scar vs niche.pptx

THE CLINICAL OUTCOME OF CESAREAN
SCAR PREGNANCIES IMPLANTED ON THE
SCAR VERSUS IN THE NICHE
09-01-2024 17:18 1
Journal Club
Department of DNB-OBG
DISTRICT HOSPITAL - BALLARI
DNB-OBG District Hospital

THE CLINICAL OUTCOME OF CESAREAN
SCAR PREGNANCIES IMPLANTED ON THE
SCAR VERSUS IN THE NICHE
Presenter: Dr Kartheeka
Dr Hafsa
Moderator: Dr Poornima
Guide: Dr Joshi Suyajna D.
DNB-OBG District Hospital 2
09-01-2024 17:18

DEFINITION OF NICHE
• Niche is an indentation in the myometrium with a depth of at least 2mm at
the site of a caesarean scar
09-01-2024 17:18 DNB-OBG District Hospital 3

TYPES OF NICHE
• SIMPLE
• SIMPLE WITH ONE BRANCH
• COMPLEX

MEASUREMENT OF NICHE
NICHE LENGTH
Both largest length and length at niche base should be measured
NICHE DEPTH
Largest depth should be measured both of main niche and including
deepest branch if branches present

RESIDUAL MYOMETRIUM THICKNESS
Thinnest point should be measured, regardless of direction both from
main niche and,if there is any branches from branch with thinnest RMT
fibrosis not included in RMT measurement

BRANCHES
width of any branch should be measured
ADJACENT MYOMETRIUM THICKNESS (AMT)
AMT should be measured close to niche where myometrium is thickest
DISTANCE B/W NICHE AND VESICOVAGINAL VVFOLD
VV fold distance should be measured from level of top of main niche to vv
fold
DISTANCE B/W NICHE AND EXTERNAL OS
niche-external os distance should be measured parallel to cervical canal,
from most distal point of niche to external os

LONG TERM SEQUALAE
POST MENSTURAL SPOTTING
DYSMENORRHEA
INFERTILITY
UTERINE RUPTURE
CS PREGNANCY
09-01-2024 17:18 DNB-OBG District Hospital
Vail Y. Ultrasound Obs Gynaec 2000
11

CEASAREAN SCAR PREGNANCY
• Caesarean scar pregnancy is an ectopic pregnancy implanted in
myometrium at the site of previous caesarean section scar
• Caesarean scar pregnancy is 1st described in 1978 in South
African journal by Larsen and Solomon

• Implantation of gestational sac into myometrial defect at site of previous
uterine incision
• Rate - < 1 % of all ectopic pregnancies
• Incidence – 1 in 1800-2500 of all pregnancies (1 in 500 previous cs)
• Can implant on scar or niche
Systemic review JMIG 2017
13

TYPES
• TYPE 1 /ENDOGENIC
Grow towards uterine cavity
Can reach viability
Risk of massive bleeding and morbid adherence
• TYPE 2 / EXOGENIC
Invades scar-towards abdominal cavity/bladder
Serious type-risk of rupture and bleeding in early pregnancy
Vail Y. Ultrasound Obs Gynaec 2000
15

AUTHOR’S CONTRIBUTION
• Dr.kaelin agten is a research fellow in the division of obstetrical and
gynecological ultrasound, newyork university school of medicine.
• Easy sonographic differential diagnosis between intrauterine pregnancy and
caesarean delivery scar pregnancy in the early first trimester.
• A new minimally invasive treatment for caesarean scar pregnancy and
cervical pregnancy.

