Search Results (37)

Background and Objectives: The isthmocele is a pouch-shaped defect in the anterior uterine wall, site of a previous cesarean section, due to a scar defect or dehiscence. The prevalence could be underestimated, but the rate of cesarean section is still high in the world. The preferable technique to correct this anomaly is not clearly indicated in the literature. Our objective is to evaluate the literature on the surgical treatment of isthmocele in pre-Cesarean women treated with minimally invasive technique. Our hypothesis is that robotic treatment is more effective than other procedures in women desirous of having children. Materials and Methods: The words “isthmocele”, “laparoscopy”, “robot” and “cesarean scar pregnancy” were searched on the main online scientific search sources (PubMed, Google Scholar, Scopus, WES, and Embase, etc.). We included articles in English and French, chosen for the relevance to the topic. We have decided to include also surgical corrections of isthmocele linked to pregnancies at the site of the defect, with particular attention to video training explanation. Results: We analyzed the literature about the minimally invasive surgery for the repair of an isthmocele, evaluating 20 articles. Comparing several surgical techniques, robotic-assisted laparoscopy could be an effective method to correct the defect, without high risk of intraoperative complications. Conclusions: As indicated in the literature, robotic tailored excision and repair of isthmocele (and of concomitant cesarean scar pregnancy) could be advantageous and safe, and it is necessary to promote video-training about this technique. Full article

Background: Ectopic pregnancy (EP) is defined as the implantation of an embryo outside the uterine cavity, which can lead to high morbidity and mortality if not diagnosed and treated promptly. A rare form of EP is myomectomy scar pregnancy (MSP), where the embryo implants in a scar from a prior myomectomy. Due to its rarity, MSP presents unique diagnostic and therapeutic challenges. This scoping review aims to map the existing literature on MSP to better understand the diagnostic strategies, management options, and clinical outcomes associated with this condition, and to identify gaps in current research. Methods: We conducted a scoping review by searching databases such as PubMed, Scopus, Web of Science, and MEDLINE for studies published between 2003 and 2023. Keywords used in combination included “myomectomy scar pregnancy”, “scar pregnancy”, “leiomyoma”, “uterine myomectomy”, “PAS disorders”, “placenta previa”, and “placenta accreta”. Studies were screened for relevance and eligibility by two independent reviewers. Data were extracted from case reports, retrospective studies, and reviews discussing MSP. Results: From an initial set of 111 studies, 28 papers met the inclusion criteria, comprising 4 retrospective studies and 24 case reports. A total of 44 cases of MSP were analyzed. The majority of diagnoses were made through ultrasound, with magnetic resonance imaging (MRI) used in more complex cases. Surgical interventions, primarily cesarean sections and myometrial repairs, were the most common treatments, while medical therapy with methotrexate was less frequently applied. Conclusions: This scoping review highlights the challenges of diagnosing and managing MSP due to its rarity. Although surgical management remains the primary approach, there is a lack of consensus on the optimal treatment for different clinical scenarios. Further research is needed to establish standardized diagnostic and therapeutic protocols for MSP and to evaluate the long-term outcomes of affected patients. Full article

Background/Objectives: Cesarean scar pregnancy (CSP) refers to a pregnancy implanted on or within a scar from a previous cesarean birth. This study aims to evaluate the treatment strategies for CSP conducted at a single center and analyze the predictive markers of a single procedure without complications. Methods: A retrospective study was performed on CSP patients who received treatment at Korea University Ansan Hospital from November 2002 to December 2022. The clinical characteristics of CSP and the occurrence of complications based on treatment methods were investigated. Results: A total of 128 patients were included in the study. Among them, 84 patients (65.6%) underwent dilatation and curettage (D&C) only, 12 patients (9.4%) received a combination of methotrexate and D&C, 21 received D&C with Foley catheter ballooning (15.7%), and 11 patients (9%) underwent invasive procedures such as uterine artery embolization, hysterectomy, and open resection. As gestational age increased, the likelihood of opting for invasive procedures (aOR = 3.52, 95% CI 1.74–10.14, p = 0.003) also increased. A total of 84 patients (65.6%) were successfully treated with D&C without transfusion, and it was found that early gestational age and sonographic hypervascularity played a significant role. Conclusions: Early gestational age, younger maternal age, and sonographic hypervascularity were independently associated with favorable treatment without adjuvant therapy and transfusion. Therefore, for a safe and bloodless approach to treatment in cases of CSP, it is advisable to promptly diagnose this condition as early as possible. Full article

