Cesarean scar pregnancy management 2012


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Cesarean scar pregnancy management 2012

  1. 1. Research www. AJOG.orgGENERAL GYNECOLOGYBilateral uterine artery chemoembolization with methotrexatefor cesarean scar pregnancyLicong Shen, MD; Aixiang Tan, MD; Huili Zhu, MD; Chun Guo, MD; Dong Liu, MD; Wei Huang, MD, PhDOBJECTIVE: The objective of the study was to assess the efficacy of mass disappearance was 33.3 days. The mean hospitalization time wasuterine arteries embolization (UAE) for the treatment of cesarean scar 10.5 days. The complications were mainly fever and pain, which werepregnancies (CSP). alleviated with symptomatic treatment. All 45 patients had recoveredSTUDY DESIGN: Forty-six women with CSP were identified between their normal menstruation at follow-up.March 2008 and March 2010. All of the patients underwent UAE com- CONCLUSION: Bilateral uterine artery chemoembolization with metho-bined with local methotrexate. trexate appears to be a safe and effective treatment for CSP and causesRESULTS: Forty-five patients were successfully treated. One patient less morbidity than current approaches.had an emergency hysterectomy after 20 days because of massive vag-inal hemorrhage. The mean time until normalization of serum ␤-human Key words: cesarean scar pregnancy, methotrexate, uterine arterychorionic gonadotrophin was 37.7 days, and the mean time until CSP chemoembolizationCite this article as: Shen L, Tan A, Zhu H, et al. Bilateral uterine artery chemoembolization with methotrexate for cesarean scar pregnancy. Am J Obstet Gynecol2012;207:386.e1-6.C esarean scar pregnancy (CSP) is a novel and life-threatening form ofabnormal implantation of a gestational China. Early and accurate diagnosis by improved ultrasound imaging and greater clinician awareness may be contributing to previous cesarean scar, dilation and cu- rettage, and systemic or local adminis- tration of drugs such as the metabolismsac within the myometrium and the fi- this rise.3 inhibitor methotrexate (MTX).7-10 Sobrous tissue of a previous cesarean scar. CSP can lead to life-threatening hemor- far, although various interventions haveIt has recently been found to be more rhage during pregnancy or curettage and been proposed, there has been no con-common than was previously thought, even to uterine rupture, disseminated in- sensus on the optimal therapeutic proto-and its estimated incidence ranges from travascular coagulation, or death.4,5 Early col for CSP. MTX, used as a conservative1 per 1800 to 1 per 2216 pregnancies, and accurate diagnosis is important for ef- treatment, was reported to have a highwith a rate of 6.1% of all ectopic preg- fective treatment to avoid these potentially risk of failure and side effects, which ne-nancies with a history of at least 1 cesar- catastrophic consequences. Ultra- cessitated treatment or even emergencyean section.1,2 It is considered to be a sound was the first widely used method of hysterectomy.4long-term complication of cesarean sec- diagnosing CSP. Recently improved ultra- Uterine artery embolization (UAE;tion (CS), and its prevalence is currently sound imaging has enabled correct early blocking of the arteries using gelatinincreasing with the rising CS rate in detection of such pregnancies with a sensi- beads or other material) has been in- tivity of 84.6%.3 However, it is difficult to creasingly used before uterine surgery to distinguish a CSP from spontaneous mis- prevent excessive bleeding in uterine carriage in progress or a cervicoisthmic myomas, cervical pregnancies, or postpar-From the Department of Obstetrics andGynecology, West China Second University pregnancy.6 Senior ultrasound practitio- tum hemorrhage or during chemotherapyHospital of Sichuan University, People’s ners may be more experienced in deter- to prevent uncontrollable bleeding in ma-Republic of China. mining the details of the location, size, age, lignancies. Along with chemoemboliza-Received May 23, 2012; revised July 14, 2012; and viability of the gestation sac and may tion (a combination of embolization andaccepted Sept. 12, 2012. thus be better able to make a correct diag- local delivery of chemotherapy) beingThe authors report no conflict of interest. nosis, which is critical for timely effective proved to be an effective anticancer treat-Reprints: Wei Huang, MD, Department of management. ment in clinical practice, bilateral uterineObstetrics and Gynecology, West China The aim in the management of CSP