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Update on
Treatment of
Cesarean Scar
Pregnancy
Prof. Aboubakr Elnashar
Benha university Hospital,
Egypt
1. INTRODUCTION
Define
GS implanted at the site of a previous CS scar.
Terminology
cesarean scar pregnancy
Ectopic pregna...
Rising
1. Increased incidence of CS
72% of CSP occur in women who have had
≥2CS
2. Increased use of TVS
3. Change in Tech...
Complications
1. Morbidly adherent placenta
2. Uterine rupture
3. Severe hemorrhage
4. Preterm labor.
5. Increased materna...
Types
(Vial et al, 2000)
1. Endogenic, superficially implanted (Type 1):
o grow toward uterine cavity
o±progress into IU ...
Superficially implanted CSP
(A) GS surrounding the myometrial
defect with a bulging toward the
endometrial cavity.
(B) A d...
Deeply implanted CSP
A. invasion of gestational trophoblasts through a
microdehiscence, well circumscribed by the myometri...
Implanted on
1. Scar
2. Niche
(Agten et al, 2017)
CSP implanted "on the scar" had a better
outcome than that implanted "...
Sonographic criteria in 1st T
1. Uterus:
 empty with a clearly visualized
endometrium
2. Cervix:
Empty
3. GS:
 within ...
5. Doppler
Marked peritrophoblastic color Doppler flow
around GS
Avoid false positive diagnosis: 30-40%
3. DIFFERENTIAL DIAGNOSIS
Failed pregnancyCx ectopicCSP
within the cervical canalanterior LUS1. GS
normalthin2. Overlying ...
The location of the center of GS relative to the midpoint axis of the uterus
differentiated between IUP and CSP (mean 17.8...
4. TREATMENT
Objective
 eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion:
most eff...
Timor-Tritsch et al, 2014
 Treatment should be individualized, based on
I. Center
1. Availability
2. Expertise of the clinicians
II. Patient
1. Age...
Treatment approaches
(Timor-Tritsch, 2015)
1. Major Surgery
require general anesthesia
(a) Excision:
Laparotomy
Laparosc...
2. Minimally invasive surgery
No general anesthesia
(a) Local injection of MTX or KCl
(b) Local injection of Vasopressin
(...
Combination of the above treatments.
Rare to find a patients managed only by one
single treatment agent or protocol.
± ...
Adjuvant measures.
1. Foley balloon placement
At the site of the CSP, blocked with 5 to 30
mL
extremely useful
can be kep...
Referral centers:
Experience
Operating rooms
Interventional radiology
Ready for emergencies.
Available immediate blo...
Jain et al (2014)
CSP
Haemodinamicly stable Haemodinamicaly unstable
HCG ≤10000IU/ml HCG≥10000IU/ml
MXT: local and Sys Hy...
Shao et al (2013): 1. GS
2. Myometrial Thickness
3. HCG
LUAO=Laparoscopic uterine a occlusion
Timor-Tritsch (2015) SR of 1223 CSP
Complication
(%)
No
6536MXT: Sys
11200MXT: Local+Sys
28309UAE
60577D&C
10119TV excisi...
{No single best treatment} :
procedure with the least complications
performed without delay.
Single-dose systemic MTX ...
Petersen et al (2016): SR of 2037 CSP
LaparotomyBleeding
≥1L
HysterectomyComplication
(%)
Success
(%)
No
0517544141Expect...
5 treatment modalities are recommended
depending on
1. availability
2. severity of patient symptoms
3. surgical skills
 ...
Hysteroscopy:
most frequently adopted 1st line approaches.
Hysteroscopy and laparoscopic hysterotomy:
safe and efficient...
SUMMARY
1. CSP
 An uncommon but potentially life-threatening
 The incidence is rising as CSR is rising.
 Precursor of m...
4. Management:
 Counseling
 Termination:
 Reliable tt that stops fetal heart beat without
delay.
 Avoid single tts unl...
ABOUBAKR ELNASHAR
You can get this lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://ww...
