Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta-analysis.

To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP). An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for 'Cesarean scar pregnancy' and 'outcome'. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: severe first-trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first- or second-trimester uterine rupture or hysterectomy; third-trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta-analyses of proportions using a random-effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis. A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8-26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1-37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9-20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6-32.8%) of all cases. Forty (76.9% (95% CI, 65.4-86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4-66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0-92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two-thirds (69.7% (95% CI, 42.8-90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4-87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9-52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7-30.3%) of cases, but hysterectomy was not required in any case. CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Calì G ，Timor-Tritsch IE ，Palacios-Jaraquemada J ，Monteaugudo A ，Buca D ，Forlani F ，Familiari A ，Scambia G ，Acharya G ，D'Antonio F ... -  《-》

[Expectant management of 11 cases of cesarean scar pregnancy].

He F ，Li JQ ，Tang XL ，Lin Y ，Su CH ，Chen DJ ... -  《-》

First-trimester prediction of surgical outcome in abnormally invasive placenta using the cross-over sign.

Ultrasound assessment of the relationship between the ectopic gestational sac and the endometrial line (cross-over sign; COS) in Cesarean scar pregnancy (CSP) has been shown to be useful in predicting the evolution of CSP towards different types of abnormally invasive placenta (AIP). The aim of this study was to ascertain whether the COS can be used to predict surgical outcome in women with AIP. A retrospective analysis was performed of early first-trimester (6-8 weeks' gestation) ultrasound images of women with AIP managed in the third trimester of pregnancy. We hypothesized that assessment of COS may identify cases of AIP at higher risk of intra- or postsurgical morbidity. Outcomes explored were estimated blood loss during surgery, need for and amount of packed red blood cells and fresh frozen plasma units required either during or after surgery, operative time, intrasurgical complications, gestational age at birth, delivery < 34 weeks of gestation, length of hospital stay and admission to intensive care unit. Differences in the explored outcomes were assessed among women with different types of COS variant (COS-1, COS-2+ or COS-2-) as observed on first-trimester ultrasound examination. Sixty-eight pregnancies were included in the study. Mean estimated blood loss was higher in AIP pregnancies with COS-1 than in those with COS-2+ (P = 0.039) or COS-2- (P = 0.01). Mean number of packed red blood cell units required during or after the operation was higher in women with COS-1 compared with those with COS-2+ (P = 0.001) and COS-2- (P = 0.029), while there was no difference between pregnancies with COS-2+ and those with COS-2- (P = 0.797). Mean operative time was longer in AIP pregnancies with COS-1 than in those with COS-2+ (P = 0.039) or COS-2- (P = 0.017). Finally, pregnancies with COS-1 were delivered earlier than those with COS-2+ (P = 0.0001) or COS-2- (P = 0.0001). First-trimester ultrasound assessment of the relationship between the ectopic gestational sac and the endometrial line (COS) may identify women with AIP who are at higher risk of intra- or postsurgical morbidity. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Calì G ，Forlani F ，Minneci G ，Foti F ，Di Liberto S ，Familiari A ，Scambia G ，D'Antonio F ... -  《-》

Outcome of cesarean scar pregnancy according to gestational age at diagnosis: A systematic review and meta-analysis.

