CESAREAN SCAR

PREGNANCY
• This term describes implantation within the myometrium of a prior
cesarean delivery scar.

• If unrecognized or inadequately managed, CSP can lead to severe fetal

and maternal morbidity

• early in pregnancy -hemorrhage, uterine rupture, placenta accreta

spectrum [PAS] and even maternal mortality
CSP and PAS
• CSP is likely a precursor to, and shares common histology with,
placenta accreta spectrum (PAS)

• The two conditions may represent a continuum of the same disease,

with CSP being a diagnosis of the first (and early second) trimester, and
PAS being diagnosed later in pregnancy (second trimester and beyond)

• Both involve the placenta attaching to or invading the myometrium,

almost always in an area of scarring caused by previous uterine surgery.
• While PAS is typically a diagnosis made in the second trimester, some
experts believe that sonographic findings may be present in the first
trimester, further strengthening the association of PAS with CSP

• Like PAS, the rate of CSP parallels that of cesarean birth and is
expected to rise as the rate of cesarean birth increases and as the
diagnostic accuracy of imaging for CSP improves.
CSP and ectopic pregnancy
• CSP is distinct from ectopic pregnancy as CSP occurs within uterine
cavity and can result in a live born infant

• Thus, treatments appropriate for ectopic pregnancy should not be

used indiscriminately to treat or manage CSP.
 INCIDENCE
• CSP occurs in approximately 1 in 2000 pregnancies

• accounts for approximately 6 percent of abnormally implanted

pregnancies among patients with a prior cesarean birth

• The incidence appears to be rising along with the cesarean

delivery rate
Type 1 / "On-the-scar“ / Endogenic CSP Type 2 / "In-the-niche“ / Exogenic CSP

• implant on the well healed scar • implant deeply within the niche
and expand toward the uterine of an incompletely healed scar
cavity and grow toward the bladder or
abdominal cavity

• In CSPs that continued to viability,

endogenic CSPs yielded variable • usually need hysterectomy as it
obstetric outcomes but overall usually progresses to placenta
more favorable accreta spectrum (PAS) at
delivery
PATHOGENESIS
theories include:

• the endogenous migration of the embryo through either a wedge

defect in the lower uterine segment or a microscopic fistula within
the scar
• invasion of placental villi into the uterine wall at a point of scar
dehiscence
• low oxygen tension of scar tissue attracting implantation of the
fertilized oocyte
NATURAL HISTORY
• Uterine rupture – CSPs are predisposed to early ie, first- or second-
trimester uterine rupture

• Rates of delivery of live born neonates and hysterectomy vary

 RISK FACTORS
• risk of recurrent CSP may be more common than previously thought
and ranges from 5 to 40 percent

• Other previous uterine surgery or procedure (eg, dilation and curettage,

endometrial ablation)

• Manual removal of the placenta

• In vitro fertilization
CLINICAL PRESENTATION
• Approximately one-third of patients with CSP are asymptomatic at the
time of ultrasound diagnosis

• vaginal bleeding is the most common symptom and usually presents in

the late first or early second trimester

• abdominal/pelvic pain

• uterine rupture with hypovolemic shock

 DIAGNOSIS
• Definitive diagnosis — CSP is a diagnosis made based on first or early second
trimester transvaginal ultrasound (TVUS) findings of a pregnancy implanted on
or in a prior hysterotomy scar/niche

• and confirmed at the time of surgery with histologic findings consistent with
placenta accreta spectrum (PAS) disorder

• TVUS combined with color Doppler evaluation is the preferred imaging modality

• TVS is the typical first-line imaging tool

• but MR imaging is useful for inconclusive cases

• A low anterior position of the gestational sac at ≤7 weeks is an
ultrasound marker for CSP only at very early gestational age

• After seven to nine weeks of gestation, the gestational sac "pushes"

into the uterine cavity (leaving behind the implanted placenta) as this
is the only available place for the sac (with the embryo/fetus) to
expand into
• The following method can be used to determine location of the gestation sac

1. On a sagittal scan, divide the uterus in half by an imaginary line

perpendicular to its longitudinal axis and determine the location of the
gestational sac related to this line

2. Mark the center of the gestational sac

3. If the center of the sac is above the aforementioned line (closer to the
uterine fundus), it is most likely an intrauterine pregnancy

4. If the center of the sac is below the line (closer to the cervix), it is a CSP or, in
rare cases, a cervical pregnancy
• When applied at or before seven weeks of gestation, this method has
reliable statistical performance

• An exception is for patients with a prior classical incision or fundal

incision (during myomectomy). For such patients, the CSP is likely to
develop in the upper, rather than lower, portion of the uterus.
 Diagnostic criteria
• Transvaginal sonogram of a uterus
with a cesarean scar pregnancy in
a sagittal plane:
• (1) an empty uterine cavity and
empty endocervical canal,
• (2) placenta or gestational sac
embedded in the hysterotomy
scar niche,
• (3) a thin myometrial mantle
between the gestational sac and
bladder
• (4) a prominent vascular pattern
at the scar.
 DIFFERENTIAL DIAGNOSIS
1. Cervical pregnancy

Sonographically, differentiating between an IUP implanted at

the cervicoisthmic junction and a CSP can be difficult
2. Early pregnancy loss

A spontaneous expelling abortus is a mimic

Color Doppler will show the intense placental vascularity around a CSP,
whereas as the aborting sac is avascular

gentle pressure applied to the cervix by the vaginal probe will fail to
move an implanted gestation—a negative sliding sign. Instead, an
aborted sac will slide against the endocervical canal
 MANAGEMENT OF 1ST AND EARLY 2ND
TRIMESTER CSP
• patients with CSP should transferred, to a tertiary care hospital in which
maternal-fetal medicine specialists, treatment options like uterine artery
embolization and blood bank services are available

