Embarazo ectópico en cicatriz de cesárea: reporte de caso y revisión de la literatura. Hospital Simón Bolívar subred norte Bogotá, Colombia / Ectopic pregnancy in cesarean section scar: case report and literature review. Hospital Simón Bolívar Subred Norte, Bogota, Colombia / Gravidez ectópica em cicatriz de cesárea: relato de caso e revisão da literatura. Hospital Simón Bolívar, subrede norte Bogotá, Colômbia

Resumen: El embarazo ectópico se define como la Implantación del saco gestaclonal fuera del útero y representa el 3 % de todos los embarazos. La ubicación anatómica más frecuente es en la trompa uterina, en donde se presenta en un 95 %, dejando así un 5 % a otras localizaciones como el ovario, la cavidad abdominal, cervlcouterina y cicatriz uterina previa. El caso es relevante por su baja prevalencia y por los hallazgos ecográficos, las posibles opciones terapéuticas para la paciente y los hallazgos intraoperatorios. Se realizó una revisión de la literatura, utilizando bases de datos como PubMed, Medline y Science Direct, con el fin de evaluar y analizar el estado del arte de esta condición patológica. Presentamos el caso de una paciente con un embarazo de 7 semanas localizado a nivel ístmico cervical por ecografía, inicialmente tratada de manera conservadora con Metotrexato (MTX) sistémico, sin respuesta al tratamiento, por lo cual requirió intervención quirúrgica y preservación de la fertilidad. Se realiza una revisión actualizada del tema con los diferentes enfoques terapéuticos.

Abstract: Ectopic pregnancy is defined as the implantation of the gestational sac outside the uterus and it represents 3% of all pregnancies. The most frequent anatomical location is in the uterine tube, where it occurs in 95% of the cases, thus leaving 5% to other locations such as the ovary, the abdominal cavity, the cervix and a previous uterine scar. The case is relevant because of its low prevalence and because of the ultrasound findings, the possible therapeutic options for the patient, and the intraoperative findings. A literature review was carried out, using databases such as PubMed, Medline and Science Direct, in order to evaluate and analyze the state of the art of this pathological condition. Here, we present the case of a patient with a 7-week pregnancy located at the cervical isthmus level by ultrasound, initially treated conservatively with systemic Methotrexate (MTX), with no response to the treatment, and therefore she required surgical intervention and preservation of fertility. An updated review of the subject is carried out with the different therapeutic approaches.

Resumo: A gravidez ectópica é definida como a Implantação do saco gestaclonal fora do útero e representa 3 % de todas as gestações. A localização anatómica mais frequente é na trompa uterina, onde é apresentada em 95 %, deixando assim 5 % a outras localizações, como ovário, cavidade abdominal, cervicouterina e cicatriz uterina prévia. O caso é relevante por sua baixa prevalência e pelos achados ecográficos, as possíveis opções terapêuticas para a paciente e os achados intraope-ratórios. Foi realizada uma revisão da literatura com a utilização de bases de dados como PubMed, Medline e Science Direct, a fim de avaliar e analisar o estado da arte dessa condição patológica. Apresentamos o caso de uma paciente com uma gravidez de sete semanas localizada no nível Istmo cervical por ecografia, inicialmente tratada de maneira conservadora com metotrexato (MTX) sistémico, sem resposta ao tratamento, razão pela qual requiriu intervenção cirúrgica e preservação da fertilidade. Foi realizada uma revisão atualizada do tema com diferentes abordagens terapêuticas.

Embarazo ectópico en cicatriz de cesárea previa, enfoque terapéutico y revisión de la literatura / Ectopic Pregnancy in Previous Cesarean Section Scar Therapeutic Approach and Literature Review

RESUMEN Introducción: El embarazo ectópico en cicatriz de cesárea previa es una forma novedosa y potencialmente mortal de implantación anormal de un saco gestacional dentro del miometrio y el tejido fibroso de la cicatriz. Se desconoce la historia natural de esta condición para lo cual no existe consenso en su manejo. Presentación de caso: Se presenta un caso que se manejó quirúrgicamente de forma conservadora por minilaparotomía, evacuación del tejido trofoblástico, lográndose preservar el útero. Con edad gestacional de 10 semanas, se aplicó metrotexate localmente e intramuscular. La paciente evolucionó satisfactoriamente hacia la mejoría siendo dada de alta. Métodos: Se realiza una revisión bibliográfica en bases de datos Pub Med y Science Direct con las palabras claves obtenidas del MeSH: "Scar ectopic pregnancy" durante los años 2000 y 2018. Se presentan las alternativas de manejo, tanto médico como quirúrgico, sin embargo, ello estará sujeto a las condiciones de la paciente y a la experiencia del médico tratante(AU)

