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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 89-96

Comparison of the efficacy and safety of different surgical strategies for patients with type II cesarean scar pregnancy


Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China

Date of Submission14-Jan-2020
Date of Decision18-Feb-2020
Date of Acceptance30-Apr-2020
Date of Web Publication26-Jun-2020

Correspondence Address:
Xiao-Fang Yi
Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, No. 419 Fangxie Road, Shanghai 200011
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2096-2924.288024

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  Abstract 


Objective: To compare the efficacy and safety of four surgical strategies currently used for the management of deep implantation cesarean scar pregnancy (CSP-II).
Methods: This was a retrospective clinical cohort study, and, in total, 131 women diagnosed with CSP-II and primarily treated in our hospital were recruited. Women treated using laparoscopy assisted by operative hysteroscopy (LAOH; Group A, n = 25), uterine artery embolization (UAE) followed by LAOH (Group B, n = 21), ultrasound-guided dilatation and curettage (D&C; Group C, n = 24), and UAE followed by D&C (Group D, n = 61) were evaluated. Univariate and multiple logistic analyses were performed to identify the risk factors.
Results: No statistically significant difference was found in patient age, gestational age, size of lesion, and pretreatment serum β-human chorionic gonadotropins (β-hCG) level. Operation time was longer (P < 0.001) and the success rate was higher (P = 0.01) in both Group A and Group B than in Group C and Group D. When the cohort was further analyzed regarding patients with myometrial thickness ≤3 mm (n = 75, defined as CSP-IIb), a lower rate of perioperative complications (P = 0.036) and a higher success rate (P < 0.001) remained in Group A (n = 15) and Group B (n = 15) but not in Group C (n = 11) or Group D (n = 34). In multiple logistic regression analysis, the risk factors related to lower treatment efficacy for patients with CSP-II were thinner myometrial thickness of cesarean scar (CS) (≤3 mm) (odds ratio [OR] = 5.470, P = 0.062), number of cesarean sections (a2) (OR = 8.877, P = 0.013), mass protruding into the bladder or abdominal cavity (OR = 25.507, P < 0.001), and direct D&C modality (OR = 38.247, P = 0.010).
Conclusions: Compared with D&C ± UAE, LAOH ± UAE showed a higher success rate for patients with CSP-II, especially when the zygote was more deeply implanted with a myometrial thickness of CS ≤ 3 mm. CSP-II treatment should be individualized on the basis of many risk factors.

Keywords: Dilatation and Curettage; Ectopic Pregnancy; Laparoscopy Assisted by Operative Hysteroscopy; Uterine artery Embolization


How to cite this article:
Cheng Q, Tian Q, Chang KK, Yi XF. Comparison of the efficacy and safety of different surgical strategies for patients with type II cesarean scar pregnancy. Reprod Dev Med 2020;4:89-96

How to cite this URL:
Cheng Q, Tian Q, Chang KK, Yi XF. Comparison of the efficacy and safety of different surgical strategies for patients with type II cesarean scar pregnancy. Reprod Dev Med [serial online] 2020 [cited 2020 Jul 8];4:89-96. Available from: http://www.repdevmed.org/text.asp?2020/4/2/89/288024




  Introduction Top


Cesarean scar pregnancy (CSP) describes the implantation of the gestational sac (GS) into the myometrial scar from a previous cesarean section (C-section). It is a rare and life-threatening condition in ectopic pregnancy. Although the exact incidence of CSP remains unknown, its incidence has been estimated to be 1/3,000 in the general obstetric population, 1/1,800 to 1/2,500 in all women with cesarean deliveries, and 1/531 in women with at least one C-section;[1],[2] this rate could rise in the future owing to the increasing rate of cesarean deliveries.[3],[4] CSP is particularly common in China because more than 50% of all deliveries are reportedly performed via C-section,[3],[5] and what's more, the “two-child policy,” which replaced the decade-long “one-child policy” in China, may lead to an increased risk of CSP.

