Fig. 14.1
Cesarean scar pregnancy before the injection: a Gestational sac (GS) with a yolk sac (arrow) embedded in the low, anterior uterine wall. b 3-mm myometrial layer between the GS and the bladder. The arrow points to the GS. c CRL of 5.5 mm consistent with a 6 2/7 days pregnancy. d Transvaginal intragestational sac injection (arrow) points to the needle. Cx = cervix. Crown–rump length (CRL)
A 3-mm myometrial layer was measured between the sac and the bladder (Fig. 14.1b). No embryonic pole or heartbeat was seen and the cervix appeared normal. The serum human chorionic hormone (hCG) was 2900 mIU/mL. These findings were consistent with a cesarean scar pregnancy (CSP) .
My Management
a.
Multidose methotrexate (MTX) injection
b.
MTX injection into the gestational sac
c.
Hysteroscopic removal of the ectopic gestation
d.
Laparoscopic removal of the ectopic gestation
e.
Laparotomy
Diagnosis and Assessment
Many obstetrics and gynecology (OB/GYN) practitioners have never diagnosed or treated a patient with a CSP . Those who did, faced a management problem. Over the past few decades, the prevalence of CDs has increased. This raise in the USA reached 60 % from 1996 to 2009 [1]. Currently, the CD rate has stabilized to 31.3 % [2]. Among the many complications of CDs, the least known is CSP, which may become a life-threatening condition [3].
CSP is defined as an abnormal implantation of a gestational sac in the niche created by the incision site of the previous CD, below or on the thin myometrium and the fibrous tissue of a previous cesarean scar in the presence of an empty uterine cavity and cervical canal. It has an estimated incidence of 1/1800–1/2500 of all CDs [4].
The diagnosis of CSP requires a high clinical index of suspicion. When evaluating patients with CSP, two main differential diagnoses should be considered: cervical pregnancy and spontaneous miscarriage in progress. The former is most likely to occur in patients with no history of previous CD. In the latter, the abortion sac happened to be “caught” passing the cervix and does not demonstrate a live embryo/fetus.
The diagnosis of CSP is based upon:
1.
A positive pregnancy test
2.
An empty uterine cavity and closed endocervical canal
3.
Detection of an early gestation and/or placenta in close proximity of the hysterotomy scar with fetal or embryonic pole and/or yolk sac with or without heartbeat (depending of the gestational age)
4.
Absent or thin myometrial layer between the gestational sac and the bladder wall
As a rule, if a low, anteriorly located gestational sac is seen in a patient with a previous CD, it should be considered as a CSP . Treatment options can be classified into two groups: surgical or minimally invasive. Surgical treatment requires general anesthesia. They include: dilation and curettage (D&C), excision by hysteroscopy, laparoscopy, or laparotomy. Minimally invasive interventions include: local and/or systemic injection of MTX or KCl. Other procedures include UAE. Lately, insertion and inflation of a Foley balloon catheter, as an adjuvant to other treatments, has also been used to prevent or to tamponade bleeding from the pregnancy site.
After the diagnosis is established, the patient should be counseled about the management. This should be personalized, taking into account the patient’s age, number of children, number of previous CDs, the patient’s expectations as well as the provider’s experience [5, 6].
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