cesarean scar pregnancy management 2012

c

asbIca1wnelti

Research www.AJOG.org

GENERAL GYNECOLOGY

Bilateral 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, PhD

m1at

OBJECTIVE: The objective of the study was to assess the efficacy ofuterine arteries embolization (UAE) for the treatment of cesarean scarpregnancies (CSP).

STUDY DESIGN: Forty-six women with CSP were identified betweenMarch 2008 and March 2010. All of the patients underwent UAE com-bined with local methotrexate.

RESULTS: Forty-five patients were successfully treated. One patienthad an emergency hysterectomy after 20 days because of massive vag-inal hemorrhage. The mean time until normalization of serum �-human
horionic gonadotrophin was 37.7 days, and the mean time until CSP
2012;207:386.e1-6.

Cict

afcsdsdtdcp

section of the gestationhttp://dx.doi.org/10.1016/j.ajog.2012.09.012

386.e1 American Journal of Obstetrics & Gynecology NOVEMBER 2012

ass disappearance was 33.3 days. The mean hospitalization time was0.5 days. The complications were mainly fever and pain, which werelleviated with symptomatic treatment. All 45 patients had recoveredheir normal menstruation at follow-up.

CONCLUSION: Bilateral uterine artery chemoembolization with metho-trexate appears to be a safe and effective treatment for CSP and causesless morbidity than current approaches.

Key words: cesarean scar pregnancy, methotrexate, uterine artery
chemoembolization
Cite this article as: Shen L, Tan A, Zhu H, et al. Bilateral uterine artery chemoembolization with methotrexate for cesarean scar pregnancy. Am J Obstet Gynecol

fbsctrch

Cesarean scar pregnancy (CSP) is anovel and life-threatening form of

bnormal implantation of a gestationalac within the myometrium and the fi-rous tissue of a previous cesarean scar.t has recently been found to be moreommon than was previously thought,nd its estimated incidence ranges fromper 1800 to 1 per 2216 pregnancies,ith a rate of 6.1% of all ectopic preg-ancies with a history of at least 1 cesar-an section.1,2 It is considered to be aong-term complication of cesarean sec-ion (CS), and its prevalence is currentlyncreasing with the rising CS rate in

From the Department of Obstetrics andGynecology, West China Second UniversityHospital of Sichuan University, People’sRepublic of China.

Received May 23, 2012; revised July 14, 2012;accepted Sept. 12, 2012.

The authors report no conflict of interest.

Reprints: Wei Huang, MD, Department ofObstetrics and Gynecology, West ChinaSecond University Hospital of SichuanUniversity, Renminnanlu 3 duan 20hao,Chengdu, Sichuan 610041, People’s Republicof China. [email protected].

0002-9378/$36.00© 2012 Mosby, Inc. All rights reserved.

hina. Early and accurate diagnosis bymproved ultrasound imaging and greaterlinician awareness may be contributing tohis rise.3

CSP can lead to life-threatening hemor-rhage during pregnancy or curettage andeven to uterine rupture, disseminated in-travascular coagulation, or death.4,5 Earlynd accurate diagnosis is important for ef-ective treatment to avoid these potentiallyatastrophic consequences. Ultra-ound was the first widely used method ofiagnosing CSP. Recently improved ultra-ound imaging has enabled correct earlyetection of such pregnancies with a sensi-ivity of 84.6%.3 However, it is difficult toistinguish a CSP from spontaneous mis-arriage in progress or a cervicoisthmicregnancy.6 Senior ultrasound practitio-

ners may be more experienced in deter-mining the details of the location, size, age,and viability of the gestation sac and maythus be better able to make a correct diag-nosis, which is critical for timely effectivemanagement.

