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Scarred for life: a review of cesarean section scar pregnancy and potential pitfalls in diagnosis

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Abstract

Cesarean section scar pregnancy (CSSP) is defined as abnormal implantation of a gestational sac on or in a previous cesarean section scar. There is an increasing incidence of detection of CSSP, likely in part due to the growing rates of cesarean deliveries and the improved rates of detection with advancing ultrasound technology. Diagnosis of CSSP is critical due to the potentially life-threatening complications to the mother if left untreated. Pelvic ultrasound is the imaging modality of choice in the initial evaluation of suspected CSSP, with MRI potentially useful if ultrasound findings are equivocal, or if confirmation is requested prior to definitive intervention. Early and accurate diagnosis of CSSP allows for prompt management to avoid severe complications and the potential to preserve the uterus and future fertility. A combination of medical and surgical treatment strategies may be needed with specific therapy tailored to each patient. Follow-up after treatment should include serial beta-hCG levels and possible repeat imaging if there is clinical concern for complications or treatment failure. This article will provide a comprehensive review of this uncommon but important phenomenon, detailing the pathophysiology and types of CSSP, imaging presentations, potential pitfalls in diagnosis, and management options.

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References

  1. Larsen JV, Solomon MH. Pregnancy in a uterine scar sacculus--an unusual cause of postabortal haemorrhage. A case report. South Afr Med J. 1978; 53(4):142-143.

    CAS  Google Scholar 

  2. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar. Ultrasound Obstet Gynecol. 2003; 21(3):220-227.

    CAS  PubMed  Google Scholar 

  3. Seow KM, Huang LW, Lin YH, Lin MYS, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol. 2004; 23(3):247-253.

    Google Scholar 

  4. Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol. 2012; 207(1):14-29.

    PubMed  Google Scholar 

  5. Timor-Tritsch IE, Monteagudo A, Calì G, D’Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis. Obstet Gynecol Clin North Am. 2019; 46(4):797-811.

    PubMed  Google Scholar 

  6. Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. BJOG Int J Obstet Gynaecol. 2007;114(3):253-263.

    CAS  Google Scholar 

  7. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021; 6(6):e005671.

    PubMed  PubMed Central  Google Scholar 

  8. Miller R, Timor-Tritsch IE, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy. Am J Obstet Gynecol. 2020; 222(5):B2-B14.

    CAS  PubMed  Google Scholar 

  9. Timor-Tritsch IE, Monteagudo A, Santos R, Tsymbal T, Pineda G, Arslan AA. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol. 2012; 207(1):44.e1-44.e13.

    PubMed  Google Scholar 

  10. Jordans IPM, Verberkt C, De Leeuw RA, et al. Definition and sonographic reporting system for Cesarean scar pregnancy in early gestation: modified Delphi method. Ultrasound Obstet Gynecol. 2022; 59(4):437-449.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. Riaz RM, Williams TR, Craig BM, Myers DT. Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes. Abdom Imaging. 2015; 40(7):2589-2599.

    PubMed  Google Scholar 

  12. Pędraszewski P, Wlaźlak E, Panek W, Surkont G. Cesarean scar pregnancy – a new challenge for obstetricians. J Ultrason. 2018; 18(72):56-62.

    PubMed  PubMed Central  Google Scholar 

  13. Dahlke JD, Mendez-Figueroa H, Rouse DJ, Berghella V, Baxter JK, Chauhan SP. Evidence-based surgery for cesarean delivery: an updated systematic review. Am J Obstet Gynecol. 2013; 209(4):294-306.

    PubMed  Google Scholar 

  14. Kan A. Classical Cesarean Section. Surg J. 2020; 6(Suppl 2):S98-S103.

    Google Scholar 

  15. Vervoort AJMW, Uittenbogaard LB, Hehenkamp WJK, Brölmann HAM, Mol BWJ, Huirne JAF. Why do niches develop in Caesarean uterine scars? Hypotheses on the aetiology of niche development. Hum Reprod Oxf Engl. 2015; 30(12):2695-2702.

    CAS  Google Scholar 

  16. CAESAR study collaborative group. Caesarean section surgical techniques: a randomised factorial trial (CAESAR). BJOG Int J Obstet Gynaecol. 2010; 117(11):1366-1376.

    Google Scholar 

  17. CORONIS Trial Collaborative Group. The CORONIS Trial. International study of caesarean section surgical techniques: a randomised fractional, factorial trial. BMC Pregnancy Childbirth. 2007; 7:24.