Update on Treatment of Cesarean Scar Pregnancy
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Update on Treatment of Cesarean Scar Pregnancy

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Update on
Treatment of Cesarean Scar Pregnancy

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Update on Treatment of Cesarean Scar Pregnancy

  1. 1. Update on Treatment of Cesarean Scar Pregnancy Prof. Aboubakr Elnashar Benha university Hospital, Egypt
  2. 2. 1. INTRODUCTION Define GS implanted at the site of a previous CS scar. Terminology cesarean scar pregnancy Ectopic pregnancy in a Caesarean scar cesarean ectopic pregnancy cesarean scar ectopic. : MXT as in tubal ectopic pregnancies: failed but disastrous
  3. 3. Rising 1. Increased incidence of CS 72% of CSP occur in women who have had ≥2CS 2. Increased use of TVS 3. Change in Techniques of uterine surgery Today the uterus is often closed in one layer, compared with the previous two-layer technique
  4. 4. Complications 1. Morbidly adherent placenta 2. Uterine rupture 3. Severe hemorrhage 4. Preterm labor. 5. Increased maternal morbidity and mortality.
  5. 5. Types (Vial et al, 2000) 1. Endogenic, superficially implanted (Type 1): o grow toward uterine cavity o±progress into IU pregnancy o birth of a live fetus o morbidly adherent placenta 2. Exogenic, deeply implanted (Type2): o deeply implanted into the defect of a scar o grow toward the bladder or abdominal cavity: o uterine rupture and severe hge [Singh et al, 2012 Jacquemyn et al, 2012].
  6. 6. Superficially implanted CSP (A) GS surrounding the myometrial defect with a bulging toward the endometrial cavity. (B) A dumbbell-shaped GS 5 ws in a low-segment uterine scar defect. (C) Hysteroscopy with the use of fluid medium, showing an ectopic gestation hanging from the anterior uterine defect.
  7. 7. Deeply implanted CSP A. invasion of gestational trophoblasts through a microdehiscence, well circumscribed by the myometrial tissues of the uterus. B. Color Doppler: extensive neovascularization encircling GS
  8. 8. Implanted on 1. Scar 2. Niche (Agten et al, 2017) CSP implanted "on the scar" had a better outcome than that implanted "in the niche". Myometrial thickness ≤2 mm in 1st T: morbidly adherent placenta at delivery.
  9. 9. Sonographic criteria in 1st T 1. Uterus:  empty with a clearly visualized endometrium 2. Cervix: Empty 3. GS:  within the anterior portion of LUS at site of the cesarean scar 4.Myometrium between GS and bladder: Thin or absent: <5 mm in 2/3 of cases.
  10. 10. 5. Doppler Marked peritrophoblastic color Doppler flow around GS Avoid false positive diagnosis: 30-40%
  11. 11. 3. DIFFERENTIAL DIAGNOSIS Failed pregnancyCx ectopicCSP within the cervical canalanterior LUS1. GS normalthin2. Overlying anterior myometrium positivenegative3. Sliding organ sign* lack color flowvascular flow around and within the GS marked peritrophoblastic color Doppler flow around GS 4. Doppler Not fixed in location, not growing ±growing5. Short follow up US *Gentle pressure with the TV probe: displace GS from its position within the endocervical canal
  12. 12. The location of the center of GS relative to the midpoint axis of the uterus differentiated between IUP and CSP (mean 17.8 vs -10.6 mm, respectively, P = .0001), indicating that most CSPs are located proximally to the midpoint axis of the uterus whereas most normal IUPs are located distally from the midpoint of the uterus. IUP & SCP 5 -10 W (Timor-Tritsch et al, 2016)
  13. 13. 4. TREATMENT Objective  eliminating GS preserving fertility No universal tt guidelines No clear conclusion: most effective least complications.