The aim in the management of CSPshould be the prevention of massivehemorrhage and conservation of theuterus for further fecundity, health, andquality of life. Traditional managementfor CSP includes hysterectomy, local re-

al mass within the

previous cesarean scar, dilation and cu-rettage, and systemic or local adminis-tration of drugs such as the metabolisminhibitor methotrexate (MTX).7-10 Soar, although various interventions haveeen proposed, there has been no con-ensus on the optimal therapeutic proto-ol for CSP. MTX, used as a conservativereatment, was reported to have a highisk of failure and side effects, which ne-essitated treatment or even emergencyysterectomy.4

Uterine artery embolization (UAE;blocking of the arteries using gelatinbeads or other material) has been in-creasingly used before uterine surgery toprevent excessive bleeding in uterinemyomas, cervical pregnancies, or postpar-tum hemorrhage or during chemotherapyto prevent uncontrollable bleeding in ma-lignancies. Along with chemoemboliza-tion (a combination of embolization andlocal delivery of chemotherapy) beingproved to be an effective anticancer treat-ment in clinical practice, bilateral uterinearterial chemoembolization has recentlybeen tried out for CSP management.

In the procedure of bilateral uterinearterial chemoembolization, MTX is ad-ministered directly into the gestationalfoci through bilateral uterine arteries,
which are its feeding blood supply, with
mailto:[email protected]

http://dx.doi.org/10.1016/j.ajog.2012.09.012

accal

gdsieau

iitteamtufbvsc

eev5paampwMbwmatw

tt

www.AJOG.org General Gynecology Research

subsequent blockage of the feeding vesselby occlusive agents that are injectedthrough the delivery catheter. Becausethis involves both chemotherapy and tis-sue ischemia, it permits a higher concen-tration of MTX to target the gestationalfoci for a longer period of time and thusproduces more effective embryocide,with much less systemic toxic effects,than embolization alone. To date, only afew reports that describe uterine arterychemoembolization with MTX for CSPtreatment11-13 are available.

We retrospectively reviewed our man-gement with bilateral uterine arterialhemoembolization with MTX of 46ases of CSP over a 2 year period andnalyzed complications and quality of

FIGURE 1Transvaginal sonogram of the cesa

Transvaginal sonogram of the cesarean scar pthe empty cervical canal and the gestational sscar at the anterior uterine wall and protrudingvascularity.Shen. Bilateral uterine artery chemoembolization with metho

ife after treatment.

MATERIALS AND METHODSThe research protocol was approved bythe institutional review board of WestChina Second University Hospital, Sich-uan University. Informed consent wasobtained from all patients, and all avail-able information on the treatments waspresented to the patients, including therisks and benefits of the therapy, poten-tial complications, and alternatives.

Between March 2008 and March 2010,46 patients were diagnosed with CSP inour hospital. We reviewed the clinic re-cords of all these patients, including pa-tient age, gravidity and parity, clinicalpresentation, weeks of gestation, thetime interval between the last cesareansection and cesarean scar pregnancy,

an scar pregnancy

nancy, showing the empty uterine cavity andimplanted into the previous cesarean sectionard the urinary bladder, with rich surrounded

ate for cesarean scar pregnancy. Am J Obstet Gynecol 2012.

clinical findings, results of ultrasound

NOVEMBER 2012 Americ

imaging examinations, therapeutic pro-cedures, blood loss, and findings atfollow-up.

In all patients, the gestational age wasestimated according to the last men-strual period and ultrasonographic exam-inations, and serum �-human chorioniconadotrophin (hCG) concentration wasetermined before treatment. The diagno-es of CSP were based on symptoms, clin-cal manifestations, history of prior cesar-an section, serum �-hCG concentration,nd special presentation on transvaginalltrasonography.The criteria of ultrasound diagnosis

nclude the following: (1) an empty uter-ne cavity and cervical canal; (2) a gesta-ional sac located at the anterior wall ofhe isthmic portion, separated from thendometrial cavity or fallopian tube; (3)gestational sac embedded within theyometrium and the fibrous tissue of

he cesarean section scar at the lowerterine segment, with an absence of de-

ect in the myometrium between theladder and the sac; and (4) and a high-elocity–low-impedance vascular flowurrounding the gestation sac.1,2,14 All 46ases matched these criteria (Figure 1).

