Cesarean Scar Ectopic Pregnancy Current Management Strategies Prof. Aboubakr Elnashar Benha University Hospital, Egypt

1. Cesarean Scar Ectopic
Pregnancy
Current Management Strategies
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt
ABOUBAKR ELNASHAR

2. PREVALENCE
 An increase
 Rising rate of CS
 Better awareness
 Diagnostic techniques
ABOUBAKR ELNASHAR

3.  Term CSEP is misleading
 occur after any myometrial trauma
 myomectomy
 manual removal of placenta
 D&C
 IVF.
 1 CS:
 6% risk of CSEP
ABOUBAKR ELNASHAR

4. PRESENTATION
 No symptoms: 37%
 Painless vaginal bleeding: 39%
 Generalized abdominal pain:25%.
(Rotas et al.2006)
ABOUBAKR ELNASHAR

5.  Miscarriage
 Vaginal bleeding: usually heavier
 US:
 gestational sac within either the cervix or lower
uterine segment
 no blood flow on Doppler examination,
indicating a detached gestational sac.
 Cervical pregnancy
 a bulbous region within the cervix
 blood flow surrounding the gestational sac
 layer of myometrium between the pregnancy and
the bladder.
 CSEP
 either limited or no myometrium between the
pregnancy and the bladder
 cervical canal is empty
ABOUBAKR ELNASHAR

6. PATHOGENESIS
 Impaired wound healing
 after previous trauma:
 myometrial defects: scar at which the blastocyst
implants.
 may be secondary to
 systemic diseases (DM): poor blood flow
 poor tissue quality
 inadequate collagen formation
 postoperative wound infections
 short-interval pregnancy
 improper closure
ABOUBAKR ELNASHAR

7. DIAGNOSIS
 Positive pregnancy test
 TVUS:
1. Empty uterus& cervical canal
2. GS at the hysterotomy site
3. Thin or absent myometrial tissue between bladder
& GS
4. Vascular area noted at the previous cesarean
scar
ABOUBAKR ELNASHAR

8. TVUS sagittal view.
1 = Empty endocervical canal
2 = cesarean scar
3 = gestational sac
4 = empty uterine cavity.ABOUBAKR ELNASHAR

9. Types
 Type 1 (endogenic)
 GS grows inward toward the cervicoisthmus
space
 Type 2 (exogenic)
 GS grows outward toward the bladder& abd
wall
 Determining the type help
 counseling on expectant management
 optimal medical/surgical approach for
termination.
ABOUBAKR ELNASHAR

10. ABOUBAKR ELNASHAR

11. TREATMENT
 ≥30 different treatment modalities
 Success rate&
 Morbidity& mortality
 vary with each method
 dependent on
 patient stability
 desire for future fertility.
ABOUBAKR ELNASHAR

12. COUNSELING CONSIDERATIONS
 Significant challenges
 morbidities
 desire for future fertility
 lack of consensus on treatment approach
 TERMINATION SOON AFTER DIAGNOSIS
 Prevents
 uterine rupture
 placentation abnormalities
 invasion into surrounding organs
 hge
 other complications
 DIC, hypovolemic shock& death.
ABOUBAKR ELNASHAR

13.  Expectant management:
 High likelihood of cesarean hysterectomy
 Close surveillance until complete resolution of the
pregnancy is confirmed.
ABOUBAKR ELNASHAR

14. TREATMENT OPTIONS
1. EXPECTANT
2. MEDICAL
3. UAE
4. SURGICAL
5. COMBINATION.
ABOUBAKR ELNASHAR

15. I. EXPECTANT MANAGEMENT
 Should not be recommended
 as 1st -line TT in most individuals
1.Complications
2. Poor outcomes
 High failure rate (44%–91%)
 Requiring additional interventions such as
surgery
ABOUBAKR ELNASHAR

16.  Complications: ≥50% of patients
1. hysterectomy
2. cesarean hysterectomy
3. preterm delivery
4. uterine rupture
5. future infertility
6. significant hge
(Maheux-Lacroix et al, 2014)
7. Maternal death
Ruptured ectopic pregnancies: 2.7% of
maternal deaths
ABOUBAKR ELNASHAR

17.  An option when
 patient desires to
 let nature take its course
 continue the pregnancy.
 Should be undertaken only with
1. thoroughly counseled
2. close surveillance& follow-up
3. stable
4. minimal symptoms
5. compliant patients
6. type 1 CSEP
 Better outcomes when
 no fetal cardiac activity
 declining β-hCG..
(Mollo et al, 2014)
ABOUBAKR ELNASHAR

18. II. MEDICAL TREATMENT
 Candidates
 ≤ 8 w
 absent fetal cardiac activity
 stable
 β-hCG ≤5000 to 12,000 mIU/mL
 ≥ 2-mm thickness between myometrium& bladder.
(Gonzalez , Tulandi,SR 2017)
 Additional surgical or medical management
 should be considered if the CSEP does not resolve
with the initial MTX treatment.
ABOUBAKR ELNASHAR

