SlideShare ist ein Scribd-Unternehmen logo
1 von 31
Downloaden Sie, um offline zu lesen
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 pregnancy in a Caesarean scar
cesarean ectopic pregnancy
cesarean scar ectopic.
: MXT as in tubal ectopic pregnancies: failed but disastrous
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
Complications
1. Morbidly adherent placenta
2. Uterine rupture
3. Severe hemorrhage
4. Preterm labor.
5. Increased maternal morbidity and mortality.
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].
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.
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
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.
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.
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 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
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)
4. TREATMENT
Objective
 eliminating GS
preserving fertility
No universal tt guidelines
No clear conclusion:
most effective
least complications.
Timor-Tritsch et al, 2014
 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
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
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
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
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
Referral centers:
Experience
Operating rooms
Interventional radiology
Ready for emergencies.
Available immediate blood transfusion/
blood products.
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
Update on Treatment of Cesarean Scar Pregnancy
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 excision
2594Laparoscopy
1113Hysteroscopy
050UAE+Hysteroscopy
2515Laparotomy
020HIFU
1223Total
{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.
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
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
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
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
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
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

Weitere ähnliche Inhalte

Was ist angesagt?

Caesarean scar pregnancy.ppt
Caesarean scar pregnancy.pptCaesarean scar pregnancy.ppt
Caesarean scar pregnancy.pptULTRAFEST
 
Recent advances in gynecologic usg
Recent advances in gynecologic  usg Recent advances in gynecologic  usg
Recent advances in gynecologic usg Bharti Gahtori
 
Vulva ca sep course quick revision 2012
Vulva ca sep course quick revision 2012Vulva ca sep course quick revision 2012
Vulva ca sep course quick revision 2012Tariq Mohammed
 
Laparoscopic myomectomy
Laparoscopic myomectomyLaparoscopic myomectomy
Laparoscopic myomectomymagdy abdel
 
Cervical and broad ligament fibroid
Cervical and broad ligament fibroidCervical and broad ligament fibroid
Cervical and broad ligament fibroidNiranjan Chavan
 
Role of hysteroscopy in Infertility, Dr Rajesh Gajbhiye
Role of hysteroscopy in Infertility, Dr Rajesh GajbhiyeRole of hysteroscopy in Infertility, Dr Rajesh Gajbhiye
Role of hysteroscopy in Infertility, Dr Rajesh GajbhiyeRajesh Gajbhiye
 
Role of tubal surgery in era of ivf
Role of tubal surgery in era of ivfRole of tubal surgery in era of ivf
Role of tubal surgery in era of ivfSanjay Makwana
 
Mri in ob gy practice
Mri in ob  gy practiceMri in ob  gy practice
Mri in ob gy practicedrmcbansal
 
Distension media in hysteroscopy
Distension media in hysteroscopyDistension media in hysteroscopy
Distension media in hysteroscopymandybhandal1
 
FIGO guidelines on Placenta Accreta Spectrum Disorders: Conservative manage...
FIGO guidelines on  Placenta Accreta Spectrum Disorders:  Conservative manage...FIGO guidelines on  Placenta Accreta Spectrum Disorders:  Conservative manage...
FIGO guidelines on Placenta Accreta Spectrum Disorders: Conservative manage...Aboubakr Elnashar
 
Ovarian tumor (revised for class)
Ovarian tumor (revised for class)Ovarian tumor (revised for class)
Ovarian tumor (revised for class)Hale Teka
 
Approach to post menopausal bleeding
Approach to post menopausal bleeding Approach to post menopausal bleeding
Approach to post menopausal bleeding Niranjan Chavan
 
Endometriosis and Infertility
Endometriosis and InfertilityEndometriosis and Infertility
Endometriosis and InfertilityMarwan Alhalabi
 
Uterine Fibroid / Uterine Leiomyoma / Indore Infertility
Uterine Fibroid / Uterine Leiomyoma / Indore Infertility Uterine Fibroid / Uterine Leiomyoma / Indore Infertility
Uterine Fibroid / Uterine Leiomyoma / Indore Infertility Indore Infertility Clinic
 
Ulipristal acetate in treatment of fibroids
Ulipristal acetate in treatment of fibroidsUlipristal acetate in treatment of fibroids
Ulipristal acetate in treatment of fibroidsIndraneel Jadhav
 
