- Email: [email protected]
Cesarean Scar Pregnancy: Imaging and Treatment with Conservative Surgery
fertilized ovum traversed the length of the abdominal cavity (likely following the circulation of peritoneal fluid) to implant on the right hemidiaphragm. The invasive biologic behavior of the trophoblastic tissue led to invasion into the pleura, with subsequent bleeding and development of recurrent hemothorax. Spontaneous hemothorax is a rare event, with the differential diagnosis including pulmonary emboli, vascular malformations, infection, and pulmonary and pleural malignancies, as well as metastatic neoplasms.5 Because of the positive pregnancy test in our patient, the differential diagnosis included metastatic gestational trophoblastic tumor in addition to ectopic pregnancy. The classic indication for thoracoscopy is pleural space disease, as in our case.6 Because our patient presented with the diagnostic dilemma of an elevated hCG level and recurrent hemothorax, thoracoscopy was used not only to diagnose but also to remove the ectopic gestation implanted on the diaphragm. A single course of actinomycin D chemotherapy, 0.5 mg intravenously daily for 5 consecutive days, as used in the treatment of nonmetastatic gestational tumors at the John I. Brewer Trophoblastic Disease Center,7 was administered postoperatively to eliminate residual pleural trophoblastic tissue. Methotrexate was not used, because pleural effusions alter the pharmacokinetics, increasing the potential for toxicity.8 Complete resolution was achieved and maintained, as evidenced by persistently normal serum hCG levels for more than 1 year.
2. Bayless RB. Nontubal ectopic pregnancy. Clin Obstet Gynecol 1987;30191–9. 3. Studdiford WE. Primary peritoneal pregnancy. Am J Obstet Gynecol 1942;44:487–91. 4. Norenberg DD, Gundersen JH, Janis JF, Gundersen AL. Early pregnancy in the diaphragm with endometriosis. Obstet Gynecol 1977;49:620 –2. 5. Martinez FJ, Villanueva AG, Pickering R, Becker FS, Smith DR. Spontaneous hemothorax: Report of six cases and review of the literature. Medicine 1992;71:354 – 68. 6. Kohman LJ. Thoracoscopy for the evaluation and treatment of pleural space disease. Chest Surg Clin N Am 1994;4:467–79. 7. Lurain JR, Brewer JI, Torok EE, Halpern B. Gestational trophoblastic disease: Treatment results at the Brewer Trophoblastic Disease Center. Obstet Gynecol 1982;60:354 – 60. 8. Evans WE, Pratt CB. Effect of pleural effusions on high-dose methotrexate kinetics. Clin Pharmacol Ther 1978;23:68 –72.
Address reprint requests to:
David A. Fishman, MD Prentice Women’s Hospital 333 East Superior Street, Suite 420 Chicago, IL 60611 E-mail: [email protected]
Received October 9, 1997. Received in revised form December 3, 1997. Accepted December 18, 1997.
References 1. Atrash HK, Friede A, Hoghe CJR. Abdominal pregnancy in the United States: Frequency and maternal mortality. Obstet Gynecol 1987;69:333–7.
Cesarean scar pregnancy: Imaging and treatment with conservative surgery Michael T. Valley, MD, John G. Pierce, MD, Timothy B. Daniel, MD, and Andrew M. Kaunitz, MD Background: Pregnancy in a cesarean scar represents a rare type of secondary abdominal pregnancy. Early diagnosis can be challenging and optimal treatment is unknown. From the Departments of Obstetrics and Gynecology and Radiology, University of Florida, Jacksonville, Florida.
838 0029-7844/98/$19.00 PII S0029-7844(97)00426-2
Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Case: A 21-year-old woman presented for an abortion at 8 weeks’ gestation. A cesarean delivery had been performed 5 months earlier. Suspecting a cervical pregnancy, her physician referred her to us, and an 8-week cesarean scar gestation was diagnosed and then confirmed by serial sonograms, cystoscopy, and magnetic resonance imaging. The patient elected pregnancy termination, which was accomplished by hysterotomy with uterine preservation followed by intramuscular methotrexate. Conclusion: We report a case of cesarean scar pregnancy treated surgically with uterine preservation. This approach should be considered when cesarean scar ectopic pregnancy is diagnosed. (Obstet Gynecol 1998;91:838 – 40. © 1998 by The American College of Obstetricians and Gynecologists.)
