Viable Cesarean scar pregnancy managed by sonographically guided application of a fibrin sealant

Abstract

We present a new management protocol for Cesarean scar pregnancies (CSP) that was applied in a case of a viable CSP. A 41-year-old pregnant woman, gravida 2 para 1, with a history of Cesarean delivery, underwent assisted reproductive techniques resulting in a positive pregnancy test at 6 + 2 weeks' gestation. One week later she presented with heavy bleeding, lower abdominal pain and an unusually high level of β-human chorionic gonadotropin (hCG) (144 000 U/L). Transvaginal ultrasound examination identified a large feeding vessel supplying a viable pregnancy (32 × 12 mm) located within the Cesarean scar1, which extended from the internal os to the myometrial wall, resulting in a thin layer of myometrium adjacent to the bladder (Figure 1a). Color Doppler sonography revealed a tangle of high-velocity (peak systolic velocity, 85.14 cm/s), low-impedance (resistance index, 0.42) blood vessels supplying the trophoblast (Videoclip S1) and an 8-mm embryo with a heart rate of 163 bpm (Figure 1b,c and Videoclip S2). During ‘out-of-office-hours’, heavy bleeding causing anemia (hemoglobin (Hb), 8.8 g/dL) and abdominal pain worsened, creating a challenging situation, especially in the context of a high level of serum β-hCG (144 000 U/L) and the presence of a large feeding vessel. Various options2 were therefore discussed, including uterine artery embolization3, local and systemic methotrexate (MTX) injection4 and hysterectomy. Based on a recently described standardized protocol for treatment of symptomatic intrauterine arteriovenous malformations5, the patient was offered a two-sided approach: first, obliteration of the feeding vessel with a human fibrin sealant (TISSEEL®, Baxter Healthcare Corporation, Munich, Germany) and second, injection of methotrexate (MTX) into the trophoblast and amniotic cavity, after draining the amniotic fluid by amniocentesis, to terminate the pregnancy. TISSEEL® is a filamentous precipitate of highly adhesive fibrin derived from human plasma containing a concentrated composition of fibrinogen, thrombin and calcium. It is conventionally used as an adjunct to hemostasis during surgery and is recommended for topical use only, however its thromboembolic properties made it the preferred treatment in our case for selectively occluding the feeding vessel. Using a 20-G needle, a total of 4 mL of TISSEEL Duo S Immuno glue was applied, under transvaginal-ultrasound guidance, in three portions in a fan-shaped manner around the placenta in general and in the feeding vessel in particular (Figure 1d and Videoclips S3 and S4). On color Doppler ultrasound, this produced a ‘flash-like’ pattern (Figure 1e) followed by a ‘snow-storm’ pattern (Figure 1f), indicating interruption of blood flow in the feeding vessel. Cessation of fetal heart activity and a significant decrease in vaginal bleeding was noted. 45 mL of yellowish amniotic fluid was drained (Videoclip S5) and 50 mg of MTX was injected into the amniotic membranes and placenta to terminate the pregnancy (Videoclip S6). Follow-up ultrasound examination after 24 h revealed markedly decreased vascularization and a collapsed amniotic cavity which led to decreasing β-hCG levels of 89 800 U/L and 30 200 U/L on days 1 and 3 after treatment, respectively. Within 4 weeks, the patient recovered fully, β-hCG level was negative and red blood cell count had increased (Hb, 12.3 g/dL). Ultrasound examination showed a hyperechoic mass within the Cesarean scar measuring 32 × 8 × 6 mm with little vascularization. Laparoscopic resection of the scar, including the remaining trophoblastic tissue, and closure of the myometrium by a two-layered suture was performed 8 weeks after the initial treatment (Figures S1–4). The postoperative period was uneventful. In conclusion, this protocol appears to be a simple and effective, fertility-preserving treatment option for CSP that is supplied by an accessible feeding vessel. The vessel is treated with a human fibrin sealant, which forms a ‘biological glue’ to cease blood flow within the vessel, in combination with amniodrainage and local injection of MTX, followed by laparoscopic scar excision. T. Rawnaq, M. Doebert, J. Beek and P. Schwaerzler* Department of Obstetrics and Gynecology, Asklepios Clinic Barmbek, Ruebenkamp 220, 22307 Hamburg, Germany *Correspondence. (e-mail: [email protected]) Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.