Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta‐analysis
ABSTRACT Objective To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP). Methods An electronic search of MEDLINE, EMBASE and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for ‘Cesarean sc...
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| Veröffentlicht in: | Ultrasound in obstetrics & gynecology 2018-02, Vol.51 (2), p.169-175 |
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| creator | Calì, G. Timor‐Tritsch, I. E. Palacios‐Jaraquemada, J. Monteaugudo, A. Buca, D. Forlani, F. Familiari, A. Scambia, G. Acharya, G. D'Antonio, F. |
| description | ABSTRACT
Objective
To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP).
Methods
An electronic search of MEDLINE, EMBASE and
ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for ‘Cesarean scar pregnancy’ and ‘outcome’. Reference lists of relevant articles and reviews were hand‐searched for additional reports. Observed outcomes included: severe first‐trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first‐ or second‐trimester uterine rupture or hysterectomy; third‐trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta‐analyses of proportions using a random‐effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis.
Results
A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8–26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1–37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9–20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6–32.8%) of all cases. Forty (76.9% (95% CI, 65.4–86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4–66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0–92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two‐thirds (69.7% (95% CI, 42.8–90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4–87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9–52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7–30.3%) of cases, but hysterectomy was not required in any case.
Conclusions
CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity includi |
| doi_str_mv | 10.1002/uog.17568 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_swepu</sourceid><recordid>TN_cdi_swepub_primary_oai_swepub_ki_se_495742</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>1998354394</sourcerecordid><originalsourceid>FETCH-LOGICAL-c4928-849788750592c446685a3fad5596fcbe662753e29f12fac5538dc890c12a256f3</originalsourceid><addsrcrecordid>eNp10c1O3DAUBWCrKioD7aIvgCx1UxYB27Edm101AloJaTawRNYd52YUmj_shGl2fQSekSdpIFMWSKx8ZX0-utYh5CtnJ5wxcTq0mxOeKW0-kAWX2iYsY-ojWTCrWZJpK_bJQYx3jDEtU_2J7AujNWeCL8jtauh9WyNtC7rECAGhodFDoF3ATQONH2kNDWwwp_inQ99D01fjGY1j7LGGvvQ04EOJWwpNTmvs4env4_SgGmMZP5O9AqqIX3bnIbm5OL9e_kyuVpe_lj-uEi-tMImRNjMmU0xZ4aXU2ihIC8iVsrrwa9RaZCpFYQsuCvBKpSb3xjLPBQili_SQJHNu3GI3rF0XyhrC6Foo3e7q9zShk1ZlUkz---y70N4PGHtXl9FjVUGD7RAdt1waabSVE_32ht61Q5j-96ysSZVMX9TxrHxoYwxYvK7AmXvuyE0duZeOJnu0SxzWNeav8n8pEzidwbascHw_yd2sLufIfzU6nBA</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>1998354394</pqid></control><display><type>article</type><title>Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta‐analysis</title><source>Wiley Free Content</source><source>Wiley Online Library Journals Frontfile Complete</source><source>Elektronische Zeitschriftenbibliothek - Frei zugängliche E-Journals</source><creator>Calì, G. ; Timor‐Tritsch, I. E. ; Palacios‐Jaraquemada, J. ; Monteaugudo, A. ; Buca, D. ; Forlani, F. ; Familiari, A. ; Scambia, G. ; Acharya, G. ; D'Antonio, F.</creator><creatorcontrib>Calì, G. ; Timor‐Tritsch, I. E. ; Palacios‐Jaraquemada, J. ; Monteaugudo, A. ; Buca, D. ; Forlani, F. ; Familiari, A. ; Scambia, G. ; Acharya, G. ; D'Antonio, F.</creatorcontrib><description>ABSTRACT
Objective
To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP).
Methods
An electronic search of MEDLINE, EMBASE and
ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for ‘Cesarean scar pregnancy’ and ‘outcome’. Reference lists of relevant articles and reviews were hand‐searched for additional reports. Observed outcomes included: severe first‐trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first‐ or second‐trimester uterine rupture or hysterectomy; third‐trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta‐analyses of proportions using a random‐effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis.
Results
A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8–26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1–37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9–20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6–32.8%) of all cases. Forty (76.9% (95% CI, 65.4–86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4–66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0–92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two‐thirds (69.7% (95% CI, 42.8–90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4–87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9–52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7–30.3%) of cases, but hysterectomy was not required in any case.
Conclusions
CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Resumen
Resultado del embarazo sobre cicatriz de cesárea tratado de forma expectante: revisión sistemática y metaanálisis
Objetivo
Investigar el resultado en mujeres tratadas de forma expectante después del diagnóstico de embarazo sobre cicatriz de cesárea (CSP, por sus siglas en inglés).
