“Cesarean Scar Pregnancy” – with Professor Ilan Timor MD

Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics and women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB/GYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Dr. Ilan Timor, welcome to the podcast. It is so great to see you and to have you here in person.
Dr. Timor: Thank you so much. I hope that I will do well because this is my first podcast. Should I say that?
Dr. Fox: No, no, no, we have a lot of first timers here. When you say it’s your first podcast, you mean recording or even listening?
Dr. Timor: No, recording.
Dr. Fox: Okay, so you’re a podcast listener, you’re ahead of the curve.
Dr. Timor: It’s a very big pleasure to see you. But it’s also an honor for our listeners, Dr. Timor, Ilan, is, without hyperbole, one of the world leaders in ultrasound specifically for pregnancy and gynecology, pioneer the imaging/ You’ve authored, as you told me, you’re on your ninth book 318 plus articles, scientific articles. So, it’s a great honor to have you here. How you doing today?
Dr. Timor: Well, first of all, thank you for having me and leave out the big honor. It’s an honor to, like, chat with you in the COVID kind of era that we have very few opportunities to do that. I’m happy to be here.
Dr. Fox: We see each other from time-to-time, whether it’s socially, academically, and we were at Andre’s house for the barbecue. And we saw each other and I said, “Oh, my God, you got to come on the podcast,” and we downloaded it to pick the date. And it just worked out great. And so this is amazing. So for our listeners, just because they might not know who you are, what your story is. So just give us a brief intro. You know, where are you from? How’d you get into medicine? How’d you end up in ultrasound specifically?
Dr. Timor: Well, I used to say when this question comes up, I used to say you don’t have enough time to listen. But yes, I was born in Hungary, grew up in Transylvania, which is part of Romania, still is. And in 1960, immigrated to Israel, spent there, very long time, went to the Hebrew University in Jerusalem. And then my residency in Haifa Rambam hospital. And then I went to do some fellowship in maternal fetal medicine in Cleveland, Ohio.
Dr. Fox: So your residency was an OB/GYN, right?
Dr. Timor: My residency was in OB/GYN.
Dr. Fox: Right. And when you did the fellowship, that must have been the very beginnings of MFM fellowships in general, right?
Dr. Timor: Well, it was not even called an MFM fellowship at that time. My chairman, who will come later in the picture, really was one of the grounding members of the Maternal Fetal Medicine arena. And so, I spent there three years doing wonderful time learning what is to be here in America and the part of the system, and did research mostly in fetal, would you believe it, it’s fetal behavior. So we looked at the little wiggles of the electronic monitoring for fetal heart and try to read into it, of what kind of sleep state the fetus is, because at that time, that was big. And wrote with my co-fellow, who is still one of my best friends, lives in Cleveland still, we wrote about six articles about fetal behavioral states, fetal movements, fetal hiccups, all these things.
And then I went back to Israel, and spent there for about six or more years, and then came back to the States to the same person, the same chairperson, who at this time was already running the department at Columbia Presbyterian. And I spent with him another couple of years. He unfortunately passed because of Lou Gehrig’s disease. But this was basically the time when I decided that it would be nice to stay in the United States, even though I tried to go back for another year or so. But then I came back to Columbia Presbyterian and from there to NYU in 1999, January 1st, and that’s the story.
Dr. Fox: And when did you get interested for the first time in ultrasound?
Dr. Timor: Okay, that’s a parallel story. When I was in residency, I did one year of Electronic Engineering at Israeli Technion, and my subject was to construct a miniature oxygen electrode for the scalp of the fetus. And at that time, I met somebody there who was interested also in ultrasound. And then we got the first ultrasound machine, which I already knew about in Cleveland, because I already operated an ultrasound machine in 1978 in Cleveland. So I was interested and I bought one of the first machines in Israel, and used it in the department. And then I bought another one for my private practice.
Dr. Fox: Right. And then at the time, you’re talking about, you know, late ’70s, what was ultrasound like, back then?
Dr. Timor: Well, ultrasound was basically a free arm scanner that went back and forth on the abdomen of the fetus, it was called mostly B-scan. And the picture was constructed by transducer producing faint echoes on the screen. And it was a guesswork.
