First-trimester diagnosis and management of Cesarean scar pregnancies after in vitro fertilization-embryo transfer: a retrospective clinical analysis of 12 cases

Reproductive Biology and Endocrinology

Guangxiu Lu²  Ge Lin²  Fei Gong²  Yan Yi¹  Xihong Li²  Yan Ouyang² 

[1] Institute of Reproductive and stem cell Engineering, Central South University, Xiangya Road, Changsha 410008, Hunan, P.R. China;Reproductive and Genetic Hospital of Citic-Xiangya, Xiangya Road, Changsha 410078, Hunan, P.R. China

关键词: In vitro fertilization-embryo transfer;    Management;    Diagnosis;    Transvaginal sonography;    First-trimester;    Heterotopic cesarean scar pregnancy;    Cesarean scar pregnancy;   

Others  :  1233937
DOI  :  10.1186/s12958-015-0120-2

 received in 2015-08-18, accepted in 2015-11-02,  发布年份 2015

【 摘 要 】

Background

Although Caesarean scar pregnancy (CSP) is rare, it can cause life-threatening complications. The increasing rate of Cesarean delivery plus rapid development of in vitro fertilization-embryo transfer (IVF-ET) may increase the occurrence of CSP as well as the ratio of heterotopic CSP (HCSP)/CSP. Therefore, early diagnosis and management of CSP are necessary to avoid serious complications. And the purpose of this article is to evaluate the importance and feasibility of the first-trimester diagnosis and management of CSP after IVF-ET.

Methods

All the 12 cases were secondary infertility patients who had a history of Cesarean section and underwent IVF-ET in our reproductive center. All cases with CSP were diagnosed using transvaginal color Doppler sonography (TVS). Medical, surgical and expectant managements were implemented, and the management results were traced.

Results

Patients with CSP (n = 12) were diagnosed from January 2011 to April 2015, 6 (50 %) of which were HCSP. The prevalence of CSP was 1:1688 pregnancies. The gestational age ranged from 5 + 3 to 7 + 4 weeks in all CSP, and from 5 + 6 to 7 + 4 weeks in HCSP at diagnosis. Five patients received successful surgical treatment. The success rate of medical and expectant management was 50 % (1/2) and 100 % (5/5), respectively. One patient with failed medical management needed an emergency laparotomy to evacuate CSP. The uterus was preserved in all 12 patients.

Conclusions

The Caesarean section and IVF-ET may increase the ratio of HCSP/CSP. TVS is a noninvasive and effective tool for use in diagnosing CSP. CSP should be carefully excluded in patients who have had a history of Caesarean section. Early diagnosis of CSP in the first trimester may contribute towards the preservation of uterus as well as intrauterine pregnancy (IUP) in HCSP.

【 授权许可】

   
2015 Ouyang et al.

【 图 表 】

Fig. 1.