The UAE procedure was performed byxperienced radiologists. After local an-sthesia, catheterization was carried outia the right femoral artery with aF-Yashiro catheter (Terumo, Tokyo, Ja-an) that was advanced into the uterinerteries on both sides; digital subtractionrteriography (AXIOM-Artis-FA; Sie-ens AG, Munich, Germany) was then

erformed to confirm that cathetersere correctly inserted, and 25 mg ofTX was injected bilaterally; and finally

oth uterine arteries were embolizedith gelatin sponge particles (0.5-1.0m). Subsequently, postembolization

ngiography was performed to validatehat the vascularity of the gestational sacas completely obstructed (Figure 2).Twenty-four to 72 hours later, the pa-

ients were carefully examined usingransvaginal ultrasound, and their serum

�-hCG levels were assessed. In patientswith persistent vaginal bleeding and/or apersistent gestational mass larger than 5cm, suction curettage was performedunder transabdominal ultrasound guid-

re

regactow

trex

ance after ultrasonic confirmation of the

an Journal of Obstetrics & Gynecology 386.e2

lnvfw

St

c(rwtami

tsoT

Research General Gynecology www.AJOG.org

absence of blood flow to the CSP regionto remove the retained products of con-ception 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, bloodoss, adverse effects (including fever,ausea and vomiting, abdominal or pel-ic pain, and abnormal liver or renalunction), and length of hospital stayere 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/subtotal hysterectomy.

Successful UAE treatment was definedas a complete recovery without severeadverse effects or complications andwithout a need for repeat embolizationor hysterectomy.

All data are expressed as mean � SD.tatistical analysis was performed usinghe Student t test and a �2 test by the SPSS

19.0 statistical package (SPSS Inc, Chi-cago, IL).

RESULTS

Forty-six cases of CSP were diagnosedover a 2 year period. The average age ofthe 46 patients was 32.7 � 6.0 (21-44)years. The average gravidity was 5.0 �1.6 (2-8) and the average parity was1.09 � 0.28 (1-3). Four women had un-dergone 2 previous cesarean deliveries.The average interval from the last cesar-ean section was 63.5 � 8.2 (4-252)
months. The average gestational age at b
386.e3 American Journal of Obstetrics & Gynecolo

presentation was 55.5 � 2.4 (37-97) days(Table).

Twenty-five women were initially di-agnosed with CSP on admission to ourhospital. The main complaints were ir-regular vaginal bleeding (19 of 25,76.0%) and mild lower abdominal pain(7 of 25, 28.0%). The serum �-hCGoncentration was 28,220.2 � 7104.4161.6-181,880) mIU/mL. By ultrosonog-aphy, the largest diameter of the CSP massas 1.0-7.6 cm, the embryo within the ges-

ational sac could be seen in 18 patients,nd 8 had fetal cardiac activity; in the re-aining 7 patients, only a yolk sac was

dentified. All these 25 women underwent

FIGURE 2Angiograms of a patient with CSP w

igital subtraction angiograms of a patient witmbolization. A and B, Angiography before embrtery is hypertrophied and tortuous, and the granches. C and D, Angiography after embolizaascularity of the gestational sac completely disaSP, cesarean scar pregnancies; UAE, uterine arteries embolizati

hen. Bilateral uterine artery chemoembolization with metho

ilateral uterine artery chemoemboliza-

gy NOVEMBER 2012

ion as primary treatment, followed byuction curettage after 72 hours. The timef hospital stay was 10.1 � 1.0 (4-28) days.he time for serum �-hCG normalization

was 32.0 � 5.5 (7-134) days. The time fortotal lesion disappearance was 32.7 � 4.0(5-58) days. All these patients experienceda rapid, uneventful recovery.

The remaining 21 patients receivedsuction curettage at their first visit toother hospitals because of misdiagnosisfor inevitable miscarriage or missedabortion. They were transferred to ourhospital owing to massive hemorrhageduring the operation. On admission toour hospital, bilateral uterine artery che-

o received transcatheter UAE

SP who received transcatheter uterine arterialation. The uterus is enlarged, bilateral uterineational sac is surrounded by numerous artery. Both uterine arteries are obstructed and theared.

ate for cesarean scar pregnancy. Am J Obstet Gynecol 2012.

h

D h Ce oliza estb tionv ppeC on.

