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Karbasi M, Aletaha R, Ahangar‐Sirous R, Alamdari AH, Gharepapagh E, Rezaei S. A rare case report of heterotopic cesarean scar pregnancy in the 8th week of gestation that was managed successfully by exploratory laparotomy with dilation and curettage. Clin Case Rep 2024; 12:e9025. [PMID: 38831983 PMCID: PMC11144611 DOI: 10.1002/ccr3.9025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 06/05/2024] Open
Abstract
Key Clinical Message Swift and precise identification of heterotopic cesarean scar pregnancy, coupled with standardized treatment approaches for handling possible serious complications, form an essential component in reaching favorable outcomes for patients experiencing this rare type of pregnancy. Abstract Heterotopic pregnancy (HP) denotes a form of multiple gestation where intrauterine and ectopic pregnancies coexist. Cesarean scar ectopic pregnancy, on the other hand, involves the implantation of a fetus over the previous cesarean scar. This condition poses a significant risk of uterine rupture, which may lead to serious health complications, and even death. We report a case of a fit 37-year-old woman with two previous cesarean deliveries who was diagnosed with a heterotopic cesarean scar pregnancy at 8 weeks gestation following symptoms of lower abdominal pain and delayed menstruation. Both pregnancies demonstrated cardiac activity and the portion of the myometrium located between the bladder wall and the gestational sac was noted to exhibit considerable thinness. The patient underwent an exploratory laparotomy coupled with dilation and curettage and recovered uneventfully. The proper management of a HCSP requires timely diagnosis through ultrasonography. Early diagnosis allows for immediate intervention to prevent complications such as uterine rupture or potentially lethal bleeding.
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Affiliation(s)
- Mahsa Karbasi
- Department of Radiology, Medical SchoolTabriz University of Medical SciencesTabrizIran
| | - Reza Aletaha
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | | | | | - Esmaeil Gharepapagh
- Department of Nuclear Medicine, Medical SchoolTabriz University of Medical SciencesTabrizIran
| | - Sahar Rezaei
- Department of Nuclear Medicine, Medical SchoolTabriz University of Medical SciencesTabrizIran
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Timor-Tritsch IE, Kaelin Agten A, Monteagudo A, Calỉ G, D'Antonio F. The use of pressure balloons in the treatment of first trimester cesarean scar pregnancy. Best Pract Res Clin Obstet Gynaecol 2023; 91:102409. [PMID: 37716338 DOI: 10.1016/j.bpobgyn.2023.102409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 08/02/2023] [Accepted: 08/17/2023] [Indexed: 09/18/2023]
Abstract
Cesarean scar pregnancy (CSP) is among the most severe complications of cesarean delivery. CSP refers to the abnormal implantation of the gestational sac in the area of the prior cesarean delivery (CD), potentially leading to severe hemorrhage, uterine rupture, or development of placenta accreta spectrum disorders (PAS). The management of women with CSP has not been standardized yet. In women who opted for termination, discussion about the treatments should consider maternal symptoms, gestational age at intervention, and the future reproductive risk. A multitude of treatments, either medical or surgical, for CSP has been reported in the published literature. The present review aims to provide up-to-date information on a recently introduced minimally invasive treatments for CSP, including the single and double balloon catheter. The methodology of using the single or double catheter is described in a step-by-step fashion illustrated by pictures as well as video recordings. Both catheters have their deserved place to be used as a primary method for terminating scar pregnancies as well as using them as adjuncts to other treatments. They were successfully used by multiple individual practitioners and institutions due to their simplicity and low complication rates. The rare, but possible post-procedure complications such as recurrent CSP and enhanced myometrial vascularity are also mentioned.
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Affiliation(s)
| | - Andrea Kaelin Agten
- Liverpool Women's Hospital NHS Foundation Trust, Liverpool, L8 7SS, United Kingdom
| | - Ana Monteagudo
- Icahn School of Medicine. Carnegie Maternal Fetal Associates New York, USA
| | - Giuseppe Calỉ
- Maternal Fetal Medicine Unit AO Villa Sofia-Cervello, Italy
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3
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Nijjar S, Jauniaux E, Jurkovic D. Definition and diagnosis of cesarean scar ectopic pregnancies. Best Pract Res Clin Obstet Gynaecol 2023; 89:102360. [PMID: 37356119 DOI: 10.1016/j.bpobgyn.2023.102360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/10/2023] [Accepted: 05/14/2023] [Indexed: 06/27/2023]
Abstract
Cesarean scar ectopic pregnancy is a rare type of ectopic pregnancy, where the pregnancy implants into a myometrial defect caused by a cesarean scar. Its incidence is predicted to increase, given the global increase in cesarean deliveries. As most cesarean scar ectopic pregnancies present as failing pregnancies or patients choose termination of pregnancy, there are limited data on their natural history. However, early first trimester diagnosis is essential, given the associated significant maternal morbidity. Transvaginal sonography is generally considered to be the optimal method for diagnosing cesarean scar ectopic pregnancy. There is no evidence that MRI adds to the diagnostic accuracy, and it is therefore not recommended for routine evaluation of cesarean scar ectopic pregnancy. There is no agreed reference standard for the diagnosis of cesarean scar ectopic pregnancy; therefore, the validity of several proposed sonographic diagnostic criteria reported by different authors remains unknown. There are also various suggested classification systems for cesarean scar ectopic pregnancy, which divide them in differet types. However, the proposals are very heterogeneous, and superiority of one classification system over another is yet to be established.
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Affiliation(s)
- Simrit Nijjar
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Davor Jurkovic
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
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4
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Chong Y, Wang W, Zhang A, Zhao Y. Ultrasound for monitoring twin cesarean scar pregnancy following feticide. J Int Med Res 2022; 50:3000605221095683. [PMID: 35485849 PMCID: PMC9067053 DOI: 10.1177/03000605221095683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective Implantation of the conceptus in a twin cesarean scar pregnancy (CSP) is considered the rarest type of ectopic pregnancy. Preserving the fetus in utero and effectively dealing with CSP can be challenging. This study aimed to determine the clinical value of ultrasonography by monitoring imaging changes in twin CSP following selective feticide. Methods Ultrasonographic and clinical data were collected from four patients with twin CSP who were treated between December 2017 and December 2018 at our hospital. Results All patients had a history of cesarean section, followed by a heterotopic CSP, with one embryo implanted into the uterine cavity and the other located in the anterior isthmus. All of the patients were pregnant with twins with double chorionic and amniotic sacs, and all gave birth in our hospital. The patients underwent feticide at 8 to 9 weeks of gestation, after which we focused on monitoring the implantation. Delivery was performed by cesarean section according to scores of an ultrasonic scoring system and clinical manifestations. The patients’ uterus was preserved and they recovered. Conclusions This study shows that ultrasound is useful for determining the timing of clinical termination of CSP by selective feticide.
