Cervical Pregnancy Diagnosis and Management

*Rubens Bermudes Musiello, Jair Luiz Fava, Luiz Camano and Eduardo de Souza*

#### **Abstract**

Cervical ectopic pregnancy is rare. Cervical implantation is a serious obstetric condition that can lead to mutilation if not promptly diagnosed and treated. The clinical diagnosis consists in physical examination, ballooned cervical canal, dilated cervix, and hourglass-shaped uterus detected by internal examination. Ultrasonography confirms the diagnosis by visually detecting cervical implantation below the internal orifice. Magnetic resonance imaging and three-dimensional ultrasonography validates the diagnosis. Conservative treatment proposed: cerclage, vasopressin, Foley catheter with hemostatic cervical ligation, cervical canal balloon, embolization of uterine artery, hysteroscopy, laparoscopic ligation of the uterine artery, and curettage by suction catheter. Shortcomings of conservative management are high, and a number of cases result in hysterectomy. Drug management is a therapeutic option to avoid mutilating surgery, and the most commonly used is systemic methotrexate (MTX). Local treatment with MTX and potassium chloride injection guided by transvaginal ultrasound is used when the embryo is alive.

**Keywords:** pregnancy, ectopic, cervical, methotrexate

#### **1. Introduction**

Ectopic pregnancy (EP) is a pregnancy in which the fertilized egg attaches itself and develops outside the uterus.

Cervical ectopic pregnancy (CEP) is considered to be exceptionally rare, and it accounts for less than 1% of ectopic pregnancies (EP) [1, 2]. Its exact incidence is not yet known; some authors report from 1:978 to 1:50,000 [1, 3–8], and other authors report 0.1% of all EP, estimating their incidence between 1:2500 and 1:98,000 pregnancies [9].

The first description of cervical pregnancy dates back to 1817 in England by Sir Everard Home [10], though the term was first used by Rokitansky in 1860 [11] (**Figure 1**).

The implantation represents a serious obstetric event [12, 13], to an extent that in 1953, Baptiste reflected: "Most great obstetricians have never seen a case of CEP; however, a minority who had this opportunity wish they had never seen it."

Some risk factors have been considered for cervical nidation of the egg: anatomical abnormalities, uterine leiomyomas, synechia, previous cervical interventions leading to cervical mucosal changes, cervical stenosis, in vitro fertilization with embryo transfer, and obstetric uterine curettage [14].

#### **Figure 1.**

*A case where hysterectomy was inevitable due to the hemorrhagic condition—The trophoblastic invasion in the endocervix can be seen (own source).*

When the zygote attaches itself in the cervical canal, it is rapidly invaded by the trophoblast, reaching the conjunctival portion of the cervix, once there is no adequate decidualization. As the pregnancy develops in the cervix, bleeding could occur, initially in small amounts and later in greater volume when it reaches larger vessels. These pregnancies last, in average, 7–10 weeks [14].

#### **2. Clinical diagnosis**

The clinical diagnosis consists in the physical examination where a ballooned cervical canal and a dilated cervix can be detected [15] and hourglass-shaped uterus can be observed by internal examination [8] (**Figure 2**).

The differential clinical diagnosis between CEP and the ongoing miscarriage is that in the former, the body of the uterus tends to be larger, with dilation of the

#### **Figure 2.**

*Clinical diagnosis: Physical examination—Arrow at the bottom shows external orifice of the cervix, and the arrow at the top shows development of cervical pregnancy in the anterior lip of the cervix.*

external and internal orifice of the cervix, and it is possible to detect placental tissue above the internal orifice; in the latter, the internal orifice is virtually closed [16].

## **3. Imaging**

More recently, ultrasonography has been confirming the diagnosis by visually detecting cervical implantation below the internal orifice (IO) [17, 18]. Transvaginal ultrasonography is the gold standard preliminary method for accurate diagnosis [19].

The ultrasound findings for the diagnosis of cervical pregnancy are empty uterine cavity, endometrial thickness due to decidual reaction, hourglass shape of the uterus, enlargement of cervical canal, gestational sac located in the cervix with or without embryo, placental tissue surrounding the gestational sac, and closed internal orifice of the cervix (**Figure 3**).

