Clinical observation of hysteroscopic surgery combined with ectopic pregnancy ⅱ decoction and methotrexate in the treatment of cesarean scar pregnancy

Objective:To explore the effectiveness and safety about the treatment of Caesarean Scar Pregnancy combined hysteroscopic surgery with extopic pregnancy Ⅱ decoction and methotrexate(MTX).Methods: A total of 80 cases of CSP patients admitted by our hospital from January 2014 to March 2017 were selected as the subjects. According to the treatment way, the patients were divided into experimental group (n=40) and control group (n=40). The control group was given MTX 50 mg/m2, IM once;and the experimental group was given extopic pregnancy Ⅱ decoction on the basis of the treatment given to the control group;the 8th day hysteroscopic surgery. Routine treatment was given after surgery. Experimental group continued to take extopic pregnancy Ⅱ decoction until monitoring the serum beta-hcg level drops below normal. The general information and curative effect, HCG levels before and after 4, 7 and 11d of treatment;mass diameter before and after 11 d of treatment, menstruation recovery time and the incidence of adverse reactions in 2 groups were observed.Results:After hysteroscopic surgery pretreatment with extopic pregnancy Ⅱ decoction and MTX, HCG levels after 4, 7 and 11d were significantly lower than before, it gradually reduced by time prolonged, and research group was lower than control group, the differences were statistically significant. After treatment with different drugs, the size of pregnancy package in the observation group was significantly smaller than that in the control group. Compared with the control group, the he package block size, beta HCG time and vaginal bleeding time were significantly reduced.Conclusion: It has significant clinical effect of hysteroscopic surgery combined with ectopic pregnancy Ⅱ and MTX in the treatment of CSP. It has worthy of clinical promotion to control the amount of blood, avoid intrauterine adhesion caused by uterine artery embolization and infection et al and reduce burden of the physical and economic of patients.

Local metothrexate treatment of cesarean scar ectopic pregnancy

Myometrial pregnancy developing in a previous caesarean section scar is the rarest of all ectopic pregnancies (EP) and probably one of the most dangerous of all because of the risk of rupture and hemorrhage. The recent recognition of this problem means that diagnosis and management are still in their infancy, and there is no consensus regarding the best management of CSP. Methotrexate (MTX) can be administered systemically or locally, or in both ways, with the aid of ultrasound. Patients diagnosed with caesarean scar pregnancies (CSP) in our clinic underwent transvaginal treatment of ectopic pregnancy. Safe and short treatment under transvaginal ultrasonographic (USG) guidance was performed uneventfully in all cases. The operating time ranged from 5 to 10 minutes with no blood loss. Serum β-hCG (β-subunit of human chorionic gonadotrophin) levels declined to normal levels within a month, and patients were discharged without further complications in two or three hours after the procedure. Our cases show that this treatment is effective, safe, and minimally invasive for patients diagnosed with CSP.

DIAGNOSIS AND TREATMENT OF CESAREAN SCAR PREGNANCY

Objective To investigate the early diagnosis and treatment of cesarean scar pregnancy （CSP）. Methods Clinical data of 28 patients with CSP in Peking Union Medical College Hospital from January 1994 to April 2007, including age, interval from the last cesarean delivery to diagnosis, clinical presentation, location of the lesion, process of diagnosis and treatment, outcome, and follow-up, were retrospectively analyzed. Re, salts CSP constituted 1.05 % of all ectopic pregnancies, and the ratio of CSP to pregnancy was 1 ： 1 221. The mean age of the group was 31.4 years. Twenty-six women had only one prior cesarean delivery. The interval from the last cesarean delivery to diagnosis ranged from 4 months to 15 years. The most common presenting symptoms of CSP were amenorrhoea and vaginal bleeding. Seventeen cases were misdiagnosed as early intrauterine pregnancies and 2 were misdiagnosed as gestational trophoblastic tumor. The other 9 were diagnosed definitely before treatment. The diagnosis was made based on cesarean delivery history, gynecologic examination, ultrasound, and magnetic resonance imaging （MRI）. The treatment of CSP included systemic or local methotrexate administration, conservative surgery, and hysterectomy. The conservative treatment was successful in 24 cases. All of the 28 women were cured through individual therapies. Conclusions CSP is rare and usually misdiagnosed as other diseases. Ultrasound is valuable for diagnosing CSP, and MRI can be used as an adjunct to ultrasound scan. Early diagnosis offers the options of conservative treatment and greatly improves the outcome of patients. Individual therapy is strongly recommended.

