Cesarean Scar Pregnancy
81
Cesarean Scar Pregnancy Aboubakr Elnashar Benha university Hospital, Egypt Aboubakr Elnashar
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Transcript of Cesarean Scar Pregnancy
Cesarean Scar Pregnancy Aboubakr Elnashar
Benha university Hospital Egypt
Aboubakr Elnashar
Aboubakr Elnashar
1 INTRODUCTION Define
Prevalence
Pathogenesis Complications
2 DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
3 MANAGEMENT
FOLLOW-UP
4 PREVENTION
SUMMARY
1 INTRODUCTION
Define
GS implanted in the myometrium at the site of a
previous CS scar
The first case 1978
Terminology
cesarean scar pregnancy Ectopic pregnancy in a Caesarean scar cesarean ectopic pregnancy cesarean scar ectopic MXT as in tubal ectopic pregnancies failed but disastrous
Aboubakr Elnashar
Prevalence Rare
Rising
1 increased incidence of CS
72 of CSP occur in women who have had ge2CS
2 increased use of TVS
Aboubakr Elnashar
Aboubakr Elnashar
Pathogenesis Prior CS fibrous scar tissue with a wedge-shaped myometrial defect Pregnancy Blastocyst implants on fibrous scar Multiple CS increase scar surface area increase the risk of implantation on the scar
Aboubakr Elnashar
The myometrial defect Develops after CS D ampC Myomectomy Metroplasty Hysteroscopy Manual removal of the placenta Due to 1 incomplete healing 2 increased fibrosis
Aboubakr Elnashar
Complications plusmndevastating
Placenta previaaccreta
Uterine rupture
Massive hge
increased maternal morbidity and mortality
Aboubakr Elnashar
2 DIAGNOSIS Time of presentation
At any time from implantation to term More commonly in 1st T
1 Vag bleeding and abd pain common
2 Asymptomatic 13
Aboubakr Elnashar
Degrees
1 Severe
little or no myometrium overlying GS
usually diagnosed in 1st T
Hge and ut rupture if untreated
2 Less severe
often diagnosed in 2nd and 3rd T as PA
plusmn normal live births but with increased
maternal morbidity
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Aboubakr Elnashar
1 INTRODUCTION Define
Prevalence
Pathogenesis Complications
2 DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
3 MANAGEMENT
FOLLOW-UP
4 PREVENTION
SUMMARY
1 INTRODUCTION
Define
GS implanted in the myometrium at the site of a
previous CS scar
The first case 1978
Terminology
cesarean scar pregnancy Ectopic pregnancy in a Caesarean scar cesarean ectopic pregnancy cesarean scar ectopic MXT as in tubal ectopic pregnancies failed but disastrous
Aboubakr Elnashar
Prevalence Rare
Rising
1 increased incidence of CS
72 of CSP occur in women who have had ge2CS
2 increased use of TVS
Aboubakr Elnashar
Aboubakr Elnashar
Pathogenesis Prior CS fibrous scar tissue with a wedge-shaped myometrial defect Pregnancy Blastocyst implants on fibrous scar Multiple CS increase scar surface area increase the risk of implantation on the scar
Aboubakr Elnashar
The myometrial defect Develops after CS D ampC Myomectomy Metroplasty Hysteroscopy Manual removal of the placenta Due to 1 incomplete healing 2 increased fibrosis
Aboubakr Elnashar
Complications plusmndevastating
Placenta previaaccreta
Uterine rupture
Massive hge
increased maternal morbidity and mortality
Aboubakr Elnashar
2 DIAGNOSIS Time of presentation
At any time from implantation to term More commonly in 1st T
1 Vag bleeding and abd pain common
2 Asymptomatic 13
Aboubakr Elnashar
Degrees
1 Severe
little or no myometrium overlying GS
usually diagnosed in 1st T
Hge and ut rupture if untreated
2 Less severe
often diagnosed in 2nd and 3rd T as PA
plusmn normal live births but with increased
maternal morbidity
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
1 INTRODUCTION
Define
GS implanted in the myometrium at the site of a
previous CS scar
The first case 1978
Terminology
cesarean scar pregnancy Ectopic pregnancy in a Caesarean scar cesarean ectopic pregnancy cesarean scar ectopic MXT as in tubal ectopic pregnancies failed but disastrous
Aboubakr Elnashar
Prevalence Rare
Rising
1 increased incidence of CS
72 of CSP occur in women who have had ge2CS
2 increased use of TVS
Aboubakr Elnashar
Aboubakr Elnashar
Pathogenesis Prior CS fibrous scar tissue with a wedge-shaped myometrial defect Pregnancy Blastocyst implants on fibrous scar Multiple CS increase scar surface area increase the risk of implantation on the scar
Aboubakr Elnashar
The myometrial defect Develops after CS D ampC Myomectomy Metroplasty Hysteroscopy Manual removal of the placenta Due to 1 incomplete healing 2 increased fibrosis
Aboubakr Elnashar
Complications plusmndevastating
Placenta previaaccreta
Uterine rupture
Massive hge
increased maternal morbidity and mortality
Aboubakr Elnashar
2 DIAGNOSIS Time of presentation
At any time from implantation to term More commonly in 1st T
1 Vag bleeding and abd pain common
2 Asymptomatic 13
Aboubakr Elnashar
Degrees
1 Severe
little or no myometrium overlying GS
usually diagnosed in 1st T