  18. Roberge S, Chaillet N, Boutin A, et al. Single- versus double-layer closure of the hysterotomy incision during cesarean delivery and risk of uterine rupture. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2011; 115(1):5-10.

    Google Scholar 

  19. Di Spiezio Sardo A, Saccone G, McCurdy R, Bujold E, Bifulco G, Berghella V. Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol. 2017; 50(5):578-583.

    Google Scholar 

  20. Qian Z-D, Guo Q-Y, Huang L-L. Identifying risk factors for recurrent cesarean scar pregnancy: a case-control study. Fertil Steril. 2014; 102(1):129-134.e1.

    PubMed  Google Scholar 

  21. Armstrong F, Mulligan K, Dermott RM, et al. Cesarean scar niche: An evolving concern in clinical practice. Obstet Gynecol. 2023; 161(2):356-366.

    Google Scholar 

  22. Ofili-Yebovi D, Ben-Nagi J, Sawyer E, et al. Deficient lower-segment Cesarean section scars: prevalence and risk factors. Ultrasound Obstet Gynecol. 2008; 31(1):72-77.

    CAS  PubMed  Google Scholar 

  23. Fylstra DL. Ectopic Pregnancy Within a Cesarean Scar: A Review. Obstet Gynecol Surv. 2002; 57(8):537-543.

    PubMed  Google Scholar 

  24. Giampaolino P, De Rosa N, Morra I, et al. Management of Cesarean Scar Pregnancy: A Single-Institution Retrospective Review. BioMed Res Int. 2018; 2018:e6486407.

    Google Scholar 

  25. Shi M, Zhang H, Qi SS, et al. Identifying risk factors for cesarean scar pregnancy: a retrospective study of 79 cases. Ginekol Pol. 2018; 89(4):196-200.

    Google Scholar 

  26. Vikhareva Osser O, Valentin L. Risk factors for incomplete healing of the uterine incision after caesarean section. BJOG Int J Obstet Gynaecol. 2010; 117(9):1119-1126.

    CAS  Google Scholar 

  27. Zhou X, Li H, Fu X. Identifying possible risk factors for cesarean scar pregnancy based on a retrospective study of 291 cases. J Obstet Gynaecol Res. 2020; 46(2):272-278.

    PubMed  PubMed Central  Google Scholar 

  28. Gonzalez N, Tulandi T. Cesarean Scar Pregnancy: A Systematic Review. J Minim Invasive Gynecol. 2017; 24(5):731-738.

    PubMed  Google Scholar 

  29. Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol. 2000; 16(6):592-593.

    CAS  Google Scholar 

  30. Ghezzi F, Laganà D, Franchi M, Fugazzola C, Bolis P. Conservative treatment by chemotherapy and uterine arteries embolization of a cesarean scar pregnancy. Eur J Obstet Gynecol Reprod Biol. 2002; 103(1):88-91.

    PubMed  Google Scholar 

  31. Liu H, Li Y, Liu D, et al. Early diagnosis and effective treatment of endogenous and exogenous cesarean scar pregnancies: A retrospective case series. Biomed Res. 2018; 29(4).

  32. Timor-Tritsch IE, Monteagudo A, Cali G, et al. Cesarean scar pregnancy is a precursor of morbidly adherent placenta. Ultrasound Obstet Gynecol. 2014; 44(3):346-353.

    CAS  PubMed  Google Scholar 

  33. Timor-Tritsch IE, Monteagudo A, Cali G, et al. Cesarean scar pregnancy and early placenta accreta share common histology. Ultrasound Obstet Gynecol. 2014; 43(4):383-395.

    CAS  PubMed  Google Scholar 

  34. Cali G, Forlani F, Timor-Tritsch IE, Palacios-Jaraquemada J, Minneci G, D’Antonio F. Natural history of Cesarean scar pregnancy on prenatal ultrasound: the crossover sign. Ultrasound Obstet Gynecol. 2017; 50(1):100-104.

    CAS  PubMed  Google Scholar 

  35. Maymon R, Halperin R, Mendlovic S, Schneider D, Herman A. Ectopic pregnancies in a Caesarean scar: review of the medical approach to an iatrogenic complication. Hum Reprod Update. 2004; 10(6):515-523.

    CAS  PubMed  Google Scholar 

  36. Liu D, Yang M, Wu Q. Application of ultrasonography in the diagnosis and treatment of cesarean scar pregnancy. Clin Chim Acta Int J Clin Chem. 2018; 486:291-297.

