Arch Gynecol Obstet DOI 10.1007/s00404-014-3143-6
REVIEW
Management of cesarean scar pregnancy with suction curettage: a report of four cases and review of the literature Yes¸ im Bayoglu Tekin • Ulku Mete Ural • Guls¸ ah Balık • Isık Ustuner • Figen Kır S¸ ahin Emine Seda Gu¨vendag˘ Gu¨ven
•
Received: 20 July 2013 / Accepted: 2 January 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To present the outcomes of four cases of cesarean scar pregnancy treated with suction curettage. Methods Four patients were ultrasonographically diagnosed with cesarean scar pregnancies treated with suction curettage in a tertiary care center. Results Serum b-human chorionic gonadotropin levels ranged between 1,681 and 15,573 mU/mL, gestational sac diameter measured from 10 to 24 mm and scar thickness was between 4.7 and 6.8 mm. All patients underwent suction curettage under general anesthesia with transabdominal ultrasonography guidance. No complications were observed during or after operation. Conclusion Suction curettage is a viable alternative for conservative treatment in selected cases of patients who are diagnosed with CSP early in gestation and who have a myometrial thickness of more than 4.5 mm. Keywords Cesarean scar pregnancy Treatment Suction curettage Ultrasonography Ectopic pregnancy
Introduction Cesarean scar pregnancy (CSP) is a type of ectopic pregnancy, and has an incidence of 0.15 % in pregnant women with prior cesarean deliveries [1]. Patients commonly present with painless vaginal bleeding, and the mean gestational week at time of diagnosis is 7.5 ± 2.5 weeks [2]. Y. Bayoglu Tekin (&) U. Mete Ural G. Balık I. Ustuner F. Kır S¸ ahin E. S. Gu¨vendag˘ Gu¨ven Department of Obstetrics and Gynecology, School of Medicine, Recep Tayyip Erdog˘an University, ˙Islampas¸ a Mah, 53200 Rize, Turkey e-mail: [email protected]
The pathophysiological mechanism is presumed to be because of implantation of the blastocyst through the uterine scar from previous surgery, and then the trophoblastic tissue is surrounded by fibrous tissue and myometrium [3]. The most catastrophic complications of CSP are uterine rupture and severe life-threatening hemorrhage that can be avoided with early and accurate diagnosis. The diagnostic accuracy is high with transvaginal ultrasonography. Diagnostic criteria are as follows: 1. 2.
3. 4. 5.
Previous history of cesarean section. Secondary amenorrhea with or without irregular vaginal bleeding and increased b-human chorionic gonadotropin (hCG) levels. Empty uterine cavity and regular endometrial lining, Empty cervical canal, The gestational sac (GS) with double ring sign at the isthmic level that is embedded at the anterior wall with functional trophoblastic activity defined with color Doppler examination and diminished myometrial layer between the bladder and GS [1].
Differential diagnosis includes abortion or cervico-isthmic pregnancy. Because of the rarity of the CSPs, the best treatment technique is still not known. Treatment options include expectant management, systemic or local administration of methotrexate (MTX), dilatation and curettage (D&C), local resection of the ectopic gestational mass and hysterectomy. We present a case series of four patients with CSP who were successfully treated with suction curettage.
Case presentations Four patients presented to our hospital with a history of missing periods for more than 5 weeks and elevation of
123
Arch Gynecol Obstet
serum b-hCG levels. The patients’ demographics, clinical features, and laboratory values are shown in Table 1. Transvaginal ultrasound revealed CSP with corresponding criteria of empty uterus, empty cervical canal, visualization of the GS embedded at the previous lower uterine segment of the cesarean scar at the anterior part of the isthmic level and
thinning of the myometrial layer between the bladder and GS (Figs. 1, 2, 3, 4). Placental circulation was imaged using Doppler sonography. There were no free fluids in the Douglas pouch. All patients were informed about the situation of the pregnancy. The patients desire to terminate the pregnancies
Table 1 Demographics, clinical features and laboratory values of patients Patient no.