The diagnosis of CSP is often difficult, and a false-negative diagnosis may result in major complications, such as severe hemorrhage, uterine rupture, and emergency hysterectomy.[6] The following criteria are required to be met for the diagnosis of CSP: (1) empty uterus and empty cervical canal; (2) development of GS or placental tissue in the anterior wall of the cervical isthmus; (3) discontinuity on the anterior uterine wall, as demonstrated on the sagittal plane of the uterus running through the amniotic sac; (4) absent or diminished healthy myometrium between the bladder and GS or placental tissue; and (5) high velocity with low impedance peritrophoblastic vascular flow clearly surrounding the sac on Doppler examination.[2],[7] According to the classification of CSP by Vial et al.,[8],[9] Type I CSP (CSP-I) refers to the implantation of the amniotic sac into the previous cesarean scar (CS), with progression of the pregnancy toward the cervicoisthmic space and uterine cavity. Type II CSP (CSP-II) refers to a deeper implantation into a CS defect, with infiltrating growth into the uterine myometrium and bulging from the uterine serosal surface of the uterus. In recent years, in view of the increasing incidence of CSP and serious complications it caused, many countries have developed their own guidelines based on treatment experience.[10] At present, surgical, medical, and minimally invasive therapies have been reported for CSP management. Due to less high-quality evidence-based medicine and randomized controlled studies, there is no consensus on CSP treatment in China and abroad.[11] Compared with CSP-I, CSP-II is more life-threatening and may lead to uncontrollable hemorrhage.[12] In view of the increasing incidence of CSP, severe complications encountered in the treatment of CSP, especially CSP-II, which was made more challenging.[13] Ultrasound-guided dilatation and curettage (D&C) is widely used for the treatment of CSP-II, but its efficacy is not satisfactory. Uterine artery embolization (UAE) has been shown to have some effects in emergency situations. In addition, with the development of minimally invasive surgery, laparoscopy assisted by operative hysteroscopy (LAOH) plays a role in the treatment of CSP-II. However, so far, there is no consensus on the optimal treatment strategy for CSP-II.

This retrospective study aimed to compare the efficacy and safety of different surgical strategies currently used for the management of CSP-II and to identify the potentially optimal approach and risk factors associated with treatment efficacy.


  Methods Top


Between April 2010 and December 2015, more than 333 patients with CSP were admitted to the Department of Gynecology, Obstetrics and Gynecology Hospital of Fudan University. Among them, 131 were patients with CSP-II and were retrospectively analyzed. All patients showed a positive urine human chorionic gonadotropins (hCG) result and subsequently underwent serial serum β-hCG testing and transvaginal color Doppler ultrasound (TVS) examination. TVS examination was performed by two senior sonographists. Diagnosis of CSP-II was made according to the criteria proposed by Godin et al.[9] and Vial et al.[8] Briefly, ultrasound findings were required to meet the following criteria: (1) an empty uterus, with a clearly demonstrated endometrium and an empty cervical canal; (2) a GS, with or without cardiac activity, deeply located in the anterior part of the uterine isthmus (previous CS) and bulging from the uterine serosal surface of the uterus. Myometrial thickness was measured at the time of the diagnosis of CSP. Once the primary diagnosis of CSP-II was established, transvaginal sonography was mandatorily performed twice before making the final diagnosis and performing the operation to confirm several indicators such as GS growth direction and myometrial thickness at the anterior wall of the lower uterine segment. Different treatment modalities were offered by attending physicians according to their preference. For patients with CSP-II who presented with higher serum β-hCG level, clinicians were more likely to choose UAE as pretreatment or laparoscopic surgery other than direct D&C. These were grouped as follows: LAOH (Group A, n = 25), UAE followed by LAOH (Group B, n = 21), D&C (Group C, n = 24), and UAE followed by D&C (Group D, n = 61). UAE was performed by two experienced radiologists. After the left or right femoral artery was successfully punctured, a 5F Roberts uterine catheter (Cook, Corporation, USA) was super selectively inserted into the bilateral uterine arteries, and 200 mg of methotrexate was infused bilaterally via the catheter. Once the blood flow slowed, gelatin sponge particles (Eric Medical Technology Co., Ltd., China) were used to block the uterine arteries until the blood flow was occluded. Angiography was performed to confirm embolization. Furthermore, the medical treatment process within 72 h after UAE, LAOH, or D&C was performed accordingly. The efficacy or success of treatment for CSP-II was defined as the continuous decrease of serum β-hCG levels and the disappearance of GS, with no need of additional treatment or changing of surgical methods. Perioperative complications included massive hemorrhage (≥500 mL), necessity of blood transfusion, and bladder or urethral injury.[14] Clinical parameters associated with treatment success rate were retrospectively compared among the four groups using logistic regression analysis.