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Affiliation(s)
- Yiwen Chong
- Obstetrics and Gynecology Department of The Third Hospital of Peking University, Beijing, China
| | - Wei Wang
- Obstetrics and Gynecology Department of The Third Hospital of Peking University, Beijing, China
| | - Aiqing Zhang
- Obstetrics and Gynecology Department of The Third Hospital of Peking University, Beijing, China
| | - Yangyu Zhao
- Obstetrics and Gynecology Department of The Third Hospital of Peking University, Beijing, China
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Kim H, Koh JH, Lee J, Sim Y, Lee SH, Lee SJ, Ahn JW, Roh HJ, Kim JS. 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. Diagnostics (Basel) 2022; 12:diagnostics12030762. [PMID: 35328315 PMCID: PMC8947258 DOI: 10.3390/diagnostics12030762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/17/2022] [Accepted: 03/18/2022] [Indexed: 02/05/2023] Open
Abstract
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.
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Authreya AJ, Agrawal P, Makam A. Ultrasound-guided procedures in the management of heterotopic caesarean scar pregnancy - A review of case reports and case series. Australas J Ultrasound Med 2021; 24:70-77. [PMID: 34765413 DOI: 10.1002/ajum.12242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 01/25/2021] [Accepted: 02/15/2021] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Ashwini J Authreya
- ADI's Advanced Centre for Fetal Care Sparsh Hospital Yeshwanthpur, Bangalore 560022 India
| | - Purvi Agrawal
- ADI's Advanced Centre for Fetal Care Sparsh Hospital Yeshwanthpur, Bangalore 560022 India
| | - Adinarayana Makam
- ADI's Advanced Centre for Fetal Care Sparsh Hospital Yeshwanthpur, Bangalore 560022 India
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Ouyang Y, Chen H, Lin G, Xiang S, Qin J, Gong F, Li X. Heterotopic Cesarean Scar Pregnancy: An Analysis of 20 Cases Following in vitro Fertilization-Embryo Transfer. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2239-2249. [PMID: 33470465 DOI: 10.1002/jum.15610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 11/27/2020] [Accepted: 12/12/2020] [Indexed: 06/12/2023]
Abstract
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.
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Affiliation(s)
- Yan Ouyang
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- College of Life Science, Hunan Normal University, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Hui Chen
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Ge Lin
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Shuanglin Xiang
- College of Life Science, Hunan Normal University, Changsha, China
| | - Jiabi Qin
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Fei Gong
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Xihong Li
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
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Chen ZY, Zhou Y, Qian Y, Luo JM, Huang XF, Zhang XM. Management of heterotopic cesarean scar pregnancy with preservation of intrauterine pregnancy: A case report. World J Clin Cases 2021; 9:6428-6434. [PMID: 34435008 PMCID: PMC8362565 DOI: 10.12998/wjcc.v9.i22.6428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/24/2021] [Accepted: 06/01/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Zheng-Yun Chen
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Yong Zhou
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Yue Qian
- Department of Sonography, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Jia-Min Luo
- Department of Sonography, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Xiu-Feng Huang
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
| | - Xin-Mei Zhang
- Department of Gynecology, Women’s Hospital School of Medicine, Zhejiang University, Hangzhou 310006, Zhejiang Province, China
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Abdelmonem AH, Sayed G, Abugazia AE, Kohla S, Youssef R. Heterotopic pregnancy after a spontaneous conception a case report with a review of clinical, laboratory and imaging findings. Clin Case Rep 2021; 9:e04649. [PMID: 34430013 PMCID: PMC8365543 DOI: 10.1002/ccr3.4649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/24/2021] [Accepted: 07/12/2021] [Indexed: 11/10/2022] Open
Abstract
Heterotopic pregnancy (HP) describes the simultaneous presence of two pregnancies at different implantation sites. Usually, one pregnancy is intrauterine and the other one is ectopic. The incidence of HP after assisted reproductive technologies reaches 1:3900, but is very rare after a spontaneous pregnancy, with a reported incidence of 1 to 30,000 pregnancies. Due to its rarity, complex clinical picture, and laboratory findings, it is challenging to diagnose HP. We present a case of spontaneous HP diagnosed in the first trimester by ultrasound (US) and magnetic resonance imaging (MRI) and subsequently managed successfully. We present an analysis of the clinical and laboratory findings as well as imaging, including MRI that we used to diagnose the condition. Additionally, we performed a literature review. CONCLUSIONS HP is a very rare condition frequently faced in obstetrics, gynecology, and emergency departments that requires a high index of clinical suspicion. US remains the imaging modality of choice in diagnosing a HP, however, in some cases, an MRI with a reported safety in the first trimester, can be used to provide additional information over US.
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Affiliation(s)
- Ahmed H. Abdelmonem
- Department of RadiologyHamad General HospitalDohaQatar
- Weill Cornell Medicine QatarDohaQatar
| | - Gamal Sayed
- Weill Cornell Medicine QatarDohaQatar
- Department of Obstetrics & GynecologyWomen’s Wellness and Research CenterDohaQatar
- Clinical DepartmentCollege of MedicineQU HealthQatar UniversityDohaQatar
- University of DundeeDundeeUK
| | | | - Samah Kohla
- Weill Cornell Medicine QatarDohaQatar
- Department of Laboratory Medicine and PathologyHematology DivisionHamad Medical CorporationDohaQatar
| | - Reda Youssef
- Weill Cornell Medicine QatarDohaQatar
- Department of RadiologyWomen’s Wellness and Research CenterDohaQatar
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Wang Y, Niu Z, Tao L, Yang Y, Ma C, Li R. Early intervention for heterotopic caesarean scar pregnancy to preserve intrauterine pregnancy may improve outcomes: a retrospective cohort study. Reprod Biomed Online 2020; 41:290-299. [PMID: 32553465 DOI: 10.1016/j.rbmo.2020.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 03/19/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Yang Wang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Ziru Niu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Liyuan Tao
- Research Center of Clinical Epidemiology, Peking University Third hospital, Beijing 100191, China
| | - Yan Yang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Caihong Ma
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China
| | - Rong Li
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing 100191, China; National Clinical Research Center for Obstetrics and Gynecology, Beijing 100191, China; Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing 100191, China; Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing 100191, China.
