title: Diagnostic multimodal imaging and therapeutic transcatheter arterial chemoembolization for conservative management of hemorrhagic cesarean scar pregnancy.
abstract: OBJECTIVE
  To evaluate the value of emergency transcatheter arterial chemoembolization (TACE) for initial conservative management of hemorrhagic cesarean scar pregnancy after multimodal image diagnosis.
  
  
  METHODS
  Five consecutive cases of hemorrhagic cesarean scar pregnancy were diagnosed for precise localization of ectopic placentation site, depth of placental invasion and uteroplacental neovascularization by imaging studies including color Doppler ultrasonography, magnetic resonance imaging (MRI) and three-dimensional computerized tomographic angiography. Emergency TACE with dactinomycin was initially performed to achieve immediate hemostasis and cytotoxic effects on chorionic villous tissue. Then, the need for either expectant management or subsequent hysteroscopic resection was individually determined. Systemic methotrexate (MTX) administration was added when delayed decline of serum hCG value was noted.
  
  
  RESULTS
  On MRI, total placental invasion to the serosa of the anterior uterine wall was diagnosed in three cases, while the two remaining cases showed subtotal invasion to the anterior uterine wall. All cases were managed by emergency TACE as an initial conservative measure. Subsequently, spontaneous expulsion of gestational products occurred in one case of subtotal placental invasion. Additional MTX administration was required to achieve complete resorption of cesarean scar pregnancy in two cases of total placental invasion. In one case of subtotal placental invasion, successful hysteroscopic resection was performed under laparoscopic guidance, whereas, in one case of total placental invasion, hysteroscopic removal of gestational products was incomplete due to the risk of uterine perforation and additional systemic MTX administration was required for complete resolution. Uterine preservation was achieved in all cases without unfavorable effects of TACE or secondary hemorrhagic complications.
  
  
  CONCLUSIONS
  This small case series emphasizes that TACE is potentially useful as an initial emergency intervention for conservative management of hemorrhagic cesarean scar pregnancy to achieve immediate hemostasis and direct cytotoxic effects on chorionic villous tissue with minimal systemic side effects of chemotherapeutic agent.
authors.affiliation: Department of Obstetrics and Gynecology, Gifu Prefectural Tajimi Hospital, Tajimi, Gifu 507-8522, Japan. gyendoscopy@gmail.com
authors.forename: Akihiro
authors.initials: A
authors.lastname: Takeda
authors.forename: Kazuyuki
authors.initials: K
authors.lastname: Koyama
authors.forename: Sanae
authors.initials: S
authors.lastname: Imoto
authors.forename: Masahiko
authors.initials: M
authors.lastname: Mori
authors.forename: Tomoko
authors.initials: T
authors.lastname: Nakano
authors.forename: Hiromi
authors.initials: H
authors.lastname: Nakamura
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000009:adverse effects*; D016461:Chemoembolization, Therapeutic; D002921:Cicatrix / Q000000981:diagnostic imaging / Q000628:therapy; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008727:Methotrexate / Q000627:therapeutic use; D011247:Pregnancy; D011248:Pregnancy Complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D011271:Pregnancy, Ectopic / Q000175:diagnosis* / Q000000981:diagnostic imaging; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D018615:Ultrasonography, Doppler, Color / Q000379:methods; D014592:Uterine Hemorrhage / Q000628:therapy*
chemical_list: D008727:Methotrexate