Research Article
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Management and reproductive outcomes following cesarean scar pregnancy: experiences of two tertiary centers in a cohort of 60 women

Year 2024, , 256 - 264, 26.10.2024
https://doi.org/10.47582/jompac.1550289

Abstract

Aims: This study aims to analyze the treatment approaches and reproductive outcomes of women diagnosed with cesarean scar pregnancy (CSP).
Methods: A retrospective analysis was conducted on sixty patients diagnosed with CSP between January 2020 and December 2023 at two tertiary centers with a combined total of 49,733 births during the study period. Demographic, clinical, and laboratory characteristics, complications, treatment methods, and reproductive outcomes were examined. Patients were categorized into two groups based on their treatment approach: isolated treatment (n=45, 75%) and combined treatment (n=15, 25%), and the
outcomes of the two groups were compared.
Results: The mean age of all patients was 34 years (±5.5) (range: 21-46). The mean gestational age at admission was 6.86 weeks (±1.82), with 35% showing positive fetal heartbeats. Complications occurred in 28.3% of cases, with hematomas being the most common (26.7%). The combined treatment group had higher rates of blood transfusions and complications, including hematomas and bladder injuries (p=0.005 and p<0.001, respectively). Of the 16 patients (26.7%) who desired future pregnancy, 14 successfully conceived. Among these pregnancies, 7 resulted in early pregnancy loss, while 7 resulted in live births, all of which were delivered after 35 weeks of gestation.
Conclusion: Early diagnosis and evidence-based treatment of CSP are essential for preventing life-threatening obstetric complications. Larger, prospective studies are required to establish optimal diagnostic and treatment strategies.

Ethical Statement

Ethics Committee Approval: The study was initiated with the approval of the Ankara Etlik City Hospital Ethics Committee (Approval No. AESH-EK1-2023-683 ).

Supporting Institution

Financial Disclosure: The authors declared that this study has received no financial support.

Thanks

Acknowledgment: The authors extend their sincere admiration and appreciation to Prof. Dr. Can Tekin Iskender, whose profound expertise and experience significantly advanced our scientific progress and passed away so early.