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Sepúlveda González G, Villagómez Martínez GE, Basurto Diaz D, Guerra de la Garza Evia ÁR, Rosales de León JC, Arroyo Lemarroy T, Soria López JA. Successful Management of Heterotopic Cervical Pregnancy with Ultrasonographic-guided Laser Ablation. J Minim Invasive Gynecol 2020; 27:977-980. [DOI: 10.1016/j.jmig.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/30/2019] [Accepted: 11/01/2019] [Indexed: 10/25/2022]
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12
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Surgical management of first-trimester bleeding in a heterotopic caesarean scar pregnancy: A case report and review of literature. Case Rep Womens Health 2020; 27:e00209. [PMID: 32420043 PMCID: PMC7217994 DOI: 10.1016/j.crwh.2020.e00209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 02/07/2023] Open
Abstract
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. First trimester bleeding in heterotopic caesarean scar pregnancy Surgical management of heterotopic caesarean scar pregnancy Ultrasound guided curettage with preservation of concurrent intrauterine pregnancy
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13
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Timor-Tritsch IE, Monteagudo A, Calì G, D'Antonio F, Kaelin Agten A. Cesarean Scar Pregnancy: Diagnosis and Pathogenesis. Obstet Gynecol Clin North Am 2020; 46:797-811. [PMID: 31677755 DOI: 10.1016/j.ogc.2019.07.009] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Cesarean scar pregnancy is a potentially dangerous consequence of a previous cesarean delivery. If unrecognized and inadequately managed, it can lead to untoward complications throughout all three trimesters of the pregnancy. The rate of occurrence parallels the mounting rate of cesarean sections. The late consequences of cesarean delivery, such as placenta previa and placenta accrete, were known for a long time. However, it took more than a decade for the obstetric community to make the connection between the cesarean scar pregnancy and the placenta accreta spectrum. This article discusses the pathogenesis and diagnosis of cesarean scar pregnancy.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, NYU School of Medicine, NYU Langone Health, 550 1st Avenue, New York, NY 10016, USA.
| | - Ana Monteagudo
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giuseppe Calì
- Department of Obstetrics and Gynecology, Arnas Civico Hospital, Palermo, Italy
| | - Francesco D'Antonio
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Foggia, Foggia, Italy
| | - Andrea Kaelin Agten
- Nottingham University Hospitals NHS, Queens Medical Centre, Derby Road, Nottingham, NG7 2UH, UK
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14
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Kwon B, Kang S, Lee HJ, Kim M, Lee YH, Im J, Moon MJ, Ahn EH, Kim YR. Non-surgical management and obstetric outcomes of heterotopic interstitial pregnancies. MINIM INVASIV THER 2019; 29:375-379. [PMID: 31432733 DOI: 10.1080/13645706.2019.1653924] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To assess the effectiveness and safety of non-surgical management for six heterotopic interstitial pregnancies.Material and methods: We retrospectively analyzed the data of six women diagnosed with heterotopic interstitial pregnancies who underwent non-surgical treatment at the CHA Bundang Medical Center between January 2007 and December 2017. Three heterotopic interstitial pregnancies were treated with sono-guided potassium chloride (KCl) injections. Two cases were managed expectantly. One heterotopic quadruplet pregnancy with twin, left interstitial, and tubal pregnancy was treated by sono-guided KCl injection and laparoscopic left salpingectomy. Complications and outcomes were measured.Results: Three cases were treated with sono-guided KCl injection and the intrauterine pregnancy continued to term. Intrauterine pregnancies were vaginally delivered without complications. One case that was treated expectantly was delivered at full term, while the other case resulted in spontaneous abortion. Quadruplet heterotopic pregnancy was successfully managed with sono-guided KCl injection and laparoscopic salpingectomy. Intrauterine twin pregnancy was successfully delivered by elective cesarean section at 37 + 0 weeks of gestation with healthy babies. Conclusions: KCl injection under ultrasonographic guidance could be a safer and more effective treatment option than surgical treatment in hemodynamically stable patients with fetal cardiac activity in interstitial pregnancy. Expectant management could be an option for patients with no fetal cardiac activity.
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Affiliation(s)
- Boram Kwon
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Sukho Kang
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Hyun Jung Lee
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Migang Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Yoon Hee Lee
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Jisun Im
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Myoung Jin Moon
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Eun Hee Ahn
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Young Ran Kim
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
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15
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Selective Reduction of a Heterotopic Cesarean Scar Pregnancy Complicated by Septic Abortion. Case Rep Obstet Gynecol 2018; 2018:6478589. [PMID: 30420929 PMCID: PMC6215580 DOI: 10.1155/2018/6478589] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 09/10/2018] [Accepted: 09/20/2018] [Indexed: 01/19/2023] Open
Abstract
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.
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16
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Vikhareva O, Nedopekina E, Herbst A. Normal vaginal delivery at term after expectant management of heterotopic caesarean scar pregnancy: a case report. J Med Case Rep 2018; 12:179. [PMID: 29925424 PMCID: PMC6011475 DOI: 10.1186/s13256-018-1713-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023] Open
Abstract
Background Heterotopic pregnancy with a combination of a caesarean scar pregnancy and an intrauterine pregnancy is rare and has potentially life-threatening complications. Case presentation We describe the case of a 27-year-old white woman who had experienced an emergency caesarean delivery at 39 weeks for fetal distress with no postpartum complications. This is a report of the successful expectant management of a heterotopic scar pregnancy. The gestational sac implanted into the scar area was non-viable. The woman was treated expectantly and had a normal vaginal delivery at 37 weeks of gestation. Conclusion Expectant management under close monitoring can be appropriate in small non-viable heterotopic caesarean scar pregnancies.
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Affiliation(s)
- Olga Vikhareva
- Department of Obstetrics and Gynaecology, Skåne University Hospital Malmö, Lund University, Box 117, 221 00, Lund, Sweden. .,Department of Obstetrics and Gynaecology, Skåne University Hospital, Lund University, Jan Waldenströms gata 47, SE-20502, Malmö, Sweden.
| | - Ekaterina Nedopekina
- Department of Obstetrics and Gynaecology, Skåne University Hospital Malmö, Lund University, Box 117, 221 00, Lund, Sweden.,Department of Obstetrics and Gynaecology, Skåne University Hospital, Lund University, Jan Waldenströms gata 47, SE-20502, Malmö, Sweden
| | - Andreas Herbst
- Department of Obstetrics and Gynaecology, Skåne University Hospital Malmö, Lund University, Box 117, 221 00, Lund, Sweden.,Department of Obstetrics and Gynaecology, Skåne University Hospital, Lund University, Jan Waldenströms gata 47, SE-20502, Malmö, Sweden
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17
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Docheva N, Slutsky ED, Borella N, Mason R, Van Hook JW, Seo-Patel S. The Rising Triad of Cesarean Scar Pregnancy, Placenta Percreta, and Uterine Rupture: A Case Report and Comprehensive Review of the Literature. Case Rep Obstet Gynecol 2018; 2018:8797643. [PMID: 29984018 PMCID: PMC6011134 DOI: 10.1155/2018/8797643] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 04/26/2018] [Indexed: 11/23/2022] Open
Abstract
As the rate of cesarean sections continues to rapidly rise, knowledge of diagnosis and management of cesarean scar pregnancies (CSPs) is becoming increasingly more relevant. CSPs rest on the continuum of placental abnormalities which include morbidly adherent placenta (accreta, increta, and percreta). A CSP poses a clinical challenge which may have significant fetal and maternal morbidity. At this point, no clear management guidelines and recommendations exist. Herein we describe the case of a second trimester CSP with rapid diagnosis and management in a tertiary care center. The case underscores the need for well-coordinated mobilization of resources and a multidisciplinary approach. A review of the literature is performed and deficits in universal management principles are underscored.
