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CLINICAL ARTICLE
Department of Gynecology and Obstetrics, First Afliated Hospital, Xi'an Jiaotong University, Xi'an, China
Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, China
a r t i c l e
i n f o
Article history:
Received 5 September 2015
Received in revised form 16 December 2015
Accepted 24 March 2016
Keywords:
Cesarean scar pregnancy
Ultrasonographic pattern
Uterine artery embolization
a b s t r a c t
Objective: To evaluate combining uterine artery embolization (UAE) with other treatments for cesarean scar
pregnancy (CSP). Methods: A retrospective study included patients attending the First afliated Hospital of
Xi'an Jiaotong University, China, between March 1, 2009 and March 31, 2014, who were diagnosed with CSP.
Patients were classied by ultrasonography as having endogenous CSP (CSP type I [CSP-I]) or exogenous CSP
(CSP type II [CSP-II]). Patient outcomes were compared between patients who underwent treatment that
included or excluded UAE. Patient records were reviewed and patients were interviewed by telephone to report
on recovery following treatment. Results: In total, 52 patients met the inclusion criteria. In patients with CSP-I, the
blood loss, length of hospital stay, and time before restoration of normal human chorionic gonadotropin levels
were signicantly higher in patients who were treated with methotrexate combined with dilatation and curettage compared with those treated with UAE combined with dilatation and curettage (P b 0.05). In patients
with CSP-II, blood loss was lower in patients treated with UAE combined with excision compared with excision
alone (P b 0.001). Conclusion: Incorporating UAE in the treatment of CSP-I and CSP-II was safe; CSP should be
properly classied to select the appropriate treatment.
2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction
Cesarean scar pregnancy (CSP) is a term that describes the implantation of a gestational sac at the site of a previous cesarean delivery scar
and was rst described by Larsen and Solomon in 1978 [1]. The incidence of CSP has been reported to be one case per 18002216 normal
pregnancies; this rate could rise in the future owing to increasing
rates of cesarean deliveries [24]. Links have been suggested between
uterine scar dehiscence or small-scar defects after cesarean deliveries
and later CSPs [5], and routine transvaginal ultrasonography has been
recommended in early pregnancy for patients who have previously undergone a cesarean delivery [6]. Vial et al. [7] classied CSP based on
transvaginal ultrasonography. Endogenous CSP (CSP type I [CSP-I]) is
caused by the implantation of the amniotic sac at the cesarean-scar
site followed by progression towards either the cervical isthmic space
or the uterine cavity. Exogenous CSP (CSP type II [CSP-II]) results from
the deep implantation of the amniotic sac into a previous cesarean
scar defect with growth that inltrates the uterine myometrium,
creating a bulge from the uterine serosal layer. The use of ultrasonography in clinical practice to assess the risks posed by CSP has been demonstrated [8,9] and this approach is widely applied in China.
Complications encountered in the treatment of CSP make it clinically
challenging. Initially, mifepristone is administered or curettage is
performed to terminate pregnancy; however, CSP is often accompanied
by repeated vaginal bleeding, abnormal beta human chorionic gonadotropin (-hCG) levels, and the growth of CSP masses. Moreover, deep
implantation in CSP-II can lead to uncontrollable hemorrhaging if highly
vascularized tissues are dissected from the uterus. Consequently, in recent years, considerable attention has focused on different methods
for managing CSP to improve patient outcomes. Protocols for the treatment of CSP that have been investigated include methotrexate (MTX)
injection (systemic or local), dilatation and curettage, uterine artery
embolization (UAE), the excision of CSP lesions via laparotomy, and
laparoscopic or hysteroscopic surgery; these approaches aim to prevent
hemorrhage and preserve fecundity [1016]. The benets of including
UAE in the treatment of CSP have been demonstrated previously [8,16,
17]. Despite UAE having been proven to be a viable intervention to
control hemorrhaging and preserve the uterus, there is no consensus
on optimal combination therapies for each CSP type.
The aim of the present study was to analyze patient outcomes and
complications following the use of UAE in the treatment of patients
with CSP.
http://dx.doi.org/10.1016/j.ijgo.2015.12.006
0020-7292/ 2016 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
203
Fig. 1. Transvaginal ultrasonography images. (a) A 30-year-old woman with cesarean scar pregnancy type I; a gestational sac is embedded at the site of a previous cesarean scar. (b) A 29year-old woman with cesarean scar pregnancy type II; the gestational sac had implanted into a previous cesarean scar defect with growth that has inltrated into the uterine myometrium
and bulges from the uterine serosal surface.
