Placenta creta is associated with massive postpartum hemorrhage and commonly leads to emergency hysterectomy. While the exact pathogenesis of placenta creta is unknown, proposed hypotheses include a primary deficiency of decidua, abnormal maternal vascular remodeling, excessive trophoblastic invasion, or a combination thereof. To assess these changes in placenta creta, we retrospectively reviewed 49 cases of gravid hysterectomy, 38 with and 11 without the diagnosis of creta, gathered clinical data, and evaluated histopathology of extravillous trophoblast. Specifically, we evaluated maternal vessels for remodeling by endovascular trophoblast, as well as the morphology and depth of invasion of interstitial trophoblast at the implantation site. Compared to controls, cases with creta had decreased proportion of remodeled vessels, with many vessels displaying partial physiologic change. Cases with creta also demonstrated vascular remodeling deeper in the myometrium; however, vascular remodeling of large outer myometrial vessels was only demonstrated in increta and percreta cases, and was absent in both non-creta and accreta. As previously reported, interstitial trophoblast invaded the uterine wall to a significantly greater depth in placenta creta; however, there was no significant difference between creta subtypes. Finally, Ki-67 staining was rarely observed in extravillous trophoblast, except in the trophoblast columns of first trimester creta cases. We, therefore, conclude that the pathogenesis of placenta creta is multi-dimensional, involving increased, but incomplete trophoblast invasion in a background of absent decidua. We further propose that placenta increta and percreta are not due to a further invasion of extravillous trophoblast in the uterine wall, rather they likely arise secondary to dehiscence of a scar, leading to the presence of chorionic villi deep within the uterine wall, and thus give extravillous trophoblast greater access to the deep myometrium.

To explore the outcome in women managed expectantly following the diagnosis of Cesarean scar pregnancy (CSP).

Caesarean scar ectopic pregnancy (CSEP) is a uncommon presentation of pregnancy with incidence of nearly 1 in 2000 pregnancies. We present this case series of scar pregnancy with a objective to help obstetricians in early diagnosis and appropriate management to prevent its catastrophic complications.

This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.Copyright © 2012. Published by Mosby, Inc.

To establish a new cesarean scar ectopic pregnancy clinical classification system with recommended individual surgical strategy and to evaluate its clinical efficacy in treatment of cesarean scar ectopic pregnancy.This retrospective cohort study included patients with cesarean scar ectopic pregnancy in Qilu Hospital in Shandong, China. From 2008 to 2015, patients with cesarean scar ectopic pregnancy were included to determine risk factors for intraoperative hemorrhage during cesarean scar ectopic pregnancy treatment. Univariable analysis and multivariable logistic regression analyses were used to explore the independent risk factors for hemorrhage (300 mL or greater) during a cesarean scar ectopic pregnancy surgical procedure. The model was internally validated with a separate cohort. Receiver operating characteristic curve methodology was used to identify optimal thresholds for the identified risk factors to further classify cesarean scar ectopic pregnancy risk, and the recommended operative treatment was established for each classification group by expert consensus. A final cohort of patients from 2014 to 2022 were classified according to the new classification system, and the recommended surgical procedure and clinical outcomes were abstracted from the medical record.Overall, 955 patients with first-trimester cesarean scar ectopic pregnancy were included; 273 were used to develop a model to predict intraoperative hemorrhage with cesarean scar ectopic pregnancy, and 118 served as an internal validation group for the model. Anterior myometrium thickness at the scar (adjusted odds ratio [aOR] 0.51, 95% CI 0.36-0.73) and average diameter of the gestational sac or mass (aOR 1.10, 95% CI 1.07-1.14) were independent risk factors for intraoperative hemorrhage of cesarean scar ectopic pregnancy. Five clinical classifications of cesarean scar ectopic pregnancy were established on the basis of the thickness and gestational sac diameter, and the optimal surgical option for each type was recommended by clinical experts. When the classification system was applied to a separate cohort of 564 patients with cesarean scar ectopic pregnancy, the overall success rate of recommended first-line treatment with the new classification grouping was 97.5% (550/564). No patients needed to undergo hysterectomy. Eighty-five percent of patients had a negative serum β-hCG level within 3 weeks after the surgical procedure; 95.2% of patients resumed their menstrual cycles within 8 weeks.Anterior myometrium thickness at the scar and the diameter of the gestational sac were confirmed to be independent risk factors for intraoperative hemorrhage during cesarean scar ectopic pregnancy treatment. A new clinical classification system based on these factors with recommended surgical strategy resulted in high treatment success rates with minimal complications.Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.

To study the risk factors leading to type II/III cesarean scar pregnancy and evaluate the efficacy of hysteroscopic treatment and subsequent reproductive outcomes.Retrospective study from 2013 to 2018.Inpatient samples.A total of 439 patients with cesarean scar pregnancy received hysteroscopic treatment. They were grouped according to the type of surgery as hysteroscopy combined with dilation and curettage, systemic methotrexate followed by hysteroscopy combined with dilation and curettage, and uterine artery embolization or laparoscopic ligation of bilateral uterine arteries followed by hysteroscopy combined with dilation and curettage. Cesarean scar pregnancy was classified as types I, II, and III on the basis of the relationship between the gestational sac and myometrial thickness by ultrasound.Not applicable.Risk factors leading to type II/III cesarean scar pregnancy. The success of hysteroscopic treatment as well as favorable reproductive outcomes.The significant variables were multiple parity, prior cesarean section (CS), hysteroscopic therapy, and dilation and curettage after the last CS between type I and type II/III. There were significant differences among the three groups in symptoms, largest diameter of the gestational sac, presence of fetal heartbeat, myometrial thickness, type of cesarean scar pregnancy, blood loss, length of hospital stay, and expense. The rates of complications and success were 8.2% and 93.6%, respectively. Thirty-seven women conceived again, and 22 women completed a term pregnancy with no uterine rupture. The recurrence rate of cesarean scar pregnancy was 10.8%.The type of cesarean scar pregnancy is related to the rates of multiple parity, cesarean deliveries, and dilation and curettage procedures after the last CS. Hysteroscopic therapy is a safe and effective surgical approach with a low risk of subsequent ectopic pregnancy.Copyright © 2021 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.