I. Uterine scar pregnancy (CSP) after cesarean section
1. What is post-cesarean uterine scar pregnancy (CSP)?
The pathogenesis of CSP is not clear, but it may be that the fertilized egg is laid in the scar tissue through the tiny cavity between the endometrium and the cesarean scar, after which the blastocyst is completely isolated from the uterine cavity by the myometrium and fibrous tissue of the scar tissue. It is now believed that, in addition to cesarean delivery, scraping, myomectomy and hysteroscopic surgery can also create microscopic tracts between the endometrium and the surgical scar. The first misdiagnosis rate of the disease is as high as 76%, and it is easy to misdiagnose as early pregnancy and perform abortion or medication abortion, resulting in intraoperative or postoperative hemorrhage. Delayed diagnosis and treatment in early pregnancy and continued pregnancy may cause uterine rupture, leading to hysterectomy and loss of fertility for the patient. Therefore, when women with a history of Cesarean section have another pregnancy, ultrasound should be performed early in pregnancy to explore the location of the gestational sac.
2.What are the serious consequences of CSP?
There are two types of Cesarean scar pregnancy: one type of gestational sac is planted on the incisional scar and grows toward the isthmus or the uterine cavity; the other type of gestational sac is planted on the defect of the incisional scar and grows outside the uterus, which can cause uterine rupture or bleeding in early pregnancy.
(1) The blastocyst can continue to develop and grow in the scar tissue, but there is a risk of natural rupture and fatal hemorrhage.CSP is a very rare ectopic pregnancy in which the pregnancy implants in the scar of the previous cesarean section, and is prone to uterine bleeding, placental implantation, uterine rupture, hysterectomy and serious complications. If diagnosed early and treated properly, it can effectively reduce complications and successfully preserve fertility. On the contrary, delayed diagnosis and improper management can lead to hemorrhage, uterine rupture, total hysterectomy or even life-threatening. The incidence of CSP is on the rise due to the increasing rate of cesarean delivery.
(2) Blastocyst blastocyst trophoblast may also: infiltrate the bladder, cause corresponding symptoms and signs, penetrate the scar tissue of the lower uterine segment, and the blastocyst falls into the abdominal cavity and continues to grow, forming abdominal pregnancy.
3.How is CSP diagnosed?
(1) Symptoms: clinical manifestations between 5-16 weeks are mostly painless small amount of vaginal bleeding, about 16% of patients have mild abdominal pain; about 9% of patients have only abdominal pain.
(2) Mainly rely on ultrasound. The criteria for ultrasound diagnosis of CSP are: no pregnancy tissue in the uterine cavity and cervical canal, gestational sac or mixed mass located in the scar of the anterior wall of the uterine isthmus, gestational sac and intervesical muscular symptoms <5 mm in thickness and defective in about 2/3 of patients, and occasionally a broken loss of muscular tissue in the lower uterine segment with the gestational sac protruding between them.
(3) If necessary, MRI, hysteroscopy and laparoscopy can be used to assist in the diagnosis of CSP, which needs to be differentiated from cervical pregnancy, which can be seen on ultrasound.
4.How is CSP treated?
If a scar pregnancy has been diagnosed, the pregnancy should be terminated promptly. Those who suspect the disease should not be scraped, but should be treated conservatively with drugs first. After embryonic death, mechanization and HCG decline, wait for the lesion to absorb on its own. Scraping can also be performed after the ultrasound image shows no local blood flow. When scarred pregnancy leads to uterine rupture and uncontrollable hemorrhage, uterine artery embolization plus chemotherapy can be chosen when available to provide an effective means of hemostasis for the patient to preserve the uterus. If not available or necessary, gestational sac lesion removal and hysterectomy or hysterectomy is required.
As the understanding of CSP deepens, treatment methods are gradually evolving. Common oncologic approaches include pharmacotherapy, surgery and uterine artery embolization, or a combination of all three:.
