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      Cesarean Scar Pregnancy: A New Challenge for Obstetricians

      case-report

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          ABSTRACT

          A cesarean scar pregnancy is an extremely rare and serious condition associated with grave complications. So, early diagnosis and individualized treatment are a must. We report a case of cesarean scar ectopic pregnancy that presented with complaints of bleeding per vaginum (PV) followed by a history of medical termination of pregnancy (MTP) pill consumption. A higher expected risk of rupture necessitated an exploratory laparotomy for excision of a cesarean scar pregnancy. In our case, uterine repair could be done, thus preserving the future fertility.

          How to cite this article

          Barkale RS, More V, Naik A, et al. Cesarean Scar Pregnancy: A New Challenge for Obstetricians. J South Asian Feder Obst Gynae 2023;15(3):338–340.

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

          R. J. Mohd Salim, Edward C Elson, K Hillaby … (2003)
          To describe first-trimester ultrasound diagnosis and management of pregnancies implanted into uterine Cesarean section scars. 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. 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. 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.
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            Cesarean scar pregnancy: issues in management.

            LING LIN, Robert Tsai, Marie Lin … (2004)
            To evaluate our experience with the diagnosis and treatment of Cesarean scar pregnancy. During a 6-year period, 12 cases of Cesarean scar pregnancy were diagnosed using transvaginal color Doppler sonography and treated conservatively to preserve fertility. Incidence, gestational age, sonographic findings, beta-human chorionic gonadotropin ( beta-hCG) levels, flow profiles of transvaginal color Doppler ultrasound, and methods of treatment were recorded. The incidence of Cesarean scar pregnancy was 1:2216 and its rate was 6.1% in women with an ectopic pregnancy and at least one previous Cesarean section. Gestational age at diagnosis ranged from 5 + 0 to 12 + 4 weeks. The time interval from the last Cesarean section to the diagnosis of Cesarean scar pregnancy ranged from 6 months to 12 years. High-velocity and low-impedance subtrophoblastic flow (resistance index, 0.38) persisted until beta-hCG declined to normal. Patients were treated as follows: transvaginal ultrasound-guided injection of methotrexate into the embryo or gestational sac (n = 3), transabdominal ultrasound-guided injection of methotrexate (n = 2), transabdominal ultrasound-guided injection of methotrexate followed by systemic methotrexate administration (n = 2), systemic methotrexate administration alone (n = 2), dilatation and curettage (n = 2), or local resection of the gestation mass (n = 1). Eleven of the 12 patients preserved their reproductive capacity; the remaining patient, treated by dilatation and curettage, underwent a hysterectomy because of profuse vaginal bleeding. The Cesarean scar mass regressed from 2 months to as long as 1 year after treatment. Uterine rupture occurred in one patient during the following pregnancy at 38 + 3 weeks' gestational age. Ultrasound-guided methotrexate injection emerges as the treatment of choice to terminate Cesarean scar pregnancy. Surgical or invasive techniques, including dilatation and curettage are not recommended for Cesarean scar pregnancy due to high morbidity and poor prognosis. Copyright 2004 ISUOG. Published by John Wiley & Sons, Ltd.
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              New ultrasound grading system for cesarean scar pregnancy and its implications for management strategies: An observational cohort study

              Shin-Yu Lin, Chia-Jung Hsieh, Yi-An Tu … (2018)
              A cesarean section pregnancy (CSP) indicated the gestational sac (GS) implanted in the previous cesarean scar. The clinical manifestations of CSP present a wide range of variations, and the optimal management is yet to be defined. We retrospectively enrolled 109 patients with the diagnosis of CSP from our department and categorized them into four grades based on the ultrasound presentation. Grade I CSP indicated the GS embedded in less than one-half thickness of the lower anterior corpus; and grade II CSP represented the GS extended to more than one-half thickness of overlying myometrium. Grade III CSP implied the GS bulged out of the cesarean scar; and grade IV CSP denoted that GS became an amorphous tumor with rich vascularity at the cesarean scar. Seventy-eight women received surgery, and the complication rate was 14.1% (11/78). Linear regression analysis demonstrated a significant association between the invasiveness of the surgery and their ultrasound gradings. The mainstream operation for grade I CSP was transcervical resection, while the majority of grade III and IV patients required hysterotomy or hysterectomy. Another 31 women received chemotherapy with methotrexate as their initial treatment. The success rate for chemotherapy was 61.3%; the remaining patients required further surgery due to persistent CSP or heavy bleeding during or after chemotherapy. Fifteen patients (48.3%) receiving chemotherapy suffered from complications (mostly bleeding). Among them, 7 (22.6%) patients experienced bleeding of more than 1,000 mL, and 9 (29.0%) of these 31 patients required blood transfusions. Our novel ultrasound grading system for CSP may help to communicate between physicians, and determine the optimal surgical strategy. Chemotherapy with methotrexate for CSP is not satisfactory and is associated with a higher rate of complications.
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                Author and article information

                Journal
                Journal ID (publisher-id): JSAFOG
                Title: Journal of South Asian Federation of Obstetrics and Gynaecology
                Abbreviated Title: JSAFOG
                Publisher: Jaypee Brothers Medical Publishers
                ISSN (Print): 0974-8938
                ISSN (Electronic): 0975-1920
                Publication date (Print): May-June 2023
                Volume: 15
                Issue: 3
                Pages: 338-340
                Affiliations
                [1,3 ]Department of Obstetrics and Gynecology, LTMMC, Mumbai, Maharashtra, India
                [2 ]Department of Obstetrics and Gynecology, KEM Hospital, Mumbai, Maharashtra, India
                [4 ]Department of Obstetrics and Gynecology, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, Maharashtra, India
                Author notes
                Rachana Suhas Barkale, Department of Obstetrics and Gynecology, LTMMC, Mumbai, Maharashtra, India, Phone: +91 9372297887, e-mail: rachana@ 123456barkale.com
                Article
                DOI: 10.5005/jp-journals-10006-2233
                SO-VID: 2e629806-2b2f-494f-821a-41a741fbc66c
                Copyright © Copyright © 2023; The Author(s).
                License:

                © The Author(s). 2023 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 09 March 2023
                Date accepted : 10 April 2023
                Date: 31 July 2023
                Categories
                Subject: CASE REPORT
                Custom metadata
                file-pdf jsafog-15-338.pdf

                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: Ectopic pregnancy,Cesarean,Cesarean scar,Cesarean scar pregnancy,Cesarean section
                Data availability:
                ScienceOpen disciplines: Obstetrics & Gynecology
                Keywords: Ectopic pregnancy, Cesarean, Cesarean scar, Cesarean scar pregnancy, Cesarean section

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