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【 参考文献 】

• [1]Lai YM, Lee JD, Lee CL, Chen TC, Soong YK. An ectopic pregnancy embedded in the myometrium of a previous cesarean section scar. Acta Obstet Gynecol Scand. 1995; 74:573-6.
• [2]Larsen JV, Solomon MH. Pregnancy in a uterine scar sacculus--an unusual cause of postabortal haemorrhage. A case report. S Afr Med J. 1978; 53:142-3.
• [3]Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol. 2004; 23:247-53.
• [4]Cheng PJ, Chueh HY, Soong YK. Sonographic diagnosis of a uterine defect in a pregnancy at 6 weeks’ gestation with a history of curettage. Ultrasound Obstet Gynecol. 2003; 21:501-3.
• [5]Rajakumar C, Agarwal S, Khalil H, Fung Kee Fung KM, Shenassa H, Singh SS. Caesarean scar pregnancy. J Obstet Gynaecol Can. 2015; 37:199-200.
• [6]Hamilton CJ, Legarth J, Jaroudi KA. Intramural pregnancy after in vitro fertilization and embryo transfer. Fertil Steril. 1992; 57:215-7.
• [7]Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar. Ultrasound Obstet Gynecol. 2003; 21:220-7.
• [8]Yela DA, Marchiani N. [Conservative management of ectopic pregnancy in cesarean scar: case report]. Rev Bras Ginecol Obstet. 2013; 35:233-7.
• [9]Einenkel J, Stumpp P, Kosling S, Horn LC, Hockel M. A misdiagnosed case of caesarean scar pregnancy. Arch Gynecol Obstet. 2005; 271:178-81.
• [10]Zhang J, Liu Y, Meikle S, Zheng J, Sun W, Li Z. Cesarean delivery on maternal request in southeast China. Obstet Gynecol. 2008; 111:1077-82.
• [11]Wang CB, Tseng CJ. Primary evacuation therapy for Cesarean scar pregnancy: three new cases and review. Ultrasound Obstet Gynecol. 2006; 27:222-6.
• [12]Barrenetxea G, Barinaga-Rementeria L, Lopez De Larruzea A, Agirregoikoa JA, Mandiola M, Carbonero K. Heterotopic pregnancy: two cases and a comparative review. Fertil Steril. 2007; 87:417.
• [13]Goldberg JM, Bedaiwy MA. Transvaginal local injection of hyperosmolar glucose for the treatment of heterotopic pregnancies. Obstet Gynecol. 2006; 107:509-10.
• [14]Wang CJ, Tsai F, Chen C, Chao A. Hysteroscopic management of heterotopic cesarean scar pregnancy. Fertil Steril. 2010; 94:1529.
• [15]Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, Pineda G, Arslan AA. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol. 2012; 207:44.
• [16]Godin PA, Bassil S, Donnez J. An ectopic pregnancy developing in a previous caesarian section scar. Fertil Steril. 1997; 67:398-400.
• [17]Fylstra DL. Ectopic pregnancy within a cesarean scar: a review. Obstet Gynecol Surv. 2002; 57:537-43.
• [18]Litwicka K, Greco E. Caesarean scar pregnancy: a review of management options. Curr Opin Obstet Gynecol. 2011; 23:415-21.
• [19]Londra L, Moreau C, Strobino D, Garcia J, Zacur H, Zhao Y. Ectopic pregnancy after in vitro fertilization: differences between fresh and frozen-thawed cycles. Fertil Steril. 2015; 104:110-8.
• [20]Fang C, Huang R, Wei LN, Jia L. Frozen-thawed day 5 blastocyst transfer is associated with a lower risk of ectopic pregnancy than day 3 transfer and fresh transfer. Fertil Steril. 2015; 103:655-61.
• [21]Sahin S, Ozay A, Ergin E, Turkgeldi L, Kurum E, Ozornek H. The risk of ectopic pregnancy following GnRH agonist triggering compared with hCG triggering in GnRH antagonist IVF cycles. Arch Gynecol Obstet. 2015; 291:185-91.
• [22]Hammoud AO, Hammoud I, Bujold E, Gonik B, Diamond MP, Johnson SC. The role of sonographic endometrial patterns and endometrial thickness in the differential diagnosis of ectopic pregnancy. Am J Obstet Gynecol. 2005; 192:1370-5.
• [23]Taskin S, Taskin EA, Ciftci TT. Heterotopic cesarean scar pregnancy: how should it be managed? Obstet Gynecol Surv. 2009; 64:690-5.
