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.

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.

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.

Reliable clinical and sonographic findings in the diagnosis of abdominal wall endometriosis near cesarean section scar

AIM: To highlight sonographic and clinical characteristics of scar endometrioma with special emphasis on size-related features. METHODS: Thirty women (mean age 30.6 years, range 20-42 years) with 33 scar endometriomas (mean diameter 27.1 mm, range 7-60 mm) were consecutively studied by Sonography and Color Doppler examination prior to surgery. Pathological examination was available in all cases. RESULTS: The most frequent (24 of 33 nodules, 74%) sonographic B-mode aspect of endometrioma was that of an inhomogenously hypoechoic roundish nodule with fibrotic changes (in the form of hyperechoic spots or strands), a peripheral inflammatory hyperechoic ring, spiculated margins and a single vascular pedicle entering the mass at the periphery. On average, 1.6 cesarean sections were recorded per patient (range 1-3). The median interval between the last cesarean section and admission to hospital was 36 mo (range 12-120 mo) and the median duration of symptoms before admission was 25.7 mo (range 0.5-80 mo). 13 patients had 13 large endometriomas (≥ 30 mm) with a mean lesion diameter of 41.3 ± 9.02 mm (range 30-60 mm). Seventeen women had 20 small endometriomas with a mean lesion size of 18.2 ± 5.17 mm (range 7-26 mm). The mean interval between the last cesarean section and admission to hospital (66.0 mo vs 39.6 mo, P < 0.01) and the mean duration of symptoms before admission (43.0 mo vs 17.4 mo, P < 0.01) were significantly longer in patients with large endometriomas; in addition, a statistically significant higher percentage of patients with large implants had undergone previous inconclusive diagnostic examinations, including either computed tomography/magnetic resonance imaging/fine needle biopsy/laparoscopy (38.4% vs 0%, P < 0.05). On sonography, large endometriomas showed frequent cystic portions and fistulous tracts (P < 0.02), loss of round/oval shape (P < 0.04) along with increased vascularity (P < 0.04). CONCLUSION: Endometrioma near cesarean section scar is an often neglected disease, but knowledge of its clinical and sonographic findings may prevent a delay in diagnosis that typically occurs in patients with larger (≥ 3 cm) endometriomas.

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.

Using laparoscopy and hysteroscopy to treat cesarean scar defects:A systematic review and meta-analysis

Objective:Rising cesarean section rates have led to an increase in cesarean scar defects.However,there is no consensus regarding the gold standard for treating cesarean scar defects.This study aims to compare the efficacy of laparoscopy combined with hysteroscopy and hysteroscopy in treating cesarean scar defects.Methods:An electronic search of the MEDLINE,EMBASE,and Clinical Trials.gov databases was conducted in May 2020,utilizing combinations of relevant medical subject headings for“cesarean scar defect”,“laparoscope”,and“hysteroscope”.Reference lists of relevant articles and reviews were hand-searched for additional reports.Observed outcomes included menstruation after surgery,blood loss,operative time,and further fertility.Results:Eight studies with 467 patients were included.The menstruation duration after surgery for the laparoscopy combined with hysteroscopy group and hysteroscopy group was comparable.While the laparoscopy combined with hysteroscopy group trended to have less blood loss(mean difference 49.60,95%CI:42.12e57.09,p<0.05)and shorter operative time(mean difference 60.40,95%CI:53.33e67.48,p<0.05)compared to hysteroscopy group.And 26 out of 51 patients were able to achieve pregnancy for those choosing the laparoscopy combined with hysteroscopy.Conclusions:Patients with cesarean scar defect should choose the appropriate technique considering their age,residual myometrial thickness,desire for further fertility,and gynecological inflammation.The current study lacked evidence to prove that laparoscopy combined with hysteroscopy is superior to hysteroscopy.

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.

Uterine artery embolization in cesarean scar pregnancy： safe and effective intervention

Background Cesarean scar pregnancy （CSP） is a very rare but life-threatening entity and there is no optimal management strategy.Here we report a successfully conservative treatment of CSP.Methods We retrospectively analyzed the clinical data of 54 women with CSP,who underwent uterine artery embolization between January 2007 and September 2012 at the Peking University People＇s Hospital.We evaluated the clinical outcomes,the technique and the complications of uterine artery embolization.Results Of the 54 patients,2 patients with hemorrhage after induced abortion received bilateral uterine artery embolization treatment alone,and 52 patients underwent suction curettage after bilateral uterine artery embolization.All 54 women were successfully cured,without any severe complications,and uterine function was restored.During the follow-up,one patient had accidental normal interuterine pregnancy and received induced abortion during the first trimester.Conclution Uterine artery embolization combined with suction curettage is an effective and safe conservative treatment for cesarean scar pregnancy.

Expectant management of heterotopic cesarean scar pregnancy

Background Heterotopic cesarean scar pregnancy （HCSP） is a very rare but life-threatening entity and there is no optimal management strategy. Here we report a successfully managed case of HCSP with expectant treatment in a tertiary referral hospital. Methods A woman with HCSP after in vitro fertilization-embryo transfer opted for expectant treatment after five days of mild bleeding and ultrasound demonstrated cardiac activity disappearance of the scar pregnancy at 8＋4 weeks of gestation. Results The patient had mild to moderate bleeding during close monitoring. Three days later, speculum examination revealed the gestational mass was partly protruding at the os of the cervix and it was removed with forceps without massive hemorrhage. A healthy male baby was delivered by cesarean section at gestational age of 36＋4 weeks. Conclusions The expectant method might be an alternative option for a HCSP with loss of cardiac activity of the scar pregnancy, when applied under supportive management and with available emergency surgery facilities.