Age (years)
No. of prior cesarean section(s)
Missing period (weeks)
1
30
1
5
2
38
3
6
3
29
3
6.4
4
37
2
7
b-hCG (mU/mL) (before suction)
b-hCG level (mU/mL) (at discharge)
Gestational sac (mm) diameter
Myometrial thickness (mm)
1,681
10
6.9
253
7,362
11.4
5.8
2,122
7,726
24
4.7
2,727
15,573
14
6.3
4,228
Fig. 1 Transvaginal ultrasonographic image at 5 weeks’ gestation. An echo-free area with a diameter of 10 mm at the uterine scar is recognized as gestational sac
Fig. 3 Transvaginal ultrasonographic image of a cesarean scar pregnancy at 6, 4 weeks. Gestational sac is located in the anterior part of the istmic portion of the uterus with diminished myometrial layer between the bladder and the sac
Fig. 2 Transvaginal ultrasonographic image of the scar pregnancy with gestational sac diameter of 11.4 mm and myometrial thickness of 5.8 mm
Fig. 4 Transvaginal ultrasonographic image of a cesarean scar ectopic pregnancy of 7 weeks. Gestational sac in the lower anterior wall of the uterus with empty uterus and cervical canal
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Arch Gynecol Obstet
but preserve their fertility. The possible management options, including exploratory laparotomy, hysterectomy, laparoscopy, suction evacuation, and medical therapy, were explained to the patients. The patients preferred conservative management with suction curettage. After informing the patients about the possible risks of uterine perforation and non-controllable uterine bleeding that may necessitate emergent hysterectomy, preparations were made for possible blood transfusion and hysterectomy. The procedures were performed under general anesthesia with ultrasonographic guidance. Patients with full bladders were laid on the operation table in the lithotomy position, and a convex abdominal probe was inserted into the suprapubic region to visualize the uterus along the longitudinal axes. After inserting the speculum into the vagina, the cervix was swabbed with gauze, and the anterior lip was caught with a toothed tenaculum. The cervix was dilated with Hegar dilators (BahadırÒ, Samsun, Turkey) until it reached the 5-mm diameter and the Karman cannula (MedbarÒ, Izmir, Turkey) could be inserted. After carefully introducing the Karman cannula into the uterus, the gestational villi and decidual endometrium were removed. There were no intraoperative complications, such as scar dehiscence or perforation. Estimated blood loss ranged from 100 to 250 mL, and intrauterine instrumentation was not required for hemostasis. Postoperative hemogram follow-up remained stable, and no vaginal bleeding was observed. After patients’ b-hCG levels decreased, they were discharged on the second or third postoperative day. Patient 1 was admitted for evaluation of secondary amenorrhea. The initial serum b-hCG level was 810 mU/mL and there was a 7.4 mm GS at the lower segment of the uterus adjacent to the scar. The patient was observed for 2 days after hospitalization and serum b-hCG levels increased to 1,681 mU/mL, and GS diameter increased to 10 mm (Fig. 1). Patient 2 presented to the outpatient clinic at 6 weeks for amenorrhea without vaginal bleeding or pain (Fig. 2). Patient 3 was admitted to the emergency service complaining of heavy vaginal bleeding for 3 days. Transvaginal ultrasonography revealed a GS diameter of 24 mm at the cesarean scar (Fig. 3). Patient 4 complained of delay of menstruation and vaginal spotting (Fig. 4). All of the patients were followed up for 2 weeks after the operation. No persistent trophoblastic tissue was observed and b-hCG levels decreased. Patient 3 conceived 3 months after the suction curettage, and the pregnancy progressed without complication.
