Introduction: The incidence of cesarean scar pregnancies (CSPs) has increased worldwide due to increase in cesarean deliveries. Laparoscopic management is an effective strategy to deal with CSP resulting in immediate recovery, remediation, and repair of the cesarean scar defect. The diagnosis and management of CSP are challenging, and awareness of this condition is needed among the patients and obstetricians.
Aims and objectives: To study preventable factors, role of minimal access surgery, and outcome in CSPs over a period of 2 years.
Materials and methods: It is a retrospective cohort study in which patient's demographic characteristics, previous obstetric and surgical record, β-hCG, USG parameters, clinical presentation, contraception, etc., were studied.
Results: Eleven cases of CSPs were admitted in a tertiary care hospital from 2019 to 2021. Median maternal age was 28 years with a median parity of two. The most common presenting symptom was vaginal bleeding. Nine out of eleven cases were successfully managed by laparoscopy. Hysteroscopy and ultrasonography were found very useful intraoperatively. Two patients required exploratory laparotomy. One patient had an intrauterine pregnancy following the CSP.
Conclusion: Minimal access surgery remains the mainstay for the treatment of CSP in stable patients. Hysteroscopy and ultrasonography could be very useful during laparoscopic management of CSP. Cesarean scar pregnancy preventable factors are to be taken into consideration while performing cesarean section as the CSP incidence is increasing.
Clinical significance: This study will help in finding out risk factors to CSP. Preventive factors of CSP, if studied further in detail, can help in reducing the incidence of this dreadful pathology. Early diagnosis and timely intervention with the help of minimal access surgery can save young women from losing their fertility.
Jurkovic D, Hillaby K, Woelfer B, et al. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol 2003;21(3):220–227. DOI: 10.1002/uog.56.
Seow K, Huang L, Lin Y, et al. Cesarean scar pregnancy: Issues in management. Ultrasound Obstet Gynecol 2004;23(3):247–253. DOI: 10.1002/uog.974.
Timor-Tritsch IE, Monteagudo A, Santos R, et al. The diagnosis, treatment and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol 2012;207:44–46. DOI: 10.1016/j.ajog.2012.03.007.
Maymon R, Svirsky R, Smorgick N, et al. Fertility performance and obstetric outcomes among women with previous cesarean scar pregnancy. J Ultrasound Med 2011;30(9):1179–1184. DOI: 10.7863/jum.2011.30.9.1179.
Yazicioglu F, Gokdogan A, Kelekci S, et al. Incomplete healing of the uterine incision after caesarean section: Is it preventable? Eur J Obstet Gynecol Reprod Biol 2006;124(1):32–36. DOI: 10.1016/j.ejogrb.2005.03.023.
Vervoort AJ, Uittenbogaard LB, Hehenkamp WJ, et al. Why do niches develop in caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod 2015;30(12):2695–2702. DOI: 10.1093/humrep/dev240.
Vachon-Marceau C, Demers S, Bujold E, et al. Single versus double-layer uterine closure at cesarean: Impact on lower uterine segment thickness at next pregnancy. Am J Obstet Gynecol 2017;217(1):65.e1–65.e5. DOI: 10.1016/j.ajog.2017.02.042.
Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. BJOG 2007;114(3):253–263. DOI: 10.1111/j.1471-0528.2006.01237.x.
Diagnosis and management of ectopic pregnancy: Green-top guideline no. 21. BJOG 2016;123(13):e15–e55. DOI: 10.1111/1471-0528.14189.
Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2000;16(6):592–593. DOI: 10.1046/j.1469-0705.2000.00300-2.x.
Larsen JV, Solomon MH. Pregnancy in a uterine scar sacculus--an unusual cause of postabortal haemorrhage. A case report. S Afr Med J 1978;53(4):142–143. PMID: 653492.
Jayaram PM, Okunoye GO, Konje J. Caesarean scar ectopic pregnancy: Diagnostic challenges and management options. Obstet Gynaecol 2017;19(1):13–20. DOI: 10.1111/tog.12355.
Xiao J, Zhang S, Wang F, et al. Cesarean scar pregnancy: Noninvasive and effective treatment with high-intensity focused ultrasound. Am J Obstet Gynecol 2014;211(4):356.e1–356.e7. DOI: 10.1016/j.ajog.2014.04.024.
Chuang J, Seow KM, Cheng WC, et al. Conservative treatment of ectopic pregnancy in a caesarean section scar. Br J Obstet Gynecol 2003;110(9):869–870. PMID: 14511972.
Chen Y, Han P, Wang YJ, et al. Risk factors for incomplete healing of the uterine incision after cesarean section. Arch Gynecol Obstet 2017;296(2):355–361. DOI: 10.1007/s00404-017-4417-6.
Antila-Langsjo RM, Maenpaa JU, Huhtala HS, et al. Cesarean scar defect: A prospective study on risk factors. Am J Obstet Gynecol 2018;219(5):458.e1–458.e8. DOI: 10.1016/j.ajog.2018.09.004.
Luo L, Ruan X, Li C, et al. Early clinical features and risk factors for cesarean scar pregnancy: A retrospective case-control study. Gynecol Endocrinol 2019;35(4):337–341. DOI: 10.1080/09513590.2018.1526276.
Shinagawa S, Nagayama M. Cervical pregnancy as a possible sequela of induced abortion. Report of 19 cases. Am J Obstet Gynecol 1969;105(2):282–284. DOI: 10.1016/0002-9378(69)90075-1.
Shi M, Zhang H, Qi SS, et al. Identifying risk factors for cesarean scar pregnancy: A retrospective study of 79 cases. Ginekol Pol 2018;89(4):195–199. DOI: 10.5603/GP.a2018.0033.
Lin Y, Xiong C, Dong C, et al. Approaches in the treatment of cesarean scar pregnancy and risk factors for intraoperative hemorrhage: A retrospective study. Front Med (Lausanne) 2021;8:682368. DOI: 10.3389/fmed.2021.682368.
Bodur S, Ozdamar O, Kilic S, et al. The efficacy of the systemic methotrexate treatment in caesarean scar ectopic pregnancy: A quantitative review of English literature. J Obstet Gynaecol 2015;35(3):290–296. DOI: 10.3109/01443615.2014.954101.
Drever N, Bertolone J, Shawki M, et al. Caesarean scar ectopic pregnancy: Experience from an Australian tertiary centre. Aust N Z J Obstet Gynaecol 2020;60(3):330–335. DOI: 10.1111/ajo.13119.