arterial chemoembolization has recentlySecond University Hospital of SichuanUniversity, Renminnanlu 3 duan 20hao, should be the prevention of massive been tried out for CSP management.Chengdu, Sichuan 610041, People’s Republic hemorrhage and conservation of the In the procedure of bilateral uterineof China. weihuang64@163.com. uterus for further fecundity, health, and arterial chemoembolization, MTX is ad-0002-9378/$36.00 quality of life. Traditional management ministered directly into the gestational© 2012 Mosby, Inc. All rights reserved.http://dx.doi.org/10.1016/j.ajog.2012.09.012 for CSP includes hysterectomy, local re- foci through bilateral uterine arteries, section of the gestational mass within the which are its feeding blood supply, with386.e1 American Journal of Obstetrics & Gynecology NOVEMBER 2012
  2. 2. www.AJOG.org General Gynecology Research imaging examinations, therapeutic pro- FIGURE 1 cedures, blood loss, and findings at Transvaginal sonogram of the cesarean scar pregnancy follow-up. In all patients, the gestational age was estimated according to the last men- strual period and ultrasonographic exam- inations, and serum ␤-human chorionic gonadotrophin (hCG) concentration was determined before treatment. The diagno- ses of CSP were based on symptoms, clin- ical manifestations, history of prior cesar- ean section, serum ␤-hCG concentration, and special presentation on transvaginal ultrasonography. The criteria of ultrasound diagnosis include the following: (1) an empty uter- ine cavity and cervical canal; (2) a gesta- tional sac located at the anterior wall of the isthmic portion, separated from the endometrial cavity or fallopian tube; (3) a gestational sac embedded within the myometrium and the fibrous tissue of the cesarean section scar at the lower uterine segment, with an absence of de- fect in the myometrium between the bladder and the sac; and (4) and a high- velocity–low-impedance vascular flow surrounding the gestation sac.1,2,14 All 46 cases matched these criteria (Figure 1). The UAE procedure was performed byTransvaginal sonogram of the cesarean scar pregnancy, showing the empty uterine cavity and experienced radiologists. After local an-the empty cervical canal and the gestational sac implanted into the previous cesarean section esthesia, catheterization was carried outscar at the anterior uterine wall and protruding toward the urinary bladder, with rich surrounded via the right femoral artery with avascularity. 5F-Yashiro catheter (Terumo, Tokyo, Ja-Shen. Bilateral uterine artery chemoembolization with methotrexate for cesarean scar pregnancy. Am J Obstet Gynecol 2012. pan) that was advanced into the uterine arteries on both sides; digital subtraction arteriography (AXIOM-Artis-FA; Sie-subsequent blockage of the feeding vessel M ATERIALS AND M ETHODS mens AG, Munich, Germany) was thenby occlusive agents that are injected The research protocol was approved by performed to confirm that cathetersthrough the delivery catheter. Because the institutional review board of West were correctly inserted, and 25 mg ofthis involves both chemotherapy and tis- China Second University Hospital, Sich- MTX was injected bilaterally; and finallysue ischemia, it permits a higher concen- uan University. Informed consent was both uterine arteries were embolizedtration of MTX to target the gestational obtained from all patients, and all avail- with gelatin sponge particles (0.5-1.0foci for a longer period of time and thus able information on the treatments was mm). Subsequently, postembolizationproduces more effective embryocide, presented to the patients, including the angiography was performed to validatewith much less systemic toxic effects, risks and benefits of the therapy, poten- that the vascularity of the gestational sacthan embolization alone. To date, only a tial complications, and alternatives. was completely obstructed (Figure 2).few reports that describe uterine artery Between March 2008 and March 2010, Twenty-four to 72 hours later, the pa-chemoembolization with MTX for CSP 46 patients were diagnosed with CSP in tients were carefully examined usingtreatment11-13 are available. our hospital. We reviewed the clinic re- transvaginal ultrasound, and their serum We retrospectively reviewed our man- cords of all these patients, including pa- ␤-hCG levels were assessed. In patientsagement with bilateral uterine arterial tient age, gravidity and parity, clinical with persistent vaginal bleeding and/or achemoembolization with MTX of 46 presentation, weeks of gestation, the persistent gestational mass larger than 5cases of CSP over a 2 year period and time interval between the last cesarean cm, suction curettage was performedanalyzed complications and quality of section and cesarean scar pregnancy, under transabdominal ultrasound guid-life after treatment. clinical findings, results of ultrasound ance after ultrasonic confirmation of the NOVEMBER 2012 American Journal of Obstetrics & Gynecology 386.e2
