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Caesarean scar pregnancy is a rare but serious early pregnancy complication. It is defined as an ectopic implantation in the myometrial defect at the site of a previous uterine incision . The estimated prevalence is rising with 1 in 2000 pregnancies being affected, and up to 1 in 530 women who have had a previous caesarean section . The increasing incidence is a result of the number of caesarean sections having doubled globally in the last two decades. These pregnancies are associated with severe maternal morbidity and mortality including uterine rupture , major haemorrhage and abnormally invasive placentation . The reasons for this are multifactorial but include late presentation, misdiagnosis, limited clinician experience with the condition and lack of knowledge regarding treatment options. The management and outcomes for women diagnosed with this condition vary greatly. Women need detailed counselling regarding the risks posed in pregnancy and the management options available. Once a decision on whether to terminate or continue the pregnancy is made, women should be managed by clinicians with expertise in scanning and in managing such pregnancies. Robust data regarding pregnancy outcomes will drive production of guidelines and a unified approach to managing this commonly increasing pregnancy complication .

ObjectivesFirst, to determine the uptake of prenatal exome sequencing (pES) and the diagnostic yield of pathogenic (causative) variants in a UK tertiary fetal medicine unit following the introduction of the NHS England Rapid Exome Sequencing Service for fetal anomalies testing (R21 pathway). Second, to identify how the decision to proceed with pES and identification of a causative variant affect perinatal outcomes, specifically late termination of pregnancy (TOP) at or beyond 22 weeks' gestation.MethodsThis was a retrospective cohort study of anomalous fetuses referred to the Liverpool Women's Hospital Fetal Medicine Unit between 1 March 2021 and 28 February 2022. pES was performed as part of the R21 pathway. Trio exome sequencing was performed using an Illumina next-generation sequencing platform assessing coding and splice regions of a panel of 974 prenatally relevant genes and 231 expert reviewed genes. Data on demographics, phenotype, pES result and perinatal outcome were extracted and compared. Descriptive statistics and the χ-square or Fisher's exact test were performed using IBM SPSS version 28.0.1.0.ResultsIn total, 72 cases were identified and two-thirds of eligible women (n = 48) consented to trio pES. pES was not feasible in one case owing to a low DNA yield and, therefore, was performed in 47 cases. In one-third of cases (n = 24), pES was not proposed or agreed. In 58.3% (14/24) of these cases, this was because invasive testing was declined and, in 41.7% (10/24) of cases, women opted for testing and underwent chromosomal microarray analysis only. The diagnostic yield of pES was 23.4% (11/47). There was no overall difference in the proportion of women who decided to have late TOP in the group in which pES was agreed compared with the group in which pES was not proposed or agreed (25.0% (12/48) vs 25.0% (6/24); P = 1.0). However, the decision to have late TOP was significantly more frequent when a causative variant was detected compared with when pES was uninformative (63.6% (7/11) vs 13.9% (5/36); P ConclusionsThis study demonstrates the potential impact of identification of a causative variant by pES on decision to have late TOP. As the R21 pathway continues to evolve, we urge clinicians and policymakers to consider introducing earlier screening for anomalies, developing robust guidance for late TOP and ensuring optimized support for couples.