Dr. Fox: The abstract. Yeah.
Dr. Timor: And we were happy if we were correct.
Dr. Fox: To see what ultrasound is like now, where it’s like sticking your head inside and looking with your eyes. Or even better compared to then. I mean, what’s that like? Because, I mean, you’re there at the start, you’re there now, you’re busy in ultrasound the entire time. So you’re talking this is, you know, 40 plus years in ultrasound. Looking back on that, what’s it been like?
Dr. Timor: It’s an amazing journey, because ultra sound basic it’s a parallel kind of pathway transabdominal ultrasound. And then derivative of this, which is the transvaginal ultrasound that started out basically with, not with me, with Alfred Kratochwil in Austria in Vienna. But here, the static scanner, which produce pictures very similar to those of abdominal ultrasound, and the electronic technology was not very good at that time. So when I went back to Israel, I stole a pediatric cardio transducer, which was the smallest footprint, but it has a very high resolution. And this is already in the internet. That’s how I did my first transvaginal probe. I put two-tongue depressors and taped it onto the handle of this tiny cardiac transducer, put a condom on it, and put it in the vagina. And that is where I was stumped. What you can see when you put the transducer close to the ovary and the uterus. That’s my aha moment of embracing transvaginal ultrasound.
And ever since I never left it for 20 years, until it was really accepted in the United States. And exactly 20 years, the editors of journals were skeptical. They said it’s only an observation, there is no data, there is no…
Dr. Fox: What data? You put it in, you look it, this is a good picture.
Dr. Timor: And then I wrote the first transvaginal ultrasound book it was in ’89. And then the second edition that was in ’90. And that’s how it started with me in terms of using the transvaginal ultrasound.
Dr. Fox: It’s amazing, you know, because of your history, and who you are, and what you do. There’s obviously so many topics we can talk about related to ultrasound in medicine and OB/GYN, but I thought that we would talk today about a really interesting topic. And it’s a little bit new on the horizon in terms of diagnosis and therapies. And it’s something you’ve been involved with a lot, we’ve been involved with together, and it’s caesarean scar pregnancy, or caesarian scar ectopic, it’s sometimes called. How would you explain to someone what that is, what is this concept?
Dr. Timor: It is basically rather a rare occurrence of a pregnancy implanted not in the right place, which is the uterine cavity. It is implanted in a faulty recess of the lower part of the uterus anteriorly, where it takes advantage of a previously performed surgery, namely the cesarean section, which many claim that is not repaired all the way or the right way, leaving a little tiny dehiscence, or we call it niche, in which the fertilized egg gets lost, so to say, and implants. And then those are the bad things that we are then seeing after the pregnancy develops.
Dr. Fox: When was this first sort of identified in the sense that it was named and the terms were coined? Because I remember I was at a conference once in ultrasound, and this is a while ago, and there was a someone giving a talk on ultrasound, and someone from the audience, I think, was a talk on ectopic pregnancy, which is normally when it implants in the tube and someone asked a question of the speaker and said, “What do you think about caesarean scar ectopic?” And the speaker had never heard of it. And the speaker is an ultrasound person and the person at the audience does ultrasound and had heard of it. I mean, there was this transition point where people didn’t even know what it was. Do you remember when that happened?
Dr. Timor: As a fact that’s a recurring thing from 1990 to about almost 1910, that was the question because people we’re not…first of all the caesarean sections were not that almost daily time. So the opportunity to have a scar pregnancy was much more rare than it is now. So people weren’t really not sure about it, and that was also the time when it was christened, or called, or termed ectopic, which I now fight with a vengeance because ectopic pregnancy is something that is all in the tube, or out in the ovary or in the cervix, and does not result in a viable fetus. While caesarean scar pregnancy results, if so, continued in a viable baby.
So I am against calling it ectopic pregnancy. And these questions came after the first publications were around 1990. And one of the first guys was a wonderful obstetrician who made a brilliant observation. His name is Yvan Vial, from Lausanne from Switzerland, we became very good friends. And he called it endogenous and exogenous. Pregnancy in the scar. He never called it ectopic. And that was one of the first observations, even though there were several papers which were published, but it was not recognized as such. Yvan Vial was the first one that really said, “This is an entity, which is a bad entity, and watch out for it.”