Hge and ut rupture if untreated
2 Less severe
often diagnosed in 2nd and 3rd T as PA
plusmn normal live births but with increased
maternal morbidity
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Prevalence Rare
Rising
1 increased incidence of CS
72 of CSP occur in women who have had ge2CS
2 increased use of TVS
Aboubakr Elnashar
Aboubakr Elnashar
Pathogenesis Prior CS fibrous scar tissue with a wedge-shaped myometrial defect Pregnancy Blastocyst implants on fibrous scar Multiple CS increase scar surface area increase the risk of implantation on the scar
Aboubakr Elnashar
The myometrial defect Develops after CS D ampC Myomectomy Metroplasty Hysteroscopy Manual removal of the placenta Due to 1 incomplete healing 2 increased fibrosis
Aboubakr Elnashar
Complications plusmndevastating
Placenta previaaccreta
Uterine rupture
Massive hge
increased maternal morbidity and mortality
Aboubakr Elnashar
2 DIAGNOSIS Time of presentation
At any time from implantation to term More commonly in 1st T
1 Vag bleeding and abd pain common
2 Asymptomatic 13
Aboubakr Elnashar
Degrees
1 Severe
little or no myometrium overlying GS
usually diagnosed in 1st T
Hge and ut rupture if untreated
2 Less severe
often diagnosed in 2nd and 3rd T as PA
plusmn normal live births but with increased
maternal morbidity
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Aboubakr Elnashar
Pathogenesis Prior CS fibrous scar tissue with a wedge-shaped myometrial defect Pregnancy Blastocyst implants on fibrous scar Multiple CS increase scar surface area increase the risk of implantation on the scar
Aboubakr Elnashar
The myometrial defect Develops after CS D ampC Myomectomy Metroplasty Hysteroscopy Manual removal of the placenta Due to 1 incomplete healing 2 increased fibrosis
Aboubakr Elnashar
Complications plusmndevastating
Placenta previaaccreta
Uterine rupture
Massive hge
increased maternal morbidity and mortality
Aboubakr Elnashar
2 DIAGNOSIS Time of presentation
At any time from implantation to term More commonly in 1st T
1 Vag bleeding and abd pain common
2 Asymptomatic 13
Aboubakr Elnashar
Degrees
1 Severe
little or no myometrium overlying GS
usually diagnosed in 1st T
Hge and ut rupture if untreated
2 Less severe
often diagnosed in 2nd and 3rd T as PA
plusmn normal live births but with increased
maternal morbidity
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Pathogenesis Prior CS fibrous scar tissue with a wedge-shaped myometrial defect Pregnancy Blastocyst implants on fibrous scar Multiple CS increase scar surface area increase the risk of implantation on the scar
Aboubakr Elnashar
The myometrial defect Develops after CS D ampC Myomectomy Metroplasty Hysteroscopy Manual removal of the placenta Due to 1 incomplete healing 2 increased fibrosis
Aboubakr Elnashar
Complications plusmndevastating
Placenta previaaccreta
Uterine rupture
Massive hge
increased maternal morbidity and mortality
Aboubakr Elnashar
2 DIAGNOSIS Time of presentation
At any time from implantation to term More commonly in 1st T
1 Vag bleeding and abd pain common
2 Asymptomatic 13
Aboubakr Elnashar
Degrees
1 Severe
little or no myometrium overlying GS
usually diagnosed in 1st T
Hge and ut rupture if untreated
2 Less severe
often diagnosed in 2nd and 3rd T as PA
plusmn normal live births but with increased
maternal morbidity
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
The myometrial defect Develops after CS D ampC Myomectomy Metroplasty Hysteroscopy Manual removal of the placenta Due to 1 incomplete healing 2 increased fibrosis
Aboubakr Elnashar
Complications plusmndevastating
Placenta previaaccreta
Uterine rupture
Massive hge
increased maternal morbidity and mortality
Aboubakr Elnashar
2 DIAGNOSIS Time of presentation
At any time from implantation to term More commonly in 1st T
1 Vag bleeding and abd pain common
2 Asymptomatic 13
Aboubakr Elnashar
Degrees
1 Severe
little or no myometrium overlying GS
usually diagnosed in 1st T
Hge and ut rupture if untreated
2 Less severe
often diagnosed in 2nd and 3rd T as PA
plusmn normal live births but with increased
maternal morbidity
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Complications plusmndevastating
Placenta previaaccreta
Uterine rupture
Massive hge
increased maternal morbidity and mortality
Aboubakr Elnashar
2 DIAGNOSIS Time of presentation
At any time from implantation to term More commonly in 1st T
1 Vag bleeding and abd pain common
2 Asymptomatic 13
Aboubakr Elnashar
Degrees
1 Severe
little or no myometrium overlying GS
usually diagnosed in 1st T
Hge and ut rupture if untreated
2 Less severe
often diagnosed in 2nd and 3rd T as PA
plusmn normal live births but with increased
maternal morbidity
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
2 DIAGNOSIS Time of presentation
At any time from implantation to term More commonly in 1st T
1 Vag bleeding and abd pain common
