Journal of Obstetrics and Gynaecology, 2015; Early Online: 1–2 © 2015 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online
GYNAECOLOGY CASE REPORT
Caesarean scar pregnancy: Early diagnosis and conservative management K. Dimassi1,2, F. Douik1, M. Derbel1, N. Ben Aissia1,2, A. Tiki1,2 & M. F. Gara1,2
J Obstet Gynaecol Downloaded from informahealthcare.com by Ryerson University on 08/10/15 For personal use only.
1Department of Obstetrics and Gynecology, Mongi Slim Hospital, La Marsa, Tunisia and 2University Tunis El Manar, Faculté de Médecine de Tunis, Tunis, Tunisia
DOI: 10.3109/01443615.2015.1019436 Correspondence: Kaouther Dimassi, Department of Obstetrics and Gynecology, Mongi Slim Hospital, La Marsa, Tunisia. E-mail address:[email protected]
Introduction Caesarean scar pregnancy (CSP) is one of the rarest forms of ectopic pregnancy. With the increasing incidence of caesarean section (CS) worldwide, an increasing number of cases are being diagnosed and reported. A delay in diagnosis and/or treatment can lead to uterine rupture, major haemorrhage, hysterectomy and serious maternal morbidity. Early diagnosis can offer conservative treatment options thus preserving the uterine integrity and future fertility. There is no consensus about the method of choice for managing CSP, and several types of conservative treatment have been used (Yin et al. 2014). In this paper, we describe two cases of CSP diagnosed early at 6 and 7 weeks of amenorrhoea (WA) with a successful medical treatment.
Case 1 A 38-year-old woman, gravida 4, para 3, with a history of three CSs was admitted to hospital for pelvic pain at 7WA. Physical examination demonstrated stable vital signs while bimanual examination revealed an enlarged uterus with no adnexal masses. Trans-vaginal ultrasound revealed an empty uterine cavity, empty cervical canal and a gestational sac (GS) within the anterior wall of the uterus, pressing anteriorly on the urinary bladder (Figure 1a). An embryonic pole was identified with a crown–rump length (CRL) of 20 mm. Foetal cardiac activity was detected. There was no fluid in the cul-de-sac. These findings were compatible with a CSP. A magnetic resonance imaging (MRI) revealed a GS embedded in the anterior lower part of the uterus and an important thinning of the myometrium near to the posterior superior wall of the urinary bladder confirming the diagnosis (Figure 1b). The patient received an injection of methotrexate (MTX) (75 mg: 1 mg/Kg of body weight) in the amniotic fluid (day 0) in order to stop the cardiac activity. Then (day 4) she received an equivalent dose of MTX intramuscularly. The patient was discharged at day 30 and followed up in outpatient setting until a total negativation of betahuman chorionic gonadotropin (ß-hCG) levels, at day 35. The GS disappeared 10 weeks after the first injection of MTX (Figure 1c). Since the patient had three CSs, we decided to perform a tubal ligation to avoid subsequent pregnancy.
Case 2 A 33-year-old woman, gravida 2, para 1, with a previous history of CS, was admitted to our unit for pelvic pain and vaginal bleeding at 6 WA.
Physical examination demonstrated stable vital signs, slight vaginal bleeding and a closed cervix. A trans-vaginal ultrasound examination showed that both the uterine cavity and cervical canal were empty, but there was a single non-viable foetus with CRL of 6.4 mm in a GS implanted in the anterior wall of the uterus at the level of uterine isthmus. The serum level of β-HCG was 6492 mUI/mL. A diagnosis of a CSP was made. As there was no cardiac activity, the patient received a first dose (Day 0) of MTX (100 mg: 1 mg/Kg of body weight) intramuscularly. The serum level of the β-HCG at the 4th day increased requiring a second dose of MTX (Figure 1d). The patient was discharged and followed up in outpatient setting. The patient had mild bleeding at the 25th day with a spontaneous expulsion of the GS. Then ultrasound scan revealed a normal empty uterus with a continuous anterior wall. The patient did not have a subsequent pregnancy yet.
