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Treatment of cesarean scar pregnancy: another chapter in the fertility preservation saga
REFLECTIONS Treatment of cesarean scar pregnancy: another chapter in the fertility preservation saga Cesarean section is the most commonly performed surgical procedure in the United States (32.9% of all deliveries), with even higher rates reported in Mexico (39%) and Brazil (43.9%) (1). The well-described ‘‘epidemic’’ of c-section has spread to other regions of the world, including rural China, where the incidence of c-section increased from 1% in 1991 to 17% in 2002. It approaches 40% in urban China (2). The reason for the rapid increase in c-section across the globe is multifaceted and varies by locality, but traditional clinical indicators do not seem to be the sole driving force behind the epidemic (1). Maternal preference (c-section on demand), physician convenience, perceived perinatal safety, and fear of litigation have driven an increase in surgical delivery. Insured women are more likely to undergo c-section than those in charitable conditions (1). More recently, attention has turned to unintended consequences of liberalized c-section, particularly among those who undergo serial procedures. Placenta accreta, bowel and urinary tract injury, transfusion, hysterectomy, prolonged ventilation, and prolonged operative time are all associated with multiple c-section (3). In addition, a substantial rise in the number of c-section scar pregnancies (CSP) has been reported (approximately 0.18% of women with at least one csection) since the first description of this entity in 1978 (4). In the absence of early identification and treatment, CSP is associated with hemorrhagic morbidity, emergency hysterectomy, and even maternal mortality. To make matters worse, a variety of treatment approaches (medical, surgical, and a combination of the two) have been proffered primarily in case series and small, underpowered trials. Given the recent emphasis on fertility preservation in all aspects of reproductive care, the systematic review by Birch Peterson et al. in this issue of Fertility and Sterility addressing fertilityconserving management of CSP is welcomed (5). Following PRISMA guidelines, the authors evaluate 14 conservative (fertility-preserving) approaches to CSP including medical and surgical treatments. Each approach is adjudicated by primary success rates, complication rate (hysterectomy, excessive blood loss, or transfusion), and requirement for additional treatment. To be included, studies and case series required five or more CSP occurrences. This inclusion criterion is important since many citations in the contemporary medical literature involve single case reports, often by practitioners with little or no experience with CSP. In such cases, only ‘‘successes’’ are likely to be reported, and the potential for introducing bias into the analysis is substantial. The robotic laparoscopic approach, the subject of a number of recent case reports, is not separately addressed. It is unlikely that the robotic approach will improve outcomes substantially in the hands of an experienced laparoscopic surgeon. Treatments scrutinized in this systematic review include expectant management, systemic methotrexate similar to protocols adopted for tubal ectopic pregnancy, combinations of systemic and local methotrexate, and a number of surgical approaches, including a rather novel approach of CSP
resection via a transvaginal approach (akin to dissecting the anterior segment at vaginal hysterectomy). The authors recommend five approaches on the basis of success rates and low complications. Each of these approaches is surgical (resection via the transvaginal approach, laparoscopic resection, uterine artery embolization [UAE] þ dilation and curettage [D&C] þ hysteroscopy, UAE with D&C but no methotrexate, and hysteroscopy with resection). It is noteworthy that the expectant and methotrexate alone approaches were associated with higher failure rates, complications, or need for additional maneuvers compared with surgical approaches. Hence, protocols widely adopted for tubal ectopic pregnancy may not be well suited for CSP. A majority of the studies—and all of the randomized trials—included in this systematic review originate in China. The authors speculate that the relatively high c-section rate, large population, and utilization of regional referral centers account for this finding. Perhaps Chinese institutions will lead the way in conducting future larger-scaled randomized trials. CSP is an emerging complication of the c-section epidemic, and early detection by transvaginal ultrasound (or magnetic resonance imaging) is critical to minimize maternal morbidity and loss of fertility. There are two important points to be gleaned from this paper: [1] purely medical protocols (i.e., methotrexate) may not be the optimal primary treatment for CSP, and [2] multicentered randomized trials comparing methotrexate therapy and UAE to surgical approaches are needed. Other salient questions in CSP management are not covered in this review and worthy of discussion in the broader sense. When is the best timing for ultrasound in pregnant women with prior c-section (assuming no other complications or use of assisted reproduction techniques)? The global recommendation by the American College of Obstetricians and Gynecologists for viability screening at 10 weeks of gestation may not be optimal for women with prior c-section since this would miss an opportunity for earlier intervention of CSP and potentially diminish the incidence of catastrophic hemorrhage and uterine rupture. Should suspected CSP cases be referred to centers with expertise in early pregnancy imaging and surgical management of this condition? Transvaginal ultrasound has a reported sensitivity of only 85% in the detection of CSP (4), and most providers of early pregnancy care have never encountered a CSP case. Accordingly, these clinicians are unlikely to be familiar with diagnostic criteria and viable treatment options. This may lead to delayed diagnosis and treatment with deleterious results. The best outcomes for CSP are likely to occur at institutions with experience in CSP and the agility to pursue a multimodal approach to imaging and treatment. Robert P. Kauffman, M.D. Department of Obstetrics and Gynecology, Texas Tech University Health Science Center School of Medicine, Amarillo, Texas
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REFLECTIONS http://dx.doi.org/10.1016/j.fertnstert.2016.01.008 You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/kauffmanr-tratment-cesareanscar-pregnancy/ Use your smartphone to scan this QR code and connect to the discussion forum for this article now.* * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
REFERENCES 1.