(1) Drug therapy
CSP is different from general ectopic pregnancies in that the location of the bed and the space for the development of gestational tissues are larger, and the pregnancy can be maintained until full term before uterine rupture occurs, so how to choose different drug treatment regimens according to the blood HCG value is subject to further study of a large number of samples.
(2) Surgical treatment
The aim is to remove the uterine scar gestation, as well as to repair the uterine scar. The surgical methods available include DC, laparoscopic, open, vaginal, hysteroscopic and OPTION. surgical treatment is characterized by significant postoperative recovery of blood HCG and absorption of the pregnancy mass, which is faster than conservative pharmacological treatment, with the disadvantage of recurrent CSP and uterine rupture, and intraoperative haemorrhage is a non-negligible risk.
(3) Uterine artery embolization (UAE)
It is a minimally invasive diagnostic treatment that can effectively and rapidly stop bleeding and prevent hemorrhage. Transabdominal hysterotomy for removal of pregnancy was once recommended as the best choice for management of CSP, and the introduction of UAE followed by combined medication or surgical treatment is effective in preventing and controlling acute hemorrhage and preserving reproductive function. Prevention through multiple routes, the primary issue at hand is postoperative contraception for CSP, early consultation in case of pregnancy, early diagnosis and timely termination.
II. Cervical pregnancy
1. What is cervical pregnancy?
Cervical pregnancy is the implantation and development of a fertilized egg in the cervical canal below the histological level of the uterine cervix. It is rare, but once it develops, it is critical and more difficult to manage.
2. What are the risk factors for cervical pregnancy?
Most commonly seen in menstruating mothers with endometrial defects and adhesions due to abortion, induction of labor, cesarean section, intrauterine device, etc.; or endometrial dysplasia, uterine malformation, uterine fibroids resulting in deformation of the uterine corpora cavernosa, all of which are not conducive to the fertilization of the fertilized egg in the uterine corpora cavernosa and the descent of the pregnant egg to the cervical canal for implantation. In cases of assisted reproductive technology, the embryo may be sent to the cervical canal for implantation. In cases of normal uterine body cavity, the egg may also descend to the cervical canal for implantation if it wanders too fast or is delayed in development
3. What are the clinical manifestations of cervical pregnancy?
Cervical pregnancy is characterized morphologically by the infiltrative and destructive growth of the trophoblastic layer into the cervical wall or the muscular layer, forming a placenta implantation. The cervical wall contains only 15% muscle tissue and the rest is non-contractile fibrous connective tissue. When spontaneous abortion occurs in cervical pregnancy or when scraping is misdiagnosed as early intrauterine pregnancy, massive bleeding often occurs because the cervical contraction is weak and the pregnancy products cannot be dispatched quickly and the open blood vessels cannot be closed.
(1) Symptoms: menopause, early pregnancy reaction, vaginal bleeding or bloody discharge, and sudden heavy vaginal bleeding that may be life-threatening, without abdominal pain is its characteristic.
(2) Gynecological examination: purple-blue, soft and dilated cervix, dilated ectocervix during bleeding, visible embryonic tissue, but normal size and hardness of the uterine body.
(3) Ancillary tests: the diagnosis is confirmed by elevated blood HCG and the gestational sac seen in the cervical canal by ultrasound.
4.How to deal with cervical pregnancy?
After diagnosis, different methods can be used depending on the amount of vaginal bleeding and, if necessary, removal of the uterus. The pregnancy products in the cervical canal may disappear completely within 9 weeks after treatment.
(1) Heavy bleeding or haemorrhage
After blood preparation, the embryonic tissue in the cervical canal is scraped and the wound is filled with gauze to stop bleeding, or the embryo is peeled off by incision of the cervix under direct vision and the wall of the canal is sutured with mattress sutures, followed by repair of the cervical canal.
