Cesarean scar pregnancy: A case report
Amanda Mustika Sari*, Ichnandy Arief Rachman**, Febriansyah Darus**
* Obstetrics and Gynecology Resident, Medical Faculty, University of Indonesia
** Departement of Obstetrics and Gynecology, RSPAD Gatot Soebroto
INTRODUCTION
The incidence of cesarean scar pregnancies (CSP) has been estimated
to range from 1/1800-1/2500, or about 6,15% of all ectopic pregnancies in
women with prior cesarean delivery. More cases of CSP has been found due
to increasing rate of cesarean delivery. Curent management modality
including medical management (with MTX) and surgical management.1 In
this case report, we describe a patient with CSP diagnosed by transvaginal
color doppler ultrasonogtraphy (TVCDUS) and managed surgically by
combined hysteroscopic and laparoscopic procedure.
CASE REPORT
A 29 yo women, diagnosed with G3P1A1 7 wga, singleton-IUFD,
previous cesarean section 1 times, right cystic ovarium neoplasma
Fetomaternal, TVCDUS Examination
A. Empty uterine cavity and cervical canal, location of gestational sac (GS) in
anterior wall at the level of isthmus embedded in the previous scar. The myometrial
thickness at the implantation site was 0,22 cm. B. Transvaginal color doppler
ultrasound shows peri-trophoblastic vascular flow surrounding the sac. C. CRL ~ 7
wga, without fetal heart activity. D. Left ovary within normal limit, right ovary
enlarged, with cystic mass size 42x48 mm
Decided to perform pregnancy evacuation by surgical method, with
hysteroscopic and laparoscopic procedure. The procedure took 180 minutes
dan the bleeding was minimal. The post operative condition was good, and
she was discharged on the 2nd day after surgery.
Hysteroscopic and Laparoscopic image of cesarean scar pregnancy management
A. (Hysteroscopic view) Gestation sac implanted in anterior lower segment wall of
uterus. B. (Laparoscopic view) The right ovarium cyst was punctured. C.
Transillumination test positive at cesarean scar defect (niche). D. Incised and repair
cesarean scar defect (niche)
DISCUSSION
The diagnostic tool is MRI and transvaginal color flow Doppler
ultrasonography (TVCDUS). The accuracy rate of TVCDUS was 82%.2,3
Sonographic criteria of a cesarean scar pregnancy (CSP) should be present,
including an empty uterus, an empty cervical canal; detection of the
placenta and/or a gestational sac with or without a fetal pole, with or
without a fetal cardiac activity embedded in the hysterotomy scar or in the
anterior lower uterine segment, thin (1-3 mm) or absent myometrial layer
between the gestational sac and the bladder.
The aim of management of CSP is to minimize life-threatening
persistent bleeding and dramatic hysterectomy. Treatment should be
individualized and several conditions must be considered, such as:
pregnancy viability, hemodynamic stability, gestational age, and
preservation of fertility.4,5,6
Medical MTX
Curretage after
Management medication
Hysteroscopy
Surgical resection of lession
Combined
hysteroscopic and or
laparoscopic
Surgical treatment offers the opportunity to remove the ectopic
pregnancy and repair the defect stimultaneously. Regardless of whether
surgical or medical treatment is chosen, both treatment goal is to remove
the gestational sac and maintain fertility of the patient. The repair of scar
after removal of the pregnancy is key for the prevention of another CSP.7,8
CONCLUSION
CSP is the rarest kind of all ectopic pregnancies and one of the most
dangerous, because of the risk of rupture and hemorrhage. CSP represents a
diagnostic and therapeutic challenge. The earlier the diagnosis can be made,
the better outcome seemed to be. In this case, hysteroscopy combined with
laparoscopy proved to be the most reliable methods for managing CSP with
short operative time, less blod loss, most importantly it enabled uterine
preservation.
REFRENCES
1. Rotas M, Haberman S, Levgur M. Cesarean Scar Ectopic Pregnancies, Etiology, Diagnosis, and
Managment. Am J Obstet Gynecol. 2006;107(6):1373-81.
2. Lee C-L, Wanng C-J, al e. Laparoscopic Management of an Ectopic Pregnancy in a Previous
Cesarean Section Scar. Eropean Society of Human Reproduction and Embryology. 1999;14(5).
Epub 1236.
3. Zhang Y, Gu Y, Wang J-M, Li Y. Analysis of cases with cesarean scar pregnancy. Journal of
Obstetrics and Gynaecology Research. 2013;39(1):195-202.
4. Ash A, Smith A, Maxwell D. Cesarean Scar Pregnancy. BJOG. 2007;114:253-63.
5. Osborn D, Williams T, Craig B. Cesarean scar pregnancy: SOnographic and Magnetic Resonance
Imaging Finding, Complications and Treatment. Journal of Ultrasound Medicine.
2012;31:1449-56.
6. Sapana S, Rupa V, Rebecca E, Punit V, Ankita G. Management of Cesarean Scar Pregnancy.
IOSR Journal of Dental and Medicinal Sciences. 2014;13(9):12-17.
7. Rizk B, Holliday C, Owens S, Abuzeid M. Cervical and cesarean scar ectopic pregnancies:
diagnosis and management. Middle East Fertility Society Journal. 2013;18:67-73.
8. Chou Y-M, Wu D, Wu K-Y, Lee C-L. Hysteroscopic removal of cesarean scar pregnancy after
methotrexate treatment failure. Gynecology and Minimally Invasive Therapy. 2013 (2):70-72.