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Affiliation(s)
- Nikolina Docheva
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Emily D. Slutsky
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Nicolette Borella
- Mercyhurst University, Department of Biology, Eerie, Pennsylvania, USA
| | - Renee Mason
- Promedica Physicians Obstetrics-Gynecology, Maumee, Ohio, USA
| | - James W. Van Hook
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
| | - Sonyoung Seo-Patel
- Department of Obstetrics and Gynecology, University of Toledo, Toledo, Ohio, USA
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18
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Yu H, Luo H, Zhao F, Liu X, Wang X. Successful selective reduction of a heterotopic cesarean scar pregnancy in the second trimester: a case report and review of the literature. BMC Pregnancy Childbirth 2016; 16:380. [PMID: 27894281 PMCID: PMC5126867 DOI: 10.1186/s12884-016-1171-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 11/17/2016] [Indexed: 02/07/2023] Open
Abstract
Background Heterotopic cesarean scar pregnancy is a cesarean scar pregnancy combined with an intrauterine pregnancy that predisposes a woman to life-threatening complications such as uterine rupture and massive bleeding. Preservation of the intrauterine pregnancy in heterotopic cesarean scar pregnancy is a great challenge. Case presentation We report a case of a 33-year-old woman with heterotopic cesarean scar pregnancy after IVF-embryo transfer (ET). Expectant management was carried out with early diagnosis of heterotopic cesarean scar pregnancy (HCSP), and selective fetal reduction of cesarean scar pregnancy (CSP) was performed by ultrasound-guided intrathoracic injection of potassium chloride (KCl) at 16 + 4 weeks of gestation due to aggravation of CSP. Preservation of the intrauterine pregnancy was successful and a healthy baby was delivered by cesarean section at 37 + 6 weeks of gestation. Conclusions Heterotopic cesarean scar pregnancy is an extremely rare form of heterotopic pregnancy. Patients should be appropriately counseled regarding the different treatment options available. An ultrasound-guided injection of potassium chloride may constitute a safe, minimally invasive and reliable way to terminate the heterotopic gestation and preserve the intrauterine pregnancy. Intensive management should be performed during the ongoing pregnancy and cesarean section. Electronic supplementary material The online version of this article (doi:10.1186/s12884-016-1171-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Haiyan Yu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Hong Luo
- Department of Ultrasonic Medicine, West China Second University Hospital, Sichuan University, Chengdu, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China.
| | - Fumin Zhao
- Department of Radiology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Xinghui Liu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China.,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China
| | - Xiaodong Wang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China. .,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, No.20, 3rd section, South Renmin Road, Chengdu, Sichuan, 610041, China.
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19
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Abstract
Heterotopic pregnancy refers to the presence of simultaneous pregnancies in two different implantation sites, generally one intra-uterine pregnancy and one extra-uterine pregnancy (usually tubal). This is a rare case of a heterotopic pregnancy involving concurrent intra-uterine pregnancy and caesarean section scar pregnancy (CSEP). CSEPs are at a high risk of bleeding and uterine rupture, carrying with them significant maternal morbidity.
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Affiliation(s)
- Debra Paoletti
- Fetal Medicine Unit The Canberra Hospital Garran ACT Australia
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20
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Rathod S, Samal SK. A rare case of heterotopic pregnancy with ruptured left rudimentary horn pregnancy. J Clin Diagn Res 2015; 9:QD03-4. [PMID: 25954670 DOI: 10.7860/jcdr/2015/10677.5639] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 09/22/2014] [Indexed: 11/24/2022]
Abstract
Heterotopic pregnancy(HP) occurs when intrauterine and ectopic pregnancies coexist. We report a case of HP at 14 wk of gestation presenting as ruptured left rudimentary horn ectopic pregnancy with live intrauterine gestation and was managed with emergency laparotomy followed by resection of left rudimentary non communicating horn of uterus. The intrauterine pregnancy continued uneventfully. A female baby was delivered vaginally at 41 wk following induction of labour.
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Affiliation(s)
- Setu Rathod
- Assistant Professor, Department of Obstetrics & Gynaecology, Mahatma Gandhi Medical College & Research Institute , Puducherry, India
| | - Sunil Kumar Samal
- Assistant Professor, Department of Obstetrics& Gynaecology, Mahatma Gandhi Medical College & Research Institute , Puducherry, India
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21
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Armbrust R, Krätschell R, Henrich W, David M. Operative Therapy for Heterotopic Scar Pregnancy and Successful Birth of the Intrauterine Foetus - Case Report and Review of the Literature. Geburtshilfe Frauenheilkd 2015; 75:384-388. [PMID: 26028696 PMCID: PMC4437755 DOI: 10.1055/s-0035-1545918] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/06/2015] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
A heterotopic pregnancy in the vicinity of a previous Caesarean section scar (HSP) occurs frequently after fertility treatment. In spite of the low incidence to date, the increasing numbers of Caesarean sections as well as IVF treatment will probably lead to a higher prevalence in the future. Up to now the literature contains only isolated case reports on therapeutic options. These range from conservative management through selective termination of the HSP by injections of methotrexate or potassium chloride into the amniotic sac to invasive methods such as resectoscopic removal or laparoscopy. In the case presented here we describe the successful excision of the HSP by laparotomy with a subsequent uncomplicated Caesarean section and delivery of a healthy baby at the 37 + 0 week of pregnancy.
