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1
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Guraslan H, Akgul OK, Aydin DE, Kovalak EE, Aksoy NK, Aydin TO. Laparoscopic removal of heterotopic cesarean scar pregnancy. Fertil Steril 2024; 122:543-545. [PMID: 38636771 DOI: 10.1016/j.fertnstert.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To present the laparoscopic management of heterotopic cesarean scar pregnancy and discuss other treatment options. DESIGN Surgical video article. The Institutional Ethics Committee approved the video reproduction. SETTING Tertiary referral to a university hospital. PATIENT A 29-year-old woman with spontaneous heterotopic cesarean scar pregnancy presented for vaginal spotting. Ultrasound revealed two gestational sacs at 7 weeks and 6 days of gestation with fetal cardiac activity. One sac was in a normal intrauterine (IU) location, and the other was in a previous cesarean section scar. INTERVENTIONS Scar pregnancy was excised laparoscopically, preserving IU pregnancy. No additional measures were taken to reduce bleeding. The bladder was filled with 150 cc isotonic to determine its boundaries. The peritoneum was dissected away from the cervix. After removing the ectopic pregnancy material, the myometrial defect was excised. The uterine wall was closed in three layers using 2-0 V-Loc sutures. MAIN OUTCOME MEASURES Ongoing IU pregnancy after laparoscopic removal of cesarean scar pregnancy and term delivery. RESULTS The procedure was completed in 67 minutes. Total blood loss was <100 cc. The ongoing pregnancy follow-up was uneventful. Delivery was planned for the 37th-38th weeks. Although instructed to visit immediately after experiencing pain, the patient arrived after the 38th week and reported having pain for 2 days. During the cesarean section, a rupture was observed at the previous incision site, which was fortunately incomplete. A healthy male infant (weight, 3,210 g; Apgar score, 9/10) was delivered. CONCLUSIONS The most common approach for heterotopic scar pregnancy is embryo reduction with potassium chloride injection. However, the mass persists in the scar area, resulting in complications associated with excessive bleeding during a cesarean section in approximately half of cases. Moreover, almost all published cases of embryo reduction resulted in premature births before week 36. Considering the present case, laparoscopic surgery may be appropriate for managing heterotopic cesarean scar pregnancy by preserving IU pregnancy.
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Affiliation(s)
- Hakan Guraslan
- Department of Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey.
| | - Ozlem K Akgul
- Department of Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Dogan E Aydin
- Department of Obstetrics and Gynecology, Ministry of Health Havran State Hospital, Balikesir, Turkey
| | - Evrim E Kovalak
- Department of Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Nursen K Aksoy
- Department of Obstetrics and Gynecology, Istanbul Bagcilar Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Tugba O Aydin
- Department of Obstetrics and Gynecology, Ministry of Health Edremit State Hospital, Balikesir, Turkey
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Karbasi M, Aletaha R, Ahangar‐Sirous R, Alamdari AH, Gharepapagh E, Rezaei S. A rare case report of heterotopic cesarean scar pregnancy in the 8th week of gestation that was managed successfully by exploratory laparotomy with dilation and curettage. Clin Case Rep 2024; 12:e9025. [PMID: 38831983 PMCID: PMC11144611 DOI: 10.1002/ccr3.9025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 06/05/2024] Open
Abstract
Key Clinical Message Swift and precise identification of heterotopic cesarean scar pregnancy, coupled with standardized treatment approaches for handling possible serious complications, form an essential component in reaching favorable outcomes for patients experiencing this rare type of pregnancy. Abstract Heterotopic pregnancy (HP) denotes a form of multiple gestation where intrauterine and ectopic pregnancies coexist. Cesarean scar ectopic pregnancy, on the other hand, involves the implantation of a fetus over the previous cesarean scar. This condition poses a significant risk of uterine rupture, which may lead to serious health complications, and even death. We report a case of a fit 37-year-old woman with two previous cesarean deliveries who was diagnosed with a heterotopic cesarean scar pregnancy at 8 weeks gestation following symptoms of lower abdominal pain and delayed menstruation. Both pregnancies demonstrated cardiac activity and the portion of the myometrium located between the bladder wall and the gestational sac was noted to exhibit considerable thinness. The patient underwent an exploratory laparotomy coupled with dilation and curettage and recovered uneventfully. The proper management of a HCSP requires timely diagnosis through ultrasonography. Early diagnosis allows for immediate intervention to prevent complications such as uterine rupture or potentially lethal bleeding.
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Affiliation(s)
- Mahsa Karbasi
- Department of Radiology, Medical SchoolTabriz University of Medical SciencesTabrizIran
| | - Reza Aletaha
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | | | | | - Esmaeil Gharepapagh
- Department of Nuclear Medicine, Medical SchoolTabriz University of Medical SciencesTabrizIran
| | - Sahar Rezaei
- Department of Nuclear Medicine, Medical SchoolTabriz University of Medical SciencesTabrizIran
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3
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Miller R, Gyamfi-Bannerman C. Society for Maternal-Fetal Medicine Consult Series #63: Cesarean scar ectopic pregnancy. Am J Obstet Gynecol 2022; 227:B9-B20. [PMID: 35850938 DOI: 10.1016/j.ajog.2022.06.024] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Cesarean scar ectopic pregnancy is a complication in which an early pregnancy implants in the scar from a previous cesarean delivery. This condition presents a substantial risk for severe maternal morbidity and mortality because of challenges in securing a prompt diagnosis. Ultrasound is the primary imaging modality for cesarean scar ectopic pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar ectopic pregnancy management, but the optimal treatment is unknown. Patients who decline treatment of a cesarean scar ectopic pregnancy should be counseled regarding the risk for severe morbidity. The following are the Society for Maternal-Fetal Medicine recommendations: we recommend against expectant management of cesarean scar ectopic pregnancy (GRADE 1B); we suggest that operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided uterine aspiration be considered for the surgical management of cesarean scar ectopic pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for the medical treatment of cesarean scar ectopic pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar ectopic pregnancy (GRADE 1C); in patients who choose expectant management and continuation of a cesarean scar ectopic pregnancy, we recommend repeated cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that patients with a cesarean scar ectopic pregnancy be advised on the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).