References

  • Lai YM, Lee JD, Lee CL, Chen TC, Soong YK. An ectopic pregnancy embedded in the myometrium of a previous cesarean section scar. Acta Obstet Gynecol Scan. Published online January 1, 1995. Accessed February 23, 2024. https://www.tandfonline.com/ doi/abs/10.3109/00016349509024394
  • Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol. 2012;207 (1):14-29. doi:10.1016/j.ajog.2012.03.007
  • Huo S, Shen L, Ju Y, Liu K, Liu W. Treatments for cesarean scar pregnancy: 11-year experience at a medical center. J Matern Fetal Neonatal Med. 2023;36(1):2162818. doi:10.1080/14767058.2022.2162818
  • Seow KM, Huang LW, Lin YH, Yan-Sheng Lin M, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol. 2004;23(3):247-253. doi:10.1002/uog.974
  • Jaunıaux E, Burton GJ. Pathophysiology of placenta accreta spectrum disorders: a review of current findings. Clin Obstet Gynecol. 2018;61(4):743-754. doi:10.1097/GRF.0000000000000392
  • Tantbirojn P, Crum CP, Parast MM. Pathophysiology of placenta creta: the role of decidua and extravillous trophoblast. Placenta. 2008;29(7):639-645. doi:10.1016/j.placenta.2008.04.008
  • Jauniaux E, Hussein AM, Elbarmelgy RM, Elbarmelgy RA, Burton GJ. Failure of placental detachment in accreta placentation is associated with excessive fibrinoid deposition at the utero-placental interface. Am J Obstet Gynecol. 2022;226(2):243.e1-243.e10. doi:10.1016/j.ajog.2021.08.026
  • Timor-Tritsch IE, Monteagudo A, Cali G, et al. Cesarean scar pregnancy is a precursor of morbidly adherent placenta. Ultrasound Obstet Gynecol. 2014;44(3):346-353. doi:10.1002/uog.13426
  • Kaelin Agten A, Cali G, Monteagudo A, Oviedo J, Ramos J, Timor-Tritsch I. The clinical outcome of cesarean scar pregnancies implanted “on the scar” versus “in the niche.” Am J Obstet Gynecol. 2017;216(5):510.e1-510.e6. doi:10.1016/j.ajog.2017.01.019
  • Timor-Tritsch IE, Monteagudo A, Calì G, Kaelin Agten A, Palacios-Jaraquemada JM, D’Antonio F. Hidden in plain sight: role of residual myometrial thickness to predict outcome of cesarean scar pregnancy. Ultrasound Obstet Gynecol. 2023;62(5):624-632. doi:10.1002/uog.26246
  • Zhang X, Pang Y, Ma Y, et al. A comparison between laparoscopy and hysteroscopy approach in treatment of cesarean scar pregnancy. Med (Baltimore). 2020;99(43):e22845. doi:10.1097/MD. 0000000000022845
  • Morlando M, Buca D, Timor-Tritsch I, et al. Reproductive outcome after cesarean scar pregnancy: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2020;99(10):1278-1289. doi: 10.1111/aogs.13918
  • Wu J, Ye J, OuYang Z, et al. Outcomes of reproduction following cesarean scar pregnancy treatment: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2021;262:80-92. doi: 10.1016/j.ejogrb.2021.05.010
  • Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol. 2006;107(6):1373. doi:10.1097/01.AOG.0000218690.24494.ce
  • Timor-Tritsch IE, Monteagudo A, Cali G, El Refaey H, Kaelin Agten A, Arslan AA. Easy sonographic differential diagnosis between intrauterine pregnancy and cesarean delivery scar pregnancy in the early first trimester. Am J Obstet Gynecol. 2016;215(2):225.e1-225.e7. doi:10.1016/j.ajog.2016.02.028
  • Osborn DA, Williams TR, Craig BM. Cesarean scar pregnancy. J Ultrasound Med. 2012;31(9):1449-1456. doi:10.7863/jum.2012.31. 9.1449
  • Lee SR, Park SY, Park MH. Cesarean scar pregnancy associated with an impending uterine rupture diagnosed with 3-dimensional ultrasonography. Am J Obstet Gynecol. 2017;216(5):531.e1-531.e2. doi:10.1016/j.ajog.2017.02.023
  • Wang CB, Chiu WWC, Lee CY, Sun YL, Lin YH, Tseng CJ. Cesarean scar defect: correlation between cesarean section number, defect size, clinical symptoms and uterine position. Ultrasound Obstet Gynecol. 2009;34(1):85-89. doi:10.1002/uog.6405
  • Toro-Bejarano M, Mora R, Timor-Tritsch IE, et al. Myomectomy scar pregnancy ‒ a serious, but scarcely reported entity: literature review and an instructive case. Case Reports Perinatal Med. 2021;10 (1). doi:10.1515/crpm-2021-0071
  • Krassas GE, Poppe K, Glinoer D. Thyroid function and human reproductive health. Endocr Rev. 2010;31(5):702-755. doi: 10.1210/er.2009-0041
  • Vasilopoulou E, Loubière LS, Lash GE, et al. Triiodothyronine regulates angiogenic growth factor and cytokine secretion by isolated human decidual cells in a cell-type specific and gestational age-dependent manner. Hum Reprod. 2014;29(6):1161-1172. doi: 10.1093/humrep/deu046
  • Ozler S, Oztas E, Kebapcilar A, Caglar AT. The role of thyroid-stimulating hormone and thyroglobulin antibody in abnormally invasive placenta. J Mater Fetal Neonatal Med. 2022;35(25):5108-5116. doi:10.1080/14767058.2021.1875430
  • Timor-Tritsch IE, Khatib N, Monteagudo A, Ramos J, Berg R, Kovács S. Cesarean scar pregnancies: experience of 60 cases. J Ultrasound Med. 2015;34(4):601-610. doi:10.7863/ultra.34.4.601
  • Calì G, Timor-Trisch IE, Palacios-Jaraquemada J, et al. Changes in ultrasonography indicators of abnormally invasive placenta during pregnancy. Int J Gynecol Obstet. 2018;140(3):319-325. doi:10.1002/ijgo.12413
  • Cali G, Forlani F, Timor-Tritsch IE, Palacios-Jaraquemada J, Minneci G, D’Antonio F. Natural history ofc esarean scar pregnancy on prenatal ultrasound: the crossover sign. Ultrasound Obstet Gynecol. 2017;50(1):100-104. doi:10.1002/uog.16216
  • Shi J, Qin J, Wang W, Zhang H. [Clinical study on 57 cases with caesarean scar pregnancy]. Zhonghua Fu Chan Ke Za Zhi. 2014;49 (1):18-21.
  • Ko JKY, Li RHW, Cheung VYT. Caesarean scar pregnancy: a 10-year experience. Aust N Z J Obstet Gynaecol. 2015;55(1):64-69. doi: 10.1111/ajo.12273