• [24]Duenas-Garcia OF, Young C. Heterotopic cesarean scar pregnancy associated with a levonorgestrel-releasing intrauterine device. Int J Gynaecol Obstet. 2011; 114:153-4.
• [25]Ravhon A, Ben-Chetrit A, Rabinowitz R, Neuman M, Beller U. Successful methotrexate treatment of a viable pregnancy within a thin uterine scar. Br J Obstet Gynaecol. 1997; 104:628-9.
• [26]Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol. 2000; 16:592-3.
• [27]Howe RS. Third-trimester uterine rupture following hysteroscopic uterine perforation. Obstet Gynecol. 1993; 81:827-9.
• [28]Hemminki E, Merilainen J. Long-term effects of cesarean sections: ectopic pregnancies and placental problems. Am J Obstet Gynecol. 1996; 174:1569-74.
• [29]Stevens EE, Ogburn P. Cesarean scar ectopic pregnancy: a case report of failed combination local and systemic methotrexate management requiring surgical intervention. J Reprod Med. 2011; 56:356-8.
• [30]Brasic N, Warden M, Vargas JE. Conservative management of cesarean scar pregnancy with sonographically guided transvaginal methotrexate injection. J Ultrasound Med. 2013; 32:1061-3.
• [31]Frishman GN, Melzer KE, Bhagavath B. Ectopic pregnancy in a cesarean-section scar: the patient >6 weeks into an ectopic pregnancy, underwent local treatment. Am J Obstet Gynecol. 2012; 207:238.
• [32]Merckel LG, Bartels LW, Kohler MO, van den Bongard HJ, Deckers R, Mali WP. MR-guided high-intensity focused ultrasound ablation of breast cancer with a dedicated breast platform. Cardiovasc Intervent Radiol. 2013; 36:292-301.
• [33]Fukuda H, Ito R, Ohto M, Sakamoto A, Karasawa E, Yamaguchi T et al.. Treatment of small hepatocellular carcinomas with US-guided high-intensity focused ultrasound. Ultrasound Med Biol. 2011; 37:1222-9.
• [34]Chen W, Zhu H, Zhang L, Li K, Su H, Jin C et al.. Primary bone malignancy: effective treatment with high-intensity focused ultrasound ablation. Radiology. 2010; 255:967-78.
• [35]Wu F, Wang ZB, Zhu H, Chen WZ, Zou JZ, Bai J et al.. Feasibility of US-guided high-intensity focused ultrasound treatment in patients with advanced pancreatic cancer: initial experience. Radiology. 2005; 236:1034-40.
• [36]Olive DL. Sustained relief of leiomyoma symptoms by using focused ultrasound surgery. Obstet Gynecol. 2008; 111:775.
• [37]Zhou M, Chen JY, Tang LD, Chen WZ, Wang ZB. Ultrasound-guided high-intensity focused ultrasound ablation for adenomyosis: the clinical experience of a single center. Fertil Steril. 2011; 95:900-5.
• [38]Zhu X, Deng X, Wan Y, Xiao S, Huang J, Zhang L et al.. High-intensity focused ultrasound combined with suction curettage for the treatment of cesarean scar pregnancy. Medicine (Baltimore). 2015; 94: Article ID e854
• [39]Xiao J, Zhang S, Wang F, Wang Y, Shi Z, Zhou X et al.. Cesarean scar pregnancy: noninvasive and effective treatment with high-intensity focused ultrasound. Am J Obstet Gynecol. 2014; 211:356.
• [40]Huang L, Du Y, Zhao C. High-intensity focused ultrasound combined with dilatation and curettage for Cesarean scar pregnancy. Ultrasound Obstet Gynecol. 2014; 43:98-101.
• [41]Hong SC, Lau MS, Yam PK. Ectopic pregnancy in previous Caesarean section scar. Singapore Med J. 2011; 52:e115-7.
• [42]Shalev E, Peleg D, Tsabari A, Romano S, Bustan M. Spontaneous resolution of ectopic tubal pregnancy: natural history. Fertil Steril. 1995; 63:15-9.
• [43]Hsieh BC, Hwang JL, Pan HS, Huang SC, Chen CY, Chen PH. Heterotopic Caesarean scar pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for selective embryo reduction: case report. Hum Reprod. 2004; 19:285-7.
• [44]Yazicioglu HF, Turgut S, Madazli R, Aygun M, Cebi Z, Sonmez S. An unusual case of heterotopic twin pregnancy managed successfully with selective feticide. Ultrasound Obstet Gynecol. 2004; 23:626-7.