Update on Treatment of Cesarean Scar Pregnancy

1. Update on
Treatment of
Cesarean Scar
Pregnancy
Prof. Aboubakr Elnashar
Benha university Hospital,
Egypt

2. 1. INTRODUCTION
Define
GS implanted at the site of a previous CS scar.
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

3. Rising
1. Increased incidence of CS
72% of CSP occur in women who have had
≥2CS
2. Increased use of TVS
3. Change in Techniques of uterine surgery
Today the uterus is often closed in one layer,
compared with the previous two-layer
technique

4. Complications
1. Morbidly adherent placenta
2. Uterine rupture
3. Severe hemorrhage
4. Preterm labor.
5. Increased maternal morbidity and mortality.

5. Types
(Vial et al, 2000)
1. Endogenic, superficially implanted (Type 1):
o grow toward uterine cavity
o±progress into IU pregnancy
o birth of a live fetus
o morbidly adherent placenta
2. Exogenic, deeply implanted (Type2):
o deeply implanted into the defect of a scar
o grow toward the bladder or abdominal
cavity:
o uterine rupture and severe hge
[Singh et al, 2012 Jacquemyn et al, 2012].

6. Superficially implanted CSP
(A) GS surrounding the myometrial
defect with a bulging toward the
endometrial cavity.
(B) A dumbbell-shaped GS 5 ws in a
low-segment uterine scar defect.
(C) Hysteroscopy with the use of
fluid medium, showing an ectopic
gestation hanging from the anterior
uterine defect.

7. Deeply implanted CSP
A. invasion of gestational trophoblasts through a
microdehiscence, well circumscribed by the myometrial tissues
of the uterus.
B. Color Doppler: extensive neovascularization encircling GS

8. Implanted on
1. Scar
2. Niche
(Agten et al, 2017)
CSP implanted "on the scar" had a better
outcome than that implanted "in the niche".
Myometrial thickness ≤2 mm in 1st T:
morbidly adherent placenta at delivery.

9. 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.

10. 5. Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis: 30-40%

11. 3. 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

12. The location of the center of GS relative to the midpoint axis of the uterus
differentiated between IUP and CSP (mean 17.8 vs -10.6 mm, respectively, P =
.0001), indicating that most CSPs are located proximally to the midpoint axis of
the uterus whereas most normal IUPs are located distally from the midpoint of
the uterus.
IUP & SCP
5 -10 W
(Timor-Tritsch et
al, 2016)

13. 4. TREATMENT
Objective
 eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion:
most effective
least complications.

14. Timor-Tritsch et al, 2014

15.  Treatment should be individualized, based on
I. Center
1. Availability
2. Expertise of the clinicians
II. Patient
1. Age
2. Number of children.
3. Number of previous CS
4. Severity of symptoms
III. CSP
1. Gestational age
2. Level of HCG
3. Thickness of covering
myometrium

16. Treatment approaches
(Timor-Tritsch, 2015)
1. Major Surgery
require general anesthesia
(a) Excision:
Laparotomy
Laparoscopy
Hysteroscopy
Transvaginal
(b) D&C
(c) Suction aspiration without dilatation of
the cervix

17. 2. Minimally invasive surgery
No general anesthesia
(a) Local injection of MTX or KCl
(b) Local injection of Vasopressin
(c) UAE
3. Medical treatment
MTX: Single or repeated doses

18. Combination of the above treatments.
Rare to find a patients managed only by one
single treatment agent or protocol.
± Planned: simultaneous or Sequential
fashion.
Changed, after failure of 1st line therapy

19. Adjuvant measures.
1. Foley balloon placement
At the site of the CSP, blocked with 5 to 30
mL
extremely useful
can be kept in situ for 3–4 days with antibiotic
coverage.
2. Shirodkar Suture
during the evacuation of CSP

20. Referral centers:
Experience
Operating rooms
Interventional radiology
Ready for emergencies.
Available immediate blood transfusion/
blood products.

21. Jain et al (2014)
CSP
Haemodinamicly stable Haemodinamicaly unstable
HCG ≤10000IU/ml HCG≥10000IU/ml
MXT: local and Sys Hysteroscopic Hysteroscopic
+
Kcl or
vasopressin
injection
Scar resection

23. Shao et al (2013): 1. GS
2. Myometrial Thickness
3. HCG
LUAO=Laparoscopic uterine a occlusion

24. Timor-Tritsch (2015) SR of 1223 CSP
Complication
(%)
No
6536MXT: Sys
11200MXT: Local+Sys
28309UAE
60577D&C
10119TV excision
2594Laparoscopy
1113Hysteroscopy
050UAE+Hysteroscopy
2515Laparotomy
020HIFU
1223Total

25. {No single best treatment} :
procedure with the least complications
performed without delay.
Single-dose systemic MTX injection:
Lengthy
usually ineffective 1st line therapy
delaying the final treatment.
MTX
an adjuvant to other treatments
MXT: US guided local, plus sys MTX:
25mg in GS, 25mg in F placenta, 25mg IM
Simple
low complication rates.

26. Petersen et al (2016): SR of 2037 CSP
LaparotomyBleeding
≥1L
HysterectomyComplication
(%)
Success
(%)
No
0517544141Expectant
925101375339MTX IM
30046574MTX local
2991485148MTX local+Asp
00127734MTX Local+IM
282369427UAE+MTX
046394295UAE+D&C
337112148243D&C
00119585UAE+D&C+
Hysteroscopy
011199118TV excision
20138395Hysteroscopy
00009769Laparoscopy
000010016HIFU
000010035HIFU+
Hysteroscopy
2188592037Total

27. 5 treatment modalities are recommended
depending on
1. availability
2. severity of patient symptoms
3. surgical skills
 An interventional rather than medical approach.
1. Resection through a TV approach
2. Laparoscopy
3. Hysteroscopy
4. UAE plus D&C and hysteroscopy
5. UAE combined with D&C without MTX

28. Hysteroscopy:
most frequently adopted 1st line approaches.
Hysteroscopy and laparoscopic hysterotomy:
safe and efficient surgical procedures
Systemic methotrexate and D&C:
not recommended as 1st line tt
{high complication and hysterectomy rates}.
Hysterectomy
(%)
Success
rate (%)
Resolution
time (D)
Bleeding
(%)
496014Systemic MTX
1185933UAE
0.039207Hysteroscopy
7624651D&C
2922028Hysterotomy
Pektas et al, 2016: 1674 CSP

29. SUMMARY
1. CSP
 An uncommon but potentially life-threatening
 The incidence is rising as CSR is rising.
 Precursor of morbidly adherent placenta
2. Early diagnosis
 important.
 At the time of discharging after a CS:
 in a future pregnancy, an early visit for TVS is
important.
3. DD
Failed pregnancy
Cx ectopic

30. 4. Management:
 Counseling
 Termination:
 Reliable tt that stops fetal heart beat without
delay.
 Avoid single tts unlikely to be effective:
 D&C
 Suction curettage
 Single-dose IM MTX
 UAE
 Each center should have protocol :
 Availability
 Skills
 Severity
if not: Referral

31. ABOUBAKR ELNASHAR
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4.My clinic: Elthwra St. Mansura, Egypt