Skip to main content
SpringerLink
Log in

MRI-based scoring model to predict massive hemorrhage during dilatation and curettage in patients with cesarean scar pregnancy

  • Kidneys, Ureters, Bladder, Retroperitoneum
  • Published:
Abdominal Radiology Aims and scope Submit manuscript

Abstract

Objective

To construct a scoring model based on MRI signs to predict massive hemorrhage during dilatation and curettage in cesarean scar pregnancy (CSP) patients.

Materials and methods

The MRIs of CSP patients admitted to a tertiary referral hospital between February 2020 and July 2022 were retrospectively reviewed. The included patients were randomly assigned to the training and validation cohorts. The univariate and multivariate logistic regression analyses were adopted to identify the independent risk factors for massive hemorrhage (the amount of bleeding ≥ 200 ml) during the dilatation and curettage. A scoring model predicting intraoperative massive hemorrhage was established where each positive independent risk factor was assigned 1 point, and the predictive power of this model was evaluated both in the training and validation cohorts via the receiver operating characteristic curve.

Results

A total of 187 CSP patients were enrolled, who were divided into the training cohort (31 in 131 patients had massive hemorrhage) and validation cohort (10 in 56 patients had massive hemorrhage). The independent risk factors for intraoperative massive hemorrhage included cesarean section diverticulum area (OR = 6.957, 95% CI 1.993–21.887; P = 0.001), uterine scar thickness (OR = 5.113, 95% CI 2.086–23.829; P = 0.025) and gestational sac diameter (OR = 3.853, 95% CI 1.103–13.530; P = 0.025). A scoring model with a total point of 3 was developed and the CSP patients were divided into low-risk (Total points < 2) and high-risk groups (Total points ≥ 2) for intraoperative massive hemorrhage accordingly. This model possessed high prediction performance both in the training cohort (area under the curve [AUC] = 0.896, 95% CI 0.830–0.942) and validation cohort (AUC = 0.915, 95% CI 0.785–1.000).

Conclusion

We first constructed a MRI-based scoring model for predicting intraoperative massive hemorrhage in CSP patients, which could help the decision-making of the patients’ therapy strategies. Low-risk patients can be cured by D&C alone to reduce the financial burden, while high-risk patients require more adequate preoperative preparation or consideration of changing surgical approaches to reduce bleeding risk.

Graphical abstract

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

Abbreviations

CSP:

Cesarean scar pregnancy

D&C:

Dilatation and curettage

MRI:

Magnetic resonance imaging

β-hCG:

β-Human chorionic gonatropin

TR:

Repetition time

TE:

Echo time

FOV:

Field of view

CSD:

Cesarean section diverticulum

ICC:

Interclass correlation coefficient

ROC:

Receiver operating characteristic curve

AUC:

Area under the curve

CI:

Confidence interval

References

  1. Grechukhina O, Deshmukh U, Fan L, et al. Cesarean Scar Pregnancy, Incidence, and Recurrence: Five-Year Experience at a Single Tertiary Care Referral Center [J]. Obstet Gynecol, 2018,132(5): 1285-1295.

    Article  PubMed  Google Scholar 

  2. Shah JS, Nasab S. Management and reproductive counseling in cervical, caesarean scar and interstitial ectopic pregnancies over 11 years: identifying the need for a modern management algorithm [J]. Hum Reprod Open, 2019,2019(4): hoz028.

  3. Family Planning Subgroup CSoOaG, Chinese Medical Association. [Expert opinion of diagnosis and treatment of cesarean scar pregnancy (2016)] [J]. Zhonghua Fu Chan Ke Za Zhi, 2016,51(8): 568-572.

  4. Le A, Li M, Xu Y, et al. Different Surgical Approaches to 313 Cesarean Scar Pregnancies [J]. J Minim Invasive Gynecol, 2019,26(1): 148-152.

    Article  PubMed  Google Scholar 

  5. Sun QL, Luo L, Gao CY, et al. Scoring system for the prediction of the successful treatment modality in women with cesarean scar pregnancy [J]. Int J Gynaecol Obstet, 2019,146(3): 289-295.

    Article  PubMed  Google Scholar 

  6. Wang Q, Ma H, Peng H, et al. Risk factors for intra-operative haemorrhage and bleeding risk scoring system for caesarean scar pregnancy: a case-control study [J]. Eur J Obstet Gynecol Reprod Biol, 2015,195: 141-145.