19. Methotrexate
 Routes of administration
1. Locally
2. Systemic
 single-dose: 1 mg/kg or 50 mg/m2 of body
surface area.
 2to3 IM (1mg/kg BW or 50 mg/mm2 of surface area) at
an interval of 2 or 3 days over course of a week.
3. US guided local, plus sys MTX:
25mg in GS, 25mg in F placenta, 25mg IM
4. In combination with surgical management.
ABOUBAKR ELNASHAR

20.  Success for local MTX if
 Myometrial thickness between GS& bladder: ≥
2mm
 β-hCG level: low
 wide range from ≤5,000 to 10,000 mIU/mL has
been reported.
(Parker et al, 2006)
ABOUBAKR ELNASHAR

21.  Pretherapeutic scoring model for treatment
(Dior et al, 2018)
 Rates of conversion to surgical treatment
1 2 3
G age(w) ≤6 6-8 ≥8
Abd pain absent present
B HCG (IU) ≤3000 3000-10000 ≥10000
G sac(mm) ≤10 10-25 ≥25
Score 6 7-8 9
Conversion to surgical TT(%) 0 15 44
ABOUBAKR ELNASHAR

22.  Success for either local or systemic MTX
 similar (50%–66%)
 increases moderately when given in more than 1
dose.
(Gonzalez N, Tulandi,SR 2017)
 The simultaneous administration of MTX both locally&
systemically
 No improve outcomes compared with a multidose
protocol.
(Jurkovic et al, 2003)
ABOUBAKR ELNASHAR

23.  Complications
 Significant hge
 Surgical intervention
 Hysterectomy
 Need for further intervention is common
(Jurkovic et al, 2003)
 Adverse effects: rare
 alopecia
 pneumonitis
 bone marrow suppression
 stomatitis
(Mollo et al, 2014)
 In severe cases, cirrhosis and hepatic fibrosis
 routine laboratory evaluation of hepatic and renal function was
unnecessary in healthy women.
ABOUBAKR ELNASHAR

24. III. UTERINE ARTERY EMBOLIZATION
 Not 1st line option
 for patients who desire future fertility.
 {high failure& complication rates
 potential detrimental impact to future fertility}.
 Should be undertaken only in those with
 arteriovenous malformations or
 when there is significant bleeding
(Kanat-Pektas et al, 2016)
ABOUBAKR ELNASHAR

25. IV. SURGICAL
 Including
 D&C
 Direct excision via
 abdominal
 laparoscopic
 hysteroscopic
 vaginal approach
 Combination approach
 Definitive management with hysterectomy.
ABOUBAKR ELNASHAR

26.  Choosing the method
1. skill of the surgeon
2. patient presentation
3. desire for future fertility
 lack of high-quality studies makes it difficult to
propose evidence-based guidelines.
ABOUBAKR ELNASHAR

27. 1. HYSTEROSCOPY
 To remove CSEP either
 alone or
 with adjuvant medical therapy.
 Methods
 hysteroscopic removal of tissue
 aspiration of GS after medication
 injection of MTX or ethanol into the GS.
(Gonzalez N, Tulandi et al, SR, 2017)
 Best indicated in
type 1 CSEP.
ABOUBAKR ELNASHAR

28.  Success rate:
 variable rate
 requirement for additional procedures, including
hysterectomy
(Maheux-Lacroix et al, SR, 2017)
 Higher in
 lower gravidity/parity
 fewer prior CS
 earlier gestational age at time of procedure.
ABOUBAKR ELNASHAR

29.  ASRM, 2016:
 hysteroscopy could be used to remove CSEP via
direct visualization or US assistance.
 dissection of the CSEP from the uterine wall using
electrosurgery had
 high success rate
 extremely low complication rate
 should be considered safe& effective
 Complications: Rare
 Fluid overload, electrolyte imbalances, perforation, infection, and hospital
admission.
ABOUBAKR ELNASHAR

30. 2. LAPAROTOMY
 Very few data on laparotomy as 1st choice
 Performing
 myometrial wedge excision
 Advantages:
 Direct visualization of the lower uterine segment
(Maheux-Lacroix et al, SR, 2017)
 Success rate
 high
 with a low complication rate
 myometrium between GS& bladder ≥2 mm.ABOUBAKR ELNASHAR

31.  ACOG 2017
 Laparotomy:
 not considered 1st line treatment
 should be avoided for CSEP management if
possible.
1. potential morbidity
 bladder/ureter injuries
 intraoperative blood loss
 wound complications
2. invasive nature
3. longer duration of hospital stay, operating time
4. slower return to normal activity
 MIS
 should be 1st line if the surgeon is adequately
trained
ABOUBAKR ELNASHAR