Objectives: To explore whether early first-trimester ultrasound can predict the third-trimester sonographic stage of placenta accreta spectrum (PAS) disorder and to elucidate whether combining first-trimester ultrasound findings with the sonographic stage of PAS disorder can stratify the risk of adverse surgical outcome in women at risk for PAS disorder. Methods: This was a retrospective analysis of prospectively collected data from women with placenta previa, and at least one previous Cesarean delivery (CD) or uterine surgery, for whom early first-trimester (5-7 weeks' gestation) ultrasound images could be retrieved. The relationship between the position of the gestational sac and the prior CD scar was assessed using three sonographic markers for first-trimester assessment of Cesarean scar (CS) pregnancy, reported by Cali et al. (crossover sign (COS)), Kaelin Agten et al. (implantation of the gestational sac on the scar vs in the niche of the CS) and Timor-Tritsch et al. (position of the center of the gestational sac below vs above the midline of the uterus), by two different examiners blinded to the final diagnosis and clinical outcome. The primary aim of the study was to explore the association between first-trimester ultrasound findings and the stage of PAS disorder on third-trimester ultrasound. Our secondary aim was to elucidate whether the combination of first-trimester ultrasound findings and sonographic stage of PAS disorder can predict surgical outcome. Logistic regression analysis and area under the receiver-operating-characteristics curve (AUC) were used to analyze the data. Results: One hundred and eighty-seven women with vasa previa were included. In this cohort, 79.6% (95% CI, 67.1-88.2%) of women classified as COS-1, 94.4% (95% CI, 84.9-98.1%) of those with gestational-sac implantation in the niche of the prior CS and 100% (95% CI, 93.4-100%) of those with gestational sac located below the uterine midline, on first-trimester ultrasound, were affected by the severest form of PAS disorder (PAS3) on third-trimester ultrasound. On multivariate logistic regression analysis, COS-1 (odds ratio (OR), 7.9 (95% CI, 4.0-15.5); P < 0.001), implantation of the gestational sac in the niche (OR, 29.1 (95% CI, 8.1-104); P < 0.001) and location of the gestational sac below the midline of the uterus (OR, 38.1 (95% CI, 12.0-121); P < 0.001) were associated independently with PAS3, whereas parity (P = 0.4) and the number of prior CDs (P = 0.5) were not. When translating these figures into diagnostic models, first-trimester diagnosis of COS-1 (AUC, 0.94 (95% CI, 0.91-0.97)), pregnancy implantation in the niche (AUC, 0.92 (95% CI, 0.89-0.96)) and gestational sac below the uterine midline (AUC, 0.92 (95% CI, 0.88-0.96)) had a high predictive accuracy for PAS3. There was an adverse surgical outcome in 22/187 pregnancies and it was more common in women with, compared to those without, COS-1 (P < 0.001), gestational-sac implantation in the niche (P < 0.001) and gestational-sac position below the uterine midline (P < 0.001). On multivariate logistic regression analysis, third-trimester ultrasound diagnosis of PAS3 (OR, 4.3 (95% CI, 2.1-17.3)) and first-trimester diagnosis of COS-1 (OR, 7.9 (95% CI, 4.0-15.5); P < 0.001), pregnancy implantation in the niche (OR, 29.1 (95% CI, 8.1-79.0); P < 0.001) and position of the sac below the uterine midline (OR, 6.6 (95% CI, 3.9-16.2); P < 0.001) were associated independently with adverse surgical outcome. When combining the sonographic coordinates of the three first-trimester imaging markers, we identified an area we call high-risk-for-PAS triangle, which may enable an easy visual perception and application of the three methods to prognosticate the risk for CS pregnancy and PAS disorder, although it requires validation in large prospective studies. Conclusions: Early first-trimester sonographic assessment of pregnancies with previous CD can predict reliably ultrasound stage of PAS disorder. Combination of findings on first-trimester ultrasound with second- and third-trimester ultrasound examination can stratify the surgical risk in women affected by a PAS disorder. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

OBJECTIVE To determine whether maternal cardiac adaptation at term differs between women with, and those without, gestational diabetes mellitus (GDM). METHODS This was a prospective case-control study of pregnant women at term with or without GDM. For both cases and controls, only women without any comorbidity or form of pre-existing diabetes who had a singleton pregnancy without complication (such as pre-eclampsia or fetal growth restriction) were included. All women underwent conventional and speckle-tracking echocardiography to assess both the left- and right-heart geometry and function. RESULTS A total of 40 women with GDM and 40 healthy controls were enrolled. Women with GDM, compared with controls, had a significantly higher heart rate (83 ± 10 vs 75 ± 9 beats per min; P

Cesarean scar pregnancy is a potentially dangerous consequence of a previous cesarean delivery. If unrecognized and inadequately managed, it can lead to untoward complications throughout all three trimesters of the pregnancy. The rate of occurrence parallels the mounting rate of cesarean sections. The late consequences of cesarean delivery, such as placenta previa and placenta accrete, were known for a long time. However, it took more than a decade for the obstetric community to make the connection between the cesarean scar pregnancy and the placenta accreta spectrum. This article discusses the pathogenesis and diagnosis of cesarean scar pregnancy.