204
Table 1
Clinical characteristics of patients with CSP at baseline.a
Characteristic
CSP-I (n = 24)
CSP-II (n = 28)
P valueb
Age, y
Duration of gestation at diagnosis, d
Gravidity
Parity
Time between previous cesarean delivery and index pregnancy, y
Pretreatment serum -hCG, mIU/mL
31.0 (29.035.0)
51 (41.362.8)
3 (24)
1 (11)
4.1 2.3
5458.5 (2277.323,259.8)
30.5 (27.335.0)
59.5 (52.380.5)
3 (34)
1 (11)
7.0 6.3
3641.0 (1029.811,404.5)
0.467
0.017
0.209
0.571
Abbreviations: CSP, cesarean scar pregnancy; CSP-I, cesarean scar pregnancy type I; CSP-II, cesarean scar pregnancy type II; -hCG, beta human chorionic gonadotropin.
a
Values are given as mean SD or median (interquartile range), unless indicated otherwise.
b
MannWhitney U test.
range of patients diagnosed with CSP was 2347 years. The duration of
pregnancy at the time of CSP diagnosis was 31112 days. The time
interval between patients' previous caesarean section and the current
CSP ranged from 0.5 years to 23.0 years. Among the 57 patients
experiencing CSP, 53 (93%) had experienced one previous cesarean
delivery, and 4 (7%) had undergone two. Placenta previa during most
recent pregnancy was reported by one patient. The range of serum
-hCG levels recorded among patients was 13.6893,207.00 mIU/
mL. The range of the largest diameter of CSP masses, measured
using ultrasonography, was 1.07.5 cm in patients with CSP-I and
1.07.8 cm in patients with CSP-II. Among the potentially eligible
patients with CSP-I, one patient had been referred to the emergency
department of the study institution with a vaginal-bleeding
emergency. This patient had been treated with MTX but had
experienced a steady increase in serum -hCG levels and an increase
in CSP-mass volume that was visible under ultrasonography
examination; the patient underwent CSP lesion excision by
laparotomy and, consequently, was excluded from the present
Fig. 2. Digital subtraction angiogram images from a patient with cesarean scar pregnancy type I who was treated using transcatheter uterine arterial embolization.
205
observed. No UAE-associated adverse effects, including postembolization syndrome and pelvic tissue damage, were observed during hospitalization. Mild lower abdominal pain continuing for several
days was recorded in all patients who underwent UAE; this pain was
controlled successfully with intravenous urbiprofen axetil (Kaifen;
Beijing Tide Pharmaceutical Co, Beijing, China). No necrosis of pelvic
organs, infection, amenorrhea, or premature ovarian failure was
recorded during the study period. During weekly follow-up, serum
-hCG levels steadily decreased without the need for additional
treatment in all patients. Following treatment, the time to normalization of serum -hCG levels was 26 weeks and 25 weeks in patients
with CSP-I and CSP-II, respectively. All of the patients were experiencing
normal menstrual cycles and menstruation volumes without
dysmenorrhoea within 48 weeks of treatment (Table 2, Table 3).
From the telephone interviews conducted, 35 patients reported
using contraception after treatment (22 patients reported using intrauterine devices and 13 patients reported using condoms); at least
2 years of follow-up data was available for these patients. Additionally,
one patient reported a successful natural intrauterine pregnancy that
occurred 20 months after treatment.
4. Discussion
Fig. 3. Cesarean scar lesion tissues from a patient with cesarean scar pregnancy type II were
subjected to pathological examination, conrming the preoperative ultrasonography
diagnosis. The arrows indicate the chorionic villi.
Table 2
Patient outcomes following treatment for CSP-I.a
Variable
P valueb
Duration of hospitalization, d
Time before -hCG normalization, wk
Intraoperative blood loss, mL
Time before resuming menstruation, d
8.5 (8.014.3)
3.5 (2.04.0)
200.0 (172.5257.5)
31.0 (29.039.3)
5.5 (4.07.5)
2.0 (1.03.0)
55.0 (30.072.5)
30.5 (29.832.3)
0.002
0.026
b0.001
0.625
Abbreviations: CSP-I, cesarean scar pregnancy type I; -hCG, beta human chorionic gonadotropin.
a
Values are given as median (interquartile range) unless indicated otherwise.
b
MannWhitney U test.
206
Table 3
Patient outcomes following treatment for CSP-II.a
Variable
P valueb
Duration of hospitalization, d
Time before -hCG normalization, wk
Intraoperative blood loss, mL
Time before resuming menstruation, d
9.0 (7.810.3)
2.0 (1.03.3)
575.0 (450.0612.5)
34.5 (32.036.3)
8.0 (6.09.0)
2.0 (1.02.0)
265.0 (200.0300.0)
34.5 (31.337.5)
0.150
0.114
b0.001
0.769
Abbreviations: CSP-II, cesarean scar pregnancy type II; CSP, cesarean scar pregnancy; -hCG, beta human chorionic gonadotropin.
a
Values are given as median (interquartile range) unless indicated otherwise.
b
MannWhitney U test.
Conicts of interest
The authors have no conicts of interest.
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