ABSTRACT Introduction: Ectopic pregnancy in a previous caesarean section is a novel and life-threatening form of abnormal implantation of a gestational sac within the myometrium and the fibrous tissue of the scar. The natural history of this condition is unknown, thus there is no consensus in its management. Case report: We report a case that was surgically managed in conservative way by minilaparotomy, trophoblastic tissue evacuation. The uterus was preserved. The gestational age was 10 weeks. Metrotexate was applied locally and intramuscularly. The patient evolved satisfactorily towards improvement and discharge. Methods: A literature review during the years 2000 and 2018 was carried out in Pub Med and Science Direct databases. The keywords from MeSH used were "Scar ectopic pregnancy". Both medical and surgical management alternatives are presented, however the patient condition and the experience of the attending physician will contribute as well(AU)

Isthmocele: from risk factors to management / Istmocele: de fatores de risco ao manejo

Abstract Objective The aim of the present study was to perform a comprehensive review of the literature to provide a complete and clear picture of isthmocele-a hypoechoic area within themyometriumat the site of the uterine scar of a previous cesarean section-by exploring in depth every aspect of this condition. Methods A comprehensive review of the literature was performed to identify the most relevant studies about this topic. Results Every aspect of isthmocele has been studied and described: pathophysiology, clinical symptoms, classification, and diagnosis. Its treatment, both medical and surgical, has also been reported according to the actual literature data. Conclusion Cesarean section is the most common surgical procedure performed worldwide, and one of the consequences of this technique is isthmocele. A single and systematic classification of isthmocele is needed to improve its diagnosis and management. Further studies should be performed to better understand its pathogenesis.

Resumo Objetivo O objetivo do presente estudo foi realizar uma revisão abrangente da literatura a fim de fornecer um quadro completo e claro da istmocele-uma área hipoecoica dentro domiométrio no local da cicatriz uterina de uma cesariana anterior- aprofundando todos os aspectos desta condição Métodos Uma revisão abrangente da literatura foi realizada para identificar os estudos mais relevantes sobre este tema. Resultados Todos os aspectos da istmocele foram estudados e descritos: fisiopatologia, sintomas clínicos, classificação e diagnóstico. Os tratamentos médico e cirúrgico também foram relatados de acordo com os dados reais da literatura. Conclusão A cesárea é o procedimento cirúrgico mais comum realizado em todo o mundo, e uma das consequências desta técnica é a istmocele. Uma classificação única e sistemática da istmocele é necessária para melhorar seu diagnóstico e manejo. Novos estudos devem ser realizados para melhor entender sua patogênese.

Evaluation of Cases of Abdominal Wall Endometriosis at Universidade Estadual de Campinas in a period of 10 Years / Avaliação dos casos de endometriose de parede abdominal na Universidade Estadual de Campinas em um período de 10 anos

Abstract Purpose To determine the clinical and epidemiological characteristics of abdominal wall endometriosis (AWE), as well as the rate and recurrence factors for the disease. Methods A retrospective study of 52 women with AWE was performed at Universidade Estadual de Campinas from 2004 to 2014. Of the 231 surgeries performed for the diagnosis of endometriosis, 52 women were found to have abdominal wall endometriosis (AWE). The frequencies, means and standard deviations of the clinical characteristics of these women were calculated, as well as the recurrence rate of AWE. To determine the risk factors for disease recurrence, Fisher's exact test was used. Results The mean age of the patients was 30.71 ± 5.91 years. The main clinical manifestations were pain (98%) and sensation of a mass (36.5%).We observed that 94% of these women had undergone at least 1 cesarean section, and 73% had used medication for the postoperative control of endometriosis. The lesion was most commonly located in the cesarean section scar (65%). The recurrence rate of the disease was of 26.9%. All 14 women who had relapsed had surgical margins compromised in the previous surgery. There was no correlation between recurrent AWE and a previous cesarean section (p = 0.18), previous laparotomy (p = 0.11), previous laparoscopy (p = 0.12) and postoperative hormone therapy (p = 0.51). Conclusion Women with previous cesarean sections with local pain or lumps should be investigated for AWE. The recurrence of AWE is high, especially when the first surgery is not appropriate and leaves compromised surgical margins.