• Outcome of fetuses with prenatal diagnosis of isolated severe bilateral
ventriculomegaly :systematic review and meta analysis.
• Value of first-trimester ultrasound in prediction of third trimester sonographic
stage of placenta accreta spectrum disorder and surgical outcome.
• Cardiac maladaptation in obese pregnant women at term

INTRODUCTION
• Cesarean scar pregnancies (CSP) are a potentially life-threatening complication of
patients with previous cesarean delivery (CD).
• The number of CSP has increased over the last decades, paralleling the rising
incidence of CD.’
• The estimated incidence of CSP is approximately 1:1800—1:2000 pregnancies
after CD.
• Approximately 52% of the patients with CSP had only 1 previous CD.
Kaelin agten A,cali Gmonteagudo A et al the clinical outcome of caesarean scar pregnancies implanted on the scar verus niche Am J obstet gynecol 2017

TYPE OF CSP
• BASED ON USG SCAN FINDING CSP CLASSIFIED INTO 2 TYPES
1. TYPE 1/ENDOGENIC CSP
Here implantation occur on the scar and the gestational sac grows toward cervico-
isthmic or uterine cavity

2. TYPE 2/EXOGENIC CSP
It occur when the gestational sac is deeply embedded in the sacr and the surrounding
myometrium and grows toward the bladder
• Patients with CSP usually terminate their pregnancy, realizing the numerous
complications of CSP described in the literature.
• Reviewing the pertinent literature resulted in describing a large number of different
treatment modalities to achieve the aforementioned goal.

• Recently, a new and ingenious method that uses a double cervical ripening balloon
to avoid surgical interventions has been proposed to terminate CSPs.
• Since that publication in 2012, several additional avenues of treatment and their
efficiency were published that use methotrexate, high-intensity focused ultrasound
scanning, hysteroscopic resection, and robotic resection.

• Complications of CSP include development of a morbidly adherent placenta,
uterine rupture, severe hemorrhage, fetal death, prematurity, and cesarean-
hysterectomy.
• Despite these risks, increasing numbers of patients decline termination and
continue their pregnancy.
• Counseling of patients who prefer to continue their pregnancy is difficult because
of limited scientific evidence.

• There is a debate in the literature about the true morbidity of CSP.'1 Because of
their relative low frequency, CSP have proved difficult to study.’
• Most of what is known today about the natural outcome of CSP is based on case
reports or case series. There might be an overestimation of the risk severity of CSP
probably because of publication and verification bias.
• The severe cases that develop into morbidly adherent placenta are likely the ones
that have been published.

• Conversely, good outcomes of CSP may have been underreported.
• CSP are a continuum of disease, that range from partial implantation over the scar to
those fully implanted within the dehiscence left behind at the incision site of a
previous CD with possible protrusion into the vesicouterine inter phase or even into
the parametrium.
• Pregnancies located entirely within a niche have been reported to behave differently
compared with those implanted on top of a well-healed scar

• The consequences of this wide spectrum of disease in CSP are 2-fold. First, it
is hard to compare studies about CSP with different sites of implantation.
• Second, the patients individual risk for adverse outcome is dependent on the
site of placental implantation.
• The aim of this study was to investigate the pregnancy outcome of CSP
depending on their implantation site in relation to the scar, which was
divided to either on the scar or in the niche.
09-01-2024 17:18
Kaelin agten A,cali Gmonteagudo A et al the clinical outcome of caesarean scar pregnancies implanted on the scar verus niche Am J obstet
gynecol 2017
DNB-OBG District Hospital
27

CESAREAN SCAR PREGNANCIES IMPLANTED ON
THE SCAR

CESAREAN SCAR PREGNANCIES IMPLANTED IN THE NICHE

METHODS AND MATERIAL
• This retrospective 2-center study was institutional review board approved. The
authors reviewed all CSP cases that were diagnosed in the first trimester at either New
York University (NYU) Medical Center or at Azienda di Rilievo Nazionale cd Alta
Specializzazione Civico, Palermo, Italy, between 2013 and 2015.
• Evidence-based counselling was presented to the patients regardless of their
symptoms (asymptomatic, bleeding, pain).