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Affiliation(s)
- R. Armbrust
- Dept. of Gynecology, Charité Berlin – Campus Virchow Klinikum, Berlin
| | - R. Krätschell
- Obstetrics, Charité Berlin – Campus Virchow Klinikum, Berlin
| | - W. Henrich
- Dept. of Gynecology, Charité Berlin – Campus Virchow Klinikum, Berlin
| | - M. David
- Obstetrics, Charité Berlin – Campus Virchow Klinikum, Berlin
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22
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OuYang Z, Yin Q, Xu Y, Ma Y, Zhang Q, Yu Y. Heterotopic cesarean scar pregnancy: diagnosis, treatment, and prognosis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1533-1537. [PMID: 25154932 DOI: 10.7863/ultra.33.9.1533] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Heterotopic cesarean scar pregnancy is a rare, life-threatening form of ectopic pregnancy. To provide information regarding the clinical manifestations, diagnosis, management, and prognosis of this condition, we reviewed all cases reported in the English literature. All literature on heterotopic cesarean scar pregnancy was retrieved by searching the PubMed database and tracking references of the relevant literature. Full texts were reviewed, and clinical manifestations, diagnostic methods, and the relationship between the treatment and prognosis were summarized. A total of 14 patients with heterotopic cesarean scar pregnancies were identified, including 6 spontaneous pregnancies and 8 following in vitro fertilization-embryo transfer. Gestational ages at diagnosis ranged from 5 weeks to 8 weeks 4 days. Only 5 cases presented with vaginal bleeding, and the others were asymptomatic. All 14 cases were diagnosed by transvaginal sonography. One patient with no future fertility requirements underwent pregnancy termination by methotrexate. Of the remaining 13 patients who desired to preserve their intrauterine gestations, 10 were treated by sonographically guided selective embryo reduction in situ (by embryo aspiration, drug injection, or both); 2 underwent laparoscopic and hysteroscopic excision of the ectopic pregnancy masses; and 1 was treated by expectant management. All operations were successful and maintained a living intrauterine gestation. Twelve cases resulted in live births by cesarean delivery (3 at term and 9 preterm). One patient underwent pregnancy termination at 12 weeks because of a fetal malformation confirmed by sonography. The possibility of heterotopic cesarean scar pregnancy after cesarean delivery should be considered, especially when pregnancy follows assisted reproductive technology. Transvaginal sonography is an important tool for diagnosis and management. Despite the many options, the best treatment for this condition remains unclear. Selective embryo reduction in situ with sonographic guidance is the main treatment modality and can result in a successful intrauterine gestation, albeit at high risk.
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Affiliation(s)
- Zhenbo OuYang
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.).
| | - Qian Yin
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.)
| | - Yujing Xu
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.)
| | - Yunyan Ma
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.)
| | - Qiushi Zhang
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.)
| | - Yanhong Yu
- Department of Gynecology, Guangdong No. 2 Provincial People's Hospital, Guangzhou, China (Z.O., Y.M., Q.Z.); Department of Obstetrics and Gynecology, Nanfang Hospital of Southern Medical University, Guangzhou, China (Q.Y., Y.Y.); and Department of Obstetrics and Gynecology, Weifang People's Hospital, Weifang, China (Y.X.)
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23
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Kim ML, Jun HS, Kim JY, Seong SJ, Cha DH. Successful full-term twin deliveries in heterotopic cesarean scar pregnancy in a spontaneous cycle with expectant management. J Obstet Gynaecol Res 2014; 40:1415-9. [DOI: 10.1111/jog.12326] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2013] [Accepted: 10/15/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Mi-La Kim
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Hye Sun Jun
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Joo Young Kim
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Seok Ju Seong
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
| | - Dong Hyun Cha
- Department of Obstetrics and Gynecology; CHA Gangnam Medical Center; CHA University; Seoul Korea
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24
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Mitwally MF, Alami R, Albuarki H, Diamond MP, Abuzeid M, Fakih MH. Gestational Sac Aspiration of Heterotopic Ectopic Pregnancy in a Cesarean Section Scar. J Gynecol Surg 2013. [DOI: 10.1089/gyn.2012.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Reda Alami
- Department of Obstetrics and Gynecology, Hurley Medical Center, Flint, MI
| | | | - Michael P. Diamond
- Division of Reproductive Endocrinology & Infertility, Wayne State University School of Medicine, Detroit, MI
- Detroit Regional Institute for Clinical and Translational Research, Detroit, MI
| | - Mostafa Abuzeid
- IVF Michigan, PC, Rochester Hills, MI
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Hurley Medical Center, Flint, MI
- Department of Obstetrics and Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, East Lansing, MI
| | - Michael H. Fakih
- IVF Michigan, PC, Rochester Hills, MI
- Department of Obstetrics and Gynecology and Reproductive Biology, College of Human Medicine, Michigan State University, East Lansing, MI
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25
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Management of cesarean heterotopic pregnancy with transvaginal ultrasound-guided potassium chloride injection and gestational sac aspiration, and review of the literature. J Minim Invasive Gynecol 2013; 19:671-3. [PMID: 22935313 DOI: 10.1016/j.jmig.2012.05.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Revised: 05/03/2012] [Accepted: 05/22/2012] [Indexed: 02/06/2023]
Abstract
Cesarean scar pregnancy is one of the rarest forms of ectopic pregnancy, located in the scar from a previous cesarean section. There are few reports of such pregnancies, and there is no consensus about the best management. Herein is reported a case of cesarean heterotopic pregnancy, diagnosed at 6 weeks' gestation and successfully treated via transvaginal ultrasound-guided potassium chloride injection and gestational sac aspiration, with preservation of the intrauterine pregnancy.
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26
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Abstract
Faced with difficulty discriminating between placenta and myometrium in a patient with three previous caesarean sections, MRI provided definitive diagnosis of caesarean scar pregnancy, allowing for a save and uneventful planned surgical procedure.
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27
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Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol 2012; 207:14-29. [PMID: 22516620 DOI: 10.1016/j.ajog.2012.03.007] [Citation(s) in RCA: 363] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 01/28/2012] [Accepted: 03/09/2012] [Indexed: 11/29/2022]
Abstract
This review concentrates on 2 consequences of cesarean deliveries that may occur in a subsequent pregnancy. They are the pathologically adherent placenta and the cesarean scar pregnancy. We explored their clinical and diagnostic as well as therapeutic similarities. We reviewed the literature concerning the occurrence of early placenta accreta and cesarean section scar pregnancy. The review resulted in several conclusions: (1) the diagnosis of placenta accreta and cesarean scar pregnancy is difficult; (2) transvaginal ultrasound seems to be the best diagnostic tool to establish the diagnosis; (3) an early and correct diagnosis may prevent some of their complications; (4) curettage and systemic methotrexate therapy and embolization as single treatments should be avoided if possible; and (5) in the case of cesarean scar pregnancy, local methotrexate- and hysteroscopic-directed procedures had the lowest complication rates.
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Affiliation(s)
- Ilan E Timor-Tritsch
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY 10016, USA.
