It has been an incredible year for complex gynecology and minimally invasive gynecologic surgery (MIGS), with several outstanding new findings and reviews in 2023. The surgical community continues to push the envelope and emphasize the value of this specialty for women’s health.
Endometriosis and adenomyosis were at the center of several large cohort studies and systematic reviews that reassessed what we know about how to evaluate and treat these challenging diseases, including both surgical and nonsurgical approaches, with an emphasis on fertility-sparing modalities.1-8 In addition, a focus on quality of life, patient-centered care, and racial biases allowed us to reflect on our own practice patterns and keep the patient at the center of care models.9-13 Finally, there was a clear expansion in the use of technologies such as artificial intelligence (AI) and machine learning for care and novel minimally invasive tools.14
In this Update, we highlight and expand on how several particularly important developments are likely to make a difference in our clinical management.
New classification system for cesarean scar ectopic pregnancy with defined surgical guidance has 97% treatment success rate
Ban Y, Shen J, Wang X, et al. Cesarean scar ectopic pregnancy clinical classification system with recommended surgical strategy. Obstet Gynecol. 2023;141:927-936. doi:10.1097/AOG.0000000000005113
A large multiarmed study by Ban and colleagues used multivariable modeling to formulate and test a classification system and recommended surgical treatment strategies for patients with a cesarean scar ectopic pregnancy (CSP).15 In the study, 273 patients were included in the predictive modeling group, 118 in the internal validation group, and 564 within the model testing cohort. Classifications were based on 2 independent risk factors for intraoperative hemorrhage: anterior myometrial thickness and mean diameter of gestational sac (MSD).
Classification types
The 3 main CSP types were defined based on the anterior myometrial thickness at the cesarean section scar (type I, > 3 mm; type II, 1–3 mm; type III, ≤ 1 mm) and subtyped based on the MSD (type IIa, MSD ≤ 30 mm; type IIb, MSD > 30 mm; type IIIa, MSD ≤ 50 mm; type IIIb, MSD > 50 mm).
The subgroups were matched with recommended surgical strategy using expert opinion: Type I CSP was treated with suction dilation and aspiration (D&A) under ultrasound guidance, with or without hysteroscopy. Type IIa CSP was treated with suction D&A with hysteroscopy under ultrasound guidance. Type IIb CSP was treated with hysteroscopy with laparoscopic monitoring or excision, or transvaginal excision. Type IIIa CSP was treated with laparoscopic excision or transvaginal excision. Type IIIb CSP was treated with laparoscopic excision after uterine artery embolization or laparotomy (TABLE).15
Treatment outcomes
These guidelines were tested on a cohort of 564 patients between 2014 and 2022. Using these treatment guidelines, the overall treatment success rate was 97.5%; 85% of patients had a negative serum ß-human chorionic gonadotropin (ß-hCG) level within 3 weeks, and 95.2% of patients resumed menstrual cycles within 8 weeks. Successful treatment was defined as:
- complete resection of the products of conception
- no need to shift to a second-line surgical strategy
- no major complications
- no readmission for additional treatment
- serum ß-hCG levels that returned to normal within 4 weeks.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Although the incidence of CSP is reported to be around 1:2,000 pregnancies, these rare findings frequently cause a clinical conundrum.16 This thoughtful study by Ban and colleagues provides guidance with the creation of a classification system aimed at decreasing the severe morbidity that can come from mismanagement of these problematic pregnancies using predictive quantitative measures. In our own practice, we have used classification (type 1 endogenic or type 2 exogenic), mean gestational sac diameter, and overlying myometrial thickness when weighing options for treatment. However, decisions have been made on a case-by-case basis and expert opinion without specific cutoffs. Having defined parameters to more accurately classify the type of ectopic pregnancy is essential for communicating risk factors with all team members and for research purposes. The treatment algorithm proposed and tested in this study is logical with good outcomes in the test group. We applaud the authors of this study on a rare but potentially morbid pregnancy outcome. Of note, this study does not discuss nonsurgical alternatives for treatment, such as intra-sac methotrexate injection, which is another option used in select patients at our institution.
Although the incidence of CSP is reported to be around 1:2,000 pregnancies, these rare findings frequently cause a clinical conundrum.16 This thoughtful study by Ban and colleagues provides guidance with the creation of a classification system aimed at decreasing the severe morbidity that can come from mismanagement of these problematic pregnancies using predictive quantitative measures. In our own practice, we have used classification (type 1 endogenic or type 2 exogenic), mean gestational sac diameter, and overlying myometrial thickness when weighing options for treatment. However, decisions have been made on a case-by-case basis and expert opinion without specific cutoffs. Having defined parameters to more accurately classify the type of ectopic pregnancy is essential for communicating risk factors with all team members and for research purposes. The treatment algorithm proposed and tested in this study is logical with good outcomes in the test group. We applaud the authors of this study on a rare but potentially morbid pregnancy outcome. Of note, this study does not discuss nonsurgical alternatives for treatment, such as intra-sac methotrexate injection, which is another option used in select patients at our institution.
Continue to: Pre-op hormonal treatment of endometriosis found to be protective against post-op complications...