The aim of this paper is to review the diagnosis and treatment of patients with a caesarean scar pregnancy (CSP), who have been managed at our unit, as well as to evaluate the effectiveness of the non-surgical treatment options. Twenty-six cases were identified over a period of 5 years and 4 months (January 2012 until April 2017). The main outcome measures were a number of previous caesarean births, a method of diagnosis of CSP, the mode of treatment and the outcome. The diagnostic criteria on the ultrasound were an empty uterine cavity and cervical canal, the presence of a gestational sac anterior to the isthmic portion of the uterus, an absent or thinned (<5 mm) myometrial thickness between the gestational sac and the bladder, with a peri-trophoblastic circulation around the gestational sac with the colour flow Doppler examination. The diagnosis was confirmed using ultrasound in 25 of the cases (96%) and by laparoscopy in one patient (4%). Fourteen women (54%) were managed conservatively, as there was evidence of a spontaneous resolution. A systemic methotrexate injection was used successfully to treat 11 (42%) patients. Only one patient (4%) needed an additional surgical treatment following an incomplete resolution. Impact Statement What is already known on this subject? A caesarean scar pregnancy is a life threatening condition whose incidence is increasing due to the global increase in the number of caesarean deliveries. Due to the relative rarity of the condition there is no consensus regarding the management of these cases. The management is mainly individualised, depending upon both the gestation and clinical symptoms. Surgical management or an intra-gestational sac injection of methotrexate with or without potassium chloride (KCl) dominates most of the published case reports and the systemic reviews. What the results of this study add? All of our patients in this case series were managed either conservatively with active monitoring, or were treated with an intramuscular methotrexate injection. Only one patient needed an additional minor surgical procedure due to an incomplete medical management. These results are very encouraging, and are attributed to the early diagnosis followed by a prompt treatment. An early detection requires a high index of suspicion, strict diagnostic criteria, and properly trained, experienced sonographers. A complete resolution was slow in some cases but the major high risk surgical procedures were avoided. What the implications are of these findings for clinical practice and/or further research? We wanted the sharing of our experience via this review to play a positive role in guiding the treatment of this rare but increasing subset of ectopic pregnancies.

Postnatal depression, with a prevalence of at least 10%, is a common complication of the puerperium. The aetiology is unclear, specific diagnostic criteria cannot be drawn and the treatment options are limited. As hormones are thought to contribute to its pathophysiology, the supplementation with either progesterone or oestrogen might be of prophylactic and/or therapeutic value in postnatal depression. Research into hormonal prophylaxis and treatment of postnatal depression (PND) is limited. This review article is aimed at exploring the evidence available regarding the use of oestrogen and progesterone in postnatal depression. A search of electronic databases Medline, Psychinfo, Embase and published books from 1970 to 2002 was carried out. The search strategy was limited to the English language. Of 193 articles, 30 were chosen and all 30 copies were identified and analysed critically. Prophylactic and treatment value were separately analysed for both oestrogen and progesterone. Some uncontrolled studies by Dalton (1982, 1985) report the benefit of progesterone in preventing postnatal depression. The value of oestrogen in preventing and treating this disorder is suggested by some articles but the methodological shortcomings in these studies make the study results unreliable. In addition, the use of oestrogen in the postnatal period may have significant side effects. Use of synthetic progesterone is associated with depression in the postnatal period and should be used with caution. Oestrogen therapy may be of modest value in severe postnatal depression.

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