Author Information
Ramesh B, Gupta P, Chandana A.
(Department of Obstetrics and Gynecology, Dr
Ramesh Hospital, Bangalore ,
India
Abstract
Herein is described a
case of a 26 year old woman who came with a history of dilatation and curettage
done for missed abortion followed by continuous painless bleeding per vaginum. On
hysterolaparoscopy, diagnosis of cesarean scar ectopic was confirmed.
Laparoscopic excision of scar ectopic with double layered repair of uterus was
done.
Introduction
Cesarean scar ectopic is
a rarest kind of ectopic pregnancy. It was first reported by Larsen and Solomon
in 1978. Its incidence has been estimated to be 0.15% of pregnant women with
prior cesarean deliveries. A cesarean scar pregnancy occurs when there is
implantation of a pregnancy within the scar of a previous section, resulting in
a gestational sac that is surrounded by myometrium and fibrous tissue. Patients
may present with painless vaginal bleeding. Complications such as uterine
rupture and massive hemorrhage may be life threatening and impact negatively on
future fertility. It is important to be able to diagnose the condition as early
as possible in order to administer conservative treatment.
Case Report
A 26 year old patient
presented to us with a complaint of continuous painless bleeding per vaginum
since 25 days. She had a history of dilatation and curettage done elsewhere 2
months back for the diagnosis of missed abortion. Since then she had irregular
bleeding per vaginum.
She underwent ultrasound
10 days back which revealed an echogenic lesion measuring 3.6 x 3.7 cm noted
over the previous scar site and protruding outwards towards the bladder, with
anterior myometrium almost deficient. The patient was planned for surgical
management.
On hysteroscopy, uterine
cavity, endometrial lining and endocervical canal appeared normal. On the
anterior wall, just above the internal os, at the level of previous scar site
trophoblastic tissues were seen protruding (figure 1).
Figure 1 Hysteroscopic
image of trophoblastic tissue at the level of cesarean scar.
On laparoscopy, a
prominent bulge was seen at the level of lower uterine segment with increased
vascularity. Vasopressin (10 units diluted in 100 ml of normal saline) 50 ml
was infiltrated at the level of the uterine isthmus. Using harmonic scalpel
vesicouterine fold was dissected and the bladder was pushed down. The products
of conception were seen bulging through the myometrium. The previous scar site
myometrium was opened by transverse incision and products of conception were
removed with grasper and suction irrigation (figure 2). Uterine wall was closed
using barbed sutures. The vesicouterine fold of peritoneum was closed using
polyglactin no 2-0. At the end of procedure cystoscopy was done to check
bladder integrity. Histopathology report confirmed the diagnosis of products of
conception.
Figure 2 Products
removed with graspers.
Discussion
Early diagnosis of
cesarean scar ectopic pregnancy is important in order to avoid severe
complications and to be able to provide conservative treatment. The most common
symptom is painless vaginal bleeding that may be massive. Ultrasound with color
flow Doppler has been used to make the diagnosis. According to a recent 2012 review, the following sonographic
findings should raise the suspicion level for a Cesarean Scar Pregnancy (CSP).[1]
·
No
fetal parts in the uterine cavity or cervix.
·
A thin
myometrial layer between the bladder and gestational sac.
·
A
triangular shaped gestational sac.
·
A
gestational sac that is close to the bladder and uterine wall.
·
Presentation
of arteriovenous malformation in the area.
MRI and hysteroscopy
have also been used to make the diagnosis. These pregnancies can be confused
with cervical ectopic pregnancy. If diagnosed early and the patient is stable
then there is an option of conservative treatment available with local and
systemic methotrexate administration,[2] dilatation and curettage,
excision of trophoblastic tissue using laparoscopy and laparotomy. Other
methods are bilateral uterine artery ligation or uterine artery embolization
followed by removal of ectopic gestational tissue and repair of uterine
scar by laparoscopy or laparotomy. Use
of titanium clips to transiently occlude the uterine arteries bilaterally as an
alternative for permanent uterine artery ligation to reduce blood loss during
laparoscopic management of CSPs combined with injection of vasopressin into the
myometrium to promote haemostasis has been described by Shao et al. Role of
transvaginal surgery for removal of ectopic gestational tissue and excision of
scar tissue and repair of wound has also been mentioned.[3] Laparoscopy
appears to be a rational alternative in the clinically stable women as the
excision of old scar by laparoscopy can facilitate complete removal of the
products of conception and the microtubular tracts, repair the scar defect,
strengthen the uterine wall of the scar area and reduce the risk of recurrence.
In cases of rupture and massive hemorrhage, hysterectomy is indicated.
References
- Osborn DA, Williams TR, Craig BM. Cesarean scar pregnancy: sonographic and magnetic resonance imaging findings, complications, and treatment. J Ultrasound Med. 2012; 31(9):1449-56.
- Timor-Tritsch IE, Monteagudo A, Santos R, et al. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol 2012;207:44.e1-13
- He M, Chen M-H, Xie H-Z, Yao S-Z, Zhu B, Feng L-P, Wu Y-P. Transvaginal removal of ectopic pregnancy tissue and repair of uterine defect for caesarean scar pregnancy. BJOG 2011;118:1136–1139.
Ramesh B, Gupta P, Chandana A. Caesarean Scar
Ectopic Pregnancy – An Unusual Presentation. JPGO 2015 Vol 2 No 8. Available
from: http://www.jpgo.org/2015/08/caesarean-scar-ectopic-pregnancy.html