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4
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Kim H, Koh JH, Lee J, Sim Y, Lee SH, Lee SJ, Ahn JW, Roh HJ, Kim JS. Successful Full-Term Delivery via Selective Ectopic Embryo Reduction Accompanied by Uterine Cerclage in a Heterotopic Cesarean Scar Pregnancy: A Case Report and Literature Review. Diagnostics (Basel) 2022; 12:diagnostics12030762. [PMID: 35328315 PMCID: PMC8947258 DOI: 10.3390/diagnostics12030762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 02/05/2023] Open
Abstract
Heterotopic cesarean scar pregnancy (HCSP) is a combination of cesarean scar pregnancy (CSP) and intrauterine pregnancy (IUP). Cesarean scar pregnancy is accompanied by life-threatening complications, such as uterine rupture and massive bleeding. Herein, we present a case of HCSP treated with selective potassium chloride injection into the CSP under ultrasonography in association with uterine cerclage to control vaginal bleeding; this led to a successful IUP preservation and full-term delivery. Additionally, we will review several previous reports on HCSP management, including our case.
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5
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Authreya AJ, Agrawal P, Makam A. Ultrasound-guided procedures in the management of heterotopic caesarean scar pregnancy - A review of case reports and case series. Australas J Ultrasound Med 2021; 24:70-77. [PMID: 34765413 DOI: 10.1002/ajum.12242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 01/25/2021] [Accepted: 02/15/2021] [Indexed: 12/29/2022] Open
Abstract
Background Heterotopic caesarean scar pregnancy (HCSP) is where one gestational sac implants in the previous caesarean section (CS) scar and another sac implants in the uterine cavity. There is limited evidence on the management of this rare condition. Here, we present a case of HCSP in which US-guided selective reduction of the CS pregnancy (CSP) was performed using potassium chloride (KCl) to salvage the intrauterine pregnancy. We also conducted a review of published case reports to understand the determinants of outcome. Methods After a MEDLINE search, 23 case reports were found eligible based on quality assessment and were included in the analysis. A composite-score indicating overall obstetric morbidity was computed, and mixed-effects linear regression was implemented to identify its predictors. Results US-guided local treatment was the most common mode of intervention for HCSP. The regression analyses revealed that the poor obstetric outcomes, especially antepartum haemorrhage (APH) and postpartum haemorrhage (PPH), were significantly predicted by advanced gestational age at treatment and a higher number of previous CS, irrespective of the mode of treatment. Conclusion These results indicate that a high index of suspicion for an early ultrasound diagnosis and treatment is critical. US-guided techniques are useful in salvaging the intrauterine pregnancy with decreased maternal morbidity. The results are preliminary due to the rarity and a small number of published reports. Every CSP should be recorded in a central international registry to obtain reliable data on the diagnosis and management of women with CSP. Given the rising rates of CS, future systematic studies are warranted.
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Affiliation(s)
- Ashwini J Authreya
- ADI's Advanced Centre for Fetal Care Sparsh Hospital Yeshwanthpur, Bangalore 560022 India
| | - Purvi Agrawal
- ADI's Advanced Centre for Fetal Care Sparsh Hospital Yeshwanthpur, Bangalore 560022 India
| | - Adinarayana Makam
- ADI's Advanced Centre for Fetal Care Sparsh Hospital Yeshwanthpur, Bangalore 560022 India
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Chen ZY, Zhou Y, Qian Y, Luo JM, Huang XF, Zhang XM. Management of heterotopic cesarean scar pregnancy with preservation of intrauterine pregnancy: A case report. World J Clin Cases 2021; 9:6428-6434. [PMID: 34435008 PMCID: PMC8362565 DOI: 10.12998/wjcc.v9.i22.6428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/24/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Heterotopic cesarean scar pregnancy (HCSP) is very rare and has a high risk of massive uterine bleeding. Preservation of concurrent intrauterine pregnancy (IUP) is one of the great challenges in the management of HCSP. No universal treatment protocol has been established when IUP is desired to be preserved.
CASE SUMMARY We report a case of HCSP at 8+ wk gestation in a 34-year-old woman with stable hemodynamics. A two-step intervention was applied. Selective embryo aspiration was performed first, and surgical removal of ectopic gestational tissue by suction and curettage was performed 2 d later. Both steps were performed under ultrasound guidance. The patient had an uneventful course, and a healthy baby was delivered at 34+6 wk gestation.
CONCLUSION Selective embryo aspiration followed by suction and curettage was successful in the preservation of IUP in the management of HCSP. This approach is an alternative option for HCSP in the first trimester when the IUP is desired to be preserved.
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Affiliation(s)
- Zheng-Yun Chen
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Yong Zhou
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Yue Qian
- Department of Sonography, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Jia-Min Luo
- Department of Sonography, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Xiu-Feng Huang
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Xin-Mei Zhang
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
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Kathopoulis N, Chatzipapas I, Samartzis K, Theodora M, Lardou I, Protopapas A. Laparoscopic management of cesarean scar pregnancy: Report of two cases with video-presentation of different operative techniques and literature review. J Gynecol Obstet Hum Reprod 2021; 50:102066. [PMID: 33484933 DOI: 10.1016/j.jogoh.2021.102066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 11/30/2022]
Abstract
Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. We present two different techniques of laparoscopic management of CSP, with the concomitant repair of the coexisting uterine isthmocele. The first case is a combination of diagnostic hysteroscopy and laparoscopic extraction of conception products, and the second technique is a combination of laparoscopy and guided Dilation & Curettage. We also conducted a thorough review of the literature to present all cases of laparoscopic treatment of CSP, focusing on the surgical technique, the operation outcome, and the future pregnancies. Laparoscopy is a potential effective treatment of CSP.