2 Asymptomatic 13
Aboubakr Elnashar
Degrees
1 Severe
little or no myometrium overlying GS
usually diagnosed in 1st T
Hge and ut rupture if untreated
2 Less severe
often diagnosed in 2nd and 3rd T as PA
plusmn normal live births but with increased
maternal morbidity
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Degrees
1 Severe
little or no myometrium overlying GS
usually diagnosed in 1st T
Hge and ut rupture if untreated
2 Less severe
often diagnosed in 2nd and 3rd T as PA
plusmn normal live births but with increased
maternal morbidity
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Difficult
Missed in 15
DampC for ldquotermination of an early pregnancyrdquo
or DampC for missed abortion
heavy bleeding
Shock
hemoperitoneum
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Sonography
TA
Panoramic view of the pelvis and uterus
Inspection of the interface between the anterior
LUS and bladder then
TV
Reference standard in 1st T Sensitivity 864 Sagittal view along the long axis of the uterus
through the plane of GS localize GS within the
anterior LUS
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Sonographic criteria in 1st T
1 Uterus
empty with a clearly visualized endometrium
2 Cervix
Empty
3 GS
within the anterior portion of LUS
at site of the cesarean scar
4Myometrium between GS and bladder
Thin or absent lt5 mm in 23 of cases
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
5 Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis 30-40
low-impedance (pulsatility lt1) high-velocity flow (gt20 cms) Resistive index lt 05 Peak systolic to diastolic blood flow ratio lt 31
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Low intrauterine pregnancies
Miscarriage in progress Cervical pregnancy
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
CSP at 6 w
GS in the anterior LUS at the site of the uterine scar
Uterus empty(thin arrows
Cervix empty(long arrows) canals
myometrium between GS and bladder (short arrows) thin
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Transverse TVS color Doppler flow around G S
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Empty uterine cavity with
GS(arrow) between cavity
and cervix (Cx)
Power Doppler of blood
vessels surrounding GS
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Triangular shape of GS (on sagittal plane) assuming shape of niche GS embedded in scar Thin (1-3 mm) or lack of myometrium (arrow) between sac and bladder
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Previous CS Vag bleeding Positive serum BHCG test Prominent richly vascular area in site of scar highlighted by power Doppler in patient Arrows point to vascular malformation Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
CSP at 9 w 5 d Sagittal (A) and transverse (B) TVS GS in the anterior LUS with thinning of the overlying anterior myometrium (A arrow) The fundus (f) and cervical canals are empty
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
CSP at 12 W Sagittal (A and B) and transverse (C) TAS GS in the anterior LUS There is thinning of the overlying anterior myometrium (short arrows) The endometrial (thin arrow) and cervical (long arrow) canals are empty
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
MRI Indication 1 US is equivocal or inconclusive before
intervention or therapy 2 To measure the lesion volume to help assess
the indication for and success of local MTX tt
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Sagittal coronal and transverse sections of T1- and T2-weighted sequences 1 GS embedded in the anterior LUS 2 Pelvic anatomy intraoperative orientation myometrial invasion and bladder involvement T1 fat bright fluid dark T2 fat intermediate-bright fluid bright
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
CSP at 9 w Sagittal T2 MRI implantation of GS in the anterior LUS with bulging of the anterior contour and thinning of the myometrium between GS and bladder (long arrows) The endometrial and cervical canals are empty (A and B) CS scar is shown in the anterior lower abdominal wall (short arrows) The patient was successfully treated with systemic MTX and TVS guided injection of Kcl B indicates bladder and U uterus
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
CSP at 12 w Sagittal (Aand C) and coronal (B) T2-weighted MRI enlarged uterus (U) with GS within the anterior LUS a thinned myometrium between GS and bladder with a suspicion of the placenta protruding through the serosa (long arrows) The endometrial and cervical canals are empty (A) The cesarean scar is shown in the anterior lower abdominal wall (short arrows) The patient went on to have a hysterectomy which revealed a very thin overlying myometrium with placental tissue protruding through the amniotic membrane anteriorly adherent to the bladder (B) Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