Métodos
Se realizó una búsqueda electrónica en las bases de datos MEDLINE, EMBASE y ClinicalTrials.gov utilizando combinaciones de encabezados de temas médicos relevantes para ‘embarazo sobre cicatriz de cesárea’ y ‘resultado’. Para encontrar más informes se realizó una búsqueda manual en la bibliografía de cada artículo. Los resultados observados incluyeron: hemorragia vaginal grave en el primer trimestre; síntomas clínicos (dolor abdominal, hemorragia vaginal) que requirieron tratamiento; aborto sin complicaciones; aborto con complicaciones que requirieron intervención; ruptura uterina o histerectomía en el primer o segundo trimestre; hemorragia, ruptura uterina o histerectomía en el tercer trimestre; muerte materna; prevalencia de placenta invasiva (AIP, por sus siglas en inglés); prevalencia de placenta percreta; indicios de ultrasonido que sugieren AIP; y nacimiento vivo. Para combinar los datos se utilizó un metaanálisis de proporciones con un modelo de efectos aleatorios. Los casos se estratificaron en función de la presencia o ausencia de actividad cardíaca del embrión o del feto en el momento del diagnóstico.
Resultados
Se incluyeron un total de 17 estudios (69 casos de CSP tratados de forma expectante, 52 con presencia de latido del embrión/feto y 17 con ausencia de este). En mujeres con CSP y actividad cardíaca del embrión/feto, el 13,0% (IC 95%, 3,8–26,7%) experimentaron un aborto espontáneo sin complicaciones, mientras que el 20,0% (IC 95%, 7,1‐37,4%) requirieron intervención médica. La rotura uterina durante el primer o segundo trimestre del embarazo ocurrió en un 9,9% (IC 95%, 2,9–20,4%) de los casos, mientras que en un 15,2% (IC 95%, 3,6–32,8%) de todos los casos se requirió histerectomía. Cuarenta mujeres (76,9% (95% CI, 65,4–86,5%)) llegaron al tercer trimestre del embarazo, de las cuales el 39,2% (IC 95%, 15,4–66,2%) experimentaron una hemorragia severa. Finalmente, el 74,8% (IC 95%, 52,0–92,1%) recibió un diagnóstico quirúrgico o patológico de AIP en el momento del parto y alrededor de dos tercios (69,7% (IC 95%, 42,8–90,1%)) tenían placenta percreta. En mujeres con CSP pero sin actividad cardíaca del embrión o del feto, en el 69,1% (95% CI, 47,4–87,1%) de los casos se produjo un aborto espontáneo sin complicaciones, mientras que en un 30,9% se requirió intervención quirúrgica o médica durante o inmediatamente después del aborto (95% CI, 12,9–52,6%). La rotura uterina durante el primer trimestre del embarazo ocurrió en un 13,4% (IC 95%, 2.7–30.3%) de los casos, pero en ningún caso se requirió histerectomía.
Conclusiones
La CSP con actividad cardíaca positiva del embrión o del feto tratada de forma expectante se asocia con una alta carga de morbilidad materna que incluye hemorragia grave, ruptura uterina temprana, histerectomía y AIP grave. A pesar de esto, una proporción significativa de embarazos complicados por CSP pueden llegar a término, o cerca de este, lo que cuestiona si la terminación del embarazo debería ser la única opción terapéutica ofrecida a estas mujeres. El tratamiento de forma expectante de la CSP sin actividad cardíaca puede ser una opción razonable, en vista de la baja probabilidad de complicaciones maternas que requieren intervención, aunque se recomienda una intensa vigilancia para evitar resultados maternos adversos.
