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Case report

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

A 36 year old woman, gravida 5, para 2, was admitted seven weeks and three days after her last menstrual period because a transvaginal ultrasound examination showed a gestational sac with yolk sac and fetal cardiac activity located within the isthmic area of the lower anterior wall of the uterus and protruding toward the vesicouterine junctional region. This appearance raised the suspicion of a caesarean scar pregnancy (CSP). Both ovaries appeared normal and there were no adnexal masses or free fluid in the cul-de-sac. The plasma β-human chorionic gonadotrophin (β-hCG) level was 28,338 miu/mL and general physical examination was normal. Her obstetric history revealed two-term transverse lower segment caesarean sections and two uterine curettages for abortion, and her youngest child was five years old.

After counseling, the patient opted for conservative treatment with diagnostic and operative hysteroscopy. Under general anaesthesia without endotracheal intubation, the patient was placed in the dorsolithotomy position. After a speculum was placed inside the vagina, a tenaculum was applied to the cervix and gentle traction was exerted to align the uterus. The cervix was dilated by Hegar dilators to 12 mm and a continuous flow 26F hysteroscopic resectoscope (Karl Stortz, Tuttlingen, Germany) with a 90° wire loop electrode was introduced under ultrasound control. Uterine distension was achieved using 10% dextrose solution propelled by simple gravity. An Aspen Excalibur (Aspen Labs, Englewood, Colorado) electrosurgical generator was used on a setting of 80 W of cutting waveform current and 100 W of coagulation current.

The intervention began by an overview of the uterine cavity. The endometrial cavity was empty and the gestation sac was implanted in a niche located in anterior endocervical wall, compatible with prior caesarean section scar (Fig. 1). The sac was pushed toward the fundal direction via wire loop electrode and blood vessels in the implantation site were identified. These vessels were coagulated by loop electrode and the resectoscope was then withdrawn. A placenta forceps followed by a vacuum curette were used to remove the partial detached gestational tissue under the ultrasound guidance. Thereafter, the resectoscope attached with a rollerball was introduced again to achieve haemostasis. During the 20-minute procedure, total fluid input was 3200 mL and output was 3150 mL. Vaginal bleeding was minimal at the end of the procedure. The patient had an unremarkable post-operative course and was discharged on the next day. The plasma β-hCG level was 5211 and 593 miu/mL at post-operative days 1 and 7, respectively. The pathology report confirmed a CSP. Urine pregnancy test was negative and plasma β-hCG level was 4.6 miu/mL at the post-operative 27th day visit and normal echotecture of the uterus was noted. Menstruation resumed three days after that visit and there has been no subsequent abnormal uterine bleeding within the three months of follow up period.

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Figure 1. Hysteroscopic view of the CSP.

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Discussion

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

CSP is a rare form of ectopic pregnancy, which carries a high risk of uncontrollable bleeding requiring hysterectomy and for which no standard treatment protocol has been established. From 1978 to July 2004, 75 cases have been reported in the English literature and treatment has included conservative ultrasound guidance suction curettage, excision of the mass of the ectopic pregnancy and hysterectomy. Successful cases have been reported after administration of systemic methotrexate (MTX), ultrasound guidance direct injection of MTX or potassium chloride (KCl) into the embryonic sac or just expectant management.1–13

However, none of these treatments is entirely satisfactory. Treatment failure is common after expectant management.2,14 Similarly, although MTX is reportedly successful in 25 of 32 cases,1,2,5–7,9,14 it took 4–16 weeks for the β-hCG resolution to occur, and regression of the ectopic mass took up to one year.2,9,14 MTX treatment may also be associated with side effects of pneumonitis, alopecia, nausea or stomatitis. Abnormal vaginal spotting or even bleeding was usually seen during the follow up period. Among MTX-treated failures, surgical intervention was required and one patient underwent hysterectomy.

Ultrasound-guided suction curettage followed by Foley catheter insertion for tamponade has been suggested.14 However, three of eight patients (38%) had massive haemorrhage (500–1000 mL blood loss) during the procedure, so the Foley needed to be placed for about 12–24 hours.

Laparoscopic excision of the mass of the CSP, and suturing of the incisional site, has been used in four cases.15 The whole procedure could be accomplished under direct observation, permitting immediate intervention such as electrocauterisation, bilateral ligation of uterine arteries or hysterectomy could be carried out to achieve better haemostasis. Nevertheless, suction curettage even under ultrasound guidance is not under direct vision.

The current report is the first in the English literature to report on the use of operative hysteroscopy accompanied with suction curettage in managing CSP successfully. This permits accurate diagnosis by observing the distribution of the blood vessels at the implantation site and allows operative hysteroscopy to separate the embryonic sac from the uterine wall and permit coagulation of the blood vessels directly. Thereafter, placenta forceps and vacuum curette could easily be utilised to remove the loosened embryonic tissue, and hysteroscopy could then be used to check bleeding and perform electrocauterisation for complete haemostasis purpose.

The method is not suitable for an inexperienced surgeon. It requires a high level of eye–hand coordination and meticulous coagulation of the implantation vessels of the ectopic mass to prevent massive bleeding, which would block the operative field. Facilities for immediate laparoscopy must be available.

This case report offers an important alterative treatment for CSP with a short operative time, less blood loss and rapid return of the pregnancy test to negative. Most importantly, the fertility is conserved after the surgery. Nevertheless, we do not know whether it can be performed under heavy bleeding or with unstable vital signs.

References

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

Accepted 16 September 2004