Approaches in the Treatment of Cesarean Scar Pregnancy and Risk Factors for Intraoperative Hemorrhage: A Retrospective Study

Abstract

Background: Cesarean scar pregnancy (CSP) involves a rare form of placental attachment that often leads to life-threatening conditions. The best treatment for CSP has been debated for decades. We aimed to evaluate the different treatments for CSP and analyzed the risk factors for intraoperative hemorrhage.Methods: CSP patients treated at the Affiliated Hospital of Jiangnan University were reviewed retrospectively from January 2014 to 2020. CSP was classified into three types based on the location and shape of gestational tissue, blood flow features, and thickness of the myometrium at the incision site. The clinical characteristics, types, approaches of treatment, and clinical outcomes of CSP were analyzed.Results: A total of 55 patients were included in this study, 29 (52.7%) of whom underwent transvaginal curettage after uterine artery embolization (UAE) and 22 (40%) of whom underwent transabdominal ultrasound-guided hysteroscopic curettage (USHC) in type I and II. Four patients (7.3%) classified as type III underwent laparoscopic cesarean scar resection (LCSR). Intraoperative blood loss, blood transfusion rate, and scar diverticulum were significantly higher in type II than in type I (P < 0.05). Even though USHC showed no differences in intraoperative blood loss, length of stay, and scar diverticulum compared with curettage after UAE (P > 0.05), superiority was found in surgical time and hospitalization cost (P < 0.05). Furthermore, the type of CSP (OR = 10.53, 95% CI: 1.69–65.57; P = 0.012) and diameter of the gestational sac (OR = 25.76, 95% CI: 2.67–248.20; P = 0.005) were found to be risk factors for intraoperative hemorrhage.Conclusions: Transabdominal ultrasound-guided hysteroscopic curettage is an effective and relatively safe treatment option for patients with CSP. Type of CSP and diameter of the gestational sac were found to be associated with excessive intraoperative hemorrhage.

Local Methotrexate Injection Followed by Dilation and Curettage for Cesarean Scar Pregnancy: A Prospective Non-randomized Study

“…According to the guide "Expert opinion of Diagnosis and Treatment of Cesarean Scar Pregnancy (2016)" issued by the Family Planning Group of Obstetrics and Gynecology Credit Association of the Chinese Medical Association, CSP is categorized into type I, type II and type III based on the location and shape of gestational tissue, blood flow features, and thickness of the myometrium at the incision site (17). Type II and III CSP were found to be associated with excessive intraoperative hemorrhaging in a previous study (7). In our study, four out of five cases with type III CSP had blood loss in excess of 200 ml during D&C. This includes three cases in group A who failed the primary treatment.…”

“…In addition, it is necessary to raise concerns about several other complications secondary to UAE, such as infectious disease, deep venous thrombosis, acute pulmonary embolism, and inadvertent embolization (31). UAE also increases the economic burden because of its specific instruments and procedure (7,25), which may limit its broader use.…”

“…In our study, four out of five cases with type III CSP had blood loss in excess of 200 ml during D&C. This includes three cases in group A who failed the primary treatment. Thus, it may be a disadvantageous option for type III CSP to undertake the approach of local intra-gestational sac methotrexate injection followed by D&C. It seems to indicate UAE or surgical resection may improve the outcome of these patients based on the current evidence (7,25,32).…”

“…Recently, concern has been gradually increasing because of the climbing rate of CSP (4). Early diagnosis and appropriate treatment play an essential role in improving patients' outcome (2,(5)(6)(7). Transvaginal ultrasound is the primary method of diagnosing CSP (8).…”

Conservative Management of Cesarean Scar Pregnancy: A Case Report and Literature Review

“…It can be performed simultaneously with the help of a Foley balloon [ 18 ]. Hysteroscopy: It is a therapeutic option with a low complication rate [ 19 , 20 ] that can be considered as an alternative to curettage in patients with the same criteria described for uterine curettage Surgical resection by laparoscopy or laparotomy [ 17 ]: It is an option in cases in which there is bladder infiltration [ 20 ], as well as in cases of suspected uterine rupture Hysterectomy may be indicated in cases of uncontrollable bleeding or the impossibility of conservative treatment [ 7 ]. …”