    CAS  Google Scholar 

  37. Xiong X, Yan P, Gao C, Sun Q, Xu F. The Value of Contrast-Enhanced Ultrasound in the Diagnosis of Cesarean Scar Pregnancy. BioMed Res Int. 2016; 2016:e4762785.

    Google Scholar 

  38. Wu Y, Zhou L, Chen L, Zhou Q, Zeng T. Efficacy of contrast-enhanced ultrasound for diagnosis of cesarean scar pregnancy type. Medicine (Baltimore). 2019; 98(44):e17741.

    PubMed  PubMed Central  Google Scholar 

  39. Ravi Selvaraj L, Rose N, Ramachandran M. Pitfalls in Ultrasound Diagnosis of Cesarean Scar Pregnancy. J Obstet Gynaecol India. 2018; 68(3):164-172.

    PubMed  Google Scholar 

  40. Kao LY, Scheinfeld MH, Chernyak V, Rozenblit AM, Oh S, Dym RJ. Beyond Ultrasound: CT and MRI of Ectopic Pregnancy. Am J Roentgenol. 2014; 202(4):904-911.

    Google Scholar 

  41. Rizk B, Holliday CP, Owens S, Abuzeid M. Cervical and Cesarean scar ectopic pregnancies: Diagnosis and management. Middle East Fertil Soc J. 2013; 18(2):67-73.

    Google Scholar 

  42. Dighe M, Cuevas C, Moshiri M, Dubinsky T, Dogra VS. Sonography in first trimester bleeding. J Clin Ultrasound. 2008; 36:352-366.

    PubMed  Google Scholar 

  43. Dibble EH, Lourenco AP. Imaging unusual pregnancy implantations: Rare ectopic pregnancies and more. AJR. 2016; 207:1380-1392.

    PubMed  Google Scholar 

  44. Lakshmy SR, Thasleem Z, Parthasarathy P, Banu S. Low lying gestation sac in early pregnancy – an algorithmic approach with ultrasound markers. Obstet Gynecol Int J. 2020; 11(2):107-114.

    Google Scholar 

  45. Gupta N, Barbara H, Kenneth E, Josef B. Cesarean Scar Ectopic Pregnancy. J Clin Gynecol Obstet. 2013; 2(1):42-44.

    CAS  Google Scholar 

  46. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol. 2006; 107(6):1373-1381.

    PubMed  Google Scholar 

  47. Salari N, Kazeminia M, Shohaimi S, Nankali A al-Dawlah, Mohammadi M. Evaluation of treatment of previous cesarean scar pregnancy with methotrexate: a systematic review and meta-analysis. Reprod Biol Endocrinol. 2020; 18(1):108.

    CAS  PubMed  PubMed Central  Google Scholar 

  48. Hoffman T, Lin J. Cesarean Scar Ectopic Pregnancy: Diagnosis With Ultrasound. Clin Pract Cases Emerg Med. 2020; 4(1):65-68.

    PubMed  PubMed Central  Google Scholar 

  49. Boza A, Boza B, Api M. Cesarean Scar Pregnancy Managed with Conservative Treatment. Iran J Med Sci. 2016; 41(5):450-455.

    PubMed  Google Scholar 

  50. Patel MA. Scar Ectopic Pregnancy. J Obstet Gynaecol India. 2015; 65(6):372-375.

    PubMed  PubMed Central  Google Scholar 

  51. Petersen KB, Hoffmann E, Larsen CR, Nielsen HS. Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril. 2016; 105(4):958-967.

    Google Scholar 

  52. Uludag SZ, Kutuk MS, Ak M, et al. Comparison of systemic and local methotrexate treatments in cesarean scar pregnancies: time to change conventional treatment and follow-up protocols. Eur J Obstet Gynecol Reprod Biol. 2016; 206:131-135.

    CAS  PubMed  Google Scholar 

  53. Wu X, Zhang X, Zhu J, Di W. Caesarean scar pregnancy: comparative efficacy and safety of treatment by uterine artery chemoembolization and systemic methotrexate injection. Eur J Obstet Gynecol Reprod Biol. 2012; 161(1):75-79.

    CAS  PubMed  Google Scholar 

  54. Peng P, Gui T, Liu X, Chen W, Liu Z. Comparative efficacy and safety of local and systemic methotrexate injection in cesarean scar pregnancy. Ther Clin Risk Manag. 2015; 11:137-142.