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Affiliation(s)
- Nikolaos Kathopoulis
- Endoscopic Surgery Unit, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece.
| | - Ioannis Chatzipapas
- Endoscopic Surgery Unit, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - Konstantinos Samartzis
- Endoscopic Surgery Unit, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - Marianna Theodora
- Unit of Gynecological Ultrasound, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - Ioanna Lardou
- Endoscopic Surgery Unit, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
| | - Athanasios Protopapas
- Endoscopic Surgery Unit, 1st Department of Obstetrics & Gynecology, National and Kapodistrian University of Athens, "Alexandra" Hospital, Athens, Greece
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8
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Wang Y, Niu Z, Tao L, Yang Y, Ma C, Li R. Early intervention for heterotopic caesarean scar pregnancy to preserve intrauterine pregnancy may improve outcomes: a retrospective cohort study. Reprod Biomed Online 2020; 41:290-299. [PMID: 32553465 DOI: 10.1016/j.rbmo.2020.03.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Abstract
RESEARCH QUESTION What is the best intervention time and method for patients who are diagnosed with heterotopic caesarean scar pregnancy (HCSP) wishing to preserve intrauterine pregnancy. DESIGN Four patients diagnosed with HCSP from January 2014 to May 2019 were enrolled. Because HCSP is rare, data on 27 published cases were extracted to augment the analysis. Clinical characteristics and medical documents related to fetal reduction and subsequent maternal-neonate outcomes were analysed. RESULTS The intervention time was significantly earlier in the full-term birth group (6.76 ± 1.05 weeks) compared with pre-term birth group (8.02 ± 1.55 weeks; P = 0.042). The cumulative full-term delivery rate was 91.48% when the intervention was at 6 weeks' gestation and decreased to 42.02% at 8 weeks. The maternal-neonate outcome was similar among the selective fetal reduction and surgical removal groups as was delivery time (34.68 ± 3.12 versus 34.80 ± 6.64 weeks; P = 0.955). In the four cases undergoing selective fetal reduction, the residual mass grew by 1.16-7.07 times compared with the area before reduction. The maximum size of the residual mass was observed at 12-13 weeks and 22-25 weeks. CONCLUSIONS Most patients with HCSP who choose to keep intrauterine pregnancy will be able to carry the fetus to term. Selective fetal reduction would be the first intervention of choice and should take place immediately after diagnosis. The residual mass after reduction could continue to grow throughout the whole pregnancy, although this should not be considered as an indication for termination. With good supervision and careful management, the pregnancy could be maintained and carried to term.
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Affiliation(s)
- Yang Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Ziru Niu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Liyuan Tao
- Research Center of Clinical Epidemiology, Peking University Third hospital, Beijing 100191, China
| | - Yan Yang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Caihong Ma
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Rong Li
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China.
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9
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Abstract
Cesarean scar pregnancy is a complication in which an early pregnancy implants in the scar from a prior cesarean delivery. This condition presents a substantial risk for severe maternal morbidity because of challenges in securing a prompt diagnosis, as well as uncertainty regarding optimal treatment once identified. Ultrasound is the primary imaging modality for cesarean scar pregnancy diagnosis, although a correct and timely determination can be difficult. Surgical, medical, and minimally invasive therapies have been described for cesarean scar pregnancy management, but the optimal treatment is not known. Women who decline treatment of a cesarean scar pregnancy should be counseled regarding the risk for severe morbidity. The following are Society for Maternal-Fetal Medicine recommendations: We recommend against expectant management of cesarean scar pregnancy (GRADE 1B); we suggest operative resection (with transvaginal or laparoscopic approaches when possible) or ultrasound-guided vacuum aspiration be considered for surgical management of cesarean scar pregnancy and that sharp curettage alone be avoided (GRADE 2C); we suggest intragestational methotrexate for medical treatment of cesarean scar pregnancy, with or without other treatment modalities (GRADE 2C); we recommend that systemic methotrexate alone not be used to treat cesarean scar pregnancy (GRADE 1C); in women who choose expectant management and continuation of a cesarean scar pregnancy, we recommend repeat cesarean delivery between 34 0/7 and 35 6/7 weeks of gestation (GRADE 1C); we recommend that women with a cesarean scar pregnancy be advised of the risks of another pregnancy and counseled regarding effective contraceptive methods, including long-acting reversible contraception and permanent contraception (GRADE 1C).
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10
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Surgical management of first-trimester bleeding in a heterotopic caesarean scar pregnancy: A case report and review of literature. Case Rep Womens Health 2020; 27:e00209. [PMID: 32420043 PMCID: PMC7217994 DOI: 10.1016/j.crwh.2020.e00209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 02/07/2023] Open
Abstract
Heterotopic caesarean scar pregnancy (HCSP) is very rare, with only 24 cases reported in the literature. Optimal management is yet to be determined. We describe a 38-year-old woman, G2P1, who presented with vaginal bleeding and haemodynamic instability at 9 weeks of gestation in a HCSP. She was managed with ultrasound-guided lower-segment curettage and bilateral uterine artery ligation. The patient's pregnancy was complicated by preterm rupture of membranes and shortened cervix at 27 weeks of gestation. This necessitated preterm delivery, with subsequent neonatal death attributed to extreme prematurity. The patient later had a spontaneously conceived pregnancy, which was complicated by placenta percreta requiring elective caesarean hysterectomy at 34 weeks of gestation. This is, to our knowledge, the first case report describing preservation of the intrauterine pregnancy and future fertility in a patient with a HCSP and significant first-trimester bleeding. We suggest that ultrasound-guided lower-segment curettage may be a suitable management option for carefully selected patients with HCSP in a tertiary centre. All patients with HCSP require judicious counselling regarding the risk of morbidly adherent placenta and need for tertiary-level obstetric management in future pregnancies.
