Novel cross-over sign in cesarean scar pregnancy helps predicts the risk of invasive placentation

power-point slide by ISUOG

First trimester ultrasound scan evaluating the relationship between the gestational sac and the endometrial line in women with cesarean scar pregnancy(CSP) helps predicts the development of abnormally invasive placenta (AIP) and consecutive intra and post-operative surgical morbidities reports the results of a retrospective case series published in Journal of International Society of Ultrasound in Obstetrics and Gynecology.

Recent advances in prenatal imaging and increase rate of cesarean sections have led to increased diagnosis of CSP. Although, most of the patients with CSP present with severe hemorrhage or rupture uterus, that requires emergency surgical management, few advance further, evolving into AIP.

There is no reliable marker that can predict whether a woman with CSP will end up in early abortion or further progress to develop placenta percreta or other less severe forms of AIP.

A novel ultrasound cross-over sign (COS) has recently been thought to predict the evolution of CSP into different forms of AIP so that the intraoperative and postoperative risk can be stratified.

A straight line is drawn from internal cervical os to the fundus of the uterus in sagittal view through the endometrium. The gestational sac is identified, and its superior-inferior diameter measured. The COS is classified according to the relationship of ectopic sac diameter with the endometrial straight line into COS-1 and COS-2.

This case series identified 102 women over a period of 8 years with AIP diagnosis confirmed by histopathological examination (HPE), of whom 68 patients had a first-trimester ultrasound with a diagnosis of CSP. The scans were read by sonographers who did not have any idea about the pregnancy outcome and pathology reports.  

COS sign was assessed as mentioned, and all patients received counseling regarding the prognosis, risk, and post-operative complications. Women with severe AIP were delivered early, as compared to less severe variants.

All women underwent cesarean hysterectomy with temporary occlusion of the internal iliac artery and ureteric stent in place. At HPE, 34 cases were diagnosed with placenta percreta, 13 with placenta increta and 21 with placenta accreta.

Pregnancies with COS-1 had early deliveries, longer operating time, more blood loss and required much more packed red blood cells during surgery mean as compared with those with COS-2+ or COS-2–.

Thus, predicting the likely course CSP diagnosed by COS sign in the first trimester can improve shared decision making between the patient and provider about the surgical difficulties endured, amount of blood loss and need for cesarean hysterectomy.

Large, multi-center studies to determine the role of COS sign in predicting the severity of AIP in CSP is needed in future.

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Pregnancy after Endometrial Ablation is rare but associated with high maternal and neonatal morbidity

https://www.invitra.com

Women undergoing Endometrial ablation should be informed that pregnancy is possible after the procedure and is associated with significant maternal and neonatal morbidity. She should be advised to use contraception after the procedure says the results of a systematic review published 27 September 2017 in British Journal of Obstetrics and Gynecology (BJOG).

This is the first systematic review published on this topic despite years of use of endometrial ablation for Abnormal Uterine Bleeding (AUB).  After a new technology is introduced, it takes years to come to know about unintended consequences and pregnancy is a late complication of EA.

This review by Kohn et al. reports 274 cases of pregnancy after endometrial ablation in median 1.5 years after the procedure (range 3 weeks – 13 years). The mean age of women was 37.5 ± 5(range 26-50 years). About 80-90% had not used any form of contraception, but the remaining does use some form of contraception.

1 in 4 pregnant women were amenorrhoeic after ablation.

About 4 out of every 5 pregnancies ended into miscarriage, ectopic or termination. Those who continued either had preterm labor, preterm premature rupture of membranes (PROM), morbidly adherent placenta, cesarean, cesarean hysterectomy and rupture of uterus. There was also higher incidence of neonatal complications like IUGR, prematurity, IUD or early neonatal demise.

Methods of doing Endometrial Ablation
http://www.cmdrc.com

It was also seen that first generations ablation devices were more commonly used in clinical practice and have higher rates of less completely ablated endometrium, with lower rates of post-ablation amenorrhea and concomitant higher risk for subsequent pregnancy.

Physicians should explain in detail the risk of post-ablation pregnancy, using reliable contraception even if they are amenorrhoeic or perimenopausal.

In an accompanying commentary, Sharp HT focuses that physicians should think of alternative ways to treat AUB like levonorgestrel-containing intrauterine devices or delay ablation until completion of childbearing. If women still desire pregnancy after ablation, surrogacy or adoption can be a valid alternative.

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