    PubMed  PubMed Central  Google Scholar 

  55. Shalev E, Peleg D, Bustan M, Romano S, Tsabari A. Limited role for intratubal methotrexate treatment of ectopic pregnancy. Fertil Steril. 1995; 63(1):20-24.

    CAS  PubMed  Google Scholar 

  56. Stovall TG, Ling FW. Single-dose methotrexate: An expanded clinical trial. Am J Obstet Gynecol. 1993; 168(6, Part 1):1759–1765.

  57. Hajenius P, Engelsbel S, Mol B, et al. Randomised trial of systemic methotrexate versus laparoscopic salpingostomy in tubal pregnancy. The Lancet. 1997; 350(9080):774-779.

    CAS  Google Scholar 

  58. Sowter MC, Farquhar CM, Petrie KJ, Gudex G. A randomised trial comparing single dose systemic methotrexate and laparoscopic surgery for the treatment of unruptured tubal pregnancy. Br J Obstet Gynaecol. 2001; 108(2):192-203.

    CAS  Google Scholar 

  59. Nazac A, Gervaise A, Bouyer J, De Tayrac R, Capella-Allouc S, Fernandez H. Predictors of success in methotrexate treatment of women with unruptured tubal pregnancies. Ultrasound Obstet Gynecol. 2003; 21(2):181-185.

    CAS  PubMed  Google Scholar 

  60. Hois EL, Hibbeln JF, Alonzo MJ, Chen ME, Freimanis MG. Ectopic pregnancy in a cesarean section scar treated with intramuscular methotrexate and bilateral uterine artery embolization. J Clin Ultrasound JCU. 2008; 36(2):123-127.

    PubMed  Google Scholar 

  61. Wang CJ, Yuen LT, Chao AS, Lee CL, Yen CF, Soong YK. Caesarean scar pregnancy successfully treated by operative hysteroscopy and suction curettage. BJOG Int J Obstet Gynaecol. 2005; 112(6):839-840.

    Google Scholar 

  62. Yoon R, Sasaki K, Miller CE. Laparoscopic Excision of Cesarean Scar Pregnancy with Scar Revision. J Minim Invasive Gynecol. 2021; 28(4):746-747.

    PubMed  Google Scholar 

  63. Maheux-Lacroix S, Li F, Bujold E, Nesbitt-Hawes E, Deans R, Abbott J. Cesarean Scar Pregnancies: A Systematic Review of Treatment Options. J Minim Invasive Gynecol. 2017; 24(6):915-925.

    PubMed  Google Scholar 

  64. Lata K, Davis AA, Panwar A, Kriplani I, Sharma S, Kriplani A. Laparoscopic Excision of Cesarean Scar Ectopic Pregnancy. J Obstet Gynaecol India. 2020; 70(5):397-401.

    PubMed  PubMed Central  Google Scholar 

  65. Timor-Tritsch IE, Horwitz G, D’Antonio F, et al. Recurrent Cesarean scar pregnancy: case series and literature review. Ultrasound Obstet Gynecol Off J Int Soc Ultrasound Obstet Gynecol. 2021; 58(1):121-126.

    CAS  Google Scholar 

  66. Gundewar T, Pandurangi M, Reddy NS, et al. Exclusive use of intrasac potassium chloride and methotrexate for treating cesarean scar pregnancy: effectiveness and subsequent fecundity. Hum Reprod Open. 2020; 2020(2):hoaa025.

    PubMed  PubMed Central  Google Scholar 

  67. Revzin MV, Pellerito JS, Moshiri M, Katz DS, Nezami N, Kennedy A. Use of Methotrexate in Gynecologic and Obstetric Practice: What the Radiologist Needs to Know. RadioGraphics. 2021; 41(6):1819-1838.

    PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Radiology, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA

    Jennifer Huang, Catherine Phillips & Mariam Moshiri

  2. PGY-5 Chief Resident, Diagnostic Radiology Residency, Vanderbilt University Medical Center, 1161 21st Ave South, Nashville, TN, 37232, USA

    Jennifer Huang

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Correspondence to Jennifer Huang.

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Catherine Phillips is the Deputy Editor of OB/GYN RSNA Case Collection. Mariam Moshiri is the Editor of RSNA Case Collection.

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Huang, J., Phillips, C. & Moshiri, M. Scarred for life: a review of cesarean section scar pregnancy and potential pitfalls in diagnosis. Abdom Radiol 48, 2672–2683 (2023). https://doi.org/10.1007/s00261-023-03953-7

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