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    Cesarean scar pregnancy diagnosis and management

    Dr Timor-Tritsch is Professor of Obstetrics and Gynecology at New York University School of Medicine and Director of Ob/Gyn Ultrasound in the Department of Obstetrics and Gynecology, New York University School of Medicine, New York, New York.

    Dr Monteagudo is Professor of Obstetrics and Gynecology at New York University School of Medicine and MFM Associate at Carnegie Hill Imaging, New York, New York.

    Dr Kaelin Agten is a Research Fellow in the Division of Obstetrical and Gynecological Ultrasound, New York University School of Medicine, New York, New York.

    None of the authors has a conflict of interest to report in respect to the content of this article.

    A 27-year-old G3P011 with one previous cesarean delivery was referred for vaginal bleeding from an outpatient facility where a radiologist, based upon a transabdominal ultrasound scan, reported a “missed abortion” at 9 weeks and some concern for a cesarean scar pregnancy (CSP). On transvaginal ultrasound (TVS) done by the ob/gyn resident, an intrauterine pregnancy was diagnosed that was consistent with dates without fetal heart beats and with evidence of a retroplacental hematoma. The patient’s hematocrit was 11g/dL.

    A D&C was performed due to active bleeding with an estimated blood loss of 1000 mL. A repeat transvaginal scan showed “ballooning of the lower uterine segment” but no evidence of perforation. The bleeding was unresponsive to tamponade by Foley balloon catheter inflated high in the cavity and “medical measures.” A repeat D&C was performed also without abatement of bleeding, now estimated at 2000 mL. An exploratory laparotomy was initiated, during which a normal-appearing anterior uterus and a ballooning lower posterior uterine segment with an area of dusky discoloration were noted.

    Heavy vaginal bleeding was still noted, which led to a total abdominal hysterectomy. Intraoperatively the patient received 3 units of packed red blood cells and 1 unit of fresh frozen plasma. An arterial line was placed and her intraoperative vital signs stabilized. She received additional blood products but was discharged on postoperative day 2 in stable condition with normal blood pressure and heart rate. The pathologist first reported a cervical ectopic pregnancy. However, after a re-reading by a senior pathologist, the diagnosis was changed to a CSP.

    CSP is a serious, iatrogenic consequence of a previous cesarean delivery. Unrecognized or left untreated, CSP can lead to clinical complications in all 3 trimesters of pregnancy. The above case is an example of how a misdiagnosis can lead to loss of the uterus. The rising incidence of CSP parallels the increasing rate of cesarean deliveries as well as that of morbidly adherent placenta. A CSP arises if a blastocyst implants in a microscopic or macroscopic tract on the uterine scar or in a niche or dehiscence left behind by the previous cesarean delivery.1

    History

    In the United States, cesarean deliveries increased steadily from 5% in 1970 to 32.9% in 2009.2,3 Recently, a leveling off of cesarean delivery rates has been reported.3 Unfortunately, CSPs are often misdiagnosed as “abortions in progress,” “ectopic pregnancies,” and “cervical pregnancies.” When the usual treatments such as D&C and systemic methotrexate (MTX) are used, profuse vaginal bleeding can be stopped only by hysterectomy.5 We have reported a complication rate of 44.1%,5 mainly secondary to missed diagnoses and potentially inappropriate treatments that caused heavy bleeding. In our series, there were 76 emergency laparotomies, 36 hysterectomies, 22 primary uterine artery embolizations (UAE), 49 secondary UAEs, as well as 14 laparotomies, and 3 hysterectomies, performed electively. Hence, CSP is a serious and potentially dangerous clinical entity.5 Despite increasing clinical data, there is still no agreed-upon management protocol for CSP.

    Incidence and risk factors

    The true incidence of CSP is unknown, however, estimates are that it follows 1 in 1800 to 1 in 2500 of all cesarean deliveries performed.6-9 It is estimated that 0.15% of all pregnancies with a history of a previous cesarean delivery will be followed by a CSP in the woman’s next pregnancy.10 The only known risk factor for CSP is prior cesarean delivery.

    NEXT: Pathogenesis

    Ilan E Timor-Tritsch, MD
    Dr Timor-Tritsch is Professor of Obstetrics and Gynecology at New York University School of Medicine and Director of Ob/Gyn Ultrasound ...
    Ana Monteagudo, MD
    Dr Monteagudo is Professor of Obstetrics and Gynecology at NewYork University School of Medicine and MFM Associate at Carnegie Hill ...
    Andrea Kaelin Agten, MD
    Dr Kaelin Agten is a Research Fellow in the Division of Obstetrical and Gynecological Ultrasound, New York University School of ...

    2 Comments

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    • christinaHemming
      Perhaps double suturing of the uterus would help prevent pregnancy within the scar line of the uterus. Has this been observed? Binding post surgery would also help reduce improper scarring. Find information on csectionrecoverykit.com Thank you
    • Dr. John Gililland
      I enjoyed reading the article "Cesarean scar pregnancy management and diagnosis" and have a couple of comments regarding its content. I realize the focus of the article was about managing CSP's (the "cat out of the bag") and undoubtedly the length of the article was restricted by the journal. However, the omission of the topic of isthmoceles following C-section as a precursor to CSP was disappointing. At a recent ASRM meeting, there was a presentation about this topic and I was amazed at the number of REI's who were unfamiliar with the term and with its management. In our own practice, we've seen several patients with isthmoceles discovered either during a saline infusion transvaginal ultrasound examination (SIS), or during a stimulation cycle with accumulation of mucus in the endometrial cavity, the latter as a result of diversion of cervical mucus in a retrograde fashion. I have never seen anything written, yet, about the incidence of CSP with isthmoceles and that information could be very useful in counseling these patients prior to conception. Perhaps one could evaluate patients with prior C-sections, contemplating another pregnancy, with an SIS prior to conception to identify isthmoceles. In this fashion, one could get an estimate of the prevalence of isthmoceles and also be in a position to advise those patients with regard to repair of the defect. One other related topic might be a brief discussion about the closure of C-section incisions and the importance of a careful, full thickness closure and possibly a double layer closure to avoid the development of an isthmocele its potential devastating consequences.

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