RESUMO
OBJECTIVE: To describe an effective two-step surgical approach for the management of cesarean scar ectopic pregnancies (CSEPs). CSEPs occur at an estimated frequency of 1 in 1,800 pregnancies, constituting approximately 6% of ectopic pregnancies in women with a history of prior cesarean delivery [1, 2]. Despite numerous recommended therapeutic approaches, the most effective treatment strategy remains uncertain [3]. DESIGN: We present an innovative double-step technique for the management of a patient with a CSEP involving hysteroscopic subchorionic injection of methotrexate (MTX), followed by laparoscopic resection of the residual gestational sac and simultaneous repair of the uterine defect. SETTING: Academic tertiary hospital. PATIENT: A 34-year-old G2P1001 with a history of prior cesarean section presented at 10 weeks of gestation. Ultrasound revealed a gestational sac within the niche of the previous cesarean scar, confirming the diagnosis of a CSEP. The patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, and Scopus, among others), and other applicable sites. INTERVENTION: The initial treatment involved hysteroscopic administration of MTX within the placental intervillous spaces, ensuring precise medication delivery. The administered dose of MTX was 1 mg/kg. Following the normalization of beta-human chorionic gonadotrophin (ß-hCG) levels, laparoscopic resection of the remaining gestational sac and reconstruction of the uterine wall defect were performed. MAIN OUTCOME MEASURES: We have implemented a management strategy focusing on ectopic pregnancy removal and addressing defect revision. The hysteroscopic approach allows for a clear assessment of the ectopic pregnancy and facilitates precise MTX administration, enhancing its effectiveness by increasing drug concentration within the placental intervillous space. Delaying surgical repair until after the ß-hCG levels have decreased reduces the risk of excessive bleeding during the procedure, as lower ß-hCG levels are associated with reduced vascularity at the ectopic site. Subsequent laparoscopic resection allows for complete removal of the remaining products of conception and repair of the defect, preserving the uterus and restoring normal anatomy. Compared to other surgical approaches, our two-step approach enables a more precise evaluation of placental implantation, making it a highly effective surgical method. RESULTS: We successfully managed a CSEP using a double-step technique. This involved hysteroscopic injection of subchorionic MTX, followed by laparoscopic resection of the residual gestational sac. Concurrently, we repaired the uterine defect. Both procedures were performed in an outpatient setting without complications detected during or after treatment. At the follow-up visit, the patient reported good health, and subsequent ultrasound confirmed an empty isthmocele. CONCLUSION: This sequential hysteroscopic and laparoscopic approach represents a definitive and effective minimally invasive surgical option for the treatment of CSEP.
Assuntos
Abortivos não Esteroides , Cesárea , Cicatriz , Histeroscopia , Laparoscopia , Metotrexato , Gravidez Ectópica , Humanos , Feminino , Metotrexato/administração & dosagem , Gravidez , Gravidez Ectópica/cirurgia , Gravidez Ectópica/etiologia , Gravidez Ectópica/tratamento farmacológico , Gravidez Ectópica/diagnóstico , Histeroscopia/métodos , Cicatriz/etiologia , Cicatriz/cirurgia , Adulto , Cesárea/efeitos adversos , Abortivos não Esteroides/administração & dosagem , Laparoscopia/efeitos adversos , Saco Gestacional/cirurgia , Resultado do TratamentoRESUMO
Magnetic resonance imaging (MRI) can provide additional information in cases of cesarean scar pregnancy beyond the first trimester. MRI and 3D reconstructions can demonstrate the relationships between the uterus, cervix, bladder, and placenta, improving the spatial perspective of the pelvic anatomy in cases requiring surgical management. MRI and 3D reconstructions can also provide more comprehensive images for parental counseling, virtual and face-to-face multidisciplinary team discussion, and medical record storage.
