Update on

Treatment of

Cesarean Scar

Pregnancy

Prof. Aboubakr ElnasharBenha university Hospital,

Egypt

1. INTRODUCTION

Define

GS implanted at the site of a previous CS scar.

Terminologycesarean scar pregnancyEctopic pregnancy in a Caesarean scar cesarean ectopic pregnancycesarean scar ectopic.: MXT as in tubal ectopic pregnancies: failed but disastrous

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

Complications

1. Morbidly adherent placenta

2. Uterine rupture

3. Severe hemorrhage

4. Preterm labor.

5. Increased maternal morbidity and mortality.

Types(Vial et al, 2000)

1. Endogenic, superficially implanted (Type 1):

o grow toward uterine cavity

o±progress into IU pregnancyo birth of a live fetus

o morbidly adherent placenta

2. Exogenic, deeply implanted (Type2):

o deeply implanted into the defect of a scaro grow toward the bladder or abdominal

cavity:

o uterine rupture and severe hge[Singh et al, 2012 Jacquemyn et al, 2012].

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.

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

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.

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.

5. Doppler

Marked peritrophoblastic color Doppler flow

around GS

Avoid false positive diagnosis: 30-40%

3. DIFFERENTIAL DIAGNOSISFailed pregnancyCx ectopicCSP

within the cervical canal anterior LUS1. GS

normalthin2. Overlying anterior

myometrium

positivenegative3. Sliding organ sign*

lack color flow vascular flow

around and within

the GS

marked

peritrophoblastic

color Doppler flow

around GS

4. Doppler

Not fixed in location, notgrowing

±growing5. Short follow up US

*Gentle pressure with the TV probe: displace GS from its

position within the endocervical canal

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)

4. TREATMENTObjective

eliminating GS

preserving fertility

No universal tt guidelines

No clear conclusion:

most effective

least complications.

Timor-Tritsch et al, 2014

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

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

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

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

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

Referral centers:

Experience

Operating rooms

Interventional radiology

Ready for emergencies.

Available immediate blood transfusion/

blood products.

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

Shao et al (2013): 1. GS

2. Myometrial Thickness

3. HCG

LUAO=Laparoscopic uterine a occlusion

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

{No single best treatment} :procedure with the least complicationsperformed without delay.

Single-dose systemic MTX injection:

Lengthy

usually ineffective 1st line therapy

delaying the final treatment.

MTXan adjuvant to other treatments

MXT: US guided local, plus sys MTX:

25mg in GS, 25mg in F placenta, 25mg IM

Simple

low complication rates.

Petersen et al (2016): SR of 2037 CSPLaparotomyBleeding

≥1LHysterectomyComplication

(%)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

5 treatment modalities are recommended depending on

1. availability2. severity of patient symptoms3. 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

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

SUMMARY1. 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

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

ABOUBAKR ELNASHAR

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