Twin cesarean scar ectopic pregnancy treated with systemic and local methotrexate

Unilateral Twin Ectopic Pregnancy: A Case Report from the Eastern Part of Ethiopia, Harar

Introduction

Twin ectopic pregnancy is the implantation of both embryos outside of the endometrial lining occurring in 1 in 20,000 up to 1 in 125,000 pregnancies. Commonly, twin ectopic pregnancies occur inside the fallopian tube either unilateral or bilateral. Unless early diagnosis and interventions are made, it may rupture causing intraperitoneal bleeding with a high risk of maternal death.

Case Report

I am reporting a rare type of ectopic pregnancy: unilateral twin ectopic pregnancy with positive cardiac activity on the left side of the fallopian tube in a 30 years old gravida III para II mother. Left side salpingectomy was done for her and discharged from the hospital after two postoperative days.

Conclusion

Twin ectopic pregnancy with a live embryo is a very rare type of pregnancy that needs a high index of suspicion to diagnose and treat early to prevent complications and maternal death.

Cell-based endometrial regeneration: current status and future perspectives

Endometrial-related disorders including Asherman's syndrome, thin endometrium, pelvic organ prolapse, and cesarean scar pregnancies can be accompanied by different symptoms such as amenorrhea, infertility, abnormal placental implantation and recurrent miscarriage. Different methods have been introduced to overcome these problems such as surgery and hormonal therapy but none of them has shown promising outcomes. On the other hand, the development of novel regenerative therapeutic strategies has opened new avenues for the treatment of endometrial-related deficiencies. In this regard, different types of scaffolds, acellular matrices and also cell therapy with adult or stem cells have been investigated for the treatment of endometrial-related deficiencies. In this paper, we review the current status of cell-based endometrium regeneration using scaffold dependent and scaffold-free methods and future perspectives in this field. Moreover, we discuss the endometrial diseases that can be candidates for cell-based treatments. Also, the cells with the potential for endometrial regeneration are explained.

The clinical outcome of cesarean scar pregnancies implanted "on the scar" versus "in the niche"

BACKGROUND

The term cesarean scar pregnancy refers to placental implantation within the scar of a previous cesarean delivery. The rising numbers of cesarean deliveries in the last decades have led to an increased incidence of cesarean scar pregnancy. Complications of cesarean scar pregnancy include morbidly adherent placenta, uterine rupture, severe hemorrhage, and preterm labor. It is suspected that cesarean scar pregnancies that are implanted within a dehiscent scar ("niche") behave differently compared with those implanted on top of a well-healed scar. To date there are no studies that have compared pregnancy outcomes between cesarean scar pregnancies implanted either "on the scar" or "in the niche."

OBJECTIVES

The purpose of this study was to determine the pregnancy outcome of cesarean scar pregnancy implanted either "on the scar" or "in the niche."

STUDY DESIGN

This was a retrospective 2-center study of 17 patients with cesarean scar pregnancy that was diagnosed from 5-9 weeks gestation (median, 8 weeks). All cesarean scar pregnancies were categorized as either implanted or "on the scar" (group A) or "in the niche" (group B), based on their first-trimester transvaginal ultrasound examination. Clinical outcomes based on gestational age at delivery, mode of delivery, blood loss at delivery, neonate weight and placental histopathologic condition were compared between the groups with the use of the Mann-Whitney U test. Myometrial thickness overlying the placenta was compared among all the patients who required hysterectomy and those who did not with the use of the Mann-Whitney U test. Myometrial thickness was also correlated with gestational age at delivery with the use of Spearman's correlation.

RESULTS

Group A consisted of 6 patients; group B consisted of 11 patients. Gestational age at delivery was lower in group B (median, 34 weeks; range, 20-36 weeks) than in group A (median, 38 weeks; range, 37-39 weeks; P=.001). In group A, 5 patients were delivered via cesarean delivery (with normal placenta), and 1 patient underwent a cesarean-hysterectomy for placenta accreta. In group B, 10 patients had a cesarean-hysterectomy for placenta increta/percreta, and 1 patient underwent gravid-hysterectomy for vaginal bleeding at 20 weeks gestation. Blood loss was increased, but not significantly higher in group B (median, 1200 mL; range, 600-4000 mL) than in group A (median, 700 mL; range, 600-1400 mL; P=.117). Myometrium was statistically significantly thinner in the patients group that require hysterectomy (median, 1 mm; range, 0-2 mm) than in the group that did not (median, 5 mm; range, 4-9 mm; P=.001). Myometrial thickness showed a positive correlation with the gestational age (r=0.820; P<.0005).

CONCLUSION

Patients with cesarean scar pregnancy implanted "on the scar" had a substantially better outcome compared with patients in whom the cesarean scar pregnancy implanted "in the niche." Myometrial thickness <2 mm in the first-trimester ultrasound examination is associated with morbidly adherent placenta at delivery.