摘要
剖宫产瘢痕妊娠期待治疗的结局:系统综述和meta分析
目的
探讨诊断为剖宫产瘢痕妊娠(Cesarean scar pregnancy,CSP)妇女经期待治疗后的结局。
方法
在MEDLINE、EMBASE和ClinicalTrials.gov数据库中进行“Cesarean scar pregnancy”和“outcome”相关医学主题词组合检索。手式检索相关文章及综述中的参考文献以发现其他研究。纳入的观察结局包括:严重的孕早期阴道出血;需治疗的临床症状(腹痛、阴道出血);单纯流产;需要干预的合并并发症的流产;孕早中期子宫破裂或子宫切除术;孕晚期出血、子宫破裂或子宫切除术;孕产妇死亡;异常侵入性胎盘 (abnormally invasive placenta,AIP)发生率;胎盘植入发生率;提示AIP的超声征象;活产。采用随机效应模型进行比例的meta分析以整合数据。基于诊断时是否存在胎芽或胎心活动对于病例进行分层。
结果
共计纳入17 项研究(69例接受期待治疗的CSP,52例有胎芽或胎心搏动,17例无)。在有胎芽或胎心活动的CSP妇女中,13.0%(95% CI,3.8%~26.7%)患者出现单纯流产,而20.0%(95% CI,7.1%~37.4%)患者需要药物干预。在孕早中期子宫破裂发生率为9.9%(95% CI,2.9%~20.4%),而15.2%(95% CI,3.6%~32.8%)患者需要行子宫切除术。40例进入孕晚期的妇女[76.9%(95% CI,65.4%~86.5%)],其中39.2%(95% CI,15.4%~66.2%)发生严重出血。最后,74.8%(95% CI,52.0%~92.1%)在分娩时手术或病理诊断AIP,约三分之二[69.7%(95% CI,42.8%~90.1%)]患者发生胎盘植入。在无胎芽或胎心活动的CSP妇女中,单纯流产发生率为69.1%(95% CI,47.4%~87.1%),而其中30.9%(95% CI,12.9%~52.6%)流产时或流产后立即需要手术或药物干预。孕早期子宫破裂发生率为13.4%(95% CI,2.7%~30.3%),而无病例需行子宫切除术。
结论
有胎芽或胎心活动的CSP妇女接受期待治疗与更高的孕产妇死亡率相关,包括严重出血、早期子宫破裂、子宫切除术以及严重AIP。尽管如此,仍有相当大比例的合并CSP的妊娠妇女几近分娩,因此质疑中断妊娠是否为此类妇女的唯一治疗选择。尽管建议对于无胎心活动的CSP妇女进行密切监测以避免孕产妇的不良结局,但鉴于需要干预的孕产妇并发症可能性较低,故接受期待治疗仍为此类妇女的理想选择。
This article's has been translated into Spanish and Chinese. Follow the links from the to view the translations.</description><identifier>ISSN: 0960-7692</identifier><identifier>EISSN: 1469-0705</identifier><identifier>DOI: 10.1002/uog.17568</identifier><identifier>PMID: 28661021</identifier><language>eng</language><publisher>Chichester, UK: John Wiley & Sons, Ltd</publisher><subject>abnormally invasive placenta ; Abortion ; Bleeding ; Cesarean scar pregnancy ; Complications ; Diagnosis ; Embryos ; Evidence-based medicine ; expectant management ; Fetuses ; Health risk assessment ; Heart ; Heart diseases ; Hemorrhage ; Hysterectomy ; Intervention ; Meta-analysis ; Miscarriage ; Morbidity ; Pain ; Placenta ; placenta accreta ; Pregnancy ; Pregnancy complications ; Rupture ; Surgery ; Systematic review ; Translations ; Ultrasound ; Uterus ; Vagina</subject><ispartof>Ultrasound in obstetrics & gynecology, 2018-02, Vol.51 (2), p.169-175</ispartof><rights>Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.</rights><rights>Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c4928-849788750592c446685a3fad5596fcbe662753e29f12fac5538dc890c12a256f3</citedby><cites>FETCH-LOGICAL-c4928-849788750592c446685a3fad5596fcbe662753e29f12fac5538dc890c12a256f3</cites><orcidid>0000-0001-9774-3107 ; 0000-0001-6880-7407 ; 0000-0002-7546-8025</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktopdf>$$Uhttps://onlinelibrary.wiley.com/doi/pdf/10.1002%2Fuog.17568$$EPDF$$P50$$Gwiley$$H</linktopdf><linktohtml>$$Uhttps://onlinelibrary.wiley.com/doi/full/10.1002%2Fuog.17568$$EHTML$$P50$$Gwiley$$H</linktohtml><link.rule.ids>230,314,776,780,881,1411,1427,27901,27902,45550,45551,46384,46808</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/28661021$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink><backlink>$$Uhttp://kipublications.ki.se/Default.aspx?queryparsed=id:137674437$$DView record from Swedish Publication Index$$Hfree_for_read</backlink></links><search><creatorcontrib>Calì, G.</creatorcontrib><creatorcontrib>Timor‐Tritsch, I. E.</creatorcontrib><creatorcontrib>Palacios‐Jaraquemada, J.</creatorcontrib><creatorcontrib>Monteaugudo, A.</creatorcontrib><creatorcontrib>Buca, D.</creatorcontrib><creatorcontrib>Forlani, F.</creatorcontrib><creatorcontrib>Familiari, A.</creatorcontrib><creatorcontrib>Scambia, G.</creatorcontrib><creatorcontrib>Acharya, G.</creatorcontrib><creatorcontrib>D'Antonio, F.</creatorcontrib><title>Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta‐analysis</title><title>Ultrasound in obstetrics & gynecology</title><addtitle>Ultrasound Obstet Gynecol</addtitle><description>ABSTRACT
Objective
To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP).
Methods
An electronic search of MEDLINE, EMBASE and
ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for ‘Cesarean scar pregnancy’ and ‘outcome’. Reference lists of relevant articles and reviews were hand‐searched for additional reports. Observed outcomes included: severe first‐trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first‐ or second‐trimester uterine rupture or hysterectomy; third‐trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta‐analyses of proportions using a random‐effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis.