BACKGROUND: Ultrasound examination of pregnancy before 24 weeks gestation may lead to more accurate dating and earlier diagnosis of pathology, but may also give false reassurance. It can be used to monitor development or diagnose conditions of an unborn baby. This review compares the effect of routine or universal, ultrasound examination, performed before 24 completed weeks' gestation, with selective or no ultrasound examination. OBJECTIVES: To assess the effect of routine pregnancy ultrasound before 24 weeks as part of a screening programme, compared to selective ultrasound or no ultrasound, on the early diagnosis of abnormal pregnancy location, termination for fetal congenital abnormality, multiple pregnancy, maternal outcomes and later fetal compromise. To assess the effect of first trimester (before 14 weeks) and second trimester (14 to 24 weeks) ultrasound, separately. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, and the World Health Organization's International Clinical Trials Registry Platform (ICTRP) on 11 August 2020. We also examined the reference lists of retrieved studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi‐RCTs, cluster‐RCTs and RCTs published in abstract form. We included all trials with pregnant women who had routine or revealed ultrasound versus selective ultrasound, no ultrasound, or concealed ultrasound, before 24 weeks' gestation. All eligible studies were screened for scientific integrity and trustworthiness. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for eligibility and risk of bias, extracted data and checked extracted data for accuracy. Two review authors independently used the GRADE approach to assess the certainty of evidence for each outcome MAIN RESULTS: Our review included data from 13 RCTs including 85,265 women. The review included four comparisons. Four trials were assessed to be at low risk of bias for both sequence generation and allocation concealment and two as high risk. The nature of the intervention made it impossible to blind women and staff providing care to treatment allocation. Sample attrition was low in the majority of trials and outcome data were available for most women. Many trials were conducted before it was customary for trials to be registered and protocols published. First trimester routine versus selective ultrasound: four studies, 1791 women, from Australia, Canada, the United Kingdom (UK) and the United States (US). First trimester scans probably reduce short‐term maternal anxiety about pregnancy (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.65 to 0.99; moderate‐certainty evidence). We do not have information on whether the reduction was sustained. The evidence is very uncertain about the effect of first trimester scans on perinatal loss (RR 0.97, 95% CI 0.55 to 1.73; 648 participants; one study; low‐certainty evidence) or induction of labour for post‐maturity (RR 0.83, 95% CI 0.50 to 1.37; 1474 participants; three studies; low‐certainty evidence). The effect of routine first trimester ultrasound on birth before 34 weeks or termination of pregnancy for fetal abnormality was not reported. Second trimester routine versus selective ultrasound: seven studies, 36,053 women, from Finland, Norway, South Africa, Sweden and the US. Second trimester scans probably make little difference to perinatal loss (RR 0.98, 95% CI 0.81 to 1.20; 17,918 participants, three studies; moderate‐certainty evidence) or intrauterine fetal death (RR 0.97, 95% CI 0.66 to 1.42; 29,584 participants, three studies; low‐certainty evidence). Second trimester scans may reduce induction of labour for post‐maturity (RR 0.48, 95% CI 0.31 to 0.73; 24,174 participants, six studies; low‐certainty evidence), presumably by more accurate dating. Routine second trimester ultrasound may improve detection of multiple pregnancy (RR 0.05, 95% CI 0.02 to 0.16; 274 participants, five studies; low‐certainty evidence). Routine second trimester ultrasound may increase detection of major fetal abnormality before 24 weeks (RR 3.45, 95% CI 1.67 to 7.12; 387 participants, two studies; low‐certainty evidence) and probably increases the number of women terminating pregnancy for major anomaly (RR 2.36, 95% CI 1.13 to 4.93; 26,893 participants, four studies; moderate‐certainty evidence). Long‐term follow‐up of children exposed to scans before birth did not indicate harm to children's physical or intellectual development (RR 0.77, 95% CI 0.44 to 1.34; 603 participants, one study; low‐certainty evidence). The effect of routine second trimester ultrasound on birth before 34 weeks or maternal anxiety was not reported. Standard care plus two ultrasounds and referral for complications versus standard care: one cluster‐RCT, 47,431 women, from Democratic Republic of Congo, Guatemala, Kenya, Pakistan and Zambia. This trial included a co‐intervention, training of healthcare workers and referral for complications and was, therefore, assessed separately. Standard pregnancy care plus two scans, and training and referral for complications, versus standard care probably makes little difference to whether women with complications give birth in a risk appropriate setting with facilities for caesarean section (RR 1.03, 95% CI 0.89 to 1.19; 11,680 participants; moderate‐certainty evidence). The intervention also probably makes little to no difference to low birthweight (< 2500 g) (RR 1.01, 95% CI 0.90 to 1.13; 47,312 participants; moderate‐certainty evidence). The evidence is very uncertain about whether the community intervention (including ultrasound) makes any difference to maternal mortality (RR 0.92, 95% CI 0.55 to 1.55; 46,768 participants; low‐certainty evidence). Revealed ultrasound results (communicated to both patient and doctor) versus concealed ultrasound results (blinded to both patient and doctor at any time before 24 weeks): one study, 1095 women, from the UK. The evidence was very uncertain for all results relating to revealed versus concealed ultrasound scan (very low‐certainty evidence). AUTHORS' CONCLUSIONS: Early scans probably reduce short term maternal anxiety. Later scans may reduce labour induction for post‐maturity. They may improve detection of major fetal abnormalities and increase the number of women who choose termination of pregnancy for this reason. They may also reduce the number of undetected twin pregnancies. All these findings accord with observational data. Neither type of scan appears to alter other important maternal or fetal outcomes, but our review may underestimate the effect in modern practice because trials were mostly from relatively early in the development of the technology, and many control participants also had scans. The trials were also underpowered to show an effect on other important maternal or fetal outcomes.

