Successful Hysteroscopic Management of Cesarean Scar Defect Pregnancy

Abstract

A 30-year-old multipara of 2 with history of 1 cesarean delivery, presented to the emergency department (ED) with one day of pelvic pain and vaginal bleeding. A positive β-human chorionic gonadotropin (β-hCG) blood test (215 mUI/mL) had been obtained 20 days prior. Upon admission, she was hemodynamically stable, and the physical exam showed no cervical changes or active bleeding. Transvaginal Ultrasound (TVUS) performed in the ED revealed a gestational sac (GS) implanted in the uterine isthmus, with a 6.7 mm embryo without cardiac activity. She was admitted for further evaluation. Formal TVUS (Figure 1) revealed an apparent cesarean scar defect (CSD) containing a 6 mm embryo without cardiac activity. Trophoblast tissue extended towards the defect, and the myometrial residual thickness (MRT) measured 1.4 mm. Adnexa appeared normal. Serial β-hCG levels were obtained, resulting on 2,177 on admission, 1,972 on the second, and 1,924 mUI/mL on the fourth day. Based on these findings, diagnosis of CSD pregnancy was made. Hysteroscopic management (Figure 2) was decided and successfully performed under regional anesthesia and continuous ultrasound guidance. Complete resection of the GS occupying the CSD was achieved using a bipolar resectoscope. Post-procedure, the patient received a prophylactic dose of Methotrexate (100 mg IM), an etonogestrel implant was inserted, and was discharged without incidents the day following surgery. The pathology report confirmed the diagnosis. On follow-up 12 days after surgery, patient was asymptomatic, β-hCG levels resulted 7.4 mIU/mL, and on a 6-month follow-up visit, was discharged to primary healthcare. Reasonable evidence supports hysteroscopic management of CSD pregnancy, with the benefit of direct visualization (1, 2, 3). Other techniques, like use of a double balloon catheter have been described (4). Hysteroscopy was chosen despite of the MRT (5), with staged laparoscopic repair due to an unclear fertility desire.