Results
A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8–26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1–37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9–20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6–32.8%) of all cases. Forty (76.9% (95% CI, 65.4–86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4–66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0–92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two‐thirds (69.7% (95% CI, 42.8–90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4–87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9–52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7–30.3%) of cases, but hysterectomy was not required in any case.
Conclusions
CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Resumen
Resultado del embarazo sobre cicatriz de cesárea tratado de forma expectante: revisión sistemática y metaanálisis
Objetivo
Investigar el resultado en mujeres tratadas de forma expectante después del diagnóstico de embarazo sobre cicatriz de cesárea (CSP, por sus siglas en inglés).
Métodos
Se realizó una búsqueda electrónica en las bases de datos MEDLINE, EMBASE y ClinicalTrials.gov utilizando combinaciones de encabezados de temas médicos relevantes para ‘embarazo sobre cicatriz de cesárea’ y ‘resultado’. Para encontrar más informes se realizó una búsqueda manual en la bibliografía de cada artículo. Los resultados observados incluyeron: hemorragia vaginal grave en el primer trimestre; síntomas clínicos (dolor abdominal, hemorragia vaginal) que requirieron tratamiento; aborto sin complicaciones; aborto con complicaciones que requirieron intervención; ruptura uterina o histerectomía en el primer o segundo trimestre; hemorragia, ruptura uterina o histerectomía en el tercer trimestre; muerte materna; prevalencia de placenta invasiva (AIP, por sus siglas en inglés); prevalencia de placenta percreta; indicios de ultrasonido que sugieren AIP; y nacimiento vivo. Para combinar los datos se utilizó un metaanálisis de proporciones con un modelo de efectos aleatorios. Los casos se estratificaron en función de la presencia o ausencia de actividad cardíaca del embrión o del feto en el momento del diagnóstico.
Resultados
Se incluyeron un total de 17 estudios (69 casos de CSP tratados de forma expectante, 52 con presencia de latido del embrión/feto y 17 con ausencia de este). En mujeres con CSP y actividad cardíaca del embrión/feto, el 13,0% (IC 95%, 3,8–26,7%) experimentaron un aborto espontáneo sin complicaciones, mientras que el 20,0% (IC 95%, 7,1‐37,4%) requirieron intervención médica. La rotura uterina durante el primer o segundo trimestre del embarazo ocurrió en un 9,9% (IC 95%, 2,9–20,4%) de los casos, mientras que en un 15,2% (IC 95%, 3,6–32,8%) de todos los casos se requirió histerectomía. Cuarenta mujeres (76,9% (95% CI, 65,4–86,5%)) llegaron al tercer trimestre del embarazo, de las cuales el 39,2% (IC 95%, 15,4–66,2%) experimentaron una hemorragia severa. Finalmente, el 74,8% (IC 95%, 52,0–92,1%) recibió un diagnóstico quirúrgico o patológico de AIP en el momento del parto y alrededor de dos tercios (69,7% (IC 95%, 42,8–90,1%)) tenían placenta percreta. En mujeres con CSP pero sin actividad cardíaca del embrión o del feto, en el 69,1% (95% CI, 47,4–87,1%) de los casos se produjo un aborto espontáneo sin complicaciones, mientras que en un 30,9% se requirió intervención quirúrgica o médica durante o inmediatamente después del aborto (95% CI, 12,9–52,6%). La rotura uterina durante el primer trimestre del embarazo ocurrió en un 13,4% (IC 95%, 2.7–30.3%) de los casos, pero en ningún caso se requirió histerectomía.
Conclusiones
La CSP con actividad cardíaca positiva del embrión o del feto tratada de forma expectante se asocia con una alta carga de morbilidad materna que incluye hemorragia grave, ruptura uterina temprana, histerectomía y AIP grave. A pesar de esto, una proporción significativa de embarazos complicados por CSP pueden llegar a término, o cerca de este, lo que cuestiona si la terminación del embarazo debería ser la única opción terapéutica ofrecida a estas mujeres. El tratamiento de forma expectante de la CSP sin actividad cardíaca puede ser una opción razonable, en vista de la baja probabilidad de complicaciones maternas que requieren intervención, aunque se recomienda una intensa vigilancia para evitar resultados maternos adversos.