Uterine artery embolization plus chemotherapy: The uterine artery is reached through the femoral artery cannula, and after angiography, selective embolization of the vessels localized to the pregnancy bed is performed, which can rapidly control vaginal bleeding. Uterine artery embolization is quick and safe, and can clearly show the bleeding vessels and accurately embolize them, creating conditions and gaining time for conservative treatment of cervical pregnancy and allowing young and infertile women to avoid hysterectomy. After the vaginal bleeding is effectively controlled by interventional treatment, immediate systemic or local MTX treatment and eventual necrosis, mechanization and shedding of embryonic tissues or surgical removal by curettage is the most effective treatment method for cervical pregnancy patients to preserve the uterus at present.
(2) Low or no bleeding
MTX systemic (same chemotherapy regimen as for ectopic pregnancy); or transcervical injection into the embryo sac. Uterine artery embolization plus chemotherapy, followed by curettage after a significant decrease in blood HCG, can reduce the risk of haemorrhage.
3. Stump pregnancy of the uterus
The type I is the one in which the cavity of the uterus is connected to the cavity of the normal uterus. type II is the one in which the cavity of the uterus is not connected to the cavity of the normal uterus; it is more common in pregnancies with a stump uterus. type III is the one in which the uterus has no cavity.
2. Stump-angle uterine pregnancy: Stump-angle uterus is a type of uterine malformation that is not connected to the cavity of a well-developed uterus. The fertilized egg enters the residual horned uterus through the fallopian tube on the side of the residual horned uterus and becomes pregnant.
3. Clinical manifestations: Some of them show symptoms similar to miscarriage due to embryonic death in early pregnancy, and if the fetus grows, the natural rupture of the stump horn often occurs in the middle of pregnancy and causes severe hemorrhagic shock. Even to the full term of pregnancy, the fetus often dies after delivery, and if blind trial of labor is not diagnosed, it also causes rupture of the stump uterus.
4. Treatment: Once diagnosed, it is possible to remove the stumped hysterus and the ipsilateral fallopian tube, and if the fetus is full term, it is possible to remove the stumped hysterus after cesarean section.
Ovarian pregnancy
1. What is ovarian pregnancy?
It refers to the implantation, growth and development of a fertilized egg in the ovarian tissue. The incidence of ectopic pregnancy ranges from 0.36% to 2.74%. The clinical presentation is very similar to tubal pregnancy and is often diagnosed as tubal pregnancy or ovarian corpus luteum rupture. Laparoscopic diagnosis is extremely valuable, but pathological examination is still needed to confirm the diagnosis.
2. What are the minimum criteria for ovarian pregnancy?
Both fallopian tubes are intact and separated from the ovaries; the blastocyst is located within the ovarian tissue; the ovary and blastocyst must be attached to the uterus by the ligament inherent to the ovary; and the blastocyst wall is lined with ovarian tissue.
3. How is it treated?
Partial ovariectomy.
V. Simultaneous intrauterine and extrauterine pregnancy
1. It refers to the coexistence of an intrauterine pregnancy and ectopic pregnancy, which may be a dizygotic twin fetus that lays in the uterus and an ectopic one, or it may be two closely spaced pregnancies that occur successively in the uterus and in the ectopic one. It used to be extremely rare, but the development of assisted reproductive techniques and the use of ovulation-promoting drugs have significantly increased its incidence (about 1%).
The diagnosis is difficult, often the clinical symptoms of ectopic pregnancy appear soon after the intrauterine pregnancy is confirmed by abortion; or the ectopic pregnancy is surgically confirmed and then the intrauterine pregnancy is found.
3. Since simultaneous intrauterine and extrauterine pregnancies mostly occur in infertility patients after receiving ovulation promotion therapy or IVF. In view of the expectation of fertility in infertility patients and the fact that about 80% of intrauterine pregnancies still reach full term in patients with ruptured ectopic pregnancy resulting in internal bleeding, the principle of management of concurrent intrauterine and ectopic pregnancies is to treat the ectopic pregnancy as soon as it is diagnosed and to avoid or minimize interference with the intrauterine pregnancy.