Discussion We present four cases of CSP treated successfully with suction curettage. The most important factor in treating CSP is early diagnosis, particularly before 8 weeks’ gestation. As already mentioned before, treatment options range from
observation to hysterectomy. For this case series, suction curettage was used as a minimally invasive treatment method and no intra- or post-operative complications were observed. Using transabdominal ultrasonographic guidance is important because it provides the clinician with accurate location and helps avoid complications. In our series, none of the patients received MTX before suction curettage. b-hCG levels ranged between 1,681 and 15,573 mU/mL and GS diameters ranged between 10 and 24 mm. The minimum thickness of the myometrium at the scar region was 4.7 mm and the maximum was 6.9 mm. CSP is an iatrogenic complication that was first reported by Larsen and Solomon [4]. The incidence of CSP has been estimated to be between 1:1,800 and 1:2,226 of pregnancies [5], but has increased in recent years correlating with the increased rates of cesarean section. CSP can be easily recognized with ultrasonographic examination and Doppler ultrasonography. Transvaginal ultrasonography must be carefully performed in symptomatic pregnant women with previous cesarean section to identify the localization of the GS and its relation with the scar region. Criteria for diagnosing CSP include an empty cavity and cervical canal with trophoblastic activity of the GS on Doppler examination at the anterior part of the isthmic level, and diminished myometrial thickness between the GS and the bladder [3]. Differential diagnoses include spontaneous abortion and cervico-isthmic pregnancy. Using ultrasonographic criteria, especially observing a defective myometrial layer between the GS and the bladder, is important to distinguish CSP from other conditions. D&C is a risky alternative to minimally invasive treatment and may necessitate a salvage therapy. Complications of D&C include uterine perforation, massive bleeding, and conversion to hysterectomy. Before performing D&C, the patient must be informed about the possible complications of the procedure and the operation room must be properly prepared for an emergency hysterectomy. Using transabdominal ultrasonographic guidance facilitates the clinician in detecting the location of the GS and avoiding uterine perforation. Proper curettage technique is another important factor that may decrease the risk of complications. Using a soft suction cannula is preferred over using a sharp curettage and the procedure should be performed with care. Integrity of the scar region, distance to the bladder and close settlement of the GS to the cesarean scar should be considered during the operation. In the literature, treatment of CSP has been reported with primary evacuation alone or in association with other methods. Arslan et al. [6] presented a case of CSP at 7 weeks gestation with a GS 3.5 mm away from the bladder, and the patient was treated uneventfully with suction curettage. Nonaka et al. [7] presented a case of CSP in which the patient was treated unsuccessfully by D&C,
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Arch Gynecol Obstet
presented with abundant vaginal bleeding 10 weeks after the procedure and underwent hysterectomy. In a study of eight women who were treated with suction curettage, Jurkovic et al. [2] reported that 38 % of the patients had suffered from heavy vaginal bleeding and Foley catheters were inserted to the uterus to achieve hemostasis. Seow et al. [8] misdiagnosed two cases of CSP as inevitable abortion, and D&C procedures ended with abundant vaginal bleeding. One of the patients underwent hysterectomy. The other patient was managed with a Foley catheter balloon for tamponade and her uterus was preserved. In another study, Polat et al. [9] performed D&C on four of the six patients and only one patient had abundant vaginal bleeding and underwent laparotomy. The author commented that D&C may be preferred for treating CSP detected at less than 7 weeks’ gestation, but if the gestational age was greater than 7 weeks, other surgical or medical treatment modalities should be performed. Wang et al. [10] performed primary evacuation for three cases of CSP and one had perforation that was laparoscopically repaired. Ash et al. [11] performed evacuation on eight patients and three of them had a Foley catheter inserted into the cervix to achieve hemostasis. Primary evacuation has a high risk of complications such as abundant vaginal bleeding and uterine perforation and most authors have reported that the procedure is likely to necessitate salvage therapy. Furthermore, evacuation therapy can be performed with other treatment modalities to reduce complication rates and to decrease the risk of morbidity and mortality. In a recent study, in which local and systemic MTX administration was followed by suction curettage in 45 patients, only three patients had salvage therapy. In this study, b-hCG levels decreased faster and patients were discharged sooner from the hospital than patients on MTX medication alone [12]. Fahg et al. [13] treated 51 cases of CSP with uterine artery embolization (UAE) and D&C with or without pretreatment medical therapy. They reported that UAE and D&C without medical therapy were safe and effective for terminating CSP and had the advantages of short hospital stay, less blood loss and low risk of hysterectomy. Yin et al. [14] managed 13 cases of CSP with UAE followed by vacuum aspiration and only one patient had a laparotomy because of intractable hemorrhage. All patients underwent vacuum aspiration 6–8 h after UAE. Pretreatment median day of amenorrhea was 57 days and b-hCG levels increased from 1,971 to 59,322 mU/mL. In another retrospective cohort study performed on 11 women treated with UAE and D&C, only three patients were free of complications after the procedure [15]. The authors stated that D&C was a risky treatment option associated with severe complications and hysterectomy.
