Influence of Clinical Pathway Implementation on the Outcome of Drug Rehabilitation Program Services

Influence of Clinical Pathway Implementation on the Outcome of Drug Rehabilitation Program Services by Jaya Mualimin in Open Access Journal of Biogeneric Science and Research

Abstract

Patient safety, quality, and efficiency are global issues, therefore hospitals must be able to apply clinical pathways through clinical pathways as the main facilities and infrastructure, especially in services for increasingly acute drug addicts. This study aims to analyze the implementation of clinical pathways for drug rehabilitation program outcomes on 1) clinical quality, 2) cost, 3) readmission, 4) satisfaction, and 5) LOS, at RSJD Atma Husada Mahakam. This type of research uses cross-sectional with observational analytic, data collection through distributing questionnaires to 111 respondents, observation and literature study. The results showed that the clinical quality before and after the implementation of the clinical pathway had a significant effect, but the cost of treatment did not show any significance. There is a positive relationship between readmission and the implementation of clinical pathways, as well as addict satisfaction in the LOS rehabilitation room has a significant effect on treatment time and clinical pathways. A recommendation that the 5 (five) variables mentioned above, apart from being cost-effective, can improve the quality of drug rehabilitation services at RSJD Atma Husada Mahakam Samarinda, so it needs to be maintained

Keywords: Outcome; Quality Clinic; Readmission; Cost, Satisfaction; Length of Stay

Introduction

Drug dependence is a type of chronic recurrent brain disease and must receive therapy and rehabilitation. According to a 2016 BNN survey, the prevalence of drug abuse in East Kalimantan is 3.1% of the population aged 15-49 years. 10% of abusers experiencing health problems need to get medical help. Relapse will affect the quality, quality and patient safety (patient safety). if no preventive measures are taken with organizational policies. The cause of the high number of repeat patients/readmissions is uncontrolled relapse. One indicator of the quality and performance of the RSJD is to reduce the readmission rate, in 2015 the RSJD reduced the readmission rate to only 0.37%. [1].

The hospital implements quality management strategies such as total quality management, quality assurance, and continuous quality management. This strategy tends to focus on management aspects. The following professional aspects will review the definition. Clinical pathway (CP) is an integrated service planning concept that summarizes every step given to patients according to medical service standards, nursing care and other evidence-based services with measurable results. Several researchers have proven the implementation of clinical pathways. Implementation of clinical pathways in opiate therapy patients with methadone, can reduce the cost of therapy and the complications that arise are well controlled. concluded that the implementation of clinical pathways in the therapy of alcoholics, although not related to the length of stay (LOS) but was strongly related to outcome.

Devapriam et al., [2]: implementation of clinical pathways can increase the capacity of per-unit services, shorten the length of stay (LOS), increase the frequency of unit visits, timely assessment of care, and reduce variability in quality. concluded that the implementation of clinical pathways can calculate all types of guarantees or financing for each episode of treatment. Barbieri found significant results in the implementation of clinical pathways for care with a structured organizational approach (clinical governance) from the aspect of quality and low-cost service processes. Cheah said that the implementation of clinical pathways significantly reduces the treatment period and without any side effects or good outcomes. Susi Research, 2009; Chan and Wong, 1999; proves that clinical pathways are associated with increasing cost-effectiveness and significantly reducing the length of treatment.

Several other researchers have found evidence that treatment in one form of regulation (similar to a clinical pathway) can prevent relapse. Prince [3] and Marchisio,proved that making a scheduled treatment similar to a clinical pathway can be used as an indicator of reducing the three-month relapse rate. Before the intervention, the mean of relapse in the intervention group was 30.38% and the control group was 27.54%. After the intervention, there was a 20% reduction in relapse. In the schizophrenic group, 24% had an intervention, while 64% had no intervention [4-10].

Enforcement of clinical pathways for drug dependence Clinical pathways on drug dependence have not been widely studied so that research needs to be done. The implementation of clinical pathways that have been applied, can affect the outcome [11-15]. This study aims to analyze the effect of clinical pathway implementation on service outcomes in the drug rehabilitation program at RSJD Atma Husada Mahakam. The results of the study can be used as an evaluation of the clinical pathway implementation process for the inpatient drug rehabilitation program at RSJD Atma Husada Mahakam. The focus of the research relates to what is in the following picture (Figure 1).

Figure 1: Model Hypothesis

Method

This research method uses a survey model with a quantitative approach that focuses on 111 respondents (patients) who follow an inpatient drug rehabilitation program at Atma Husada Hospital (RSJAH) Mahakam, East Kalimantan, Indonesia [16-18]. The type of data is cross-sectional with analytical observation and literature review. Primary data was obtained from data from clinical pathway forms taken from addicts' medical records and reports on costs for services in drug rehabilitation programs [19-25]. The data analysis technique used the reliability and validity test of the instrument through the SPSS version 22 program, with the data analysis technique in the form of multiple linear regression and associative-causal. This is intended to be able to determine the relationship of influence between the independent variable and the dependent variable through partial and simultaneous tests and prove whether the alternative hypothesis (Ha) is accepted or rejected [25-30].

Research Result

Descriptive Analysis

Based on the results of the study, it was obtained that the description of the status of new patients was still greater than that of old or repeat patients. In (Table 1) in 2015 new patients were 84 addicts (75.7%) and in 2016 new patients were 102 addicts (89.5%). According to the 2016 BNN survey, the prevalence of drug abuse in East Kalimantan is 3.1% of the population aged 15 - 49 years. 10% of abusers experiencing health problems need to get medical help BNN, The prevalence rate of ever used decreased from 8.1% in 2006 to 3.8% in 2016. With the 2012 Accreditation plenary category, the Atma Husada Hospital has an impact on the stigma of mental illness and narcotics [31-35].

Table 1: Distribution of Respondents Characteristics.

Gender of respondents 84.8% are male. The results of this study according to the theory that there are more addicts in men than women, men are more at risk of using drugs than women. The ratio of men to women is about 4 to 1, meaning that among 4 male users there is 1 woman who has tried [36]. The prevalence rate was 13.7% for men and 3.3% for women (2006), while in 2016 it was 6.4% for men and 1.6% for women. The prevalence rate of ever tried using men tends to decrease from 13.7% (2006) to 6.4% (2016). However, in the female group, the trend of decreasing prevalence rates forever and a year using drugs began to be seen from 2009 to 2016 (BNN Survey, 2016).