The association between the most severe types of placenta accreta spectrum disorders and caesarean scar pregnancy (CSP) poses the question of whether early diagnosis may impact the clinical outcome of these anomalies. The aim of this study is to report the outcome of cesarean scar pregnancy (CSP) diagnosed in the early (≤9 weeks) versus late (>9 weeks) first trimester of pregnancy. Medline, Embase and Clinicaltrail.gov databases were searched. Studies including cases of CSP with an early (≤9 weeks of gestation) compared to a late (>9 weeks) first trimester diagnosis of CSP, followed by immediate treatment, were included in this systematic review. The primary outcome was a composite measure of severe maternal morbidity including either severe first trimester bleeding, need for blood transfusion, uterine rupture or emergency hysterectomy. The secondary outcomes were the individual components of the primary outcome. Random-effect meta-analyses were used to combine data. Thirty-six studies (724 women with CSP) were included. Overall, composite adverse outcome complicated 5.9 % (95 % CI 3.5-9.0) of CSP diagnosed ≤9 weeks and 32.4 % (95 % CI 15.7-51.8) of those diagnosed >9 weeks. Massive hemorrhage occurred in 4.3 % (95 % CI 2.3-7.0) of women with early and in 28.0 % (95 % CI 14.1-44.5) of those with late first trimester diagnosis of CSP, while the corresponding figures for the need for blood transfusion were 1.5 % (95 % CI 0.6-2.8) and 15.8 % (95 % CI 5.5-30.2) respectively. Uterine rupture occurred in 2.5 % (95 % CI 1.2-4.1) of women with a prenatal diagnosis of CSP ≤ 9 weeks and in 7.5 % (95 % CI 2.5-14.9) of those with CSP > 9 weeks, while an emergency intervention involving hysterectomy was required in 3.7 % (95 % CI 2.2-5.4) and 16.3 % (95 % CI5.9-30.6) respectively. When computing the risk, early diagnosis of CSP was associated with a significantly lower risk of composite adverse outcome, (OR: 0.14; 95 % CI 0.1-0.4 p < 0.001). Early first trimester diagnosis of CSP is associated with a significantly lower risk of maternal complications, thus supporting a policy of universal screening for these anomalies in women with a prior cesarean delivery although the cost-effectiveness of such policy should be tested in future studies.

Timor-Tritsch I ，Buca D ，Di Mascio D ，Cali G ，D'Amico A ，Monteagudo A ，Tinari S ，Morlando M ，Nappi L ，Greco P ，Rizzo G ，Liberati M ，Jose-Palacios-Jaraquemada ，D'Antonio F ... -  《-》

Natural history of Cesarean scar pregnancy on prenatal ultrasound: the crossover sign.

Advances in prenatal imaging techniques have led to an increase in the diagnosis of Cesarean scar pregnancy (CSP). However, antenatal counseling when CSP is diagnosed is challenging, and current evidence is derived mainly from small series reporting high rates of adverse maternal outcomes. The aim of this study was to ascertain the performance of prenatal ultrasound in predicting the natural history of CSP using a new sonographic sign, the crossover sign (COS). This was a retrospective analysis of early first-trimester (6-8 weeks' gestation) ultrasound images in women with morbidly adherent placenta (MAP) managed in the third trimester of pregnancy. The relationship between the gestational sac of the CSP, anterior uterine wall and Cesarean scar, defined as the COS, was analyzed to determine whether it could predict evolution in these cases. Odds ratios (ORs) were calculated and logistic regression analysis was performed to investigate the association between different types of COS (COS-1, COS-2+ or COS-2-) and the occurrence of MAP. Sixty-eight pregnancies with MAP were included. The risk of placenta percreta was significantly higher in pregnancies with COS-1 than in those with COS-2 (OR, 6.67 (95% CI, 1.3-33.3)). When evaluating the two variants of COS-2 separately, the risk of placenta percreta was significantly higher in pregnancies with COS-1 vs COS-2+ (OR, 5.83 (95% CI, 1.1-30.2)) and this risk was even higher when comparing cases with COS-1 vs COS-2- (OR, 12.0 (95% CI, 1.9-75.7)). Logistic regression analysis showed that COS-1 was associated independently with severe forms of MAP, such as placenta percreta and increta (OR, 12.85 (95% CI, 2.0-84.0)), while COS-2+ was associated independently with placenta accreta (OR, 4.37 (95% CI, 1.1-17.0)). Ultrasound assessment of the relationship between the gestational sac of a CSP and the endometrial line (the COS) may help to determine whether a CSP will progress towards a less severe form of MAP, amenable to postnatal treatment, and successful pregnancy outcome. Large prospective studies are needed to confirm our findings and elucidate the natural history of this condition. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Cali G ，Forlani F ，Timor-Tritsch IE ，Palacios-Jaraquemada J ，Minneci G ，D'Antonio F ... -  《-》