Caesarean scar ectopic pregnancy – diagnostic challenges and management options TOG 2017 Flashcards
Incidence of CS scar ectopic
1/2500-8000
What proportion of women with atleast 1 CS will be Dx with CSP
6%
Rate of recurrence CSP?
3-5%
Increased risk if uterine segment <5mm, gestational sac bulging into UV fold, CS rural community hospital, Hx irregular PV bleeding or pain.
USS feature CSP
Empty uterine cavity and closed and empty cervical canal
Placenta and/or a gestational sac embedded in the scar of a previous caesarean section
A triangular/round or oval-shaped gestational sac that fills the niche of the scar
A thin or absent myometrial layer between the gestational sac and the bladder
Yolk sac, embryo and cardiac activity may or may not be present
Evidence of functional trophoblastic/placental circulation on colour flow Doppler examination, characterised by high velocity and low impedance blood flow
Negative ‘sliding organs’ sign
2 main classification of CSP based on USS finding
Type 1, or endogenic, CSP is where implantation occurs on the scar and the gestational sac grows towards the cervico-isthmic or uterine cavity.
Type 2, or exogenic, CSP occurs when the gestational sac is deeply embedded in the scar and the surrounding myometrium and grows towards the bladder. Higher risk rupture
What proportion of CSP and misdiagnosed?
13%
When can medical treatment with methotrexate be used?
Success rares? Which cases more likely to fail;?
If haemdynamically stable
40% resolved without further Tx
Less likely to succeed if bHCG >5000, >8 weeks.
Can be used before surgery, if surgery anticipated to be complex.
Optons ofr local injection and embolisation
Local injection of methotrexate with sac aspiration
Local injection of other embryocides
Uterine artery chemoembolisation - reduce risk bleeding during surgery
Surgical options for management of CSP
Dilatation and surgical evacuation
Hysteroscopic resection
Vaginal excision and resuturing
Laparoscopic excision and resuturing
Open excision and resuturing
Combined laparoscopic and hysteroscopic procedure
Combined laparoscopic and vaginal surgery
Hysterectomy
For Dilatation and surgical evacuation what must the endometrial thickness be? Methods to reduced bloodloss
2mm
UAE with MTX
Shirodkars suture
Foleys catheter
In expectant management, what proportion of women needed further intervention, how many needed hysterectomy
Further intervention 67%
Hysterectomy 29%