DIFFERENTIAL DIAGNOSIS Failed pregnancy Cx ectopic CSP
within the cervical canal anterior LUS 1 GS
normal thin 2 Overlying anterior
myometrium
positive negative 3 Sliding organ sign
lack color flow vascular flow
around and within
the GS
marked
peritrophoblastic
color Doppler flow
around GS
4 Doppler
Not fixed in
location not
growing
plusmngrowing 5 Short follow up
US
Gentle pressure with the TV probe displace GS from its
position within the endocervical canal
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Cervical ectopic pregnancy Sagittal TAS of the midline uterus (A) GS centered in the endocervical canal normal myometrial thickness between GS and bladder (arrow) Sagittal and TVS of the endocervical canal (B and C) with vascular flow around and within the GS on color Doppler ( C) Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Cervical ectopic pregnancy GS is seen within the cervical canal myometrium is not thinned out as seen in LSCS scar pregnancy
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Failed pregnancy TV color Doppler sagittal midline
cervix avascular GS centered within the endocervical
canal Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
3 MANAGEMENT Objective
eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion
most effective
least or no complications
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Timor-Tritsch et al 2014 Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Treatment should be individualized based on
1 Patientrsquos age
2 Number of children
3 Number of previous CS
4 Anterior uterine wall thickness
when the trophoblast reaches the bladder-
uterine space Non surgical tt
5 Expertise of the clinicians
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Gynecologic surgeons laparoscopy and hysteroscopy or laparotomy Obstetricians radiologists and IVF specialists IM MTX or US local MTX (or Kcl) UAE occasionally
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Counseling of the patient
Immediate and decisive action to prevent further
growth of the embryo or fetus
Options
1 Continuation of the pregnancy
Successful births
uneventful term pregnancy poor
Hysterectomy rate 71
increased risk of placenta previaaccreta and
massive hge
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
2 Termination of the pregnancy in 1st T
Substantial hge 20-40
Hysterectomy substantially lower
Termination Recommended particularly when
Early evidence of progression toward the abdominal
cavity or bladder
increased risk of life-threatening complications and
loss of fertility
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Potential complications
751 cases reviewed 218 resulted in major surgery or interventional
radiology procedures (primary or emergency) The total planned primary (nonemergency) interventions performed were 66 (87) which included 3 hysterectomies 14 laparotomies and 49 uterine artery embolizations or ligations There were 98 (130) emergency interventions which included 36 hysterectomies 40 laparotomies and 22 uterine artery embolizations or ligations (Timor-Tritsch et al 2014)
(Immediate or delayed) Need secondary tt for blood loss ge200 mL or blood transfusion Complications are most often when the following
tt used alone
bull Single IM MTX
bull DampC
bull UAE Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
lowest complication rate
1 Local and US directed MTX injection with or
without additional IM MTX
2 Surgical excision by hysteroscopic guidance
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Management approaches I Surgical Excision Laparotomy or Hysterectomy or Laparoscopic or Hysteroscopic followed by DampC II Minimally invasive local injection of MTX or Kcl or UAE in combination with IM MTX Medical tt alone not recommended
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Medical 1 Systemic single-dose MTX 1 mgkg or 50 mgm2 of body surface area complication rate 646 second tt when the fetal heart beat did not cease after several days
High failure rate slow action and questionable ability to stop cardiac activity and placental expansion The expected result can take days and all the while GS the embryo or fetus and its vascularity are growing Secondary tt has to address a larger gestation with more abundant vascularization
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Systemic MTX as a single tt should be avoided 1 Waiting days for its effect to stop the heart beats which may not happen 2 It also led to the additional growth of the embryofetus as well as the vascularization of GS 3 Wastes precious time
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
2 Systemic multidose sequential MTX Two to three IM (1 mgkg BW or 50 mgmm2 of surface area) at an interval of 2 or 3 days over the course of a week