Resumo Objetivos Determinar as características clínicas e epidemiológicas da endometriose de parede, bem como sua taxa de recorrência e os fatores que levam a ela. Métodos Estudo retrospectivo, em que se avaliaram 52 mulheres com endometriose de parede na Universidade Estadual de Campinas no período de 2004 a 2014. Entre as 231 cirurgias para diagnosticar endometriose, foram encontradas 52 mulheres que apresentavam endometriose de parede. Foram calculadas as frequências, a média e o desvio padrão das características clínicas destas mulheres, bem como a taxa de recorrência da endometriose de parede. Para determinar os fatores de risco de recorrência, foi utilizado o teste exato de Fisher. Resultados A idade média das mulheres foi de 30.71 ± 5,91 anos. As principais manifestações clínicas foram dor (98%) e sensação do nódulo (36,5%). Foi observado que 94% dessas mulheres tinham pelo menos uma cesárea, e 73% destas fizeram uso de medicação para controle da endometriose no pós-operatório. A localizaçãomais frequente da lesão foi na cicatriz da cesárea (65%). A taxa de recorrência da doença foi de 26,9%. Todas as 14mulheres que tiveramrecidiva tinhammargens cirúrgicas comprometidas na cirurgia prévia. Não houve correlação entre a endometriose de parede recorrente e a cesariana prévia (p = 0,18), a laparotomia prévia (p = 0,11), a laparoscopia prévia (p = 0,12) e receber terapia hormonal no pós-operatório (p = 0,51). Conclusão Mulheres com antecedente de cesárea anterior com dor local ou nódulo devem ser investigadas com relação à endometriose de parede. A recorrência do endometrioma de parede é alta, principalmente quando a primeira cirurgia não é adequada, e deixa margens cirúrgicas comprometidas.

Clinical effect of hysteroscopic scar defect orthopedic surgery on cicatrical scar of uterine incision / 中国综合临床

Objective To explore the clinical effect of hysteroscopic scar defect correction in the treatment of cesarean scar.Methods Eighty-four cases patients with cesarean section uterine incision scars who were treated in Affiliated Hospital of Hubei Polytechnic University from August 2015 to July 2016 were selected and randomly divided into observation group with hysteroscopic surgery and control group with vaginal surgery,42 cases in each group.The operation condition,clinical efficacy and the incidence of complications of the two groups were observed and compared.Results The amomt of blood loss,hospitalization expenses,hospitalization time and operation time in the observation group were (22.45±3.78) ml,(3028.89±218.79) yuan,(3.89 ±0.80) d,(20.13±2.90) min respectively,in the control group were (40.56±5.48) ml,(4189.58±269.78)yuan,(5.46 ± 1.02) d,(30.78 ± 6.99) min respectively,the differences were significant (P ＞ 0.05).The incidence of infection,relapse and incisional wound healing in the observation group were significantly lower than in the control group,the differences were significant (P＜0.05).The total effective rate was 90.48％ in the observation group and 85.71％ in the control group after treatment,the difference was not significant(P ＞0.05).Conclusion Hysteroscopic scar repair has the same effect as that of vaginal surgery,but the rate of blood loss and complication is lower than that of vaginal operation,which is safer and more effective.