Discussion The CSP is the rarest form of ectopic pregnancy. Its incidence ranges from 1/1800 to 1/2216 pregnancies and it constitutes 6.1% of all ectopic pregnancies with a history of at least one caesarean delivery (Rotas et al. 2006). A recent literature search identified 751 cases of CSP (Timor-Tritsch and Monteagudo 2012). The exact cause of CSP is still unknown. Nonetheless, its occurrence may be linked to an existing scar defect or microscopic dehiscent tract generated between the prior caesarean scar and the endometrial canal (Godin et al. 1997). Ultrasound is the first-line diagnostic tool for CSP and strict imaging criteria have to be used to establish the diagnosis: empty uterus, empty cervical canal, development of the sac in the anterior part of isthmic portion and a diminished myometrial layer between the bladder and the GS (Godin et al. 1997). All those signs were present in our cases. MRI serves as an adjunct method. It is superior to ultrasonography because the resolution of soft tissue is better, and it has been applied as a problem-solving modality for suspected CSP when ultrasound scan has been inconclusive (Huang et al. 2014). Because of the rarity of CSP, the optimal treatment has not been established. The early diagnosis of CSP led to a high success rate of conservative treatment. CSP patients with no or mild symptoms, no viable GS or embryo in the previous CS scar and rapidly decreased β-HCG level may be expectantly treated and the natural history of such CSP may be naturally demised (Liu et al. 2010). Conservative medical treatment is appropriate for a woman who is pain free and stable vital signs with an unruptured CSP of less than 8 WA and a myometrial thickness inferior to 2 mm between the CSP and the bladder (Maymon et al. 2004). Under ultrasound guidance, MTX can be injected locally to the gestation sac via trans-abdominal or via trans-vaginal route. We used this injection only in the first case because of the positive cardiac activity. Nevertheless, the trans-vaginal approach is known to be preferable because it allows for a shorter distance to the GS with minimal risk of bladder injury. Because of the unavailability of vaginal puncture needle we used the abdominal approach. Local MTX administration increases the success rate due to the high concentration of MTX deposited in the lesion, avoiding the side effects produced with systemic administration (Seow et al. 2004). Some authors have recommended surgical repair of the scar before the next conception following MTX treatment (Vial et al. 2000). However, repair of the uterine laparotomy scar may not prevent the occurrence of uterine rupture in the subsequent pregnancy (Seow et al. 2004).
J Obstet Gynaecol Downloaded from informahealthcare.com by Ryerson University on 08/10/15 For personal use only.
2
Gynaecology Case Reports
Figure 1. (a) A midline sagittal trans-vaginal image demonstrating a GS with foetus implanted in the lower anterior wall of the uterus (white arrow). (b) Sagittal T2-weighted MR image showing a GS embedded in the anterior lower part of the uterus (white arrow). (c) Ultrasound image of a sagittal section of uterus showing an empty uterine cavity. (d) Quantitative β-HCG rate variation.
A subsequent pregnancy should be avoided for at least 3 months and probably 1 or 2 years. For the pregnancy following a CSP, an early CS should be done as soon as the foetal lungs become mature, to avoid the possibility of spontaneous uterine rupture (Seow et al. 2004).
Conclusion In summary, CSP is a very unusual and possibly life-threatening complication of pregnancy. Uterine rupture is a possible but rare complication in the subsequent pregnancy. Decisions on treatment options should be dictated in part by gestational age, β-HCG levels, the presence of foetal cardiac activity, the desire of future fertility and the experience and facilities available. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Godin PA, Bassil S, Donnez J. 1997. An ectopic pregnancy developing in a previous cesarean section scar. Fertility Sterily 67:398–400.
Liu H, Leng J, Shi H et al. 2010. Expectant treatment of cesarean scar pregnancy: two case reports and a glimpse at the natural courses. Archives of Gynecology and Obstetrics 282:455–458. Maymon R, Halperin R, Mendlovic S et al. 2004. Ectopic pregnancies in a caesarean scar: review of the medical approach to an iatrogenic complication. Human Reproduction Update 10:515–523. Huang Q, Zhang M, Zhai RY. 2014. The use of contrast-enhanced magnetic resonance imaging to diagnose cesarean scar pregnancies. International Journal of Gynecology and Obstetrics 127:144–146. Rotas MA, Haberman S, Levgur M. 2006. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstetrics & Gynecology 107: 1373–1381. Seow KM, Huang LW, Lin YH et al. 2004. Cesarean scar pregnancy: issues in management. Ultrasound in Obstetrics & Gynecology 23:247–253. Timor-Tritsch IE, Monteagudo A. 2012. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean section scar pregnancy. A review. American Journal of Obstetrics & Gynecology 207:14–29. Vial Y, Petignat P, Hohlfeld P. 2000. Pregnancy in a cesarean scar. Ultrasound in Obstetrics & Gynecology 16:592–593. Yin XH, Yang SZ, Wang ZQ et al. 2014. Injection of MTX For the treatment of cesarean scar pregnancy: comparison between different methods. International Journal of Clinical and Experimental Medicine 7:1867–1872.