123
However, regarding the complicated cases with severe bleeding or large GS, the outcomes were strikingly better with UAE followed by D&C. Zhang et al. [16] reported that eight of ten women were misdiagnosed as inevitable abortion and underwent D&C, complicated with heavy vaginal bleeding of 1,000–3,500 mL. Five cases were successfully treated with UAE followed by D&C, and three cases underwent hysterectomy. Administration of MTX and consecutive D&C was performed in two cases. Recently, a new method of performing UA chemoembolization with MTX and subsequent D&C was reported to be more likely to avoid any severe complications. Duration of hospitalization was shortened and risks of massive vaginal bleeding and hysterectomy were lowered with this treatment option [17]. The implantation patterns of CSP can be classified into endogenic and exogenic types. The endogenic form grows through the uterine cavity and allows the pregnancy to progress with a higher risk of massive bleeding. The exogenic type is localized to the dehiscence tract and progresses through the deep myometrial layer resulting in the rupture of the cesarean scar [18]. Furthermore, the placenta is circumscribed by myometrium and fibrotic tissue of the wound. This scarred region is not suitable and strong enough for the development of the pregnancy. The lower resistance and strength of the fibrotic tissue lead to the undesirable results. D&C increases the risk of uterine wall perforation and heavy vaginal bleeding. Before attempting D&C, the thickness of the scar region and distance from the urinary bladder must be evaluated carefully to avoid the complications. Because of the increased popularity of cesarean section, CSP rates are likely to increase throughout the world. Although a diverse range of treatments has been previously reported, there is no standard treatment approach. Clinicians should determine the method of therapy on an individualized basis and should first consider several parameters, such as gestational age, serum b-hCG levels, myometrial thickness, initial clinical presentation and desire for uterus preservation. D&C may be an alternative for cases at early gestation that have lower levels of b-hCG and a myometrial thickness of more than 4.5 mm. Conflict of interest Authors state that there is no competing interest or financial disclosure for this manuscript.
References 1. Rotas MA, Haberman S, Levgur M (2006) Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 107:1373–1381
Arch Gynecol Obstet 2. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ (2003) First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol 21:220–227 3. Fylstra DL (2002) Ectopic pregnancy within a cesarean scar: a review. Obstet Gynecol Surv 57:537–543 4. Larsen JV, Solomon MH (1978) Pregnancy in a uterine scar sacculus-an unusual cause of postabortal haemorrhage. A case report. S Afr Med J 28:123–142 5. Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, Pineda G, Arslan AA (2012) The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol 207:44.e1–44.e13 6. Arslan M, Pata O, Dilek TU, Aktas A, Aban M, Dilek S (2005) Treatment of viable cesarean scar ectopic pregnancy with suction curettage. Int J Gynaecol Obstet 89:163–166 7. Nonaka M, Toyoki H, Imai A (2006) Cesarean section scar pregnancy may be the cause of serious hemorrhage after firsttrimester abortion by dilatation and curettage. Int J Gynaecol Obstet 95:50–51 8. Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL (2004) Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynaecol 23:247–253 9. Polat I, Alkis I, Sahbaz A, Sahin O, Ekiz A, Gulac B, Tekirdag AI (2012) Diagnosis and management of cesarean scar pregnancy. Clin Exp Obstet Gynecol 39:365–368 10. Wang CB, Tseng CJ (2006) Primary evacuation therapy for cesarean scar pregnancy: three new cases and review. Ultrasound Obstet Gynecol 27:222–226