Dr. Fox: Right. You know, I think there’s a lot of sense to separate it from the term ectopic, because for a lot of reasons, ectopic has a long, long history in obstetrics and gynecology, and doctors know what it is, nurses know what it is, other doctors know what it is. Patients, some know, some don’t. And everyone understands like that’s a pregnancy, it’s outside the uterus. It’s very dangerous. It’s life threatening. You’re not gonna have a baby, this that. And then this thing was called ectopic because it’s sort of not in the right place. But it is in the uterus. It’s just in a crevice in the uterus where it shouldn’t be ideally. And so if you call it ectopic, it’s not all those other things, and people also get confused and the treatments and the dangers. And so I do think that we just call caesarean scar pregnancy for that reason, just like you mentioned. I think that does make sense. So why is it so risky? Like, if they can have a live baby, so it’s not like an ectopic in the tube, what is it about the pregnancy, finding that old caesarean scar and burrowing into there, why is that an issue?
Dr. Timor: The danger comes from two major occurrences. One, it can burrow itself so deep into the anterior wall of myometrium, as a matter of actually it’s very seen there. And that’s why it happens that it penetrates into the area of the bladder.
Dr. Fox: Right. So it sort of burst through the uterus. Yeah.
Dr. Timor: And there are numerous articles about ruptures of these when it really enters the area of the anterior wall in the bladder, which is covering that area of the uterus. The second danger comes from the fact that usually that at least 80%, 90% of the cases, it is associated with the placenta being very, very low and very vascular. And when the placenta and this area becomes vascular, any kind of small insert will start bleeding. So these hemorrhage, these bleed, these pregnancies, and that is the second danger.
Dr. Fox: Right. So it’s the uterus rupturing. And that’s before labor, right? This is earlier pregnancy?
Dr. Timor: Earlier in the second and third trimester.
Dr. Fox: Yeah. that itself is clearly life threatening. And then also even without that the bleeding. And the pregnancies that do continue and don’t have a rupture, and don’t have bleeding, and more than 50% of the time, much higher are gonna have probably a placenta accreta, because it’s so burrowed in there, it’s gonna get stuck to the uterus, it’s not gonna peel off nicely at delivery.
Dr. Timor: Right, correct. So to explain that accreta, basically, it is, there is a layer between a normal pregnancy and the uterine wall, which one was called the fibrinoid layer of [inaudible 00:15:38], which now it’s not called anymore. Eric Junior changed everything in the UK. And that layer is disrupted by the caesarean section, by the incision. And therefore, the placenta burrows itself into the myometrium, deep into the myometrium. And then when it goes really, very much through it, then that’s dangerous. And we also, you know, that we usually differentiate these kinds of placenta as very little penetration, then a little more penetration, and then full penetration. There are terms for this which is not that important. But the ones that are really going in deep those are the bad ones.
Dr. Fox: Yeah. And it’s interesting. One of the other issues with this condition, caesarean scar, is it’s hard to know that that was the reason all this is going on, unless you had an ultrasound very early in pregnancy. And the person doing the ultrasound or reading the ultrasound knows to look for this, right? Because I’ll see a lot of people who will come and they’ve had an ultrasound, and then I see them like, “Oh, my God, this is like sitting in the caesarean scar.” And they’re like, “Well, my doctor didn’t tell me that.” I was like, “What?” They don’t really know. They didn’t know to look for this. They didn’t understand how to interpret it. They don’t think of it in the same way, which is okay. They don’t do ultrasound all day. But if this is missed, it could be a really dangerous pregnancy.