GYNAECOLOGY CASE REPORT
Caesarean scar pregnancy: Early diagnosis and conservative management K. Dimassi1,2, F. Douik1, M. Derbel1, N. Ben Aissia1,2, A. Tiki1,2 & M. F. Gara1,2
J Obstet Gynaecol Downloaded from informahealthcare.com by Ryerson University on 08/10/15 For personal use only.
1Department of Obstetrics and Gynecology, Mongi Slim Hospital, La Marsa, Tunisia and 2University Tunis El Manar, Faculté de Médecine de Tunis, Tunis, Tunisia
DOI: 10.3109/01443615.2015.1019436 Correspondence: Kaouther Dimassi, Department of Obstetrics and Gynecology, Mongi Slim Hospital, La Marsa, Tunisia. E-mail address:[email protected]
Introduction Caesarean scar pregnancy (CSP) is one of the rarest forms of ectopic pregnancy. With the increasing incidence of caesarean section (CS) worldwide, an increasing number of cases are being diagnosed and reported. A delay in diagnosis and/or treatment can lead to uterine rupture, major haemorrhage, hysterectomy and serious maternal morbidity. Early diagnosis can offer conservative treatment options thus preserving the uterine integrity and future fertility. There is no consensus about the method of choice for managing CSP, and several types of conservative treatment have been used (Yin et al. 2014). In this paper, we describe two cases of CSP diagnosed early at 6 and 7 weeks of amenorrhoea (WA) with a successful medical treatment.
Case 1 A 38-year-old woman, gravida 4, para 3, with a history of three CSs was admitted to hospital for pelvic pain at 7WA. Physical examination demonstrated stable vital signs while bimanual examination revealed an enlarged uterus with no adnexal masses. Trans-vaginal ultrasound revealed an empty uterine cavity, empty cervical canal and a gestational sac (GS) within the anterior wall of the uterus, pressing anteriorly on the urinary bladder (Figure 1a). An embryonic pole was identified with a crown–rump length (CRL) of 20 mm. Foetal cardiac activity was detected. There was no fluid in the cul-de-sac. These findings were compatible with a CSP. A magnetic resonance imaging (MRI) revealed a GS embedded in the anterior lower part of the uterus and an important thinning of the myometrium near to the posterior superior wall of the urinary bladder confirming the diagnosis (Figure 1b). The patient received an injection of methotrexate (MTX) (75 mg: 1 mg/Kg of body weight) in the amniotic fluid (day 0) in order to stop the cardiac activity. Then (day 4) she received an equivalent dose of MTX intramuscularly. The patient was discharged at day 30 and followed up in outpatient setting until a total negativation of betahuman chorionic gonadotropin (ß-hCG) levels, at day 35. The GS disappeared 10 weeks after the first injection of MTX (Figure 1c). Since the patient had three CSs, we decided to perform a tubal ligation to avoid subsequent pregnancy.
Case 2 A 33-year-old woman, gravida 2, para 1, with a previous history of CS, was admitted to our unit for pelvic pain and vaginal bleeding at 6 WA.
Physical examination demonstrated stable vital signs, slight vaginal bleeding and a closed cervix. A trans-vaginal ultrasound examination showed that both the uterine cavity and cervical canal were empty, but there was a single non-viable foetus with CRL of 6.4 mm in a GS implanted in the anterior wall of the uterus at the level of uterine isthmus. The serum level of β-HCG was 6492 mUI/mL. A diagnosis of a CSP was made. As there was no cardiac activity, the patient received a first dose (Day 0) of MTX (100 mg: 1 mg/Kg of body weight) intramuscularly. The serum level of the β-HCG at the 4th day increased requiring a second dose of MTX (Figure 1d). The patient was discharged and followed up in outpatient setting. The patient had mild bleeding at the 25th day with a spontaneous expulsion of the GS. Then ultrasound scan revealed a normal empty uterus with a continuous anterior wall. The patient did not have a subsequent pregnancy yet.