S trex

moembolization was performed with

7t5

amdmdh

to

wt

hqi

cstiftmottappqc

t(tctdtwpc


adequate preparation, including bloodsupply and surgical preparation in caseemergency surgery was needed. Seventy-two hours later, 11 received suction cu-rettage because of persistent vaginalbleeding (7 of 11 patients) and/or a per-sistent gestational mass larger than 5 cm(5 of 11). The time of hospital stay ofthese 11 patients was 10.7 � 1.2 (7-33)days; the time for serum �-hCG normal-ization was 35.3 � 4.6 (6-140) days; andthe time for gestational mass disappear-ance was 30.5 � 5.4 (5-60) days.

The other 10 patients, who had no per-sistent vaginal bleeding and showed asteady decrease of serum �-hCG levelsand gradual disappearance of concep-tion mass on ultrasonography, receivedno additional treatment. For these 10patients, the time of hospital stay was11.0 � 1.0 (8-35) days; the time for se-rum �-hCG normalization was 38.1 �

.2 (6-150) days; and the time for gesta-ional mass disappearance was 36.3 �.9 (7-60) days.One patient without suction curettage

fter chemoembolization had only inter-ittent vaginal spotting and was then

ischarged, but 20 days later she sufferedassive active vaginal bleeding and un-

erwent a life-saving emergency subtotalysterectomy.Overall, 45 patients were successfully

reated, with a success rate of 97.8% (45

TABLECharacteristics of 46 women with c

Characteristic

Mean age, y...................................................................................................................

Previous pregnancies, n..........................................................................................................

1..........................................................................................................

2...................................................................................................................

Time from the last CS, mo...................................................................................................................

Gestational age, d...................................................................................................................

Time for serum �-hCG normalization, d...................................................................................................................

Time for CSP mass disappearance, d...................................................................................................................

Hospitalization, d...................................................................................................................

Successful cases, n (%)...................................................................................................................

Unless otherwise indicated, data are expressed as mean � S�-hCG, �-human chorionic gonadotropin; CS, cesarean secti

Shen. Bilateral uterine artery chemoembolization with m2012.

f 46). The average time of hospital stay

as 10.5 � 1.0 (4-35) days. The meanime for serum �-hCG normalization

was 37.7 � 4.8 (7-150) days. The time forCSP mass disappearance by ultrasonog-raphy was 33.3 � 4.3 (5-60) days(Table). Thirty-six women underwentsuction curettage 2-12 days after chemo-embolization, blood loss intraoperativelywas 5-150 mL.

These clinical outcomes were com-pared between patients (n � 25) with di-agnosis made prior to any interventionand patients (n � 21) with previous cu-rettage before being transferred owingto massive hemorrhage, and the datashowed no significant differences. Theconception products were confirmed byhistological examination, which showedclusters of chorionic villi and tropho-blastic cells within fibrotic myometriumin all these patients.

No adverse effects of MTX, such asleukopenia, alopecia, stomatitis, nauseaor vomiting, or liver or renal dysfunctionwere observed in these patients. Nine-teen patients experienced fever of 38-40°C (10 of the 25 patients initially diag-nosed CSP, and 9 of the 21 casesmisdiagnosed in other hospitals), whichreturned to normal at a mean time of1.2 � 0.3 days. Forty-one patients hadmild abdominal pain, pelvic pain, orpain in the right leg (23 of the 25 patientsinitially diagnosed CSP, and 18 of the 21

arean scar pregnancies

Mean � SD (range)

32.7 � 6.0 (21–44)..................................................................................................................

5.0 � 1.6 (2–8)..................................................................................................................

42..................................................................................................................

4..................................................................................................................

63.5 � 8.2 (4–252)..................................................................................................................

55.5 � 2.4 (37–97)..................................................................................................................

37.7 � 4.8 (7–150)..................................................................................................................

33.3 � 4.3 (5–60)..................................................................................................................

10.5 � 1.0 (4–35)..................................................................................................................