Dr. Timor: Well, you are so right. But it depends when the first ultrasound was done. And patients who are unsuspecting, they may go to the doctor when they are only 9 or 10 weeks. They say, “Okay, I had a positive pregnancy test. I was always okay. I took it before the last one was a caesarean section, and now it’s fine.” And then the doctor who does the first ultrasound sees the gestational sac and the embryo pretty low, but almost in the cavity, but does not look at the placenta, which is implanted in the lower anterior part deeply going into the area of the bladder, and does not look at the vascularity of it. So reassures the patient, “Oh, the pregnancy is in a good side, and a good place.” But that is preventable by doing an ultrasound very, very early.
Dr. Fox: Right. Because you’ll see exactly where it is.
Dr. Timor: Five weeks, just after the first positive pregnancy test if they are doing that five, six weeks, I think that an ultrasound would make the diagnosis. Now, we wrote an article and said, “Every patient who had a previous caesarean section and has a new pregnancy, should go for an ultrasound at five to seven weeks.” Now, this article was embraced and accepted in the literature. But it was an opinion article because the societies such as the Society of Maternal Fetal Medicine, the American Journal, American Institute of Ultrasound in Medicine, the Radiology Society don’t endorse this. They say, “Oh, this is an extra scan. It will ruin the economy of the United States.” I’m being facetious. And therefore, it’s not endorsed, but many already have realized this. And there is a follow-up paper that was peer reviewed, and it is, like, considered the real article or a particular…
Dr. Fox: The original research.
Dr. Timor: The original research article that was followed-up and there it is, clearly said that if recognizing a scar pregnancy before nine weeks, has less of a complication burden of complications, then it is diagnosed after nine weeks. Absolutely big difference.
Dr. Fox: Right. Yeah. And it makes a lot of sense because we’re gonna talk about what the options are for treatment of this. And that I think that that’s an important point because for, you know, we have a lot of listeners, and many of them are pregnant or will get pregnant. And since there’s so many women who have cesareans in the United States and in the world, at this the rate of caesarean is higher, and that’s its own topic, but okay, it’s the truth. That’s what happens. Many women are gonna get pregnant, who have a history of a caesarean. And it’s not meant to scare them, because this usually does not happen. This is a rare occurrence. But it can. And so it’s something women have to decide and say, “If my doctor is not gonna do an ultrasound early, maybe say, well, maybe I’m a little worried about this can you take a look? Can you make sure this is not going on?” And they’ll say, “Well, maybe your insurance won’t cover it.” So maybe “I wanna pay for it.” Like, you know, people should decide for themselves much testing they wanna do to rule out rare but very dangerous things. And there isn’t a right or wrong here, but when it’s just sort of dismissed and, oh, it’s not gonna be offered or anything like that. Yeah, I mean, we’ve seen it, where if it’s diagnosed too late, it’s much harder to treat or not possible at all. And if it’s early, as we’ll talk about, you can have like a perfect outcome and everything go okay. And not so much with the pregnancy, but with the mother’s life.
So if someone does come to you at five to seven weeks with a prior caesarean, in early pregnancy, in the ultrasound, not so much, what technically you have to do, but how easy is it for you to see this versus not? Is it usually obvious or is it subtle? I mean, what is it that you need to do in order to make this assessment to say, “It is a caesarean scar, or it’s not a caesarean scar pregnancy.”
Dr. Timor: Well, if you have a vaginal probe, and you put it in the right place, which, you know, it’s the anterior part of the cervix, it is impossible to miss it.
Dr. Fox: Right. You get the right picture. It’s there.
Dr. Timor: Now there is nothing 100% in life, but it is really one of the most obvious diagnosis at 5, 6, 7 weeks. Put together previous cesarean section low gestational sac caesarean scar pregnancy. There is no other diagnosis. Okay, cervical pregnancy. I am right now rewriting the up-to-date, which was so archaic, that I was really mad and they accepted a rewriting. So I am now rewriting the up-to-date.
Dr. Fox: For caesarean scar pregnancies?
Dr. Timor: Yes.
Dr. Fox: And I was gonna ask you about that. Because the current one doesn’t even mention this balloon technique, which we’re gonna talk about. It’s not even mentioned.
