Treatment of heterotopic caesarean scar pregnancy complicated with post termination increase in size of residual mass and morbidly adherent placenta

Heterotopic Cesarean Scar Pregnancy: A Case Report

Heterotopic pregnancy is a rare condition with an intrauterine pregnancy coexisting with extrauterine pregnancy. It is considered a rare condition, with an incidence of one in 30,000 spontaneous pregnancies. Because of its rarity, there are no international management guidelines. It is associated with increased maternal morbidity and mortality. Heterotopic pregnancy is a challenging condition to diagnose because it can be missed due to the intrauterine pregnancy. The most common signs and symptoms to support and help us reach a diagnosis would be adnexal mass, abdominal pain, and enlarged uterus. In this case report, we aim to compare the clinical course and the outcome of intrauterine gestation while coexisting with scar pregnancy and the management options. This case report concerns a 34-year-old pregnant woman with a heterotopic pregnancy managed in Bahrain Defence Force Hospital.

Dichorionic diamniotic heterotopic twin gestation with cesarean section scar implantation and placenta increta

Heterotopic cesarean scar pregnancy is an extremely rare form of pregnancy and is defined as an intrauterine pregnancy coexisting with an ectopic pregnancy implanted in the cesarean scar. Cesarean scar ectopic pregnancy can also be a precursor for placenta accreta spectrum, a potentially life-threatening condition in which the placenta is abnormally adherent to the uterine myometrium and possibly adjacent organs. Although cesarean scar ectopic pregnancies are rare, there has been an increase in their incidence due to the rise in cesarean deliveries. We present the case of a 35-year-old patient with a heterotopic pregnancy with ectopic implantation in a cesarean scar and associated placenta increta, as well as the radiologic evaluation of placenta accreta spectrum and subsequent management.

Successful Full-Term Delivery via Selective Ectopic Embryo Reduction Accompanied by Uterine Cerclage in a Heterotopic Cesarean Scar Pregnancy: A Case Report and Literature Review

Heterotopic cesarean scar pregnancy (HCSP) is a combination of cesarean scar pregnancy (CSP) and intrauterine pregnancy (IUP). Cesarean scar pregnancy is accompanied by life-threatening complications, such as uterine rupture and massive bleeding. Herein, we present a case of HCSP treated with selective potassium chloride injection into the CSP under ultrasonography in association with uterine cerclage to control vaginal bleeding; this led to a successful IUP preservation and full-term delivery. Additionally, we will review several previous reports on HCSP management, including our case.

Ultrasound-guided procedures in the management of heterotopic caesarean scar pregnancy - A review of case reports and case series

Background

Heterotopic caesarean scar pregnancy (HCSP) is where one gestational sac implants in the previous caesarean section (CS) scar and another sac implants in the uterine cavity. There is limited evidence on the management of this rare condition. Here, we present a case of HCSP in which US-guided selective reduction of the CS pregnancy (CSP) was performed using potassium chloride (KCl) to salvage the intrauterine pregnancy. We also conducted a review of published case reports to understand the determinants of outcome.

Methods

After a MEDLINE search, 23 case reports were found eligible based on quality assessment and were included in the analysis. A composite-score indicating overall obstetric morbidity was computed, and mixed-effects linear regression was implemented to identify its predictors.

Results

US-guided local treatment was the most common mode of intervention for HCSP. The regression analyses revealed that the poor obstetric outcomes, especially antepartum haemorrhage (APH) and postpartum haemorrhage (PPH), were significantly predicted by advanced gestational age at treatment and a higher number of previous CS, irrespective of the mode of treatment.

Conclusion

These results indicate that a high index of suspicion for an early ultrasound diagnosis and treatment is critical. US-guided techniques are useful in salvaging the intrauterine pregnancy with decreased maternal morbidity. The results are preliminary due to the rarity and a small number of published reports. Every CSP should be recorded in a central international registry to obtain reliable data on the diagnosis and management of women with CSP. Given the rising rates of CS, future systematic studies are warranted.

Heterotopic Cesarean Scar Pregnancy: An Analysis of 20 Cases Following in vitro Fertilization-Embryo Transfer

We report a series of 20 cases of heterotopic cesarean scar pregnancy in this study. The results show that transvaginal sonography offers highly accurate diagnoses of heterotopic cesarean scar pregnancy during the first trimester. Careful exclusion of cesarean scar pregnancy is of great clinical importance for patients with a history of cesarean section after in vitro fertilization-embryo transfer, even when an intrauterine pregnancy has been detected. We recommend single embryo transfer for patients with a history of cesarean section. Expectant management may provide the opportunity for a live cesarean scar pregnancy to develop, albeit at high risks of placenta accreta and hemorrhage, and this needs further verification in the future.

Management of heterotopic cesarean scar pregnancy with preservation of intrauterine pregnancy: A case report

BACKGROUND

Heterotopic cesarean scar pregnancy (HCSP) is very rare and has a high risk of massive uterine bleeding. Preservation of concurrent intrauterine pregnancy (IUP) is one of the great challenges in the management of HCSP. No universal treatment protocol has been established when IUP is desired to be preserved.

CASE SUMMARY

We report a case of HCSP at 8⁺ wk gestation in a 34-year-old woman with stable hemodynamics. A two-step intervention was applied. Selective embryo aspiration was performed first, and surgical removal of ectopic gestational tissue by suction and curettage was performed 2 d later. Both steps were performed under ultrasound guidance. The patient had an uneventful course, and a healthy baby was delivered at 34⁺⁶ wk gestation.