Sezaryen skar gebeliği sonrası yönetim ve reprodüktif sonuçlar: 60 kadından oluşan bir kohortta iki üçüncül merkezin deneyimler

Year 2024, , 256 - 264, 26.10.2024
https://doi.org/10.47582/jompac.1550289

Abstract

Amaçlar: Bu çalışmanın amacı sezaryen skar gebeliği (CSP) tanısı almış kadınların tedavi yaklaşımlarını ve reprodüktif sonuçlarını analiz etmektir.
Yöntemler: Ocak 2020 ile Aralık 2023 tarihleri arasında, toplamda 49,733 doğumun gerçekleştiği iki üçüncü basamak merkezde CSP tanısı konmuş altmış hastanın retrospektif analizi yapıldı. Demografik, klinik ve laboratuvar özellikler, komplikasyonlar, tedavi yöntemleri ve reprodüktif sonuçlar incelendi. Hastalar, uygulanan tedavi yöntemine göre iki gruba ayrıldı: izole tedavi uygulananlar (n=45, %75) ve kombine tedavi uygulananlar (n=15, %25) ve bu grupların sonuçları karşılaştırıldı.
Sonuçlar: Hastaların ortalama yaşı 34 yıl (±5.5) (aralık: 21-46) idi. Başvuru sırasındaki ortalama gebelik yaşı 6.86 hafta (±1.82) olup, vakaların %35'inde fetal kalp atımı pozitif olarak saptandı. Vakaların %28.3'ünde komplikasyonlar gelişti ve en yaygın komplikasyon hematomdu (%26.7). Kombine tedavi grubunda kan transfüzyonu ve hematom ile mesane yaralanması gibi komplikasyonlar daha yüksek oranlarda görüldü (sırasıyla p=0.005 ve p<0.001). Tekrar gebelik isteyen 16 hastanın (%26.7) 14’ü başarılı bir şekilde gebe kaldı. Bu gebeliklerden 7’si erken gebelik kaybı ile sonuçlanırken, 7’si 35 haftadan sonra canlı doğumla sonuçlandı.
Tartışma: CSP'nin erken teşhisi ve kanıta dayalı tedavisi, hayatı tehdit eden obstetrik komplikasyonların önlenmesinde kritik öneme sahiptir. Optimal tanı ve tedavi stratejilerini belirlemek için daha geniş, prospektif çalışmalara ihtiyaç vardır.