Dr. Timor: Right now, I am at the place where the differential diagnosis is mentioned. So what is the differential diagnosis for scar pregnancy when you look at it? And the first one, cervical pregnancy. And then I say in the narrative there, however, in the previous cesarean delivery patient, it is almost entirely can be rolled out. So, again, take the clinical part which is easy, previous cesarean section, low insertion, of the gestational sac, scar pregnancy. There is no other diagnosis.
Dr. Fox: So obviously, you’re in favor of for some of the prior caesarean having an early ultrasound in pregnancy. I’m curious what your opinion is about do you recommend that women should have an evaluation of their scar before pregnancy like doing a saline sonohysterogram, to look at that scar. Is it full thickness? Is there a niche? You know, do you recommend that routinely in certain women or is that still being determined?
Dr. Timor: Okay, we are getting very deep into this but this is an unbelievably good question. Because I…
Dr. Fox: This is a serious podcast. This is 60 minutes of medicine. I’m gonna pound you with questions, Ilan. There’s no softballs here.
Dr. Timor: I do almost six to eight saline infusions sonohysterography, procedures, which is putting for the audience and this is putting a little bit of fluid in the cavity with a very thin catheter it is not painful. It’s not dangerous. And then looking with ultrasound, whether the scar is healed or not. And you alluded to the fact that sometimes that scar is not completely healed, and you have a large dehiscence, or niche. And the question is whether at that time you tell the patient, or the referring physician, or yourself, corrected before you get pregnant? I have one answer to this.
The very last large ones are mostly corrected. And this is a new branch of gynecological surgery. There are surgeons who specialize in correcting this niche. I am against it. I think that if they are really very large, and there is no myometrium there, yes, it is probably useful. There are articles about pregnancies with corrected niches or without corrected niches, and their chance of getting pregnant into that niche are basically unknown. Basically, it’s unknown. And I always say, “You replace with this repair of the niche, you replace an old scar with a new scar.” And then the pathophysiology or the reason for this implantation, which is today discussed much in the literature. It really has absolutely no value because you cannot predict in which pregnancies it really implant in the scar or it will not?
Dr. Fox: Yeah, we’ve had a hard time with that. Also, I mean, we don’t routinely do saline sonohysterograms on people just because they had a prior caesarean.
Dr. Timor: Correct.
Dr. Fox: People who have had multiple caesareans, and this, and uterine ruptures, and just sort of they’re coming to us for consultation to evaluate, “Should I get pregnant? Should I not?” Sometimes it depends on the situation. Sometimes we’ll look sometimes we don’t. And then it’s the same thing , as we say if the Dobbin over it, you get this image and you see how much is left of the, you know, if the full thickness is let’s say, 10 millimeters or 1 centimeter…
Dr. Timor: About. Yes.
Dr. Fox: …and you see that she has it sort of, like, chewed out that she has like four millimeters left, you’re like, “Okay, what’s my cutoff? Is four okay? Is three okay? Is two okay?”
Dr. Timor: Nobody knows.
Dr. Fox: Yeah. Nobody knows. And so we tell them like, “We don’t know.” And we’ve had situations where people did get surgery, people didn’t. We’ve had people who got surgery, and then they come back six months later and the uterus, looks perfect. And we have people who had surgery, and they come back six months later in the uterus looks exactly the same. And so, it’s hard. This is an area that hopefully will sort out over the next several years. But it is very interesting.
Dr. Timor: Can I make a comment here?
Dr. Fox: Do whatever you want. The mic is yours.
Dr. Timor: I think that this issue has to be addressed not by looking at the niche and repairing it or not repairing it, letting the patient be pregnant or not. It is how you suture the uterus, after a caesarean section. And there is now starts to be a very good literature on the fact that if you do an endometrial free closure of the incision of the caesarean section, then there is no niche remaining, or the niche is so small that it’s hardly seen. And therefore, this may be the primary thing that we have to concentrate on and not to repair a niche that’s already there.
Dr. Fox: So prevent rather than to treat. Yeah.
Dr. Timor: So there are now at least two or three articles. And one of my colleagues at NYU is into this. We have already two articles put in the literature, the difference between the appearance of this niche when you close it correctly and if you don’t.