Uterine artery embolization in the treatment of recurrent cesarean scar pregnancy: report of two cases and literature review

Despite the optimal therapeutic protocols of cesarean scar pregnancy （CSP） has not been established, and in the majority of cases, most of women＇s uterus and fertility can be preserved through prompt and active treatment. But due to the rarity of CSP, little is known about the outcome of subsequent pregnancies, especially in an even rarer situation, a recurrent CSP. We report 2 cases of recurrent CSP women who want to preserve their fertility treated by repeated uterine artery embolization and provide a review of the literatures.

Uterine Arteriovenous Malformation:Inducedby A Cesarean Scar Pregnancy

Cesarean scar pregnancy （CSP） occurs when a gestation sac is implanted in the previous lower segment cesarean scar. The incidence of CSP is increasing worldwide. Uterine ateriovenous malformation （UA VM） is a rare gynecologic disease. Both of these diseases can cause severe vaginal bleeding and produce high morbidity rate. We describe a ease of UA VM induced by a CSP. The patient suffered intermittent vaginal bleeding after two dilatation and curettage （D＆C） one month before admission. The suspected diagnosis of CSP and UA VM were made after using transvaginal ultra- sound with color Doppler and human chorionic gonadotropin （hCG） examination. Resection of the involved area including the cesarean scar and UA VM by laparotomy was performed successfully and the diagnosis was confirmed by the last pathologic result.

Successful Pregnancy by In Vitro Fertilization after Bilateral Uterine Arterial Embolization for Cesarean Scar Pregnancy:A Case Report

A 35-year-old woman who had one delivery by cesarean section got pregnant again. Color Doppler flow imaging and Magnetic resonance imaging （MRI） showed a cesarean scar pregnancy （CSP）. Uterine arterial embolization （UAE） and curettage was performed successfully to terminate the pregnancy. Six months after the curettage, the patient＇s menstrual flow was reduced to one non-drenched sanitary pad per day for only 1-2 d, every 30 d. The patient underwent hysterosalpingography （HSG）, which suggested the presence of a filling-defect of the left uterine cavity, with obstructed bilateral Fallopian tubes. The patient subsequently underwent lysis of adhesions by hysteroscopy plus an exploratory laparoscopy, under general anesthesia. Her men- struation gradually increased to 5-7 d every 30 d. As the patient did not become pregnant during the first year after surgery, she underwent in vitro fertilization （IVF） treatment and a repeat ultrasound showed a somewhat thin endometrial line. At last, the patient got pregnant and gave birth to a live baby by IVF.

Comparison of Five Treatment Strategies for Cesarean Scar Pregnancy

Objective:To explore appropriate treatment strategy for cesarean scar pregnancy(CSP)in the first and second trimester.Methods:Clinical characteristics and treatment strategies in 182 patients with CSP were retrospectively analyzed.Treatment strategies were as follows:Group A(n=102),uterine artery chemoembolization(UACE)followed by dilation and curettage(D&C);Group B(n=63),D&C;Group C(n=6),hysteroscopy;Group D(n=6),laparotomy;and Group E(n=5),laparoscopy.The basic clinical findings were collected and analyzed,along with the curative effects.Results:The preoperative serum beta-human chorionic gonadotropin(β-HCG)level was in the order of Group D,A>B,C>E(P=0.001);the size of gestational sac(GS)was in the order of Group D,E>A,C>B(P=0.000);and the thickness of the anterior myometrium was in the order of Group B>A,C>D,E(P=0.000).Three cases in the second trimester were all in Group D;two cases were treated with UACE before laparotomy with moderate blood loss(100 and 200 mL,respectively)and the third case was initially treated with D&C and had severe hemorrhage.Conclusions:The diameter of GS,thickness of the anterior myometrium,and preoperativeβ-HCG level are important factors for the choice of treatment.UACE combined with D&C is a useful measure for most Type 2 CSP cases in the first trimester.For Type 2 CSP cases in the second trimester,UACE before laparotomy could be a reasonable choice.

Correlation Questions Clinical Discussion of Uterine Artery Embolization in Induced Abortion Patients with Management of Cesarean Scar Pregnancy

Objective To analyze retrospectively the utility of uterine arterial embolization （UAE） for cesarean scar pregnancy （CSP）.Methods Fifty-one women with CSP were pretreated with UAE before dilatation ＆ curettage （D＆C）. Indexes such as blood loss volume, operation-associated complications, serum hCG level ultrasound imaging and hospitalization cost were analyzed.Results Thirty-eight women accepted D＆C following UAE （group A）, 10 patients had medicine （3 took trichosanthin injection, 7 took MTX injection） before UAE and D＆C （group B）. Uterine packing following emergency UAE were performed in another 3 women due to severe hemorrhage during direct curettage without pretreatment （group C）. There were no statistically significant differences between group A and group B about the serum fl-hCG level resolution time and the blood loss in the opertation. Patients had shorter duration of hospital stay （P〈0.01） and cheaper cost of hospitalization （P〈0.05） of group A than group B.Conclusion Pretreatment with UAE before curettage is safe and effective in terminating CSP, reducing hospitalization cost. UAE followed by curettage is recommended to medical facilities where UAE is available.

Cesarean Scar Pregnancy with Iniencephaly and Progression to Placenta Accreta Due to Early Management Rejection

To editor:Cesarean scar pregnancy(CSP)is a rare pathology,with an increasingly clear association with morbidly adherent placenta(MAP).1 Although the most recommended treatment is pregnancy termination by cesarean section and scar resection shortly after diagnosis.2 The final decision regarding management depends on the patient's choice,medical advice,the fertility desire,and the social,religious and emotional background that should also be taken into account.

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.