Cesarean scar pregnancy, a rare form of ectopic pregnancy, can have various presentations.1–5 It is a form of
Obstetrics & Gynecology
secondary abdominal pregnancy defined as a pregnancy located anterior to the uterine isthmus in a patient with a previous cesarean delivery. At least a portion of the sac is not covered by myometrium. Because outcomes and treatments may differ, cesarean scar pregnancy must be distinguished from other types of abnormally implanted pregnancies, including cervical, cervico-isthmic, and cervico-isthmic corporeal pregnancy.6 For example, some cases of cervico-isthmic pregnancy have significant morbidity but others have resulted in good outcomes.6,7 One report4 suggests that magnetic resonance imaging (MRI) may facilitate evaluation of cesarean scar pregnancy. One report5 is found of an early cesarean scar pregnancy treated with conservative surgery. We report a cesarean scar pregnancy confirmed by MRI and treated conservatively with surgery. Case A 21-year-old asymptomatic woman, gravida 3, para 2, was referred to us from an abortion clinic because of suspected cervical pregnancy. She had undergone a lower segment transverse cesarean delivery 5 months earlier. Vaginal sonography showed cervical length to be normal at 3.3 cm; a pregnancy of 8 weeks and 4 days with cardiac activity appeared extrauterine, anterior to the uterine isthmus. Because of concern that a tubal pregnancy might be present, laparoscopy was performed. The uterine fundus was soft and globular; the tubes and ovaries were normal. A small ecchymotic area was present just lateral to the left uterine isthmus in an area of adhesions associated with the previous hysterotomy site. These laparoscopic findings did not exclude the possibility of intrauterine pregnancy and the patient then wished to continue the pregnancy; hence, further follow-up and testing were chosen. Serial sonographic examinations with color-flow Doppler imaging were performed to determine whether the pregnancy was implanted in the uterus or was ectopic. No normal myometrium was visualized between the bladder and gestational sac (Figure 1). In addition, serial imaging did not suggest the sac was growing toward the fundus, confirming no corporeal (fundal) development of the pregnancy. Cystoscopy showed no evidence of bladder musculature or mucosal involvement of the pregnancy. Magnetic resonance imaging at 10 weeks also demonstrated that no normal myometrium existed between the pregnancy and bladder (Figure 2). After extensive counseling, the patient chose laparotomy with the intention of definitively localizing and terminating the pregnancy. At 10 weeks’ gestation, a laparotomy was performed with intraoperative ultrasound and cystoscopy. Initial attempts at entering the left lateral aspect of the gestational sac resulted in profuse bleeding. Therefore, abdominal ultrasound was used to locate a thin part of myometrium anteriorly near the midline but superior to the bladder reflection; the 5-MHz vaginal probe was placed directly on the uterus. Hysterotomy
VOL. 91, NO. 5, PART 2, MAY 1998
Figure 1. Transvaginal ultrasonogram showing bladder (large black arrow) and bladder wall thickness of 4.6 mm (open arrows). The fetus and sac are adjacent (solid white arrow), and the sac wall thickness is 4.4 mm (curved arrows).
at this site was performed with bilateral ascending uterine artery ligation and myometrial injection with dilute vasopressin. The fetus was removed without removal of the entire placenta because of concerns that this might provoke uncontrollable bleeding. The base of the pregnancy site was sutureligated to help with hemostasis. Microfibrillar collagen was placed in the pregnancy site and the hysterotomy was closed. Estimated blood loss was 1700 mL and the discharge hemoglobin was 7.6 g/dL (preoperative, 10.3 g/dL). No blood transfusion was given. Methotrexate, 50 mg/m2 (80 mg), was administered intramuscularly on postoperative day 1. The quantitative hCG level was 21,866 mIU/mL on the day of surgery, 3028 mIU/mL on postoperative day 4, and 419 mIU/mL on day 11. On postoperative day 5, the patient was admitted with sus-
Figure 2. Sagittal oblique, T2-weighted magnetic resonance imaging shows relationship of sac (solid white arrow) with placenta (open black arrow) to the bladder (open white arrow). Curved black arrows show bladder wall with absence of normal myometrium between the bladder and sac.