Cumulative adverse effects on the liver and bone marrow Success rate 75 Hysterectomy 6 Best results βHCG le 5000 mUmL Fibrous tissue within the scar around GS can delay systemic MTX absorption into GS Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Minimally invasive
1 Intragestational-sac injection of MTX or Kcl
with US guidance
Indications
hemodynamically stable
unruptured CSP
le8w gestation
myometrial thickness between GS and bladder
le 2 mm
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Approach
TV approach is favored over TA
1 better visualization of the needle 2 shorter distance to reach the sac 3 decreased risk of bladder injury TAS guidance slighter higher complication rate (15) than those
using TVS guidance
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Steps
1 After confirming the placement of needle 25 mg
of MTX in 1 mL of solution is injected slowly in
the GS
2 25 mg is injected outside GS as the needle is
withdrawn preferably the placental site
3 TVS 60-90 m after the procedure confirm
cessation of FH and to identify local bleeding
4 IM of 25 mg MTX (for a total combined dose of
75 mg) before discharge from our unit
5 24-48 h follow-up scan Close monitoring
hge may still occur
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
TVS -guided intragestational-sac injection of MTX in a
live CSP at 6 w 4 days The arrow points to the needle
in place (F = fetus) Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Advantages
No anesthesia
Complications fewest 108
most effective intervention
decrease the need for additional interventions
provides a higher concentration of the
embryocide locally
avoidance of systemic side effects
more rapid interruption of the pregnancy
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP (Kong et al 2014)
Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
2 Use of a Foley balloon catheter
Indications
1 Alone (usually in gestations of 5ndash7 w) in the
hope of stopping the evolution of the pregnancy
by placing pressure on a small GS
2 In conjunction with another tt
3 Backup if bleeding occurs
French-12 size 10-mL silicone balloon catheter or French-14 catheter with a 30-mL balloon
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
The catheter with the
balloon inflated with 5
mL of saline
TV power Doppler image
of the inflated balloon
(B) in a case of a CSP at
6 w 4 days after
injection of MXT
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Steps GA not required TAS guidance Or TVS guidance allow for more precise placement and assess the pressure avoiding over inflation of the balloon Catheter is kept 24 to 48 h with the outer end of the catheter fastened to the patientrsquos thigh Antibiotics Reevaluate after 48H Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
3 UAE alone or in combination Indication 1 As a rescue procedure in the case of significant
bleeding or an A-VM 2 Concurrent with MTH Not as a primary tt delay between tt and effect allows the gestation to
grow and vascularity to increase Disadvantages 1 GA 2 Complication rate 47 3 Not the best 1st -line tt
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Surgical excision
laparoscopy or laparotomy may be best tt
No response to conservative medical tt
Patient late to present
Allows for revision of the CS scar with new uterine closure that may minimize risk of recurrence Risks postoperative adhesions impair future fertility increased size of surgical wounds longer hospital stay and recovery increased risk of future placenta previaaccreta
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
1 Excision by laparotomy alone or in combination with hysteroscopy
18 cases 5 complications and only when used in an emergency situation
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
2 Laparoscopic excision Complication rate 306 Laparoscopy combined with hysteroscopy Complication rate 20
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
3 Hysteroscopy alone or in combination complication rate 138 Hysteroscopy combined with TA US guidance 9 cases no complications reasonable operative solution Hysteroscopy combined with mifepristone complication rate17
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
4 Suction aspiration or DampC alone or in
combination
Isolated D amp C should be avoided
1 Trophoblastic tissue and villi are implanted
within the myometrium D ampC is unlikely to expel
the GS without rupturing the uterine wall or
damaging the bladder
2 massive bleeding emergency laparotomies
loss of the uterus
3 exposed vessels in the cervical scar tissue bleed no muscle grid to contract and contain the profuse bleeding
4 Complication rate 62 (29ndash86)
bleeding complications necessitating 3rd -line tt that almost always was surgical Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
MTX followed by suction curettage Mean blood loss 707 mL (100ndash2000 mL) tt failure 3 out of 45 despite insertion of a Foley balloon catheter If DampC is still the preferred tt of choice blood products should be available balloon catheter should be inserted in the cervix