Dr. Fox: It’s so interesting. So let’s talk about treatments. You find someone who pregnant prior caesarean. You diagnose her with the caesarean scar pregnancy. We’re gonna finish by talking about the technique you developed with the balloons. What were the older techniques that you knew about or tried or people have done? Like, what are the treatments that had been proposed?
Dr. Timor: First of all, when a patient comes you have to really first of all, make sure that you explain with based on all what you have, and the knowledge, the literature, the experience of previous case, we have to talk to the patient whether she wants to continue or not. If the patient wants to continue and accepts the fact that may have maybe complications, then you just manage the pregnancy with a lot of caution. And you do that every single day. You can practice. Or you can say you can talk about this much better than I can.
If the patient decides that she doesn’t want to take or she already…this is a pregnancy that was not planned or she doesn’t wanna take the risk of this, then we talk about what to do and that is gestational age dependent. And, again, I have to tell you that there are very few papers in the professional literature, our literature, that hinges the treatment to the gestational age. Because it’s totally different to what you do at six weeks and what you do at 12 weeks and in between. So, again, at this point, and you asked what did I do? I started out by injecting these scar pregnancies, or by transvaginal ultrasound, or guidance, or by transabdorminal ultrasound guidance. And that was my go-to technique.
Dr. Fox: Right, with something like either potassium or methotrexate or something to stop the pregnancy.
Dr. Timor: Usually, I inject methotrexate. My best friends who do that every day in Boston, for instance, Peter du Bellay, excellent person. [Inaudible 00:30:34] I don’t think there is a difference of this because, basically, the damage is almost done by the mechanical insertion of the needle. And I used to joke and say, “You can inject also whiskey. It will do the same.” But indeed, the local injection is the first one that I tried. And I got pretty good at it.
Dr. Fox: The injection, just for our listeners is you’re using ultrasound and you’re guiding a needle either through the mom’s belly or through the vagina, into their pregnancy. And then you inject something that’s intended…
Dr. Timor: In the scar.
Dr. Fox: Yeah, to stop the growth of the pregnancy, and then it stops developing and eventually, you know, either withers down or miscarries out. There’s still risk, obviously, and bleeding afterwards. But if the pregnancy stopped, the blood flow will decrease, the hormones are gonna decrease. It’ll sort of past the hump and on the way down in terms of the [crosstalk 00:31:33]
Dr. Timor: Absolutely correct.
Dr. Fox: And that’s done…that’s a treatment that’s known. It’s cervical pregnancies have been treated this way. I mean, there are other conditions. So it’s a technique that was already there that you just apply to this…
Dr. Timor: This exact similar.
Dr. Fox: Okay, so that was the first thing you did.
Dr. Timor: Then the other thing is that, many swear, and they’re countless articles of just injecting systemic methotrexate. That means that you take the methotrexate, which acts on the placenta and inject it intramuscularly in the buttock of the patients.
Dr. Fox: To be mom, right. It’s like a chemotherapy sort of.
Dr. Timor: Exactly.
Dr. Fox: And it sort of kills the pregnancy through her bloodstream
Dr. Timor: And many swear that helps. I am totally against it. I use methotrexate with every single scar pregnancy but only as an adjuvant, systemically.
Dr. Fox: Right. And the reason people would try that is because methotrexate has been used for ectopic pregnancies…
Dr. Timor: Ectopic pregnancy.
Dr. Fox: …which is a great success with 80%, you know, based on circumstance, so they thought it would work for this. But why do you think it doesn’t work as well for this compared to one in the tube?
Dr. Timor: I have my own view, which is unsubstantiated, not a research…
Dr. Fox: You are the only one I’m interviewing today. Give me your view.
Dr. Timor: …but I think that the placenta when the placenta implants in a place that is hostile, not hostile, but it’s not friendly. Plus, you give them methotrexate, it may act upon the scar pregnancy. But these pregnancies are usually much more viable than ectopic pregnancies. So the placenta…
Dr. Fox: Right. They have the uterus supplying it. Yeah.
Dr. Timor: The placenta is more resilient to the methotrexate. And my dislike of systemic methotrexate, no matter how you use it, one injection, or subsequent injections to cancer treatment. I think that, in my view, at least 50%, it did not work. But that you find out only after a week. And then the pregnancy is…
Dr. Fox: It’s way bigger.