Patient information including mean age, number of previous C-sections, time since last C-section, gestational age, size of GS or mass, and thickness of the anterior lower uterine segment myometrium were collected. Further, data were compared among different treatment modalities. One-way ANOVA and nonparametric Kruskal–Wallis test were used for the analysis of quantitative data, and Chi-square test, continuous corrected Chi-square test, or Fisher's exact test was used for the analysis of qualitative data. Clinical parameters associated with treatment success rate were retrospectively compared among the four groups using logistic regression analysis. A univariate logistic regression analysis was conducted, and variates with P < 0.1 were further included in the multivariate logistic regression model to explore potential risk factors associated with treatment efficacy. When 95% confidence interval (95% CI) of the relative risk excluded a value of 1, the risk was considered significant, and a probability value of <0.05 was also considered significant. All analyses mentioned above were performed using Statistical Package for the Social Sciences software (SPSS, version 16.0, IBM corporation, Chicago, IL, USA) (Stata/SE, version 15.0, Stata Corporation, College Station, TX, USA), and P < 0.05 was considered statistically significant.

The present study was approved by the Institutional Review Board of Obstetrics and Gynecology Hospital of Fudan University. Owing to the retrospective nature of the study, requirement of obtaining informed consent from patients for the use of medical record data was waived.


  Results Top


Clinical characteristics and initial serum β-human chorionic gonadotropins level before treatment

All patients met the diagnostic criteria for CSP-II [representative pictures of lesions are shown in [Figure 1]. No patient had contraindications as a result of treatment, and all surgical procedures were successfully performed. As shown in [Table 1], no significant difference was found in patient age, number of previous C-sections, time since last C-section, gestational age, size of GS, or thickness of anterior lower uterine segment myometrium (P > 0.05). Patients with higher serum β-hCG level were more likely to receive treatment other than D&C (P < 0.05, P < 0.05, and P < 0.001 when Group C was compared with Group A, B, or D, respectively).
Figure 1: Representative ultrasound images of different types of CSP-I and CSP-II and laparoscopic findings during surgery for a patient with CSP-II. (A) Part of a gestational sac being implanted into the CS but growing toward the uterine cavity: CSP-I. (B and C) Deep implantation into a CS defect with infiltrating growth into the uterine myometrium (>3 mm or ≤3 mm): CSP-IIa (b) and CSP-IIb (c). (D1-D3) Laparoscopic view of CSP-II during surgery. A bulging mass over the serosal surface of CS (D1). The vesicouterine peritoneal fold is opened, and the bladder is pushed downward (D2). The lesion at the anterior wall of the uterus is starting to be removed. As the removal is further progressed, the upper part of the lesion is detached and the gestational tissue is visualized (D3). CSP: Cesarean scar pregnancy; CS: Cesarean scar.