Valley et al
Cesarean Scar Pregnancy
839
pected endomyometritis, which responded to 48 hours of intravenous antibiotics. She was lost to follow-up but eventually returned to the clinic 4 months postoperatively. A urine pregnancy test sensitive to 25 mIU/mL was negative and she had resumed normal menses.
Comment Few cesarean scar–secondary abdominal pregnancies have been reported. In 1978, a uterine scar sacculus pregnancy was reported.3 This woman presented early in pregnancy with an incomplete abortion and excessive bleeding. A ruptured cesarean scar was palpated vaginally, and laparotomy was required to evacuate the pregnancy from a sacculus anterior to the ruptured scar. In 1990, a 7-week cesarean scar pregnancy was resected surgically with uterine conservation.5 In 1995, another case of cesarean scar pregnancy was followed expectantly because of early sonographic evidence of the sac growing toward the fundus.2 However, the sac and fundus did not coalesce and the pregnancy remained isthmic. Abdominal pain prompted urgent cesarean delivery at 35 weeks; intravascular coagulopathy developed and hysterectomy was required. Pathology revealed villi outside the uterus. In another report1 in 1995, a case of cesarean scar pregnancy was treated with methotrexate but laparotomy was required for excessive vaginal bleeding 2 weeks later. Finally, in 1997 a 9-week cesarean scar pregnancy was treated successfully with fetal intrathoracic potassium chloride followed by methotrexate injection into the sac and surrounding myometrium.4 In our case, methotrexate was used not as primary treatment but postoperatively to hasten resolution of any remaining placental tissue.8 In retrospect, the laparoscopy did not benefit this patient. Some might argue that the diagnosis could have been made at laparoscopy had adhesiolysis been performed at the previous anterior uterine scar site. However, excessive bleeding might have occurred before a definitive diagnosis was made. Also, further imaging studies should have been performed without delay. Intraoperative sonography with the transducer placed directly on the uterine serosa, though novel, proved useful in locating an appropriate hysterotomy site. For future pregnancies, we have counseled our patient to undergo elective cesarean delivery near term following mature fetal lung studies.
840 Valley et al
Cesarean Scar Pregnancy
Because of the rarity of cesarean scar pregnancy, optimal treatment is unknown. Confirming that the pregnancy is ectopic (ie, growing out of the scar and not covered by myometrium) is paramount, and treatment is dictated in part by gestational age. Our case underscores the usefulness of sonography and MRI in establishing early diagnosis of cesarean scar ectopic pregnancy, allowing effective surgical treatment with uterine preservation.
References 1. Lai YM, Lee JD, Chen TC, Soong YK. An ectopic pregnancy embedded in the myometrium of a previous cesarean section scar. Acta Obstet Gynecol Scand 1995;74:573– 6. 2. Herman A, Weinraub Z, Avrech O, Maymon R, Ron-El R, Bukovsky Y. Follow up and outcome of isthmic pregnancy located in a previous caesarean section scar. Br J Obstet Gynaecol 1995;102:839 – 41. 3. Larsen JV, Solomon MH. Pregnancy in a uterine scar sacculus—An unusual cause of postabortal haemorrhage. S Afr Med J 1978;53: 142–3. 4. Godin PA, Bassil S, Donnez J. An ectopic pregnancy developing in a previous caesarean section scar. Fertil Steril 1997;67:398 – 400. 5. Rempen A, Albert P. Diagnosis and therapy of an early pregnancy implanted in the scar of a cesarean section. Z Geburtshilfe Perinatol 1990;194:46 – 8. 6. David MP, Bergman A, Dilighdish L. Cervico-isthmic pregnancy carried to term. Obstet Gynecol 1980;56:247–52. 7. Jelsema RD, Zuidema L. First-trimester diagnosed cervico-isthmic pregnancy resulting in term delivery. Obstet Gynecol 1992;80:517–9. 8. Graczykowski JW, Mishell DR. Methotrexate prophylaxis for persistent ectopic pregnancy after conservative treatment by salpingostomy. Obstet Gynecol 1997;89:118 –22.