Management of Cesarean Scar Pregnancy: A Case Series

Objective To survey effective treatment strategies for cesarean scar pregnancy(CSP). Methods The clinical data of 78 patients diagnosed with CSP from January 2010 to December 2013 were reviewed. Results Among these patients, 17 patients were first treated at our hospital; of them, 2 were misdiagnosed. The other 61 patients were referred from other hospitals; of them, 21 were initially misdiagnosed. There were 9 patients who were treated with laparotomy, 50 patients with curettage after uterine artery embolization(UAE) with or without local methotrexate(MTX) infusion, 10 patients with dilatation and curettage, 6 patients with transvaginal sonographic guided local intragestational MTX injection, and 3 patients with systemic MTX injection. All patients finally recovered. Patients with excessive vaginal hemorrhage underwent either emergency UAE treatment or laparotomy. These two treatments had similar success rates(81.82% vs. 100%, χ2 =0.289, P>0.05). Conclusions The accurate diagnosis of CSP is important. Curettage after UAE with or without local MTX infusion is a safe and effective method.

Management of heterotopic cesarean scar pregnancy with preservation of intrauterine pregnancy:A case report

BACKGROUND Heterotopic cesarean scar pregnancy(HCSP)is very rare and has a high risk of massive uterine bleeding.Preservation of concurrent intrauterine pregnancy(IUP)is one of the great challenges in the management of HCSP.No universal treatment protocol has been established when IUP is desired to be preserved.CASE SUMMARY We report a case of HCSP at 8+wk gestation in a 34-year-old woman with stable hemodynamics.A two-step intervention was applied.Selective embryo aspiration was performed first,and surgical removal of ectopic gestational tissue by suction and curettage was performed 2 d later.Both steps were performed under ultrasound guidance.The patient had an uneventful course,and a healthy baby was delivered at 34+6 wk gestation.CONCLUSION Selective embryo aspiration followed by suction and curettage was successful in the preservation of IUP in the management of HCSP.This approach is an alternative option for HCSP in the first trimester when the IUP is desired to be preserved.

The Value of Transvaginal Ultrasound in Clinical Surgical Treatment of Cesarean Scar Pregnancy

The clinical value of transvaginal ultrasound in clinical surgical treatment of cesarean scar pregnancy（CSP） was evaluated. The clinical data of 104 patients with CSP admitted at Tongji Hospital from 2013 to 2016 were collected and analyzed retrospectively, including the patients＇ age, gestational age, the size of gestational sac or uneven mass, the uterine scar thickness, β human chorionic gonadotropin（h CG） levels and so on. Of these 104 cases, 30 cases were subjected to laparotomy, 29 cases to laparoscopy, 27 cases to hysteroscopy, 16 cases to ultrasound-guided uterine curettage, and 2 cases to conservative treatment. The transvaginal ultrasound showed that uterine scar thickness and gestational sac or uneven mass size had significant difference（P〈0.05） among different surgical methods by comparatively analyzing the patients＇ data. It was suggested that transvaginal ultrasound may provide the valuable reference for choosing clinical surgical procedures for CSP.

Cesarean Scar Pregnancy: A Report of 11 Cases and Review of the Literature Regarding Subsequent Pregnancy

Background: There is no consensus regarding the optimal treatment for cesarean scar pregnancy (CSP) because treatment efficacy, safety, and the influence on subsequent pregnancy must be taken into consideration. Here we report our experience with 11 cases of CSP and review the literature regarding subsequent pregnancy. Methods: Records of 11 CSP cases that were treated at our hospital were retrospectively reviewed. CSP was treated by local methotrexate (MTX) injection or laparotomic or laparoscopic removal of the gestational mass and myometrial repair. Outcome of subsequent pregnancy after treatment was followed-up until delivery. Results: Local MTX injection was performed for six cases, laparotomic removal of the gestational mass and myometrial repair was performed for two, and laparoscopic removal of the gestational mass and myometrial repair was performed for three. The uterus was preserved in all cases. After CSP treatment, eight pregnancies occurred in five cases, resulting in six live births and two miscarriages. Conclusion: Advantages and disadvantages of various treatment methods for CSP continue to be elucidated. Serum hCG level, location of the gestational mass, thickness of the lower uterine segment at the time of diagnosis, and whether the patient wishes for fertility preservation should be considered when choosing a treatment plan.