Background/Objectives: To assess the effectiveness of the levonorgestrel-releasing intrauterine device (LNG-IUD) compared to hysteroscopic resection for managing women with symptomatic cesarean scar defects (CSDs). Methods: This systematic review and meta-analysis followed PRISMA guidelines. A comprehensive search of four electronic databases was conducted to identify studies comparing LNG-IUD with hysteroscopic management for symptomatic CSDs. Studies reporting outcomes of bleeding and spotting days and effectiveness rates were included. Quality assessment was performed using the ROBINS-I and RoB-2 tools. Results: Three studies involving 344 patients met the inclusion criteria. At 6 months, LNG-IUD use significantly reduced total bleeding days (MD −4.13; 95% CI: −5.17 to −3.09; p < 0.00001) and spotting days (MD 1.90; 95% CI: 0.43 to 3.37; p = 0.01) compared to hysteroscopic treatment. By 12 months, LNG-IUD demonstrated superior effectiveness (OR 3.46; 95% CI: 1.53 to 7.80; p = 0.003), with fewer total bleeding days (MD −5.69; 95% CI: −6.55 to −4.83; p < 0.00001) and spotting days (MD 3.09; 95% CI: 1.49 to 4.69; p = 0.0002). Approximately 50% of LNG-IUD users experienced amenorrhea within 1 year. Conclusions: LNG-IUD offers a minimally invasive and effective alternative to hysteroscopic resection for women with symptomatic CSD and no desire for future pregnancies. Its role should be considered in clinical practice, but further research is needed to validate these findings and define its long-term benefits and limitations. Full article

Background and Objectives: Caesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy in which the early pregnancy implants at the site of the uterine scar. Methotrexate (MTX) in lower doses can be used to treat CSPs. However, MTX administration is associated with a spectrum of side effects that include hematological toxicities. This case report presents a CSP treated with an intragestational injection of MTX and subsequently developed pancytopenia. Materials and Methods: A 23-year-old woman at six weeks and six days of pregnancy was referred as a potential case of CSP. After establishing the diagnosis, she was treated with a transvaginal ultrasound-guided intragestational administration of 80 mg MTX (adjusted to 50 mg/m² body surface area) under sedation. Results: On day four after the MTX injection, she developed oral ulcers, fever, and pruritic phlyctenular maculopapular rash. Subsequently, the patient developed febrile neutropenia and was admitted to the Intensive Care Unit. On day six, a subsequent exacerbation of the rash was observed with the formation of blisters and purplish spots with concurrent odynophagia and sialorrhea. Ultimately, the patient developed pancytopenia due to bone marrow suppression. Fifteen days after MTX administration, the patient recovered and was discharged from the hospital hemodynamically stable, afebrile, with dropping β-hcg levels, and in good clinical condition. Conclusions: Although methotrexate administration is the preferred option for the treatment of cesarean scar pregnancies, clinicians should be aware of the fact that its use entails potential risks, even when it is used locally. To our knowledge, this case is the first description of pancytopenia due to bone marrow suppression following a single low dose of intragestational methotrexate injection. Full article

A cesarean scar ectopic pregnancy (CSP) represents an uncommon yet potentially life-threatening condition requiring immediate and efficient management. We present a case of a 32-year-old woman diagnosed with a scar pregnancy at 8 weeks of gestation. Laparoscopic surgical management was chosen due to its minimally invasive nature and potential for preserving fertility. During the procedure, temporary clipping of uterine arteries was employed to control intraoperative bleeding. The patient recovered well postoperatively with no complications. This case highlights the feasibility and effectiveness of laparoscopic intervention combined with temporary uterine artery clipping in the management of scar pregnancies, offering a valuable approach for clinicians faced with similar cases. Through this report, we aim to contribute to the existing literature on the optimal management of CSP and highlight the efficacy of laparoscopic surgery in this context. Full article

Isthmocele is a gynecological condition characterized by a disruption in the uterine scar, often associated with prior cesarean sections. This anatomical anomaly can be attributed to inadequate or insufficient healing of the uterine wall following a cesarean incision. It appears that isthmocele may impact a woman’s quality of life as well as her reproductive capacity. The incidence of isthmocele can range from 20% to 70% in women who have undergone a cesarean section. This review aims to sum up the current knowledge about the effect of isthmocele on fertility and the possible therapeutic strategies to achieve pregnancy. However, currently, there is not sufficiently robust evidence to indicate the need for surgical correction in all asymptomatic patients seeking fertility. In cases where surgical correction of isthmocele is deemed necessary, it is advisable to evaluate residual myometrial thickness (RMT). For patients with RMT >2.5–3 mm, hysteroscopy appears to be the technique of choice. In cases where the residual tissue is lower, recourse to laparotomic, laparoscopic, or vaginal approaches is warranted. Full article