11. Ash A, Smith A, Maxwell D (2007) Caesarean scar pregnancy. BJOG 114:253–263 12. Jiang T, Liu G, Huang L, Ma H, Zhang S (2011) Methotrexate therapy followed by suction curettage followed by Foley tamponade for caesarean scar pregnancy. Eur J Obstet Gynecol Reprod Biol 156:209–211 13. Fahg A, Chen Q, Qian Z, Li Q, Meng Y (2009) Correlation questions clinical discussion of uterine artery embolization in induced abortion patients with management of cesarean scar pregnancy. J Reprod Contra 20:153–160 14. Yin X, Su S, Dong B, Ban Y, Li C, Sun B (2012) Angiographic uterine artery chemoembolization followed by vacuum aspiration: an efficient and safe treatment for managing complicated cesarean scar pregnancy. Arch Gynecol Obstet 285:1313–1318 15. Yang XY, Yu H, Li KM, Chu YX, Zheng A (2010) Uterine artery embolisation combined with local methotrexate for treatment of caesarean scar pregnancy. BJOG 117:990–996 16. Zhang Y, Gu Y, Wang JM, Yi L (2013) Analysis of cases with cesarean scar pregnancy. J Obstet Gynaecol Res. 39:195–202 17. Lan W, Hu D, Li Z, Wang L, Yang W, Hu S (2013) Bilateral uterine artery chemoembolization combined with dilation and curettage for treatment of cesarean scar pregnancy: a method for preserving the uterus. J Obstet Gynaecol Res. 39:1153–1158 18. Ghezzi F, Lagana` D, Franchi M, Fugazzola C, Bolis P (2002) Conservative treatment by chemotherapy and uterine arteries embolization of a cesarean scar pregnancy. Eur J Obstet Gynecol Reprod Biol 103:88–91
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REVIEW
Management of cesarean scar pregnancy with suction curettage: a report of four cases and review of the literature Yes¸ im Bayoglu Tekin • Ulku Mete Ural • Guls¸ ah Balık • Isık Ustuner • Figen Kır S¸ ahin Emine Seda Gu¨vendag˘ Gu¨ven
•
Received: 20 July 2013 / Accepted: 2 January 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Abstract Purpose To present the outcomes of four cases of cesarean scar pregnancy treated with suction curettage. Methods Four patients were ultrasonographically diagnosed with cesarean scar pregnancies treated with suction curettage in a tertiary care center. Results Serum b-human chorionic gonadotropin levels ranged between 1,681 and 15,573 mU/mL, gestational sac diameter measured from 10 to 24 mm and scar thickness was between 4.7 and 6.8 mm. All patients underwent suction curettage under general anesthesia with transabdominal ultrasonography guidance. No complications were observed during or after operation. Conclusion Suction curettage is a viable alternative for conservative treatment in selected cases of patients who are diagnosed with CSP early in gestation and who have a myometrial thickness of more than 4.5 mm. Keywords Cesarean scar pregnancy Treatment Suction curettage Ultrasonography Ectopic pregnancy
Introduction Cesarean scar pregnancy (CSP) is a type of ectopic pregnancy, and has an incidence of 0.15 % in pregnant women with prior cesarean deliveries [1]. Patients commonly present with painless vaginal bleeding, and the mean gestational week at time of diagnosis is 7.5 ± 2.5 weeks [2]. Y. Bayoglu Tekin (&) U. Mete Ural G. Balık I. Ustuner F. Kır S¸ ahin E. S. Gu¨vendag˘ Gu¨ven Department of Obstetrics and Gynecology, School of Medicine, Recep Tayyip Erdog˘an University, ˙Islampas¸ a Mah, 53200 Rize, Turkey e-mail: [email protected]
The pathophysiological mechanism is presumed to be because of implantation of the blastocyst through the uterine scar from previous surgery, and then the trophoblastic tissue is surrounded by fibrous tissue and myometrium [3]. The most catastrophic complications of CSP are uterine rupture and severe life-threatening hemorrhage that can be avoided with early and accurate diagnosis. The diagnostic accuracy is high with transvaginal ultrasonography. Diagnostic criteria are as follows: 1. 2.
3. 4. 5.