Cesarean scar pregnancy

Cesarean scar ectopic pregnancy is a consequence of a scar from previous cesarean section.It is rare and is associated with catastrophic complications of early pregnancy.It can occur in women with only one prior cesarean delivery.With increasing rate of cesarean section worldwide,more and more cases are diagnosed and reported.The incidence is likely to rise substantially in the near future.A delay in diagnosis and the treatment can lead to uterine rupture,major haemorrhage,hysterectomy and serious maternal morbidity.Early diagnosis can offer treatment options of avoiding uterine rupture and haemorrhage,thus preserving the uterus and future fertility.Aim of this article is to find the demography,pathophysiology,clinical presentation,most appropriate methods of early diagnosis and management.

Emergency internal iliac artery temporary occlusion after massive hemorrhage during surgery of cesarean scar pregnancy:A case report

BACKGROUND Cesarean scar pregnancy(CSP)is rare but may result in uterine rupture during pregnancy or massive hemorrhage during abortion procedures.Awareness of this condition is increasing,and most patients with CSP are now diagnosed early and can be managed safely.However,some atypical patients are misdiagnosed,and their surgical risks are underestimated,increasing the risk of fatal hemorrhage.CASE SUMMARY A 27-year-old Asian woman visited our institution because of abnormal pregnancy,and she was diagnosed with a hydatidiform mole through transvaginal ultrasound(TVS).Under hysteroscopy,a large amount of placental tissue was found in the scar of the lower uterine segment,and a sudden massive hemorrhage occurred during the removal process.The bilateral internal iliac arteries were temporarily blocked under laparoscopy,and scar resection and repair were rapidly performed.She was discharged in good condition 5 d after the operation.CONCLUSION Although TVS is widely used in the diagnosis of CSP,delays in the diagnosis of atypical CSP remain.Surgical treatment following internal iliac artery temporary occlusion may be an appropriate management method for unanticipated massive hemorrhage during CSP surgery.

The Diagnosis and Treatment for a Special Type of Cesarean Scar Pregnancy

Caesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy, and its incidence has been increased due to the increased rate of Cesarean sections performed. A special type of CSP, concealed CSP, was found in the clinical work in our institution. A retrospective review was performed. From September 2011 to June 2014, 208 women were presented with cesarean scar pregnancy by use of transvaginal color Doppler sonography. The medical records were consulted to collect the demographics and pertinent information. Six of them were determined to be concealed CSP. Four women were diagnosed in the first-trimester pregnancy after termination of pregnancy. The initial ultrasound of the other two women displayed that the gestational sacs were located in the lower uterine cavity. Placenta accrete, increta and previa were diagnosed by the following ultrasounds. Concealed CSP is a very unusual form of CSP. Continued pregnancy may be sufficiently evaluated because of subsequently serious complications. Our results indicate that continued pregnancy increases the risk of laparotomy and hysterectomy. Medical abortion in the first-trimester pregnancy should be considered as the optimal choice for the women with prior cesarean sections who want to terminate the gestation.