摘要
剖宫产瘢痕妊娠期待治疗的结局:系统综述和meta分析
目的
探讨诊断为剖宫产瘢痕妊娠(Cesarean scar pregnancy,CSP)妇女经期待治疗后的结局。
方法
在MEDLINE、EMBASE和ClinicalTrials.gov数据库中进行“Cesarean scar pregnancy”和“outcome”相关医学主题词组合检索。手式检索相关文章及综述中的参考文献以发现其他研究。纳入的观察结局包括:严重的孕早期阴道出血;需治疗的临床症状(腹痛、阴道出血);单纯流产;需要干预的合并并发症的流产;孕早中期子宫破裂或子宫切除术;孕晚期出血、子宫破裂或子宫切除术;孕产妇死亡;异常侵入性胎盘 (abnormally invasive placenta,AIP)发生率;胎盘植入发生率;提示AIP的超声征象;活产。采用随机效应模型进行比例的meta分析以整合数据。基于诊断时是否存在胎芽或胎心活动对于病例进行分层。
结果
共计纳入17 项研究(69例接受期待治疗的CSP,52例有胎芽或胎心搏动,17例无)。在有胎芽或胎心活动的CSP妇女中,13.0%(95% CI,3.8%~26.7%)患者出现单纯流产,而20.0%(95% CI,7.1%~37.4%)患者需要药物干预。在孕早中期子宫破裂发生率为9.9%(95% CI,2.9%~20.4%),而15.2%(95% CI,3.6%~32.8%)患者需要行子宫切除术。40例进入孕晚期的妇女[76.9%(95% CI,65.4%~86.5%)],其中39.2%(95% CI,15.4%~66.2%)发生严重出血。最后,74.8%(95% CI,52.0%~92.1%)在分娩时手术或病理诊断AIP,约三分之二[69.7%(95% CI,42.8%~90.1%)]患者发生胎盘植入。在无胎芽或胎心活动的CSP妇女中,单纯流产发生率为69.1%(95% CI,47.4%~87.1%),而其中30.9%(95% CI,12.9%~52.6%)流产时或流产后立即需要手术或药物干预。孕早期子宫破裂发生率为13.4%(95% CI,2.7%~30.3%),而无病例需行子宫切除术。
结论
有胎芽或胎心活动的CSP妇女接受期待治疗与更高的孕产妇死亡率相关,包括严重出血、早期子宫破裂、子宫切除术以及严重AIP。尽管如此,仍有相当大比例的合并CSP的妊娠妇女几近分娩,因此质疑中断妊娠是否为此类妇女的唯一治疗选择。尽管建议对于无胎心活动的CSP妇女进行密切监测以避免孕产妇的不良结局,但鉴于需要干预的孕产妇并发症可能性较低,故接受期待治疗仍为此类妇女的理想选择。
This article's has been translated into Spanish and Chinese. Follow the links from the to view the translations.</description><subject>abnormally invasive placenta</subject><subject>Abortion</subject><subject>Bleeding</subject><subject>Cesarean scar pregnancy</subject><subject>Complications</subject><subject>Diagnosis</subject><subject>Embryos</subject><subject>Evidence-based medicine</subject><subject>expectant management</subject><subject>Fetuses</subject><subject>Health risk assessment</subject><subject>Heart</subject><subject>Heart diseases</subject><subject>Hemorrhage</subject><subject>Hysterectomy</subject><subject>Intervention</subject><subject>Meta-analysis</subject><subject>Miscarriage</subject><subject>Morbidity</subject><subject>Pain</subject><subject>Placenta</subject><subject>placenta accreta</subject><subject>Pregnancy</subject><subject>Pregnancy complications</subject><subject>Rupture</subject><subject>Surgery</subject><subject>Systematic review</subject><subject>Translations</subject><subject>Ultrasound</subject><subject>Uterus</subject><subject>Vagina</subject><issn>0960-7692</issn><issn>1469-0705</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2018</creationdate><recordtype>article</recordtype><recordid>eNp10c1O3DAUBWCrKioD7aIvgCx1UxYB27Edm101AloJaTawRNYd52YUmj_shGl2fQSekSdpIFMWSKx8ZX0-utYh5CtnJ5wxcTq0mxOeKW0-kAWX2iYsY-ojWTCrWZJpK_bJQYx3jDEtU_2J7AujNWeCL8jtauh9WyNtC7rECAGhodFDoF3ATQONH2kNDWwwp_inQ99D01fjGY1j7LGGvvQ04EOJWwpNTmvs4env4_SgGmMZP5O9AqqIX3bnIbm5OL9e_kyuVpe_lj-uEi-tMImRNjMmU0xZ4aXU2ihIC8iVsrrwa9RaZCpFYQsuCvBKpSb3xjLPBQili_SQJHNu3GI3rF0XyhrC6Foo3e7q9zShk1ZlUkz---y70N4PGHtXl9FjVUGD7RAdt1waabSVE_32ht61Q5j-96ysSZVMX9TxrHxoYwxYvK7AmXvuyE0duZeOJnu0SxzWNeav8n8pEzidwbascHw_yd2sLufIfzU6nBA</recordid><startdate>201802</startdate><enddate>201802</enddate><creator>Calì, G.</creator><creator>Timor‐Tritsch, I. E.</creator><creator>Palacios‐Jaraquemada, J.</creator><creator>Monteaugudo, A.</creator><creator>Buca, D.</creator><creator>Forlani, F.</creator><creator>Familiari, A.</creator><creator>Scambia, G.</creator><creator>Acharya, G.</creator><creator>D'Antonio, F.</creator><general>John Wiley & Sons, Ltd</general><general>Wiley Subscription Services, Inc</general><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7QO</scope><scope>8FD</scope><scope>FR3</scope><scope>K9.</scope><scope>P64</scope><scope>7X8</scope><scope>ADTPV</scope><scope>AOWAS</scope><orcidid>https://orcid.org/0000-0001-9774-3107</orcidid><orcidid>https://orcid.org/0000-0001-6880-7407</orcidid><orcidid>https://orcid.org/0000-0002-7546-8025</orcidid></search><sort><creationdate>201802</creationdate><title>Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta‐analysis</title><author>Calì, G. ; Timor‐Tritsch, I. E. ; Palacios‐Jaraquemada, J. ; Monteaugudo, A. ; Buca, D. ; Forlani, F. ; Familiari, A. ; Scambia, G. ; Acharya, G. ; D'Antonio, F.