Previous history of cesarean section. Secondary amenorrhea with or without irregular vaginal bleeding and increased b-human chorionic gonadotropin (hCG) levels. Empty uterine cavity and regular endometrial lining, Empty cervical canal, The gestational sac (GS) with double ring sign at the isthmic level that is embedded at the anterior wall with functional trophoblastic activity defined with color Doppler examination and diminished myometrial layer between the bladder and GS [1].
Differential diagnosis includes abortion or cervico-isthmic pregnancy. Because of the rarity of the CSPs, the best treatment technique is still not known. Treatment options include expectant management, systemic or local administration of methotrexate (MTX), dilatation and curettage (D&C), local resection of the ectopic gestational mass and hysterectomy. We present a case series of four patients with CSP who were successfully treated with suction curettage.
Case presentations Four patients presented to our hospital with a history of missing periods for more than 5 weeks and elevation of
123
Arch Gynecol Obstet
serum b-hCG levels. The patients’ demographics, clinical features, and laboratory values are shown in Table 1. Transvaginal ultrasound revealed CSP with corresponding criteria of empty uterus, empty cervical canal, visualization of the GS embedded at the previous lower uterine segment of the cesarean scar at the anterior part of the isthmic level and
thinning of the myometrial layer between the bladder and GS (Figs. 1, 2, 3, 4). Placental circulation was imaged using Doppler sonography. There were no free fluids in the Douglas pouch. All patients were informed about the situation of the pregnancy. The patients desire to terminate the pregnancies
Table 1 Demographics, clinical features and laboratory values of patients Patient no.
Age (years)
No. of prior cesarean section(s)
Missing period (weeks)
1
30
1
5
2
38
3
6
3
29
3
6.4
4
37
2
7
b-hCG (mU/mL) (before suction)
b-hCG level (mU/mL) (at discharge)
Gestational sac (mm) diameter
Myometrial thickness (mm)
1,681
10
6.9
253
7,362
11.4
5.8
2,122
7,726
24
4.7
2,727
15,573
14
6.3
4,228
Fig. 1 Transvaginal ultrasonographic image at 5 weeks’ gestation. An echo-free area with a diameter of 10 mm at the uterine scar is recognized as gestational sac
Fig. 3 Transvaginal ultrasonographic image of a cesarean scar pregnancy at 6, 4 weeks. Gestational sac is located in the anterior part of the istmic portion of the uterus with diminished myometrial layer between the bladder and the sac
Fig. 2 Transvaginal ultrasonographic image of the scar pregnancy with gestational sac diameter of 11.4 mm and myometrial thickness of 5.8 mm
Fig. 4 Transvaginal ultrasonographic image of a cesarean scar ectopic pregnancy of 7 weeks. Gestational sac in the lower anterior wall of the uterus with empty uterus and cervical canal
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Arch Gynecol Obstet
but preserve their fertility. The possible management options, including exploratory laparotomy, hysterectomy, laparoscopy, suction evacuation, and medical therapy, were explained to the patients. The patients preferred conservative management with suction curettage. After informing the patients about the possible risks of uterine perforation and non-controllable uterine bleeding that may necessitate emergent hysterectomy, preparations were made for possible blood transfusion and hysterectomy. The procedures were performed under general anesthesia with ultrasonographic guidance. Patients with full bladders were laid on the operation table in the lithotomy position, and a convex abdominal probe was inserted into the suprapubic region to visualize the uterus along the longitudinal axes. After inserting the speculum into the vagina, the cervix was swabbed with gauze, and the anterior lip was caught with a toothed tenaculum. The cervix was dilated with Hegar dilators (BahadırÒ, Samsun, Turkey) until it reached the 5-mm diameter and the Karman cannula (MedbarÒ, Izmir, Turkey) could be inserted. After carefully introducing the Karman cannula into the uterus, the gestational villi and decidual endometrium were removed. There were no intraoperative complications, such as scar dehiscence or perforation. Estimated blood loss ranged from 100 to 250 mL, and intrauterine instrumentation was not required for hemostasis. Postoperative hemogram follow-up remained stable, and no vaginal bleeding was observed. After patients’ b-hCG levels decreased, they were discharged on the second or third postoperative day. Patient 1 was admitted for evaluation of secondary amenorrhea. The initial serum b-hCG level was 810 mU/mL and there was a 7.4 mm GS at the lower segment of the uterus adjacent to the scar. The patient was observed for 2 days after hospitalization and serum b-hCG levels increased to 1,681 mU/mL, and GS diameter increased to 10 mm (Fig. 1). Patient 2 presented to the outpatient clinic at 6 weeks for amenorrhea without vaginal bleeding or pain (Fig. 2). Patient 3 was admitted to the emergency service complaining of heavy vaginal bleeding for 3 days. Transvaginal ultrasonography revealed a GS diameter of 24 mm at the cesarean scar (Fig. 3). Patient 4 complained of delay of menstruation and vaginal spotting (Fig. 4). All of the patients were followed up for 2 weeks after the operation. No persistent trophoblastic tissue was observed and b-hCG levels decreased. Patient 3 conceived 3 months after the suction curettage, and the pregnancy progressed without complication.