According to data from the US Substance Abuse and Mental Health Services Administration in 2013, men are more dominant than women in substance abuse of all types and men often overdose and die than women. Including abuse of doctor's prescription. For most age groups, men have a higher level of dependence. However, women can also experience dependence. If women are dependent, the risk is stronger. Robbins et al 1999; Hitschfeld et al 2015; Fox et al 2014; Kennedy et al 2013 and more severe relapses, including women experiencing many legal and social complications including asocial behaviour and abuse. sexual. This problem causes the prevalence of women to be smaller than men [37-45].

Meanwhile, based on age group, table 4.3 was found in 2016 the most age groups were 17-25 late teens group of 115 patients (51.1%) and 26-35 years of early adulthood, 68 patients (30.2%). In 2015, the age group of 17-25 late teens was 58 patients (52.3%). In 2016 at the age of 17-25 late teens as many as 57 patients (50.0%), looking at this number it can be concluded that drug dependence users are dominated by the age group of late teens and early adults. Meanwhile, the education level of most drug rehabilitation patients is junior high school and senior high school, namely 175 (77.7%). In 2015, 2016 consecutively were 80 patients (72.0%), 95 patients (83.3%). However, the large proportion of drug abusers with a bachelor's degree in education does not mean they graduated, some of them are no longer in the campus environment, but are already working in various sectors or even some of them may be unemployed [46-50].

Meanwhile, judging from marital and unmarried status, the most addicted respondents were unmarried status with 121 (53.8%); 56.1% in 2016 and 51.3% in 2015. The place where addicts live is still the most in Samarinda City in 2015 there were 87 patients (78.4%) and in 2016 there were 48 patients (42.1%). In 2016 after the mandatory reporting program (IPWL) and the rehabilitation program for 100,000 addicts, the city of Balikpapan had 19 addicts, as can be seen in Table 1 below

Inferential Descriptive Analysis

LOS Drug Rehabilitation Patient

The average value for the length of stay for drug patients in 2015 or before the implementation of the clinical pathway, which was 42.29 days and in 2016 or after the implementation of the clinical pathway, which was 43.41 days, wherein 2015 it was 74 (66.7%). Meanwhile, in 2016 there were 65 (57.0) less or equal to the average value. The results of the independent sample t-test for LOS obtained p-value = 0.022 < 0.05, which means that there is a significant effect between LOS in 2015 (before clinical pathway implementation) and 2016 (before clinical pathway implementation).

Rehabilitation Patient Fee

The average cost in 2015 was Rp. 14,550,357.87 and in 2016 of Rp. 14,525,219.48, where the number of paying patients is below the mean value of 138 (61.3%). Regulation of the Minister of Health of the Republic of Indonesia. number 50 of 2016 that the cost of drug rehabilitation for a 1-month package is Rp. 6,500,000,000.00. When compared, the Ministry of Health tariff is much lower, if converted to days the Ministry of Health tariff is Rp. 216,666,-/day. the results of the independent sample t-test for the cost of care obtained a value of p = 0.98 > 0.05, which means that there is no significant effect between the cost of care in 2015 (before the implementation of the clinical pathway) and 2016 (before the implementation of the clinical pathway).

Service Quality

There are still a lot of new patient data from old or repeat patients. In 2015 new patients were 84 addicts (75.7%) and in 2016 new patients were 102 addicts (89.5%). From the repeat visit data in 2015 data, addicts who were readmission 2 times were 27 addicts (34.3%) while in 2016; addicts who were treated >2 times there were 12 addicts (10.9%). The results of the independent sample t-test for readmission obtained p-value = 0.006 < 0.05, which means that there is a significant effect between readmission in 2015 (before the implementation of clinical pathways) and 2016 (before the implementation of clinical pathways). Based on the results of the independent sample t-test of the clinical quality variable, the p-value = 0.042, the exit method p = 009 and the visit status p = 006 of the three variables, the p-value = < 0.05, which means a significant influence between clinical quality in 2015 (before implementation of clinical pathways) and 2016 (before the implementation of clinical pathways) [51-57].

Consumer Satisfaction

The satisfaction index of addicts who are being treated in the rehabilitation room is an average of 78.0%. All respondents' satisfaction variables gave satisfying answers above 93.3% to the implementation of clinical pathways asked respondents. The inferential statistics of the findings can be tabulated as follows (Table 2):

Table 2: Bivariate Analysis.

Discussion

With law no. 35 of 2009 on Narcotics article 54 that addicts must be rehabilitated medical and social rehabilitation, with PP no. 25 of 2011 concerning mandatory reporting for drug addicts, following the mandate of the narcotics law that mandatory reporting is the rehabilitation process for addicts at a mandatory reporting institution appointed by the ministry of health and social affairs. Although the diagnosis of drug dependence is included in ICD IX, it is not included in the BPJS health financing, so the government through this mandatory reporting program uses separate financing through the IPWL program. The regulation of the Minister of Health has been revised 3 times (Permenkes No. 50 of 2015) regarding the mandatory reporting technical guidelines for addicts and the procedures for financing and billing inpatient and outpatient rehabilitation costs for addicts.

The purpose of the clinical pathway is an efficient and effective rehabilitation process, reducing variations in procedures and reducing costs. Although cost savings are important, the use of clinical pathways must be evaluated, because the main focus is quality and patient safety. Van Herck et al., 82.5% of the studies reported a positive impact on cost reduction, while 13.5% did not explain the effect and 4% a negative effect.. A 2013 study on the introduction of clinical pathways in postoperative clinical care after major head and neck surgery found a 27% reduction in per-patient costs and several other studies have identified a reduction in length of stay after. Several researchers have proven the implementation of clinical pathways. Ronny Rivani (2014); Implementation of clinical pathways in opiate therapy patients with methadone, can reduce the cost of therapy and the complications that arise are well controlled.

Lacko et. al (2008): concluded that the implementation of clinical pathways can calculate all types of guarantees or financing for each episode of treatment. Barbieri (2009): found significant results in the implementation of clinical pathways for care with a structured organizational approach (clinical governance) from the aspect of quality and low-cost service processes. Cheah (2005): said that the implementation of clinical pathways significantly reduces the treatment period and without any side effects or good outcomes.

The use of clinical pathways has been associated with reduced hospital complications (Rotter et al., 2010) and improved service quality. Van Herck et al. found that 65.5% of the studies reported a positive effect on the outcome, while 32% reported no association with outcome. (Van Herck et al., 2000). Dowdeswell and Yasbeck cited previous studies providing quality and outcome for geriatric patients with depression, (Hindle, Dowdeswell and Yasbeck, 2004). According to Nielsen and Nielsen (2015) that the implementation of clinical pathways in the therapy of alcoholics, although is not related to the length of stay (LOS) but is closely related to the outcome.