Endometriosis an overview by dr. sharda Jain, Dr. Jyoti Agarwal , Dr. Jy...
Endometriosis an overview by  dr. sharda Jain,   Dr. Jyoti Agarwal  ,  Dr. Jy...Endometriosis an overview by  dr. sharda Jain,   Dr. Jyoti Agarwal  ,  Dr. Jy...
Endometriosis an overview by dr. sharda Jain, Dr. Jyoti Agarwal , Dr. Jy...Lifecare Centre
 

Was ist angesagt? (20)

Caesarean scar pregnancy.ppt
Caesarean scar pregnancy.pptCaesarean scar pregnancy.ppt
Caesarean scar pregnancy.ppt
 
Recent advances in gynecologic usg
Recent advances in gynecologic  usg Recent advances in gynecologic  usg
Recent advances in gynecologic usg
 
Managing adenomyosis
Managing adenomyosisManaging adenomyosis
Managing adenomyosis
 
Vulva ca sep course quick revision 2012
Vulva ca sep course quick revision 2012Vulva ca sep course quick revision 2012
Vulva ca sep course quick revision 2012
 
Laparoscopic myomectomy
Laparoscopic myomectomyLaparoscopic myomectomy
Laparoscopic myomectomy
 
Cervical and broad ligament fibroid
Cervical and broad ligament fibroidCervical and broad ligament fibroid
Cervical and broad ligament fibroid
 
Role of hysteroscopy in Infertility, Dr Rajesh Gajbhiye
Role of hysteroscopy in Infertility, Dr Rajesh GajbhiyeRole of hysteroscopy in Infertility, Dr Rajesh Gajbhiye
Role of hysteroscopy in Infertility, Dr Rajesh Gajbhiye
 
Role of tubal surgery in era of ivf
Role of tubal surgery in era of ivfRole of tubal surgery in era of ivf
Role of tubal surgery in era of ivf
 
Mullerian anomalies
Mullerian anomaliesMullerian anomalies
Mullerian anomalies
 
Mri in ob gy practice
Mri in ob  gy practiceMri in ob  gy practice
Mri in ob gy practice
 
Distension media in hysteroscopy
Distension media in hysteroscopyDistension media in hysteroscopy
Distension media in hysteroscopy
 
FIGO guidelines on Placenta Accreta Spectrum Disorders: Conservative manage...
FIGO guidelines on  Placenta Accreta Spectrum Disorders:  Conservative manage...FIGO guidelines on  Placenta Accreta Spectrum Disorders:  Conservative manage...
FIGO guidelines on Placenta Accreta Spectrum Disorders: Conservative manage...
 
Ovarian tumor (revised for class)
Ovarian tumor (revised for class)Ovarian tumor (revised for class)
Ovarian tumor (revised for class)
 
Approach to post menopausal bleeding
Approach to post menopausal bleeding Approach to post menopausal bleeding
Approach to post menopausal bleeding
 
MULLERIAN ANOMALIES
MULLERIAN ANOMALIES MULLERIAN ANOMALIES
MULLERIAN ANOMALIES
 
Endometriosis and Infertility
Endometriosis and InfertilityEndometriosis and Infertility
Endometriosis and Infertility
 
Uterine Fibroid / Uterine Leiomyoma / Indore Infertility
Uterine Fibroid / Uterine Leiomyoma / Indore Infertility Uterine Fibroid / Uterine Leiomyoma / Indore Infertility
Uterine Fibroid / Uterine Leiomyoma / Indore Infertility
 
Ulipristal acetate in treatment of fibroids
Ulipristal acetate in treatment of fibroidsUlipristal acetate in treatment of fibroids
Ulipristal acetate in treatment of fibroids
 
Intrapartum sonography
Intrapartum sonographyIntrapartum sonography
Intrapartum sonography
 
Endometriosis an overview by dr. sharda Jain, Dr. Jyoti Agarwal , Dr. Jy...
Endometriosis an overview by  dr. sharda Jain,   Dr. Jyoti Agarwal  ,  Dr. Jy...Endometriosis an overview by  dr. sharda Jain,   Dr. Jyoti Agarwal  ,  Dr. Jy...
Endometriosis an overview by dr. sharda Jain, Dr. Jyoti Agarwal , Dr. Jy...
 

