Cesarean

Scar Pregnancy

Aditiawarman
SMF/Depart Obstetric and Gynecology
Dr Sutomo General Hospital/Airlangga University
Surabaya
Introduction

One of consequences of
cesarean deliveries that
may occur in a
subsequent pregnancy
(Timor-Tritsch.2012.
Expert Reviews.
American Journal of
Obstetrics &
Gynecology).
 Incidence:

72% of CSP occur Detection rate

Increased
in women who increased as TVS
incidence of CS
have had ≥2CS used
Definition
GS implanted in the
myometrium at the the scar or
the niche of a previous CS scar
of a previous cesarean delivery.

CSP is fundamentally different

from a cornual and tubal as well
as a cervical pregnancy
Complications of CSP
Morbidly adherent
placenta

Uterine rupture

Severe hemorrhage

Preterm labor
Pathogenesis

Prior Fibrous scar tissue

with a wedge- Blastocyst implants

CS:
shaped myometrial on fibrous scar
defect .

Multiple Increase scar

Increase the risk of
implantation on

CS:
surface area:
the scar
•  The myometrial defect after:
•  CS
•  D &C
•  Myomectomy •  Incomplete healing
•  Increased fibrosis
•  Metroplasty
•  Hysteroscopy
•  Manual removal of the placenta.
 Diagnosis
Structure and Region Imaginary line
Diagnosis
•  Early diagnosis by transvaginal ultrasound is the gold standard
•  Accurate identification of CSP depends on the following sonographic
criteria:
•  Empty uterine cavity and cervical canal
•  Close proximity of the gestational sac and the placenta to the anterior uterine
surface within the scar or niche of the previous cesarean delivery
•  Color flow signals between the posterior bladder wall and the gestation
within the placenta
•  Abundant blood flow around the gestational sac, at times morphing into an
arteriovenous malformation with a high peak systolic velocity blood flow
demonstrable on pulsed Doppler.
American Journal of Obstetrics & Gynecology, 2016
Rac, 2016, J Ultrasound Med
NORMAL

Rac, 2016, J Ultrasound Med

60 pregnancies were included in the study.
The risk of placenta percreta was
significantly higher in pregnancies with COS1 compared to
COS2 insertion (OR: 6.67, 95% CI 1.3-
33.3; p= 0.001);
There was a significant difference in the occurrence of
placenta percreta between COS1 and COS 2+ (10/12 vs
18/39, p= 0.04), with an OR of 5.83, 95% CI 1.1-30.2 Women with COS2- had a lower risk of developing
(p=0.036); furthermore, this risk was even higher when placenta percreta compared to those with COS1 (OR:
comparing cases with COS1 with COS2- (OR: 12.0, 0.069, 95% CI 0.01-0.4).
95% CI 1.9-75.7; p= 0.003). Logistic regression analysis showed that COS1
insertion was independently associated with the
Manuscrip of publication; doi:10.1002/uog.16216 occurrence of severe forms of MAP such as placenta
percreta and increta (OR: 12.85, 95% CI 2.0-84.0),
while COS2+ insertion was associated independently
associated with the occurrence of placenta accreta
(OR: 4.37, 95% CI 1.1-
17.0).
 USG Prognosis
•  Myometrial thickness below 2mm in the first trimester ultrasound is
associated with morbidly adherent placenta at delivery.
•  (Agten. 2016. Am J Obstet Gynecol).
Different diagnosis

Spontaneous miscarriage in progress—In a

number of cases, the miscarriage happened to be
Cervical pregnancy—This type of gestation is
caught on imaging as it passed the area where the
more likely to occur in women with no history of
CSP usually resides. Because there is no live
cesarean delivery
embryo or fetus in spontaneous miscarriage, a
heartbeat cannot be documented.
Treatment

•  Various treatment modalities

•  Most treatment regimens and combinations there of can be classified as one of the
following (Fadhlaoui, 2012, Case Reports in Obstetrics and Gynecology):
•  Surgical—requiring general anesthesia and either laparotomy with excision or
hysterectomy, or laparoscopic or hysteroscopic excision followed by dilation and
curettage (D&C).
•  Minimally invasive—involving local injection of methotrexate or potassium chloride or
systemic intervention, involving a major procedure such as uterine artery embolization
in combination with a less complicated one: intramuscular injection of methotrexate in
a single or a multidose regimen.
•  A variety of simultaneous as well as sequential combination treatments also were used.
More recently, an ingenious adjunct to treatment is gaining attention: insertion and
inflation of a Foley balloon catheter to prevent or tamponade bleeding
•  Cesarean scar ectopic pregnancy, with a live embryo, who was treated locally with
transvaginal ultrasound-guided injection of methotrexate, complemented with
various doses of systemic methotrexate ( Freitas Leite.Rev Assoc Med Bras 2016)

USG reporting
Thank you