  14. 14. Timor-Tritsch et al, 2014
  15. 15.  Treatment should be individualized, based on I. Center 1. Availability 2. Expertise of the clinicians II. Patient 1. Age 2. Number of children. 3. Number of previous CS 4. Severity of symptoms III. CSP 1. Gestational age 2. Level of HCG 3. Thickness of covering myometrium
  16. 16. Treatment approaches (Timor-Tritsch, 2015) 1. Major Surgery require general anesthesia (a) Excision: Laparotomy Laparoscopy Hysteroscopy Transvaginal (b) D&C (c) Suction aspiration without dilatation of the cervix
  17. 17. 2. Minimally invasive surgery No general anesthesia (a) Local injection of MTX or KCl (b) Local injection of Vasopressin (c) UAE 3. Medical treatment MTX: Single or repeated doses
  18. 18. Combination of the above treatments. Rare to find a patients managed only by one single treatment agent or protocol. ± Planned: simultaneous or Sequential fashion. Changed, after failure of 1st line therapy
  19. 19. Adjuvant measures. 1. Foley balloon placement At the site of the CSP, blocked with 5 to 30 mL extremely useful can be kept in situ for 3–4 days with antibiotic coverage. 2. Shirodkar Suture during the evacuation of CSP
  20. 20. Referral centers: Experience Operating rooms Interventional radiology Ready for emergencies. Available immediate blood transfusion/ blood products.
  21. 21. Jain et al (2014) CSP Haemodinamicly stable Haemodinamicaly unstable HCG ≤10000IU/ml HCG≥10000IU/ml MXT: local and Sys Hysteroscopic Hysteroscopic + Kcl or vasopressin injection Scar resection
  22. 22. Shao et al (2013): 1. GS 2. Myometrial Thickness 3. HCG LUAO=Laparoscopic uterine a occlusion
  23. 23. Timor-Tritsch (2015) SR of 1223 CSP Complication (%) No 6536MXT: Sys 11200MXT: Local+Sys 28309UAE 60577D&C 10119TV excision 2594Laparoscopy 1113Hysteroscopy 050UAE+Hysteroscopy 2515Laparotomy 020HIFU 1223Total
  24. 24. {No single best treatment} : procedure with the least complications performed without delay. Single-dose systemic MTX injection: Lengthy usually ineffective 1st line therapy delaying the final treatment. MTX an adjuvant to other treatments MXT: US guided local, plus sys MTX: 25mg in GS, 25mg in F placenta, 25mg IM Simple low complication rates.
  25. 25. Petersen et al (2016): SR of 2037 CSP LaparotomyBleeding ≥1L HysterectomyComplication (%) Success (%) No 0517544141Expectant 925101375339MTX IM 30046574MTX local 2991485148MTX local+Asp 00127734MTX Local+IM 282369427UAE+MTX 046394295UAE+D&C 337112148243D&C 00119585UAE+D&C+ Hysteroscopy 011199118TV excision 20138395Hysteroscopy 00009769Laparoscopy 000010016HIFU 000010035HIFU+ Hysteroscopy 2188592037Total
  26. 26. 5 treatment modalities are recommended depending on 1. availability 2. severity of patient symptoms 3. surgical skills  An interventional rather than medical approach. 1. Resection through a TV approach 2. Laparoscopy 3. Hysteroscopy 4. UAE plus D&C and hysteroscopy 5. UAE combined with D&C without MTX
  27. 27. Hysteroscopy: most frequently adopted 1st line approaches. Hysteroscopy and laparoscopic hysterotomy: safe and efficient surgical procedures Systemic methotrexate and D&C: not recommended as 1st line tt {high complication and hysterectomy rates}. Hysterectomy (%) Success rate (%) Resolution time (D) Bleeding (%) 496014Systemic MTX 1185933UAE 0.039207Hysteroscopy 7624651D&C 2922028Hysterotomy Pektas et al, 2016: 1674 CSP
  28. 28. SUMMARY 1. CSP  An uncommon but potentially life-threatening  The incidence is rising as CSR is rising.  Precursor of morbidly adherent placenta 2. Early diagnosis  important.  At the time of discharging after a CS:  in a future pregnancy, an early visit for TVS is important. 3. DD Failed pregnancy Cx ectopic
  29. 29. 4. Management:  Counseling  Termination:  Reliable tt that stops fetal heart beat without delay.  Avoid single tts unlikely to be effective:  D&C  Suction curettage  Single-dose IM MTX  UAE  Each center should have protocol :  Availability  Skills  Severity if not: Referral
  30. 30. ABOUBAKR ELNASHAR You can get this lecture 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: Elthwra St. Mansura, Egypt

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