Expectant management of cesarean scar pregnancy:a case report and a review of literature

Pregnancy in previous cesarean scar is the rarest form of ectopic pregnancy.Little is known about its natural history and optimal management.All literatures except one reported that the expectant treatments for such patients were unsuccessful or led to complication.This paper presents one case of cesarean scar pregnancy(CSP) with expectant management,and discusses the value of this expectant management.The paper also appears a glimpse of the natural courses of certain cesarean scar pregnancies. A 32-year-old woman with a history of cesarean section presented to our outpatient clinic with amenorrhea and bleeding.Sonography and magnetic resonance imaging(MRI) revealed the diagnosis of CSP without viable gestation sac.The patient opted for expectant treatment.We closely monitored the patient with a detailed plan.The patient had mild bleeding during monitoring and her serumβ-hCG levels dropped quickly to normal range after seven weeks.She was fully recovered with total absorption of the mixed mass in the scar of the anterior wall of uterus. If patient with CSP has no viable gestation sac and serumβ-hCG levels are rapidly decreased,she can be expectantly treated.Such cesarean scar pregnancies may be naturally demised.Patient with CSP should be followed up strictly.Medical or surgical therapy should be considered prior to rupture to remove the gestational sac and retain the patient future fertility.

Experience in Surgical Coordination of Type III Cesarean Scar Pregnancy Removal with Combined Assistance of Hysteroscopy and Laparoscopy

Objective:This paper aims to summarize the operative nursing coordination essentials of type III cesareans car pregnancy removal.Methods:Six patients were recruited for this study,and the patient’s condition was fully evaluated before the operation.In addition,the personnel,environment,and materials were well prepared before the operation,and the preparation of special intraoperative instruments and equipment was perfected.Results:The operation is successfully performed in all six patients.Each surgery lasted 70 to 120 minutes with an average duration of 90 minutes.Postoperative blood loss was about 100-500 ml.Postoperative recovery was good without complications in all the patients.Conclusion:In summary,laparoscopic removal of gestational tissue from type III cesareans car pregnancy in conjunction with hysteroscopy ensures compete removal of gestational tissue,while avoiding damaging the surrounding organs and tissues,thus greatly avoiding common complications which usually occur during the surgery.Effective surgical coordination is helpful to further improve the success rate of the operation.

Caesarean Scar Ectopic Pregnancies—Case Series from a District General Hospital

Caesarean Scar Ectopic Pregnancy (CSEP) is a rare, but potentially catastrophic complication of a previous Caesarean Section (CS) birth. This is a review of 5 cases of CSEP managed in our Early Pregnancy Unit at Watford General Hospital within a 10-month period. Two patients had only one previous CS, whilst 2 had two and the last had 3 previous CS. All our patients presented within the first trimester of pregnancy (range 6 to 11 weeks’ gestation) with light vaginal bleeding;4 of them had associated mild to moderate abdominal pain. All were diagnosed using transvaginal ultrasound scan. Three of our patients were managed surgically by Suction Evacuation under Ultrasound guidance and insertion of a Foley’s catheter prophylactically for tamponade in order to reduce blood loss both intra- and post-operatively. One of our patients had a heterotopic pregnancy with a viable intrauterine pregnancy and a live CSEP. She declined any intervention so she was managed conservatively with weekly Consultant appointments and scans. There was a subsequent demise of the CSEP and she continued with a singleton pregnancy. None of our patients were managed medically. There is no absolute consensus on diagnostic criteria and there is no standard management protocol so each woman should be given all the available information and the opportunity to decide on the management of her pregnancy. The risk of a CSEP in a subsequent pregnancy should be part of the consent process for CS.

Hydatidiform mole in a scar on the uterus:A case report

BACKGROUND Cesarean scar molar pregnancy is extremely rare,but the incidence has been rising due to the continuous increase in the rate of cesarean section.The presence of a hydatidiform mole in the scar left on the uterus by the procedure may lead to severe complications.We performed a literature review and found only seven reported cases of cesarean scar molar pregnancy.Accurate diagnosis and appropriate treatment are extremely important for the patients’prognosis.CASE SUMMARY A 35-year-old woman,gravida 4,para 1,complained of vaginal bleeding lasting more than 1 mo and amenorrhea lasting more than 2 mo.The patient’s serum human chorionic gonadotropin was 4287800 IU/L.Ultrasound showed a 11.5 cm×7.5 cm mass at the anterior lower wall of the uterus.The patient underwent suction evacuation,and partial grape-like tissue mixed with blood clots was removed.Uterine arterial embolization was performed to control intraoperative and postoperative bleeding.Histological examination confirmed the presence of a hydatidiform mole in uterine scar.After surgery,there was still a mass with heterogeneous intensity near the isthmus of the uterus on magnetic resonance imaging.The patient then underwent chemotherapy.During the 6-mo follow-up period,the mass disappeared and the serum human chorionic gonadotropin level gradually decreased to normal level.CONCLUSION We report a case of cesarean scar molar pregnancy successfully cured by comprehensive treatment.We found that cesarean scar molar pregnancy was subject to intraoperative bleeding,and uterine arterial embolization before surgery may be helpful.

