Faculty Bibliography

OBJECTIVE:To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP). METHODS: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. RESULTS: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. CONCLUSIONS: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.

Stuart Campbell was the first to use the metaphor of the parallel universes discussing the utilization of ultrasound in pregnancy.1 The controversy around the use of magnetic resonance imaging (MRI) versus sonography to diagnose cerebral malformations is just another example in this regard. In one spatio-temporal continuum fetal neurosonography allows an accurate diagnosis of central nervous system anatomy2-5 and malformations 6-9 including complex lesions such as commissural anomalies 10, 11 , posterior fossa malformations 12, 13 , disruptions 14-16 , and cortical anomalies17 ; it performs similarly to magnetic resonance in the second and third trimester18, 19 ; eventually, it allows a precise diagnosis of many malformations since the first trimester.20-22.

The increase in the cesarean delivery (CD) rate, from 5% in 1970 to 32% in 2015, has been associated with an increase in cesarean scar pregnancies (CSP) approximately 1 in 1,800-2,500 pregnancies complicated by previous cesarean deliveries (CD). There is currently no consensus on the optimal management of CSP or recurrent CSP. We describe the case of a 35-year-old G7P2042 with two prior CD and four prior CSP with positive fetal heart activity, all treated with intra-gestational injection of methotrexate, in conjunction with the practice of favoring termination of CSP. Transabdominal and transvaginal ultrasound was used to perform serial 2D and 3D renderings. A live CSP was diagnosed on initial scan at 6 4/7 weeks as a gestational sac was noted to be at the cesarean scar niche with a mostly posterior placenta previa wrapping anteriorly to the level of the bladder. By 9 4/7 weeks the placenta had multiple lacunae and hypervascularity therefore a morbidly adherent placenta (MAP) was diagnosed. A placenta percreta was diagnosed by 17 5/7 weeks. An MRI was performed at 32 2/7 weeks with an impression of placenta previa with increta. Outpatient betamethasone course was given 48 hours prior to scheduled cesarean hysterectomy at 34 0/7 weeks. The pathology confirmed a MAP, placenta percreta. The details of this case highlight that although CSP is a rare pregnancy complication of CD, its frequency is mirroring the increasing CD rates. Cases of recurrent CSP are even more infrequent, and a fifth repeat has not been previously described and adds more to the mounting data that CSP is a precursor to MAP. Additionally, this case displays how the counseling of CSP has shifted over time; indicating that patients with CSP can be offered continuation of pregnancy with understanding the maternal risks, including uterine rupture and cesarean hysterectomy for MAP.

Cesarean scar pregnancy and cervical pregnancy are 2 relatively rare types of abnormally implanted pregnancies. Both if unrecognized can result in significant morbidity to the patient. The most important issue regarding cesarean scar pregnancy and cervical pregnancy is to establish the diagnosis early in order for the patient to be adequately counseled and appropriate management carried out. For both of these conditions early detection and treatment can result in preservation of fertility.

OBJECTIVE: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). METHODS: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. RESULTS: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)). CONCLUSIONS: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.

OBJECTIVES: To elucidate if there are any ultrasound features that can be used to discriminate between benign and malignant cysts with papillary projections but no other solid components in pregnant women. METHODS: Thirty-four women with an ultrasound diagnosis of an ovarian cyst with papillary projections but no other solid components that had been surgically removed during pregnancy were identified from the databases of four ultrasound units. Some clinical and ultrasound information had been collected prospectively. Missing information was obtained retrospectively from ultrasound images, ultrasound reports and patient records. Using the prospectively and retrospectively collected data, the ultrasound appearance of the tumors was described using the terms and definitions of the International Ovarian Tumor Analysis (IOTA) group. The ultrasound characteristics were compared with the histological diagnosis. RESULTS: Nine-teen (56%) lesions were benign (16 decidualized endometriomas, one cystadenofibroma, one simple cyst, one struma ovarii), 12 (35%) borderline tumors, three (9%) primary invasive tumors (two immature teratomas, one endometroid cystadenocarcinoma). The contour of the papillations was smooth in 79% (15/19) of the benign tumors versus in 27% (4/15) of the malignant ones (P = 0.002), ground glass echogenicity of cyst fluid was present in 74% (14/19) versus in 13% (2/15) (P = 0.0005). All ovarian masses with smooth contour of the papillations and ground glass cyst content (n = 12) were decidualized endometriomas. The papillary projections were vascularized and the color score was 3 or 4 in 87% (14/16) of decidualized endometriomas versus in 41% (5/12) of borderline tumors (P = 0.017). CONCLUSIONS: During pregnancy cysts with papillations with smooth contour and ground glass echogenicity of cyst fluid on ultrasound are most likely to be decidualized endometriomas. Papillations with irregular contour and anechoic or low level echogenicity of cyst fluid suggest borderline malignancy.

BACKGROUND: The term "cesarean scar pregnancy" (CSP) refers to placental implantation within the scar of a prior cesarean delivery. The rising numbers of cesarean deliveries in the last decades have lead to an increased incidence of CSP. Complications of CSP include: morbidly adherent placenta, uterine rupture, severe hemorrhage, and preterm labor. It is suspected that CSPs implanted within a dehiscent scar ("niche") behave differently compared to those implanted on top of a well healed scar. To date there are no studies comparing pregnancy outcomes between CSPs implanted either "on the scar" or "in the niche". OBJECTIVES: To determine the pregnancy outcome of CSP implanted either "in the scar" or "in the niche". MATERIAL AND METHODS: This was a retrospective two-center study of 17 patients with CSP diagnosed between 5-9 weeks gestation (median 8 weeks). All CSPs were categorized as either implanted or "on the scar" (Group A) or "in the niche" (Group B), based on their first trimester transvaginal ultrasound examination. Clinical outcomes based on gestational age at delivery, mode of delivery, blood loss at delivery, neonate weight and placental histopathology were compared between the groups using Mann-Whitney U-test. Myometrial thickness overlying the placenta was compared between all the patients requiring hysterectomy and those who did not, using Mann-Whitney U test. Myometrial thickness was also correlated with gestational age at delivery using Spearman's correlation. RESULTS: Group A consisted of 6 patients, and 11 patients were in group B. Gestational age at delivery was lower in group B (median 34 weeks, range 20-36 weeks) than in group A (median 38 weeks , range 37-39 weeks), p=0.001. In group A, 5 patients were delivered via cesarean delivery (with normal placenta) and one underwent a cesarean-hysterectomy for placenta accreta. In group B, 10 patients had a cesarean-hysterectomy for placenta increta/percreta and one patient underwent gravid-hysterectomy for vaginal bleeding at 20 weeks. Blood loss was increased, but not significantly higher in group B (median 1200ml, 600-4000ml) than in group A (median 700ml, 600-1400ml) p=0.117. Myometrium was statistically significantly thinner in the patients group requiring hysterectomy (median 1mm, range 0-2) than in than in the group that did not (median 5mm, range 4-9mm), p=0.001. Myometrial thickness showed a positive correlation with the gestational age (r=0.820, p<0.0005). CONCLUSION: Patients with CSP implanted "on the scar" had a substantially better outcome compared to patients in which the CSP implanted "in the niche". Myometrial thickness below 2mm in the first trimester ultrasound is associated with morbidly adherent placenta at delivery.