2.
3.
4. 5.
Haberman S, Saraf S, Zhang J, Landy HJ, Branch DW, Burkman R, et al. Nonclinical parameters affecting primary cesarean rates in the United States. Am J Perinatol 2014;31:213–22. Klemetti R, Che X, Gao Y, Raven J, Wu Z, Tang S, et al. Cesarean section delivery among primiparous women in rural China: an emerging epidemic. Am J Obstet Gynecol 2010;202:e1–6. Silver R, Landon MB, Rouse DJ, Leveno K, Spong CY, Thom E, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107:1226–32. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 2006;107:1373–81. Birch Petersen K, Hoffmann E, Larsen C, Nielsen S. Cesarean scar pregnancy—a systemic review of treatment studies. Fertil Steril 2016.
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resection via a transvaginal approach (akin to dissecting the anterior segment at vaginal hysterectomy). The authors recommend five approaches on the basis of success rates and low complications. Each of these approaches is surgical (resection via the transvaginal approach, laparoscopic resection, uterine artery embolization [UAE] þ dilation and curettage [D&C] þ hysteroscopy, UAE with D&C but no methotrexate, and hysteroscopy with resection). It is noteworthy that the expectant and methotrexate alone approaches were associated with higher failure rates, complications, or need for additional maneuvers compared with surgical approaches. Hence, protocols widely adopted for tubal ectopic pregnancy may not be well suited for CSP. A majority of the studies—and all of the randomized trials—included in this systematic review originate in China. The authors speculate that the relatively high c-section rate, large population, and utilization of regional referral centers account for this finding. Perhaps Chinese institutions will lead the way in conducting future larger-scaled randomized trials. CSP is an emerging complication of the c-section epidemic, and early detection by transvaginal ultrasound (or magnetic resonance imaging) is critical to minimize maternal morbidity and loss of fertility. There are two important points to be gleaned from this paper: [1] purely medical protocols (i.e., methotrexate) may not be the optimal primary treatment for CSP, and [2] multicentered randomized trials comparing methotrexate therapy and UAE to surgical approaches are needed. Other salient questions in CSP management are not covered in this review and worthy of discussion in the broader sense. When is the best timing for ultrasound in pregnant women with prior c-section (assuming no other complications or use of assisted reproduction techniques)? The global recommendation by the American College of Obstetricians and Gynecologists for viability screening at 10 weeks of gestation may not be optimal for women with prior c-section since this would miss an opportunity for earlier intervention of CSP and potentially diminish the incidence of catastrophic hemorrhage and uterine rupture. Should suspected CSP cases be referred to centers with expertise in early pregnancy imaging and surgical management of this condition? Transvaginal ultrasound has a reported sensitivity of only 85% in the detection of CSP (4), and most providers of early pregnancy care have never encountered a CSP case. Accordingly, these clinicians are unlikely to be familiar with diagnostic criteria and viable treatment options. This may lead to delayed diagnosis and treatment with deleterious results. The best outcomes for CSP are likely to occur at institutions with experience in CSP and the agility to pursue a multimodal approach to imaging and treatment. Robert P. Kauffman, M.D. Department of Obstetrics and Gynecology, Texas Tech University Health Science Center School of Medicine, Amarillo, Texas
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REFLECTIONS http://dx.doi.org/10.1016/j.fertnstert.2016.01.008 You can discuss this article with its authors and with other ASRM members at http://fertstertforum.com/kauffmanr-tratment-cesareanscar-pregnancy/ Use your smartphone to scan this QR code and connect to the discussion forum for this article now.* * Download a free QR code scanner by searching for “QR scanner” in your smartphone’s app store or app marketplace.
REFERENCES 1.
2.
3.
4. 5.
Haberman S, Saraf S, Zhang J, Landy HJ, Branch DW, Burkman R, et al. Nonclinical parameters affecting primary cesarean rates in the United States. Am J Perinatol 2014;31:213–22. Klemetti R, Che X, Gao Y, Raven J, Wu Z, Tang S, et al. Cesarean section delivery among primiparous women in rural China: an emerging epidemic. Am J Obstet Gynecol 2010;202:e1–6. Silver R, Landon MB, Rouse DJ, Leveno K, Spong CY, Thom E, et al. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstet Gynecol 2006;107:1226–32. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 2006;107:1373–81. Birch Petersen K, Hoffmann E, Larsen C, Nielsen S. Cesarean scar pregnancy—a systemic review of treatment studies. Fertil Steril 2016.
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