OBJECTIVE Obesity is an increasing problem worldwide, with well recognized detrimental effects on cardiovascular health; however, very little is known about the effect of obesity on cardiovascular adaptation to pregnancy. The aim of the present study was to compare biventricular cardiac function at term between obese pregnant women and pregnant women with normal body weight, utilizing conventional echocardiography and speckle-tracking assessment. METHODS This was a prospective case-control study of 40 obese, but otherwise healthy, pregnant women with a body mass index (BMI) of ≥ 35 kg/m2 and 40 healthy pregnant women with a BMI of ≤ 30 kg/m2 . All women underwent a comprehensive echocardiographic examination and speckle-tracking assessment at term. RESULTS Obese pregnant women, compared with controls, had significantly higher systolic blood pressure (117 vs 109 mmHg; P = 0.002), cardiac output (6.73 vs 4.90 L/min; P

Abnormal placental invasion is associated with increased maternal morbidity and mortality. In an abnormally invasive placenta (AIP), the placental villi are not confined by the innate barrier of the uterine endometrium and invade the uterine myometrium and potentially even the uterine serosa . During the antenatal period , signs of abnormal invasion can be seen on ultrasound from as early as the first trimester . Typically, placental lacunae, a thin myometrium, abnormal blood flow in the placenta and myometrium, and/or an interrupted bladder edge should raise the clinical suspicion of AIP. Women with suspected AIP should be referred to centres with appropriate experience in the management of these cases, to optimize outcomes. Women are at significant risk of haemorrhage and other surgical complications . Therefore, skilled surgeons, anaesthetists and interventional radiologists should be involved in the planning and conduct of delivery of the baby. Some cases are not detected antenatally, only being recognized at the time of delivery. Appropriate assistance should be sought to plan and complete the delivery in these cases.

The midaortic syndrome (MAS) is a rare anomaly, characterised by narrowing of the distal aorta and its major branches. The most common symptom is severe arterial hypertension. The combination of hyponatremia, polyuria and renovascular hypertension caused by a unilateral renal artery stenosis is described as hyponatremic hypertensive syndrome. We report a case of MAS with unilateral renal artery stenosis in a preterm female neonate. A pregnant woman at 34 weeks of gestation was referred with fast growing abdominal circumference and pain. The ultrasound revealed severe polyhydramnios and fetal myocardial hypertrophy. Within the first 48 hours of the neonatal period, the diagnosis of MAS was made. We conclude that symptomatic MAS, caused by unilateral renal artery stenosis, resulting in increased renin–angiotensin–aldosterone system activity and subsequent polyuria of the non-stenotic kidney, lead to clinically significant polyhydramnios.