Three-dimensional ultrasonography is also useful in the diagnosis of GC [20, 21]. Magnetic resonance imaging validates the diagnosis [22, 23] (**Figure 4**).

#### **Figure 3.**

*Diagnosis by imaging—Ultrasonography showing ovular implantation below internal orifice of the cervix.*

#### **Figure 4.**

*Diagnosis by imaging—MRI. Arrows show pregnancy developing in the cervical region, below the IO. Source: Bader-Armstrong et al. [22].*

#### **4. Management**

The classical treatment used to be total hysterectomy due to profuse bleeding. However, some authors, eager to keep their nulliparous patients' fertility, tried the conservative treatment of uterine curettage or local suture [15, 16, 24].

Reviewing the literature CEP was only cited only in the ninth edition of Williams Obstetrics in 1945. The treatment proposed at that time was [25] blood transfusion, vaginal tamponade and hysterectomy [26].

#### **5. Conservative surgical treatment**

The conservative surgical treatment proposed in the literature are:

1.Cerclage [27]

2.Foley catheter with hemostatic cervical ligation [28, 29]

3.Uterine curettage by suction catheter [30–33]

4.Hysteroscopy [19, 34]

5.Laparoscopic ligation of the uterine artery [35]

However, the majority of the conservative surgical treatments fail and result in hysterectomy.

#### **6. Medical treatment**

The following drugs are used in the medical treatment:

1.Vasopressin [36]


#### 5.Intramuscular methotrexate with dead embryo [41]

Among the drugs mentioned above, methotrexate (MTX) is the most used in the current literature for the treatment of EP. It is an antimetabolic chemotherapeutic and folic-acid antagonist which operates through the competitive inhibition of the dihydrofolate reductase enzyme, which in turn reduces the dihydrofolic acid into folinic acid [42], interfering the DNA synthesis and, consequently, the cell division.

Our experience advocates the therapy using a single dose of MTX as first-line treatment for CEP if the embryo does not show cardiac activity.

In cases of embryos without heart beating with high β-hcg titers greater than 5000 mui/ml and often greater than 10,000 mui/ml, a systemic treatment with multiple doses of MTX is the preferred therapeutic.

When the embryo has cardiac activity, local treatment with MTX and potassium chloride is recommended [40]. Elito et al. published a series of eight cases of CEP where embryos are presenting cardiac activity treated with puncture of gestational sac guided by vaginal ultrasonography with MTX injection (1 mg/kg) and KCl injection [42].

#### **7. Expectant management**

We can rarely adopt the expectant management, monitoring throughout the development of the cervical pregnancy, as some cases can spontaneously solve itself. Patients with small-volume CEP and low and declining serum beta-hCG concentrations are candidates for this type of management. Titers of beta-hCG lower than 1500 mIU/ml and declining indicate a high possibility of spontaneous involution.

#### **8. Conclusion**

According to the historical evolution of CEP, the treatment was carried out with total abdominal hysterectomy in a heroic attempt to solve the hemorrhage after the rupture of the cervix. When the authors began to try a traditional treatment, it was usually a surgery. Early diagnosis of CEP is extremely important for choosing the appropriate treatment. Several treatment options can be used, such as surgical interventions, medical treatment, and expectant management. The treatment with MTX has a high rate of success, and it is the first choice. CEP with cardiac activity is treated with intra-aminiotic MTX and potassium chloride injection. In cases of CEP without heart beating, systemic treatment with MTX should be used in a single- or multiple-dose regimen depending on the levels of beta-hCG. When the levels of beta-hCG are low and declining, the expectant management may be chosen. The clinical treatment of CEP prevents mutilating surgeries, and the patient can preserve their original condition for an obstetric future.

