Cesarean scar pregnancy - a new challenge for obstetricians

Abstract

Diagnosis and treatment of ectopic cesarean scar pregnancy has become a challenge for contemporary obstetrics. With an increase in the number of pregnancies concluded with a cesarean section and with the development of transvaginal ultrasonography, the frequency of cesarean scar pregnancy diagnoses has increased as well. The aim of the study is to evaluate various diagnostic methods (ultrasonography in particular) and analyze effective treatment methods for cesarean scar pregnancy. An ultrasound scan, Doppler examination and magnetic resonance imaging are all useful in early detection of asymptomatic cesarean scar pregnancy, thus enabling effective treatment and preservation of fertility. Dilatation and curettage is not recommended as it carries significant risk of bleeding and very high risk of hysterectomy and fertility loss. Systemic methotrexate treatment should not be applied on the routine basis due to its low efficacy, high risk of fertility loss and adverse effects. Local methotrexate therapy (under ultrasound or hysteroscopy guidance) should be considered a perfect management method as it offers fertility preservation in asymptomatic pregnant patients without concomitant hemodynamic disorders. Synchronous usage of several treatment methods is an effective way to manage cesarean scar pregnancy. The combination of local methotrexate with simultaneous aspiration of gestational tissues under ultrasound or hysteroscopy guidance seems optimal. Subsequently, the remaining gestational tissues can be removed hysteroscopically in combination with vascular coagulation at the implantation site. In more advanced cases, local methotrexate treatment should be considered followed by laparoscopic or laparotomic wedge resection with subsequent surgical correction of the cesarean section scar.

Keywords: cesarean scar pregnancy; ectopic pregnancy; methotrexate; transvaginal transducer; ultrasonography.

Fig. 1

TV US. Longitudinal section of the uterus. Cesarean scar pregnancy (week 6 day 1) (authors’ own material)

Fig. 2

TV US. Longitudinal section of the uterus and cervix 5 months after effective cesarean scar pregnancy treatment (authors’ own material)

Fig. 3

TV US with color Doppler imaging. Longitudinal section of the uterus with CSP (week 6 day 3) with visible fetal heart rate; CSP protruding towards the urinary bladder with strong peripheral color Doppler signal⁽⁵⁾

Fig. 4

Color Doppler US. Turbulent flow surrounding CSP, with high peak systolic velocity (65.2 m/s) and low resistance index (0.52)(⁽¹⁴⁾

Fig. 5

3D US. Gestational sac protruding towards the urinary bladder⁽¹⁸⁾

Fig. 6

Sagittal T2-weighted MRI. CSP (week 8 day 3) in the lower segment of the anterior uterine wall in a cesarean section scar (arrow). Thin myometrium between the gestational sac and urinary bladder⁽¹⁹⁾