INTRODUCTION: Ultrasound signs of abnormal placental invasion are subjective in nature. We tested the hypothesis that placental thickness in the lower uterine segment is increased when there is abnormally invasive placenta (AIP) in women with a low-lying placenta. MATERIAL AND METHODS: Retrospective analysis of data of placental thickness in women with ultrasound evidence of major placenta previa or a low-lying anterior placenta was done. The diagnosis of AIP was confirmed both intraoperatively and on histopathology for those managed by partial myometrial excision with uterine conservation or by hysterectomy. RESULTS: In all, 131 records were available for analysis after exclusion of 33 cases due to unsuitable images and eight cases without pregnancy outcomes. The diagnosis of AIP was confirmed in 28 (21.4%) of the 131 cases. The lower segment placental thickness was significantly higher in women with AIP (median = 50.3 mm, IQR: 42.7-64.3) than in those with normal placentation (median = 30.9 mm, IQR: 22.9-42.2, P CONCLUSIONS: Lower uterine segment placental thickness is increased in women with AIP compared with those with noninvasive placentation. This association constitutes a pragmatic objective sign and may be of clinical value in improving prenatal detection of AIP in women with placental implantation in the lower uterine segment. Prospective studies are necessary to ascertain lower segment placental thickness as a predictor for AIP.

OBJECTIVES To assess whether cesarean delivery changes the natural position of the uterus. METHODS In this retrospective Institutional Review Board-approved cohort study, we conducted a search of our university gynecologic ultrasonography (US) database. Patients with transvaginal US images before and after either vaginal or cesarean delivery between 2012 and 2015 were included. Women with prior cesarean delivery were excluded. Two readers independently measured antepartum and postpartum flexion angles between the longitudinal axis of the uterine body and the cervix. We calculated intraclass correlation coefficients to measure inter-reader agreement. Antepartum and postpartum uterine flexion angles were compared between patients with vaginal and cesarean delivery. RESULTS We included 173 patients (107 vaginal and 66 cesarean delivery). The mean interval between scans ± SD was 18 ± 10 months. Inter-reader agreement for flexion angles was almost perfect (intraclass correlation coefficients: antepartum, 0.939; postpartum, 0.969; both P

There is no universally agreed upon and adopted management protocol supported by professional societies in the United States or around the world for the treatment of cesarean scar pregnancy. There is a wide range of management options in the literature, and many of them can to lead to severe bleeding complications, which can result in loss of fertility or even maternal death. If inadequately managed, it can lead to untoward complications throughout all 3 trimesters of the pregnancy. Early detection of CSP has a paramount clinical importance.

Cesarean scar pregnancy is a potentially dangerous consequence of a previous cesarean delivery. If unrecognized and inadequately managed, it can lead to untoward complications throughout all three trimesters of the pregnancy. The rate of occurrence parallels the mounting rate of cesarean sections. The late consequences of cesarean delivery, such as placenta previa and placenta accrete, were known for a long time. However, it took more than a decade for the obstetric community to make the connection between the cesarean scar pregnancy and the placenta accreta spectrum. This article discusses the pathogenesis and diagnosis of cesarean scar pregnancy.

AIM Postpartum haemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality. Studies have reported an increase in incidence of postpartum haemorrhage in recent years. Our goal was to investigate changes in the incidence of postpartum haemorrhage (PPH) and its risk factors in Switzerland from 1993 to 2014. METHODS This population-based retrospective cohort study used data from the national Swiss Hospital in-patient database for obstetric and gynaecological hospital admissions - "Arbeitsgemeinschaft Schweizer Frauenkliniken" (ASF Statistik). All patients with deliveries between January 1993 and December 2014 were included. We used the database codes to identify patients with PPH, maternal factors, pregnancy-related and delivery-related factors. Significant changes in temporal trends were determined using Mantel-Haenszel test for trend. Multivariable logistic regression analyses were conducted to assess PPH and risk factors. RESULTS Births complicated by PPH in Switzerland increased from 2.5% in 1993 to 4.5% in 2014 (p