### **Author details**

Rubens Bermudes Musiello1,2\*, Jair Luiz Fava1,2, Luiz Camano2 and Eduardo de Souza<sup>2</sup>

1 Escola Superior de Ciências da Santa Casa de Misericórdia de Vitória, EMESCAM, Brasil

2 Escola Paulista de Medicina – Universidade Federal de São Paulo – UNIFESP, Brasil

\*Address all correspondence to: rubens.musiello@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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#### **Chapter 5**

## Caesarean Scar Ectopic Pregnancy

*Workineh Getaneh Tadesse*

#### **Abstract**

Caesarean scar ectopic pregnancy (CSEP) is one of the rarest forms of ectopic pregnancy. It is characterised by a gestation implanted in a caesarean section scar and surrounded by the myometrium and the fibrous tissue of the scar. With rising caesarean delivery rates and widespread use of ultrasound in early pregnancy, there is a parallel upward trend in the incidence of CSEP. The most significant risk associated with a CSEP is an early uterine rupture with life-threatening maternal haemorrhage leading to hysterectomy and loss of reproductive potential. An early diagnosis can offer conservative treatment options capable of preserving the uterus. This chapter discusses the clinical presentation, diagnosis and evidence-based treatment options of CSEP.

**Keywords:** scar ectopic pregnancy, caesarean section, complications of early pregnancy, uterine rupture

#### **1. Introduction**

CSEP is one of the rarest forms of ectopic pregnancies [1–5]. However, in the last two to three decades, an increasing number of case reports and case series have been published [4]. CSEP results from the implantation of the embryo in a previous caesarean scar (CS) instead of the endometrial cavity [6]. The pregnancy is surrounded by the myometrium and the fibrous tissue of the scar. It usually manifests with painless vaginal bleeding and often misdiagnosed as spontaneous miscarriage or cervical ectopic pregnancy [1, 4]. A misdiagnosis or a late diagnosis of CSEP can result in early uterine rupture with life-threatening maternal haemorrhage leading to hysterectomy and loss of reproductive potential [6]. Ultrasonography with colour flow Doppler is the primary diagnostic tool in the workup of CSEP [4]. An early diagnosis can offer conservative treatment options that enable the preservation of the uterus [2, 5, 6].

#### **2. Epidemiology**

The exact incidence of CSEP is unknown. It is estimated to occur in 0.05–0.4% (1 in 1800 to 1 in 2500) of all pregnancies [1]. A recent publication from the UK's Early Pregnancy Surveillance Service (UKEPSS) reported an estimated incidence of 1.5 per 10,000 maternities [7]. The incidence of CSEP is rising, which is believed to be due to the increasing caesarean delivery rate itself and improved detection rate as a result of widespread use of ultrasonography during early pregnancy [8].

CSEP has been reported in women with only one previous caesarean delivery as well as in those with multiple caesarean deliveries. It is not clear whether the

number of previous caesarean delivery (CD) or the time interval between the CD and subsequent pregnancy affect the incidence of CSEP. Similar to other types of ectopic pregnancies, CSEP has been reported in both spontaneously conceived pregnancy as well as after in vitro fertilisation (IVF) and embryo transfer [9, 10].

#### **3. Pathophysiology**

The exact cause and mechanism are not well understood. The most plausible mechanism is that the blastocyst implants into microtubular tracts, which persisted at the site of the caesarean scar as a result of incomplete healing [1]. However, it is not clear if an increase in the number of previous caesarean deliveries or short interval between caesarean delivery and subsequent pregnancy increase the risk of CSEP by way of affecting the healing process at the caesarean scar. Additionally, there is no evidence if uterine closure technique (e.g. single vs. double layer closure) has any effect on the risk of CSEP.

Two types of CSEP have been described [8]. Type I (endogenic type) is characterised by implantation on the CS with progression towards the direction of the endometrial cavity. Type II (exogenic type) CSEP is a deep implantation in the CS defect growing mainly towards the abdominal cavity. Type I CSEP can potentially continue to develop into the endometrial cavity and may even progress to the second and third trimesters. Type II is associated with early uterine rupture or invasion into the urinary bladder [8].

CSEP should be differentiated from placenta accreta or increta, where the pregnancy is intrauterine with an invasion of the trophoblast into the myometrium. In contrast, CSEP is characterised by a gestation separated from the endometrial cavity and surrounded by the myometrium and the fibrous tissue of the scar.