CONCLUSION

Selective embryo aspiration followed by suction and curettage was successful in the preservation of IUP in the management of HCSP. This approach is an alternative option for HCSP in the first trimester when the IUP is desired to be preserved.

Cesarean scar pregnancy combined with arteriovenous malformation successfully treated with transvaginal fertility-sparing surgery: A case report and literature review

INTRODUCTION

A cesarean scar pregnancy (CSP), when combined with an arteriovenous malformation (AVM), is a rare, but potentially life-threatening condition that may be associated with uncontrolled hemorrhage. Hysterectomy is indicated when conservative treatment fails. Preservation of fertility is challenging.

PATIENT CONCERNS

We reported a 33-year-old woman with a CSP combined with an AVM who failed methotrexate administration as conservative treatment.

DIAGNOSES

A CSP combined with an AVM was diagnosed via three-dimensional color Doppler angiogram and magnetic resonance imaging.

INTERVENTIONS

Transvaginal removal of the ectopic gestation and repair of the uterine defect was performed without incident.

OUTCOMES

The fertility of the patient was preserved and hysterectomy was avoided.

CONCLUSION

Transvaginal fertility-sparing surgery may be successfully performed to prevent hysterectomy when conservative treatment fails in patients with a CSP combined with an AVM.

Early intervention for heterotopic caesarean scar pregnancy to preserve intrauterine pregnancy may improve outcomes: a retrospective cohort study

RESEARCH QUESTION

What is the best intervention time and method for patients who are diagnosed with heterotopic caesarean scar pregnancy (HCSP) wishing to preserve intrauterine pregnancy.

DESIGN

Four patients diagnosed with HCSP from January 2014 to May 2019 were enrolled. Because HCSP is rare, data on 27 published cases were extracted to augment the analysis. Clinical characteristics and medical documents related to fetal reduction and subsequent maternal-neonate outcomes were analysed.

RESULTS

The intervention time was significantly earlier in the full-term birth group (6.76 ± 1.05 weeks) compared with pre-term birth group (8.02 ± 1.55 weeks; P = 0.042). The cumulative full-term delivery rate was 91.48% when the intervention was at 6 weeks' gestation and decreased to 42.02% at 8 weeks. The maternal-neonate outcome was similar among the selective fetal reduction and surgical removal groups as was delivery time (34.68 ± 3.12 versus 34.80 ± 6.64 weeks; P = 0.955). In the four cases undergoing selective fetal reduction, the residual mass grew by 1.16-7.07 times compared with the area before reduction. The maximum size of the residual mass was observed at 12-13 weeks and 22-25 weeks.

CONCLUSIONS

Most patients with HCSP who choose to keep intrauterine pregnancy will be able to carry the fetus to term. Selective fetal reduction would be the first intervention of choice and should take place immediately after diagnosis. The residual mass after reduction could continue to grow throughout the whole pregnancy, although this should not be considered as an indication for termination. With good supervision and careful management, the pregnancy could be maintained and carried to term.

Surgical management of first-trimester bleeding in a heterotopic caesarean scar pregnancy: A case report and review of literature

Heterotopic caesarean scar pregnancy (HCSP) is very rare, with only 24 cases reported in the literature. Optimal management is yet to be determined. We describe a 38-year-old woman, G2P1, who presented with vaginal bleeding and haemodynamic instability at 9 weeks of gestation in a HCSP. She was managed with ultrasound-guided lower-segment curettage and bilateral uterine artery ligation. The patient's pregnancy was complicated by preterm rupture of membranes and shortened cervix at 27 weeks of gestation. This necessitated preterm delivery, with subsequent neonatal death attributed to extreme prematurity. The patient later had a spontaneously conceived pregnancy, which was complicated by placenta percreta requiring elective caesarean hysterectomy at 34 weeks of gestation. This is, to our knowledge, the first case report describing preservation of the intrauterine pregnancy and future fertility in a patient with a HCSP and significant first-trimester bleeding. We suggest that ultrasound-guided lower-segment curettage may be a suitable management option for carefully selected patients with HCSP in a tertiary centre. All patients with HCSP require judicious counselling regarding the risk of morbidly adherent placenta and need for tertiary-level obstetric management in future pregnancies.

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First trimester bleeding in heterotopic caesarean scar pregnancy

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Surgical management of heterotopic caesarean scar pregnancy

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Ultrasound guided curettage with preservation of concurrent intrauterine pregnancy

Selective Reduction of a Heterotopic Cesarean Scar Pregnancy Complicated by Septic Abortion

Background

Heterotopic pregnancy involving the implantation of an ectopic pregnancy into a prior cesarean scar with a concurrent intrauterine pregnancy is a rare and potentially life-threatening condition with minimal information in the literature to guide treatment and management options.

Case

A 40-year-old G5P3103 at 12 weeks and 3 days with a history of two cesarean deliveries was diagnosed with a live heterotopic pregnancy containing a cesarean scar ectopic and an intrauterine pregnancy. After selective reduction of the cesarean scar gestation with potassium chloride (KCl), the patient presented ten days later to the emergency department with septic abortion and sepsis. The patient underwent bilateral uterine artery embolization followed by ultrasound guided uterine evacuation with dilation and curettage, which was complicated by intraoperative hemorrhage and persistent bacteremia. The patient had resolution of her bacteremia after total abdominal hysterectomy.

Conclusion

Conservative management of uterine infection resulting from selective reduction of a heterotopic pregnancy cesarean scar pregnancy may be considered; however, severe septicemia and persistent bacteremia may necessitate definitive surgical management.