  3. 3. Research General Gynecology www.AJOG.orgabsence of blood flow to the CSP region FIGURE 2to remove the retained products of con- Angiograms of a patient with CSP who received transcatheter UAEception and blood clot. If massive hem-orrhage occurred during investigation orcurettage, an emergency hysterectomyor local CSP resection was carried out. Patients were hospitalized duringtreatment. Serum ␤-hCG levels, bloodloss, adverse effects (including fever,nausea and vomiting, abdominal or pel-vic pain, and abnormal liver or renalfunction), and length of hospital staywere recorded and summarized. Serum␤-hCG levels were determined beforethe intervention, on day 1 after therapy,every 3 days until discharged from thehospital, and then every week until re-covery to normality. At the same time,the sizes of the retained gestational prod-ucts were measured by ultrasound andclinical status (bleeding pattern and re-sumption of menses) were assessed. Follow-up was arranged until the se-rum ␤-hCG concentration dropped tonormal and pregnancy remnants couldnot be detected through ultrasound.Women who had massive, active vaginalbleeding and stable serum ␤-hCG con-centration after UAE were diagnosed ashaving their treatment failed and that re-quired repeat embolization or partial/ Digital subtraction angiograms of a patient with CSP who received transcatheter uterine arterialsubtotal hysterectomy. embolization. A and B, Angiography before embolization. The uterus is enlarged, bilateral uterine Successful UAE treatment was defined artery is hypertrophied and tortuous, and the gestational sac is surrounded by numerous arteryas a complete recovery without severe branches. C and D, Angiography after embolization. Both uterine arteries are obstructed and theadverse effects or complications and vascularity of the gestational sac completely disappeared. CSP, cesarean scar pregnancies; UAE, uterine arteries embolization.without a need for repeat embolization Shen. Bilateral uterine artery chemoembolization with methotrexate for cesarean scar pregnancy. Am J Obstet Gynecol 2012.or hysterectomy. All data are expressed as mean Ϯ SD.Statistical analysis was performed using presentation was 55.5 Ϯ 2.4 (37-97) days tion as primary treatment, followed bythe Student t test and a ␹2 test by the SPSS (Table). suction curettage after 72 hours. The time19.0 statistical package (SPSS Inc, Chi- Twenty-five women were initially di- of hospital stay was 10.1 Ϯ 1.0 (4-28) days.cago, IL). agnosed with CSP on admission to our The time for serum ␤-hCG normalization hospital. The main complaints were ir- was 32.0 Ϯ 5.5 (7-134) days. The time for regular vaginal bleeding (19 of 25, total lesion disappearance was 32.7 Ϯ 4.0R ESULTS 76.0%) and mild lower abdominal pain (5-58) days. All these patients experiencedForty-six cases of CSP were diagnosed (7 of 25, 28.0%). The serum ␤-hCG a rapid, uneventful recovery.over a 2 year period. The average age of concentration was 28,220.2 Ϯ 7104.4 The remaining 21 patients receivedthe 46 patients was 32.7 Ϯ 6.0 (21-44) (161.6-181,880) mIU/mL. By ultrosonog- suction curettage at their first visit toyears. The average gravidity was 5.0 Ϯ raphy, the largest diameter of the CSP mass other hospitals because of misdiagnosis1.6 (2-8) and the average parity was was 1.0-7.6 cm, the embryo within the ges- for inevitable miscarriage or missed1.09 Ϯ 0.28 (1-3). Four women had un- tational sac could be seen in 18 patients, abortion. They were transferred to ourdergone 2 previous cesarean deliveries. and 8 had fetal cardiac activity; in the re- hospital owing to massive hemorrhageThe average interval from the last cesar- maining 7 patients, only a yolk sac was during the operation. On admission toean section was 63.5 Ϯ 8.2 (4-252) identified. All these 25 women underwent our hospital, bilateral uterine artery che-months. The average gestational age at bilateral uterine artery chemoemboliza- moembolization was performed with386.e3 American Journal of Obstetrics & Gynecology NOVEMBER 2012