#### **4. Clinical presentation and diagnosis**

A large proportion of patients with CSEP are asymptomatic and diagnosed incidentally during a routine first-trimester ultrasound [1, 4]. The most frequent symptom of CSEP is light and painless vaginal bleeding [4, 6]. Some patients may have associated mild to moderate lower abdominal pain. Severe pain with or without haemodynamic instability, may indicate ruptured CSEP. There may be mild lower abdominal or uterine tenderness on palpation; however, clinical examination in stable women is usually unremarkable. The gestational age at diagnosis ranges from 5 to 16 weeks, with an average of 7.5 ± 2.5 weeks [4].

#### **4.1 Investigations**

#### *4.1.1 Serum beta – human chorionic gonadotropin (hCG)*

Quantitative serum beta-hCG measurement confirms the presence of pregnancy, and also provides a baseline for posttreatment follow up.

#### *4.1.2 Ultrasound*

Ultrasonography is the primary diagnostic tool [1, 4, 6]. Transvaginal ultrasound (TVS) has a diagnostic sensitivity of around 85% [1, 4]. There are

#### *Caesarean Scar Ectopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.89023*

proposed ultrasound diagnostic criteria, allowing a differential diagnosis from cervical ectopic pregnancy and miscarriage. These include (1) Empty uterus with clearly visualised endometrium, (2) Empty cervical canal, (3) Gestational sac located within the anterior isthmic portion of the uterus at the presumed site of the CS, (4) Thinned (<5 mm) or absent myometrium between the gestational sac and bladder [5]. Additionally, Doppler colour flow may show distinct circular peritrophoblastic perfusion surrounding the gestational sac (see **Figures 1** and **2**).

The crossover sign (COS) is an ultrasound sign that is proposed to describe the relationship between the gestational sac, the caesarean scar and the anterior uterine wall [12]. In a sagittal view of the uterus a straight line connecting the internal os and the uterine fundus through the endometrium is drawn (endometrial line). The superior–inferior (S-I) diameter of the gestational sac, perpendicular to the endometrial line, is traced (see **Figure 3**).

#### **Figure 1.**

*Transvaginal ultrasound, sagittal view of a gestational sac with a yolk sac within a caesarean scar [11].*

Patients can be categorised into groups based on the relationship between the endometrial line and the S-I diameter of the gestational sac [12]:


This categorisation based on the COS may help to determine the natural progression of CSEP [12].

#### *4.1.3 Magnetic resonance imaging*

Magnetic resonance imaging (MRI) is rarely required to clarify the diagnosis of CSEP [1]. Sagittal, coronal and transverse sections of T1- and T2- weighted MRI sequences can clearly show the gestational sac embedded in the anterior lower uterine wall [5] (**Figure 5**). MRI can also help in decision making and pre-operative planning through detailed characterisation of CSEP location, depth of myometrial invasion and presence of bladder involvement [1, 5] (**Figure 6**).

#### **Figure 3.**

*Diagrammatic representation of relationship between gestational sac, caesarean scar and anterior uterine wall, defined as crossover sign (COS) [12]. (a) Normal implantation, (b) COS-1, (c) COS-2+, (d) COS-2−.*

#### **Figure 4.**

*Ultrasound images of different types of crossover sign (COS): (a) COS-1, (b) COS-2+ and (c) COS-2<sup>−</sup>. B = bladder, C = cervix, CS = caesarean scar, EL = endometrial line, GS = gestational sac, SID = superior– inferior diameter [12].*

#### **Figure 6.**

*Surgical specimen of a total hysterectomy from a case of a 2nd trimester CSEP. Note the distended lower segment of the uterus with near total absence of myometrium at the previous caesarean scar.*

#### **Figure 7.**

*Cervical ectopic pregnancy: Hourglass appearance of the uterus with gestational sac in the intracervical canal [14].*

#### **4.2 Differential diagnoses**

CSEP can be mistaken for spontaneous miscarriage in progress [11, 13] or cervical ectopic pregnancy [13]. In cervical pregnancy, unlike CSEP, there would be a layer of myometrium visible between the bladder and the gestational sac and bleeding as the presenting symptom is much more substantial [5, 6, 11, 13]. The uterus

#### *Caesarean Scar Ectopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.89023*

is empty with an endometrial stripe, the gestational sac presents predominantly within the cervix, giving an hour-glass shape of the uterus with a ballooned cervical canal (see **Figure 7**) [5, 6, 14]. In case of spontaneous miscarriage in progress, an avascular gestational sac is seen in the cervical canal indicating that it has been detached from its implantation site, in contrast to the well-perfused CSEP located in the anterior lower uterine wall [5, 13]. A significant fall in serum beta-hCG level would also be noticed in a miscarriage.