First trimester bleeding in heterotopic caesarean scar pregnancy Surgical management of heterotopic caesarean scar pregnancy Ultrasound guided curettage with preservation of concurrent intrauterine pregnancy
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11
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Timor-Tritsch IE, Monteagudo A, Calì G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis. Obstet Gynecol Clin North Am 2020; 46:797-811. [PMID: 31677755 DOI: 10.1016/j.ogc.2019.07.009] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cesarean scar pregnancy is a potentially dangerous consequence of a previous cesarean delivery. If unrecognized and inadequately managed, it can lead to untoward complications throughout all three trimesters of the pregnancy. The rate of occurrence parallels the mounting rate of cesarean sections. The late consequences of cesarean delivery, such as placenta previa and placenta accrete, were known for a long time. However, it took more than a decade for the obstetric community to make the connection between the cesarean scar pregnancy and the placenta accreta spectrum. This article discusses the pathogenesis and diagnosis of cesarean scar pregnancy.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Health, 550 1st Avenue, New York, NY 10016, USA.
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calì
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Francesco D'Antonio
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Andrea Kaelin Agten
- Nottingham University Hospitals NHS, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
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12
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Qi F, Chai ZY, Liu MM, Zheng LZ, Zhu Y, Chen ZW, Lv WG. Type 2 Cesarean Scar Pregnancy Successfully Treated via Hysteroscopy-Assisted Laparoscopy. J Minim Invasive Gynecol 2019; 26:1273-1281. [DOI: 10.1016/j.jmig.2018.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 11/08/2018] [Accepted: 11/12/2018] [Indexed: 02/08/2023]
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13
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Vikhareva O, Nedopekina E, Herbst A. Normal vaginal delivery at term after expectant management of heterotopic caesarean scar pregnancy: a case report. J Med Case Rep 2018; 12:179. [PMID: 29925424 PMCID: PMC6011475 DOI: 10.1186/s13256-018-1713-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023] Open
Abstract
Background Heterotopic pregnancy with a combination of a caesarean scar pregnancy and an intrauterine pregnancy is rare and has potentially life-threatening complications. Case presentation We describe the case of a 27-year-old white woman who had experienced an emergency caesarean delivery at 39 weeks for fetal distress with no postpartum complications. This is a report of the successful expectant management of a heterotopic scar pregnancy. The gestational sac implanted into the scar area was non-viable. The woman was treated expectantly and had a normal vaginal delivery at 37 weeks of gestation. Conclusion Expectant management under close monitoring can be appropriate in small non-viable heterotopic caesarean scar pregnancies.
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Affiliation(s)
- Olga Vikhareva
- Department of Obstetrics and Gynaecology, Skåne University Hospital Malmö, Lund University, Box 117, 221 00, Lund, Sweden. .,Department of Obstetrics and Gynaecology, Skåne University Hospital, Lund University, Jan Waldenströms gata 47, SE-20502, Malmö, Sweden.
| | - Ekaterina Nedopekina
- Department of Obstetrics and Gynaecology, Skåne University Hospital Malmö, Lund University, Box 117, 221 00, Lund, Sweden.,Department of Obstetrics and Gynaecology, Skåne University Hospital, Lund University, Jan Waldenströms gata 47, SE-20502, Malmö, Sweden
| | - Andreas Herbst
- Department of Obstetrics and Gynaecology, Skåne University Hospital Malmö, Lund University, Box 117, 221 00, Lund, Sweden.,Department of Obstetrics and Gynaecology, Skåne University Hospital, Lund University, Jan Waldenströms gata 47, SE-20502, Malmö, Sweden
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14
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Surgical Management of a Heterotopic Cesarean Scar Pregnancy With Preservation of an Intrauterine Pregnancy. Obstet Gynecol 2017; 128:613-616. [PMID: 27500331 DOI: 10.1097/aog.0000000000001514] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Spontaneously conceived heterotopic pregnancies are rare. A heterotopic cesarean scar pregnancy involves an intrauterine pregnancy and a second pregnancy in the cesarean scar. Treatment approaches include both medical and surgical management. We present a surgical approach to the treatment of a heterotopic cesarean scar pregnancy with preservation of an intrauterine gestation. CASE A 29-year-old woman, gravida 4 para 1021, presented at 5 weeks of gestation with spotting. Ultrasonography revealed a heterotopic cesarean scar pregnancy. The patient underwent resection of the ectopic pregnancy through minilaparotomy in an attempt to conserve the intrauterine pregnancy. She subsequently delivered an early-term neonate. CONCLUSION Laparotomy with resection of the ectopic pregnancy is an option for treatment of an early heterotopic cesarean scar pregnancy when the patient desires conservation of the intrauterine pregnancy. Excision was not associated with pregnancy complications.