Assuntos
Cesárea , Cicatriz , Imageamento por Ressonância Magnética , Primeiro Trimestre da Gravidez , Adulto , Feminino , Humanos , Gravidez , Cesárea/efeitos adversos , Cicatriz/diagnóstico por imagem , Imageamento Tridimensional/métodos , Imageamento por Ressonância Magnética/métodosRESUMO
Abstract Objectives: to determine efficiency and safety of three misoprostol regimens for 2nd trimester pregnancy termination in individuals with two or more cesarean section scars. Methods: a cross-sectional study included 100 pregnant ladies at 13th-26th weeks gestation with previous two cesarean sections (CSs) who were scheduled for pregnancy termination using misoprostol. Patients were conveniently assigned to 100µg/3h, 200µg/3h or 400 µg/3h regimens. Primary outcome was time to abortion, secondary outcomes were side effect and complications. Results: a significant association was found between number previous CSs and longer time to abortion (p=0.01). A highly significant association was identified between earlier gestational age and longer time to abortion (p<0.001). Lower side effects and complications were associated with 200 µg misoprostol every 3 hours of (p<0.001). Incomplete abortion was the most frequent recorded complication for the successive doses of misoprostol. Conclusions: misoprostol is an effective drug at low doses for pregnancy termination in women with prior two or more caesarean sections. However, its safety needs monitoring of the patient in the hospital to decrease morbidity and mortality behind its use.
Resumo Objetivos: determinar a eficiência e segurança de três regimes de misoprostol para interrupção da gravidez no segundo trimestre em indivíduos com duas ou mais cicatrizes de cesariana. Métodos: um estudo transversal incluiu 100 gestantes entre 13ª e 26ª semanas de gestação com duas cesarianas (CEs) anteriores que foram agendadas para interrupção da gravidez com uso de misoprostol. Os pacientes foram convenientemente designados para regimes de 100 µg/3 horas, 200 µg/3 horas ou 400 µg/3 horas. O desfecho primário foi o tempo para o aborto, os desfechos secundários foram efeitos colaterais e complicações. Resultados: foi encontrada associação significativa entre o número de cesáreas anteriores e o maior tempo até o aborto (p=0,01). Foi identificada associação altamente significativa entre idade gestacional mais precoce e maior tempo para abortar (p<0,001). Menores efeitos colaterais e complicações foram associados com 200 µg de misoprostol a cada 3 horas (p<0,001). O aborto incompleto foi a complicação mais frequente registrada para as doses sucessivas de misoprostol. Conclusões: o misoprostol é um medicamento eficaz em doses baixas para interrupção da gravidez em mulheres com duas ou mais cesarianas anteriores. Porém, sua segurança necessita de monitoramento do paciente no hospital para diminuir a morbimortalidade por trás de seu uso.
Assuntos
Humanos , Feminino , Gravidez , Segundo Trimestre da Gravidez , Misoprostol/administração & dosagem , Aborto Induzido , Recesariana , Estudos TransversaisRESUMO
OBJECTIVE: Cesarean scar pregnancy (CSP) is a potentially life-threatening disease that has been steadily increasing in prevalence. Pregnancy termination is usually recommended given the risk of life-threatening complications. In some cases, patients refuse to terminate viable CSPs, even after counseling. Recent studies report that, even with a high burden of possible complications and maternal morbidity, many CSPs progress to live, close to term births. The aim of this study is to further demonstrate the natural history of viable cesarean scar pregnancies. METHODS: We conducted a systematic review of original studies reporting cases of expectant management of CSPs with positive fetal heartbeats. RESULTS: After selection, 28 studies were included in the review, with a total of 398 cases of CSP, 136 managed expectantly and 117 with positive fetal heartbeat managed expectantly. This study confirmed that the majority of patients experience live births, as 78% of patients selected for expectant management experienced live births at or close to term, with 79% developing morbidly adherent placenta, 55% requiring hysterectomy, and 40% having severe bleeding. DISCUSSION: The optimal management protocol for CSP is still to be defined and more studies are needed to further elucidate this rare but rising disease. Our study provides information on the natural history of untreated CSPs and suggests that termination may not be the only option offered to the patient.
