Since 1994, the Department of Obstetrics and Gynecology, PUMCH, has dealt with 817 cases of Cesarean scar pregnancy (CSP), the most ever found in a single center of the world. It managed to preserve the womb and fertility for 98.9% patients. Through a Multiple Disciplinary Team (MDT) it responded to 12 cases of second trimester hemorrhage, with a success rate of 100%.
CSP is a condition in which a fertilized ovum landed at the scar from a previous C-section, with placental villi invading myometrium to form an implantation. This is a life-threatening pregnancy complication which may lead to hemorrhage, shock, uterus perforation, secondary infection and organs failure. It often leaves little time for clinical response and results in a high death rate. During the past three decades China has seen a high rate of C-section due to a special family planning policy. Then, after allowing for a second child, it entered a “post-C-section plus second child” era. CSP increased gradually, giving a sharp rise in the occurrence of postpartum bleeding and hysterectomy, and therefore threatening the fertility and life of pregnant women.
In PUMCH, for example, occurrence of CSP increased from once in a few years before 2003 to dozens or even more than a hundred yearly after 2009. During 14 years, our hospital treated 12 cases of second trimester CSP hemorrhage, including eight with hemorrhagic shock, one with septic shock and one with multiple organ failure. A team consisting staff from multiple departments-- obstetrics and gynecology, medical ultrasonics, interventional radiology, emergency, ICU, urology, infection and anaesthesiology-- worked together and brought all the patients back, and also succeeded in preserving the womb for nine of them.
Since 2009, our Department of Obstetrics and Gynecology started research into standardized treatment of CSP, and was in charge of five projects at national and capital levels. The principle of treating CSP is early termination of pregnancy. Researchers found that the commonest and safest method is curettage after UAE, and endoscopic or open removal and repair of lower uterine segment. When ßHCG is lower than 20000U/L and the focus is smaller than 3cm in diameter, drugs are considered better for the termination of pregnancy. In a case of early stage pregnancy, when myometrium is thicker than 3mm at the scar and blood supply around the focus is small, direct curettage is recommended provided that complete measures for bleeding stop are in place.
To avoid CSP, the researchers established a systematic management of giving birth after C-section, which emphasizes measures taken at an earlier time. According to Professor Liu Xinyan, birth control is recommended for two years after a C-section, and measures can be taken at the same time of the C-section. Strict long-term, irreversible birth control measures are recommended to couples who have a C-section history and do not want a second child. In case of pregnancy after a C-section, whether planned or an accident, ultrasonic inspection shall be taken around 40 days after the previous period so as to rule out CSP.
Our hospital took a leading role in the formulation of Consensus on CSP Diagnosis and Treatment (2012), and took part in the formulation of Clinical Pathway for Pregnancy after C-section led by the National Health Commission. As a standing member of the Society of Family Planning, Chinese Medical Association, our hospital also took the lead in formulating the Consensus on CSP Diagnosis and Treatment, which is a part of the CMA Clinical Guideline and Practice--Birth Control 2017. At the 46th AAGL annual conference in 2017, Academician Lang Jinghe chaired the CSP section, and Professor Liu Xinyan reported on our 817 cases, the world’s largest sample size, which demonstrated our world-leading capability in treating CSP.