Preoperative determination of CSP implantation depth and extent is important in selecting candidates for surgical treatment Primary single-step surgical evacuation was successful in most patients with superficial implantation but patients should be informed of the possibility of salvage interventions before undergoing surgical evacuation (Kong et
al 2014)
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
FOLLOW-UP Placenta is implanted mostly within fibrous
tissue absorption of the GS is slow after med tt
1 9 w to obtain clearance of βHCG
2 3 months for clearance of GS on TVS
1 βHCG weekly until it is undetectable
2 TVS Monthly to evaluate the size of retained
products of conception
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
3 SIS in a nonpregnant patient uterine wall integrity size of the cesarean scar which may relate to the possibility of uterine scar complications in future pregnancies 4 Early TVS After CSP After CS to confirm an intrauterine location of the new gestation
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
5 Avoiding pregnancy No guidelines 12 to 24 months 6 Repair of scar before future pregnancies not known whether required or not Severely deficient uterine scars 10 of women who have had prior CS but CSP are much more rare
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Outcomes Uneventful viable pregnancies have been reported after all modalities of conservative management Recurrence rate 5 IU pregnancy 95 spontaneous pregnancy 88 Normal pregnancy 65 Spontaneous abortion 35 higher than expected
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
4 PREVENTION OF CSP
1 Surgical repair of the uterine dehiscence (niche) in patients with previous CS while not pregnant
Ben Nagi et al reported on a successful surgical repair Donnez et al hysteroscopic repair Klemm et al laparoscopic-assisted vaginal repair Yalcinkaya et al robotic-assisted laparoscopic repair More research is necessary before making recommendations for such surgical tt to prevent CSP
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
2 Specific surgical technique single- or double-layer closure of the incision can minimize or avoid a CSP
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
SUMMARY CSP
An uncommon but potentially life-threatening
The incidence is rising as CSR is rising
Precursor of morbidly adherent placenta
Do not confuse CSP with ectopic pregnancy
Early diagnosis is important TVS is the most
effective and preferred diagnostic tool
A key first step Determine whether heart activity is
present
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
If heart activity is documented Counsel the patient
inform the patient of the risks of pregnancy
continuation
If continuation an additional counseling session
risks
If termination a reliable tt that stops fetal heart beat
without delay
Avoid single tts unlikely to be effective
DampC
suction curettage
single-dose IM MTX and
UAE
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Consider combination treatments best results
direct injection of MTX or Kcl into GS with TVS
guidance
Keep a catheter at hand
At the time of discharging after a CS in a future
pregnancy an early visit for TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Thank You httpswwwfacebookcomgroups
227744884091351
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
(Timor-Tritsch et al 2012)
Timor-Tritsch et al (2012)
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Management 31 primary approaches systemic therapy local injection surgical aspiration of GS hysteroscopic laparoscopic and open removal
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Intracervical vasopressin should also be
considered
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
CSP 4 w after 2 doses of systemic
MTX Sagittal TVS (Aand B) through
the midline uterus GS in the anterior
LUS There is minimal peripheral flow
around GS on color Doppler imaging
(C) but no heart beat activity was
detected via M-mode analysis
Incidentally a large ovarian cyst (CY)
is partially visualized in B
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Aboubakr Elnashar