To assess whether cesarean delivery changes the natural position of the uterus.In this retrospective Institutional Review Board-approved cohort study, we conducted a search of our university gynecologic ultrasonography (US) database. Patients with transvaginal US images before and after either vaginal or cesarean delivery between 2012 and 2015 were included. Women with prior cesarean delivery were excluded. Two readers independently measured antepartum and postpartum flexion angles between the longitudinal axis of the uterine body and the cervix. We calculated intraclass correlation coefficients to measure inter-reader agreement. Antepartum and postpartum uterine flexion angles were compared between patients with vaginal and cesarean delivery.We included 173 patients (107 vaginal and 66 cesarean delivery). The mean interval between scans ± SD was 18 ± 10 months. Inter-reader agreement for flexion angles was almost perfect (intraclass correlation coefficients: antepartum, 0.939; postpartum, 0.969; both P .001). There was no difference in mean antepartum flexion angles for cesarean delivery (154.8° ± 45.7°) versus vaginal delivery (145.8° ± 43.7°; P = .216). Mean postpartum flexion angles were higher after cesarean delivery (180.4° ± 51.2°) versus vaginal delivery (152.8° ± 47.7°; P = .001. Differences in antepartum and postpartum flexion angles between cesarean and vaginal delivery were statistically significant (25.6° versus 7.0°; P = .027).Cesarean delivery can change the uterine flexion angle to a more retroflexed position. Therefore, all women with a history of cesarean delivery should undergo a transvaginal US examination before any gynecologic surgery or intrauterine device placement to reduce the possibility of surgical complications.

Background Cesarean scar pregnancy and cervical pregnancy are unrelated forms of pathological pregnancies carrying significant diagnostic and treatment challenges, with a wide range of treatment effectiveness and complication rates ranging from 10% to 62%. At times, life-saving hysterectomy and uterine artery embolization are required to treat complications. Based on our previous success with using a single-balloon catheter for the treatment of cesarean scar pregnancy after local injection of methotrexate, we evaluated the use of a double-balloon catheter to terminate the pregnancy while preventing bleeding without any additive treatment. This was a retrospective study. Objectives The objective of the study was to describe the placement of a cervical ripening double-balloon catheter as a novel, minimally invasive treatment in patients with cesarean scar and cervical pregnancies to terminate the pregnancy and at the same time prevent bleeding by compressing the blood supply of the gestational sac. Study Design Patients with diagnosed, live cervical pregnancy and cesarean scar pregnancy between 6 and 8 weeks' gestation were considered for the office-based treatment. Paracervical block with 1% lidocaine was administered in 3 patients for pain control. Insertion of the catheter and inflation of the upper balloon were done under transabdominal ultrasound guidance. The lower (pressure) balloon was inflated opposite the gestational sac under transvaginal ultrasound guidance. After an hour, the area of the sac was scanned. When fetal cardiac activity was absent and no bleeding was noted, patients were discharged. After 2-3 days, a follow-up appointment was scheduled for possible catheter removal. Serial ultrasound (US) and serum human chorionic gonadotropin were followed weekly or as needed. Results Three live cervical pregnancies and 7 live cesarean scar pregnancies were successfully treated. Median gestational age at treatment was 6 6/7 weeks (range 6 1/7 through 7 4/7 weeks). Patients' acceptance for the double-balloon treatment was high in spite of the initial low abdominal pressure felt at the inflation of the balloons. All but 1 patient noted vaginal spotting at the follow-up appointment. Only 1 patient experienced bleeding of dark blood. The balloons were in place for a median of 3 days (range, 1–5 days). Median time from treatment to the total drop of human chorionic gonadotropin was 49 days (range, 28–97 days). Conclusion The double balloon is a successful, minimally invasive and well-tolerated single treatment for cervical pregnancy and cesarean scar pregnancy. This simple treatment method has 4 main advantages: it effectively stops embryonic cardiac activity, prevents bleeding complications, does not require any additional invasive therapies, and is familiar to obstetricians-gynecologists who use the same cervical ripening catheters for labor induction. Its wider application, however, has to be validated on a larger patient population.

