Australian and New Zealand Journal of Obstetrics and Gynaecology 2015; 55: 64–69
DOI: 10.1111/ajo.12273
Original Article
Caesarean scar pregnancy: A 10-year experience Jennifer K.Y. KO, Raymond H.W. LI and Vincent Y.T. CHEUNG Department of Obstetrics and Gynecology, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
Aims: To review the management and outcome of all women with caesarean scar pregnancy (CSP) at a single centre. Methods: A retrospective review of women diagnosed with CSP between January 2004 and December 2013 was performed. Women were identified from the admission and Early Pregnancy Assessment Clinic records. Results: Twenty-two cases of CSP were identified during the study period. The median gestational age at diagnosis was 6.7 weeks (range 4.7–11.8 weeks). All diagnoses were made by ultrasound, the most common finding of which was a heterogeneous mass at the site of the caesarean scar (100%). The median duration for human chorionic gonadotropin to return to undetectable level was 10 weeks (range 2–20 weeks), although the duration for sonographic resolution of the CSP can take much longer. The success rate of intralesional methotrexate was 80% in our series. Conclusion: There is no consensus regarding the method of choice for managing CSP. Medical management using intralesional methotrexate appears to be an acceptable treatment in clinically stable women. Key words: caesarean scar, ectopic pregnancy.
Introduction Caesarean scar pregnancy (CSP) is a pregnancy developing in the uterine scar of a previous caesarean section. It was first reported in 19781 and was considered one of the rarest forms of ectopic pregnancy. A rising caesarean section rate in recent years has resulted in an increasing number of reported cases with an incidence ranging from 1:1800 to 1:2216 pregnancies.2,3 A CSP can lead to life-threatening consequences from uterine scar rupture and haemorrhage. Delayed diagnosis is common, and various treatment modalities have been described. However, despite the rising incidence, current evidence is still based on case series and individual case reports, and there are no consensus or established guidelines on the management of CSP. In this report, we reviewed our experience in the management of CSP over the past 10 years.
Materials and Methods The study was a retrospective chart review on all CSP admitted to Queen Mary Hospital, Hong Kong, the main affiliated hospital of the University of Hong Kong, between January 2004 and December 2013. Women were
Correspondence: Dr Jennifer K.Y. Ko, 6/F, Professorial Block, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China. Email: [email protected] Received 28 June 2014; accepted 9 September 2014.
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identified from the admission and Early Pregnancy Assessment Clinic records. This information was crossreferenced with our admission and Early Pregnancy Assessment Clinic computer database to ensure all women admitted with the diagnosis in the study period were included. Ethics approval was obtained from the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster. The diagnosis of CSP in our institution was based on identification of the typical ultrasound features as described by Jurkovic et al.,3 which included an empty uterine cavity and cervical canal, presence of the gestational sac in the anterior part of the uterine isthmus with a diminished myometrial layer between the bladder and the sac, peritrophoblastic perfusion surrounding the gestational sac and a negative ‘sliding sign’ defined as the inability to displace the gestational sac from its position at the level of the internal os using gentle pressure applied by the transvaginal probe. The usual treatment was determined on a case-by-case basis depending on the woman’s presenting symptoms and preference, with the exception of surgical management being chosen for women who were haemodynamically unstable or had signs of uterine rupture. For clinically stable women, medical management in the form of systemic or intralesional methotrexate was given. Serum human chorionic gonadotropin (hCG) was checked on days 1, 4 and 7, and weekly thereafter until it returned to
DOI: 10.1111/ajo.12273
Original Article
Caesarean scar pregnancy: A 10-year experience Jennifer K.Y. KO, Raymond H.W. LI and Vincent Y.T. CHEUNG Department of Obstetrics and Gynecology, Queen Mary Hospital, University of Hong Kong, Hong Kong SAR, China
Aims: To review the management and outcome of all women with caesarean scar pregnancy (CSP) at a single centre. Methods: A retrospective review of women diagnosed with CSP between January 2004 and December 2013 was performed. Women were identified from the admission and Early Pregnancy Assessment Clinic records. Results: Twenty-two cases of CSP were identified during the study period. The median gestational age at diagnosis was 6.7 weeks (range 4.7–11.8 weeks). All diagnoses were made by ultrasound, the most common finding of which was a heterogeneous mass at the site of the caesarean scar (100%). The median duration for human chorionic gonadotropin to return to undetectable level was 10 weeks (range 2–20 weeks), although the duration for sonographic resolution of the CSP can take much longer. The success rate of intralesional methotrexate was 80% in our series. Conclusion: There is no consensus regarding the method of choice for managing CSP. Medical management using intralesional methotrexate appears to be an acceptable treatment in clinically stable women. Key words: caesarean scar, ectopic pregnancy.
Introduction Caesarean scar pregnancy (CSP) is a pregnancy developing in the uterine scar of a previous caesarean section. It was first reported in 19781 and was considered one of the rarest forms of ectopic pregnancy. A rising caesarean section rate in recent years has resulted in an increasing number of reported cases with an incidence ranging from 1:1800 to 1:2216 pregnancies.2,3 A CSP can lead to life-threatening consequences from uterine scar rupture and haemorrhage. Delayed diagnosis is common, and various treatment modalities have been described. However, despite the rising incidence, current evidence is still based on case series and individual case reports, and there are no consensus or established guidelines on the management of CSP. In this report, we reviewed our experience in the management of CSP over the past 10 years.
Materials and Methods The study was a retrospective chart review on all CSP admitted to Queen Mary Hospital, Hong Kong, the main affiliated hospital of the University of Hong Kong, between January 2004 and December 2013. Women were
Correspondence: Dr Jennifer K.Y. Ko, 6/F, Professorial Block, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong, China. Email: [email protected] Received 28 June 2014; accepted 9 September 2014.
64
identified from the admission and Early Pregnancy Assessment Clinic records. This information was crossreferenced with our admission and Early Pregnancy Assessment Clinic computer database to ensure all women admitted with the diagnosis in the study period were included. Ethics approval was obtained from the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster. The diagnosis of CSP in our institution was based on identification of the typical ultrasound features as described by Jurkovic et al.,3 which included an empty uterine cavity and cervical canal, presence of the gestational sac in the anterior part of the uterine isthmus with a diminished myometrial layer between the bladder and the sac, peritrophoblastic perfusion surrounding the gestational sac and a negative ‘sliding sign’ defined as the inability to displace the gestational sac from its position at the level of the internal os using gentle pressure applied by the transvaginal probe. The usual treatment was determined on a case-by-case basis depending on the woman’s presenting symptoms and preference, with the exception of surgical management being chosen for women who were haemodynamically unstable or had signs of uterine rupture. For clinically stable women, medical management in the form of systemic or intralesional methotrexate was given. Serum human chorionic gonadotropin (hCG) was checked on days 1, 4 and 7, and weekly thereafter until it returned to