Discussion We present four cases of CSP treated successfully with suction curettage. The most important factor in treating CSP is early diagnosis, particularly before 8 weeks’ gestation. As already mentioned before, treatment options range from
observation to hysterectomy. For this case series, suction curettage was used as a minimally invasive treatment method and no intra- or post-operative complications were observed. Using transabdominal ultrasonographic guidance is important because it provides the clinician with accurate location and helps avoid complications. In our series, none of the patients received MTX before suction curettage. b-hCG levels ranged between 1,681 and 15,573 mU/mL and GS diameters ranged between 10 and 24 mm. The minimum thickness of the myometrium at the scar region was 4.7 mm and the maximum was 6.9 mm. CSP is an iatrogenic complication that was first reported by Larsen and Solomon [4]. The incidence of CSP has been estimated to be between 1:1,800 and 1:2,226 of pregnancies [5], but has increased in recent years correlating with the increased rates of cesarean section. CSP can be easily recognized with ultrasonographic examination and Doppler ultrasonography. Transvaginal ultrasonography must be carefully performed in symptomatic pregnant women with previous cesarean section to identify the localization of the GS and its relation with the scar region. Criteria for diagnosing CSP include an empty cavity and cervical canal with trophoblastic activity of the GS on Doppler examination at the anterior part of the isthmic level, and diminished myometrial thickness between the GS and the bladder [3]. Differential diagnoses include spontaneous abortion and cervico-isthmic pregnancy. Using ultrasonographic criteria, especially observing a defective myometrial layer between the GS and the bladder, is important to distinguish CSP from other conditions. D&C is a risky alternative to minimally invasive treatment and may necessitate a salvage therapy. Complications of D&C include uterine perforation, massive bleeding, and conversion to hysterectomy. Before performing D&C, the patient must be informed about the possible complications of the procedure and the operation room must be properly prepared for an emergency hysterectomy. Using transabdominal ultrasonographic guidance facilitates the clinician in detecting the location of the GS and avoiding uterine perforation. Proper curettage technique is another important factor that may decrease the risk of complications. Using a soft suction cannula is preferred over using a sharp curettage and the procedure should be performed with care. Integrity of the scar region, distance to the bladder and close settlement of the GS to the cesarean scar should be considered during the operation. In the literature, treatment of CSP has been reported with primary evacuation alone or in association with other methods. Arslan et al. [6] presented a case of CSP at 7 weeks gestation with a GS 3.5 mm away from the bladder, and the patient was treated uneventfully with suction curettage. Nonaka et al. [7] presented a case of CSP in which the patient was treated unsuccessfully by D&C,
123
Arch Gynecol Obstet
presented with abundant vaginal bleeding 10 weeks after the procedure and underwent hysterectomy. In a study of eight women who were treated with suction curettage, Jurkovic et al. [2] reported that 38 % of the patients had suffered from heavy vaginal bleeding and Foley catheters were inserted to the uterus to achieve hemostasis. Seow et al. [8] misdiagnosed two cases of CSP as inevitable abortion, and D&C procedures ended with abundant vaginal bleeding. One of the patients underwent hysterectomy. The other patient was managed with a Foley catheter balloon for tamponade and her uterus was preserved. In another study, Polat et al. [9] performed D&C on four of the six patients and only one patient had abundant vaginal bleeding and underwent laparotomy. The author commented that D&C may be preferred for treating CSP detected at less than 7 weeks’ gestation, but if the gestational age was greater than 7 weeks, other surgical or medical treatment modalities should be performed. Wang et al. [10] performed primary evacuation for three cases of CSP and one had perforation that was