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c4928-849788750592c446685a3fad5596fcbe662753e29f12fac5538dc890c12a256f3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2018</creationdate><topic>abnormally invasive placenta</topic><topic>Abortion</topic><topic>Bleeding</topic><topic>Cesarean scar pregnancy</topic><topic>Complications</topic><topic>Diagnosis</topic><topic>Embryos</topic><topic>Evidence-based medicine</topic><topic>expectant management</topic><topic>Fetuses</topic><topic>Health risk assessment</topic><topic>Heart</topic><topic>Heart diseases</topic><topic>Hemorrhage</topic><topic>Hysterectomy</topic><topic>Intervention</topic><topic>Meta-analysis</topic><topic>Miscarriage</topic><topic>Morbidity</topic><topic>Pain</topic><topic>Placenta</topic><topic>placenta accreta</topic><topic>Pregnancy</topic><topic>Pregnancy complications</topic><topic>Rupture</topic><topic>Surgery</topic><topic>Systematic review</topic><topic>Translations</topic><topic>Ultrasound</topic><topic>Uterus</topic><topic>Vagina</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Calì, G.</creatorcontrib><creatorcontrib>Timor‐Tritsch, I. E.</creatorcontrib><creatorcontrib>Palacios‐Jaraquemada, J.</creatorcontrib><creatorcontrib>Monteaugudo, A.</creatorcontrib><creatorcontrib>Buca, D.</creatorcontrib><creatorcontrib>Forlani, F.</creatorcontrib><creatorcontrib>Familiari, A.</creatorcontrib><creatorcontrib>Scambia, G.</creatorcontrib><creatorcontrib>Acharya, G.</creatorcontrib><creatorcontrib>D'Antonio, F.</creatorcontrib><collection>PubMed</collection><collection>CrossRef</collection><collection>Biotechnology Research Abstracts</collection><collection>Technology Research Database</collection><collection>Engineering Research Database</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Biotechnology and BioEngineering Abstracts</collection><collection>MEDLINE - Academic</collection><collection>SwePub</collection><collection>SwePub Articles</collection><jtitle>Ultrasound in obstetrics & gynecology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Calì, G.</au><au>Timor‐Tritsch, I. E.</au><au>Palacios‐Jaraquemada, J.</au><au>Monteaugudo, A.</au><au>Buca, D.</au><au>Forlani, F.</au><au>Familiari, A.</au><au>Scambia, G.</au><au>Acharya, G.</au><au>D'Antonio, F.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta‐analysis</atitle><jtitle>Ultrasound in obstetrics & gynecology</jtitle><addtitle>Ultrasound Obstet Gynecol</addtitle><date>2018-02</date><risdate>2018</risdate><volume>51</volume><issue>2</issue><spage>169</spage><epage>175</epage><pages>169-175</pages><issn>0960-7692</issn><eissn>1469-0705</eissn><abstract>ABSTRACT
Objective
To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP).
Methods
An electronic search of MEDLINE, EMBASE and
ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for ‘Cesarean scar pregnancy’ and ‘outcome’. Reference lists of relevant articles and reviews were hand‐searched for additional reports. Observed outcomes included: severe first‐trimester vaginal bleeding; clinical symptoms (abdominal pain, vaginal bleeding) requiring treatment; uncomplicated miscarriage; complicated miscarriage requiring intervention; first‐ or second‐trimester uterine rupture or hysterectomy; third‐trimester bleeding, uterine rupture or hysterectomy; maternal death; incidence of abnormally invasive placenta (AIP); prevalence of placenta percreta; ultrasound signs suggestive of AIP; and live birth. Meta‐analyses of proportions using a random‐effects model were used to combine data. Cases were stratified based on the presence or absence of embryonic/fetal heart activity at the time of diagnosis.