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28
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Gupta A, Sirohiwal D, Duhan N, Bishnoi S. Lower Segment Cesarean Scar Pregnancy: A Cause of Uterine Rupture in the First Trimester. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2011.0008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Anjali Gupta
- Department of Obstetrics and Gynaecology, Pt. B.D. Sharma, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Daya Sirohiwal
- Department of Obstetrics and Gynaecology, Pt. B.D. Sharma, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Nirmala Duhan
- Department of Obstetrics and Gynaecology, Pt. B.D. Sharma, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
| | - Sarita Bishnoi
- Department of Obstetrics and Gynaecology, Pt. B.D. Sharma, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India
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29
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Qiong Z, Yanping L, Deep JP, Prasad DJ, Lin Z. Treatment of cornual heterotopic pregnancy via selective reduction without feticide drug. J Minim Invasive Gynecol 2011; 18:766-8. [PMID: 21945745 DOI: 10.1016/j.jmig.2011.08.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2011] [Revised: 08/09/2011] [Accepted: 08/12/2011] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE To treat heterotopic pregnancy with a minimally invasive procedure, absent a feticide drug. DESIGN Retrospective study (Canadian Classification III). SETTING University-affiliated hospital, center of reproductive medicine, department of obstetrics and gynecology, central south university, Changsha Hunan China. PATIENTS A total of nine patients' diagnosed cornual heterotopic pregnancy resulted from assisted reproduction technology. Among nine, five patients selected the cornual embryo reduction. INTERVENTIONS Cornual embryo reduction and preservation of intrauterine embryo were done under guidance of transvaginal ultrasonography at 4-6 weeks after embryo transfer. No drug was given. MEASUREMENTS Safety of operative procedure and pregnancy outcome. MAIN RESULTS All five patients who underwent selective embryo reduction has no intraoperative or postoperative complication, however 3 of them delivered healthy babies while two aborted. CONCLUSION An early intervention should be carried in vital stable patients by means of puncturing and aspirating cornual heterotopic pregnancy under transvaginal ultrasound guidance.
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Affiliation(s)
- Zhang Qiong
- Centre for Reproductive Medicine, Department of Obstetrics and Gynecology, Xiang-Ya Hospital, Central South University, Changsha, Hunan, China.
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30
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Ebner F, Hanna N, Petrich S, Paterson H. Caesarean scar pregnancy at 19 weeks gestation. Australas J Ultrasound Med 2011; 14:31-33. [PMID: 28191118 PMCID: PMC5024898 DOI: 10.1002/j.2205-0140.2011.tb00121.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Due to the increased numbers of caesarean sections in the last decade, women with a caesarean section scar in pregnancy are becoming more commonly diagnosed using ultrasound. One of the rare but more severe complications of this is an implantation of the pregnancy in the caesarean section scar.
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Affiliation(s)
- Florian Ebner
- Diakonieklinikum Schwaebisch HallGermany; Women's Health Dunedin HospitalDunedinNew Zealand
| | - Nadar Hanna
- Women's Health Dunedin Hospital Dunedin New Zealand
| | | | - Helen Paterson
- Department of Women's and Children's Health Dunedin School of Medicine University of Otago Dunedin North New Zealand
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31
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Successful management of a triplet heterotopic caesarean scar pregnancy after in vitro fertilization-embryo transfer. Fertil Steril 2011; 95:291.e1-3. [DOI: 10.1016/j.fertnstert.2010.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 04/26/2010] [Accepted: 05/06/2010] [Indexed: 10/19/2022]
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32
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33
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Hysteroscopic management of cesarean scar ectopic pregnancy. Fertil Steril 2010; 93:1735-40. [DOI: 10.1016/j.fertnstert.2008.12.099] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 12/18/2008] [Accepted: 12/18/2008] [Indexed: 11/30/2022]
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Wang CJ, Tsai F, Chen C, Chao A. Hysteroscopic management of heterotopic cesarean scar pregnancy. Fertil Steril 2010; 94:1529.e15-1529.e18. [PMID: 20347078 DOI: 10.1016/j.fertnstert.2010.02.039] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 02/13/2010] [Accepted: 02/17/2010] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To report a cesarean scar pregnancy (CSP) with a coexistent viable intrauterine pregnancy. DESIGN Case report. SETTING Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, Taiwan. PATIENT(S) A 31-year-old woman, with previous cesarean delivery, presented with vaginal bleeding, was transferred to our hospital at 7 weeks' gestation for heterotopic pregnancy after an IVF-embryo transfer. A diagnosis of intrauterine pregnancy combined with CSP was made by ultrasonography. INTERVENTION(S) Hysteroscopic-directed evacuation of CSP. MAIN OUTCOME MEASURE(S) Good hemostasis at cesarean site and ongoing intrauterine pregnancy. RESULT(S) A healthy baby was delivered by cesarean delivery at term. CONCLUSION(S) With the increasing number of IVF-embryo transfers, the amount of heterotopic pregnancies is also increasing. Hysteroscopic management of CSP is a minimally invasive procedure that leads to successful obstetric outcomes in the corresponding intrauterine pregnancies.
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Affiliation(s)
- Chin-Jung Wang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Kwei-Shan, Tao-Yuan
| | | | | | - Angel Chao
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Kwei-Shan, Tao-Yuan.
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Al-Nazer A, Omar L, Wahba M, Abbas T, Abdulkarim M. Ectopic intramural pregnancy developing at the site of a cesarean section scar: a case report. CASES JOURNAL 2009; 2:9404. [PMID: 20072685 PMCID: PMC2806401 DOI: 10.1186/1757-1626-2-9404] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 12/30/2009] [Indexed: 11/10/2022]
Abstract
Introduction Cesarean section scar pregnancy is a rare but serious complication. It occurs in women with previous uterine scar when implantation takes place at the site of this scar. If early diagnosis is missed the woman's future fertility and eve her life are at risk. Earlier reports on the condition suggesting different management approaches have been described. Case presentation A 37 year-old woman gravida 4, para 3, was referred to our emergency department, as a case of missed miscarriage following 14 weeks amenorrhea. Ultrasound examination revealed a picture suggestive of intramural pregnancy near the Cesarean section scar. The case was managed by laparotomy evacuation of products of conception and repair of the scar. Conclusion The diagnosis of ectopic intramural pregnancy in a cesarean section scar is possible with ultrasound and high level of suspicion. This serious complication must be suspected in a pregnant woman with previous uterine scar when early ultrasound show a gestational sac that is implanted anteriorly in the lower uterine segment, near the uterine scar. Ultrasound criteria for diagnosis include empty uterus, empty cervical canal and a discontinuity on the anterior wall of the uterus demonstrated on a sagittal plane of the uterus running through the amniotic sac. Early intervention is recommended to avoid serious consequences in such cases.
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Affiliation(s)
- Adel Al-Nazer
- Department of Obstetrics and Gynocology Dubai Hospital, Dubai, UAE
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Demirel LC, Bodur H, Selam B, Lembet A, Ergin T. Laparoscopic management of heterotopic cesarean scar pregnancy with preservation of intrauterine gestation and delivery at term: case report. Fertil Steril 2008; 91:1293.e5-7. [PMID: 18353320 DOI: 10.1016/j.fertnstert.2008.01.067] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Revised: 01/15/2008] [Accepted: 01/17/2008] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To present a case of laparoscopic removal of a heterotopic cesarean scar pregnancy under ultrasound guidance. DESIGN Case report. SETTING Private hospital. PATIENT(S) A 34-year-old woman with heterotopic cesarean scar pregnancy. INTERVENTION(S) Laparoscopic removal of heterotopic cesarean scar pregnancy. MAIN OUTCOME MEASURE(S) Delivery at term after laparoscopic management of heterotopic cesarean scar pregnancy. RESULT(S) An ongoing intrauterine pregnancy ended with a live birth after successful removal of the heterotopic gestational mass by a laparoscopic approach. CONCLUSION(S) Surgical removal of the ectopic mass by laparoscopy may be a radical approach in cases of heterotopic cesarean scar pregnancy. Laparoscopic excision of the cesarean scar pregnancy gives the opportunity to preserve the viable intrauterine gestation while maintaining a strong lower uterine segment. Ultrasound is an adjunctive tool that enables precise location of the ectopic mass during the operation.