Ähnlich wie Update on Treatment of Cesarean Scar Pregnancy

Lower segment ceaserean section
Lower segment ceaserean sectionLower segment ceaserean section
Lower segment ceaserean sectionBimal Pokharel
 
Scar ectopic pregnancy
Scar ectopic pregnancyScar ectopic pregnancy
Scar ectopic pregnancyAlkaPandey24
 
Jsm caeserean scar pregnancy
Jsm caeserean scar pregnancyJsm caeserean scar pregnancy
Jsm caeserean scar pregnancyDeepti Jain
 
Jsm caeserean scar pregnancy
Jsm caeserean scar pregnancyJsm caeserean scar pregnancy
Jsm caeserean scar pregnancyDeepti Jain
 
Role of MRIversus US in placental abnormalities and diseases
Role of MRIversus US in placental abnormalities and diseasesRole of MRIversus US in placental abnormalities and diseases
Role of MRIversus US in placental abnormalities and diseasesSoha Hamed
 
M crc ppt
M crc pptM crc ppt
M crc pptmadurai
 
Morbidly adherent placenta
Morbidly adherent placentaMorbidly adherent placenta
Morbidly adherent placentamagdy abdel
 
Management of cesarean scar pregnancy
Management of cesarean scar pregnancyManagement of cesarean scar pregnancy
Management of cesarean scar pregnancyOsama Warda
 
Infected cesarean section scar
Infected cesarean section scar Infected cesarean section scar
Infected cesarean section scar Ahmed Elagwany
 
Cesarean Scar Pregnancy Resulting in Live Birth: A Case Report
Cesarean Scar Pregnancy Resulting in Live Birth: A Case ReportCesarean Scar Pregnancy Resulting in Live Birth: A Case Report
Cesarean Scar Pregnancy Resulting in Live Birth: A Case Reportsemualkaira
 
Cesarean Scar Pregnancy Resulting in Live Birth: A Case Report
Cesarean Scar Pregnancy Resulting in Live Birth: A Case ReportCesarean Scar Pregnancy Resulting in Live Birth: A Case Report
Cesarean Scar Pregnancy Resulting in Live Birth: A Case Reportsemualkaira
 
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...semualkaira
 
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...semualkaira
 
Port site tuberculosis after laparoscopic cholecystectomy
Port site tuberculosis after laparoscopic cholecystectomy Port site tuberculosis after laparoscopic cholecystectomy
Port site tuberculosis after laparoscopic cholecystectomy Dr Kaushal Deep Singh Mathuria
 
Hp mar06 rqectopic
Hp mar06 rqectopicHp mar06 rqectopic
Hp mar06 rqectopicAbeer Ahmed
 
Management Of Early Stage Ca Cervix [Autosaved]
Management Of Early Stage Ca Cervix [Autosaved]Management Of Early Stage Ca Cervix [Autosaved]
Management Of Early Stage Ca Cervix [Autosaved]PGIMER, AIIMS
 

Ähnlich wie Update on Treatment of Cesarean Scar Pregnancy (20)

Lower segment ceaserean section
Lower segment ceaserean sectionLower segment ceaserean section
Lower segment ceaserean section
 
Scar ectopic pregnancy
Scar ectopic pregnancyScar ectopic pregnancy
Scar ectopic pregnancy
 
Jsm caeserean scar pregnancy
Jsm caeserean scar pregnancyJsm caeserean scar pregnancy
Jsm caeserean scar pregnancy
 
Jsm caeserean scar pregnancy
Jsm caeserean scar pregnancyJsm caeserean scar pregnancy
Jsm caeserean scar pregnancy
 
Role of MRIversus US in placental abnormalities and diseases
Role of MRIversus US in placental abnormalities and diseasesRole of MRIversus US in placental abnormalities and diseases
Role of MRIversus US in placental abnormalities and diseases
 
M crc ppt
M crc pptM crc ppt
M crc ppt
 
Morbidly adherent placenta
Morbidly adherent placentaMorbidly adherent placenta
Morbidly adherent placenta
 
Management of cesarean scar pregnancy
Management of cesarean scar pregnancyManagement of cesarean scar pregnancy
Management of cesarean scar pregnancy
 
Infected cesarean section scar
Infected cesarean section scar Infected cesarean section scar
Infected cesarean section scar
 