• The presently available evidence was used to counsel all patients, and the patients’
choices were honored.
• Only patients who declined termination of pregnancy and opted for continuation
of their pregnancy were included in the study.
• The cases of 3 patients from the NYU cohort that showed CSP as a precursor for
morbidly adherent placenta have already been published, but placental
implantation as being in the niche or on the scar was not addressed specifically.

• For the diagnosis of a CSP, the following five diagnostic criteria had to
be fulfilled
 A gestational sac embedded eccentrically in the lower uterine segment
Implanted in the location of the previous CD scar;
 An empty uterine cavity and cervical canal;
A thin or absent myometrial layer overlying the scar;
 The presence of a rich vascular pattern in the area of the CD scar and the
placenta on Doppler ultrasound evaluation.

• Each patient’s first sonogram was evaluated to reconfirm the diagnosis
who are providers experienced in the diagnosis and management of CSP.
• The reviewers were blinded to pregnancy outcome when reviewing the
ultrasound images.
• Patients were divided into 2 groups according to the placental location as
either “on the scar” (group A) or “in the niche” (group B).

• The 2 groups were compared regarding maternal age, gestational age at diagnosis, and
the number of previous CDs (Mann-Whitney U-test).
• The minimum myometrial thickness, overlying the placenta was measured, and
gestational age was documented.
• The definition for on the scar was that the placenta implanted partially or fully on top of
a well-healed scar.

• The definition for in the niche was that the placenta implanted into a
deficient or dehiscent scar All follow-up sonographic examinations in the
second and third trimester were evaluated.
• ultrasound findings for morbidly adherent placenta included vascular
lacunae, interrupted bladder line, myometrial thinning, and utcrovesical
hypervascularity

• The patients records were reviewed for patient demographics and
pregnancy outcomes.
• Clinical outcomes were compared between groups A and B with the
use of the Mann-Whitney U test.
• Clinical outcomes included mode of delivery (gravid-hysterectomy,
CD, or cesarean-hysterectomy), gestational age at delivery, blood loss
at delivery, antepartum complications, histopathologic condition, and
neonate weight.

• Myometrial thickness overlying the placenta was compared
among all the patients whose condition required hysterectomy
• Those who did not with the use of the Mann-Whitney U test
Myometrial thickness was also correlated with gestational age at
delivery with the use of Spearman correlation.

• During the study period, 17 patients who continued their
pregnancy were included in the study.
• 10 patients from NYU
• 10 patients from ARNAS.
RESULTS

• Six patients were in group A, and 11 patients were in group B
• The median maternal age in group A was 34 years (range, 20—42
years) and in group B was 35 years (range, 27—42 years; P=.88).
• The median gestational age at diagnosis in group A was 8 weeks
(range, 6—9 weeks gestation) and in group B was 7 weeks (range,
5—9 weeks gestation; P=.679).

• The patients in group A had a median of 1.5 previous CD (range, 1—2
previous CD) and in group B was 1.0 previous CD (range, 1—4 previous
CD; P=.884).
• Gestational age at delivery was statistically significantly lower in group B
(median, 34 weeks; range, 20—36 weeks) than in group A (median, 38
weeks; range, 37—39 weeks; P=^.001). Neonatal weight was statistically
significantly higher in group A

• Patients in group A showed no sonographic signs of morbidly
adherent placenta .
 There were no antepartum complications in group A.
 Modes of delivery in the 6 patients in group A included 5
CDs (83%) with delivery of the placenta with the Crede
maneuver (manual fundal pressure to help placental delivery)

 1 cesarean-hysterectomy (17%) because of incomplete
removal of the placenta and intractable hemorrhage.
The patient with cesarean-hysterectomy had a myometrial
thickness of only 2 mm in the first-trimester ultrasound scan.
Partial placenta accreta was also histologically confirmed in a
small area.

