Cesarean scar ectopic pregnancy

Czech version

Authors: L. Zahálková ¹; M. Kacerovský ²
Authors‘ workplace: Gynekologicko-porodnické oddělení Oblastní nemocnice, Náchod primář MUDr. M. Střecha ¹; Porodnická a gynekologická klinika FN, Hradec Králové přednosta doc. MUDr. J. Špaček, Ph. D. ²
Published in: Ceska Gynekol 2016; 81(6): 414-419

Overview

Objective:
To summarize current knowledge about cesarean scar pregnancy and to provide a review about available managements of this serious pregnancy pathology.

Design:
Review article.

Setting:
Department of Gynecology and Obstetrics, District Hospital Náchod.

Results:
Cesarean scar pregnancy is likely to be a result of impaired healing of the scar along with an increased affinity of trophoblast cells to extracellular matrix. A transvaginal ultrasonography represents a key tool in the cesarean scar pregnancy identification. The main goal of the cesarean scar pregnancy treatment is to preserve fertility. There are different approaches how to manage this pregnancy complication. A surgical treatment is characterized by an exstirpation of ectopic pregnancy. This approach makes a repair of lower uterine segment possible and it may improve a prognosis for subsequent pregnancy. However, the most common management is a conservative treatment with a methotrexate administration. Recently, an innovative mini-invasive treatment with a Foley catheter has been reported. A regular evaluation of βhCG concentrations and a transvaginal ultrasound examination are used for a follow-up. Subsequent pregnancy is possible, yet it should be considered as a high-risk.

Conclusion:
Despite the fact the frequency of cesarean scar pregnancy increases, cesarean scar pregnancy still represents a rare but serious pregnancy pathology. In case of an early diagnosis, it should be managed with respect to preserve fertility.

Keywords:
cesarean section, ectopic pregnancy, methotrexate, fertility

Sources

1. Cecchino, GN., Araujo Júnior, E., Elito Júnior, J. Methotrexate for ectopic pregnancy: when and how. Arch Gynecol Obstet, 2014, 290, p. 417–423.

2. Graesslin, O., Dedecker, F. Jr., Quereux, C., Gabriel, R. Conservative treatment of ectopic pregnancy in a cesarean scar. Obstet Gynecol, 2005, 105, 4, p. 869–871.

3. Haimov-Kochman, R., Sciaky-Tamir, Y., Yanai, N., Yagel, S. Conservative management of two ectopic pregnancies implanted in previous uterine scars. Ultrasound Obstet Gynecol, 2002, 19, p. 616–619.

4. Horne, AW., Skubisz, MM., Tong, S., et al. Combination gefitinib and methotrexate treatment for non-tubal ectopic pregnancies: a case series. Hum Reprod, 2014, 29, 7, p. 1375–1379.

5. Karásek, V. Gravidita v jizvě po císařském řezu – kazuistika. Čes Gynek, 2015, 80, 5, s. 382–385.

6. Kučera, E., Křepelka, P., Krofta, L., Feyereisl, J. Ektopická gravidita v jizvě po císařském řezu. Čes Gynek, 2007, 72, 3, s. 207–213.

7. Maymon, R., Halperin, R., Mendlovic, S., et al. Ectopic pregnancies in a Cesarean scar: review of the medical approach to an iatrogenic complication. Hum Reprod Update, 2004, 10, p. 515–523.

8. Mou Y., et al. Giant uterine artery pseudoaneurysm after a missed miscarriage termination in a cesarean scar pregnancy. BMC Women‘s Health, 2014, 14, p. 89.

9. Nawroth, F., Foth, D., Wilhelm, L., et al. Conservative treatment of ectopic pregnancy in a cesarean section scar with methotrexate: a case report. Eur J Obstet Gynecol Reprod Biol, 2001, 99, p. 135–137.

10. Nonaka, M., Toyoki, H., Imai, A. Cesarean section scar pregnancy may be the cause of serious hemorrhage after first-trimester abortion by dilatation and curettage. Int J Gynecol Obstet, 2006, 95, p. 50–51.

11. Rizk, B., Holliday, CP., Owens, S., Abuzeid, M. Cervical and Cesarean scar ectopic pregnancies: Diagnosis and management. Middle East Fertil Soc J, 2013, 18, p. 67–73.

12. Rotas, MA., Haberman, S., Levgur, M. Cesarean scar ectopic pregnancies: etiology, diagnosis and management. Obstet Gynecol, 2006, 107(6), p. 1373–1381.

13. Seow, KM., Huang, LW., Lin, YH., et al. Cesarean scar pregnancy: issues and management. Ultrasound Obstet Gynecol, 2004, 23, p. 247–253.

14. Shah Sapana, R., Vyas Rupa, C., Edwin, R., et al. Management of cesarean scar pregnancy. IOSR-J Dent Med Sci, 2014, 13, 9, IV, p. 12–17.

15. Shao, M., Hu, M., Xu, X., Zhang, L., Hu, M. Management of Cesarean scar pregnancies using an intrauterine or abdominal approach based on the myometrial thickness between the gestational mass and the bladder wall. Gynecol Obstet Invest, 2013, 76, p. 151–157.

16. Skubisz, MM., Lee, J., Wallace, EM., Tong, S. Decline in βhCG levels between days 0 and 4 after a single dose of methotrexate for ectopic pregnancy predicts treatment success: a retrospective cohort study. BJOG, 2011, 118, p. 1665–1668.

17. Sun, YY., Xi, XW., Yan, Q., et al. Management of type II unruptured cesarean scar pregnancy: Comparison of gestational mass excision and uterine artery embolization combined with methotrexate. Taiwan J Obstet Gynecol, 2015, 54, p. 489–492.

18. Takacs, P., Chakhtoura, N., De Santis, T., Verma, U. Evaluation of the relationship between endometrial thickness and failure of single-dose methotrexate in ectopic pregnancy. Arch Gynecol Obstet, 2005, 272, p. 269–272

19. Timor-Tritsch, IE., Monteagudo, A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol, 2012, 207, p. 14–29.

20. Timor-Tritsch, IE., Monteagudo, A., Santos, R., et al. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol, 2012, 207, p. 44.e1–44e13.

21. Timor-Tritsch, IE., Monteagudo, A., Cali, G., et al. Cesarean scar pregnancy and early placenta accreta share common histology. Ultrasound Obstet Gynecol, 2014, 43, p. 383–395

22. Timor-Tritsch, IE., Khatib, N., Monteagudo, A., et al. Cesarean scar pregnancies. J Ultrasound Med, 2015, 34, p. 601–610.

23. Timor-Tritsch, IE., Monteagudo, A., Cali, G., et al. Easy sonographic differential diagnosis between intrauterine pregnancy and cesarean delivery scar pregnancy in the early first trimester. Am J Obstet Gynecol, 2016, p. 1.e1–1.e7

24. Timor-Tritsch, IE., Monteagudo, A., Bennett TA., et al. A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy. Am J Obstet Gynecol, 2016, p. 1.e1–1.e8

25. Wang, CJ., Chao, AS., Yuen, LT., et al. Endoscopic management of cesarean scar pregnancy. Fertil Steril, 2006, 85, p. 494.

26. Wang, Y., Su, T., Chen, H. Operative laparoscopy for unruptured ectopic pregnancy in a cesarean scar. BJOG, 2006, 113, p. 1035–1038.