The Analysis of Ultrasonic Classification and Treatment Effect for Cesarean Scared Pregnancy / 实用妇产科杂志

Objective:To explore the ultrasonic classification in cesarean scared pregnancy (CSP)and its effect on guiding the clinical treatment.Methods:The clinical data of 41 patients with CSP in the Third people's hospital of Chengdu from January 2013 to January 2016 were analyzed retrospectively.Diagnosis was confirmed according to the diagnostic criteria for ultrasound imaging by Godin etal and the history of cesarean section.Patients were divided into type Ⅰ group and type Ⅱ group through measuring the outside uterine muscle layer thickness of pregnant bursa,based on the criteria by Vial et al.Type Ⅰ:MTX intramuscular injection followed by ultrasound guided Dilation and Curettage(D&C)3 days later.Type Ⅱ]:Uterine artery chemo-embolization (UACE)followed by ultrasound guided D&C 2 days later,or lesion resection and repair of the uterus by trans-abdominal or laparoscopic or trans-vaginal operations 2 days later.Results:The outside uterine muscle layer of pregnant bursa in type Ⅱ] was more thinner than that in type Ⅰ (2.1 ± 1.1 mm vs 3.7 ±0.6 mm,P ＜ 0.05).The number of abortion in type Ⅱ was more than that in type Ⅰ (2.8 ± 0.7 vs 1.5 ± 0.6,P ＜ 0.05).There were no statistically significant differences in age,amenorrhea duration and the number of cesarean section (P ＞ 0.05).Patients from two group were treated successfully,and there was no statistical significance about,intraoperative bleeding volume,preoperative serum levels of β-HCG and average recovery time of serum β-HCG(P＞0.05).The average hospital stays and cost in type Ⅰ were less than that in type Ⅱ,with statistical significance (4.7 ± 2.5 vs 8.6 ± 2.7 days,5234.6 ± 1688.8 vs 15668.4 ±4623.4 RMB,P ＜ 0.05).Conclusions:The ultrasonic classification of CSP plays a directive role in making treatment option,with reliabe effect and the good prognosis.UACE as a pretreatment which can control intraoperative bleeding,is an effective method for CSP.For its higher cost,UACE should be selectively used in type Ⅱ[CSP,with cost-effective.MTX intramuscular injection used in type Ⅰ CSP before D&C is reliable and cost-effective.

Research on color doppler ultrasound in the diagnosis of cesarean scar pregnancy / 中国医学装备

Objective:To evaluate color doppler ultrasound diagnosis value of cesarean scar pregnancy.Methods: Using color doppler ultrasound probe belly and vaginal probe, faceted searches in patients with suspected scar pregnancy, observe suspicious gestational sac or clutter echo of the location, size, shape, and presence of complications, and radiography, video records, follow-up.Results: The abdominal and vaginal color to exceed cesarean scar pregnancy can make a definite diagnosis.Conclusion: Color doppler flow imaging (CDFI) in cesarean scar pregnancy has a characteristic ultrasonographic performance, ultrasound can accurately make a clear diagnosis. It is the first choice for clinical diagnosis.

Current Status and Progress on Management of Cesarean Section Scar Defect / 中国微创外科杂志

[Summary] Cesarean section scar defect is one of the most common long-term complications after cesarean section .However the indications and efficacy judgment are not definite .The main managements include medical and surgical interventions .The drug generally used in medical management is oral contraceptives , and the surgical management includes vaginal repair of cesarean section scar defect and hysteroscopic or laparoscopic repair of the defect .To minimize the incidence of cesarean section scar defect , the surgical indications should be strictly followed and the operation should be carefully performed , including application of aseptic techniques , complete removal of decidua and placental tissues , effective hemostasis , and proper suturing .

A Case of Cutaneous Endometriosis Combined with Epidermal Cyst in the Cesarean Section Scar / 대한피부과학회지

Endometriosis is the abnormal growth of endometrial glands and stroma outside the uterine cavity. Cutaneous endometriosis is a very rare form of extrapelvic endometriosis, and this most commonly occurs at the site of a previous abdominal or pelvic procedure such as hysterectomy, laparoscopy, episiotomy and cesarean section. The classic symptom is a painful nodule that becomes bigger and tenderer during menstruation. Because cutaneous endometriosis is unfamiliar to dermatologists, it can be easily misdiagnosed as other skin tumors. We present here a case of cutaneous endometriosis combined with epidermal cyst, and this developed in the cesarean section scar of a 28-year-old woman.