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Affiliation(s)
- L Cem Demirel
- Department of Obstetrics and Gynecology, Acibadem Health Group, Istanbul, Turkey.
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Wang CN, Chen CK, Wang HS, Chiueh HY, Soong YK. Successful management of heterotopic cesarean scar pregnancy combined with intrauterine pregnancy after in vitro fertilization–embryo transfer. Fertil Steril 2007; 88:706.e13-6. [PMID: 17681305 DOI: 10.1016/j.fertnstert.2006.11.192] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Revised: 11/27/2006] [Accepted: 11/30/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To present a case of cesarean scar pregnancy combined with intrauterine pregnancy after IVF-embryo transfer. Successful embryo reduction was performed and preserved the normal intrauterine gestation. DESIGN Case report. SETTING Tertiary referral case center. PATIENT(S) A woman with cesarean scar pregnancy combined with intrauterine pregnancy after IVF-embryo transfer. INTERVENTION(S) Early diagnosis of heterotopic cesarean scar pregnancy and selective embryo reduction was performed by ultrasound-guided potassium chloride (KCl) directed injection. MAIN OUTCOME MEASURE(S) Successful pregnancy outcome. RESULT(S) A 38-year-old woman achieve pregnancy by IVF-embryo transfer. Heterotopic cesarean scar pregnancy was diagnosed at 7 weeks gestational age. A transvaginal ultrasound-guided KCl injection was given to terminate the cesarean scar embryo and a healthy infant was delivered 6 months later. CONCLUSION(S) Heterotopic cesarean scar pregnancy after IVF is extremely rare. Transvaginal intracardiac injection of KCl is a safe and reliable method to terminate the cesarean scar pregnancy. Satisfactory pregnancy outcome should be achieved.
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Affiliation(s)
- Chao-Nin Wang
- Department of Obstetrics and Gynecology, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
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Abstract
Caesarean scar pregnancy is one of the rarest forms of ectopic pregnancy. Little is known about its incidence and natural history. With increasing incidence of caesarean section worldwide, more and more cases are diagnosed and reported. Transvaginal ultrasound and colour flow Doppler provides a high diagnostic accuracy with very few false positives. A delay in diagnosis and/or treatment can lead to uterine rupture, major haemorrhage, hysterectomy and serious maternal morbidity. Early diagnosis can offer treatment options of avoiding uterine rupture and haemorrhage, thus preserving the uterus and future fertility. Management plan should be individually tailored. Available data suggest that termination of pregnancy is the treatment of choice in the first trimester soon after the diagnosis. Expectant treatment has a poor prognosis because of risk of rupture. There are no reliable scientific data on the risk of recurrence of the condition in future pregnancy, role of the interval between the previous caesarean delivery and occurrence of caesarean scar pregnancy, and effect of caesarean wound closure technique on caesarean scar pregnancy. In this article, we aim to find the demography, pathophysiology, clinical presentation, most appropriate methods of diagnosis and management, with their implications in clinical practice for this condition.
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Affiliation(s)
- A Ash
- Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Heterotopic pregnancy: two cases and a comparative review. Fertil Steril 2006; 87:417.e9-15. [PMID: 17074353 DOI: 10.1016/j.fertnstert.2006.05.085] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2005] [Revised: 05/01/2006] [Accepted: 05/01/2006] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To analyze the incidence, diagnostic, and therapeutic management of heterotopic pregnancy by comparing a review for the 1971-1993 period with the one carried out in the present study (1994-2004). DESIGN Review of the literature. SETTING University teaching assisted reproductive technology (ART) center. PATIENT(S) Two case reports included in a comparative review of the literature on heterotopic pregnancy. INTERVENTION(S) Review of the published literature from January 1994 to December 2004 was performed by means of MEDLINE database. Medical subject heading words used were: heterotopic pregnancy, assisted reproductive technology, and ectopic pregnancy. A comparison with a previously reported review, including cases from 1971 to 1993. MAIN OUTCOME MEASURE(S) Comparative study of the diagnosis and treatment of ectopic pregnancy. RESULT(S) During the 1971-1993 period the definitive diagnosis of heterotopic pregnancy was performed by laparoscopy or laparotomy in 59% of cases. This proportion increased to 74% from 1994 to 2004. Likewise, the percentage of cases in which an early diagnosis was possible (performed before the ninth week of pregnancy) did not vary in any of the time periods evaluated (71% vs. 74%). CONCLUSION(S) Despite the increased medical knowledge and use of improved reproductive technologies, heterotopic pregnancy still remains a diagnostic and therapeutic challenge to practitioners.
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Abstract
Eight women diagnosed by transvaginal ultrasonography with unruptured caesarean scar pregnancy underwent operative laparoscopy as an alternative treatment to laparotomy. The ultrasonographic diagnosis of caesarean scar pregnancy was confirmed in all women at laparoscopy. None of the women required conversion of the procedure to laparotomy. The total operative time ranged from 75 to 120 minutes. The total blood loss was limited, ranging from 50 to 200 ml. All women tolerated the operation well and had uneventful recoveries. Our results show that in the hands of a well-trained operator, laparoscopy appears to be a reasonable alternative for the management of an unruptured caesarean scar pregnancy.
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Affiliation(s)
- Y-L Wang
- Department of Obstetrics and Gynecology, Mackay Memorial Hospital and Mackay Medicine, Nursing and Management College, Taipei, Taiwan.
