myometrial thickness <2 mm
5. Gestation >8 w
Complications:
1. Hge: 5-10%
2. Uterine atony: 5%
3. Infection: 1-2%
4. Nec
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
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. 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
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. 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. Difficult
Missed in: 15%
D&C for “termination of an early pregnancy”
or D&C for missed abortion:
heavy bleeding
Shock
hemoperitoneum
AboubakrElnashar
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. 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
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
18. Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx).
Power Doppler of blood
vessels surrounding GS.
AboubakrElnashar
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Cervical ectopic pregnancy
GS is seen within the cervical canal
myometrium is not thinned out as seen in LSCS
scar pregnancy.
Aboubakr Elnashar
30. Failed pregnancy TV color Doppler: sagittal midline
cervix: avascular GS centered within the endocervical
canal AboubakrElnashar
31. 3. MANAGEMENT
Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion:
most effective
least or no complications.
AboubakrElnashar
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. 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. 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. 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. 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. lowest complication rate:
1. Local and US directed MTX injection with or
without additional IM MTX
2. Surgical excision by hysteroscopic guidance
AboubakrElnashar
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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
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
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. 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. 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. 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. 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. 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. 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. 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. 2. Specific surgical technique
single- or double-layer closure of the incision
can minimize or avoid a CSP
Aboubakr Elnashar
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. 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. 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
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. 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. 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. 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. 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. 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. 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. 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. 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