45 (97.8)..................................................................................................................

nge).SP, cesarean scar pregnancies.

rexate for cesarean scar pregnancy. Am J Obstet Gynecol

cases misdiagnosed in other hospitals), f


which was alleviated with symptomatictreatment.

The average follow-up time was 29.7 �6.9 (20-43) months. Of the 45 patients whohad uterine preservation, 22 women ob-tained restoration of normal menses 1month after the intervention therapy, 3had regular menses 3 months later, 16 ex-perienced menstrual disorders of reducedmenstrual amounts, and the remaining 4experienced dysmenorrhea. All 45 of thesewomen had normal menstrual cycle andmenstrual amounts without dysmenor-rhea at follow-up and stated that they hadno desire to have a child. Two experiencedunexpected intrauterine pregnancy 3 and24 months after intervention, and both re-ceived medical abortions.

COMMENTCesarean scar pregnancy is one of thelong-term complications after cesareandelivery.15 Since the first reported case byLarsen and Solomon in 1978,16 cases

ave been reported with increasing fre-uency, resulting in better understand-

ng of the disease in recent years.The mechanism of CSP remains un-

ertain. It is possible that this abnormalcar implantation is primarily due to ainy defect or dehiscence in the uterinencision, which is believed to developrom the poor healing of the priorrauma caused by cesarean deliveries,

ultiple uterine curettage, or adenomy-sis.5,17 If an embryo implants early intohe myometrium via a microtubularract in this tiny defect, the CSP occursnd grows. Little is known about the im-act of the time interval between therior cesarean section and the subse-uent scar implantation and the naturalourse of CSP.

In this study, the average interval fromhe last cesarean section was 63.5 � 8.24-252) months, which was similar tohat in previous reports.2 It is also un-lear whether there is any correlation be-ween the number of previous cesareaneliveries and the occurrence of CSP. Ofhe 46 patients in the present study, 42omen (91.3%) had undergone only 1revious cesarean section, so multipleesarean sections may not be a risk factor

es

.........

.........

.........

.........

.........

.........

.........

.........

.........

.........

D (raon; C

ethot

or CSP.


tbbiidtm

cnrtm

amr

Mvca

azameTaltuocbf

tcatwbre

ttpttnfwf

crapmtpargtcfst

BzttcC

Research General Gynecology www.AJOG.org

Literatures are conflicting as to the im-portance of a single-layer vs multiple-layer uterine closure on the developmentof uterine scar defects. 18-21All the pa-ients in our study had undergone dou-le-layer uterine closures. It remains toe determined whether a change in uter-

ne closure technique improves the heal-ng of the uterine scar and consequentlyecreases the rate of CSP. Further inves-igation is warranted to identify an opti-

al uterine closure technique.It is recommended that clinicians pay

lose attention to the diagnosis of preg-ant women with previous CS. High-esolution ultrasound scanning is essen-ial for differential diagnosis to avoid

isdiagnosis.2 In our study, 21 patientswere initially misdiagnosed with sponta-neous abortion or cervicoisthmic preg-nancy in other hospitals. Some authorshave suggested strategies to make a dis-tinction between them. Godin et al22

suggested that in a cervicoisthmic preg-nancy there would be a layer of healthymyometrium visible between the blad-der and the gestation sac, whereas Tan etal23 considered that a sac that appearsvascular should indicate a spontaneousiscarriage. An exponential drop in se-

um �-hCG concentration would also benoticed in a miscarriage.6

Effective termination of CSP shouldbe carried out in the first trimester toachieve the optimal treatment objec-tives, including termination of the em-bryo before rupture, ablation of theconception mass, and preservation ofa patient’s future fertility.6 Systematic

TX is considered as a possible conser-ative treatment but takes a long time toause the CSP mass to disappear and hashigh failure rate.4,13

As an invasive radiological procedure,bilateral arterial embolization, which hasbeen used in tumor or other gynecolog-ical disease, has recently gained wide ac-ceptance as a conservative method fortreating CSP.4,9 Delivery of intravascularMTX before occlusion facilitates highMTX concentration in the CSP mass,with less toxicity and fewer adverse ef-fects than are common with systemic ad-ministration of MTX. The subsequentarterial occlusion obstructs blood flow to
the CSP region, so that a low dose of t
386.e5 American Journal of Obstetrics & Gynecolo

MTX produces a high local drug concen-tration, resulting in effective embryocidewith minimal systemic toxic side effects.Bilateral arterial embolization alonemerely blocks the blood, whereas MTXperfusion carries out direct embryocide.This combination has been effectivelyused for treatment of cervical gestation,gestational trophoblastic diseases, andCSP.