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Abstract
OBJECTIVE To clarify the appropriate way to diagnose and treat an ectopic pregnancy in the uterine scar of a prior cesarean delivery. DATA SOURCES Articles written in English that were published from January 1966 to August 2005 and quoted in the computerized database MEDLINE/PubMed retrieved by using the words "cesarean section," "cesarean delivery," "cesarean section scar pregnancy," and "ectopic pregnancy." Additional articles were obtained from reference lists of pertinent case reports and reviews. METHODS OF STUDY SELECTION Fifty-nine articles that met the inclusion criteria provided data on the clinical presentation, diagnosis, and treatment modalities of 112 cases of cesarean delivery scar pregnancies. TABULATION, INTEGRATION, AND RESULTS Review of the 112 cases revealed a considerable increase in the incidence of this condition over the last decade, with a current range of 1:1,800 to 1:2,216 normal pregnancies. More than half (52%) of the reported cases had only one prior cesarean delivery. The mean gestational age was 7.5 +/- 2.5 weeks, and the most frequent symptom was painless vaginal bleeding. Endovaginal ultrasonography was the diagnostic method in most cases, with a sensitivity of 84.6% (95% confidence interval 0.763-0.905). Expectant management of 6 patients resulted in uterine rupture that required hysterectomy in 3 patients. Dilation and curettage was associated with severe maternal morbidity. Wedge resection and repair of the implantation site via laparotomy or laparoscopy were successful in 11 of 12 patients. Simultaneous administration of systemic and intragestational methotrexate to 5 women, all with beta-hCG exceeding 10,000 milli-International Units/mL required no further treatment. CONCLUSION Surgical treatment or combined systemic and intragestational methotrexate were both successful in the management of cesarean delivery scar pregnancy. Because subsequent pregnancies may be complicated by uterine rupture, the uterine scar should be evaluated before, as well as during, these pregnancies.
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Affiliation(s)
- Michael A Rotas
- Department of Obstetrics and Gynecology, Maimonides Medical Center, Brooklyn, New York 11219, USA
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Chang CY, Wu MT, Shih JC, Lee CN. Preservation of Uterine Integrity via Transarterial Embolization under Postoperative Massive Vaginal Bleeding due to Cesarean Scar Pregnancy. Taiwan J Obstet Gynecol 2006; 45:183-7. [PMID: 17197366 DOI: 10.1016/s1028-4559(09)60223-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Cesarean scar pregnancy (CSP) is an uncommon type of ectopic pregnancy. It results in uterine rupture and severe hemorrhage during the proceeding gestation. Whether diagnosed early or not, it may cause maternal mortality or morbidity during emergency management. Life-saving emergency hysterectomy is usually the treatment of choice when there is profuse bleeding intraoperatively or after initial management. CASE REPORT A 38-year-old woman with a history of two previous cesarean deliveries was referred to our clinic under the impression of CSP at 11 weeks' gestation. A viable embryo with a crown-rump length of 4.8 cm in the anterior wall of the uterus at the cervico-isthmic region was detected. Under the confirmation of CSP via ultrasonography, she was admitted for management. During hysterotomy, profuse bleeding with 1,000 mL blood loss was noted. After conservative procedure for hemostasis, however, massive vaginal bleeding persisted. As a result, we immediately transferred the patient to receive transarterial embolization (TAE) for bleeding control. The patient was discharged 4 days after the operation and TAE and her period resumed 1 month later. CONCLUSION Management of CSP is usually accompanied by profuse blood loss. Hysterectomy is inevitable if massive blood loss occurs during surgical intervention. For preservation of fertility and avoidance of mortality, our physicians offered an alternative life-saving policy even under catastrophic blood loss.
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Affiliation(s)
- Chih-Yuan Chang
- Department of Obstetrics and Gynecology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Fernandez H. Grossesse isthmique localisée au niveau d'une cicatrice d'hystérotomie traitée par méthotréxate. À propos d'un cas. ACTA ACUST UNITED AC 2006; 34:181. [PMID: 16495114 DOI: 10.1016/j.gyobfe.2006.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Einenkel J, Stumpp P, Kösling S, Horn LC, Höckel M. A misdiagnosed case of caesarean scar pregnancy. Arch Gynecol Obstet 2005; 271:178-81. [PMID: 15645280 DOI: 10.1007/s00404-004-0683-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2004] [Accepted: 08/25/2004] [Indexed: 10/25/2022]
Abstract
CASE REPORT We report a case of an ectopic pregnancy in a caesarean section scar, which was initially misdiagnosed despite using ultrasound. For the first time, a strongly vascularised pelvic tumour developed while the titre of serum human chorionic gonadotrophin decreased after a curettage abortion for an unwanted pregnancy. OUTCOME Due to uncontrollable haemorrhage, an emergency hysterectomy had to be performed 8 weeks later.
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Affiliation(s)
- Jens Einenkel
- Department of Obstetrics and Gynaecology, University of Leipzig, Philipp-Rosenthal-Strasse 55, 04103 Leipzig, Germany.
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Wang YL, Su TH, Chen HS. Laparoscopic management of an ectopic pregnancy in a lower segment cesarean section scar: A review and case report. J Minim Invasive Gynecol 2005; 12:73-9. [PMID: 15904604 DOI: 10.1016/j.jmig.2004.12.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Implantation of a pregnancy within the scar of a previous cesarean delivery is the rarest of ectopic pregnancy locations, with only 32 cases reported in the English-language medical literature. A 28-year-old woman was admitted to our institution with a suspected ectopic pregnancy located in the scar from a previous cesarean section. Ultrasound revealed a well-encapsulated, bulging mass with a gestational sac within the anterior uterine isthmus in the site of an old cesarean delivery scar. Laparoscopy was performed to confirm the diagnosis, and the gestational products also were removed laparoscopically. The defect in the uterus was then repaired by suturing. Total operative time was 120 minutes, blood loss was limited, and no transfusion was needed. Laparoscopy may be a reasonable alternative to laparotomy for an unruptured ectopic pregnancy in a cesarean scar.
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Affiliation(s)
- Yeou-Lih Wang
- Department of Obstetrics and Gynecology, Mackay Memorial Hospital, and Mackay Medicine, Nursing and Management College, Taipei, Taiwan
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Maymon R, Halperin R, Mendlovic S, Schneider D, Herman A. Ectopic pregnancies in a Caesarean scar: review of the medical approach to an iatrogenic complication. Hum Reprod Update 2004; 10:515-23. [PMID: 15375087 DOI: 10.1093/humupd/dmh042] [Citation(s) in RCA: 167] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Implantation of a pregnancy within a Caesarean fibrous tissue scar is considered to be the rarest form of ectopic pregnancy and a life-threatening condition. We conducted a computer search of the English literature of all studies since 2002 to gather updated data on the outcome of such pregnancies. Sixty-six new cases were reported since 2002, possibly reflecting the increasing number of Caesareans currently being performed as well as the more widespread use of the transvaginal scan allowing their earlier detection. Analysis of these women's obstetric history revealed that those at risk for pregnancy in a Caesarean scar appear to have a history of dilatation and curettage, placental pathology, ectopic pregnancy, and IVF. Twenty-one out of 39 for which this information was available (54%) had undergone multiple (> or =2) Caesareans and 13 had previous dilatation and curettage, which might also be an associated factor. We review and discuss the features of contemporary work-ups, including a high index of awareness, a detailed history and a skillful ultrasound examination for an early and accurate diagnosis. Healthcare professionals should be familiar with the possibility of untoward sequelae and how a modern work-up can help in guiding conservative options, thus reducing morbidity and preserving fertility.
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Affiliation(s)
- R Maymon
- Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Tel Aviv University, Tel Aviv, Israel.
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