The Avalos standard is based on the Minister of Health Regulation No. 50 of 2015 that the 1 monthly package for inpatient rehabilitation treatment is a minimum of 30 days. The average value for the length of stay for drug patients at the Atma Husada Mahakam Mental Hospital in 2015 or before the implementation of the clinical pathway was 42.29 days and in 2016 or after the implementation of the clinical pathway was 43.41 days, wherein 2015 there were 74 (66.7%) while in 2015 2016 as many as 65 (57.0) less or equal to the average value.

Van Herck et al. stated that 62.2% of previous studies had a positive effect on satisfaction, only 29.7% had no effect on satisfaction. Including the research of Renholm, Bryson and Browning who agree that there is an improvement in patient satisfaction. One of the potential benefits of the care pathway is to improve communication between professionals. While one study revealed that although integrated clinical pathways resulted in better health care trust, there was little evidence to suggest that interpersonal relationships and communication needed to be improved, although there was no measurable improvement. On the other hand, based on clinical results, interprofessional communication improved. Interdisciplinary teamwork can be supported by clinical pathways in other fields (Figure 2).

Figure 2: Research Model Results.

Conclusion

In this study, three important things can be found, first, the clinical quality which consists of a) patients running away, b) forced discharge, and c) readmission is highly dependent on the implementation of clinical pathways, secondly, the implementation of clinical pathways has no connection at all with costs. drug rehabilitation treatment, and thirdly the application of clinical pathways makes an important contribution to the satisfaction of patients being treated for drug rehabilitation. This means that the satisfaction factor makes an important contribution to drug rehabilitation services at the Atma Husada Mahakam Hospital.

This means that the service outcomes provided by the Atma Husada Mahakam Hospital are generally good. This can be shown by the number of high satisfaction responses from respondents to each research variable. Similarly, the service quality variable from the five dimensions has a positive and significant influence on customer satisfaction. This reinforces the previous theory that the provision of quality services can certainly create satisfaction for everyone, including the treatment of drug rehabilitation patients.

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Study on the Indications of Interbody Fusion and Internal Fixation for Lumbar Vertebral Fractures with Expected Malunion

Study on the Indications of Interbody Fusion and Internal Fixation for Lumbar Vertebral Fractures with Expected Malunion by Chen Yuanzhen* in Open Access Journal of Biogeneric Science and Research

Abstract

Objective: To explore the indications of interbody fusion and internal fixation for vertebral fractures with expected malunion by reporting the case of vertebral fractures. Because of lumbar fracture, the patient underwent posterior total laminectomy, spinal canal decompression and internal fixation without interbody fusion. After the internal fixation was removed, the patient developed kyphosis with symptoms of lower extremities, and was subsequently given interbody fusion and internal fixation. After the operation, the patient’s lumbar spine stability was restored and the patient’s symptoms were relieved. Conclusion: interbody fusion and internal fixation is suitable for vertebral fractures with expected malunion

Keywords: Lumbar fracture; malunion Interbody; Fusion indications

Introduction

Spinal fractures with nerve compression are generally treated with spinal canal decompression and internal fixation [1]. If the spine is reduced timely and the reduction is better. Then, less intervertebral fusion is performed. If the prognosis of vertebral fracture is poor, interbody fusion can not only increase the stability of the spine, but also overcome the spinal instability caused by poor healing of the vertebral body.

Case Summary

The patient is a 29-year-old male with lumbar fracture caused by fall injury. Lumbar imaging examination showed lumbar L2 fracture with spinal canal stenosis. The loss of lumbar height was 41.38%, the positive Cobb angle was 10.86 °, and the lateral Cobb angle was 28.44 ° (Figure 1.1). After decompression and reduction, the height of the vertebral body was reduced well, the placement of pedicle screw and titanium rod was satisfactory, and there was no kyphosis and lateral displacement (Figure 1.2). One year after operation, the patient removed the thoracolumbar internal fixation and developed progressive lower limb numbness and kyphosis (Figure 1.3). CT showed that the L2 vertebral body was not completely healed, the large fracture blocks were separated, and there was an "empty shell" phenomenon in the interior (Figure 1.4). In order to correct the spinal instability, L1 and L2 and L3 fusion were performed. The postoperative symptoms were improved and the stability of the spine was restored (Figure 1.5).

Figure 1.1

Figure 1.2

Figure 1.3

Figure 1.4

Figure 1.5

Discussion

In this case, the patient's vertebral fracture healing is expected to determine the surgical plan [2]. Although surgical indications are still controversial [3], surgical options should be carefully selected if there is a poor recovery of anterior column height or poor expectation of vertebral body healing before operation, Because if the patient's vertebral body is healed poorly and can not bear axial pressure, there is a weak point of mechanical stress. The postoperative DR film seems to be highly recovered, but the healing of the vertebral body itself is poor and the supporting force of the anterior column is fragile, which can be regarded as a "reduction illusion". A cavity is formed between the fracture blocks, resulting in an "empty shell" phenomenon, resulting in an increase in the rate of nonunion [4-6]. Because of the large space between vertebral fracture blocks, the fretting of internal bone mass is also one of the physical factors of vertebral fracture nonunion [7]. Stabilizing vertebral internal fracture blocks plays a positive role in vertebral fracture healing. Correspondingly, the stability of vertebral body also provides stable biomechanical conditions for interbody fusion. In order to avoid this situation, the injured vertebrae should be scanned by CT and MR in time during or after operation [8]. In addition, there must be intervertebral disc injury after violent injury, which accelerates the process of spinal degeneration, and the biomechanical compression ability and stability have been lost. So the operation should be performed as soon as possible, together with intervertebral disc resection and fusion.

The clinical results are affected by many factors, in addition to intervertebral disc injury, patients' age, body weight, injury site, posterior column resection and postoperative nursing can also affect postoperative vertebral body healing and overall stability [9,10]. Improving the healing rate of injured vertebrae is an important link in the treatment of spinal fractures, and intravertebral bone grafting is a common means to promote the healing of vertebral fractures, which has achieved satisfactory results in clinic. Proper bone grafting can not only improve the success rate of internal fixation, but also effectively prevent progressive kyphosis of the spine. Pedicle screw titanium rod system is an important device for maintaining postoperative stability of lumbar fracture and dislocation. Its advantage in promoting fracture healing is to enhance the overall stability of the internal fixation system and the internal stability of the injured vertebrae. Early or hasty removal can easily lead to kyphosis. Because screws can disperse local stress and strengthen the overall stability of internal fixation, thus reducing the immediate height loss of injured vertebrae and slow height loss for a long time after operation. therefore, it not only promotes the fracture healing of injured vertebrae, but also reduces the risk of chronic deformity after operation.