In our study, all patients underwentbilateral arterial embolization with de-livery of intravascular MTX before oc-clusion. The intervention was success-fully performed in all 46 patients, withno serious complications and adverse ef-fects during the procedure. Althoughthese data are encouraging, further ran-domized trials will be necessary to com-pare the effect of embolization with andwithout MTX.

It takes a long time for the gestationalsac to be spontaneously reabsorbed, usu-ally several months to a year.2 Addition-lly, despite the fact that chemoemboli-ation can obstruct local blood flowround the lesion, there is still a risk ofassive hemorrhage with the gradual re-

stablishment of collateral circulation.hus, suction curettage can be used as andditional treatment after chemoembo-ization. However, regular suction curet-age alone may create a predisposition toncontrollable aggressive massive hem-rrhage, even necessitating an inevitableonversion to hysterectomy, and it haseen reported to be suboptimal, with aailure rate of 70%.8 This may be as-

cribed to early embryo implantation inthe previous cesarean scar in CSP, oftencovered by a thin myometrium with amass of peripheral blood flow. However,the bilateral arterial chemoembolizationwith MTX gives the procedure greatertolerance and allows suction curettage tobe performed with substantially reducedrisk of excessive hemorrhage. The inter-val between suction curettage and embo-lization should be not too long in casethe vessels are reopened because of dis-solution and absorption of the gelatin.

In this study, 36 patients received suc-tion curettage 24-72 hours after bilateraluterine artery chemoembolization. Com-pared with previous reports,24 these 36 pa-
ients had much less bleeding during suc-
gy NOVEMBER 2012

ion curettage. Because suction curettagean remove the gestation sac, patients hadrapid decline in the �-hCG concentra-

ion and a shorter hospital stay. Therefore,e recommend that suction curettage cane used as a safe secondary treatment foremoving the gestational tissue after bilat-ral uterine artery chemoembolization.

Because chemoembolization blockedemporary uterine arterial blood flow,here is a concern about whether ovarianerfusion is affected. Although all 45 ofhese women recovered their menstrua-ion and there were 2 unexpected preg-ancies at follow-up, the long-lasting ef-

ects of UAE on ovarian function andomen’s fecundity need to be studied

urther.In summary, CSP is a dangerous and

omplex disorder with increasing occur-ence in recent years. Accurate early di-gnosis and effective management is im-ortant to preserve fertility and reduceaternal mortality. Bilateral uterine ar-

ery chemoembolization with MTX ap-ears to be a safe and effective treatmentnd produces less morbidity than cur-ent approaches, and it thus could be aood alternative treatment for CSP. Fur-her prospective studies are required toonfirm this observation, and long-termollow-up needs to be carried out to as-ess the delayed effects on ovarian func-ion and future fertility.

CLINICAL IMPLICATIONS

ilateral uterine arterial chemoemboli-ation appears to be a safe and effectivereatment and produces less morbidityhan current approaches, and it thusould be a good alternative treatment forSP. f

REFERENCES1. Jurkovic D, Hillaby K, Woelfer B, et al. Firsttrimester diagnosis and management of preg-nancies implanted into the lower uterine seg-ment cesarean section scar. Ultrasound ObstetGynecol 2003;21:220-7.2. Seow KM, Huang LW, Lin YH, et al. Cesar-ean scar pregnancy: issues in management. Ul-trasound Obstet Gynecol 2004;23:247-53.3. Rotas MA, Haberman S, Levgur M. Cesareanscar ectopic pregnancies: etiology, diagnosis,and management. Obstet Gynecol 2006;107:
1373-81.