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15
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Jayaram PM, Okunoye GO, Konje J. Caesarean scar ectopic pregnancy: diagnostic challenges and management options. ACTA ACUST UNITED AC 2017. [DOI: 10.1111/tog.12355] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Pradeep M Jayaram
- Sidra Medical and Research Centre & Weill Cornell Medical College; Doha PO Box 26999 Qatar
| | - Gbemisola O Okunoye
- Sidra Medical and Research Centre & Weill Cornell Medical College; Doha PO Box 26999 Qatar
| | - Justin Konje
- Women's Services Clinical Management Group; Sidra Medical and Research Centre; Doha PO Box 26999 Qatar
- University of Leicester; UK
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16
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Yu H, Luo H, Zhao F, Liu X, Wang X. Successful selective reduction of a heterotopic cesarean scar pregnancy in the second trimester: a case report and review of the literature. BMC Pregnancy Childbirth 2016; 16:380. [PMID: 27894281 PMCID: PMC5126867 DOI: 10.1186/s12884-016-1171-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 11/17/2016] [Indexed: 02/07/2023] Open
Abstract
Background Heterotopic cesarean scar pregnancy is a cesarean scar pregnancy combined with an intrauterine pregnancy that predisposes a woman to life-threatening complications such as uterine rupture and massive bleeding. Preservation of the intrauterine pregnancy in heterotopic cesarean scar pregnancy is a great challenge. Case presentation We report a case of a 33-year-old woman with heterotopic cesarean scar pregnancy after IVF-embryo transfer (ET). Expectant management was carried out with early diagnosis of heterotopic cesarean scar pregnancy (HCSP), and selective fetal reduction of cesarean scar pregnancy (CSP) was performed by ultrasound-guided intrathoracic injection of potassium chloride (KCl) at 16 + 4 weeks of gestation due to aggravation of CSP. Preservation of the intrauterine pregnancy was successful and a healthy baby was delivered by cesarean section at 37 + 6 weeks of gestation. Conclusions Heterotopic cesarean scar pregnancy is an extremely rare form of heterotopic pregnancy. Patients should be appropriately counseled regarding the different treatment options available. An ultrasound-guided injection of potassium chloride may constitute a safe, minimally invasive and reliable way to terminate the heterotopic gestation and preserve the intrauterine pregnancy. Intensive management should be performed during the ongoing pregnancy and cesarean section. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1171-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Haiyan Yu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Hong Luo
- Department of Ultrasonic Medicine, West China Second University Hospital, Sichuan University, Chengdu, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China.
| | - Fumin Zhao
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Xinghui Liu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China.
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17
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Jurkovic D, Knez J, Appiah A, Farahani L, Mavrelos D, Ross JA. Surgical treatment of Cesarean scar ectopic pregnancy: efficacy and safety of ultrasound-guided suction curettage. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:511-7. [PMID: 26764166 DOI: 10.1002/uog.15857] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 10/12/2015] [Accepted: 12/04/2015] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To assess the efficacy of ultrasound-guided suction curettage for management of pregnancies implanted into the lower uterine segment Cesarean section scar. METHODS This was a retrospective study including women diagnosed with Cesarean section scar pregnancy at two large tertiary referral early pregnancy units between 1997 and 2014. Surgical evacuation was offered to selected women presenting in the first trimester ≤ 14 weeks' gestation. All procedures were performed transcervically under ultrasound guidance using suction curettage. A modified Shirodkar cervical suture was used in women who required additional measures to secure hemostasis. RESULTS A total of 232 women with Cesarean section scar pregnancy were seen at the referral units; 191/232 (82.3%) women were treated surgically. The median intraoperative blood loss was 100 mL (range, 10-3000 mL); 9/191 (4.7% (95% CI, 1.7-7.7%)) women required blood transfusion and, in one (0.5% (95% CI, 0-1.5%)), life-saving hysterectomy had to be performed because of uncontrollable intraoperative bleeding. Of the women who attended for follow-up, 7/116 (6.0% (95% CI, 1.7-10.3%)) required a repeat surgical procedure because of retained products of conception. Multivariable analysis showed that the gestational sac diameter (odds ratio (OR), 1.10 (95% CI, 1.03-1.17)) and pregnancy vascularity on Doppler examination (OR, 3.41 (95% CI, 1.39-8.33)) were significant predictors of heavy intraoperative blood loss (> 1000 mL). CONCLUSIONS Ultrasound-guided suction curettage is an effective method for the treatment of pregnancies implanted into a lower uterine segment Cesarean section scar and is associated with a low risk of blood transfusion and hysterectomy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Jurkovic
- Institute of Women's Health, University College Hospital, London, UK
| | - J Knez
- Institute of Women's Health, University College Hospital, London, UK
| | - A Appiah
- Early Pregnancy Unit, King's College Hospital, London, UK
| | - L Farahani
- Early Pregnancy Unit, King's College Hospital, London, UK
| | - D Mavrelos
- Institute of Women's Health, University College Hospital, London, UK
| | - J A Ross
- Early Pregnancy Unit, King's College Hospital, London, UK
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18
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Collins K, Kothari A. Catastrophic consequences of a caesarean scar pregnancy missed on ultrasound. Australas J Ultrasound Med 2015; 18:150-156. [PMID: 28191259 PMCID: PMC5024973 DOI: 10.1002/j.2205-0140.2015.tb00222.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Ectopic pregnancy that implants within the scar tissue of a previous caesarean scar is a situation that is seldom encountered and is almost invariably incompatible with a successful pregnancy. Caesarean scar ectopic pregnancies are fraught with life threatening complications such as scar rupture, significant haemorrhage, disseminated intravascular coagulation and the need for emergency life saving hysterectomy. The clinical diagnosis can be elusive, particularly in the early stages; therefore clinicians should be familiar with the condition's sonographic hallmarks. Early diagnosis and management is the key to preventing these complications. We describe a case of caesarean scar pregnancy which was initially misdiagnosed as “a spontaneous miscarriage in progress”, resulting in uncontrollable bleeding, necessitating an emergency abdominal hysterectomy. We also endeavour to review the literature with regards to the use of ultrasound in its management, treatment and follow up.
