Scar; Previous Cesarean Section Clinical Trial
Official title:
Cesarean Scar Pregnancy Managed by Dilatation and Evacuation (D&E) Versus Hysteroscopic Surgery
Cesarean scar pregnancy (CSP) is a relative "new" type of ectopic pregnancy where the
fertilized egg is implanted in the muscle or fibrous tissue of the scar after a previous
cesarean section.
A recent review amounts almost 31 different treatment modalities for CSP. A broad spectrum of
options represents a real challenge for the health care provider. The choice may be made
among expectant management, medical treatment, local treatment and surgical approach, also
combined together. There is insufficient evidence to recommend any one specific intervention
over another for caesarean scar pregnancy. Future studies are needed to define the optimal
management of pregnancy for caesarean section scars.
Thus, we aim to compare the success rate of two different treatment of CSP: the medical
management by using two-dose of Methotrexate (MTX) followed by dilation and evacuation (D&E)
compared to single dose of two-dose of Methotrexate followed by hysperoscopic approach.
Cesarean scar pregnancy (CSP) is a relative "new" type of ectopic pregnancy where the
fertilized egg is implanted in the muscle or fibrous tissue of the scar after a previous
cesarean section. Since the first description of cesarean scar pregnancy in 1978, its
frequency has increased dramatically due to the significant increase in the percentage of
cesarean section and development of transvaginal (TV) ultrasonography (US). The overall
incidence of CSP is 1 in 1,800 to 1 in 2,200 pregnancies, it means 0.05-0.04% of all
pregnancies. In women after a cesarean section, the frequency of CSP is approximately 0.15%,
which constitutes 6.1% of all ectopic pregnancies in patients after at least one cesarean
operation. The risk factors that favour implantation in the CS scar are not well understood;
therefore, there are no guidelines for the practicing physicians to determine the women at
risk. Uterine surgery, anomalous healing of the scar, previous preterm CS without labour or a
term elective CS, breech presentation at previous CS short intervals between the CSP and last
pregnancy, last pregnancy ended with abortion may be some of the risk factors for CSP.
Although the 15% of CSPs remain undiagnosed, developed egographic techniques and several new
US signs of CSP invasiveness are allowing ever better diagnoses. Cali et al. tested the
hypothesis the relationship between the gestational sac of the CSP, previous caesarean scar
and the anterior uterine wall can be used to predict the evolution of these cases. In order
to do this, they propose a new sonographic sign, the "cross-over sign" (COS) . This
echographic sign is reflected in the clinical presentation of the CSP, so we can divide the
patients into two different groups: type I "endogenic type" characterized by the COS2
insertion, ance type II "exogenic type" characterized by COS1 insertion, the latter with
worse outcomes in term of maternal morbidity and mortality.
A recent review amounts almost 31 different treatment modalities for CSP. A broad spectrum of
options represents a real challenge for the health care provider. The choice may be made
among expectant management, medical treatment, local treatment and surgical approach, also
combined together. There is insufficient evidence to recommend any one specific intervention
over another for caesarean scar pregnancy. Future studies are needed to define the optimal
management of pregnancy for caesarean section scars.
Thus, we aim to compare the success rate of two different treatment of CSP: the medical
management by using two-dose of Methotrexate (MTX) followed by dilation and evacuation (D&E)
compared to single dose of two-dose of Methotrexate followed by hysperoscopic approach.
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