Dr. Timor: …is already bigger. The vasculature is bigger. The complications are bigger. And the route of termination is more complex. So, here’s what I do. “Yes, you have a scar pregnancy. Are you sure you want to terminate it? Give me an answer not later than tomorrow. But tomorrow, I need an answer.”
Dr. Fox: Because it’s…
Dr. Timor: Not more than tomorrow. Because if you give it to me, like, if there is a weekend in between, there is already a pregnancy that’s five days bigger. And my job will be harder to terminate it and you will have more complications.
Dr. Fox: Right. And sometimes this leads to treatments like major surgery to like resect it and sow the uterus together. I mean, that’s a huge operation potentially. And that could also lead to serious issues for future pregnancies.
Dr. Timor: Yes. So, the surgical excision can be done from within the uterus by looking at the area and then manipulating the excision under direct region but from the inside hysteroscopically. And then the other one is to open up or go into the abdomen of the patient, or robotically, or whatever, peel off the placenta…their bladder and then do the excision and repair it. Those who do this, it’s very interesting, they swear that this is the way to go because you don’t leave a niche. And I agree with that anyways. I have a friend in Argentina, one of the best placental accreta surgeons. His name is Jose Palacios Jaraquemada, a wonderful man. He does only excisions. Only. I respect him. But I always tell him, “Why would you do that after 5, 6, 7, 8, 9, weeks pregnancy?” We have more less invasive ways to do it.
Dr. Fox: Right. So, tell us about the technique that you studied, you developed with the double balloon, because that’s the one that we use now. We think it’s terrific.
Dr. Timor: That was basically invented without being aware of it by a Chinese guy who placed a balloon in the uterine cavity. But that was a larger pregnancy. So then, I started to put in single Foley balloon after I injected it locally, but it started to bleed. And my balloon was not to terminate the pregnancy, but to stop the bleeding. And then I said to myself, “Wait a minute, let’s use the balloon to compress the pregnancy. And if it’s small, it will cut off the blood supply.” So, then I started to use the single balloon. And we published 18 cases with two Italian friends of mine who started to use it also. And then three patients expelled the balloon because the uterus does not tolerate any single shot. That’s why we have abortions, as it expands the content. The single balloon popped out. So then I said, “Wait a minute, how do we retain that balloon?” So, I worked a lot in the labor and delivery room with double balloons before my present career. And I did put in the double balloon, and the upper balloon is the anchor balloon that keeps in the whole system. And the lower balloon does the job.
Dr. Fox: Right. So just to explain this visually, right, so there’s a pregnancy in the uterus, it’s growing very low in the uterus towards the cervix, and up towards 12:00 to inside the scar. And the thought is, if we can put a little thing inside the uterus and then inflate it, like a balloon, it’s going to compress that pregnancy, for lack of a better word, smoosh it, and it’ll compress the blood flow, it’ll sort of smoosh the pregnancy, it’ll stop the pregnancy from growing. And it’s no incisions, no injections, it’s just there. And then that’s the lower balloon. And then there’s like a balloon on top, it looks like it’s like a double balloon on top, looks like a peanut almost. And the top one sits in the top of the uterus to hold it in and the bottom one compresses it. And, you know, goes in it doesn’t…there’s no anesthesia required. It’s really, it’s tolerated. It’s not horrifically painful for people, and then you leave it in for what overnight, typically?
Dr. Timor: It varies. It depends on what day of the week I’m doing it. If I do it on a regular, like, the beginning of the week, I usually keep it in for like two days. If I do it Friday, I’ll keep it until Monday.
Dr. Fox: Yeah, so two to three days. Yeah.
Dr. Timor: But it’s very interesting that I did many of these and I even shortened the time I put it in at 8:00, at 12:00 I deflated the lower balloon and the rotor sound and there was no more heartbeat. Then I deflated the upper balloon also not extracting the gutter, and at 5:00, took another look, no bleeding, no heartbeats, I took out the…but I became aware of the fact that it may not coagulate all the vessels. And that some of these patients had a little more bleeding. So, I then I kept it in two days and sometimes even three days. And then when you take it out, then all the vessels are already closed and there is no source of bleeding. So, I think that now, I don’t go for the one day, like, extraction.