Discussion The CSP is the rarest form of ectopic pregnancy. Its incidence ranges from 1/1800 to 1/2216 pregnancies and it constitutes 6.1% of all ectopic pregnancies with a history of at least one caesarean delivery (Rotas et al. 2006). A recent literature search identified 751 cases of CSP (Timor-Tritsch and Monteagudo 2012). The exact cause of CSP is still unknown. Nonetheless, its occurrence may be linked to an existing scar defect or microscopic dehiscent tract generated between the prior caesarean scar and the endometrial canal (Godin et al. 1997). Ultrasound is the first-line diagnostic tool for CSP and strict imaging criteria have to be used to establish the diagnosis: empty uterus, empty cervical canal, development of the sac in the anterior part of isthmic portion and a diminished myometrial layer between the bladder and the GS (Godin et al. 1997). All those signs were present in our cases. MRI serves as an adjunct method. It is superior to ultrasonography because the resolution of soft tissue is better, and it has been applied as a problem-solving modality for suspected CSP when ultrasound scan has been inconclusive (Huang et al. 2014). Because of the rarity of CSP, the optimal treatment has not been established. The early diagnosis of CSP led to a high success rate of conservative treatment. CSP patients with no or mild symptoms, no viable GS or embryo in the previous CS scar and rapidly decreased β-HCG level may be expectantly treated and the natural history of such CSP may be naturally demised (Liu et al. 2010). Conservative medical treatment is appropriate for a woman who is pain free and stable vital signs with an unruptured CSP of less than 8 WA and a myometrial thickness inferior to 2 mm between the CSP and the bladder (Maymon et al. 2004). Under ultrasound guidance, MTX can be injected locally to the gestation sac via trans-abdominal or via trans-vaginal route. We used this injection only in the first case because of the positive cardiac activity. Nevertheless, the trans-vaginal approach is known to be preferable because it allows for a shorter distance to the GS with minimal risk of bladder injury. Because of the unavailability of vaginal puncture needle we used the abdominal approach. Local MTX administration increases the success rate due to the high concentration of MTX deposited in the lesion, avoiding the side effects produced with systemic administration (Seow et al. 2004). Some authors have recommended surgical repair of the scar before the next conception following MTX treatment (Vial et al. 2000). However, repair of the uterine laparotomy scar may not prevent the occurrence of uterine rupture in the subsequent pregnancy (Seow et al. 2004).
J Obstet Gynaecol Downloaded from informahealthcare.com by Ryerson University on 08/10/15 For personal use only.
2
Gynaecology Case Reports
Figure 1. (a) A midline sagittal trans-vaginal image demonstrating a GS with foetus implanted in the lower anterior wall of the uterus (white arrow). (b) Sagittal T2-weighted MR image showing a GS embedded in the anterior lower part of the uterus (white arrow). (c) Ultrasound image of a sagittal section of uterus showing an empty uterine cavity. (d) Quantitative β-HCG rate variation.
A subsequent pregnancy should be avoided for at least 3 months and probably 1 or 2 years. For the pregnancy following a CSP, an early CS should be done as soon as the foetal lungs become mature, to avoid the possibility of spontaneous uterine rupture (Seow et al. 2004).
Conclusion In summary, CSP is a very unusual and possibly life-threatening complication of pregnancy. Uterine rupture is a possible but rare complication in the subsequent pregnancy. Decisions on treatment options should be dictated in part by gestational age, β-HCG levels, the presence of foetal cardiac activity, the desire of future fertility and the experience and facilities available. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
References Godin PA, Bassil S, Donnez J. 1997. An ectopic pregnancy developing in a previous cesarean section scar. Fertility Sterily 67:398–400.
Liu H, Leng J, Shi H et al. 2010. Expectant treatment of cesarean scar pregnancy: two case reports and a glimpse at the natural courses. Archives of Gynecology and Obstetrics 282:455–458. Maymon R, Halperin R, Mendlovic S et al. 2004. Ectopic pregnancies in a caesarean scar: review of the medical approach to an iatrogenic complication. Human Reproduction Update 10:515–523. Huang Q, Zhang M, Zhai RY. 2014. The use of contrast-enhanced magnetic resonance imaging to diagnose cesarean scar pregnancies. International Journal of Gynecology and Obstetrics 127:144–146. Rotas MA, Haberman S, Levgur M. 2006. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstetrics & Gynecology 107: 1373–1381. Seow KM, Huang LW, Lin YH et al. 2004. Cesarean scar pregnancy: issues in management. Ultrasound in Obstetrics & Gynecology 23:247–253. Timor-Tritsch IE, Monteagudo A. 2012. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean section scar pregnancy. A review. American Journal of Obstetrics & Gynecology 207:14–29. Vial Y, Petignat P, Hohlfeld P. 2000. Pregnancy in a cesarean scar. Ultrasound in Obstetrics & Gynecology 16:592–593. Yin XH, Yang SZ, Wang ZQ et al. 2014. Injection of MTX For the treatment of cesarean scar pregnancy: comparison between different methods. International Journal of Clinical and Experimental Medicine 7:1867–1872.