References

  • Lai YM, Lee JD, Lee CL, Chen TC, Soong YK. An ectopic pregnancy embedded in the myometrium of a previous cesarean section scar. Acta Obstet Gynecol Scan. Published online January 1, 1995. Accessed February 23, 2024. https://www.tandfonline.com/ doi/abs/10.3109/00016349509024394
  • Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol. 2012;207 (1):14-29. doi:10.1016/j.ajog.2012.03.007
  • Huo S, Shen L, Ju Y, Liu K, Liu W. Treatments for cesarean scar pregnancy: 11-year experience at a medical center. J Matern Fetal Neonatal Med. 2023;36(1):2162818. doi:10.1080/14767058.2022.2162818
  • Seow KM, Huang LW, Lin YH, Yan-Sheng Lin M, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol. 2004;23(3):247-253. doi:10.1002/uog.974
  • Jaunıaux E, Burton GJ. Pathophysiology of placenta accreta spectrum disorders: a review of current findings. Clin Obstet Gynecol. 2018;61(4):743-754. doi:10.1097/GRF.0000000000000392
  • Tantbirojn P, Crum CP, Parast MM. Pathophysiology of placenta creta: the role of decidua and extravillous trophoblast. Placenta. 2008;29(7):639-645. doi:10.1016/j.placenta.2008.04.008
  • Jauniaux E, Hussein AM, Elbarmelgy RM, Elbarmelgy RA, Burton GJ. Failure of placental detachment in accreta placentation is associated with excessive fibrinoid deposition at the utero-placental interface. Am J Obstet Gynecol. 2022;226(2):243.e1-243.e10. doi:10.1016/j.ajog.2021.08.026
  • Timor-Tritsch IE, Monteagudo A, Cali G, et al. Cesarean scar pregnancy is a precursor of morbidly adherent placenta. Ultrasound Obstet Gynecol. 2014;44(3):346-353. doi:10.1002/uog.13426
  • Kaelin Agten A, Cali G, Monteagudo A, Oviedo J, Ramos J, Timor-Tritsch I. The clinical outcome of cesarean scar pregnancies implanted “on the scar” versus “in the niche.” Am J Obstet Gynecol. 2017;216(5):510.e1-510.e6. doi:10.1016/j.ajog.2017.01.019
  • Timor-Tritsch IE, Monteagudo A, Calì G, Kaelin Agten A, Palacios-Jaraquemada JM, D’Antonio F. Hidden in plain sight: role of residual myometrial thickness to predict outcome of cesarean scar pregnancy. Ultrasound Obstet Gynecol. 2023;62(5):624-632. doi:10.1002/uog.26246
  • Zhang X, Pang Y, Ma Y, et al. A comparison between laparoscopy and hysteroscopy approach in treatment of cesarean scar pregnancy. Med (Baltimore). 2020;99(43):e22845. doi:10.1097/MD. 0000000000022845
  • Morlando M, Buca D, Timor-Tritsch I, et al. Reproductive outcome after cesarean scar pregnancy: a systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2020;99(10):1278-1289. doi: 10.1111/aogs.13918
  • Wu J, Ye J, OuYang Z, et al. Outcomes of reproduction following cesarean scar pregnancy treatment: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2021;262:80-92. doi: 10.1016/j.ejogrb.2021.05.010
  • Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol. 2006;107(6):1373. doi:10.1097/01.AOG.0000218690.24494.ce
  • Timor-Tritsch IE, Monteagudo A, Cali G, El Refaey H, Kaelin Agten A, Arslan AA. Easy sonographic differential diagnosis between intrauterine pregnancy and cesarean delivery scar pregnancy in the early first trimester. Am J Obstet Gynecol. 2016;215(2):225.e1-225.e7. doi:10.1016/j.ajog.2016.02.028
  • Osborn DA, Williams TR, Craig BM. Cesarean scar pregnancy. J Ultrasound Med. 2012;31(9):1449-1456. doi:10.7863/jum.2012.31. 9.1449
  • Lee SR, Park SY, Park MH. Cesarean scar pregnancy associated with an impending uterine rupture diagnosed with 3-dimensional ultrasonography. Am J Obstet Gynecol. 2017;216(5):531.e1-531.e2. doi:10.1016/j.ajog.2017.02.023
  • Wang CB, Chiu WWC, Lee CY, Sun YL, Lin YH, Tseng CJ. Cesarean scar defect: correlation between cesarean section number, defect size, clinical symptoms and uterine position. Ultrasound Obstet Gynecol. 2009;34(1):85-89. doi:10.1002/uog.6405
  • Toro-Bejarano M, Mora R, Timor-Tritsch IE, et al. Myomectomy scar pregnancy ‒ a serious, but scarcely reported entity: literature review and an instructive case. Case Reports Perinatal Med. 2021;10 (1). doi:10.1515/crpm-2021-0071
  • Krassas GE, Poppe K, Glinoer D. Thyroid function and human reproductive health. Endocr Rev. 2010;31(5):702-755. doi: 10.1210/er.2009-0041
  • Vasilopoulou E, Loubière LS, Lash GE, et al. Triiodothyronine regulates angiogenic growth factor and cytokine secretion by isolated human decidual cells in a cell-type specific and gestational age-dependent manner. Hum Reprod. 2014;29(6):1161-1172. doi: 10.1093/humrep/deu046
  • Ozler S, Oztas E, Kebapcilar A, Caglar AT. The role of thyroid-stimulating hormone and thyroglobulin antibody in abnormally invasive placenta. J Mater Fetal Neonatal Med. 2022;35(25):5108-5116. doi:10.1080/14767058.2021.1875430
  • Timor-Tritsch IE, Khatib N, Monteagudo A, Ramos J, Berg R, Kovács S. Cesarean scar pregnancies: experience of 60 cases. J Ultrasound Med. 2015;34(4):601-610. doi:10.7863/ultra.34.4.601
  • Calì G, Timor-Trisch IE, Palacios-Jaraquemada J, et al. Changes in ultrasonography indicators of abnormally invasive placenta during pregnancy. Int J Gynecol Obstet. 2018;140(3):319-325. doi:10.1002/ijgo.12413
  • Cali G, Forlani F, Timor-Tritsch IE, Palacios-Jaraquemada J, Minneci G, D’Antonio F. Natural history ofc esarean scar pregnancy on prenatal ultrasound: the crossover sign. Ultrasound Obstet Gynecol. 2017;50(1):100-104. doi:10.1002/uog.16216
  • Shi J, Qin J, Wang W, Zhang H. [Clinical study on 57 cases with caesarean scar pregnancy]. Zhonghua Fu Chan Ke Za Zhi. 2014;49 (1):18-21.
  • Ko JKY, Li RHW, Cheung VYT. Caesarean scar pregnancy: a 10-year experience. Aust N Z J Obstet Gynaecol. 2015;55(1):64-69. doi: 10.1111/ajo.12273
There are 27 citations in total.