• In group B, the sonographic evaluation of the placenta in the second and
third trimester showed a high suspicion for morbidly adherent placenta in
all patients
 In group B, all patients underwent hysterectomy.
 Ten patients (91%) underwent cesarean-hysterectomy with histologically
confirmed placenta increta or percreta.
One of these cesarean-hysterectomies was performed as an emergency for
vaginal bleeding at 32 weeks gestation.

One patient (9%) had a gravid-hysterectomy for severe vaginal bleeding at
20 weeks gestation, and the histologic report revealed placenta percreta.
One of these cesarean-hysterectomies was performed as an emergency for
vaginal bleeding at 32 weeks gestation.
One patient (9%) had a gravid-hysterectomy for severe vaginal bleeding at
20 weeks gestation, and the histologic report revealed placenta percreta.

• Blood loss was increased but did not reach statistical significance
in group B (median, 1200 mL; range, 300—4000 mL) compared
with group A (median, 700 mL; range, 600—1400 mL; P=.I17).
• Three patients (27%) in group B whose condition required
cesarean hysterectomy had prophylactic occlusion of the iliac
arteries at delivery

• Six patients (55%) in group B required blood transfusion (median, 2 units of
packed red blood cells; range, 2—6 units).
• The myometrium was statistically significantly thinner in the patients' group
that required hysterectomy (median, 1 mm; range, 0—2 mm) than in the
group that did not require a hysterectomy (median, 5 mm; range, 4—9 mm;
P=.001). Myometrial thickness showed a positive correlation with gestational
age (r=0.820; P-C.0005).

Demographic and clinical data of the 17 patients with cesarean scar pregnancy
Case
Gestationa
l age at
diagnosis,
wk Age, y
Myometrial
thickness,
mm
Previous
cesarean
deliveries,
n
Gestationa
l age at
delivery,
wk
Delivery
mode
Neonat
e
weight,
g
Blood
loss, mL
Units of
packed red
blood cells,
n
On the scar
1 9 31 4 1 38 CD 3140 1000 0
2 8 42 8 2 38 CD 3510 700 0
3 8 20 5 1 39 CD 3569 700 0
4 7 36 9 2 39 CD 3090 700 0
5 6 30 4 2 38 CD 2900 600 0
63 8 42 2 1 37 CH 3300 1400 0
In the niche
7 6 32 1 2 35 CH 2550 800 0
8 8 29 2 1 36 CH 2850 1000 0
9" 7 42 0 1 32 CH 1900 3000 5
10" 9 27 1 1 36 CH 2450 1100 0
11 7 35 2 2 34 CH 2650 1300 2
12c 9 34 2 1 33 CH 2050 4000 4
13 8 39 1 1 34 CH 2550 3000 6
14" 5 31 0 1 20 GH 270 600 0
15 6 39 1 4 34 CH 2650 600 0
16 9 37 1 3 35 CH 2400 1500 2
17 7 38 1 1 35 CH 2350 1200 2

STUDY FINDINGS
• The results of our study showed that patients with CSP implanted on
the scar had a significantly better outcome compared with patients
with CSP implanted in the niche
• All patients with a good outcome had a myometrial thickness of >4
mm in their first-trimester scan.

• In contrast, myometrial thickness measured only 2 mm in 1
patient with CSP “on the scar” who experienced morbidly
adherent placenta.
• All 11 patients in the cohort with the CSP implanted “in the
niche” underwent hysterectomy for morbidly adherent placenta.
• Their myometrium measured <2 mm in the first trimester.

• Clinical outcomes clearly differed between the patients with CSP
implanted “on the scar” compared with “in the niche.”
• Furthermore, myometrial thickness might be a helpful variable for
adverse outcome, because all of our patients with morbidly adherent
placenta had a myometrial thickness of <2 mm in their first scan.

• Dividing CSP into 2 categories and measuring myometrial thickness maybe
helpful to individualize patient counseling.-
• Patients with CSP implanted “on the scar” and a myometrial thickness of >4
mm are good candidates for expectant treatment.
• Expectant management of CSP was shown to offer the possibility to deliver a
liveborn neonate, although with considerable risk for hysterectomy.