• Hemodynamically unstable patients — A patient with hemorrhage and

existing or impending hemodynamic instability requires immediate
surgical intervention like
• wedge resection
• gravid hysterectomy and/or
• a minimally invasive procedure ie, UAE
• In hemodynamically stable patients, management options include
termination of pregnancy (medical or surgical) or continuation of the
pregnancy

• Shared decision-making is essential and guided by factors such as CSP

type, gestational age, desire for future fertility, and experience of the
physician.
 TREATMENT APPROACHES
1. CSPs with embryonic/fetal demise may be managed expectantly
especially for those patients in the first trimester, as spontaneous
resolution of the pregnancy may occur

• weekly follow-up with serum human chorionic gonadotropin (hCG) and

transvaginal ultrasound (TVUS) are performed until the hCG is
undetectable and the pregnancy recedes completely on imaging

• incomplete resolution (eg, persistently elevated hCG levels, incomplete

resolution on TVUS), or for patients who desire to hasten the resolution of
the demised CSP, treatment with systemic MTX or uterine aspiration may
be performed
2. Patients with a live pregnancy — may be managed expectantly or
with medical or surgical therapy

• expectant management of a CSP with a live gestation is associated with

severe maternal morbidity (hemorrhage, early uterine rupture,
hysterectomy, PAS, maternal death)
• counsel patients undergoing expectant management
• managed in the same manner as patients with PAS and a repeat
cesarean birth is planned between 34 and 37 weeks of gestation
• However, expert groups, including the Society of Maternal-Fetal
Medicine, generally advise against this approach
• Pregnancy termination - treatment is time-sensitive, the morbidity
associated with pregnancy termination increases with increasing
gestational age
• surgical or medical management is effective and depends on the
following factors:
• Trimester
• Future pregnancy
SURGICAL MANAGEMENT
1. Operative resection

(1) laparoscopic uterine isthmic resection

(2) transvaginal isthmic resection through an anterior colpotomy,
(3) UAE, followed by D & C with or without hysteroscopy
(4) hysteroscopic resection
(5) wedge resection through laparotomy
• performed only by highly experienced surgeons

• advantage of resection over other therapies is that the scar can be

excised and the uterus reapproximated

• Operative resection is likely to be curative; however, monitoring

serum hCG levels weekly until undetectable is reasonable to confirm
resolution
2. Ultrasound-guided suction aspiration - performed for patients in the
early first trimester (five to seven weeks of gestation) with use of a
transcervical balloon catheter if heavy bleeding occurs

3. Gravid hysterectomy - should only be performed in patients in whom

future childbearing is not desired
• in those with life-threatening hemorrhage,
• may be the preferred approach for patients with second-trimester
CSPs
• Gravid hysterectomy may be performed with or without prior UAE
MEDICAL THERAPY
1. Intragestational injection of MTX - Ultrasound-guided
(transabdominal or transvaginal) intragestational injection of MTX is
an effective treatment for CSP
2. Intragestational injection of KCl – Ultrasound-guided
(transabdominal or transvaginal) KCl injection (5 mEq into the
gestational sac) into a CSP with embryonic/fetal cardiac activity
• This regimen may also be used as a secondary procedure if other
treatments (eg, UAE, balloon catheters) do not result in cessation of
fetal heart activity.
3. Transcervical insertion of balloon catheters – For patients with a
CSP ≥6 0/7 and ≤8 6/7 weeks of gestation, balloon catheters are an
efficient, safe, well-tolerated, and minimally invasive treatment option
• At later gestational ages (ie, >8 6/7 weeks), cervical ripening balloon
catheter use is limited as the pregnancy may be too large to be
sufficiently compressed by the balloon.
• These catheters can effectively stop fetal cardiac activity and prevent
possible bleeding complications (by applying direct pressure to the
pregnancy)
• can be used with or without other treatments
PROCEDURE
• Antibiotic prophylaxis
• Pain control
• insertion
• inflation of the intrauterine (anchor) balloon with saline
• The lower (pressure) balloon is inflated opposite the gestational sac
under transvaginal ultrasound guidance
• and left in place for 24 to 48 hours
• Before deflating the balloon(s), embryonic/fetal cardiac activity is
rechecked to confirm cessation.
• If cardiac activity has ceased, the balloon catheter is removed
• If cardiac activity is still present, the balloon may be inflated to a
higher pressure for an additional 24 to 48 hours; adjuvant therapies
may be administered
• After catheter removal, the patient is closely monitored for any heavy
bleeding
• Serial ultrasound examinations and hCG levels are typically followed
until complete resolution of the CSP.
ADJUNCTIVE THERAPY
 

• UAE can be used alone or in combination with other therapies

• systemic MTX is used as an adjunct to all of the above medical
therapies , its not used alone
Treatments not used
• Systemic MTX alone in patients with a live gestion
• Misoprostol
• Sharp curettage
(perforation, hemorrhage, need for reintervention, profuse
hemorrhage may occur as a result of the deeply implanted placental
vessels and scant (or no) myometrium to stop the bleeding vessels
severed by sharp curetting)
FUTURE PREGNANCIES

• recurrent scar implantation, abnormal placentation, and uterine

rupture (resulting in maternal or fetal death)
• such patients are counseled to contact their obstetrician soon after
their positive pregnancy test and undergo a transvaginal ultrasound
(TVUS) as early as five to seven weeks of gestation
• ultrasound should be performed by an expert sonologist
THANKYOU