Conclusion

Through clinical practice, intervertebral fusion can be directly selected if the expectation of fracture healing of injured vertebrae is poor. If there is a possibility of upper and lower endplate injury or intervertebral disc injury, interbody fusion can also be performed directly to improve spinal stability. The expected evaluation method of vertebral fracture healing and the evaluation of the therapeutic effect of interbody fusion and internal fixation still need to be proved by more practice.

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Hospital Clinical Del Centro’s Patterns of Bacterial Resistance in Urine Cultures

Hospital Clinical Del Centro’s Patterns of Bacterial Resistance in Urine Cultures by Daniel Medina García in Open Access Journal of Biogeneric Science and Research

Abstract

Introduction: Urinary tract infection is one of the most prevalent diseases in clinical practice. They represent the third cause of morbidity in Mexico. It is advisable to carry out epidemiological studies in each hospital, at least once a year, in order to identify the current pattern of bacterial resistance and establish clinical practice guidelines for the empirical treatment of urinary infections. This study seeks to establish the pattern of antimicrobial resistance of urine cultures performed in patients with urinary tract infection to determine the most common uropathogens to guide the appropriate use of empirical antibiotic therapy. Methods: A descriptive, cross-sectional, retrospective study was carried out on the main etiological agents, the profile of sensitivity and resistance to antibiotics from urine cultures performed from urine samples of patients from the clinical hospital of the center in the city of Chihuahua, Mexico. from 2017 to 2019. Results: 214 urine cultures were analyzed, finding the most frequently isolated microorganisms were Gram-negative bacteria in 85% and Gram-positive bacteria in 15%, of which, firstly E. coli, followed by Staphylococci spp, Klebsiella spp and Pseudomonas . A general resistance greater than 75% was found for cephalothin and ampicillin; for quinolones greater than 50%, the cephalosporins: ceftriaxone (53%), cefuroxime (46.6%), cefotaxime (40.78%), cefepime (37.43%) and ceftazidime (37.43%); trimethoprim associated with sulfamethoxazole (51.8%), amoxicillin with clavulanic acid (42.11%), nitrofurantoin (28.99%) and carbapenems together with amikacin were the only antibiotics with a general resistance lower than 30%. Conclusion: The importance of the urine culture registry is extended not only in patients with recurrent urinary infections, complicated or with treatment failures, but also to maintain a local registry of the most frequent uropathogens and the antimicrobial resistance patterns of the population attended.

Keywords

Urinary infection, bacterial resistance, uropathogens, urine culture, Escherichia coli, antibiotics, cephalosporins, quinolones, general urinary examination.

Introduction

Urinary tract infection (UTI) is one of the most prevalent diseases in clinical practice, being found in both hospitalized and outpatient patients around the world [1-3] They represent the third cause of morbidity in Mexico, with respiratory and gastrointestinal infections occupying the first and second place respectively [4]. In 2017, 4,474,599 new cases of urinary tract infections were diagnosed in our country [5,6]. Except for some microorganisms that can be found in the anterior urethra, the urinary tract is free of microorganisms, therefore their presence in the urine is likely to be indicative of infection [7].

Invasion of the healthy urinary system is restricted to a very select group of microorganisms, called "uropathogens", which are capable, through the expression of virulence factors, of bypassing or minimizing the defense mechanisms of the host [8]. In general, women are more affected by UTIs than men. It is estimated that, by the age of 24 years, 33% of women will require antimicrobial treatment for at least one episode of UTI and more than 50% will experience at least one UTI during their lifetime, in fact, 75.6% of the cases of urinary tract infections reported in 2008 in Mexico were diagnosed in female patients.6 Women with a diagnosis of urinary tract infection have a 44% risk of becoming infected the following year [9-13].

The reason why the infection is more frequent in women is due to the proximity of the urethra; Furthermore, the distance between the urethra and the bladder is shorter in women and facilitates colonization of the bladder [3,14]. In women there are two stages in which the frequency of urinary infections increases: in sexually active women, since the colonization of the urinary tract is favored, and during pregnancy, since progesterone conditions the decrease in bladder emptying, due to its inhibitory effect on smooth muscle contraction, and there is compression of the ureteral system, with increased urinary stasis [15]. In men, it is more frequent in those over 50 years of age, secondary to obstruction by prostate growth. In the hospital environment, urinary tract infections are among the first three causes of nosocomial infections and are usually associated with the presence of urinary catheters [14].

Urinary tract infections are one of the most frequent abnormalities and cause of increased morbidity both in the hospital and in the community, so knowing the main isolated germs, as well as the resistance patterns, allows determining the variation that exists between the different bacterial species and guide the empirical initiation of antibiotics with greater elements of success [15].

In recent years, the number of bacteria that are resistant to first-line antibiotics has increased dramatically. It is defined as multi-resistant bacteria when there is bacterial resistance to 3 or more groups of antibiotics and pan-resistance when there is resistance to all the antibiotics of the ordinary antibiogram. Since the 1990s, Gram negative bacteria capable of producing enzymes that hydrolyze the beta-lactam ring of antibiotics began to emerge. These bacteria are called ESBL (Extended Spectrum Betalactamases) [16], These bacteria can be the cause of the infection acquired in the community in 14-31% [17,18] This has been associated in patients with a history of previous administration of antibiotics [19,20].

The frequency of pathogen isolation and bacterial resistance vary widely depending on the different geographic regions, even between hospitals in the same country and city [21]. The World Health Organization has considered the emergence and spread of antimicrobial resistance as a priority problem and therefore since September 2001 a global measure for the containment of antimicrobial resistance (Global Strategy for Containment of Antimicrobial Resistance) was instituted, which includes as a fundamental measure the surveillance of antimicrobial susceptibility [22]. That is why it is important to publish and make known the patterns and trends of sensitivity in the different hospitals of the country and the world in order to apply or intensify strict measures of surveillance and control of the use of antibiotics [15, 23,24].

In Mexico, an incidence of multidrug resistance in urine cultures of up to 22% and pan-resistance of 0.5% has been reported. In response to the appearance of these resistant microorganisms, new drugs have been developed that are resistant to the defense mechanisms of bacteria, there are also "old" drugs that continue to be effective against bacteria, such as aminoglycosides and nitrofurantoin. It is advisable to carry out epidemiological studies in each hospital, at least once a year, in order to identify the current pattern of bacterial resistance and establish clinical practice guidelines for the empirical treatment of urinary infections [20].

