Author Information
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V*,
Hatkar
P**,
Shetty
A***,
Gupta
AS****
(* Assistant Professor, **Associate
Professor,***First year resident **** Professor, Department of
Obstetrics and
Gynecology, Seth G. S. Medical College and KEM Hospital, Mumbai, India.)
Abstract
Cesarean
scar pregnancy is extremely rare and is associated with serious
complications. Hence early diagnosis and therapy is necessary. We
report a case of cesarean
scar ectopic which presented with multiple episode of first trimester
bleeding.
Failed
conservative management with methotrexate
and suspected
rupture, necessitated
an exploratory
laparotomy for
excision
of the
cesarean
scar pregnancy. In our case uterine repair could be done, thus
preserving the future fertility.
Introduction
Cesarean
scar
pregnancy
is defined as implantation of pregnancy into a prior Cesarean uterine
scar. The incidence of cesarean
scar pregnancy is about 1: 2000 pregnancies.[1,2] Its incidence is on
the rise, due to increase rate of cesarean
section. It is associated with high risk serious complications like
uterine rupture and extensive hemorrhage.
This
condition poses a diagnostic as well as therapeutic challenge, as
little is known about the epidemiology, screening methodologies and
treatment options.
Case
Report
Elderly,
36
year old,
gravida
4 para 3 living 2 and NND 1 married since 12 years was referred to
our institute in view of cesarean
scar pregnancy.
She
had previous two
normal
deliveries,
third was hysterotomy at 26 weeks for bleeding
placenta
previa, with NND on day 21. In the present pregnancy, she had her
last menstrual period 3 months back and pregnancy was confirmed with
urine pregnancy test at 5 weeks of gestation. At 7 weeks of
gestation, patient went to private practitioner for medical
termination of pregnancy
(MTP).
Following MTP, the patient had heavy vaginal bleeding for 6 days and
mild bleeding for another 10 days. After that she again started
bleeding heavily for which she visited another private consultant.
She was advised ultrasonography
(USG)
of the pelvis, which showed an ill defined complex lesion measuring
approximated 5.9
x
5.9 cm
at the level of previous lower segment
uterine
scar. Upper segment endometrial thickness measured 0.6
cm.
Uterus measured 12.5
x
6.0
x
4.9 cm.
Adnexa was normal. On doppler study there was increased vascularity
at the level of the
scar,
it showed arterial flow R.I of 0.4 and S/D ratio of 1.7. USG
findings were suggestive of scar pregnancy. She was referred to our
tertiary
institute for further management.
On
admission at our institute, she
had tachycardia of
104
beats/min.
Patient had
sever pallor.
Rest of the general and systemic examination was normal.
On abdominal examination, Pfannensteil scar was seen.
Uterine
size was corresponding to 14 weeks gestation. On vaginal examination,
uterus was
14 weeks
in size,
ante-verted
and ante-flexed in position,
cervical os was
closed,
fornices clear and non tender, minimal bleeding was present. One
unit whole blood was given in view of severe anemia.
USG was
repeated at our hospital which showed a heterogenous mass in the
region of the
scar
measuring approximately 5.8
x
4.8 cm, with peripheral vascularity showing high diastolic flow and
diagnosis of cesarean
scar pregnancy was confirmed.
Quantitative
β
HCG level was 177.84 mIU
/
ml.
Patient and relatives desired future pregnancy
so they opted for
conservative medical management
with parenteral
methotrexate.
Complete blood count, liver and renal chemistry were within normal
limits. Patient was given single dose of intramuscular
Methotrexate 80 mg as per body surface area followed by intramuscular
Leucovorin 8 mg next
day.
There was more than 15% decrease in her β
HCG level. Repeat β
HCG level was 112.55 mIU
/
ml
on day 3 post
methotrexate.
β
HCG level were repeated prior to discharge on
day 6
was 70.66 mIU
/
ml.
Patient returned
back
to the
hospital
2 days after discharge with complains of profuse vaginal bleeding.
She had tachycardia and hypotension on admission. Urgent USG
was
performed. USG
report
showed a 6
x
3.7
x
3.6
cm mass at the region of the
previous
scar with minimal free fluid in the pelvis, suggestive of probability
of a ruptured
of the
scar ectopic
pregnancy.
Emergency exploratory laparotomy was performed
due to hemodynamic instability and suspected rupture
after informed
consent
for excision of scar ectopic and or
emergency hysterectomy
if the need arose.
Intraoperatively uterus was bulky. Upper segment was normal in size
and appearance. Bladder peritoneum was reflected. There was a mass of
3
x
4
cm seen and felt in the lower segment. There was no rupture or
abnormal vascularity in the lower segment or at the site of the mass.