Address reprint requests to:
Michael T. Valley, MD Obstetrics-Gynecology Female Urology-Women’s Care Osler Medical 930 South Harbor City Boulevard Melbourne, FL 32901
Received April 18, 1997. Received in revised form June 26, 1997. Accepted July 18, 1997.
Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology
2. Bayless RB. Nontubal ectopic pregnancy. Clin Obstet Gynecol 1987;30191–9. 3. Studdiford WE. Primary peritoneal pregnancy. Am J Obstet Gynecol 1942;44:487–91. 4. Norenberg DD, Gundersen JH, Janis JF, Gundersen AL. Early pregnancy in the diaphragm with endometriosis. Obstet Gynecol 1977;49:620 –2. 5. Martinez FJ, Villanueva AG, Pickering R, Becker FS, Smith DR. Spontaneous hemothorax: Report of six cases and review of the literature. Medicine 1992;71:354 – 68. 6. Kohman LJ. Thoracoscopy for the evaluation and treatment of pleural space disease. Chest Surg Clin N Am 1994;4:467–79. 7. Lurain JR, Brewer JI, Torok EE, Halpern B. Gestational trophoblastic disease: Treatment results at the Brewer Trophoblastic Disease Center. Obstet Gynecol 1982;60:354 – 60. 8. Evans WE, Pratt CB. Effect of pleural effusions on high-dose methotrexate kinetics. Clin Pharmacol Ther 1978;23:68 –72.
Address reprint requests to:
David A. Fishman, MD Prentice Women’s Hospital 333 East Superior Street, Suite 420 Chicago, IL 60611 E-mail: [email protected]
Received October 9, 1997. Received in revised form December 3, 1997. Accepted December 18, 1997.
References 1. Atrash HK, Friede A, Hoghe CJR. Abdominal pregnancy in the United States: Frequency and maternal mortality. Obstet Gynecol 1987;69:333–7.
Cesarean scar pregnancy: Imaging and treatment with conservative surgery Michael T. Valley, MD, John G. Pierce, MD, Timothy B. Daniel, MD, and Andrew M. Kaunitz, MD Background: Pregnancy in a cesarean scar represents a rare type of secondary abdominal pregnancy. Early diagnosis can be challenging and optimal treatment is unknown. From the Departments of Obstetrics and Gynecology and Radiology, University of Florida, Jacksonville, Florida.
838 0029-7844/98/$19.00 PII S0029-7844(97)00426-2
Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Case: A 21-year-old woman presented for an abortion at 8 weeks’ gestation. A cesarean delivery had been performed 5 months earlier. Suspecting a cervical pregnancy, her physician referred her to us, and an 8-week cesarean scar gestation was diagnosed and then confirmed by serial sonograms, cystoscopy, and magnetic resonance imaging. The patient elected pregnancy termination, which was accomplished by hysterotomy with uterine preservation followed by intramuscular methotrexate. Conclusion: We report a case of cesarean scar pregnancy treated surgically with uterine preservation. This approach should be considered when cesarean scar ectopic pregnancy is diagnosed. (Obstet Gynecol 1998;91:838 – 40. © 1998 by The American College of Obstetricians and Gynecologists.)