Knowing the main microorganisms involved, as well as the susceptibility patterns in hospital centers, allows initiating an empirical directed antimicrobial treatment, which is very useful especially for immunosuppressed patients or with data of severe sepsis [25].

There are multiple forms of presentation, from asymptomatic bacteriuria to pyelonephritis with all the signs and symptoms that can occur in different types of patients, say pediatric, elderly, pregnant, cancer patients, etc. The mechanisms by which urinary infection occurs are varied and complex and not only depend on host factors but also on the pathogenicity mechanisms that bacteria have [26]. Uncomplicated urinary infection is one that affects subjects with a structurally normal urinary tract and whose defense mechanisms are intact [8]. UTIs can be complicated by bacteremia and sepsis, which increases morbidity and mortality, length of hospital stay, and related costs. In the last decade, an increase in resistant bacterial strains in urine was identified, both from community patients and hospitalized patients [25].

The financial burden is notable, especially in Latin American countries, where the prescription of antimicrobials is less strictly controlled. A cross-sectional study conducted in a pediatric hospital in the state of Sonora, found that the average cost of medical care per episode of nosocomial urinary infection was $ 2,062.00 USD.6.

Resistance to antibiotics and appeared with the introduction of these drugs in medical institutions, and increased as it was widespread clinical use and other areas of human endeavor (livestock, aquaculture, forestry, etc.) is therefore from The emergence of antimicrobials raised concerns about the emergence of bacterial resistance to antibiotics, as was pointed out early by Fleming and Waksman (both Nobel Prize winners for discovering penicillin and streptomycin, respectively) who pointed out that their inappropriate use could generate resistance. bacterial infection in microorganisms with greater significance in the clinic and in public health, with a high risk of treatment failure [14]. The empirical use of antibiotics improperly in the treatment of UTIs can facilitate the development of resistanc to antimicrobial agents, which poses a great challenge for clinicians and researchers, since data on the prevalence of Uropathogens and antimicrobial susceptibility vary between care centers and cities and must be identified for each hospital [3, 27-29].

Due to their characteristics and virulence, uropathogens have for many years been subjected to the action of multiple antimicrobials: beta-lactams (with or without inhibitors), fluoroquinolones, aminoglycosides, furans, among others, all of them have been present at some point in the therapeutic schemes of UTIs, [20] which is why these bacteria have evolved resistance mechanisms that make them currently included within the group called ESCAPE together with such invasive microorganisms as Escherichia coli, Staphylococcus aureus methicillin resistant, Clostridium difficcile, Acinetobacter baumannii, Pseudomona aeruginosa and Vancomycin resistant Enterococcus [26].

The increase in antimicrobial resistance may be due, in small part, to the recommendation to initiate treatment empirically without the need for microbiological documentation in the face of predictive symptoms of low uncomplicated urinary tract infection [27,30,31]. On the other hand, resistance records obtained from urine culture laboratory reports tend to overestimate the true prevalence of resistance due to the selection bias inherent in the indication of these studies (patients who failed initial treatments, complicated urinary tract infections or associated resistance factors) [8,32-35] Resistance mechanisms have been thoroughly studied in E. coli and it is suspected that these are shared by the rest of the uropathogens.

Some of the mechanisms described are:

1. Alterations in permeability: low level of resistance, nonspecific, although it is generally accompanied by another mechanism.
2. Extended spectrum β-lactamase (ESBL): Class A (Ambler) Group 2b KB: TEM-1, TEM-2 and SHV-1 show resistance to ampicillin and ticarcillin. Inhibitable by sulbactam, clavulanic and tazobactam. Overproduction of TEM-1 or SHV-1 generates resistance to ampicillin, ticarcillin, amoxicillin / clavulanate, ampicillin / sulbactam, and cephalothin.
3. Extended spectrum β-lactamase (ESBL): Group 2be KB: TEM, SHV, CTX-M, PER, VEB, GES, OXAs. They are resistant to ampicillin, ticarcillin, piperacillin, 1st, 2nd, 3rd cephalosporins (cefotaxime, ceftriaxone, ceftazidime) and 4th generation (cefepime) and monobactams. They generally have accompanying resistance to quinolones and aminoglycosides.
4. Plasmid AmpC-type β Lactamase: Class C (Ambler) - Group 1 (KB). They have the characteristic of giving resistant cefoxitin, although there are exceptions. They are inhibible by oxa / cloxa and boronic acid. They generate resistance to 3rd generation cephalosporins and decrease in the sensitivity of 4th generation. In the case of uncomplicated urinary tract infection, the use of sensitive 3rd generation cephalosporins in the antibiogram can be successful in treatment [36].
5. Quinolone resistance: Chromosomal mutations (non-transferable): Target site alterations (QRDR mutations of gyrA, gyrB, parC, parE genes). The main resistance mechanism in quinolones. Decrease in the cytoplasmic concentration of the drug (reduced permeability, E-flux)

Plasmid mechanisms (transferable):Protection of the target site (Qnr protein protects DNA gyrase and Topo IV) ,Enzymatic modification of ATB (enzyme AAC (6`) -1b acetylates the NH2), E-flux group specific for fluoroquinolones.

6. Carbapenemases: they are classified into serine carbapenemases, metallo β-lactamase (MBL). They are enzymes that inactivate all beta-lactam antibiotics (penicillins, cephalosporins, and carbapenems). Cut-off points to suspect the presence of carbapenemase: CAZ≤22 and MER≤23 [37].

In recent years, the presence of KPC has been reported in Enterobacteria, with Klebsiella pneumoniae being the main pathogen that carries this resistance, but cases have already been detected in E. coli, C. freundii, Serratia marcescens and Enterobacter cloacae [13].

Methods

Methodological Design

Descriptive, cross-sectional, retrospective study on the main etiological agents, the profile of sensitivity and resistance to antibiotics from urine cultures performed from urine samples of patients treated in the emergency department and internal medicine of the clinical hospital of the center in the city of Chihuahua, Chihuahua, Mexico from January 8, 2017 to August 23, 2019.

Data Analysis

The following type of analysis was performed: identification of urine cultures, of drugs evaluated for sensitivity and resistance in the antibiogram , the bacteria isolated in all the processed urine cultures and the results of the antibiograms in the clinical and microbiological laboratory of the hospital were identified throughout the study period, these urine cultures were processed using the manual Chromagar technique of the supplier Beckton Dickinson Diagnostics ( BD) with calibrated loop, incubation at 37ºC for 24 hours, including those with more than 100,000 Colony Forming Units per milliliter (CFU) in the analysis.