Cesarean Scar Pregnancy Resulting in Live Birth: A Case Report
Cesarean Scar Pregnancy Resulting in Live Birth: A Case ReportCesarean Scar Pregnancy Resulting in Live Birth: A Case Report
Cesarean Scar Pregnancy Resulting in Live Birth: A Case Report
 
Cesarean Scar Pregnancy Resulting in Live Birth: A Case Report
Cesarean Scar Pregnancy Resulting in Live Birth: A Case ReportCesarean Scar Pregnancy Resulting in Live Birth: A Case Report
Cesarean Scar Pregnancy Resulting in Live Birth: A Case Report
 
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...
 
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...
Breast Desmoid Tumor with Spectacular Evolution : A Case Report and Review of...
 
Morbidly adherent placenta
Morbidly adherent placentaMorbidly adherent placenta
Morbidly adherent placenta
 
Port site tuberculosis after laparoscopic cholecystectomy
Port site tuberculosis after laparoscopic cholecystectomy Port site tuberculosis after laparoscopic cholecystectomy
Port site tuberculosis after laparoscopic cholecystectomy
 
CIN.ppt
CIN.pptCIN.ppt
CIN.ppt
 
CSP ACOG2021.pdf
CSP ACOG2021.pdfCSP ACOG2021.pdf
CSP ACOG2021.pdf
 
Hp mar06 rqectopic
Hp mar06 rqectopicHp mar06 rqectopic
Hp mar06 rqectopic
 
Management Of Early Stage Ca Cervix [Autosaved]
Management Of Early Stage Ca Cervix [Autosaved]Management Of Early Stage Ca Cervix [Autosaved]
Management Of Early Stage Ca Cervix [Autosaved]
 
Ca endometrium
Ca endometriumCa endometrium
Ca endometrium
 

Mehr von Aboubakr Elnashar

WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGISTWHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGISTAboubakr Elnashar
 
Adenomyosis associated infertility
Adenomyosis associated  infertilityAdenomyosis associated  infertility
Adenomyosis associated infertilityAboubakr Elnashar
 
Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022Aboubakr Elnashar
 
Aesthetic gynecology controversy
Aesthetic gynecology controversyAesthetic gynecology controversy
Aesthetic gynecology controversyAboubakr Elnashar
 
Hormonal assay in clinical gyn
Hormonal assay in clinical gynHormonal assay in clinical gyn
Hormonal assay in clinical gynAboubakr Elnashar
 
Unnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicineUnnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicineAboubakr Elnashar
 
Individualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulationIndividualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulationAboubakr Elnashar
 
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA Aboubakr Elnashar
 
cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021  cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021 Aboubakr Elnashar
 
Management of pregnancy of unknown location
Management of pregnancy of unknown locationManagement of pregnancy of unknown location
Management of pregnancy of unknown locationAboubakr Elnashar
 
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021Aboubakr Elnashar
 

Mehr von Aboubakr Elnashar (20)

WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGISTWHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
WHAT IS NEW IN ESHRE 2022 AND FIGO 2022 FOR GENERAL GYNAECOLOGIST
 
hepatitis B.pdf
hepatitis B.pdfhepatitis B.pdf
hepatitis B.pdf
 
hepatitis c2022.pdf
hepatitis c2022.pdfhepatitis c2022.pdf
hepatitis c2022.pdf
 
Adenomyosis associated infertility
Adenomyosis associated  infertilityAdenomyosis associated  infertility
Adenomyosis associated infertility
 
Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022Endometriosis associated infertility: ESHRE2022
Endometriosis associated infertility: ESHRE2022
 
Adenxal mass guidelines2020
Adenxal mass guidelines2020Adenxal mass guidelines2020
Adenxal mass guidelines2020
 
Aesthetic gynecology controversy
Aesthetic gynecology controversyAesthetic gynecology controversy
Aesthetic gynecology controversy
 
Hormonal assay in clinical gyn
Hormonal assay in clinical gynHormonal assay in clinical gyn
Hormonal assay in clinical gyn
 
FIRST TRIMESTER ANC OF IVF
FIRST TRIMESTER ANC OF IVFFIRST TRIMESTER ANC OF IVF
FIRST TRIMESTER ANC OF IVF
 
Unnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicineUnnecessary investigations in reproductive medicine
Unnecessary investigations in reproductive medicine
 