laparoscopically repaired. Ash et al. [11] performed evacuation on eight patients and three of them had a Foley catheter inserted into the cervix to achieve hemostasis. Primary evacuation has a high risk of complications such as abundant vaginal bleeding and uterine perforation and most authors have reported that the procedure is likely to necessitate salvage therapy. Furthermore, evacuation therapy can be performed with other treatment modalities to reduce complication rates and to decrease the risk of morbidity and mortality. In a recent study, in which local and systemic MTX administration was followed by suction curettage in 45 patients, only three patients had salvage therapy. In this study, b-hCG levels decreased faster and patients were discharged sooner from the hospital than patients on MTX medication alone [12]. Fahg et al. [13] treated 51 cases of CSP with uterine artery embolization (UAE) and D&C with or without pretreatment medical therapy. They reported that UAE and D&C without medical therapy were safe and effective for terminating CSP and had the advantages of short hospital stay, less blood loss and low risk of hysterectomy. Yin et al. [14] managed 13 cases of CSP with UAE followed by vacuum aspiration and only one patient had a laparotomy because of intractable hemorrhage. All patients underwent vacuum aspiration 6–8 h after UAE. Pretreatment median day of amenorrhea was 57 days and b-hCG levels increased from 1,971 to 59,322 mU/mL. In another retrospective cohort study performed on 11 women treated with UAE and D&C, only three patients were free of complications after the procedure [15]. The authors stated that D&C was a risky treatment option associated with severe complications and hysterectomy.
123
However, regarding the complicated cases with severe bleeding or large GS, the outcomes were strikingly better with UAE followed by D&C. Zhang et al. [16] reported that eight of ten women were misdiagnosed as inevitable abortion and underwent D&C, complicated with heavy vaginal bleeding of 1,000–3,500 mL. Five cases were successfully treated with UAE followed by D&C, and three cases underwent hysterectomy. Administration of MTX and consecutive D&C was performed in two cases. Recently, a new method of performing UA chemoembolization with MTX and subsequent D&C was reported to be more likely to avoid any severe complications. Duration of hospitalization was shortened and risks of massive vaginal bleeding and hysterectomy were lowered with this treatment option [17]. The implantation patterns of CSP can be classified into endogenic and exogenic types. The endogenic form grows through the uterine cavity and allows the pregnancy to progress with a higher risk of massive bleeding. The exogenic type is localized to the dehiscence tract and progresses through the deep myometrial layer resulting in the rupture of the cesarean scar [18]. Furthermore, the placenta is circumscribed by myometrium and fibrotic tissue of the wound. This scarred region is not suitable and strong enough for the development of the pregnancy. The lower resistance and strength of the fibrotic tissue lead to the undesirable results. D&C increases the risk of uterine wall perforation and heavy vaginal bleeding. Before attempting D&C, the thickness of the scar region and distance from the urinary bladder must be evaluated carefully to avoid the complications. Because of the increased popularity of cesarean section, CSP rates are likely to increase throughout the world. Although a diverse range of treatments has been previously reported, there is no standard treatment approach. Clinicians should determine the method of therapy on an individualized basis and should first consider several parameters, such as gestational age, serum b-hCG levels, myometrial thickness, initial clinical presentation and desire for uterus preservation. D&C may be an alternative for cases at early gestation that have lower levels of b-hCG and a myometrial thickness of more than 4.5 mm. Conflict of interest Authors state that there is no competing interest or financial disclosure for this manuscript.
References 1. Rotas MA, Haberman S, Levgur M (2006) Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 107:1373–1381
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