Caesarean scar ectopic pregnancy – diagnostic challenges and management options TOG 2017

Question 1

Incidence of CS scar ectopic

Answer 1

1/2500-8000

Question 2

What proportion of women with atleast 1 CS will be Dx with CSP

Answer 2

6%

Question 3

Rate of recurrence CSP?

Answer 3

3-5%

Increased risk if uterine segment <5mm, gestational sac bulging into UV fold, CS rural community hospital, Hx irregular PV bleeding or pain.

Question 4

USS feature CSP

Answer 4

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

Question 5

2 main classification of CSP based on USS finding

Answer 5

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

Question 6

What proportion of CSP and misdiagnosed?

Answer 6

13%

Question 7

When can medical treatment with methotrexate be used?
Success rares? Which cases more likely to fail;?

Answer 7

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.

Question 8

Optons ofr local injection and embolisation

Answer 8

Local injection of methotrexate with sac aspiration

Local injection of other embryocides

Uterine artery chemoembolisation - reduce risk bleeding during surgery

Question 9

Surgical options for management of CSP

Answer 9

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

Question 10

For Dilatation and surgical evacuation what must the endometrial thickness be? Methods to reduced bloodloss

Answer 10

2mm

UAE with MTX
Shirodkars suture
Foleys catheter

Question 11

In expectant management, what proportion of women needed further intervention, how many needed hysterectomy

Answer 11

Further intervention 67%
Hysterectomy 29%