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Affiliation(s)
| | - Alka Kothari
- The University of QueenslandSt LuciaQueenslandAustralia; Redcliffe HospitalRedcliffeQueenslandAustralia
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19
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Yapar Eyi EG. Minimally invasive procedure for type II canal defect caesarean scar pregnancy with cardiac activity and high hCG titres at 8+2 weeks of gestation. CASE REPORTS IN PERINATAL MEDICINE 2015. [DOI: 10.1515/crpm-2014-0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Type II caesarean scar pregnancy (CSP) not only poses important maternal hazards, such as severe bleeding, uterine rupture, disseminated intravascular coagulation and maternal death due to its abnormal location and invasive characteristics, but its surgical management may lead to operative complications and even loss of fertility. The sonographic and Doppler findings of a “canal defect CSP” that has previously been hypothesised, but not illustrated, are presented here. A minimally invasive approach was performed in the presence of a 38.3 mm gestational sac (GS) with a crown rump length of 11.3 mm embryo (8+2 weeks of gestation) and cardiac activity with high (118,839.2 mIU/mL) human chorionic gonadotropin (hCG) levels. A transabdominal intragestational sac injection of potassium chloride to stop cardiac activity, and consecutively, methotrexate (MTX) was given before systemic MTX therapy. Embryonic cardiac activity stopped. Systemic methotrexate was repeated 8 days after the procedure. While vaginal bleeding ceased in 3 weeks with gradual shrinkage of the GS, hCG fell to non-pregnant levels within 112 days (16 weeks); complete resolution of the ectopic mass required 8 months. This is the first report presenting the success of a minimally invasive procedure at a hCG level of 118,839.2 mIU/mL with embryonic cardiac activity in type II CSP.
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Affiliation(s)
- Elif Gul Yapar Eyi
- Obstetrics and Gynaecology/Subdivision of Perinatology, Zekai Tahir Burak Women’s Health Education and Research Hospital, Talatpasa Bulvarı, 06230 Ankara, Turkey
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20
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Refaat B, Dalton E, Ledger WL. Ectopic pregnancy secondary to in vitro fertilisation-embryo transfer: pathogenic mechanisms and management strategies. Reprod Biol Endocrinol 2015; 13:30. [PMID: 25884617 PMCID: PMC4403912 DOI: 10.1186/s12958-015-0025-0] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/03/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Ectopic pregnancy (EP) is the leading cause of maternal morbidity and mortality during the first trimester and the incidence increases dramatically with in vitro fertilisation and embryo transfer (IVF-ET). The co-existence of an EP with a viable intrauterine pregnancy (IUP) is known as heterotopic pregnancy (HP) affecting about 1% of patients during assisted conception. EP/HP can cause significant morbidity and occasional mortality and represent diagnostic and therapeutic challenges, particularly during fertility treatment. Many risk factors related to IVF-ET techniques and the cause of infertility have been documented. The combination of transvaginal ultrasound (TVS) and serum human chorionic gonadotrophin (hCG) is the most reliable diagnostic tool, with early diagnosis of EP/HP permitting conservative management. This review describes the risk factors, diagnostic modalities and treatment approaches of EP/HP during IVF-ET and also their impact on subsequent fertility treatment. METHODS The scientific literature was searched for studies investigating EP/HP during IVF-ET. Publications in English and within the past 6 years were mostly selected. RESULTS A history of tubal infertility, pelvic inflammatory disease and specific aspects of embryo transfer technique are the most significant risk factors for later EP. Early measurement of serum hCG and performance of TVS by an expert operator as early as gestational week 5 can identify cases of possible EP. These women should be closely monitored with repeated ultrasound and hCG measurement until a diagnosis is reached. Treatment must be customised to the clinical condition and future fertility requirements of the patient. In cases of HP, the viable IUP can be preserved in the majority of cases but requires early detection of HP. No apparent negative impact of the different treatment approaches for EP/HP on subsequent IVF-ET, except for risk of recurrence. CONCLUSIONS EP/HP are tragic events in a couple's reproductive life, and the earlier the diagnosis the better the prognosis. Due to the increase incidence following IVF-ET, there is a compelling need to develop a diagnostic biomarker/algorithm that can predict pregnancy outcome with high sensitivity and specificity before IVF-ET to prevent and/or properly manage those who are at higher risk of EP/HP.
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Affiliation(s)
- Bassem Refaat
- Laboratory Medicine Department, Faculty of Applied Medical Sciences, Umm Al-Qura University, Al-Abdiyah Campus, PO Box 7607, Makkah, KSA.
| | - Elizabeth Dalton
- School of Women's & Children's Health, University of New South Wales, Sydney, NSW, 2031, Australia.
| | - William L Ledger
- School of Women's & Children's Health, University of New South Wales, Sydney, NSW, 2031, Australia.
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21
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Armbrust R, Krätschell R, Henrich W, David M. Operative Therapy for Heterotopic Scar Pregnancy and Successful Birth of the Intrauterine Foetus - Case Report and Review of the Literature. Geburtshilfe Frauenheilkd 2015; 75:384-388. [PMID: 26028696 PMCID: PMC4437755 DOI: 10.1055/s-0035-1545918] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/06/2015] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
A heterotopic pregnancy in the vicinity of a previous Caesarean section scar (HSP) occurs frequently after fertility treatment. In spite of the low incidence to date, the increasing numbers of Caesarean sections as well as IVF treatment will probably lead to a higher prevalence in the future. Up to now the literature contains only isolated case reports on therapeutic options. These range from conservative management through selective termination of the HSP by injections of methotrexate or potassium chloride into the amniotic sac to invasive methods such as resectoscopic removal or laparoscopy. In the case presented here we describe the successful excision of the HSP by laparotomy with a subsequent uncomplicated Caesarean section and delivery of a healthy baby at the 37 + 0 week of pregnancy.