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Table 1: Clinical characteristics for each groups in CSP-II

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Comparison of complications, laparotomy conversion rate, and treatment success rate

The most common complication in CSP treatment is massive hemorrhage (≥500 mL). As shown in [Table 2], 9 out of 131 (6.9%) patients had complications. None of the patients in Group B (0.0%) suffered from severe bleeding or required transfusion. In contrast, 2 out of 25 (8.0%) patients in Group A, 3 out of 24 (12.5%) in Group C, and 2 out of 61 (3.3%) in Group D experienced massive hemorrhage; however, no significant difference was found within the four groups (P > 0.05). In addition, shorter operation time was observed in Group D compared with that in Group A or B (20 [range, 15–20] min vs. 50 [range, 40–64] min; 20 [range, 15–20] min vs. 45 [range, 38–73] min; P < 0.001 and P < 0.01, respectively), but the difference was not statistically significant when compared with Group C (20 [range, 15–20] min vs. 20 [range, 15–40] min, P > 0.05).
Table 2: Parameters of efficacy within different groups in CSP-II

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In all cases, about 8.3% (2/24) in Group C and 4.9% (3/61) in Group D eventually were converted to laparoscopic surgery or laparotomy for hemorrhagic shock and bladder injury when removing conceptus during the procedure. Although no severe complications, including massive hemorrhage (≥500 mL), bladder and urethra injury, and hemorrhagic shock, were observed in Group A or B, when comparing the complication rate and negative conversion rate of serum β-hCG level, no statistical significance was found among the four groups [P > 0.05; [Table 2].

Regarding treatment success rate, a significant advantage was observed in Group A (96.0%) and B (100.0%) compared with Group C (70.8%) (P < 0.05 and P < 0.05, respectively). Combination with UAE did not significantly improve the success rate of D&C (Group C vs. Group D, P > 0.05) or laparoscopic surgery (Group A vs. Group B, P > 0.05) in this study [Table 2].

Further comparison between cesarean scar pregnancy-IIa and cesarean scar pregnancy-IIb

To further investigate the high-risk factors associated with treatment success rate, we divided CSP-II patients into two subtypes according to the myometrial thickness of CS (>3 mm, CSP-IIa; ≤3 mm, CSP-IIb), with grouping following the same criteria [Table 3]. In this cohort, the median myometrial thickness of CS was 4.0 (range, 3.3 to 5.0) mm for CSP-IIa and 1.1 (range, 1.0–2.0) mm for CSP-IIb. For patients diagnosed with CSP-IIa, laparotomy was not performed and no major complications occurred; the differences in treatment success rate and serum β-hCG normalization rate among the four surgical groups disappeared. In contrast, for patients with CSP-IIb, approximately 2 out of 11 (18.2%) patients in Group C and 3 out of 34 (8.8%) in Group D were converted to laparotomy owing to major complications. However, the differences were not significant among the four groups (P > 0.05). Laparoscopic surgery hastened the normalization of serum β-hCG level in Group A and B compared with that in Group C (Group A and B [100% and 100%, respectively] vs. Group C [63.6%]; P < 0.05), but no significant difference was observed when compared with Group D (P > 0.05). About 3–4 weeks after surgery, patients were tested for serum hCG levels. Approximately 2 out of 4 (50%) patients with slow decline in hCG levels in Group C and 1 out of 5 (20%) in Group D were received secondary curettage or mifepristone treatment. In contrast, only 1 patient in laparoscopic surgery group possessed a slow decline in serum β-hCG (3–4 weeks after surgery), and no special treatment was performed. The results also turned negative after 1 week follow-up [Supplementary Table 1]. Laparoscopic technique made blood hCG level drop to normal more quickly after surgery [Supplementary Table 2], P < 0.05 and P < 0.05, respectively]. In addition, a lower rate of perioperative complications and a higher treatment success rate continued to be observed in Group A (13.3% and 100.0%, respectively) and Group B (0.0% and 100.0%, respectively) compared with Group C (36.36% and 36.4%, respectively) and Group D (8.8% and 70.6%, respectively; P = 0.036 and P < 0.001, respectively).
Table 3: Comparison of treatment efficacy within different groups in patients with CSP-II

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Potential risk factors associated with treatment success rate

