A C TA Obstetricia et Gynecologica
AOGS LE TT E R TO THE EDIT O R
Intrauterine hypoechoic mass cephalad to cesarean scar pregnancy
Sir, Early ultrasound diagnosis is important for a cesarean scar pregnancy (CSP): it can rupture (1), and if un-terminated, often ends in abnormally invasive placentation (2). Concern was expressed for its misdiagnosis (1), especially on initial ultrasound diagnosis (3). We propose another ultrasound finding: presence of an intrauterine hypoechoic mass suggestive of hematoma cephalad to the CSP site. All three women had past history of cesarean section (CS). The first woman had a gestational sac (GS) extending to the previous CS scar and intrauterine hypoechoic mass (Figure 1a). After evacuation in the eighth week of gestation, vaginal bleeding continued. Ultrasound revealed a mass at the cervico-isthmic myometrium bulging to the bladder, indicative of a CSP remnant. Considering the active bleeding, transarterial embolization was performed, with hemostasis. The second woman had a GS at the previous CS scar and intrauterine hypoechoic mass in the sixth week of gestation (Figure 1b). Magnetic resonance imaging revealed a GS nearly penetrating the myometrium. Methotrexate injection into the GS led to its absorption. The third woman with a CSP also had an intrauterine hypoechoic mass (Figure 1c), which disappeared at 16 weeks of gestation following vaginal bleeding. She desired pregnancy continuation: placenta increta at the CS scar was clinically diagnosed, which was confirmed histologically after cesarean hysterectomy. We analyzed the ultrasound figures in the recent article by Timor-Tritsch et al. describing 10 women with CSP (2) and found
well-proportioned peanut
(a)
hypoechoic or anechoic intrauterine masses cephalad to the CSP in at least three women (Cases 1, 2, and 3). Case 6 had “a significant collection of blood and blood clots in the uterine cavity.” Thus, of 10 women with CSP, four had ultrasounddetectable intrauterine mass or hematoma. We found similar intrauterine masses in other reports [fig. 1A in Liang and He (1), fig. 1 in Cok et al. (4), and fig. 1B in Cheng et al. (5)]. No mention was made of this ultrasound finding in the text of these articles (1,2,4,5). We cannot definitely determine the nature of this mass at present, but its features suggest intrauterine hematoma. Intrauterine hematoma usually exists around the internal ostium (caudal to GS). In these three cases, importantly, intrauterine mass was present cephalad to the GS, an uncommon finding. CSP is also a rare event. We believe that the coexistence of the two rare phenomena may not be a coincidence. Nagy et al. (6) showed that hematoma (+) women, compared with hematoma ( ) women, had a significantly higher incidence of “cotyledon retention,” which was interpreted as showing that, “abnormally adherent placentation was increased in hematoma group” and “this may reflect the ability of a hematoma to impair normal placentation, or the hematoma could be a result of impaired placentation,” suggesting some association between these two phenomena. As CSP is also considered to be an abnormal invasive placentation, the data of Nagy et al. (6) may suggest some pathophysiological mechanism underlying the present observation.
distorted peanuts
(a)′
(b)′
(b)
(c)′
(c)
Figure 1. The gestational sac and intrauterine mass observed in the first (a), second (b), and third (c) cases, with each resembling a “peanut” (a’, b’, and c’, respectively). Large hypoechoic areas suggestive of intrauterine hematomas (arrow) are located cephalad to the gestational sac (arrowhead). These intrauterine masses occupy at least half of the uterine cavity. The longest diameters are 4.5 cm (a), 4.7 cm (b), and 6.0 cm (c), respectively. The masses (peanut-shape) look to have no communication with the gestational sac.
670
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 670–671
Letter to the Editor
Previously reported ultrasound findings of CSP were all based on pattern recognition of the CSP site itself. Let us change our perspective and look at intrauterine features cephalad to the site. Even relatively inexperienced practitioners can easily determine the presence of an intrauterine mass, which may lead to higher vigilance of the CSP site, leading to CSP detection.
Hironori Takahashi and Shigeki Matsubara* Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi Japan *Corresponding Author: Shigeki Matsubara E-mail: [email protected] DOI: 10.1111/aogs.12628
References 1. Liang F, He J. Methotrexate-based bilateral uterine arterial chemoembolization for treatment of cesarean scar pregnancy. Acta Obstet Gynecol Scand. 2010;89:1592–4.