In addition, all cultures that had their corresponding antibiogram based on the semi-automatic MicroScan autoSCAN-4 system were evaluated. Antibiotics used for the management of UTI and Gram-positive bacterial infections were included. For data analysis, the statistical package SPSS Statistics, version 22.0 (IBM, USA) for Windows was used, descriptive statistics were used as mean, standard deviation for continuous variables and percentages for categorical variables, the test was performed of Pearson's Chi-square for the categorical ones, was determined a p <0.05as a level of statistical significance, comparing the resistance and sensitivity for each antibiotic with the previous years. The protocol was submitted for approval and authorization by the president of the teaching and research committee of the Hospital Clínica del Centro in the category of research without risk, Dr. Belinda Sofía Gómez Quintana.

Table 1: Most frequently found pathogens in 329 urine cultures from patients with UTI.

Figure 1: Most frequent pathogens in the 329 urine cultures of patients with UTI.

Figure 2: General antibiotic resistance in E. coli obtained from urine cultures.

Figure 3: General antibiotic resistance in staphylococci obtained from urine cultures.

Figure 4: General antibiotic resistance in klebsiella spp obtained from urine cultures.

Results

Statistical Analysis

214 positive urine cultures were analyzed for bacterial growth, finding that the most frequently isolated microorganisms were Gram-negative bacteria in 85% and Gram-positive bacteria in 15%, of which, in the first place, Escherichia coli, followed by Staphylococci sp, Klebsiella sp and Pseudomonas As can be seenin (Table 1) and (Figure 1).

The general resistance of the analyzed cultures that were positive for E. coli, as we can analyze in (Figure 2), showed a high percentage of cephalothin (94.74%) and ampicillin (73.98 %); Antibiotics such as norfloxacin, ampicillin associated with sulbactam, levofloxacin, ciprofloxacin, cefazolin, and trimethropin associated with sulfamethoxazole, in order from highest to lowest resistance, remain between (68% and 55%). Between 50% and 40% are the second, third and fourth generation cephalosporins: cefuroxime, cefepime, cefotaxime, ceftazidime and ceftriaxone. Antibiotics such as amoxicillin associated with clavulanic acid, aminoglycosides (amikacin and gentamicin) and nitrofurantoin maintain low resistance (less than 30%). carbapenemic antibiotics (ertapenem and imipenem) show zero resistance (less than 5%).

The general resistance pattern in the cultures that were analyzed and that were positive for the staphylococcal strains, as shown in (Figure 3), we found absolute resistance to ampicillin, the antibiotics amoxicillin with clavulanic acid, ampicillin associated with sulbactam, ceftriaxone, and the quinolones ciprofloxacin and levofloxacin showed resistance between 80 and 60%. With an intermediate resistance between 55 and 30% are the antibiotics gentamicin, tetracycline, vancomycin and trimethoprim associated with sulfamethoxazole, it should be noted that nitrofurantoin shows a general resistance of only 30%, being the most sensitive for the treatment of infections urinary tract by staphylococci.

The general resistance of the analyzed cultures that were positive for the Klebsiella strains, as we can analyze in (Figure 4), showed absolute resistance to ampicillin; antibiotics such as nitrofurantoin, cefazolin and ampicillin associated with sulbactam maintain resistance between 60% and 40%. The cephalosporins cefuroxime and cefotaxime, together with amoxicillin associated with clavulanic acid, trimethoprim with sulfamethoxazole and ciprofloxacin maintain low resistances between 30% and 20%. The third and fourth generation cephalosporins: cefepime, ceftazidime and ceftriaxone, together with levofloxacin maintain resistance rates of less than 20%. Carbapenemic antibiotics (ertapenem and imipenem) and aminoglycosides (gentamicin and amikacin show very low resistance (less than 15%).

Pearson's Chi-square statistical test was performed, relating the annual resistance of antibiotics compared to each year (2017, 2018 and 2019) yielded, for the following antibioticsvalues p less than 0.05, amoxicillin with acid clavulanic(p = 0.014), cefazolin (p = 0.027), trimethoprim associated with sulfamethoxazole (p = 0.037), nitrofurantoin (p = 0.005) and piperacillin with tazobactam (p = 0.009); therefore we can reject the null hypothesis and it is established that there have been no changes in the resistance patterns during the years 2017 to 2019. The data obtained for the antibiotics amikacin (p = 0.061), tetracycline (p = 0.070), cefepime (p = 0.522), cefotaxime (p = 0.131), ceftazidime (p = 0.469), ceftriaxone (p = 0.214), cefuroxime (p = 0.225), ertapenem (p = 0.572), gentamicin (p = 0.775), imipenem (p = 0.77 5), yieldedvalues p greater than 0.05, which accepts the null hypothesis, indicating statistically significant changes in resistance patterns; however, these changes are evidently due to an increase in the antimicrobial sensitivity of uropathogens. Lastly, the antibiotics tobramycin (p = 0.427), ciprofloxacin (p = 0.469), levofloxacin (p = 0.375), vancomycin (p = 0.447), norfloxacin (p= 0.178), ampicillin with sulbactam (p= 0.347), ampicillin (p = 0.173), cephalothin (p = 0.943), showedvalues p higher than 0.05, which accepts the null hypothesis, indicating statistically significant changes, but they are demonstrated in a statistically significant increase in the resistance of uropathogens to said antibiotics through time studied.

Discussion

The results obtained highlight the fact that, as reported by surveillance studies of urinary infections from other regions of the world, gram-negative bacteria are the most commonly isolated pathogens, of which Enterobacteriaceae are the most often isolated pathogens. E. coli ranked first in isolates, albeit in a lower percentage (57.9%) compared to literature reports (~ 70%), followed by Staphylococci (10.7%) and Klebsiella third (7.9%).