32. 3. COLPOTOMY TV approach
 Steps:
 An anterior colpotomy incision to access the CSEP
 Removal&repair of previous scar.
(Maheux-Lacroix et al, SR, 2017)
 Many studies supports
 use of a TV hysterotomy for
 stable patients
 who desire future fertility
 Advantages:
 Morbidity: minimal
 Success rates: ≥90%.
 Faster resolution of β-hCG when compared with
UAE or hysteroscopic removal +MTX.ABOUBAKR ELNASHAR

33.  The least to be utilized compared with hysterotomy
via laparoscopy or laparotomy.?
(Kanat-Pektas et al, 2016)
1. Incomplete visualization of
 CSEP
 Previous hysterotomy scar±: persistent
embryonic tissue
3. Risks
 Infection
 bleeding
 damage to surrounding structures.
ABOUBAKR ELNASHAR

34. 4. LAPAROSCOPY
 Best suited in
 type 2 CSEP
(Gonzalez N, Tulandi SR, 2017)
 Steps:
 Laparoscopic hysterotomy with wedge resection of
the CSEP& previous scar
 Temporarily occluding blood supply to the uterus:
 decrease blood loss
 enable complete resection of the CSEP
ABOUBAKR ELNASHAR

35.  It has been encouraged as one of the primary
approache
(Maheux-Lacroix et al SR, 2017)
1. minimally invasive
2. direct visualization of pregnancy
3. removal of the scar
4. success rate: 97%
5. faster resolution of β-hCG
6. long-term outcomes
 higher rate of subsequent pregnancies
 reduction of CSEP reoccurrence
ABOUBAKR ELNASHAR

36.  Risks of laparoscopic surgery
 initial entry into the abdomen
 perforation of vessels or intestines
 trocar site
 infection or hernia
 Advanced skills
 Nessaray
(Birch Petersen et al, 2016)
ABOUBAKR ELNASHAR

37. V. COMBINATION APPROACHES
1. MTX administered in combination with other
interventions
 UAE
 Hysteroscopic or laparoscopic removal of the ectopic
 Suction curettage
 Needle aspiration.
(Qiao et al, 2016)
 Success rate: ≥80%
 Greater with less morbid sequelae than MTX
alone.
 MTX + UAE
 MTX + hysteroscopic or laparoscopic excision
 MTX + needle aspiration
(Birch Petersen et al, SR, 2016) ABOUBAKR ELNASHAR

38.  Complications
 hge
 need for blood transfusion
 hysterectomy
 laparotomy, have been reported in all of these treatment
protocols
(Gonzalez , Tulandi et al, SR, 2017)
 MTX with or without surgical intervention
should not be considered as a primary method of
CSEP termination.?
1. likely need for additional intervention
2. potential for adverse events
(Gonzalez , Tulandi et al, SR, 2017)
ABOUBAKR ELNASHAR

39.  MTX with or without D&C or suction curettage
 conflicting results when compared with MTX alone.
 Some research:
 No differences.
(Gonzalez , Tulandi et al, SR, 2017)
 RCT:
 UAE + curettage Vs. MTX + curettage
 Fewer adverse events
 blood loss
 hospitalization
 resolution of β-hCG
(Qiao et al, SR, 2016)ABOUBAKR ELNASHAR

40. 3. Hysteroscopic resection in combination with
UAE, D&C & adjuvant MTX
 variable levels of success to accelerate the resolution of
the gestational sac.
ABOUBAKR ELNASHAR

41. CONCLUSION
ABOUBAKR ELNASHAR

42.  There are numerous strategies to treat CSEP,&
currently level I evidence is not available
 Level II evidence: any method that removes the
CSEP& previous scar (via transvaginal, laparoscopy, or
laparotomy) is best practice.
 high success rate
 minimal complications.
hge, hysterectomy, higher rate of preserved fertility.
 Level II evidence: supports any minimally invasive
method that removes the pregnancy& scar at once,
such as
 hysteroscopic or
 laparoscopic hysterotomy.ABOUBAKR ELNASHAR

43.  ASRM recommends (level III evidence)
 multiple mechanisms can be utilized
 D&C
 laparoscopy/laparotomy excision, or
 local or systemic MTX.
 Treatment should fit
 Patient
 hemodynamic status
 desire for future fertility
 compliance
 CSEP
 location
 gestational age
 Surgeon expertise.
ABOUBAKR ELNASHAR

44.  Expectant management
 highest of morbid outcomes
 Medical management
 often requires further treatment with additional
medication or surgery.
 high failure& complication rate
 not recommended as 1st -line approach.
ABOUBAKR ELNASHAR

45.  Different surgical methods
 UAE
 D& C
 surgical removal via vaginal, laparoscopic, or laparotomic
approach; & hysterectomy.
 Various levels of success depending on
 surgeon skill
 patient presentation.
 Optimal method should be
 as least invasive as possible
 pending surgeon ability and patient stability.ABOUBAKR ELNASHAR

46. You can get this lecture and 440
lectures from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3.elnashar53@hotmail.com
4.My clinic: Elthwara St. Mansura
ABOUBAKR ELNASHAR