MRI联合AMH、PAPP-A、β-HCG对剖宫产术后早期子宫瘢痕妊娠的评估价值研究

目的探究核磁共振(MRI)联合β-人绒毛膜促性腺激素(β-HCG)、血抗苗勒氏管激素(AMH)、妊娠相关血浆蛋白A(PAPP-A)对剖宫产术后早期子宫瘢痕妊娠(CSP)的评估价值。方法选取2021年12月至2023年12月我院收治的103例疑似剖宫产术后早期CSP患者,所有受试者均接受MRI检查,并检测其AMH、PAPP-A、β-HCG水平,以手术病理结果为标准,将其分为CSP组和非CSP组,采用受试者工作特征(ROC)曲线分析AMH、PAPP-A、β-HCG对剖宫产术后早期CSP的预测价值,以手术病理结果为标准,采用Kappa一致性检验分析MRI联合AMH、PAPP-A、β-HCG对剖宫产术后早期CSP的预测价值。结果CSP组AMH水平高于非CSP组,PAPP-A、β-HCG水平低于非CSP组(P<0.05);AMH、PAPP-A、β-HCG预测剖宫产术后早期CSP的曲线下面积(AUC)分别为0.780、0.751、0.884,其中β-HCG的AUC最大,敏感度为78.16%,特异度为87.50%(P均<0.05);四者联合诊断的准确率为91.26%,敏感度为94.25%,特异度为75%。结论MRI联合AMH、PAPP-A、β-HCG对剖宫产术后早期CSP具有较高的诊断价值,其且准确度高于单一指标。

3D-TAS联合3D-TVS检查在剖宫产术后瘢痕妊娠早期诊断及分型中的应用价值

目的评估经腹部三维超声(3D-TAS)联合经阴道三维超声(3D-TVS)检查在剖宫产术后瘢痕妊娠(CSP)患者早期诊断和分型中的应用价值。方法选取2020年3月至2023年3月洛阳市第一人民医院收治的疑似CSP者135例,均接受3D-TAS、3D-TVS检查,以术后病理作为“金标准”,分析3D-TAS、3D-TVS单独及联合检查在CSP者早期诊断和分型中的价值。结果135例疑似CSP患者中,术后病理证实CSP 100例(74.07%),非CSP 35例(25.93%)。且3D-TAS与3D-TVS联合检查诊断早期CSP的敏感度、准确率均明显高于3D-TAS、3D-TVS单独检查,而漏诊率、阴性预测值均明显低于3D-TAS、3D-TVS单独检查,差异均有统计学意义(P<0.05)。术后病理证实,100例CSP患者中Ⅰ型25例、Ⅱ型57例、Ⅲ型18例;3D-TAS、3D-TVS联合检查分型结果:Ⅰ型18例、Ⅱ型45例、Ⅲ型17例,分型检出率为80.00%(80/100),与病理结果CSP分型一致性检验较好(Kappa值为0.769,95%可信区间0.598~0.881,P<0.001)。结论3D-TAS、3D-TVS联合检查对CSP患者具有较高的早期诊断价值,并能为CSP分型诊断提供可靠依据,故可作为剖宫产术后再次妊娠患者筛查CSP的首选方式。

