A Prediction Nomogram for Residual After Negative Pressure Aspiration for Endogenic Cesarean Scar Ectopic Pregnancy: a Retrospective Study

Overview

Journal BMC Pregnancy Childbirth

Publisher Biomed Central

Date 2025 Feb 3

PMID 39901095

Authors

Yan Lei

Na Zhang

Yu Liu

Xin Du

Affiliations

Soon will be listed here.

Abstract

Background: We aimed to establish a predictive nomogram to evaluate the incidence of residual tissue in patients with endogenic cesarean scar ectopic pregnancy after negative pressure aspiration.

Methods: This retrospective study included patients treated in the gynecology department of our institution from May 2017 to August 2023 who underwent negative pressure suction treatment, ultrasound examinations before and after treatment, and received telephone follow-up for at least 6 months. A total of 899 patients met the inclusion criteria and were divided into a training cohort (629 patients, 70%) and a validation cohort (270 patients, 30%). Independent predictive factors were established using multivariate logistic regression. The resulting nomogram was validated using 1,000 bootstrap resampling, and calibration curves were plotted. Receiver operating characteristic (ROC) analysis was performed to calculate the area under the curve, sensitivity, specificity, and other metrics to assess its discriminative performance. Clinical decision curves were constructed to evaluate clinical applicability and quantify the net benefit within a range of threshold probabilities. The model was externally validated in the validation cohort.

Results: Predictive factors included in the nomogram included age (hazard ratio [HR]: 1.220, 95% confidence interval [CI]: 1.135-1.316), BMI (HR: 0.890, 95% CI: 0.796-0.986), intraoperative major hemorrhage (HR: 4.457, 95% CI: 1.610-12.292), maximum diameter of the gestational sac (HR: 1.572, 95% CI: 1.295, 1.914), and thickness of the remaining muscle layer of the lower uterine segment (HR: 1.572, 95% CI: 0.014, 0.430). The ROC curve of the resulting nomogram showed similar area under the curve values for the training (0.809, 95% CI: 0.751-0.867) and validation cohorts (0.814, 95% CI: 0.739, 0.888). The Hosmer-Lemeshow test indicated good model fit (P = 0.861), and the calibration curve was close to the ideal diagonal line. Decision curve analysis demonstrated good net benefit, and external validation confirmed its reliability.

Conclusions: The model may aid in individual clinical decision-making, allowing clinicians to perform immediate postoperative assessments for patients with endogenous ectopic pregnancy in cesarean section scars treated with negative pressure suction, identify high-risk subpopulations, and select appropriate supplementary treatment in advance, making it particularly suitable for low-income areas and resource-limited primary hospitals.

References

Riaz R, Williams T, Craig B, Myers D . Cesarean scar ectopic pregnancy: imaging features, current treatment options, and clinical outcomes. Abdom Imaging. 2015; 40(7):2589-99. DOI: 10.1007/s00261-015-0472-2. View

Jurkovic D, Knez J, Appiah A, Farahani L, Mavrelos D, Ross J . Surgical treatment of Cesarean scar ectopic pregnancy: efficacy and safety of ultrasound-guided suction curettage. Ultrasound Obstet Gynecol. 2016; 47(4):511-7. DOI: 10.1002/uog.15857. View

Li Y, Xiang Y, Wan X, Feng F, Ren T . [Clinical study on 39 cases with caesarean scar pregnancy with sonographic mass]. Zhonghua Fu Chan Ke Za Zhi. 2014; 49(1):10-3. View

Stabile G, Vona L, Carlucci S, Zullo F, Lagana A, Etrusco A . Conservative treatment of cesarean scar pregnancy with the combination of methotrexate and mifepristone: A systematic review. Womens Health (Lond). 2024; 20:17455057241290424. PMC: 11481064. DOI: 10.1177/17455057241290424. View

Zhang Y, Duan H, Cheng J, Guo Y . Treatment options to terminate persistent cesarean scar pregnancy. Gynecol Obstet Invest. 2013; 75(2):115-9. DOI: 10.1159/000345503. View

Vial Y, Petignat P, Hohlfeld P . Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol. 2001; 16(6):592-3. DOI: 10.1046/j.1469-0705.2000.00300-2.x. View

