Pregnancy within a Cesarean section (CS) scar is a rare form of ectopic pregnancy. Since the first reported case in 19781, several case reports and case series have been published2, 3. Primary surgical treatment has been attempted by laparotomy and hysterotomy, with various degrees of success4. Medical treatment with systemic methotrexate (MTX)5, 6, direct injection of MTX, potassium chloride or hyperosmolar glucose3, 7, or a combination of treatments, have been described2. The combination of MTX and uterine artery embolization8 and laparoscopic excision, followed by hysteroscopy to assess scar integrity9, has been reported. Here we report on a case of CS scar ectopic pregnancy diagnosed laparoscopically. The patient was a 36-year-old gravida 4, with a history of two first-trimester miscarriages and one term delivery by Cesarean section, which had been complicated by vasa previa, hemorrhage, and subsequent neonatal death. These pregnancies were all conceived with in vitro fertilization (IVF). The patient's current pregnancy was conceived spontaneously following laparoscopic adhesiolysis and neosalpingostomy. She presented at 6 weeks' gestation with amenorrhea, a positive pregnancy test, vaginal spotting and lower abdominal pain. Transvaginal ultrasound (TVS) scan showed an empty uterus and 7 mm of free fluid. Her quantitative β-human chorionic gonadotropin (βhCG) was 4390 IU/L. Laparoscopy showed a hemorrhagic mass measuring 2.5 cm in diameter, protruding into the uterovesical fold. There was no visible bleeding. Postoperatively, βhCG fell spontaneously to 2840 IU/L on the third postoperative day and then plateaued at 2900 IU/L. The patient received a single intramuscular dose of MTX (50 mg/m2) on the fifth postoperative day. She remained asymptomatic, with decreasing βhCG which reached 53 and < 1 IU/L on days 35 and 47, respectively. Transabdominal ultrasound examination showed that the mass persisted unchanged, indenting the bladder (Figure 1). At 3 months, a further laparoscopy was performed. Persistent trophoblastic tissue was seen at the left lateral end of the CS scar (Figure 2). This was excised laparoscopically after instillation of local pitressin and the defect repaired. Hysteroscopic examination of the cervical canal and endometrial cavity was normal. Transabdominal scan showing Cesarean ectopic pregnancy indenting the bladder (arrow). At laparoscopy 3 months after the Cesarean ectopic pregnancy, persistent trophoblastic tissue (arrow) was seen at the left lateral end of the Cesarean section scar. Cesarean section causes disruption of the endometrium and myometrium and is a risk factor for abnormal implantation. Early clinical diagnosis of CS scar ectopic pregnancy is a challenge. Ultrasound diagnosis is made by the identification of a gestational sac located anterior to the uterus, without myometrium between the sac and the bladder7. In this case, the gestational sac was not recognized on initial transvaginal scanning. The CS scar pregnancy was difficult to see transvaginally with an empty bladder, but was easily visible on transabdominal ultrasound examination. Clinical suspicion will aid in the early diagnosis of this rare ectopic pregnancy. Future fertility was a priority here. The CS scar ectopic pregnancy was extremely vascular and was located adjacent to the uterine vessels, so that laparoscopic management was not attempted on initial diagnosis. The pregnancy persisted on ultrasound scan and, as the couple wished to have another try at IVF, a ‘second-look’ laparoscopy was carried out to assess the integrity of the CS scar and the endometrial cavity. The pregnancy was not accessible from the uterine cavity, otherwise dilatation and curettage might have been considered. The ectopic pregnancy consisted of biologically inactive tissue and was less vascular at the second-look laparoscopy. If fertility had not been an issue, it might have been sufficient to allow spontaneous resolution. I. Hassan*, A. Lower , C. Overton , * Department of Obstetrics and Gynaecology, Birmingham Women's Health Care NHS Trust, Metchley Park Road, Edgbaston, Birmingham, B15 2TG, UK, Gynaecology and Minimal Access Surgery, London, UK, Department of Obstetrics and Gynaecology, St Michael's Hospital and University of Bristol, Bristol, UK
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Jun 1, 2011
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