A case of ectopic pregnancy in the previous cesarean section scar treated by transvaginal hysterotomy / 대한산부인과학회지

Implantation of a pregnancy within the scar of previous cesarean section is the rarest form of ectopic pregnancy. Delayed diagnosis and treatment can lead to uterine rupture, hemorrhage and maternal morbidity. But diagnosed early by transvaginal sonography, treatment options are capable of preserving the uterus and subsequent fertility. Suction curettage, exploratory laparotomy, laparoscopic surgery, systemic or local injection of methotrexate is the treatment method currently performed. In this report, we treated a case of this patient by transvaginal hysterotomy. This is the first case report in the recent literature. By this surgery, we could successfully remove gestational sac from the implantation site and repair the defect by primary suture and preserve uterus.

Successful Conservative Management of Cesarean Section Scar Pregnancy / 대한산부인과학회지

A Cesarean section scar pregnancy is a rare but possibly life-threatening condition. The diagnosis is made mainly based on transvaginal ultrasonography. We used the Doppler and serial beta HCG in determining the severity and prognosis. Because of the rarity, universal treatment has not been established. In our cases, the severity of bleeding was independent of the level of beta HCG and the duration of amenorrhea. The shorter the interval from the previous cesarean section, the more severe the symptom, in such case, we were able to preserve fertility by uterine artery embolization. Cesarean section scar pregnancy can be managed conservatively with methotrexate injection. Based on our case review, we can conclude that it is very important that we choose the each therapeutic management based on her history and condition. In our review, we present four cases diagnosed with Cesarean section scar pregnancy all managed conservatively to preserve future fertility.

A case of ectopic pregnancy in the previous Cesarean section scar treated by laparoscopic surgery / 대한산부인과학회지

Pregnancy in the previous Cesarean section scar is a very rare form of ectopic pregnancy. This ectopic pregnancy may cause grave complications such as severe vaginal bleeding or spontaneous uterine rupture. Suction curettage, exploratory laparotomy, or systemic or local injection of methotrexate is the treatment method currently performed. In this report, we treat a case of this patient by laparoscopic surgery. By this surgery, we could successfully remove gestational sac from the implantation site and repair the defect by primary suture and preserve uterus.

A Case of Treatment with Methotrexate Local Injection on Intramural Pregnancy within a Previous Cesarean Scar / 대한산부인과학회지

Intramural pregnancy on a cesarean section scar is one of the rarest forms of ectopic pregnancy that may cause serious complications such as uterine rupture and massive bleeding. The common treatment in the past was laparotomy, but today early diagnosis is available thanks to the development of image diagnostic technology and, as a consequence, cases of less invasive conservative management are reported. Using vaginal ultrasonography and MRI, we made an early diagnosis on a case of intramural pregnancy on the scar of a previous cesarean section. We injected methotrexate locally into the gestational sac, and the intramural pregnancy was completely cured. Thus, here we report this case with a brief review of relevant literature.

A Case of Conservative Management of Ectopic Pregnancy Embedded in the Myometrium of Previous Cesarean Section Scar / 대한주산의학회잡지

Intramural pregnancy, implanted in the previous cesarean section scar, is one of the rare and dangerous forms of ectopic pregnancies, because a delay in either diagnosis or treatment can lead to uterine rupture, hysterectomy, or significant maternal morbidity, due to severe hemorrhaging. With the development of transvaginal ultrasound and MRI, early diagnosis and conservative treatment of intramural pregnancy is possible. For young patients who wish to maintain their fertility, an earlier diagnosis and more conservative treatment are desirable. We experienced a case of intramural pregnancy developed in the previous cesarean section scar and successfully treated it with conservative management. So we report this case with a brief review of literature.

Diagnosis and Management of Pregnancies Implanted into the Lower Uterine Segment Cesarean Section Scar / 대한산부인과학회잡지

OBJECTIVE: To describe diagnosis and management of Cesarean section scar pregnancy increased at recently due to high Cesarean section rate. METHODS: Eleven cases of pregnancies implanted into the lower uterine segment Cesarean section scar were diagnosed and treated at Daegu Fatima hospital during January 1999 to May 2004. All cases are confirmed by transvaginal ultrasound scan. The management of Cesarean section scar pregnancies included transvaginal evacuation, hysterotomy and medical treatment with methotrexate systemic or local injection into gestational sac. RESULTS: Eleven Cesarean section scar pregnancies were diagnosed. Medical treatment was used in nine women and four women was successful. The success rate were 44% (4/9). Surgical treatment was used in two women included transvaginal evacuation and hysterotomy. Seven women (63%) required blood transfusion and one women (9%) had a hysterectomy. CONCLUSION: Cesarean section scar pregnancies are more common. When the diagnosis is made in early pregnancy the prognosis is good and prevent late pregnancy complication include placenta previa, placental accreta and uterine rupture. The risk of hystrectomy is relatively low.