Arch Gynecol Obstet 2014 Dec 23 [Epub ahead of print] Ultrasonography-guided multidrug stratification interventional therapy for cesareanscar pregnancy Kong D1 Dong X Qi Y Author information Abstract PURPOSE To explore the clinical value of ultrasonography-guided multidrug stratification interventional therapy for cesarean scar pregnancy (CSP) METHODS Aspiration of gestational sac fluid injection of methotrexate in the sac injection of homeostatic agent and pituitrin in the uterine muscle layer and injection of triple anti-inflammatory drugs around the uterus in 12 patients with CSP The lesion volume serum β-hCG level and blood flow were observed RESULTS The mean β-hCG level continued to decrease posttreatment and the greatest reduction occurred in week 1 The mean number of days needed for serum β-hCG values to decrease to normal level was 391 plusmn 101 days Mass volumes reduced and the mean number of days for the masses to disappear was 246 plusmn 141 days The blood flow around the lesions continued to decrease CONCLUSIONS Ultrasonography-guided multidrug interventional therapy for CSP is a new safe effective minimally invasive method
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Aboubakr Elnashar
Ultrasound Med 2014 Sep33(9)1533-7 doi 107863ultra3391533
Heterotopic cesarean scar pregnancy diagnosis treatment and
prognosis
OuYang Z1 Yin Q2 Xu Y2 Ma Y2 Zhang Q2 Yu Y2
Author information
Abstract
Heterotopic cesarean scar pregnancy is a rare life-threatening form of
ectopic pregnancy To provide information regarding the clinical
manifestations diagnosis management and prognosis of this condition
we reviewed all cases reported in the English literature All literature on
heterotopic cesarean scar pregnancy was retrieved by searching the
PubMed database and tracking references of the relevant literature Full
texts were reviewed and clinical manifestations diagnostic methods and
the relationship between the treatment and prognosis were summarized A
total of 14 patients with heterotopic cesarean scar pregnancies were
identified including 6 spontaneous pregnancies and 8 following in vitro
fertilization-embryo transfer Gestational ages at diagnosis ranged from 5
weeks to 8 weeks 4 days Only 5 cases presented with vaginal bleeding
and the others were asymptomatic All 14 cases were diagnosed by
transvaginal sonography One patient with no future fertility requirements
underwent pregnancy termination by methotrexate Of the remaining 13
patients who desired to preserve their intrauterine gestations 10 were
treated by sonographically guided selective embryo reduction in situ (by
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
Aboubakr Elnashar
Fertil Steril 2014 Oct102(4)1085-1090e2 doi
101016jfertnstert201407003 Epub 2014 Aug 11
Outcomes of primary surgical evacuation during the first trimester in
different types of implantation in women with cesarean scar pregnancy
Cheng LY1 Wang CB1 Chu LC1 Tseng CW1 Kung FT2
Author information
Abstract
OBJECTIVE
To assess the efficacy and safety of primary surgical evacuation therapy
for cesarean scarpregnancy (CSP) of the first trimester and to evaluate its
possible prognostic factors
DESIGN
Retrospective consecutive cohort study
SETTING
Tertiary care university hospital
SUBJECT(S)
A cohort of patients with CSP and clear ultrasound images who underwent
primary surgical evacuation from January 2000 to December 2012
INTERVENTION(S)
Patients fulfilling the ultrasound criteria of CSP were further classified into
superficial and deep groups according to their implantation locations and
extents The final decision on the method of treatment including
methotrexate chemotherapy surgical evacuation and others was made by
the patients after consultation with the physician Pretreatment patient
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
I All are correct regarding CS scar
pregnancy (CSP) except
1 Incidence is rising
2Asymptomatic in 13 of cases
3Time of presentation is commonly 2nd trimester
4Diagnosis is missed in 14 of cases
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
II Sonographic criteria of CSP include
all except
1 Empty uterus with a clearly visualized
endometrium
2 Empty cervical canal
3 Gestational sac
within the anterior portion of lower uterine
segment
at site of the cesarean scar
4 Sliding organ sign is positive
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
III For treatment of CSP all are correct
except
1Anterior uterine wall thickness is important
2With pregnancy continuation hysterectomy
rate is 17
3Termination of the pregnancy in first
trimester is recommended
4Immediate and decisive action is
recommended
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
IV All are correct regarding CSP treatment
except
1 Complications are most often when single
IM Methotrexate or DampC
2 Complications are at lowest rate with
Local and US directed MTX injection with
or without additional IM MTX
3 Use of a Foley balloon catheter is not
recommended
4 laparoscopy or laparotomy with excision
of the pregnancy may be best treatment
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
V For follow up after treatment of CSP
all are correct except 1 5 w are required to obtain clearance of
βHCG
2 TVS is done monthly to evaluate the size
of retained products of conception
3 Avoiding pregnancy for 12 to 24 months
4 In a future pregnancy an early visit for
TVS is important
Aboubakr Elnashar