Background Cesarean scar pregnancy (CSP) is a serious complication of pregnancy, which consists of implantation of the gestational sac in the hysterotomy scar. This condition is increasing in frequency and often poses a diagnostic challenge. Its diagnosis is dependent on visual assessment of the uterus on the longitudinal sagittal ultrasound plane. Misdiagnosing a low intrauterine chorionic sac as a CSP, or a true scar pregnancy as an intrauterine pregnancy (IUP), may lead to adverse outcomes including hysterectomy. Objective The objective of the study is to describe a sonographic method for the differential diagnosis of CSP vs IUP in early gestation. The current study tests the hypothesis that on a first-trimester ultrasound performed between 5-10 weeks of gestation, the relative location of the center of gestational sac to the midpoint of the uterus along a longitudinal line between the external cervical os and the fundus can be used for early detection of CSPs. Study Design This is a retrospective review of electronically archived ultrasound images of IUP and CSP between 5-10 weeks of gestation. A total of 242 ultrasound images were analyzed: 185 cases of normal IUPs (including 128 in anteverted uteri, 31 in retroverted uteri, and 26 IUPs with history of cesarean delivery) and 57 cases of CSPs diagnosed from 2004 through 2015 in a single institution. The following measurements were made for each case: distance from the external cervical os to the uterine fundus, the midpoint axis of the uterus, the distance from the external cervical os to the center of gestational sacs, and the distance from the external cervical os to the most distant edge of the gestational sacs from the cervix. Results The location of the center of the gestational sac relative to the midpoint axis of the uterus between 5-10 weeks of gestation differentiated between IUP and CSP (mean 17.8 vs –10.6 mm, respectively, P = .0001), indicating that most CSPs are located proximally to the midpoint axis of the uterus whereas most normal IUPs are located distally from the midpoint of the uterus. Using location of the center of the gestational sac as a marker of CSPs between 5-10 weeks of gestation yielded the following characteristics of diagnostic accuracy: sensitivity 93.0% and specificity 98.9%. The likelihood ratio of the positive test was 84.5. The likelihood ratio of the negative test was 0.07. Conclusion The location of the center of the gestational sac relative to the midpoint axis of the uterus can be used as an easy method for sonographic differentiation of IUP and CSP between 5-10 weeks of gestation.

Background Cesarean scar pregnancy and cervical pregnancy are unrelated forms of pathological pregnancies carrying significant diagnostic and treatment challenges, with a wide range of treatment effectiveness and complication rates ranging from 10% to 62%. At times, life-saving hysterectomy and uterine artery embolization are required to treat complications. Based on our previous success with using a single-balloon catheter for the treatment of cesarean scar pregnancy after local injection of methotrexate, we evaluated the use of a double-balloon catheter to terminate the pregnancy while preventing bleeding without any additive treatment. This was a retrospective study. Objectives The objective of the study was to describe the placement of a cervical ripening double-balloon catheter as a novel, minimally invasive treatment in patients with cesarean scar and cervical pregnancies to terminate the pregnancy and at the same time prevent bleeding by compressing the blood supply of the gestational sac. Study Design Patients with diagnosed, live cervical pregnancy and cesarean scar pregnancy between 6 and 8 weeks' gestation were considered for the office-based treatment. Paracervical block with 1% lidocaine was administered in 3 patients for pain control. Insertion of the catheter and inflation of the upper balloon were done under transabdominal ultrasound guidance. The lower (pressure) balloon was inflated opposite the gestational sac under transvaginal ultrasound guidance. After an hour, the area of the sac was scanned. When fetal cardiac activity was absent and no bleeding was noted, patients were discharged. After 2-3 days, a follow-up appointment was scheduled for possible catheter removal. Serial ultrasound (US) and serum human chorionic gonadotropin were followed weekly or as needed. Results Three live cervical pregnancies and 7 live cesarean scar pregnancies were successfully treated. Median gestational age at treatment was 6 6/7 weeks (range 6 1/7 through 7 4/7 weeks). Patients' acceptance for the double-balloon treatment was high in spite of the initial low abdominal pressure felt at the inflation of the balloons. All but 1 patient noted vaginal spotting at the follow-up appointment. Only 1 patient experienced bleeding of dark blood. The balloons were in place for a median of 3 days (range, 1–5 days). Median time from treatment to the total drop of human chorionic gonadotropin was 49 days (range, 28–97 days). Conclusion The double balloon is a successful, minimally invasive and well-tolerated single treatment for cervical pregnancy and cesarean scar pregnancy. This simple treatment method has 4 main advantages: it effectively stops embryonic cardiac activity, prevents bleeding complications, does not require any additional invasive therapies, and is familiar to obstetricians-gynecologists who use the same cervical ripening catheters for labor induction. Its wider application, however, has to be validated on a larger patient population.