Using logistic regression, univariate and multivariate analyses were conducted to compare treatment success rates within different substratifications of each factor. Among these, the thickness of the anterior lower uterine segment myometrium was graded into two levels (≤3 mm and >3 mm), and the remaining parameters were divided into two layers [Table 4]. In this series, univariate analysis showed that number of C-sections, time since last C-section, myometrial thickness of CS, protruding mass, and surgical methods were associated with the success rate of CSP-II treatment. Multivariate analysis demonstrated that in patients who underwent more than one C-section (adjusted odds ratio [OR] = 8.877, 95% CI = 1.600–49.264; P = 0.013), a mass protruding into the bladder or abdominal cavity (OR = 25.507, 95% CI = 4.241–153.407; P < 0.001), and direct D&C modality (OR = 38.247, 95% CI = 2.347–623.162; P = 0.01) were correlated with a lower treatment success rate.
Table 4: Univariate and Multivariate analysis of efficacy-associated risk factors in treatment of CSP-II

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  Discussion Top


Current status of treatment modality for cesarean scar pregnancy-II

CSP is a rare type of ectopic pregnancy that has a potentially high risk of massive hemorrhage and uterine rupture if not diagnosed early and properly managed. Currently, transvaginal ultrasonography or transvaginal combined with transabdominal ultrasonography is recommended as a routine check in early pregnancy for all patients who previously underwent C-section to exclude the possibility of CSP.[15]

In view of the increasing incidence of CSP, severe complications encountered as a result of its treatment make management of CSP more and more challenging.[16] Several treatments, including conservative treatment (local or systemic application of methotrexate and UAE), excision of GS using hysteroscopy or laparoscopy, D&C, or combinations of these, have been reported.[17] However, the efficacy of these methods dramatically varies, and there is no consensus on the optimal treatment for CSP.[11],[14],[18] One possible explanation for this is the diversity of the definition of CSP. In 2000, Vial et al.[8] categorized CSP as CSP-I and CSP-II according to the severity of implantation and growth direction of GS in the uterine scar. Compared with patients with CSP-I, those with CSP-II present a greater treatment challenge. Although this classification appears reasonable, it has not been widely accepted owing to lack of quantitative indicators. An increasing number of authors suggested that the ideal classification of CSP should take into account some of the potential risk factors, including the myometrial thickness of CS and mass protruding into the bladder or peritoneal cavity.[14] Before a new classification of CSP is fully developed, the use of the subtype CSP-II is encouraged to emphasize the risk of severe complications.[19] A safe and efficient clinical approach to CSP-II is yet to be determined, but surgical approaches are recommended depending on availability, CSP types, ultrasonography features, and surgical preference. UAE is an efficient treatment before curettage for the prevention of bleeding; patients treated using UAE experienced much less bleeding during curettage, a shorter hospital stay, and normalization of serum β-hCG level;[14] however, it requires an interventional radiologist, which may limit the availability of the treatment. Because there are no suggested guidelines, among the four treatment modalities in this study, LAOH, D&C, or UAE are usually chosen by surgeons according to their own preference.[13]

Increasing evidence shows that there is a higher failure rate[14],[20] following conservative treatment (administration of methotrexate) for patients with CSP, especially for those with CSP-II.[11],[19] In the present study, all 131 patients with CSP-II were managed with surgery; of these, 9 (6.9%) had complications. The success rate of LAOH with (21/21, 100.0% patients) or without UAE (24/25, 96.0% patients) was higher than that of D&C (17/24, 70.8% patients) and that of UAE + D&C [50/61, 82.0% patients; [Table 2], especially when the zygote was more deeply implanted with a myometrial thickness of CS ≤3 mm [CSP-IIb; [Table 3].