    Article  CAS  PubMed  Google Scholar 

  7. Ma Y, Shao M, Shao X. Analysis of risk factors for intraoperative hemorrhage of cesarean scar pregnancy [J]. Medicine (Baltimore), 2017,96(25): e7327.

    Article  PubMed  Google Scholar 

  8. Chiang YC, Tu YA, Yang JH, et al. Risk factors associated with failure of treatment for cesarean scar pregnancy [J]. Int J Gynaecol Obstet, 2017,138(1): 28-36.

    Article  CAS  PubMed  Google Scholar 

  9. Zhang Y, Chen L, Zhou M, et al. Risk factors of persistent cesarean scar pregnancy after dilation and curettage: a matched case-control study [J]. Taiwan J Obstet Gynecol, 2020,59(2): 237-242.

    Article  PubMed  Google Scholar 

  10. Lin Y, Xiong C, Dong C, et al. Approaches in the Treatment of Cesarean Scar Pregnancy and Risk Factors for Intraoperative Hemorrhage: A Retrospective Study [J]. Front Med (Lausanne), 2021,8: 682368.

    Article  PubMed  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  12. Peng KW, Lei Z, Xiao TH, et al. First trimester caesarean scar ectopic pregnancy evaluation using MRI [J]. Clin Radiol, 2014,69(2): 123-129.

    Article  PubMed  Google Scholar 

  13. Xiao X, Ding R, Peng L, et al. Diagnostic performance of magnetic resonance imaging and ultrasonography on the detection of cesarean scar pregnancy: A meta-analysis [J]. Medicine (Baltimore), 2021,100(48): e27532.

    Article  PubMed  Google Scholar 

  14. Guo S, Wang H, Yu X, et al. The diagnostic value of 3.0T MRI in cesarean scar pregnancy [J]. Am J Transl Res, 2021,13(6): 6229-6235.

  15. Hoffmann J, Exner M, Bremicker K, et al. Cesarean section scar in 3 T magnetic resonance imaging and ultrasound: image characteristics and comparison of the methods [J]. Arch Gynecol Obstet, 2019,299(2): 439-449.

    Article  PubMed  Google Scholar 

  16. Du Q, Liu G, Zhao W. A novel method for typing of cesarean scar pregnancy based on size of cesarean scar diverticulum and its significance in clinical decision-making [J]. J Obstet Gynaecol Res, 2020,46(5): 707-714.

    Article  CAS  PubMed  Google Scholar 

  17. Du Q, Zhao W. Exploring the value of cesarean section diverticulum area to predict the safety of hysteroscopic management for cesarean scar pregnancy patients [J]. Int J Gynaecol Obstet, 2022,156(3): 488-493.

    Article  PubMed  Google Scholar 

  18. Wang X, Yang B, Chen W, et al. Clinical efficacy and re-pregnancy outcomes of patients with previous cesarean scar pregnancy treated with either high-intensity focused ultrasound or uterine artery embolization before ultrasound-guided dilatation and curettage: a retrospective cohort study [J]. BMC Pregnancy Childbirth, 2023,23(1): 85.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Wang J, Zhao R, Qian H, et al. Pituitrin local injection versus uterine artery embolization in the management of cesarean scar pregnancy: A retrospective cohort study [J]. J Obstet Gynaecol Res, 2021,47(5): 1711-1718.

    Article  CAS  PubMed  Google Scholar 

  20. Soares DM, Junior HW, Bittencourt LK, et al. The role of cine MR imaging in the assessment of uterine function [J]. Arch Gynecol Obstet, 2019,300(3): 545-553.

    Article  PubMed  Google Scholar 

  21. Fang Q, Sun L, Tang Y, et al. Quantitative risk assessment to guide the treatment of cesarean scar pregnancy [J]. Int J Gynaecol Obstet, 2017,139(1): 78-83.

    Article  PubMed  Google Scholar 

  22. Tang M, Zhou Q, Huang M, et al. Nomogram development and validation to predict hepatocellular carcinoma tumor behavior by preoperative gadoxetic acid-enhanced MRI [J]. Eur Radiol, 2021,31(11): 8615-8627.

    Article  PubMed  Google Scholar 

  23. Mu L, Weng H, Wang X. Evaluation of the treatment of high intensity focused ultrasound combined with suction curettage for exogenous cesarean scar pregnancy [J]. Arch Gynecol Obstet, 2022,306(3): 769-777.