Cesarean scar pregnancy, a rare form of ectopic pregnancy, can have various presentations.1–5 It is a form of
Obstetrics & Gynecology
secondary abdominal pregnancy defined as a pregnancy located anterior to the uterine isthmus in a patient with a previous cesarean delivery. At least a portion of the sac is not covered by myometrium. Because outcomes and treatments may differ, cesarean scar pregnancy must be distinguished from other types of abnormally implanted pregnancies, including cervical, cervico-isthmic, and cervico-isthmic corporeal pregnancy.6 For example, some cases of cervico-isthmic pregnancy have significant morbidity but others have resulted in good outcomes.6,7 One report4 suggests that magnetic resonance imaging (MRI) may facilitate evaluation of cesarean scar pregnancy. One report5 is found of an early cesarean scar pregnancy treated with conservative surgery. We report a cesarean scar pregnancy confirmed by MRI and treated conservatively with surgery. Case A 21-year-old asymptomatic woman, gravida 3, para 2, was referred to us from an abortion clinic because of suspected cervical pregnancy. She had undergone a lower segment transverse cesarean delivery 5 months earlier. Vaginal sonography showed cervical length to be normal at 3.3 cm; a pregnancy of 8 weeks and 4 days with cardiac activity appeared extrauterine, anterior to the uterine isthmus. Because of concern that a tubal pregnancy might be present, laparoscopy was performed. The uterine fundus was soft and globular; the tubes and ovaries were normal. A small ecchymotic area was present just lateral to the left uterine isthmus in an area of adhesions associated with the previous hysterotomy site. These laparoscopic findings did not exclude the possibility of intrauterine pregnancy and the patient then wished to continue the pregnancy; hence, further follow-up and testing were chosen. Serial sonographic examinations with color-flow Doppler imaging were performed to determine whether the pregnancy was implanted in the uterus or was ectopic. No normal myometrium was visualized between the bladder and gestational sac (Figure 1). In addition, serial imaging did not suggest the sac was growing toward the fundus, confirming no corporeal (fundal) development of the pregnancy. Cystoscopy showed no evidence of bladder musculature or mucosal involvement of the pregnancy. Magnetic resonance imaging at 10 weeks also demonstrated that no normal myometrium existed between the pregnancy and bladder (Figure 2). After extensive counseling, the patient chose laparotomy with the intention of definitively localizing and terminating the pregnancy. At 10 weeks’ gestation, a laparotomy was performed with intraoperative ultrasound and cystoscopy. Initial attempts at entering the left lateral aspect of the gestational sac resulted in profuse bleeding. Therefore, abdominal ultrasound was used to locate a thin part of myometrium anteriorly near the midline but superior to the bladder reflection; the 5-MHz vaginal probe was placed directly on the uterus. Hysterotomy
VOL. 91, NO. 5, PART 2, MAY 1998
Figure 1. Transvaginal ultrasonogram showing bladder (large black arrow) and bladder wall thickness of 4.6 mm (open arrows). The fetus and sac are adjacent (solid white arrow), and the sac wall thickness is 4.4 mm (curved arrows).
at this site was performed with bilateral ascending uterine artery ligation and myometrial injection with dilute vasopressin. The fetus was removed without removal of the entire placenta because of concerns that this might provoke uncontrollable bleeding. The base of the pregnancy site was sutureligated to help with hemostasis. Microfibrillar collagen was placed in the pregnancy site and the hysterotomy was closed. Estimated blood loss was 1700 mL and the discharge hemoglobin was 7.6 g/dL (preoperative, 10.3 g/dL). No blood transfusion was given. Methotrexate, 50 mg/m2 (80 mg), was administered intramuscularly on postoperative day 1. The quantitative hCG level was 21,866 mIU/mL on the day of surgery, 3028 mIU/mL on postoperative day 4, and 419 mIU/mL on day 11. On postoperative day 5, the patient was admitted with sus-
Figure 2. Sagittal oblique, T2-weighted magnetic resonance imaging shows relationship of sac (solid white arrow) with placenta (open black arrow) to the bladder (open white arrow). Curved black arrows show bladder wall with absence of normal myometrium between the bladder and sac.
Valley et al
Cesarean Scar Pregnancy
839
pected endomyometritis, which responded to 48 hours of intravenous antibiotics. She was lost to follow-up but eventually returned to the clinic 4 months postoperatively. A urine pregnancy test sensitive to 25 mIU/mL was negative and she had resumed normal menses.