Background and Objectives: Our report contributes a unique case of a non-neural GCT occurring in an unusual location, with its development during pregnancy adding to its rarity. Materials and Methods: Granular cell tumors (GCTs), also known as Abrikossoff’s tumors, are rare neoplasms of Schwann cell origin with predominantly benign behavior. We present a case of a 29-year-old female with a non-neural variant of a GCT discovered incidentally during a cesarean section, situated on the posterior surface of the rectus abdominis muscle. Results: Histologically, the tumor exhibited features consistent with a benign non-neural GCT, confirmed through an immunohistochemical analysis. Despite the atypical presentation and challenging surgical removal due to prior scarring, the patient experienced no postoperative complications and showed no signs of recurrence during follow-up. Conclusions: This case highlights the importance of considering GCTs in differential diagnoses, particularly in unusual anatomical locations, and underscores the favorable prognosis associated with timely surgical intervention. Full article

Background: The greatest risk for the occurrence of the placenta accreta spectrum (PAS) is represented by uterine scars, which most frequently result after cesarean sections. Uterine rupture is a rare condition and appears mainly in the third trimester of pregnancy. The association between these two conditions is extremely rare in the first trimester of pregnancy. Methods: We performed a systematic review of abnormal placental adhesions and spontaneous uterine ruptures in the first trimester of pregnancy. We also reported a case of spontaneous uterine rupture in a 12-week pregnancy that presented with massive hemoperitoneum and hemorrhagic shock. Results: A 33-year-old patient with two previous cesarean sections, at the twelfth week of pregnancy at the time to this visit to the emergency room, presented with syncope and intense pelvic–abdominal pain. A clinical examination and ultrasound scan established the diagnosis of hemoperitoneum and hemorrhagic shock. Surgical exploration was performed, uterine rupture was identified, and hemostasis hysterectomy was necessary. The histopathological results showed placenta percreta. There have been eight reported cases of spontaneous uterine rupture in the first trimester of pregnancy associated with PAS. In these cases, it was found that 62.5% of the patients had undergone at least one cesarean section in the past; in 75% of the cases, hysterectomy was performed; and, in 87.5% of the cases, the presence of placenta percreta was confirmed. Conclusions: A high rate of cesarean sections determines the increase in the incidence of placenta accreta spectrum disorders. The possible life-threatening complications caused by this pathology can be observed in early pregnancies. Full article

Background and Objectives: Cesarean scar pregnancy (CSP) represents a type of ectopic pregnancy in which the embryo implants inside the scar of a previous cesarean section. This condition can lead to maternal morbidity and mortality. The best therapeutic approach in terms of clinical effectiveness and patient safety for CSP has not been described yet, although different therapeutic strategies are currently available. The purpose of the present study was to analyze the success rate of two different treatments in a single institution. Materials and Methods: A retrospective study was performed among patients diagnosed with CSP at the Gynecology and Obstetrics Department of the “Cannizzaro” Hospital in Catania (University of Enna—Italy) from January 2016 to December 2022. The diagnosis was made by 2D/3D transvaginal ultrasound, following Timor-Tritsch criteria. Two treatment strategies were performed: local and systemic methotrexate (MTX) injection and uterine artery embolization (UAE) with subsequent dilatation and curettage (D&C). All treated women underwent subsequent clinical and sonographic follow-up. Complete recovery was defined as the reduction of β-HCG values until it was undetectable and the disappearance of the mass in the uterine scar on ultrasound. Results: Nineteen patients were included; nine were in the MTX group and ten were in the UAE + D&C group. No significant differences were found between the two groups in terms of clinical parameters. Treatment was successful in 4 of 10 (44%) patients in the MTX group and 10 of 10 (100%) in the UAE + D&C group (p = 0.01); the length of hospital stay was significantly shorter in the latter group (p < 0.0001). Conclusions: In our experience, administration of MTX is not recommended as the primary treatment or pre-treatment. Dilatation and curettage after uterine artery embolization are better than methotrexate injection for the treatment of cesarean scar pregnancy in a single-institution series in terms of complete recovery and length of hospital stay. Full article

A standardized consensus for the management of cesarean scar pregnancy (CSP) is lacking. The study objective is to evaluate the efficacy, safety and outcomes of the laparoscopic management of CSP as a single therapeutic surgical approach without being preceded by vascular pretreatment or vasoconstrictors injection. This is a retrospective bi-centric study, a case series. Eight patients with a future desire to conceive underwent the laparoscopic treatment of unruptured CSPs. Surgery consisted of “en bloc” excision of the deficient uterine scar with the adherent tissue of conception, followed by immediate uterine repair. The data collected for each patient was age, gestity, parity, number of previous c-sections, pre-pregnancy isthmocele-related symptoms, gestational age, fetal cardiac activity, initial β-human chorionic gonadotropin levels, intra-operative blood loss, blood transfusion, operative time and the postoperative complications, evaluated according to Clavien–Dindo classification. The CSP was successfully removed in all patients by laparoscopy. The surgical outcomes were favorable. All patients with histories of isthmocele-related symptoms reported postoperative resolution of symptoms. The median residual myometrium thickness increased significantly from 1.2 mm pre-operatively to 8 mm 3 to 6 months after surgery. The laparoscopic management seems to be an appropriate treatment of CSP when performed by skilled laparoscopic surgeons. It can be safely proposed as a single surgical therapeutic approach. Larger series and further prospective studies are needed to confirm this observation and to affirm the long-term gynecological and obstetrical outcomes of this management. Full article