    Article  PubMed  Google Scholar 

  24. Sun QL, Wu XH, Luo L, et al. Characteristics of women with mixed mass formation after evacuation following uterine artery chemoembolization for cesarean scar pregnancy [J]. Arch Gynecol Obstet, 2018,297(4): 1059-1066.

    Article  PubMed  Google Scholar 

  25. Bourgioti C, Konstantinidou A, Zafeiropoulou K, et al. Intraplacental Fetal Vessel Diameter May Help Predict for Placental Invasiveness in Pregnant Women at High Risk for Placenta Accreta Spectrum Disorders [J]. Radiology, 2020,298(2): 403-412.

    Article  PubMed  Google Scholar 

  26. Ueno Y, Maeda T, Tanaka U, et al. Evaluation of interobserver variability and diagnostic performance of developed MRI-based radiological scoring system for invasive placenta previa [J]. J Magn Reson Imaging, 2016,44(3): 573-583.

    Article  PubMed  Google Scholar 

  27. Wang Y, Zhu Q, Lin F, et al. Development and internal validation of a Nomogram for preoperative prediction of surgical treatment effect on cesarean section diverticulum [J]. BMC Womens Health, 2019,19(1): 136.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Gui T, Peng P, Liu X, et al. Clinical and ultrasound parameters in prediction of excessive hemorrhage during management of cesarean scar pregnancy [J]. Ther Clin Risk Manag, 2017,13: 807-812.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Ying X, Zheng W, Zhao L, et al. Clinical characteristics and salvage management of persistent cesarean scar pregnancy [J]. J Obstet Gynaecol Res, 2017,43(8): 1293-1298.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Liu J, Chai Y, Yu Y, et al. The value of 3-dimensional color Doppler in predicting intraoperative hemorrhage for cesarean scar pregnancy [J]. Medicine(Baltimore), 2018,97(33): e11969.

  31. Zhang Y, Zhang C, He J, et al. The impact of gestational sac size on the effectiveness and safety of high intensity focused ultrasound combined with ultrasound-guided suction curettage treatment for caesarean scar pregnancy [J]. Int J Hyperthermia, 2018,35(1): 291-297.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors want to thank the Chengdu Municipal Health Commission for the financial support. The authors would like to dedicate the paper as a memorial for the wedding of Dr. Fengleng Yang and Miss Fanyu Lin on 18 June 2023.

Funding

This study has received funding by the Chengdu Medical Research Projects (Grant No. 2021030).

Author information

Author notes

  1. Fengleng Yang and Xilin Yang have contributed equally to this work and share first authorship.

Authors and Affiliations

  1. Department of Radiology, School of Medicine, Chengdu Women’s and Children’s Central Hospital, University of Electronic Science and Technology of China, Chengdu, China

    Fengleng Yang, Chen Deng, Fang Wang, Yongzhong Shuai, Zhigang Wang & Hua Lai

  2. Department of Radiation Oncology, School of Medicine, Chengdu Women’s and Children’s Central Hospital, University of Electronic Science and Technology of China, Chengdu, China

    Xilin Yang

  3. Department of Radiation Oncology, Chinese Academy of Medical Sciences and Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China

    Xilin Yang

  4. Department of Gynecology, Chengdu Women’s and Children’s Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China

    Huaibo Jing, Xiaodan Wang & Zhaolin Gong

Authors
  1. Fengleng Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Xilin Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Huaibo Jing
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Xiaodan Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Zhaolin Gong
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Chen Deng
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Fang Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yongzhong Shuai
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Zhigang Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Hua Lai
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

FLY and ZGW participated in the conception/design. HBJ and XDW participated in the provision of study material or patients. YZS, XDW, and CD participated in the collection and/or assembly of data. FLY and YZS participated in the data analysis and interpretation. FLY and XLY participated in the manuscript writing. HL and ZGW participated in the manuscript revision. All authors contributed to final approval of manuscript.

Corresponding authors

Correspondence to Zhigang Wang or Hua Lai.

Ethics declarations

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

This study was approved by the medical ethics committee of Chengdu women’s and children’s Central Hospital [Approval number: 2021 (107)], and the written informed consent of the research subjects was also obtained.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Yang, F., Yang, X., Jing, H. et al. MRI-based scoring model to predict massive hemorrhage during dilatation and curettage in patients with cesarean scar pregnancy. Abdom Radiol 48, 3195–3206 (2023). https://doi.org/10.1007/s00261-023-03968-0

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00261-023-03968-0

Keywords

Search

Navigation