Agten A, Cali G, Monteagudo A, Oviedo J, Ramos J, Timor-Tritsch I . The clinical outcome of cesarean scar pregnancies implanted "on the scar" versus "in the niche". Am J Obstet Gynecol. 2017; 216(5):510.e1-510.e6. DOI: 10.1016/j.ajog.2017.01.019. View

Fu L, Yuan H, Cao H, Zhou Q, Tan X, Guo J . Clinical value of ultrasonic indicators in predicting the outcome of caesarean scar pregnancy after pregnancy termination. BMC Pregnancy Childbirth. 2023; 23(1):863. PMC: 10722759. DOI: 10.1186/s12884-023-06197-x. View

Shen M, Li L, Zhu L, Liu J, Lin T, Liu X . Predictive value of crossover sign for outcome of ultrasound-guided vacuum aspiration in women with Cesarean scar pregnancy. Ultrasound Obstet Gynecol. 2023; 63(4):544-550. DOI: 10.1002/uog.27459. View

10.

de Braud L, Knez J, Mavrelos D, Thanatsis N, Jauniaux E, Jurkovic D . Risk prediction of major haemorrhage with surgical treatment of live cesarean scar pregnancies. Eur J Obstet Gynecol Reprod Biol. 2021; 264:224-231. DOI: 10.1016/j.ejogrb.2021.07.030. View

11.

Yang F, Yang X, Jing H, Wang X, Gong Z, Deng C . MRI-based scoring model to predict massive hemorrhage during dilatation and curettage in patients with cesarean scar pregnancy. Abdom Radiol (NY). 2023; 48(10):3195-3206. DOI: 10.1007/s00261-023-03968-0. View

12.

Zhang Y, Chen L, Zhou M, Li Y, Luo J, Chen Z . Risk factors of persistent cesarean scar pregnancy after dilation and curettage: a matched case-control study. Taiwan J Obstet Gynecol. 2020; 59(2):237-242. DOI: 10.1016/j.tjog.2020.01.011. View

13.

Qian Z, Weng Y, Du Y, Wang C, Huang L . Management of persistent caesarean scar pregnancy after curettage treatment failure. BMC Pregnancy Childbirth. 2017; 17(1):208. PMC: 5493865. DOI: 10.1186/s12884-017-1395-4. View

14.

Peng P, Gui T, Liu X, Chen W, Liu Z . Comparative efficacy and safety of local and systemic methotrexate injection in cesarean scar pregnancy. Ther Clin Risk Manag. 2015; 11:137-42. PMC: 4315462. DOI: 10.2147/TCRM.S76050. View

15.

Mou Y, Xu Y, Hu Y, Jiang T . Giant uterine artery pseudoaneurysm after a missed miscarriage termination in a cesarean scar pregnancy. BMC Womens Health. 2014; 14:89. PMC: 4118154. DOI: 10.1186/1472-6874-14-89. View

16.

Riemma G, De Franciscis P, Torella M, Narciso G, La Verde M, Morlando M . Reproductive and pregnancy outcomes following embryo transfer in women with previous cesarean section: A systematic review and meta-analysis. Acta Obstet Gynecol Scand. 2021; 100(11):1949-1960. DOI: 10.1111/aogs.14239. View

17.

Timor-Tritsch I, Monteagudo A . Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol. 2012; 207(1):14-29. DOI: 10.1016/j.ajog.2012.03.007. View

18.

Miller R, Timor-Tritsch I, Gyamfi-Bannerman C . Society for Maternal-Fetal Medicine (SMFM) Consult Series #49: Cesarean scar pregnancy. Am J Obstet Gynecol. 2020; 222(5):B2-B14. DOI: 10.1016/j.ajog.2020.01.030. View

19.

Miller R, Gyamfi-Bannerman C . Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy. Am J Obstet Gynecol. 2022; 227(3):B9-B20. DOI: 10.1016/j.ajog.2022.06.024. View

20.

Timor-Tritsch I, Monteagudo A, Bennett T, Foley C, Ramos J, Agten A . A new minimally invasive treatment for cesarean scar pregnancy and cervical pregnancy. Am J Obstet Gynecol. 2016; 215(3):351.e1-8. DOI: 10.1016/j.ajog.2016.03.010. View