Two Cases of Ectopic Pregnancy Implanted in the Previous Cesarean Section Scar Treated with Dilatation and Evacuation after Vaginal Misoprostol / 대한산부인과학회잡지

Implantation of a pregnancy within the scar of previous cesarean section is the rarest form of ectopic pregnancy. If diagnosed early, treatment options are capable of preserving the uterus and subsequent fertility. However, delayed diagnosis and treatment can lead to uterine rupture, hemorrhage and maternal morbidity. We present two cases of ectopic pregnancy developing in the previous cesarean section scar in which successfully treated with dilatation and evacuation after vaginal misoprostol.

Conservative Management of Intramural Pregnancy Implanting in The Cesarean Section Scar / 대한산부인과학회잡지

OBJECTIVE: To evaluate of safety and effectiveness of conservative treatment of previous cesarean section scar pregnancy. METHODS: Ten patients with previous cesarean section scar pregnancy were treated systemic methotrexate or intra-amnionic methotrexate injection. After treatment, patients were measured for the levels of serum beta-hCG and underwent ultrasound. According to the results, additional dose of methotrexate or curettage were done. Serum beta-hCG and ultrasound were checked several times until the level of serum beta-hCG and the finding of ultrasound had been normalized. RESULTS: Two patients showed normal serum beta-hCG levels and ultrasound findings after intra-amnionic methotrexate injection only. Two patients showed normal serum beta-hCG levels and ultrasound findings after systemic methotrexate/folinic acid therapy followed by dilatation and curettage. Six patients showed normal serum beta-hCG levels and ultrasound findings after intra-amnionic methotrexate injection followed dilatation and curettage. Two patients were transfused due to massive bleeding and other patients were not experienced severe complications. CONCLUSION: These results suggest that systemic or intra-amnionic methotrexate therapy with or without dilatation and curettage is safe and effective as a primary therapy for intramural pregnancy implanting in the cesarean section scar.

A Case of Successful Treatment with Methotrexate Injection on Intramural Pregnancy Embedded in the Myometrium of Previous Cesarean Section Scar / 대한산부인과학회잡지

Intramural pregnancy implanting in the previous cesarean section scar is one of the rarest form of an ectopic pregnancy and probably the most dangerous form because of its risk of rupture and hemorrhage. For its sonographic diagnosis, the gestational sac should be in the anterior wall of uterine isthmic portion, there should be no myometrium between bladder and gestational sac, and it should be verified that uterine cavity and cervix should be isolated from gestational sac. For young patients who wish to maintain their fertility, an earlier diagnosis and more conservative treatment are desirable. We have recently experienced a case of intramural pregnancy implanting in the scar of cesarean section, treated with systemic methotrexate injection. So, we report this case with a brief review of the literature.

A case of successful treatment of an ectopic pregnancy embedded in the myometrium of previous cesarean section scar with systemic methotrexate injection / 대한산부인과학회잡지

Intramural pregnancy implanting in the previous cesarean section scar is one of the rarest form of an ectopic pregnancy and probably the most dangerous form because of its risk of rupture and hemorrhage. Pathologically, the location of the gestational sac is completely isolated from the uterine cavity and entirely surrounded by myometrium without any contact of endometrium. For young patients who wish to maintain their fertility, an earlier diagnosis and more conservative treatment are highly desirable. We have recently experienced a case of intramural pregnancy implanting in the scar of cesarean section, treated completely with systemic methotrexate injection. So, we report this case with a brief review of the literature.

Three Cases of Conservative Management of Ectopic Pregnancy Implanting in The Previous Cesarean Section Scar / 대한산부인과학회잡지

Ectopic pregnancy developing in the previous cesarean section scar is the rarest forms of ectopic pregnancy and very dangerous because of the risk of uterine rupture and hemorrhage. Hysterectomy was usually done in the management but, conservative treatment is desirable for young women who want to maintain her fertility. We present three cases of ectopic pregnancy developing in the previous cesarean section scar in which successfully treated with conservative management.