Author Information
Shah NH*, Paranjpe S**, Shah VN***.
(* Director, Vardann Multispeciality Hospital, ** Director, Velankar Hospital and Paranjpe Maternity Home, *** Consultant Anesthetist, Vardann Multispeciality Hospital, Mumbai, India.)
Abstract
Intramural pregnancy with implantation in a previous cesarean section (CS) scar is probably the rarest location for ectopic pregnancy. The true incidence of pregnancy occurring in a uterine scar has not been determined because so few cases have been reported in the literature. However, the incidence of such cases seems to be on the rise. Here we present a case of a 28-year-old woman with a history of previous 1 CS 5 years ago, who presented with a history of 2 months amenorrhea with positive urine pregnancy test and pain in abdomen. USG was suggestive of scar ectopic, which we managed laparoscopically.
Introduction
Any form of ectopic pregnancy is one of the leading causes of mortality and morbidity in women of child bearing age group. Among ectopic pregnancies, fallopian tubal ectopic is the commonest. Apart from the fallopian tube, an ectopic pregnancy can also occur in the cervix, ovary, previous cesarean scar, or abdomen. An intramural pregnancy with implantation occurring in the previous cesarean scar is probably the rarest location for all ectopic pregnancies.[1] The exact incidence of ectopic pregnancy occurring in previous cesarean scar has not yet been determined because of small number of cases reported. However, incidence is on the rise.[1] The diagnosis can be done by ultrasonography and confirmed by magnetic resonance imaging (MRI) or by laparoscopy/ laparotomy.
Case Report
A 28-year-old woman came to our OPD with complaints of pain in abdomen with a history of 2 months amenorrhea. A urine pregnancy test was done and was positive. Patient was second gravida with a history of previous one LSCS done 5 years back. An ultrasonography was done which showed a regular endometrial cavity with a gestational sac at the anterior border of the myometrium corresponding to 7 weeks pregnancy suggestive of a scar ectopic pregnancy. On examination, patient had tenderness over the lower abdomen. On vaginal examination uterus was 6-8 weeks size. External os was closed.
Figure 1. Sonography showing scar ectopic pregnancy.
A laparoscopy was done, which showed bladder and anterior wall adhesions to the previous uterine scar. A bulge was seen at the previous uterine scar. Keeping in mind the severity of bleeding, bilateral uterine arteries were ligated at the origin beforehand.
Figure 2. Uterine artery ligation done beforehand.
Local injection of vasopressin was done around the lower uterine scar area to minimize the bleeding. The adhesions over the previous uterine scar were separated. Bladder peritoneum was dissected off the uterus. After separating the bladder peritoneum off the uterus, a clear blue bulge was visible protruding from the uterine scar. The thinned out uterine wall over the protruding sac was incised. The gestational sac was exposed and was enucleated completely along with the fetus and the choriodecidual tissue and were removed in an endo-bag. The previous uterine scar was excised. After confirming hemostasis, the uterine incision was closed with polyglactin No. 1. Postoperative period was uneventful and patient was discharged on 3rd day.
Figure 3. Enucleation of sac being performed.
Figure 4. Uterus sutured after removal of contents.
Discussion
A scar ectopic pregnancy is a rare form of ectopic pregnancy whose incidence is rising due to increasing number of cesarean sections and increasing diagnostic sensitivity. The incidence of scar ectopic has gone to 1 in 2000 pregnancies.[2] The commonly accepted theory for the formation of a scar ectopic pregnancy is that either the embryo implants through the wedge defect over the lower uterine segment or it passes through a microscopic fistula extending into the scar.[3] Other causes of myometrial implantation also include adenomyosis, previous dilatation and curettage, manual removal of placenta and in vitro fertilization.[4]
Clinical presentation of a scar ectopic pregnancy can vary from being asymptomatic to vaginal bleeding, abdominal tenderness or even hypovolemia and shock in case of rupture.[5] Barring a few exceptions, most of the cases of scar ectopic pregnancy are diagnosed and managed in the first trimester only.[2] A differential diagnosis may include cervical ectopic pregnancy and placenta accreta.[6]
The time interval of a scar implantation from the previous cesarean section ranges from 5 months to 12 years. The first laparoscopic surgical management of a scar ectopic pregnancy was done by Lee et al.[4] Principles of laparoscopic management include:
- Scar ectopic pregnancy is removed in an endo- bag
- Bleeding is minimized by locally injecting vasopressin
- Hemostasis is achieved by bipolar cautery
- Uterine incision is closed by endo- suturing
Primary open laparotomy may be considered in cases presenting late, or in shock or non-availability of endoscopic expertise and instruments. Various other treatment modalities have also been used in cases of scar ectopic pregnancies which include systemic or local methotrexate, or hysteroscopic evacuation of ectopic pregnancy. A simple dilatation and curettage has also been done but in a review of literature by Arslan [7], out of the 9 women who underwent dilatation and curettage, 8 women required surgical intervention due to complications of heavy bleeding during dilatation and curettage.
Our patient underwent a successful laparoscopic approach with minimal amount of bleeding and no intra -operative complications.
Conclusion
With increasing number of cesarean operations, we can expect more number of scar ectopic pregnancies in the future, wherein we have to keep in mind the possibility of a scar ectopic in patients with even 1 previous cesarean section. A transvaginal sonography is a fairly reliable modality of diagnosing a scar ectopic pregnancy. There is no general consensus for management of a scar ectopic but is usually decided upon factors such as gestational age, scar rupture, expertise of obstetrician and facilities available.
References
- Fylstra DL, Pound-Chang T, Miller MG, Cooper A, Miller KM. Ectopic pregnancy within a cesarean delivery scar: a case report. Am J Obstet Gynecol. 2002; 187(2):302–4.
- Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol. 2006; 107(6):1373–81.
- Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol. 2000; 16(6): 592–3.
- Lee CL, Wang CJ, Chao A, Yen CF, Soong YK. Laparoscopic management of an ectopic pregnancy in a previous caesarean section scar. Hum Reprod. 1999; 14(5):1234–6.
- Graesslin O, Dedecker F Jr, Quereux C, Gabriel R. Conservative treatment of ectopic pregnancy in a cesarean scar. Obstet Gynecol. 2005: 105(4): 869–71.
- Ofili-Yebovi D, Ben-Nagi J, Sawyer E, Yazbek J, Lee C, Gonzalez J et al. Deficient lower-segment cesarean section scars: prevalence and risk factors. Ultrasound Obstet Gynecol. 2008; 31: 72–7.
- Arslan M, Pata O, Dilek TU, Aktas A, Aban M, Dilek S. Treatment of viable cesarean scar ectopic pregnancy with suction curettage. Int J Gynecol Obstet. 2005; 89(2):163–6.
Shah NH, Paranjpe S, Shah VN. Scar Ectopic Pregnancy Managed Laparoscopically. JPGO 2017. Volume 4 No.7. Available from: http://www.jpgo.org/2017/07/scar-ectopic-pregnancy-managed.html