2. Timor-Tritsch IE, Monteagudo A, Cali G, PalaciosJaraquemada JM, Maymon R, Arslan AA, et al. Cesarean scar pregnancy is a precursor of morbidly adherent placenta. Ultrasound Obstet Gynecol. 2014;44:346–53. 3. Michener C, Dickinson JE. Caesarean scar ectopic pregnancy: a single centre case series. Aust N Z J Obstet Gynaecol. 2009;49:451–5. 4. Cok T, Kalayci H, Ozdemir H, Haydardedeoglu B, Parlakgumus AH, Tarim E. Transvaginal ultrasound-guided local methotrexate administration as the first-line treatment for caesarean scar pregnancy: follow-up of 18 cases. J Obstet Gynaecol Res. 2014. Dec 10. doi: 10.1111/jog.12627. [Epub ahead of print] 5. Cheng LY, Wang CB, Chu LC, Tseng CW, Kung FT. Outcomes of primary surgical evacuation during the first trimester in different types of implantation in women with cesarean scar pregnancy. Fertil Steril. 2014;102:1085–90.e2. 6. Nagy S, Bush M, Stone J, Lapinski RH, Gard o S. Clinical significance of subchorionic and retroplacental hematomas detected in the first trimester of pregnancy. Obstet Gynecol. 2003;102:94–100.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 670–671
671
AOGS LE TT E R TO THE EDIT O R
Intrauterine hypoechoic mass cephalad to cesarean scar pregnancy
Sir, Early ultrasound diagnosis is important for a cesarean scar pregnancy (CSP): it can rupture (1), and if un-terminated, often ends in abnormally invasive placentation (2). Concern was expressed for its misdiagnosis (1), especially on initial ultrasound diagnosis (3). We propose another ultrasound finding: presence of an intrauterine hypoechoic mass suggestive of hematoma cephalad to the CSP site. All three women had past history of cesarean section (CS). The first woman had a gestational sac (GS) extending to the previous CS scar and intrauterine hypoechoic mass (Figure 1a). After evacuation in the eighth week of gestation, vaginal bleeding continued. Ultrasound revealed a mass at the cervico-isthmic myometrium bulging to the bladder, indicative of a CSP remnant. Considering the active bleeding, transarterial embolization was performed, with hemostasis. The second woman had a GS at the previous CS scar and intrauterine hypoechoic mass in the sixth week of gestation (Figure 1b). Magnetic resonance imaging revealed a GS nearly penetrating the myometrium. Methotrexate injection into the GS led to its absorption. The third woman with a CSP also had an intrauterine hypoechoic mass (Figure 1c), which disappeared at 16 weeks of gestation following vaginal bleeding. She desired pregnancy continuation: placenta increta at the CS scar was clinically diagnosed, which was confirmed histologically after cesarean hysterectomy. We analyzed the ultrasound figures in the recent article by Timor-Tritsch et al. describing 10 women with CSP (2) and found
well-proportioned peanut
(a)
hypoechoic or anechoic intrauterine masses cephalad to the CSP in at least three women (Cases 1, 2, and 3). Case 6 had “a significant collection of blood and blood clots in the uterine cavity.” Thus, of 10 women with CSP, four had ultrasounddetectable intrauterine mass or hematoma. We found similar intrauterine masses in other reports [fig. 1A in Liang and He (1), fig. 1 in Cok et al. (4), and fig. 1B in Cheng et al. (5)]. No mention was made of this ultrasound finding in the text of these articles (1,2,4,5). We cannot definitely determine the nature of this mass at present, but its features suggest intrauterine hematoma. Intrauterine hematoma usually exists around the internal ostium (caudal to GS). In these three cases, importantly, intrauterine mass was present cephalad to the GS, an uncommon finding. CSP is also a rare event. We believe that the coexistence of the two rare phenomena may not be a coincidence. Nagy et al. (6) showed that hematoma (+) women, compared with hematoma ( ) women, had a significantly higher incidence of “cotyledon retention,” which was interpreted as showing that, “abnormally adherent placentation was increased in hematoma group” and “this may reflect the ability of a hematoma to impair normal placentation, or the hematoma could be a result of impaired placentation,” suggesting some association between these two phenomena. As CSP is also considered to be an abnormal invasive placentation, the data of Nagy et al. (6) may suggest some pathophysiological mechanism underlying the present observation.
distorted peanuts
(a)′
(b)′
(b)
(c)′
(c)
Figure 1. The gestational sac and intrauterine mass observed in the first (a), second (b), and third (c) cases, with each resembling a “peanut” (a’, b’, and c’, respectively). Large hypoechoic areas suggestive of intrauterine hematomas (arrow) are located cephalad to the gestational sac (arrowhead). These intrauterine masses occupy at least half of the uterine cavity. The longest diameters are 4.5 cm (a), 4.7 cm (b), and 6.0 cm (c), respectively. The masses (peanut-shape) look to have no communication with the gestational sac.
670
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 670–671
Letter to the Editor
Previously reported ultrasound findings of CSP were all based on pattern recognition of the CSP site itself. Let us change our perspective and look at intrauterine features cephalad to the site. Even relatively inexperienced practitioners can easily determine the presence of an intrauterine mass, which may lead to higher vigilance of the CSP site, leading to CSP detection.
Hironori Takahashi and Shigeki Matsubara* Department of Obstetrics and Gynecology, Jichi Medical University, Shimotsuke, Tochigi Japan *Corresponding Author: Shigeki Matsubara E-mail: [email protected] DOI: 10.1111/aogs.12628
References 1. Liang F, He J. Methotrexate-based bilateral uterine arterial chemoembolization for treatment of cesarean scar pregnancy. Acta Obstet Gynecol Scand. 2010;89:1592–4.
2. Timor-Tritsch IE, Monteagudo A, Cali G, PalaciosJaraquemada JM, Maymon R, Arslan AA, et al. Cesarean scar pregnancy is a precursor of morbidly adherent placenta. Ultrasound Obstet Gynecol. 2014;44:346–53. 3. Michener C, Dickinson JE. Caesarean scar ectopic pregnancy: a single centre case series. Aust N Z J Obstet Gynaecol. 2009;49:451–5. 4. Cok T, Kalayci H, Ozdemir H, Haydardedeoglu B, Parlakgumus AH, Tarim E. Transvaginal ultrasound-guided local methotrexate administration as the first-line treatment for caesarean scar pregnancy: follow-up of 18 cases. J Obstet Gynaecol Res. 2014. Dec 10. doi: 10.1111/jog.12627. [Epub ahead of print] 5. Cheng LY, Wang CB, Chu LC, Tseng CW, Kung FT. Outcomes of primary surgical evacuation during the first trimester in different types of implantation in women with cesarean scar pregnancy. Fertil Steril. 2014;102:1085–90.e2. 6. Nagy S, Bush M, Stone J, Lapinski RH, Gard o S. Clinical significance of subchorionic and retroplacental hematomas detected in the first trimester of pregnancy. Obstet Gynecol. 2003;102:94–100.
ª 2015 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 94 (2015) 670–671
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