| Cesarean scar pregnancy(CSP)means that the gestational sac is implanted in the scar of the previous cesarean section.It is a serious long-term complication of cesarean section.The incidence of CSP has surged dramatically especially in China with the sudden opening of the “two-child policy” and many women with previous cesarean section got pregnant again.CSP is a life-threatening situation because of the massive hemorrhaging that occurs during pregnancy or surgical curettage.Although there exist diagnostic criteria and type-differentiating method,there is no systematic method of classifying severity of CSP and the intensity of treatment needed.A variety of treatment modalities have been reported for CSP with different effects,however,no standardized treatment guidelines were available.Objectives1.To establish an ultrasound quantitative pre-scoring system by retrospectively analyse the ultrasound and clinical parameters which predicted the severity of CSP.2.Conduct a prospective study based on retrospective studies to calculate the weight value of each parameter according to its contribution to the clinical outcome by employing optimal scaling regression,and finally develop a scientific CSP ultrasound quantitative scoring system.The scoring system was then employed to guide the clinical decision of appropriate treatment options and realize individualized treatment of CSP.Materials and MethodsData of 395 women with clear CSP images received uterine artery chemoembolization(UACE)followed by surgical evacuation were retrospectively collected between January 1,2012 and December 31,2015 in the Department of Obstetrics and Gynecology of the Second Clinical Medical College of Army Medical University of China.All the cases were divided into two groups according to whether there was residual mixed mass or not.The clinical and sonographic characteristics were analysed and those parameters which were closely correlated to clinical outcome were picked out,thus to develop a pre-evaluation scoring system.A prospective study was conducted on 228 patients with CSP collected between June 1,2016 and June 30,2018.All women received an evacuation under careful surveillance with transabdominal ultrasonography and UAE and/or laparoscopic surgery were used as a salvage treatment if necessary.According to the final successful treatment,the patients were divided into the evacuation group,the uterine artery embolization group and the laparoscopic group.The clinical and ultrasonographic characteristics were analysed among the three groups to determine the clinical and ultrasound factors that actually affect the prognosis of CSP.Using the optimal scaling regression method,the different grades of each prognostic factor were given different weighted numerical values denoting the magnitude of their prediction of the eventual successful treatment,thus develop quantitative scoring system for CSP.The CSP quantitative scoring system was used to recalculate the corresponding scores of each patient in the sample of the trial,and the actual treatment method was compared with the predicted treatment method to verify the effectiveness of the scoring system.ResultsIn the retrospective study,a total of 395 women received UACE followed by surgical evacuation.Sonography performed a week later showed that 105(26.6%)cases had residual gestational tissue in the scar with mixed mass formation to some extent,and 290 cases(73.4%)without mixed mass formation.Such indicators as blood loss during evacuation,salvage measures needed,days for mixed mass resolution,days of ?-hCG concentrations to drop to normal and days for menses restoration in women with mass formation were significantly higher than those of women without mass formation.2.In the retrospective study,univariate analysis and logistic regression statistical analysis were used to analyze the 16 factors(including age,gravidity,parity,ultrasound,and laboratory parameters)which may be associated with CSP gestational sac implantation.Such clinical characteristics as maximal diameter of gestational sac,remnant myometrial thickness,grading of Doppler signals,presence of a fetal heart beat and location of gestational sac showed significant differences between the two groups(P < 0.05).A ROC curve of the potential prognostic factors was created and areas under the curve(AUC)were all larger than 0.5.3.A CSP ultrasound quantitative pre-scoring system was developed based on the above mentioned five parameters based on clinical experience and literatures.In the pre-scoring system,the remaining muscle layer thickness,blood flow grading,and gestational sac classification are divided into three levels and accordingly assigned 0,1 and 2point respectively.The maximum diameter of the gestational sac and the presence or absence of fetal heartbeat are divided into two levels and according assigned 0 and 1 point.The highest score of the pre-scoring system is 8 points.4.In the prospective study,the groups were significantly different with regards to maximal diameter of the gestational sac,location of the gestational sac,remnant myometrial thickness,Doppler signal grading,presence of a fetal heartbeat and the number of cesarean sections(P < 0.01).Six variables with their corresponding weights were included in the predictive model: the number of cesarean sections(accounting for 2.3% of the risk),the maximal diameter of the gestational sac(accounting for 21.0% of the risk),the remnant myometrial thickness(accounting for 29.1% of the risk),the grading of Doppler signals(accounting for 30.1% of the risk),the presence of a fetal heartbeat(accounting for 12.3% of the risk),and the location of the gestational sac(accounting for 5.2% of the risk).Each grade of the six variables was given a calculated value for predicting the severity of CSP,and it was converted to a 10-point system according to its proportion,to develop the scoring system.In a prospective study,144(63.1%)patients with CSP in the evacuation group,73 patients(32%)in the UAE group,11 cases(4.9%)required a laparoscopic pregnancy lesion or hysterectomy to completely resolve the pregnancy.The Contingency Coefficient and Kappa value were 0.724 and 0.807,respectively.ConclusionThe factors affecting the clinical outcome of CSP include maximal diameter of the gestational sac,location of the gestational sac,remnant myometrial thickness,Doppler signal grading,presence of a fetal heartbeat and the number of cesarean sections.The establishment of the quantitive scoring system aids to predict the severity of CSP and the corresponding suitable treatment modality selection,thus provide reliable measure for individualized treatment decision for clinicians to achieve safe and effective treatment effect. |
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