Assuntos
Aborto Induzido , Gravidez Ectópica , Gravidez , Feminino , Humanos , Cicatriz/etiologia , Conduta Expectante , Cesárea/efeitos adversos , Gravidez Ectópica/etiologia , Aborto Induzido/efeitos adversosRESUMO
A istmocele (ou "defeito cicatricial de cesariana") é uma alteração anatômica na parede uterina responsável por formar um "nicho", que é visualizado como uma área hipoecoica por histerografia ou por outros métodos de imagem, devido a uma cicatrização inapropriada de uma cesárea anterior. Essa modificação leva a complicações ginecológicas e obstétricas. Este estudo pretendeu analisar, entre os fatores de risco, a relação da istmocele com a técnica de fechamento uterino, comparando a sutura em camada simples com a dupla. Foi realizada uma revisão de literatura por meio de pesquisa bibliográfica em diferentes bases de dados eletrônicos. Foram encontrados 31 artigos, todavia apenas 13 estudos foram incluídos no presente estudo após avaliação criteriosa. A técnica de fechamento uterino é um dos fatores de risco possível de prevenir, sendo que a sutura em camada simples é associada a maior chance de se desenvolver a istmocele. A sutura de camada simples (ancorada) incluindo o endométrio está relacionada a menor espessura miometrial residual, associada a probabilidade de ruptura uterina e a istmocele, que a camada dupla não ancorada com a exclusão do endométrio.(AU)
The isthmocele is an anatomical alteration in the uterine wall responsible for forming a "niche", which is visualized as a hypoechoic area by hysterography or other imaging methods, due to inappropriate healing of a previous cesarean section. This modification leads to gynecological and obstetric complications. This study aimed to analyze among the risk factors the relation of isthmocele and the uterine closure technique comparing the single- and double-layer suture. It was conducted an electronic based search in different electronic databases. The research led to the retrieval of 31 articles; however only 13 studies were included in the present research after careful reading. The uterine closure technique is one of the possible risk factors to be modified; the single-layer suture is associated with a greater chance of developing isthmocele. The locked single-layer suture including the decidua is related to the decreased residual myometrial thickness, associated with the likelihood of uterine rupture and the isthmocele, than the double-layer unlocked excluding the decidua.(AU)
Assuntos
Humanos , Feminino , Gravidez , Cesárea/efeitos adversos , Cesárea/métodos , Técnicas de Fechamento de Ferimentos Abdominais/efeitos adversos , Ruptura Uterina , Fatores de Risco , Bases de Dados BibliográficasRESUMO
INTRODUCCIÓN Y OBJETIVOS: El embarazo en cicatriz de cesárea previa (ECC) es una entidad poco frecuente que puede tener graves consecuencias. Hasta la fecha no existen esquemas estandarizados de tratamiento y su manejo óptimo sigue siendo controvertido. Nuestro objetivo es realizar una revisión de la literatura publicada sobre el manejo del ECC y proponer un algoritmo. También exponemos tres casos de ECC resueltos con diferentes tratamientos en el Hospital Universitario Infanta Elena MÉTODOS: Búsqueda de la literatura en bases de datos utilizando las palabras clave: "embarazo en cicatriz cesárea"," gestación ectópica en cicatriz cesárea", "tratamiento", "manejo". RESULTADOS: Las opciones terapéuticas pueden ser médicas, quirúrgicas o una combinación de ambas. Los tratamientos quirúrgicos tienen altas tasas de éxito, sin embargo, son más invasivos y no están exentos de riesgo. La combinación de tratamientos parece aumentar la tasa de éxito, no obstante, podría implicar un mayor riesgo de efectos secundarios y costes. CONCLUSIONES: El manejo de los ECC debe de ser individualizado, basado en la evidencia científica, en los medios disponibles y la experiencia de los profesionales en los distintos procedimientos, guiándonos por el tipo de ECC y su grado de vascularización e invasión, grosor del miometrio, niveles de beta-hCG, presencia de actividad cardiaca, clínica y estabilidad hemodinámica de la paciente. Deben tenerse en cuenta las circunstancias y patología intercurrente de la mujer, así como su deseo genésico o de preservación del útero.