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Affiliation(s)
- R. Armbrust
- Dept. of Gynecology, Charité Berlin – Campus Virchow Klinikum, Berlin
| | - R. Krätschell
- Obstetrics, Charité Berlin – Campus Virchow Klinikum, Berlin
| | - W. Henrich
- Dept. of Gynecology, Charité Berlin – Campus Virchow Klinikum, Berlin
| | - M. David
- Obstetrics, Charité Berlin – Campus Virchow Klinikum, Berlin
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22
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Fuchs N, Manoucheri E, Verbaan M, Einarsson JI. Laparoscopic management of extrauterine pregnancy in caesarean section scar: description of a surgical technique and review of the literature. BJOG 2014; 122:137-40. [DOI: 10.1111/1471-0528.13060] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2014] [Indexed: 11/29/2022]
Affiliation(s)
- N Fuchs
- Division of Minimally Invasive Gynecologic Surgery, Obstetrics and Gynecology; Brigham and Women's Hospital; Boston MA USA
| | - E Manoucheri
- Division of Minimally Invasive Gynecologic Surgery, Obstetrics and Gynecology; Brigham and Women's Hospital; Boston MA USA
| | - M Verbaan
- Division of Minimally Invasive Gynecologic Surgery, Obstetrics and Gynecology; Brigham and Women's Hospital; Boston MA USA
| | - JI Einarsson
- Division of Minimally Invasive Gynecologic Surgery, Obstetrics and Gynecology; Brigham and Women's Hospital; Boston MA USA
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23
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Moshiri M, Osman S, Bhargava P, Maximin S, Robinson TJ, Katz DS. Imaging Evaluation of Maternal Complications Associated with Repeat Cesarean Deliveries. Radiol Clin North Am 2014; 52:1117-35. [DOI: 10.1016/j.rcl.2014.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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24
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OuYang Z, Yin Q, Xu Y, Ma Y, Zhang Q, Yu Y. Heterotopic cesarean scar pregnancy: diagnosis, treatment, and prognosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1533-1537. [PMID: 25154932 DOI: 10.7863/ultra.33.9.1533] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Heterotopic cesarean scar pregnancy is a rare, life-threatening form of ectopic pregnancy. To provide information regarding the clinical manifestations, diagnosis, management, and prognosis of this condition, we reviewed all cases reported in the English literature. All literature on heterotopic cesarean scar pregnancy was retrieved by searching the PubMed database and tracking references of the relevant literature. Full texts were reviewed, and clinical manifestations, diagnostic methods, and the relationship between the treatment and prognosis were summarized. A total of 14 patients with heterotopic cesarean scar pregnancies were identified, including 6 spontaneous pregnancies and 8 following in vitro fertilization-embryo transfer. Gestational ages at diagnosis ranged from 5 weeks to 8 weeks 4 days. Only 5 cases presented with vaginal bleeding, and the others were asymptomatic. All 14 cases were diagnosed by transvaginal sonography. One patient with no future fertility requirements underwent pregnancy termination by methotrexate. Of the remaining 13 patients who desired to preserve their intrauterine gestations, 10 were treated by sonographically guided selective embryo reduction in situ (by embryo aspiration, drug injection, or both); 2 underwent laparoscopic and hysteroscopic excision of the ectopic pregnancy masses; and 1 was treated by expectant management. All operations were successful and maintained a living intrauterine gestation. Twelve cases resulted in live births by cesarean delivery (3 at term and 9 preterm). One patient underwent pregnancy termination at 12 weeks because of a fetal malformation confirmed by sonography. The possibility of heterotopic cesarean scar pregnancy after cesarean delivery should be considered, especially when pregnancy follows assisted reproductive technology. Transvaginal sonography is an important tool for diagnosis and management. Despite the many options, the best treatment for this condition remains unclear. Selective embryo reduction in situ with sonographic guidance is the main treatment modality and can result in a successful intrauterine gestation, albeit at high risk.
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Affiliation(s)
- Zhenbo OuYang
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.).
| | - Qian Yin
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.)
| | - Yujing Xu
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.)
| | - Yunyan Ma
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.)
| | - Qiushi Zhang
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.)
| | - Yanhong Yu
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.)
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25
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Kim ML, Jun HS, Kim JY, Seong SJ, Cha DH. Successful full-term twin deliveries in heterotopic cesarean scar pregnancy in a spontaneous cycle with expectant management. J Obstet Gynaecol Res 2014; 40:1415-9. [DOI: 10.1111/jog.12326] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 10/15/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Mi-La Kim
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Hye Sun Jun
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Joo Young Kim
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Dong Hyun Cha
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
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26
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Wang DB, Chen YH, Zhang ZF, Chen P, Liu KR, Li Y, Fu L. Evaluation of the transvaginal resection of low-segment cesarean scar ectopic pregnancies. Fertil Steril 2014; 101:602-6. [DOI: 10.1016/j.fertnstert.2013.10.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 10/14/2013] [Accepted: 10/14/2013] [Indexed: 11/24/2022]
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27
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Management of cesarean heterotopic pregnancy with transvaginal ultrasound-guided potassium chloride injection and gestational sac aspiration, and review of the literature. J Minim Invasive Gynecol 2013; 19:671-3. [PMID: 22935313 DOI: 10.1016/j.jmig.2012.05.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 05/03/2012] [Accepted: 05/22/2012] [Indexed: 02/06/2023]
Abstract
Cesarean scar pregnancy is one of the rarest forms of ectopic pregnancy, located in the scar from a previous cesarean section. There are few reports of such pregnancies, and there is no consensus about the best management. Herein is reported a case of cesarean heterotopic pregnancy, diagnosed at 6 weeks' gestation and successfully treated via transvaginal ultrasound-guided potassium chloride injection and gestational sac aspiration, with preservation of the intrauterine pregnancy.