#### **5. Treatment**

Due to the rarity of CSEP, there is no consensus regarding its management. Treatment options discussed here are mostly based on case reports and small case series. In general, there are expectant, medical and surgical options of treatment. Factors influencing the choice of treatment options include the type of the CSEP (Type I or II), haemodynamic stability, size of the pregnancy mass and gestational age, serum beta-hCG level, presence or absence of fetal cardiac activity, wish for future fertility, and availability of expertise (e.g. endoscopic surgery, interventional radiology) [8, 15–17]. A comprehensive review from UKEPSS demonstrates that the success rate of expectant, medical and surgical management were 43, 46 and 96%, respectively [7]. The complication rates were 71% with expectant, 60% with medical and 36% with surgical management [7].

#### **5.1 Expectant management**

Even though expectant management of CSEP has been described [2, 3, 15, 18], the safety of continuing pregnancy is questionable. Caution must be exercised when choosing expectant management in cases of viable CSEP as it carries a significant risk of complications, including uterine rupture, severe haemorrhage and hysterectomy [4, 18, 19]. In a systematic review of a total of 56 cases (including 44 cases with fetal cardiac activity) of CSEP managed expectantly, live births were achieved in 73% with a very high hysterectomy rate of 70% [18]. Women with viable CSEP and relatively favourable findings on imaging such as endogenic type, COS-2 on ultrasound and residual myometrial thickness of >5 mm on MRI may continue with the pregnancy if they have a strong desire to do so [19]. Women need to understand that expectant management of a viable CSEP carries a significant risk of severe haemorrhage, uterine rupture, hysterectomy and severe invasive placentation [7, 15, 19]. Expectant management can be considered in those with no fetal cardiac activity and with evidence of spontaneous resolution [18–20].

#### **5.2 Medical management**

#### *5.2.1 Methotrexate*

Methotrexate (MTX) can be administered locally or systemically as single or multiple doses. Primary systemic treatment with MTX is indicated in patients with non-viable CSEP. CSEPs have been shown to respond well to systemic administration of MTX (50 mg/m2 ), especially in those with low serum beta-hCG levels (<5000 mIU/ml). Like in tubal ectopic pregnancy, MTX is appropriate for a woman who is pain-free and hemodynamically stable with unruptured pregnancy of <8 weeks' gestation. While a single dose treatment may be adequate for cases with low serum beta-hCG levels (<5000 mIU/ml), multiple doses may be necessary in those with high beta-hCG levels.

Methotrexate can also be given directly into the gestational sac. Local MTX administration is preferable in cases with viable CSEP. Ramkrishna et al. have described their medical management protocol [21]. They use ultrasound guided intra-sac injection of 50 mg of MTX into the gestational sac using 18G chorionic villus sampling needle after aspirating the content of the sac. Prior injection of 2 ml (30 mmol/ml) KCL is used when fetal cardiac activity is present [21]. Additional dose(s) of systemic MTX is used for those cases with plateaued serum hCG level. The success rate of primary medical management (systemic/local) was 86% for CSEP in their study subjects [21].

There is a suggestion that direct injection of MTX into the sac achieves a high concentration locally and therefore interrupts the pregnancy more rapidly than a systemic administration of the drug [22]. The local injection can be done under ultrasound guidance (transabdominal or transvaginal), or direct vision through laparoscopy or hysteroscopy. A larger gauge needle is preferable to ensure better aspiration of the content of the gestational sac at the same time.

A high dose of intravenous MTX infusion, followed by oral folinic acid rescues, has also been used with a success rate of 85.7% [23].

#### *5.2.2 Local embryocidal injection*

Local injection of potassium chloride (or other embryocides- e.g. lignocaine [1]) can be used when there is fetal cardiac activity, or for selective embryocidal action in cases of heterotopic pregnancies [10, 24]. Similar to local MTX injection, this can be done under ultrasound guidance (transabdominal or transvaginal), or direct vision through laparoscopy or hysteroscopy followed by local or systemic MTX.

