Heterotopic Cesarean Scar Pregnancy: How Should It Be Managed?

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

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.

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

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

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

Background

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

Methods

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

Results

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

Conclusion

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

Spontaneously conceived 17-week heterotopic pregnancy: a challenging and unusual diagnosis

A 37-year-old woman, gravida 2 para 1, arrived in our emergency clinic at 16 2/7 weeks of a spontaneously conceived pregnancy for abdominal pain. She was on oral antibiotics for 2 days to treat a suspected urinary tract infection with no improvement. Blood tests, abdominal ultrasound and intrauterine fetus were all normal. She left our emergency unit with laxatives. Four days later, she returned to our clinic with severe abdominal pain. We repeated abdominal and foetal ultrasonography and identified a left para-uterine 7×5 cm mass. As adnexal torsion was suspected, we performed an emergency laparoscopy. At laparoscopy, we found a left haematosalpinx and realised a left salpingectomy. Histology confirmed the presence of a heterotopic pregnancy (HP). This case illustrates the importance of exploring the adnexa in a gravid woman presenting with abdominal pain in the first and early second trimesters. Although rare, excluding a HP may prevent a life-threatening haemorrhage.

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

RESEARCH QUESTION

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

DESIGN

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

RESULTS

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

CONCLUSIONS

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

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

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

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First trimester bleeding in heterotopic caesarean scar pregnancy

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Surgical management of heterotopic caesarean scar pregnancy

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Ultrasound guided curettage with preservation of concurrent intrauterine pregnancy

Cesarean Scar Pregnancy: Diagnosis and Pathogenesis

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.

Successful selective reduction of a heterotopic cesarean scar pregnancy in the second trimester: a case report and review of the literature

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.

First-trimester diagnosis and management of Cesarean scar pregnancies after in vitro fertilization-embryo transfer: a retrospective clinical analysis of 12 cases

BACKGROUND

Although Caesarean scar pregnancy (CSP) is rare, it can cause life-threatening complications. The increasing rate of Cesarean delivery plus rapid development of in vitro fertilization-embryo transfer (IVF-ET) may increase the occurrence of CSP as well as the ratio of heterotopic CSP (HCSP)/CSP. Therefore, early diagnosis and management of CSP are necessary to avoid serious complications. And the purpose of this article is to evaluate the importance and feasibility of the first-trimester diagnosis and management of CSP after IVF-ET.

METHODS

All the 12 cases were secondary infertility patients who had a history of Cesarean section and underwent IVF-ET in our reproductive center. All cases with CSP were diagnosed using transvaginal color Doppler sonography (TVS). Medical, surgical and expectant managements were implemented, and the management results were traced.

RESULTS

Patients with CSP (n = 12) were diagnosed from January 2011 to April 2015, 6 (50 %) of which were HCSP. The prevalence of CSP was 1:1688 pregnancies. The gestational age ranged from 5 + 3 to 7 + 4 weeks in all CSP, and from 5 + 6 to 7 + 4 weeks in HCSP at diagnosis. Five patients received successful surgical treatment. The success rate of medical and expectant management was 50 % (1/2) and 100 % (5/5), respectively. One patient with failed medical management needed an emergency laparotomy to evacuate CSP. The uterus was preserved in all 12 patients.

CONCLUSIONS

The Caesarean section and IVF-ET may increase the ratio of HCSP/CSP. TVS is a noninvasive and effective tool for use in diagnosing CSP. CSP should be carefully excluded in patients who have had a history of Caesarean section. Early diagnosis of CSP in the first trimester may contribute towards the preservation of uterus as well as intrauterine pregnancy (IUP) in HCSP.

Operative Therapy for Heterotopic Scar Pregnancy and Successful Birth of the Intrauterine Foetus - Case Report and Review of the Literature

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.

Heterotopic cesarean scar pregnancy: diagnosis, treatment, and prognosis

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.

Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review

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.

Heterotopic pregnancy

Heterotopic pregnancy is a life-threatening condition. A recent case at our institution prompted a systematic review of the literature from 2005 to 2010. In the majority (71%) of cases reviewed, risk factors for a heterotopic pregnancy were present. However, in several instances (33%), previous sonographic reports of a normal intrauterine pregnancy gave false reassurance. These results highlight the complexity of diagnosis. In addition, our findings were compared with two previous reviews covering cases from 1971 to 2004. This comparison highlighted two important trends: first, the increasing role of ultrasound in the definitive diagnosis of a heterotopic pregnancy, and second, the development of conservative approaches to management. Medical knowledge and technology may be improving, but ultimately, even in the presence of a known intrauterine pregnancy, the simple dictum 'think ectopic' must not be forgotten.