Details

Primary Language English
Subjects Obstetrics and Gynaecology
Journal Section Research Articles [en] Araştırma Makaleleri [tr]
Authors

Zeynep Şeyhanlı 0000-0003-3924-3723

Burak Bayraktar 0000-0001-6233-4207

Gülşan Karabay 0000-0003-2567-2850

Mevlüt Bucak 0000-0002-5035-8727

Nazan Vanlı Tonyalı 0000-0002-7284-6887

Gizem Aktemur 0000-0003-3696-1287

Betül Tokgöz 0000-0003-0202-4981

Büşra Demir Çendek 0000-0002-6338-1408

Şevki Çelen 0000-0001-7033-3474

Ali Çağlar 0000-0002-7022-3029

Yaprak Üstün 0000-0002-1011-3848

Publication Date October 26, 2024
Submission Date September 15, 2024
Acceptance Date October 1, 2024
Published in Issue Year 2024

Cite

AMA Şeyhanlı Z, Bayraktar B, Karabay G, Bucak M, Vanlı Tonyalı N, Aktemur G, Tokgöz B, Demir Çendek B, Çelen Ş, Çağlar A, Üstün Y. Management and reproductive outcomes following cesarean scar pregnancy: experiences of two tertiary centers in a cohort of 60 women. J Med Palliat Care / JOMPAC / Jompac. October 2024;5(5):256-264. doi:10.47582/jompac.1550289

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