INTRODUCTION AND OBJECTIVES: Cesarean scar pregnancy (CSP) is a rare entity that can cause serious consequences. Up to now, there are no standardized treatment schemes, and its optimal management remains controversial. Our objetive is to review the literature regarding CSP management and propose an algorithm. We also present three cases of CSP resolved with different treatments at Hospital Universitario Infanta Elena. METHODS: Literature search in databases using the following keywords: pregnancy with cesarean section, ectopic pregnancy with cesarean section, treatment, management. RESULTS: The therapeutic options can be medical, surgical or a combination of both. Surgical treatments have high success rates; however, they are more invasive and are not without risk. The combination of treatments seems to increase the success rate; however, it could imply a higher risk of side effects and costs. CONCLUSIONS: The management of CSP must be individualized; based on scientific evidence, on the means available, and on the experience of the professionals in the different procedures; guided by the type of CSP and its degree of vascularization and invasion, by the thickness of the myometrium, beta-hCG levels, presence of cardiac activity, and by clinical and hemodynamic stability of the patient. The circumstances and intercurrent pathology of the patient must be considered, as well as her desire for future pregnancy or preservation of the uterus.
Assuntos
Humanos , Feminino , Gravidez , Adulto , Gravidez Ectópica/terapia , Cesárea/efeitos adversos , Cicatriz/etiologia , Cicatriz/terapia , Gravidez Ectópica/cirurgia , Gravidez Ectópica/tratamento farmacológico , Metotrexato/uso terapêutico , Cicatriz/cirurgia , Cicatriz/tratamento farmacológico , Embolização da Artéria Uterina , Ablação por Ultrassom Focalizado de Alta Intensidade , HisterectomiaRESUMO
Cesarean scar (ectopic) pregnancy is due to blastocyst implantation on a Caesarean scar. The current case presented by vaginal bleeding after a failed surgical termination of pregnancy. The ultrasound scan revealed a cesarean scar ectopic pregnancy managed by surgical removal. The possibility of cesarean scar ectopic pregnancy should be considered in any case presenting with a low-lying gestational sac.
Assuntos
Aborto Espontâneo , Gravidez Ectópica , Cesárea/efeitos adversos , Cicatriz/complicações , Cicatriz/diagnóstico por imagem , Cicatriz/patologia , Feminino , Humanos , Gravidez , Primeiro Trimestre da Gravidez , Gravidez Ectópica/diagnóstico por imagem , Gravidez Ectópica/etiologiaRESUMO
We report a case of a secundipara with heterotopic cesarean scar pregnancy (HCSP) treated with potassium chloride injection into the ectopic embryo followed by sac aspiration. The remaining "mass" increased in size threefold and was surrounded by a rich vascular network. An arteriovenous malformation was suspected; however, appropriate treatment was precluded because of the viability of the ectopic gestation. Sonographic examination revealed a morbidly adherent placenta, and attempt to resect the mass laparoscopically was complicated by bleeding that required hysterectomy. This case illustrates a complication of the intervention performed to preserve the intrauterine gestation in case of HCSP. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 46:227-230, 2018.