Dr. Fox: So, it’s an amazing technique. It’s like when you see one or do one, it’s like, it’s the simplest concept. It makes so much sense. It’s such a high level working such low morbidity. Why hasn’t this taken off more? Why do you think?
Dr. Timor: Before I answer this question, you said before that no anesthesia is required. Usually, the only one, and sometimes the patients are sensitive. And in these patients, I do use a little bit of a local anesthetic service.
Dr. Fox: Okay, that’s fair.
Dr. Timor: So that’s just to cut into that sentence of yours. So, it’s interesting. We had a webinar about three months ago, the Europeans did it. And I talked about balloons. And this question came up, why do people not embrace it? So, there are many reasons.
One, I don’t have the balloons. So, my answer in the slide was could balloon number so and so cost that much. Number two, I have never worked in the labor and delivery, I don’t know how to use it. My answer, “Go up to the labor and delivery.” If your place uses it, take a look at it. If your base doesn’t use it, there are many articles on the site. Number three, I cannot use it in the office because I’m afraid that something happens. My answer, do it in the operating room, do it in the office, put the patient in for an overnight or some hours to look at it. So, there are answers to every excuse, so to say, but these are legal excuses of people who don’t yet know the procedure. And I think that if people would do a little bit of an effort, people would use it.
Right now, there is a registry and people upload cases. And we started by uploading cases. Now there are more than 350 cases in, not all balloons, but a large number of balloons because in Poland, they do it. In Switzerland, they do it. I have friends in Texas, known people who are in the accreta business. And they are doing it in Italy, they are doing it. So, there are lots of cases. So that’s the way that people learn how to really try to do it.
Dr. Fox: Yes, we went online. The website is www.csp-registry.com. Welcome to the caesarean scar pregnancy registry. So, there’s information on it, steering committee centers, project sponsors resources, is there a video here of the balloon technique?
Dr. Timor: I don’t think so.
Dr. Fox: All right, we’re gonna have to put that up on our website were gonna get that video because I know you have it.
Dr. Timor: I have it. I have one.
Dr. Fox: So that’s a good one. We’ll put it up on the website for people to see
Dr. Timor: So it’s managed in the UK. And there are three people who manage it. One is Basky Thilaganathan, and Andrea Kaelin, who was my research assistant for many years, and myself.
Dr. Fox: Amazing stuff, full circle from the early days of the machine where you can barely tell someone’s pregnant to, now, you’re seeing someone at six weeks diagnosing something potentially, counseling them, maybe continuing the pregnancy, knowing to watch for these complications, maybe ending the pregnancy in a safe way. It must be pretty satisfying to sort of to take it full circle like that.
Dr. Timor: It is and again, we always say it’s rare. But and yes, nowadays the caesarean section rate stabilized. Sorry to point….
Dr. Fox: Whatever.
Dr. Timor: …some of the change percent and yes, it is rare, but it is a serious… I think that the breakthrough of realizing the importance is when the connection between scar pregnancy and placenta accreta spectrum was made, probably my biggest pride is that I have two articles in which I said at the very beginning that scar pregnancies are baby accretas. And the second one, even more important, that I gave products of the pregnancy of scar, pregnancy and of placenta accreta to two pathologies and I said, “Put it under the microscope tell me which one is which,” and they couldn’t.
Dr. Fox: Right, the same thing.
Dr. Timor: That means that the histology is even the same. So that I think focused the attention towards an early diagnosis. And the fact that if you don’t treat or you don’t want to treat, or you missed to treat, it develops into something much more consequential.
Dr. Fox: Ilan, thank you so much for coming in, for coming on the podcast and sharing your story and this really important information about caesarean scar pregnancies.
Dr. Timor: Of course, thank you for having me. It was a pleasure ventilating.
Dr. Fox: Great. Thank you for listening to the “Healthful Woman,” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com. That’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.
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