4. Litwicka K, Greco E. Caesarean scar preg-nancy: a review of management options. CurrOpin Obstet Gynecol 2011;23:415-21.5. Rosen T. Placenta accreta and cesareanscar pregnancy: overlooked cost of the risingcesarean section rate. Clin Perinatol 2008;35:519-29.6. Ash A, Smith A, Maxwell D. Caesarean scarpregnancy. Int J Obstet Gynecol 2007;114:253-63.7. Ravhon A, Ben-Chetrit A, Rabinowitz R, et al.Successful methotrexate treatment of a viablepregnancy within a thin uterine scar. Br J ObstetGynaecol 1997;104:628-9.8. Arslan M, Pata O, Dilek TU, et al. Treatmentof viable cesarean scar ectopic pregnancy withsuction curettage. Int J Gynecol Obstet 2005;89:163-6.9. Zhang YL, Huang LL. Uterine artery emboli-zation compared with methotrexate for themanagement of pregnancy implanted with in acesarean scar. Am J Obstet Gynecol 2009;201:152.e1-3.10. Vial Y, Petignat P, Hohlfeld P. Pregnancy ina cesarean scar. Ultrasound Obstet Gynecol2000;16:592-3.11. Liang FB, He J. Methotrexate-based bilat-eral uterine arterial chemoembolization for treat-ment of cesarean scar pregnancy. Acta Obstet
Gynecol Scand 2010;89:1592-4.
12. Li C, Li C, Feng D, et al. Transcatheterarterial chemoembolization versus systemicmethotrexate for the management of cesareanscar pregnancy. Int J Gynecol Obstet 2011;113:178-82.13. Lian F, Wang Y, Chen W, et al. Uterine ar-tery embolization combined with local metho-trexate and systemic methotrexate for treat-ment of cesarean scar pregnancy with differentultrasonographic pattern. Cardiovasc InterventRadiol 2012;35:286-91.14. Pascual MA, Hereter L, Graupera B, et al.Three-dimensional power Doppler ultrasounddiagnosis and conservative treatment of ecto-pic pregnancy in a cesarean section scar. FertilSteril 2007;88:706.e5-7.15. Silver RM. Delivery after previous cesarean:long-term maternal outcomes. Semin Perinatol2010;34:258-66.16. Larsen JV, Solomon MH. Pregnancy in auterine scar sacculus—an unusual cause ofpostabortal haemorrhage. A case report. S AfrMed J 1978;53:142-3.17. Seow KM, Hwang JL, Tsai YL, et al. Sub-sequent pregnancy outcome after conservativetreatment of a previous cesarean scar preg-nancy. Acta Obstet Gynecol Scand 2004;83:1167-72.18. Hayakawa H, Itakura A, Mitsui T, et al.
Methods for myometrium closure and other fac-

tors impacting effects on cesarean sectionscars of the uterine segment detected by theultrasonography. Acta Obstet Gynecol Scand2006;85:429-34.19. Yazicioglu F, Gökdogan A, Kelekci S, et al.Incomplete healing of the uterine incision aftercaesarean section: is it preventable? Eur J Ob-stet Gynecol Reprod Biol 2006;124:32-6.20. Hamar BD, Saber SB, Cackovic M, et al.Ultrasound evaluation of the uterine scar aftercesarean delivery: a randomized controlled trialof one- and two-layer closure. Obstet Gynecol2007;110:808-13.21. Vikhareva Osser O, Valentin L. Risk factorsfor incomplete healing of the uterine incision af-ter caesarean section. Int J Obstet Gynecol2010;117:1119-26.22. Godin PA, Bassil S, Donnez J. An ectopicpregnancy developing in a previous caesareansection scar. Fertil Steril 1997;67:398-400.23. Tan G, Chong YS, Biswas A. Caesareanscar pregnancy: a diagnosis to consider care-fully in patients with risk factors. Ann Acad MedSingap 2005;34:216-9.24. Graesslin O, Dedecker FJ, Quereux C, et al.Conservative treatment of ectopic pregnancy ina cesarean scar. Obstet Gynecol 2005;105:
869-71.

cesarean scar pregnancy management 2012

Health & Medicine