Cesarean scar ectopic pregnancies: etiology, diagnosis, and management.

Gestational Trophoblastic Disease

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

Caesarean scar pregnancy

The diagnosis, treatment, and follow-up of cesarean scar pregnancy.

Objective
To describe first-trimester ultrasound diagnosis and management of pregnancies implanted into uterine Cesarean section scars.

Methods
All women referred for an ultrasound scan because of suspected early pregnancy complications were screened for pregnancies implanted into a previous Cesarean section scar. The management of Cesarean section scar pregnancies included transvaginal surgical evacuation, medical treatment with local injection of 25 mg methotrexate into the exocelomic cavity and expectant management.

Results
Eighteen Cesarean section scar pregnancies were diagnosed in a 4-year period. The prevalence in the local population was 1 : 1800 pregnancies. Surgical treatment was used in eight women and it was successful in all cases. The respective success rates of medical treatment and expectant management were 5/7 (71%) and 1/3 (33%). Five women (28%) required blood transfusion and one woman (6%) had a hysterectomy.

Conclusions
Cesarean section scar pregnancies are more common than previously thought. When the diagnosis is made in the first trimester the prognosis is good and the risk of hysterectomy is relatively low. Copyright © 2003 ISUOG. Published by John Wiley & Sons, Ltd.

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1002/uog.56

First‐trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar

Severe complications might ensue when the placenta is implanted in the uterine scar left by a previous cesarean section. Both placenta previa and placenta accreta are encountered. It is estimated that an abnormally inserted placenta accounts for at least 50% of obstetric hysterectomies. The authors report 18 pregnancies implanted in an existing lower-segment cesarean section scar. These cases were encountered over 4 years, all of them in the first trimester. The population screened were women referred for transvaginal ultrasonography because of suspected early pregnancy complications. The diagnosis rested on an empty uterus; the presence of a gestational sac anteriorly at the level of the internal os covering the site of a previous lower-segment cesarean section scar and Doppler evidence of functional trophoblastic/placental circulation. Medically treated women had 25 mg methotrexate injected directly into the pregnancy through the transvaginal route guided by continuous ultrasound monitoring. They also received a single intravenous dose of 1.5 g cefuroxime and 500 mg metronidazole. Embryocide using potassium chloride was the initial step when embryonic cardiac activity was detected. Surgery consisted of suction curettage, also performed under ultrasound guidance. A saline-filled Foley catheter was used to control heavy intraoperative bleeding by compression. It was left in place for 12-24 hours. The estimated prevalence of cesarean scar pregnancy in this patient population was 1 in 1800. A majority of women had had multiple previous sections. Gestational age ranged from 4-23 weeks. Eight women were initially treated surgically, 7 medically, and 3 expectantly. Surgery succeeded in all cases, although 3 women had significant bleeding. There were no retained products of conception present after surgery in any case. Five of 7 women had a good outcome with medical management but 2 required surgery and blood transfusion. Expectant management succeeded in 1 of 3 cases. Seven women have attempted another pregnancy, and 5 of them went on to have normal singleton intrauterine pregnancies. Women treated in the first trimester for pregnancy in a cesarean section score do much better than those found.in late pregnancy to have placenta previa or placenta accreta. Expectant management seems to be unwarranted. When the patient agrees to be actively treated, local injection of methotrexate and transcervical aspiration are preferable to laparoscopy or laparotomy.

First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar

Objective

The aim of the study was to evaluate whether the presence of normal ovarian tissue adjacent to an adnexal tumor (the ‘ovarian crescent sign’) could assist in the preoperative differential diagnosis of adnexal lesions.



Methods

This was a prospective observational study including 100 women with a preoperative diagnosis of an adnexal mass. Demographic and biochemical data were collected and all women underwent a detailed transvaginal ultrasound scan. Tumor volume, morphological characteristics and Doppler features were recorded in each case. In addition, the tissue adjacent to the cyst was systematically examined for the presence of normal ovarian tissue. All the findings were compared to the final histological diagnosis.



Results

Sixty-seven (67%) of the cysts removed were benign, nine (9%) were borderline and 24 (24%) women had invasive malignant lesions. Normal ovarian tissue was seen in 58/76 (76%) women with non-invasive lesions, and in one woman (4%) with an invasive malignancy. In the absence of normal ovarian tissue, ovarian cancer was diagnosed with a sensitivity of 96% and specificity of 76%.



Conclusion

The presence of normal ovarian tissue adjacent to an ovarian cyst is a useful morphological feature that may be used to help exclude an invasive ovarian malignancy in women with adnexal masses detected on ultrasound scan. Copyright © 2003 ISUOG. Published by John Wiley & Sons, Ltd.

The value of detection of normal ovarian tissue (the ‘ovarian crescent sign’) in the differential diagnosis of adnexal masses

Cesarean scar pregnancy (CSP) presents a diagnostic as well as a therapeutic challenge. Since more cesarean deliveries (CDs) are performed, its frequency is increasing. Although there are no general guidelines for the management of this rather threatening entity, this chapter deals with a set of diagnostic and treatment criteria of this complication of pregnancy. Awareness and timely diagnosis of CSP by a very early transvaginal ultrasound scan (TVS) of a new pregnancy in a patient with previous CD may enable early treatment and mitigate complications.

A. Lawrence

Papers

First‐trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar

First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar

The value of detection of normal ovarian tissue (the ‘ovarian crescent sign’) in the differential diagnosis of adnexal masses

Cesarean scar pregnancy.

Three-dimensional ultrasound diagnosis of interstitial pregnancy.