Results
A total of 17 studies (69 cases of CSP managed expectantly, 52 with and 17 without embryonic/fetal heart beat) were included. In women with CSP and embryonic/fetal heart activity, 13.0% (95% CI, 3.8–26.7%) experienced an uncomplicated miscarriage, while 20.0% (95% CI, 7.1–37.4%) required medical intervention. Uterine rupture during the first or second trimester of pregnancy occurred in 9.9% (95% CI, 2.9–20.4%) of cases, while hysterectomy was required in 15.2% (95% CI, 3.6–32.8%) of all cases. Forty (76.9% (95% CI, 65.4–86.5%)) women progressed to the third trimester of pregnancy, of whom 39.2% (95% CI, 15.4–66.2%) experienced severe bleeding. Finally, 74.8% (95% CI, 52.0–92.1%) had a surgical or pathological diagnosis of AIP at delivery and around two‐thirds (69.7% (95% CI, 42.8–90.1%)) of them had placenta percreta. In women with CSP but no embryonic/fetal cardiac activity, an uncomplicated miscarriage occurred in 69.1% (95% CI, 47.4–87.1%) of cases, while surgical or medical intervention during or immediately after miscarriage was required in 30.9% (95% CI, 12.9–52.6%). Uterine rupture during the first trimester of pregnancy occurred in 13.4% (95% CI, 2.7–30.3%) of cases, but hysterectomy was not required in any case.
Conclusions
CSP with positive embryonic/fetal heart activity managed expectantly is associated with a high burden of maternal morbidity including severe hemorrhage, early uterine rupture, hysterectomy and severe AIP. Despite this, a significant proportion of pregnancies complicated by CSP may progress to, or close to, term, thus questioning whether termination of pregnancy should be the only therapeutic option offered to these women. Expectant management of CSP with no cardiac activity may be a reasonable option in view of the low likelihood of maternal complications requiring intervention, although close surveillance is advisable to avoid adverse maternal outcome. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
Resumen
Resultado del embarazo sobre cicatriz de cesárea tratado de forma expectante: revisión sistemática y metaanálisis
Objetivo
Investigar el resultado en mujeres tratadas de forma expectante después del diagnóstico de embarazo sobre cicatriz de cesárea (CSP, por sus siglas en inglés).
Métodos
Se realizó una búsqueda electrónica en las bases de datos MEDLINE, EMBASE y ClinicalTrials.gov utilizando combinaciones de encabezados de temas médicos relevantes para ‘embarazo sobre cicatriz de cesárea’ y ‘resultado’. Para encontrar más informes se realizó una búsqueda manual en la bibliografía de cada artículo. Los resultados observados incluyeron: hemorragia vaginal grave en el primer trimestre; síntomas clínicos (dolor abdominal, hemorragia vaginal) que requirieron tratamiento; aborto sin complicaciones; aborto con complicaciones que requirieron intervención; ruptura uterina o histerectomía en el primer o segundo trimestre; hemorragia, ruptura uterina o histerectomía en el tercer trimestre; muerte materna; prevalencia de placenta invasiva (AIP, por sus siglas en inglés); prevalencia de placenta percreta; indicios de ultrasonido que sugieren AIP; y nacimiento vivo. Para combinar los datos se utilizó un metaanálisis de proporciones con un modelo de efectos aleatorios. Los casos se estratificaron en función de la presencia o ausencia de actividad cardíaca del embrión o del feto en el momento del diagnóstico.
Resultados
Se incluyeron un total de 17 estudios (69 casos de CSP tratados de forma expectante, 52 con presencia de latido del embrión/feto y 17 con ausencia de este). En mujeres con CSP y actividad cardíaca del embrión/feto, el 13,0% (IC 95%, 3,8–26,7%) experimentaron un aborto espontáneo sin complicaciones, mientras que el 20,0% (IC 95%, 7,1‐37,4%) requirieron intervención médica. La rotura uterina durante el primer o segundo trimestre del embarazo ocurrió en un 9,9% (IC 95%, 2,9–20,4%) de los casos, mientras que en un 15,2% (IC 95%, 3,6–32,8%) de todos los casos se requirió histerectomía. Cuarenta mujeres (76,9% (95% CI, 65,4–86,5%)) llegaron al tercer trimestre del embarazo, de las cuales el 39,2% (IC 95%, 15,4–66,2%) experimentaron una hemorragia severa. Finalmente, el 74,8% (IC 95%, 52,0–92,1%) recibió un diagnóstico quirúrgico o patológico de AIP en el momento del parto y alrededor de dos tercios (69,7% (IC 95%, 42,8–90,1%)) tenían placenta percreta. En mujeres con CSP pero sin actividad cardíaca del embrión o del feto, en el 69,1% (95% CI, 47,4–87,1%) de los casos se produjo un aborto espontáneo sin complicaciones, mientras que en un 30,9% se requirió intervención quirúrgica o médica durante o inmediatamente después del aborto (95% CI, 12,9–52,6%). La rotura uterina durante el primer trimestre del embarazo ocurrió en un 13,4% (IC 95%, 2.7–30.3%) de los casos, pero en ningún caso se requirió histerectomía.