• In our study, 16 of 17 patients (94.1%) who were treated expectantly delivered a live
neonate, which is similar to the results noted by Zosmer et al, in which all patients
delivered a live neonate and substantially higher than in the study by Michaels et al, in
which only 62.5% live birth rate was noted
• Twelve of the 17 patients (70.5%) in our study required hysterectomy because of
morbidly adherent placenta. This rate was lower than other studies, in which all
patients required hysterectomy however, Michaels et al reported a hysterectomy rate
of only 37.5%.

• Already in the late 1900s, 2 big retrospective studies that analyzed the
relationship between previous CD and morbidly adherent placenta showed
that, when the placenta was implanted over a uterine scar, the rate of
morbidly adherent placenta was 30—40%.
• Recently, other articles have mentioned the issue of implanted CSP over
the scar of a previous CD.

• However, none of these studies assessed the exact site of placental
implantation, which might explain the differences in incidence.
• The results of our study proved earlier suspicions that the site of implantation
of CSP might impact their natural outcome.
• The strength of our study is the inclusion of patients from 2 major centers
with significant experience in diagnosing and treating patients with CSP.

• Ultrasound images were evaluated by blinded reviewers. Furthermore, this study was
aimed to improve patient counseling based on dividing CSP that were implanted either
“on the scar” or “in the niche” by measuring the implantation distance between the
placenta and the anterior uterine surface.
• A strength of our population is that our 2 groups showed no differences in the number
of previous CDs. Additionally, the surgical technique of the actual CD and cesarean-
hysterectomy followed an institutional protocol.

• Surgeon-depended differences in surgical techniques of CD and cesarean
hysterectomy cannot be excluded and might contribute to the discrepancies between
the groupsbecause data concerning the long-term outcome (uterine scar dehiscence,
morbidly adherent placenta) of the different surgical techniques of CDs are lacking.
• Another limitation of the study is clearly the small number of patients, even though
this is the largest series published to date of expectantly managed CSPs that were
diagnosed in the first trimester that continued the pregnancy to term.

Example of a patient with caesarean scar pregnancy implanted on
the scar with a normal placenta at delivery

Example of a patient with caesarean scar pregnancy implanted in
the niche with a placenta percreta at delivery

IMPLICATIONS FOR TREATMENT
• The diagnosis of CSP is preferably made between 6 and 8 weeks
gestation because during that time the developing placenta can be seen
clearly on ultrasound scans.
• Furthermore, we recommend that at least 3 ultrasound images of the
uteroplacental interface should be obtained.

• Of these images, the thinnest myometrial thickness overlying the
placenta should be chosen.
• Three-dimensional ultrasound tomography can be helpful in finding the
thinnest myometrial thickness.

• It is important to diagnose a CSP early because, if a patient decides to
terminate the pregnancy, procrastination only increases the risks for
complications.
• Early diagnosis also provides an opportunity to counsel patients about ante-
and intrapartum complications and allows appropriate surveillance if the
patient decides to continue the pregnancy.

• Patient safety is also improved with planning for a safer delivery by assuring a
well-supplied blood bank and the availability of skilled surgical personnel.
• Patient safety is also improved with planning for a safer delivery by assuring a
well-supplied blood bank and the availability of skilled surgical personnel.
• The information provided by the results of our study can be helpful in determining
a patient’s risk for adverse outcome and in counseling patients with CSP.

• Pregnancy outcomes differentiate significantly between CSP that
are implanted “on the scar” compared with “in the niche.“
• Patients with CSP implanted on the scar and a myometrial
thickness of >4 mm appear to be good candidates for expectant
treatment.

•Contact :
Dr Kartheeka :77080 43170
Dr Hafsa : 95022 73865

THANK
YOU
09-01-2024 17:18 DNB-OBG District Hospital SWETHA U

scar vs niche.pptx

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