A general resistance greater than 75% was found for cephalothin and ampicillin (82.35% and 78.2%, respectively) for which it is recommended not to be used as therapy for urinary tract infection. In general, quinolones (levofloxacin, ciprofloxacin and norfloxacin) presented a resistance greater than 50%, so it is advisable not to be used as first-line antibiotics in the treatment of uncomplicated urinary tract infections and that their use is restricted to administration intrahospital or under documentation of urine culture with sensitivity to these quinolones. Carbapenems (imipenem and ertapenem) together with amikacin were the only antibiotics with a general resistance lower than 25%, for which their use is recommended in patients with urosepsis. The first generation cephalosporins cephalothin (82.35%) and cefazolin (56.74%) show resistance greater than 50% and are not recommended as outpatient therapy, in addition to not having oral presentations. second, third and fourth generation cephalosporins, with the exception of ceftriaxone (53%), maintain resistances lower than 50%, of which only cefuroxime (46.6%) is found in the oral route, the rest: cefotaxime (40.78% ), cefepime (37.43%) and ceftazidime (37.43%) are only found in the parenteral route, so they should be used only in the hospital and not as outpatient treatment.

Trimethoprim associated with sulfamethoxazole (51.8%) maintains relatively high general resistance, however the resistance for E coli increases to 55.75%, compared to the resistance, less than 50%, that it presents for Klebsiella and staphylococci (23.53% and 36.36%, respectively). Amoxicillin with clavulanic acid (42.11%) maintains a resistance lower than 50%, it is in oral presentation and maintains low resistance for bacteria such as E. coli (30.89%) and Klebsiella spp (23.53%), however it maintains a resistance high for Gram-positive bacteria, such as streptococci (78.26%) and enterococci; Therefore, its use is suggested empirically for urinary tract infections when it is suspected that the uropathogen belongs to the Gram-negative group. Nitrofurantoin (28.99%) maintains a low resistance rate in general, is found in oral therapy and should be used in urinary tract infections with failure prior to treatment, with or without urine culture that confirms the sensitivity of the uropathogen, or in patients with recurrent urinary infections.

Resistance of E. coli to drugs frequently used in outpatients with urinary tract infections, such as ciprofloxacin and levofloxacin, was recognized as alarmingly high (60.98% and 61.48%, respectively); Consequently, it is possible to conclude that due to this high rate of resistance, these drugs should be left out of the arsenal of empirical therapy for urinary tract infections in the community and only be used for complicated or intrahospital urinary tract infections. Nitrofurantoin (11.76%) remains with a low resistance, which is why it should be the initial therapy in patients with recurrent symptoms, with or without urine culture that confirms the sensitivity of the uropathogen.

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Diagnosis and Treatment of Intramyometrial Placental Tissue Invasion in Cesarean Scar: A Case Report

Diagnosis and Treatment of Intramyometrial Placental Tissue Invasion in Cesarean Scar: A Case Report by Ying Xiao Yan* in Open Access Journal of Biogeneric Science and Research

Abstract

Morbidly adherent placenta is one of the rare complications of Cesarean Section Pregnancy. This is the implantation (part or whole) of the placenta via the niche (dehiscence at the hysterotomy site) or scar of the prior cesarean section into the uterine wall. It is divided into placenta accreta, placenta increta or placenta percreta depending on the degree of placental tissue uterine invasion. It poses a high risk of maternal morbidity and mortality due to missed diagnosis and non-existence of clear treatment guidelines. We present a case of adherent placental tissue in cesarean scar pregnancy diagnosed with laparoscopy. We highlight the importance of early diagnosis and treatment of placental tissue uterine invasion in cesarean scar pregnancy.

Introduction

Cesarean Scar Pregnancy is reported to range from 1 in 1,800 to 1 in 2,500 of all cesarean deliveries performed. Morbidly adherent placenta is one of the rare dangerous complications of cesarean scar pregnancy [3]. Depending on the degree of invasion in the uterine wall, placenta tissue invasion can be classified into accreta, increta and percreta. Over the last few decades, numbers of cesarean section deliveries have increased [1]. This has also led to the increase in the number of uterine scar placental tissue invasion complications like hemorrhage which often leads to many other complications including hypovolemic shock, disseminated intravascular coagulopathy, hysterectomy, and even morbidity. Increase in cesarean section delivery has led to reduced number of vaginal operative procedures [1,2]. ACOG has advocated for vaginal delivery in the trial of scar for appropriate candidates, the rate of repeat cesarean deliveries is now close to 91% [2].

Proposed pathogenesis of cesarean scar pregnancy is that the conceptus invades through a defect or microscopic dehiscence in the scar of previous hysterotomy. This is due to the poor vascularization with fibrosis of the lower uterine segment. There is also disruption of the endometrium and myometrium that predisposes to improper implantation at the site of the prior hysterotomy [3,4]. The placental invasion is due to compromised decidua basalis, which normally is a barrier to trophoblastic invasion of myometrium.

It is important that early and accurate diagnosis is obtained in order to avoid complications. Though missed diagnoses of placental insertion disease (morbidly adherent placenta) have been reported, ultrasonography remains the main tool for diagnosis of morbidly adherent placenta, mostly with a sensitivity of 90.7% [95% confidence interval (CI), 87.2e93.6], specificity 96.9% (95% CI, 96.3e97.5), a positive likelihood ratio of 11 (95% CI, 6e20), and a negative likelihood ratio of 0.16 (95% CI, 0.11e0.23) from a meta-analysis in 2013 [4]. Ultrasonography clues on morbidly adherent placenta include abnormal vasculature, increased size and numbers of vascular sinus, absence of uterovesicle border or retroplacental hypoechoic zone, and invaded placenta insertion on myometrium [3,4].

Case Presentation

We are presenting a female 32-year-old, G3P2, Chinese, Han tribe, initially presented to the local hospital with 3 months amenorrhea. She requested to terminate the pregnancy due to satisfied parity. Cesarean Scar Pregnancy was confirmed at the local hospital with ultrasonography showing 15weeks gestational age. She had no history of bleeding, dizziness, abdominal pain, vaginal discharge, dysuria, diarrhoe, coughing or headache. A known polycystic ovarian syndrome patient, with history of appendectomy and cesarean section delivery 2 years and 8 years ago respectively prior to hospital presentation. According to ultrasound finding, the patient was commenced on medical abortion therapy on the same day of admission, followed by dilatation and curettage on day 2 post admission. During the procedure, patient developed hemorrhage due to retained products of conception (placenta) adherent to the anterior wall of the lower part of the uterine cavity. Estimated blood loss during the procedure was 1500ml. The heavy bleeding in this cesarean scar pregnant patient was treated with uterine artery embolization interventional therapy, blood transfusion and IV fluids. The local hospital decided to refer the patient to our hospital for further evaluation and treatment on the same day she underwent the D&C procedure. Upon arrival in our hospital, patient was seen in the outpatient department with normal vitals and minimal vaginal bleeding noted on vaginal examination. Human chorionic gonadotropin (hCG) was 3562miU/ μL, hemoglobin 81g/L. Hysteroscopy examination revealed retained products of conception tissue in the anterior wall of the lower part of the uterine cavity measuring 5 * 4cm diameter. Under the guidance of B-ultrasound, curettage was done and about 100g of retained products of conception were evacuated. Some of the tissues adhered tightly to the anterior wall of the uterus, and vaginal bleeding was more when scrapped. The procedure was successful and hemostasis was achieved with estimated blood loss of 100ml. Patient was treated with uterotonics to prevent further vaginal bleeding. She was treated as an outpatient to be followed up with a recheck ultrasonography after four days.