Infertility prevention
Infertility prevention Infertility prevention
Infertility prevention
 
Individualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulationIndividualisation of controlled ovarian stimulation
Individualisation of controlled ovarian stimulation
 
Female infertility
Female infertility Female infertility
Female infertility
 
Maternal near miss
Maternal near missMaternal near miss
Maternal near miss
 
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
THE MANAGEMENT OF SEVERE PET/ECLAMPSIA
 
cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021  cesarean birth: procedural aspects: NICE2021
cesarean birth: procedural aspects: NICE2021
 
Management of pregnancy of unknown location
Management of pregnancy of unknown locationManagement of pregnancy of unknown location
Management of pregnancy of unknown location
 
Aerobic Vaginitis
Aerobic Vaginitis Aerobic Vaginitis
Aerobic Vaginitis
 
COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021COVID 19 infection and pregnancy RCOG2021
COVID 19 infection and pregnancy RCOG2021
 
Imaging in pregnancy 2 in1
Imaging in pregnancy 2 in1Imaging in pregnancy 2 in1
Imaging in pregnancy 2 in1
 

Kürzlich hochgeladen

SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptPradnya Wadekar
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfDolisha Warbi
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Vaikunthan Rajaratnam
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondSujoy Dasgupta
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisSujoy Dasgupta
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.pptRamDBawankar1
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyZurück zum Ursprung
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionkrishnareddy157915
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets barmohitRahangdale
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Peter Embi
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxkomalt2001
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 

Kürzlich hochgeladen (20)

SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
ayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologypptayurvedic formulations herbal drug technologyppt
ayurvedic formulations herbal drug technologyppt
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdfPAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
PAIN/CLASSIFICATION AND MANAGEMENT OF PAIN.pdf
 
Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.Generative AI in Health Care a scoping review and a persoanl experience.
Generative AI in Health Care a scoping review and a persoanl experience.
 
Male Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and BeyondMale Infertility, Antioxidants and Beyond
Male Infertility, Antioxidants and Beyond
 
Adenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosisAdenomyosis or Fibroid- making right diagnosis
Adenomyosis or Fibroid- making right diagnosis
 
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D.  Bawankar.pptPharmacokinetic Models by Dr. Ram D.  Bawankar.ppt
Pharmacokinetic Models by Dr. Ram D. Bawankar.ppt
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
How to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturallyHow to cure cirrhosis and chronic hepatitis naturally
How to cure cirrhosis and chronic hepatitis naturally
 
EXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung functionEXERCISE PERFORMANCE.pptx, Lung function
EXERCISE PERFORMANCE.pptx, Lung function
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
Role of Soap based and synthetic or syndets bar
Role of  Soap based and synthetic or syndets barRole of  Soap based and synthetic or syndets bar
Role of Soap based and synthetic or syndets bar
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024Clinical Research Informatics Year-in-Review 2024
Clinical Research Informatics Year-in-Review 2024
 
Basic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptxBasic structure of hair and hair growth cycle.pptx
Basic structure of hair and hair growth cycle.pptx
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 

Update on Treatment of Cesarean Scar Pregnancy

  • 1. Update on Treatment of Cesarean Scar Pregnancy Prof. Aboubakr Elnashar Benha university Hospital, Egypt
  • 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. 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. Complications 1. Morbidly adherent placenta 2. Uterine rupture 3. Severe hemorrhage 4. Preterm labor. 5. Increased maternal morbidity and mortality.
  • 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. 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. 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. 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. 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. 5. Doppler Marked peritrophoblastic color Doppler flow around GS Avoid false positive diagnosis: 30-40%
  • 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. 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. 4. TREATMENT Objective  eliminating GS preserving fertility No universal tt guidelines No clear conclusion: most effective least complications.
  • 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. 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. 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. 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. 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. Referral centers: Experience Operating rooms Interventional radiology Ready for emergencies. Available immediate blood transfusion/ blood products.
  • 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
  • 23. Shao et al (2013): 1. GS 2. Myometrial Thickness 3. HCG LUAO=Laparoscopic uterine a occlusion
  • 24. 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
  • 25. {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.
  • 26. 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
  • 27. 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
  • 28. 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
  • 29. 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
  • 30. 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
  • 31. 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