Role of uterine artery embolization in the treatment of patients with cesarean scar pregnancy-II

Initially, D&C was adopted as the first-choice surgical treatment for patients with CSP, but intraoperative or postoperative complications, such as profuse hemorrhage, uterine perforation, heavy bleeding, and even life-threatening events, prevented its application.[2],[21],[22],[23] The introduction of UAE may reduce hemorrhage complications and risk of hysterectomy[24] and is gradually being considered, but it has not been widely accepted. There is some concern regarding UAE in that the independent cure rate of this technique is rather low,[25] and the scar tissue can be extremely fragile after UAE, especially after coadministration of methotrexate. Furthermore, UAE may reduce the blood supply to the ovaries, and its impact on uterine integrity and future fertility remains unknown.[26] For patients with CSP-II who presented with higher serum β-hCG level, clinicians were more likely to choose UAE as pretreatment or laparoscopic surgery compared with direct D&C [P < 0.001, P < 0.05, P < 0.05, respectively; [Table 1]. There is a trend that patients who underwent surgery with UAE as pretreatment, as opposed to control groups, suffered less blood loss, but no statistically significant difference was observed in this cohort (50 [range: 20–100] mL vs. 50 [range: 30–100] mL, P > 0.05; 10 [range: 10–20] mL vs. 15 [range: 10–125] mL, P > 0.05; [Table 2]) [Supplementary Table 3]. The reason for this may be the relatively small sample size in our study. On the other hand, UAE + D&C, as opposed to LAOH, significantly shortened the operation time (20 [range: 15–20] min vs. 50 [range: 40–64] min, P < 0.001) or UAE + LAOH (20 [range: 15–20] min vs. 45 [range: 38–73] min, P < 0.01), but UAE did not shorten the operation time of LAOH (45 [range: 38–73] min vs. 50 [range: 40–64] min, P > 0.05; [Table 2]). Furthermore, pretreatment with UAE did not show any advantage in reducing the complication rate in patients with CSP-IIb (Group A [13.3%] vs. Group B [0.0%], P > 0.05; Group C [36.4%] vs. Group D [8.8%], P > 0.05; [Table 3]). Considering the benefits and potential risks of UAE, further clinical evidence is needed to assess the role of UAE in the treatment of patients with CSP-II.



In addition, we attempted to combine UAE with laparoscopic surgery (LAOH + UAE) and curettage surgery (D&C + UAE), the results of which are shown in [Supplementary Table 1], [Table 2], [Table 3]. For patients diagnosed with CSP-IIb, fewer major complications occurred in those treated with LAOH with or without UAE, but the differences were not significant between the two groups (P = 0.301). Laparoscopic surgery still shows an obvious advantage in success rate and normalization of serum β-hCG level (P < 0.001 and P = 0.019, respectively). It seems that UAE possibly plays an important role in reducing the complications during surgery but does not affect the outcome of CSP treatment [Tables 3 and [Supplementary Table 3].

Role of laparoscopy assisted by operative hysteroscopy in the treatment of patients with cesarean scar pregnancy-II

With the development of minimally invasive techniques, an increasing number of CSP cases are treated laparoscopically.[10],[11],[19],[21] Laparoscopic surgery offers the opportunity to remove gestational tissue and potentially allows for defect repair, especially when uterine scar dehiscence is accompanied. Leeet al.[27] first reported a case of CSP successfully treated using laparoscopic resection of CS gestational product in 1999. Further, more positive results followed. Hysteroscopy can reduce the incidence of hemorrhage by directly determining GS location and vascular distribution around the gestational implant. In 2005, evacuation of CSP by LAOH was inspired by Wang et al.[28] This approach aimed to minimize bladder injury and provide a strategy for the minimally invasive management of hemorrhage and for scar repair, for which LAOH showed superiority.[14],[29] In our studies, the four treatment modalities (LAOH with or without UAE and D&C with or without UAE) did not reveal pros and cons in complication rate, laparotomy conversion rate, or serum β-hCG normalization rate (P = 0.130, P = 0.405, and P = 0.201, respectively) for the management of patients with CSP-II. However, not surprisingly, LAOH with or without UAE, as opposed to D&C alone, reflected an obvious advantage in success rate [P = 0.023 and P = 0.01, respectively; [Table 2].