Assuntos
Cicatriz/diagnóstico por imagem , Doenças Placentárias/diagnóstico por imagem , Gravidez Ectópica/terapia , Ultrassonografia/métodos , Adulto , Cesárea , Diagnóstico Diferencial , Feminino , Humanos , Histerectomia , Placenta/diagnóstico por imagem , Doenças Placentárias/cirurgia , Cloreto de Potássio/administração & dosagem , Gravidez , Resultado do TratamentoRESUMO
El embarazo localizado dentro de una cicatriz de cesárea previa es el menos frecuente de los embarazos ectópicos y no existe un tratamiento estándar. Se presenta el caso de una paciente de sexo femenino de 33 años de edad, que ingresó por el servicio de emergencias de Ginecología y Obstetricia del Hospital Obrero Nº2, con reporte ecográfico de embarazo de 6,3 semanas, a nivel de cicatriz de cesárea previa, con embrión único con actividad cardiaca; por la solicitud de la paciente de preservar la fertilidad se le ofreció tratamiento médico con metotrexato.
The pregnancy located within the previous cesarean section scar is the less frequent of the ectopics pregnancies and a standard treatment doesn't exist. We present the case of a 33 year-old female patient admitted by the Servicio de Emergencias de Ginecología y Obstetricia del Hospital Obrero Nº2, with ultrasonography report of pregnancy of 6,3 weeks, and ectopic cesarean scar pregnancy, with single embryo with heart activity; By the request of the patient to preserve fertility were offered treatment medical with metotrexato.
Assuntos
Gravidez Ectópica , Metotrexato/administração & dosagemRESUMO
El embarazo ectópico con implantación en la cicatriz de una cesárea previa es un evento muy raro a pesar de la alta tasa de cesárea a nivel mundial, el mecanismo fisiopatológico aún no se establece con claridad. Presentamos un caso de una paciente con diagnóstico de embarazo ectópico sobreinfectado en cicatriz de cesárea previa, tratada con resección quirúrgica de la lesión por histeroscopia y laparoscopia.
Ectopic pregnancy implantation in a previous cesarean scar is a very rare condition despite the high caesarean rate worldwide. The pathophysiological mechanism is not yet clearly established. We present a case of a patient with an overinfected ectopic pregnancy, implanted in a previous cesarean scar treated with resection of the lesion by hysteroscopy and laparoscopy.
Assuntos
Humanos , Feminino , Gravidez , Adulto , Gravidez Ectópica/cirurgia , Histeroscopia/métodos , Cicatriz/etiologia , Laparoscopia/métodos , Gravidez Ectópica/diagnóstico por imagem , Cesárea/efeitos adversos , Cicatriz/cirurgia , InfecçõesRESUMO
El embarazo localizado dentro de una cicatriz de cesárea previa es el menos frecuente de los embarazos ectópicos y no existe un tratamiento estándar. Se presenta el caso de una paciente de sexo femenino de 36 años de edad, derivada de la Unidad de ultrasonografía con reporte ecográfico de embarazo de 9,4 semanas, saco gestacional de implantación baja con signos de inserción placentaria anormal en la zona de la cicatriz por histerorrafia (acretismo-percretismo precoz total).
The ectopic cesarean scar pregnancy is the less frequent of the ectópics pregnancies and a treatment standard doesn't exist. We report the case of a patient of feminine sex 36 years old, derived of the ultrasonography unit with report of pregnancy of 9,4 weeks, sack gestacional of low installation with signs of abnormal insert of placenta in the area of the scar cesarean (precocious placenta acreta).
Assuntos
Humanos , Feminino , Gravidez , Adulto , Gravidez Ectópica , Ameaça de Aborto , AnamneseRESUMO
A implantação da gravidez na cicatriz de cesárea é considerada uma forma rara de gestação ectópica com uma alta morbidade e mortalidade. Esse tipo de gestação ectópica pode causar complicações graves que pode resultar em histerectomia e comprometimento do futuro reprodutivo da mulher. Reportamos um caso de um tratamento conservador com sucesso.
Implantation of a pregnancy with in a cesarean delivery scar is considered to be the rarest form of ectopic pregnancy. with a high morbidity and mortality. Pregnancy in a cesarean delivery scar may cause catastrophic complications which may result in hysterectomy and compromise the reproductive future of a woman. We report a case that was treated conservatively with success.