A small transverse incision was taken at the lower segment at the
level of the previous scar. Products of conception were felt in the
anterior wall slightly below the level of scar. All the products of
conception were removed manually and sent for histopathology
examination. About 2-3cm of the lower edge of the incision in the
lower segment was excised.The uterine cavity opened inadvertently and
was found to be empty. There was bleeding from the lower segment,
multiple hemostatic stitches were taken over the
anterior
lower segment and complete hemostasis was achieved. Uterine incision
was closed with continuous interlocking sutures of polyglactin no 1.
Hemostasis was confirmed and abdomen was closed. Intraoperatively she
received 2 units of blood. Postoperative course was uneventful.
Histopathology
report was suggestive of
chorionic villi, blood clots and myometrial tissue.
Figure
1.
Site
of scar pregnancy on the lower uterine segment. Black
arrow shows a bulge of 3cm of cesarean scar pregnancy and yellow
arrow shows depression of previous scar
Figure
2.
Opened
Scar Ectopic Site. Black
arrow depicts the scar ectopic bed with the ectopic tissue and yellow
arrow shows anterior uterine wall.
Discussion
Cesarean
scar pregnancy is implantation of otherwise normal pregnancy into a
prior cesarean
uterine scar. The invasion of the myometrium through microscopic
tracts develop from trauma from previous uterine surgeries like
dilatation and curettage, myomectomy and cesarean
section is believed to be the probable mechanism.[3] It was reported
more than 30 years ago by Larsen and Solomon
(1978).[4]
The incidence of cesarean
scar pregnancy is about 1: 2000
pregnancies.[1,2]
The
incidence is likely to rise due to increase in rate of cesarean
section. Whether the incidence is affected with multiple procedure
or either one or two layer closure is not known. Clinical
presentation of cesarean
scar pregnancy varies depending on gestational age which ranges from
5-6 weeks to mid-pregnancy. The most common presenting complain is
pain and bleeding.
Our
patient also
presented
with multiple episodes
of first trimester bleeding and failed MTP. Forty percent of cases
are asymptomatic and diagnosis is made during routine ultrasound
examination.[1]
The
probable differential diagnosis for this condition is spontaneous
abortion in progress and cervical pregnancy. Risk factors linked with
cesarean
scar pregnancy are previous cesarean
section, myomectomy, dilatation and curettage, manual removal of
placenta. It is associated with serious complications like uterine
rupture and extensive hemorrhage. The presentation of cesarean
scar pregnancy is too variable to have concise recommendation for
diagnosis. Hence, a high clinical index of suspicion is required in a
woman
with a prior cesarean
section. Imaging demonstrate myometrium completely around the
gestation sac with no communication with the endometrial cavity. USG
helps
in early diagnosis.[5] If USG
is
inconclusive MRI
can be helpful. Prevention of massive blood loss and conservation of
the uterus are the main objective of management of cesarean
scar pregnancy. Management depends on gestation age and treatment
options
include systemic
or intra-sac methotrexate
treatment, curettage, hysteroscopic resection, uterine
preserving
resection by laparotomy or laproscopy, uterine artery embolization, a
combination of these, or hysterectomy. In our case, methotrexate had
shown partial response with falling levels of β
HCG, but later onset of profuse vaginal bleeding and ultrasonographic
impression of ruptured scar pregnancy
necessitated
emergency
surgery. In earlier gestational age the chances
of conserving the uterus is higher as the pregnancy occupies a lesser
area and bleeding can be controlled by local wedge excision. However,
their future pregnancy results can only be postulated and outcomes
can
be studied only in
the distant future
and that too if a registry for such patients is maintained.
These patients will most probably be at an increased risk of morbidly
adherent placenta, repeat scar ectopic or cervical ectopic
pregnancies and will have a greater
chance of scar ruptures in future pregnancies and this category of
pregnant women will need close
observation
and monitoring in
their future pregnancies.
References
- Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 2006; 107:1373-1381.
- Ash A, Smith A, Maxwell D. Cesarean scar pregnancy. BJOG 2007; 114(3): 253-263.
- Fait G, Goyert G, Sundareson A, Pickens A Jr. Intramural pregnancy with fetal survival: case history and discussion of etiologic factors. Obstet Gynecol 1987; 70: 472-474.
- Larsen JV, Solomon MH. Pregnancy in a uterine scar sacculus: an unusual cause of post abortal haemorrhage. S Afr Med J 1978; 53: 142-143.
- Moschos E, Sreenarasimhaiah S, Twickler DM. First-trimester diagnosis of cesarean scar ectopic pregnancy. J Clin Ultrasound 2008; 36(8): 504-511.
More
V,
Hatkar
P,
Shetty
A,
Gupta
AS. Excision
of Cesarean Scar Pregnancy.
JPGO
2016. Volume 3 No. 2. Available from: http://www.jpgo.org/2016/01/excision-of-cesarean-scar-pregnancy.html