In patients with CSP, the myometrial thickness of CS was usually <4 mm,[11] and a myometrial thickness of CS <3 mm was reported to be a high-risk factor for the failure of D&C and that of <1.2 mm was a high-risk factor of uterine scar dehiscence (most likely, of uterine rupture).[14],[19] When we further divided CSP-II into CSP-IIa (myometrial thickness of CS >3 mm) and CSP-IIb (myometrial thickness of CS ≤3 mm) groups based on the myometrial thickness of CS, none of the treatment modalities for CSP-IIa showed superiority in perioperative complications or success rate. However, because the cost of LAOH was quite high for patients, D&C with or without UAE possessed advantages such as simplicity, minimal trauma, rapid recovery, and less hospitalization expense, and therefore, it may be preferable for clinicians to choose as an appropriate treatment modality for patients with CSP-IIa. However, in patients with CSP-IIb, approximately 20% of cases showed a blue-tinted GS or mass located in the previous CS, protruding into the uterine serosal surface and the anterior uterus myometrial wall was very thin or absent [Figure 1]C and D]. In patients with CSP-IIb, the success rate of LAOH with or without UAE was 100%, whereas that of D&C with or without UAE was lower (70.6% and 36.4%, respectively; P < 0.001). Importantly, the LAOH approach removed the gestational product completely, which made the normalization of serum β-hCG faster [Supplementary Table 3], P < 0.05 and P < 0.05, respectively], and patients may benefit from fewer complications [Table 3]. Accordingly, in this study, LAOH showed superiority in success rate for patients with CSP-IIb.

Potential efficacy-associated risk factors in patients with cesarean scar pregnancy-II

Some risk factors potentially influenced treatment efficacy. In recent years, clinicians proposed that CSPs should be divided pathologically into two subtypes (endogenous or exogenous) or more subtypes (I, II, III, and so on) based on risk factors using ultrasonic measurement of scar thickness.[14],[19] Univariate and multivariate analyses in our study showed that a history of multiple C-sections, CS with protruding mass, and D&C modality alone were independent risk factors associated with lower treatment efficacy [P = 0.013, P < 0.001, and P = 0.010, respectively; [Table 4]. On the contrary, some factors, including preoperative serum β-hCG level and size of GS, were not related with the treatment success rate. Time since last C-section might be obviously influenced by the number of C-sections, and thus, it was not an independent risk factor. In this retrospective study, the myometrial thickness of CS did not show a significant difference in multivariate analysis, although it was correlated with treatment success rate in univariate analysis. Our findings are in line with those of other researches,[17],[30] i.e., for patients with CSP-IIb, when the myometrial thickness of CS is ≤3 mm, whether or not UAE is undertaken, caution should be taken when choosing D&C alone. Considering β-hCG is mainly secreted by the villi and decidua, high serum β-hCG level was usually associated with a well-grown embryo sac and abundant blood supply. Further, Yang et al. indicated that the risk of massive bleeding could be increased in patients with preoperative serum β-hCG level of >50,000 mIU/mL during curettage.[31] In other words, for patients whose initial hCG was at relatively low level, the clinicians might consider that the pregnancy-related lesion was not active, and the risk of bleeding was relatively low, and thus they were more willing to choose the fastest and most economical method, that was, D&C. As for the subsequent course of recovery, it is not clear until doing this research. However, in this cohort, we did not find any significant impact of serum β-hCG level on the therapeutic efficacy.

In conclusion, it is the first time to compare the safety and efficacy of D&C ± UAE and LAOH ± UAE on managing CSP-II; our data suggest that compared with D&C ± UAE, LAOH ± UAE showed a higher success rate for patients with CSP-II, especially when the zygote was more deeply implanted with a myometrial thickness of CS ≤3 mm. CSP-II treatment should be individualized on the basis of many risk factors. However, it is difficult to draw a solid conclusion from a single institute's retrospective study; a larger-scale prospective study from multicenter on optimizing therapeutic strategy for CSP should be warranted.

Acknowledgment

Part of this work has been accepted for Poster Presentation in the 45th AAGL on November 17th, 2016 in Orlando, FL, USA.

Supplementary information is linked to the online version of the paper on the Reproductive and Developmental Medicine website.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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