Cesarean scar pregnancies (CSPs) are a type of ectopic pregnancy that occur when an embryo implants within the fibrous scar tissue of a previous cesarean surgery. If not promptly detected and treated, CSPs can result in serious maternal complications, such as uterine rupture and hemorrhage. TVUS (transvaginal ultrasonography) represents the imaging of choice for the diagnosis of CSPs; however, recent studies proposed a complementary role of MRI due to its capability in soft tissue characterization that may impact the therapeutical decision-making process. The purpose of our study was to explore the role of MRI in the diagnosis and its impact on therapeutical options in CSPs. Our experience showed that MRI has a complementary role to TVSU in correctly diagnosing CSPs, identifying the type, and guiding the therapeutical approach. Full article

A cesarean scar pregnancy is a rare type of ectopic pregnancy that occurs when a fertilized egg implants in the scar from a previous cesarean section. It is a serious condition that can lead to significant morbidity and mortality if not managed promptly and appropriately. In this literature review and case report, we discuss the etiology, diagnosis, and management of cesarean scar pregnancy. We conducted a comprehensive search of relevant literature using electronic databases and included studies that reported on the diagnosis and management of cesarean scar pregnancy. We also present a case report of a patient with cesarean scar pregnancy who was managed surgically. The diagnosis of cesarean scar pregnancy is primarily done via transvaginal or transabdominal ultrasound, and medical or surgical management can be used depending on the gestational age, hemodynamic status, and patient preferences. The surgical approach, which involves hysteroscopy, laparoscopy, or laparotomy, is usually preferred, since it is associated with fast recovery and lower recurrence rates. However, it is crucial to consider the patient’s plans for future fertility when selecting the management approach. In conclusion, cesarean scar pregnancy is a rare but potentially life-threatening condition that requires prompt and appropriate management. Early diagnosis and treatment can prevent significant morbidity and mortality, and surgical management is usually preferred due to its higher success rates and lower recurrence rates. Full article

We have suggested that adipocytes in uterine scars may affect the development of the placenta accrete spectrum (PAS). In the experimental part, we explored adipocytes in the uterine wall by the twelfth sexual cycle after surgery. In the clinical part, we investigated adipocyte clusters in the cesarean scar of pregnant women with and without PAS. The uterine wall was evaluated in gross and histological sections using morphometry, histochemistry (hematoxylin and eosin stain, Mallory stain), and immunohistochemistry for FABP4 (adipocyte markers), CD68, CD163, CD206 (macrophages), CD 34 (endothelium), cytokeratin 8 (epithelium), aSMA (smooth muscle cells). The design included an experimental study on Sprague–Dawley rats (n = 18) after a full-thickness surgical incision on the seventh (n = 6), 30th (n = 6), and 60th day (n = 6). The clinical groups include pregnant women without uterine scars (n = 10), pregnant women with a uterine scar after previous cesarean sections (n = 10), and women with PAS (n = 11). Statistical processing was carried out using nonparametric methods. Comparisons were conducted using the Mann–Whitney U-test and Kruskal–Wallis test. Statistical significance was considered at p < 0.05. On the seventh day, the rat uterine horn was enveloped by adipose tissue, which contained crown-like structures with FABP4+, CD68+, CD206+, and CD163+ cells. FABP4+ cells in the uterine wall were absent by the 30th day. The number of CD206+ and CD163+ cells in the adipose tissue decreased by the 30th day. On the 60th day, the attachment of fat tissue was revealed in the form of single strands. The serous layer around the damaged area totally recovered on the 60th day. FABP4+ cells were not detected in the uterine wall samples from pregnant women without a previous cesarean section. Adipocytes were found in the scar during non-complicated pregnancy and with PAS. Reducing the number of CD68+ cells in adipocyte clusters, there were in myometrium with PAS. Increased CD206+ and CD163+ cells were revealed in uterine adipocyte clusters of the group. According to the experimental finding, adipocytes should be absent in the uterine wall by the 12th sexual cycle after a full-thickness surgical incision. The presence of adipocyte clusters in cesarean scar indicated the disturbance of cell interaction. Differences in the numbers of CD206 and CD163 cells in adipocyte clusters between groups with and without PAS may be indirect evidence that uterine adipocytes affect the development of PAS. Full article