[Cesarean scar ectopic pregnancies: combined modality therapies with uterine artery embolization before surgical procedure].
OBJECTIVE
To offer a therapeutic management of cesarean scar pregnancies (GSC) in the first trimester of pregnancy with a first approach by uterine artery embolization (UAE) PATIENTS AND METHODS: This study describes seven cases of GSC diagnosed between 2009 and 2013 in the clinic of the University Hospital of the Hospital of Croix-Rousse. We present the symptoms and how imagery has led to the diagnosis and the therapeutic management conducted.


RESULTS
The mean gestational age at diagnosis was 9 weeks gestation. There were ongoing pregnancies with cardiac activity present for each patient. An additional MRI was performed in five patients. Five patients were treated with methotrexate injection, two patients received the Mifegyne. All patients then received a selective uterine artery embolization. Finally within 48hours, suction curettage was performed in 6 patients. A patient at 13 WA+1 required a subtotal hysterectomy for placenta accreta. Intra-operative complications were represented by a bladder injury, two bleeding of 1000mL in patients at 13 WA+1 and 12 WA. For the 6 cases of GSC with a gestational age less than 10 WA, average blood loss was less than 500mL. Three patients underwent resection of scar isthmocele confirmed by EVAC. An intrauterine pregnancy was carried to term after care.


CONCLUSIONS
Cesarean scar pregnancies is a diagnostic and therapeutic challenge, which should be diagnosed as early as soon as possible with care in a medical facility with a uterine artery embolization technical platform. Our protocol combining Mifegyne and methotrexate for termination of pregnancy and uterine artery embolization (UAE) followed by curettage for evacuation of pregnancy allows conservative treatment while minimizing the risk of bleeding (for GSC diagnosed before 10 WA).
Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France. Electronic address: jlegall@9online.fr.
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Le Gall
Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France.
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Fichez
Service de gynécologie-obstétrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69500 Bron, France.
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Lamblin
Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France.
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Philip
Service de gynécologie-obstétrique, hôpital de la Croix-Rousse, hospices civils de Lyon, 93, Grande-Rue-de-la-Croix-Rousse, 69004 Lyon, France; Inserm U846, Stem Cell and Brain Research Institute, université de Lyon-1, 18, avenue Doyen-Lepine, 69500 Bron, France; UMR-S 846, 69003 Lyon, France.
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Huissoud
D000020:Abortifacient Agents, Nonsteroidal; D000021:Abortifacient Agents, Steroidal; D016063:Blood Loss, Surgical; D002585:Cesarean Section / Q000009:adverse effects*; D002921:Cicatrix / Q000209:etiology; D003131:Combined Modality Therapy; D003475:Curettage; D005260:Female; D005865:Gestational Age; D006801:Humans; D007044:Hysterectomy; D008727:Methotrexate / Q000008:administration & dosage; D015735:Mifepristone / Q000008:administration & dosage; D011247:Pregnancy; D011261:Pregnancy Trimester, First; D011271:Pregnancy, Ectopic / Q000175:diagnosis / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D055357:Uterine Artery Embolization / Q000009:adverse effects / Q000379:methods
D000020:Abortifacient Agents, Nonsteroidal; D000021:Abortifacient Agents, Steroidal; D015735:Mifepristone; D008727:Methotrexate
Aspiration et curetage utérin; Cesarean scar pregnancy; Combined Modality Therapies; Embolisation des artères utérines; First trimestre; Grossesse sur cicatrice de césarienne; Methotrexate; Premier trimestre; Traitement combiné; Uterine artery embolization; Uterine curettage