#### **5.3 Surgical treatment**

Several surgical treatment options are described.

#### *5.3.1 Uterine curettage*

By definition, the gestational mass in a CSEP is not actually within the uterine cavity. Therefore, not only the trophoblastic tissue is inaccessible by the curettage but also such attempts can potentially rupture the uterine scar leading to severe haemorrhage and cause more harm [4]. A recently published meta-analysis suggested favourable outcomes (less blood loss, lower incidence of adverse events and shorter duration of hospital stay) following high-intensity focused ultrasound compared to uterine artery embolization before uterine curettage [25]. In a casecontrol study, advanced gestational age, higher serum hCG level, bigger gestational sac diameter, thinner myometrial layer and significant peritrophoblastic perfusion were associated with excessive intra-operative haemorrhage (≥ 200 ml) during suction evacuation of CSEP [26].

#### *5.3.2 Hysteroscopy or laparoscopy*

Aspiration/resection of gestational contents can be accomplished either through operative hysteroscopy or laparoscopy [27–29]. The choice between laparoscopy and hysteroscopy depends on the type of CSEP. The hysteroscopic approach is more appropriate for CSEP that grows inward towards the uterine cavity (Type I), while a laparoscopy is more justified for a deeply implanted CSEP growing towards the abdominal cavity (type II).

#### *5.3.3 Laparotomy*

Wedge resection of the gestation (hysterotomy) or hysterectomy should be considered in women who do not respond to conservative medical or surgical treatments, present too late or if facilities and expertise for operative endoscopy are not available. Laparotomy is mandatory when uterine rupture is confirmed or strongly suspected.

#### **5.4 Uterine artery embolization**

Uterine artery embolization (UAE) in combination with other treatment modalities such as MTX, dilatation and curettage (D & C) or hysteroscopic resection has been used to treat CSEP [15, 30]. Catheterisation of the uterine arteries is carried out through a transfemoral approach under local anaesthesia. If embolization is combined with a dose of MTX it is split between the two uterine arteries and infused via the arterial catheter. Finally, both uterine arteries are embolized with gelatin sponge particles or polyvinyl alcohol [15].

In a systematic review, UAE combined with D & C was highly effective with only 6.4% of cases needed additional treatment and severe complications (haemorrhage, hysterectomy) occurred in 3.4% of cases [15]. A combination of UAE, D & C and hysteroscopy also resulted in a high success rate of 95.4% and a very low complication rate of 1.2%. In women treated with a combination of UAE, D & C and MTX, additional treatment was needed in 31.4% because of treatment failure and hysterectomy rate was 2.8%. In comparison, between one-fourth to one-third of patient treated primarily with MTX required additional treatment [15].

#### **5.5 Combination**

In reality, most cases of CSEP are managed with a combination of both medical and surgical approaches [31]. Medical treatment - systemic or local, single agent or combined regiment can be used in conjunction with surgical treatment options. e.g.


Uterine artery embolization, bilateral uterine artery ligation, local vasopressin injection and intrauterine balloon tamponade have been used successfully as an adjunct to other conservative treatments for the prevention and control of heavy bleeding.

#### **Figure 8.**

*Changes in weekly serum beta-hCG levels of four patients with CSEP before and after the medical treatment. The values on the curve represent the beta-hCG measurements at each given week. MTX = methotrexate; LCV = Leucovorin; KCl = potassium chloride [42].*

#### **5.6 Post-treatment follow-up**

Close follow up is essential to confirm complete resolution of the CSEP. Patients need serial serum beta-hCG measurements and pelvic ultrasound until the hCG level is undetectable, and the pregnancy mass disappears, which may take several weeks (see **Figure 8**) [34, 41]. In general, posttreatment weekly measurement of serum beta-hCG is required to confirm resolution [42, 43]. Patients who have undergone hysterectomy do not require hCG monitoring. Serial transvaginal colour flow Doppler is useful for monitoring the response to medical treatment. It is worth to note that uterine rupture and severe maternal haemorrhage can occur despite a satisfactory drop in serum hCG levels [1]. Continuation of fetal cardiac activity or growth of the sac with rising serum hCG concentration indicates failure of medical treatment. In a tubal ectopic pregnancy, a higher failure rate of medical treatment is associated with a gestational age of ≥ 9 weeks, a fetal pole of >10 mm, presence of fetal cardiac activity and a serum beta-hCG concentration > 10,000 mIU/ml. However, no similar or consistent pattern could be observed for a CSEP.