One week post curettage, patient was admitted to our hospital due to minor vaginal bleeding mixed with clots. Recheck B-ultrasound examination revealed that the anterior uterus was irregularly enlarged with a heterogeneous hyperechoic mass of 7.3*4.9cm in the middle and lower part of the anterior uterine wall. The mass protruded outward reaching the serosa layer. Color blood flow was seen in and around the mass. There was no obvious abnormality in bilateral adnexa. At this time, placental tissue uterine cesarean scar invasion was suspected.

Discussions with the patient regarding her imaging findings, potential complications of continuation of cesarean scar placental tissue invasion and reproductive goals were done. The patient stated that she desired permanent sterilization. She was scheduled for an urgent laparoscopic removal of the adherent cesarean scar placental tissue and bilateral tubal ligation.

Intraoperatively, during laparoscopic abdominal and pelvic exploration, the uterus showed a subserosal 4*5cm enlarged mass on the lower segment of the uterus as shown is (Figure 1a). The mass was noted to be enlarged with hyper vascularization. Incision on the mass was made to open the intramyometrial mass as observed in (Figure 1b). Access to the intramyometrial space was achieved and complete evacuation of the adherent placental tissue was done (Figure 1c & Figure 1d).

After the evacuation of the intramyometrial adherent placental tissue, the intramyometrial cavity was sutured; uterine scar repair and bilateral tubal ligation were successfully done. Hemostasis was achieved with estimated blood loss of 1000ml. Patient received 4 units of packed red blood cells, 1000ml crystalloid solution and intramyometrial injection of methotrexate. Retained products of conception were taken for pathological assessment which confirmed the presence of degenerated placenta villi and decidua, trophoblastic tissue implanted in an area of markedly attenuated myometrium. Post operatively, patient improved clinically. She had no vaginal bleeding, abdominal pain, dizziness, headache, fever or constipation. Laboratory results showed reduction in hCG levels i.e 558.26 miU/ μL and 234.8 miU/ μL on day 4 and day 7 post operation respectively compared to the hCG on admission of 3562miU/ μL. After 10 days in the hospital, the patient was discharged to be followed up in the gynecology clinic for review.

Figure 1: (a) Laparoscopic view of the pelvic cavity showing the intramyometrial subserosal mass (black arrows). (b) Opening and exploration of the intramyometrial mass review the adherent placenta tissue being evacuated. (c) Evacuated products of conception were sent for pathology examination. (d) View of the intramyometrial cavity after complete evacuation of the products of conception just before suturing it, the intramyometrial cavity did not communicate with the uterine cavity.

Discussion

Morbidly adherent placenta is one of the rare complications of Cesarean Section Pregnancy. This is implantation (part or whole) of the placenta via the niche (dehiscence at the hysterotomy site) or scar of the prior cesarean section into the uterine wall [5,6]. Morbidly adherent placenta is divided into placenta accreta, placenta increta or placenta percreta depending on the degree of placental tissue uterine invasion. Prevalence of Cesarean Scar Pregnancy is reported to range from 1 in 1,800 to 1 in 2,500 of all cesarean deliveries performed [6,7]. Research has shown that, in cesarean section pregnancy, conceptus invades through a defect or microscopic dehiscence in the scar of previous hysterotomy [7]. This is due to the poor vascularization with fibrosis of the lower uterine segment.

Cases of placental tissue cesarean scar invasion are on the rise due to an increase in the number of cesarean sections being performed. Depth of placental invasion increase as the gestation advances. Some of the other risk factors for morbidly adherent placenta include placenta previa after a prior cesarean delivery, a history of uterine surgery (e.g., myomectomy entering the uterine cavity, hysteroscopic removal of intrauterine adhesions, cornual resection of ectopic pregnancy, dilatation and curettage, endometrial ablation), cesarean scar pregnancy, maternal age older than 35 years, history of pelvic irradiation, and infertility and/or infertility procedures (e.g., in vitro fertilization) [8].

Diagnosis of this placental insertion disease is by ultrasonography, mostly with a sensitivity of 90.7% [95% confidence interval (CI), 87.2e93.6], specificity 96.9% (95% CI, 96.3e97.5), a positive likelihood ratio of 11 (95% CI, 6e20), and a negative likelihood ratio of 0.16 (95% CI, 0.11e0.23) from a meta-analysis in 2013 [2,8]. Diagnosis is often difficulty and missed by ultrasonography diagnosis. Magnetic Resonance Imaging has been used as an adjuvant to ultrasound as well as aid in preparation for surgery and intraoperative orientation but it is expensive and has low diagnostic value.

Our case highlights the importance of early diagnosis and management of adherent placental tissue in the cesarean scar to prevent catastrophic patient morbidity or death. If left untreated, patient can develop hemorrhagic shock which may lead to death. No clear treatment guidelines have been suggested for the treatment of Morbidly Adherent Placenta. It has been shown that if cesarean scar pregnancy is complicated with morbidly adherent placenta (cesarean scar adherent placental tissue invasion), the most frequently therapeutic approach is hysterectomy [9].

Conclusion

Our case presentation demonstrates the importance of early diagnosis and treatment of cesarean scar pregnancy, especially if it is complicated with placental tissue uterine scar invasion. The following are highly recommended to prevent serious complications of this condition:

1. If cesarean scar pregnancy is suspected, dilatation and curettage can be done under the guidance of B-ultrasound or laparoscopy monitoring to avoid puncturing the thin uterine muscle on the scar.
2. A patient with suspected cesarean scar pregnancy with heavy vaginal bleeding can undergo uterine artery embolization interventional therapy to minimize blood loss.
3. If a patient does not respond to the 1st blinded dilatation and curettage procedure, a 2nd D&C can be done under the guidance of hysteroscopy monitoring to make sure all products of conception are visualized and evacuated.
4. For patients with cesarean scar pregnancy and suspected placental tissue implantation, laparoscopy for diagnosis and surgical treatment can be done.

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