Conclusiones
La CSP con actividad cardíaca positiva del embrión o del feto tratada de forma expectante se asocia con una alta carga de morbilidad materna que incluye hemorragia grave, ruptura uterina temprana, histerectomía y AIP grave. A pesar de esto, una proporción significativa de embarazos complicados por CSP pueden llegar a término, o cerca de este, lo que cuestiona si la terminación del embarazo debería ser la única opción terapéutica ofrecida a estas mujeres. El tratamiento de forma expectante de la CSP sin actividad cardíaca puede ser una opción razonable, en vista de la baja probabilidad de complicaciones maternas que requieren intervención, aunque se recomienda una intensa vigilancia para evitar resultados maternos adversos.
摘要
剖宫产瘢痕妊娠期待治疗的结局:系统综述和meta分析
目的
探讨诊断为剖宫产瘢痕妊娠(Cesarean scar pregnancy,CSP)妇女经期待治疗后的结局。
方法
在MEDLINE、EMBASE和ClinicalTrials.gov数据库中进行“Cesarean scar pregnancy”和“outcome”相关医学主题词组合检索。手式检索相关文章及综述中的参考文献以发现其他研究。纳入的观察结局包括:严重的孕早期阴道出血;需治疗的临床症状(腹痛、阴道出血);单纯流产;需要干预的合并并发症的流产;孕早中期子宫破裂或子宫切除术;孕晚期出血、子宫破裂或子宫切除术;孕产妇死亡;异常侵入性胎盘 (abnormally invasive placenta,AIP)发生率;胎盘植入发生率;提示AIP的超声征象;活产。采用随机效应模型进行比例的meta分析以整合数据。基于诊断时是否存在胎芽或胎心活动对于病例进行分层。
结果
共计纳入17 项研究(69例接受期待治疗的CSP,52例有胎芽或胎心搏动,17例无)。在有胎芽或胎心活动的CSP妇女中,13.0%(95% CI,3.8%~26.7%)患者出现单纯流产,而20.0%(95% CI,7.1%~37.4%)患者需要药物干预。在孕早中期子宫破裂发生率为9.9%(95% CI,2.9%~20.4%),而15.2%(95% CI,3.6%~32.8%)患者需要行子宫切除术。40例进入孕晚期的妇女[76.9%(95% CI,65.4%~86.5%)],其中39.2%(95% CI,15.4%~66.2%)发生严重出血。最后,74.8%(95% CI,52.0%~92.1%)在分娩时手术或病理诊断AIP,约三分之二[69.7%(95% CI,42.8%~90.1%)]患者发生胎盘植入。在无胎芽或胎心活动的CSP妇女中,单纯流产发生率为69.1%(95% CI,47.4%~87.1%),而其中30.9%(95% CI,12.9%~52.6%)流产时或流产后立即需要手术或药物干预。孕早期子宫破裂发生率为13.4%(95% CI,2.7%~30.3%),而无病例需行子宫切除术。
结论
有胎芽或胎心活动的CSP妇女接受期待治疗与更高的孕产妇死亡率相关,包括严重出血、早期子宫破裂、子宫切除术以及严重AIP。尽管如此,仍有相当大比例的合并CSP的妊娠妇女几近分娩,因此质疑中断妊娠是否为此类妇女的唯一治疗选择。尽管建议对于无胎心活动的CSP妇女进行密切监测以避免孕产妇的不良结局,但鉴于需要干预的孕产妇并发症可能性较低,故接受期待治疗仍为此类妇女的理想选择。
This article's has been translated into Spanish and Chinese. Follow the links from the to view the translations.</abstract><cop>Chichester, UK</cop><pub>John Wiley & Sons, Ltd</pub><pmid>28661021</pmid><doi>10.1002/uog.17568</doi><tpages>7</tpages><orcidid>https://orcid.org/0000-0001-9774-3107</orcidid><orcidid>https://orcid.org/0000-0001-6880-7407</orcidid><orcidid>https://orcid.org/0000-0002-7546-8025</orcidid><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
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| ispartof | Ultrasound in obstetrics & gynecology, 2018-02, Vol.51 (2), p.169-175 |
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| subjects | abnormally invasive placenta Abortion Bleeding Cesarean scar pregnancy Complications Diagnosis Embryos Evidence-based medicine expectant management Fetuses Health risk assessment Heart Heart diseases Hemorrhage Hysterectomy Intervention Meta-analysis Miscarriage Morbidity Pain Placenta placenta accreta Pregnancy Pregnancy complications Rupture Surgery Systematic review Translations Ultrasound Uterus Vagina |
| title | Outcome of Cesarean scar pregnancy managed expectantly: systematic review and meta‐analysis |
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