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28
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Gibson KR, Horne AW. Ruptured heterotopic pregnancy: an unusual presentation of an uncommon clinical problem. BMJ Case Rep 2012. [PMID: 23192579 DOI: 10.1136/bcr-2012-007423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 30-year-old nulliparous lady presented to our Emergency Gynaecology Service with a 3-day history of epigastric pain and vomiting at 7 weeks of gestation. An intrauterine pregnancy had been confirmed 3 days earlier when she had attended with an episode of left-iliac fossa pain. Unfortunately, she became more unwell within 1 h of admission and as the cause of her symptoms was unclear, she was taken to the theatre for a joint gynaecology and general surgical diagnostic laparoscopy. This revealed a haemoperitoneum of 2 litres and a ruptured ectopic pregnancy in her left fallopian tube. A left salpingectomy was undertaken to remove the ectopic pregnancy. The patient made an excellent recovery and delivered a healthy baby at 39 weeks of gestation without further complication.
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Affiliation(s)
- Kyle R Gibson
- MRC Centrefor Reproductive Health, University of Edinburgh, Edinburgh, UK [corrected].
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29
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Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012; 207:14-29. [PMID: 22516620 DOI: 10.1016/j.ajog.2012.03.007] [Citation(s) in RCA: 378] [Impact Index Per Article: 29.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 01/28/2012] [Accepted: 03/09/2012] [Indexed: 11/29/2022]
Abstract
This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY 10016, USA.
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30
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Current World Literature. Curr Opin Obstet Gynecol 2011; 23:481-5. [DOI: 10.1097/gco.0b013e32834dce59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Baxi A, Kaushal M, Karmalkar H, Sahu P, Kadhi P, Daval B. Successful expectant management of tubal heterotopic pregnancy. J Hum Reprod Sci 2011; 3:108-10. [PMID: 21209757 PMCID: PMC2970786 DOI: 10.4103/0974-1208.69333] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 05/22/2010] [Accepted: 06/14/2010] [Indexed: 11/16/2022] Open
Abstract
Expectant management for tubal heterotopic pregnancy could be considered as a successful option in a symptom-free patient where the ectopic embryo has a limited craniocaudal length with no cardiac activity. We report the obstetric outcome after expectant management for a right tubal heterotopic pregnancy. Heterotopic pregnancy was first recognized at 6 weeks gestation in a 32-year-old salpingectomized woman with an 8-year history of subfertility who conceived after in utero transfer of three embryos obtained by in vitro fertilization. Expectant management and close ultrasonographic and clinical monitoring were done. The intrauterine pregnancy proceeded unremarkably. A cesarean section was performed for breech presentation, and it allowed the delivery of a healthy 2260-g male infant. The examination of the adnexa showed a pre-rupture of the right fallopian tube.
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Affiliation(s)
- Asha Baxi
- Disha Fertility and Surgical Center, Indore, (M. P.), India
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32
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Abstract
Heterotopic pregnancy is a life-threatening condition. A recent case at our institution prompted a systematic review of the literature from 2005 to 2010. In the majority (71%) of cases reviewed, risk factors for a heterotopic pregnancy were present. However, in several instances (33%), previous sonographic reports of a normal intrauterine pregnancy gave false reassurance. These results highlight the complexity of diagnosis. In addition, our findings were compared with two previous reviews covering cases from 1971 to 2004. This comparison highlighted two important trends: first, the increasing role of ultrasound in the definitive diagnosis of a heterotopic pregnancy, and second, the development of conservative approaches to management. Medical knowledge and technology may be improving, but ultimately, even in the presence of a known intrauterine pregnancy, the simple dictum 'think ectopic' must not be forgotten.
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Affiliation(s)
- K Talbot
- The John Radcliffe Hospital, Oxford, UK.
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Wang CJ, Tsai F, Chen C, Chao A. Hysteroscopic management of heterotopic cesarean scar pregnancy. Fertil Steril 2010; 94:1529.e15-1529.e18. [PMID: 20347078 DOI: 10.1016/j.fertnstert.2010.02.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 02/13/2010] [Accepted: 02/17/2010] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To report a cesarean scar pregnancy (CSP) with a coexistent viable intrauterine pregnancy. DESIGN Case report. SETTING Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, Taiwan. PATIENT(S) A 31-year-old woman, with previous cesarean delivery, presented with vaginal bleeding, was transferred to our hospital at 7 weeks' gestation for heterotopic pregnancy after an IVF-embryo transfer. A diagnosis of intrauterine pregnancy combined with CSP was made by ultrasonography. INTERVENTION(S) Hysteroscopic-directed evacuation of CSP. MAIN OUTCOME MEASURE(S) Good hemostasis at cesarean site and ongoing intrauterine pregnancy. RESULT(S) A healthy baby was delivered by cesarean delivery at term. CONCLUSION(S) With the increasing number of IVF-embryo transfers, the amount of heterotopic pregnancies is also increasing. Hysteroscopic management of CSP is a minimally invasive procedure that leads to successful obstetric outcomes in the corresponding intrauterine pregnancies.
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Affiliation(s)
- Chin-Jung Wang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Kwei-Shan, Tao-Yuan
| | | | | | - Angel Chao
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Kwei-Shan, Tao-Yuan.
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A novel surgical treatment for cesarean scar pregnancy: laparoscopically assisted operative hysteroscopy. Fertil Steril 2009; 92:1497.e13-1497.e16. [DOI: 10.1016/j.fertnstert.2009.07.996] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 07/07/2009] [Accepted: 07/15/2009] [Indexed: 11/19/2022]
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Treatment of a viable caesarean scar pregnancy with transvaginal methotrexate and potassium chloride injection. Arch Gynecol Obstet 2009; 280:869-72. [DOI: 10.1007/s00404-009-1070-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Accepted: 03/24/2009] [Indexed: 10/20/2022]
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