#### **6. Recurrence and management of subsequent pregnancies**

The risk of recurrence in subsequent pregnancies is unknown. Uneventful viable intrauterine pregnancies have been reported after all modalities of conservative management of CSEP [34, 44]. Additionally, there are case reports whereby

*Caesarean Scar Ectopic Pregnancy DOI: http://dx.doi.org/10.5772/intechopen.89023*

patients had one or more episodes of recurrence of CSEP [44–46]. Owing to insufficient data, patients should be counselled about this uncertain risk of recurrence, and like patients with other types of ectopic pregnancies, they should be advised to avail of an early ultrasound examination in subsequent pregnancies to localise the pregnancy. Likewise, no reliable statistics exist on the safe interval between successfully treated CSEP and subsequent pregnancy. In the absence of other obstetric indication for repeat caesarean delivery, women who are pregnant following successful treatment of CSEP can consider delivering vaginally.

#### **7. Conclusion**

CSEP is a rare form of ectopic pregnancy but potentially associated with severe maternal complications. The incidence of CSEP is rising owing to the rise in caesarean delivery rate worldwide and widespread use of imaging in early gestation. Little is known about its exact mechanism and natural history. Ultrasonography with colour flow Doppler yields a high diagnostic accuracy. Recommendations of treatment options for CSEP are based on pieces of evidence from case reports and small case series. Therefore, treatment is individualised according to clinical presentation, availability of treatment options and expertise as well as the wish of the woman for future fertility.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

Workineh Getaneh Tadesse Coombe Women and Infants University Hospital, Dublin, Republic of Ireland

\*Address all correspondence to: wtadesse@coombe.ie

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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**79**

**1. Introduction**

**Chapter 6**

Pregnancy

*and Taro Koshiishi*

**Abstract**

A Minimally Invasive Hemostatic

Cesarean scar pregnancy (CSP) and cervical pregnancy are categorized as non-tubal ectopic pregnancy, because these are associated with a high burden of maternal and fetal morbidity including early uterine rupture, prevalence of placenta previa accrete spectrum, massive hemorrhage, and hysterectomy. Although management methods vary according to the week of gestation, recent reviews and reports support an interventional or a combination of surgical and medical approaches for treatment of unruptured CSP and cervical pregnancy rather than medical approach alone. In cases of massive hemorrhage, pressure hemostasis using balloon tamponade should first be performed. If such hemostasis proves to be ineffective, surgical excision or transcatheter arterial embolization (TAE) should be selected next. TAE reportedly achieves a high hemostasis rate. However, complications such as subsequent endometrial hypoplasia, menstruation disorder, infertility, placenta accreta, and uterine rupture have been reported, even in cases that have undergone successful hemostasis with TAE using an absorbable embolus. Recently, a minimally invasive hemostatic strategy in obstetrics, which aims to preserve uterine function and enhance the safety of subsequent pregnancies, has been developed. Therefore, we should reconsider uterus-preserving hemostatic strategies for critical hemorrhage and management of non-tubal ectopic pregnancy under these

circumstances by using safe and minimally invasive treatment modalities.

scar pregnancy, massive hemorrhage, methotrexate

**Keywords:** arterial embolization, balloon tamponade, cervical pregnancy, cesarean

Cesarean scar pregnancy (CSP) and cervical pregnancy are categorized as non-tubal ectopic pregnancy and may cause massive hemorrhage, uterine rupture, and hysterectomy. In CSP and cervical pregnancy cases, it is possible that the location of the gestational sac (GS) may lead to a misdiagnosis of abortion. Another possibility is a failure to detect CSP until massive hemorrhage occurs following curettage. Therefore, diagnosis and treatment strategies in early pregnancy are

Strategy for Cesarean Scar

Pregnancy and Cervical

*Satoru Takeda, Jun Takeda, Takashi Yorifuji*

#### **Chapter 6**