Ⅱ型子宫瘢痕妊娠术前HIFU和UAE预处理的比较研究

目的评估Ⅱ型子宫瘢痕妊娠(CSP)患者宫腔镜手术治疗前高强度聚焦超声(HIFU)或子宫动脉栓塞术(UAE)预处理的有效性及安全性。方法采用回顾性队列研究,选取2019年7月至2020年12月清远市人民医院收治的55例Ⅱ型CSP患者,观察组(24例)宫腔镜手术前采用HIFU,对照组(31例)宫腔镜手术前采用UAE,比较两组患者的术中风险、术后不良反应、术后月经复潮等情况。结果两组术中均未发生大出血、子宫穿孔、水中毒及宫内组织物残留,手术时间、术中出血量差异无统计学意义(P>0.05);观察组术后疼痛、发热的发生率明显低于对照组,但差异无统计学意义(P>0.05);观察组术后连续3次的月经量及月经中期子宫内膜厚度明显高于对照组,差异有统计学意义(P<0.05)。结论对于Ⅱ型CSP患者,宫腔镜术前HIFU或UAE预处理均安全有效,相比于UAE,HIFU联合宫腔镜手术对患者的子宫内膜损伤较小,生育功能影响的可能性小,更适用于有生育要求的患者。

A Recurrent Ectopic Pregnancy within A Previous Caesarean Scar: A Case Report

Objective To investigate the clinical diagnosis and treatment of caesarean scar pregnancy （CSP）. Methods We reported here a case of recurrent ectopic pregnancy within a previous cesarean scar and reviewed the literature. Results Surgical evacuation of a CSP was a small side effect and effective treatment of CSP. Conclusion Early and accurate diagnosis, timeliness and effective treatment were extremely important in saving patients＇ life and retaining their fertility.

剖宫产瘢痕妊娠保守治疗的相关危险因素Meta分析

目的：对剖宫产瘢痕妊娠（CSP）保守治疗的相关危险因素进行系统评价。方法：计算机检索Pubmed、Embase、Google、中国知网、维普、万方数据库,并辅以手工检索,检索时限2000~2013年,纳入研究的CSP为保守治疗失败的患者,其相关危险因素包括超声检查分型、胎血管搏动、治疗前血β-HCG值、年龄、孕周。采用Rev Man 5.0软件对纳入文献的数据进行Meta分析,计算相关危险因素的比值比（OR）及95%可信区间（CI）。结果：共筛选出相关文献8篇,中文文献2篇,英文文献6篇。保守治疗患者254例,失败82例,全部入选患者保守治疗失败率32.28%。Meta分析结果显示：包块型CSP（Z=3.46,OR=0.19,95%CI 0.07~0.48,P=0.0005）为保守治疗失败的危险因素,而高龄孕产妇、治疗前可探及胎血管搏动、血β-HCG值〉20000 U/L及孕周≥8周为CSP保守治疗失败的不确定因素（P〉0.05）。结论：包块型CSP显著增加治疗过程中严重并发症的发生而导致保守治疗失败,建议对CSP患者治疗前行超声检测评估分型,以避免严重并发症的发生。

子宫动脉化疗栓塞治疗瘢痕妊娠的Meta分析

目的评价子宫动脉化疗栓塞术(uterine artery chemoembolization,UACE)与甲氨蝶呤肌内注射(methotrexate,MTX)系统治疗相比,在治疗剖宫产子宫瘢痕部位妊娠(cesarean scar,CSP)方面的有效性和安全性。方法检索国内外的数据库Cochrane图书馆、PubMed、EMBASE、中国生物医学文献数据库、CNKI、维普中文科技期刊数据库和万方数据库,纳入有关子宫动脉化疗栓塞术治疗瘢痕妊娠的随机对照试验(randomized controlled trial,RCT),评价文献的方法学质量,并采用Revman 5.0软件进行Meta分析。结果共纳入19项研究,913名病例。Meta分析结果显示:UACE与MTX全身治疗相比,成功率、术中出血量、血β-HCG降到正常时间、住院时间、严重合并症,差异均具有统计学意义(P<0.05);而轻度不良反应、住院费用的比较,差异无统计学意义(P>0.05)。结论 UACE治疗CSP的疗效优于系统MTX治疗,且UACE联合清宫具有术中出血量、严重合并症少,血β-HCG降到正常时间短,住院时间短的优点,值得临床推广。由于综合分析的试验数量较少、质量不高,影响了结果的可靠性,仍需大样本,多中心的临床随机对照试验来进一步完善,才能更好地客观评价UACE技术。