Comment Few cesarean scar–secondary abdominal pregnancies have been reported. In 1978, a uterine scar sacculus pregnancy was reported.3 This woman presented early in pregnancy with an incomplete abortion and excessive bleeding. A ruptured cesarean scar was palpated vaginally, and laparotomy was required to evacuate the pregnancy from a sacculus anterior to the ruptured scar. In 1990, a 7-week cesarean scar pregnancy was resected surgically with uterine conservation.5 In 1995, another case of cesarean scar pregnancy was followed expectantly because of early sonographic evidence of the sac growing toward the fundus.2 However, the sac and fundus did not coalesce and the pregnancy remained isthmic. Abdominal pain prompted urgent cesarean delivery at 35 weeks; intravascular coagulopathy developed and hysterectomy was required. Pathology revealed villi outside the uterus. In another report1 in 1995, a case of cesarean scar pregnancy was treated with methotrexate but laparotomy was required for excessive vaginal bleeding 2 weeks later. Finally, in 1997 a 9-week cesarean scar pregnancy was treated successfully with fetal intrathoracic potassium chloride followed by methotrexate injection into the sac and surrounding myometrium.4 In our case, methotrexate was used not as primary treatment but postoperatively to hasten resolution of any remaining placental tissue.8 In retrospect, the laparoscopy did not benefit this patient. Some might argue that the diagnosis could have been made at laparoscopy had adhesiolysis been performed at the previous anterior uterine scar site. However, excessive bleeding might have occurred before a definitive diagnosis was made. Also, further imaging studies should have been performed without delay. Intraoperative sonography with the transducer placed directly on the uterine serosa, though novel, proved useful in locating an appropriate hysterotomy site. For future pregnancies, we have counseled our patient to undergo elective cesarean delivery near term following mature fetal lung studies.
840 Valley et al
Cesarean Scar Pregnancy
Because of the rarity of cesarean scar pregnancy, optimal treatment is unknown. Confirming that the pregnancy is ectopic (ie, growing out of the scar and not covered by myometrium) is paramount, and treatment is dictated in part by gestational age. Our case underscores the usefulness of sonography and MRI in establishing early diagnosis of cesarean scar ectopic pregnancy, allowing effective surgical treatment with uterine preservation.
References 1. Lai YM, Lee JD, Chen TC, Soong YK. An ectopic pregnancy embedded in the myometrium of a previous cesarean section scar. Acta Obstet Gynecol Scand 1995;74:573– 6. 2. Herman A, Weinraub Z, Avrech O, Maymon R, Ron-El R, Bukovsky Y. Follow up and outcome of isthmic pregnancy located in a previous caesarean section scar. Br J Obstet Gynaecol 1995;102:839 – 41. 3. Larsen JV, Solomon MH. Pregnancy in a uterine scar sacculus—An unusual cause of postabortal haemorrhage. S Afr Med J 1978;53: 142–3. 4. Godin PA, Bassil S, Donnez J. An ectopic pregnancy developing in a previous caesarean section scar. Fertil Steril 1997;67:398 – 400. 5. Rempen A, Albert P. Diagnosis and therapy of an early pregnancy implanted in the scar of a cesarean section. Z Geburtshilfe Perinatol 1990;194:46 – 8. 6. David MP, Bergman A, Dilighdish L. Cervico-isthmic pregnancy carried to term. Obstet Gynecol 1980;56:247–52. 7. Jelsema RD, Zuidema L. First-trimester diagnosed cervico-isthmic pregnancy resulting in term delivery. Obstet Gynecol 1992;80:517–9. 8. Graczykowski JW, Mishell DR. Methotrexate prophylaxis for persistent ectopic pregnancy after conservative treatment by salpingostomy. Obstet Gynecol 1997;89:118 –22.
Address reprint requests to:
Michael T. Valley, MD Obstetrics-Gynecology Female Urology-Women’s Care Osler Medical 930 South Harbor City Boulevard Melbourne, FL 32901
Received April 18, 1997. Received in revised form June 26, 1997. Accepted July 18, 1997.
Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology