SEARCH

SEARCH BY CITATION

Case report

  1. Top of page
  2. Case report
  3. Discussion
  4. References

A 40 year old woman was admitted with severe vaginal bleeding at seven weeks amenorrhea. In her past she had previously undergone one caesarean delivery and one miscarriage. A pregnancy test was positive and pelvic examination revealed profuse haemorrhage from the cervical canal. An ultrasound scan showed a sac embedded in the myometrium of the isthmus of the uterus (Fig. 1). The woman's blood pressure was 94/48 mmHg, pulse was 120 bpm and haemoglobin concentration was 6.1 g/dL. A blood transfusion was given. In the operating theatre, using vaginal ultrasound guidance and an oocyte retrieval needle, vasopressin 20 units diluted in 60 mL normal saline was administered into the sac. The myometrium of the isthmus bulged with the solution of vasopressin and the bleeding became sero-sanguinous. This procedure was followed by balloon tamponade using a size 18 F Foley catheter with a three-way tap. About 30 mL of saline was injected into the balloon. The bleeding diminished after the vasopressin injection, ceasing altogether following the balloon placement.

image

Figure 1. After injection with vasopressin and balloon tamponade. The gestational sac is clearly seen in the myometrium, between the bladder and the endometrium.

Download figure to PowerPoint

She was then given four doses of methotraxate 1 mg/kg on alternate days. The balloon was removed after 72 hours, and only spotting of blood occurred. She was discharged five days later. Her β-hCG level decreased from 7052 mIU/mL on the day of admission to 4.9 mIU/mL one month later, at which time no blood flow was detected at the isthmus of the uterus on Doppler examination. Menstruation resumed one month after her discharge from hospital.

Discussion

  1. Top of page
  2. Case report
  3. Discussion
  4. References

A pregnancy in the scar of a caesarean section is rare. A review of the literature from 1970 to 2001 using Medline yielded just 14 case reports1–14. As in other types of ectopic pregnancy, when haemorrhage occurs, the condition may be life threatening1–3. In these 14 women, the most likely cause of the haemorrhage was dilatation and curettage, as a result of misdiagnosis of an inevitable miscarriage1,4,5. If massive bleeding occurs, hysterectomy may be required6–8. In the case presented by Hermann et al.3 conservative treatment was given after the diagnosis of an ectopic in the scar of a previous caesarean section; the caesarean section was made during the seventh gestational week. The fetus developed uneventfully until the 35th week when haemorrhage occurred, with hysterectomy being performed due to the uncontrollable bleeding6. Lee et al.9 also reported a case of wedge resection and laparoscopic repair. Wedge resection may result in post-operative adhesions, however, and fertility may be lost10. In the light of this important consideration, we decided to attempt a less invasive procedure, which included local vasopressin injection and balloon tamponade. Balloon tamponade has been reported elsewhere for the treatment of cervical pregnancy11. Vasopressin has been used for some time as an effective haemostatic agent in vaginal surgery12. Furthermore, the in vitro study of Bryman et al.18 proved the effect of vasopressin as a contractile agent to the cervix. We treated the woman in our case report with vasopressin and balloon tamponade because of her strong desire to have more children. The bleeding stopped. In 7 of the 14 cases in the literature, methotraxate was used, sometimes locally. In six women bleeding did not recur, but in the seventh massive haemorrhage occurred two weeks after a single dose of methotraxate, requiring laparotomy and wedge resection for its control4.

Women with an ectopic pregnancy embedded in scar of a caesarean section will have a variable amount of bleeding, from spotting to severe haemorrhage. The most important investigation is ultrasound, which will show a sac in the myometrium low in the anterior part of the uterus. The most important alternative diagnosis is a miscarriage, because curettage may result in detrimental haemorrhage if the pregnancy is in the scar of a previous caesarean section. The number of previous caesarean sections does not appear to be a factor in ectopic pregnancy in a caesarean section scar, as 10 of the 14 cases had only one previous section, three had two and one had four. Previous dilatation and curettage is possibly an aetiological factor. However, this could not be determined in the 14 case reports because, in most cases, the medical history was incomplete.

References

  1. Top of page
  2. Case report
  3. Discussion
  4. References