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Cesarean section scar pregnancy may be the cause of serious hemorrhage after first-trimester abortion by dilatation and curettage
International Journal of Gynecology and Obstetrics (2006) 95, 50 — 51
www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Cesarean section scar pregnancy may be the cause of serious hemorrhage after first-trimester abortion by dilatation and curettage M. Nonaka, H. Toyoki, A. Imai * Department of Obstetrics and Gynecology, Gifu University School of Medicine, Yanagido, Gifu, Japan Received 30 March 2006; received in revised form 6 June 2006; accepted 14 June 2006
KEYWORDS Ectopic pregnancy; Uterine scar pregnancy; Dilatation-induced hemorrhage
Implantation within the fibrous tissue of a cesarean scar is considered to be the rarest form of ectopic pregnancy and constitutes a life-threatening condition [1,2]. The literature warns that implantation in the uterine scar can cause serious bleeding after otherwise uncomplicated dilatation and evacuation procedures [3,4]. A 36-year-old woman, gravida 4, para 3, was referred to the Department of Obstetrics and Gynecology of the Gifu University School of Medicine, Gifu, Japan, for further management of a missed abortion. Her obstetrics history revealed 3 lower transverse cesarean sections performed 7, 5, * Corresponding author. Tel.: +81 58 230 6349; fax: +81 58 230 6348. E-mail address: [email protected] (A. Imai).
and 2 years previously because of cephalopelvic disproportion at term. On ultrasonographic examination the gestational sac could be seen in the lower part of uterine cavity, and the patient underwent in-hospital dilatation and curettage. Insertions of the osmotic dilating device induced a sudden, severe hemorrhage requiring a gauze pack in the vagina and cervical canal. The next day, after sufficient cervical dilation, an elective abortion was performed and chorionic villi, decidua, and a shrunken embryo were removed. Moderate uterine bleeding began immediately after uterine evacuation, and on ultrasonographic examination there was no suspicion of pregnancy tissue remaining in the uterus. A diagnosis of atonic bleeding was made, and the patient was treated with an intrauterine gauze pack, high-dose uterotonic therapy for 2 days, and iron tablets against anemia. Blood loss was estimated at 1200 mL. The patient was discharged home 5 days after admission. The patient had intermittent vaginal bleeding until the seventh postoperative week, when an acute hemorrhage with severe noncrampy abdominal pain occurred. A solid and painful tumor was palpated approximately 3 cm above the closed external cervical os, extending from the anterior and left
0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.06.019
Cesarean section scar pregnancy
51
Figure 1 (A) Magnetic resonance imaging (T2-weighed, sagittal view) shows a discontinuity in the isthmic area of the lower anterior wall of the uterus, with a bulging mass measuring approximately 4 3 2 cm and containing several serpentine and nonhomogenous areas and no evidence of retained tissue. (B) Macroscopic photograph of the surgically removed uterus with the tumor in the region of the cesarean scar; the corpus and cervix were opened through the anterior wall. A normal-sized uterine corpus with normal bilateral adnexa was located above a large pelvic tumor arising from the uterine isthmus. (C) Microscopic view of the tumor tissue (hematoxylin and eosin; original magnification 100). The tumor consisted of progressively transformed trophoblastic cells invading the fibrous scar.
lateral cervix to the pelvic wall. The result of a human chorionic gonadotropin test was negative but magnetic resonance imaging revealed a bulging mass in the cervicoisthmic region of the uterus (Fig. 1A). No blood was found in the abdominal cavity on emergency laparotomy, and the serosa was intact. The uterus was removed en bloc with the tumor (Fig. 1B). A microscopic examination led to the diagnosis of denatured placenta increta embedded in a cesarean section scar (Fig. 1C). The patient was discharged on the 10th postoperative day after an uneventful recovery. Cesarean section scar pregnancies have become more common because of the increasing rate of cesarean deliveries [2,4]. This patient’s history, tumor size, low titer of urine human chorionic gonadotropin, and histologic findings—which revealed regressively transformed chorionic villi—are similar to patients’ histories in other reports [3]. Prognosis is good and the risk of hysterectomy is low when the proper diagnosis is made in the first trimester [1]. This information should alert the
sonographer to look for scars in the pregnant uterus and verify the integrity of the uterine wall, especially in the presence of an anterior gestational sac close to the cesarean section scar.
References [1] Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson C. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol 2003;21:220 – 7. [2] 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. [3] Einenkel J, Stumpp P, Kosling S, Horn L, Hockel M. A misdiagnosed case of caesarean scar pregnancy. Arch Gynecol Obstet 2005;271:178 – 81. [4] Lam P, Lo K, Lau T. Unsuccessful medical treatment of cesarean scar ectopic pregnancy with systemic methotrexate: a report of two cases. Acta Obstet Gynecol Scand 2004;83:108 – 11.
www.elsevier.com/locate/ijgo
BRIEF COMMUNICATION
Cesarean section scar pregnancy may be the cause of serious hemorrhage after first-trimester abortion by dilatation and curettage M. Nonaka, H. Toyoki, A. Imai * Department of Obstetrics and Gynecology, Gifu University School of Medicine, Yanagido, Gifu, Japan Received 30 March 2006; received in revised form 6 June 2006; accepted 14 June 2006
KEYWORDS Ectopic pregnancy; Uterine scar pregnancy; Dilatation-induced hemorrhage
Implantation within the fibrous tissue of a cesarean scar is considered to be the rarest form of ectopic pregnancy and constitutes a life-threatening condition [1,2]. The literature warns that implantation in the uterine scar can cause serious bleeding after otherwise uncomplicated dilatation and evacuation procedures [3,4]. A 36-year-old woman, gravida 4, para 3, was referred to the Department of Obstetrics and Gynecology of the Gifu University School of Medicine, Gifu, Japan, for further management of a missed abortion. Her obstetrics history revealed 3 lower transverse cesarean sections performed 7, 5, * Corresponding author. Tel.: +81 58 230 6349; fax: +81 58 230 6348. E-mail address: [email protected] (A. Imai).
and 2 years previously because of cephalopelvic disproportion at term. On ultrasonographic examination the gestational sac could be seen in the lower part of uterine cavity, and the patient underwent in-hospital dilatation and curettage. Insertions of the osmotic dilating device induced a sudden, severe hemorrhage requiring a gauze pack in the vagina and cervical canal. The next day, after sufficient cervical dilation, an elective abortion was performed and chorionic villi, decidua, and a shrunken embryo were removed. Moderate uterine bleeding began immediately after uterine evacuation, and on ultrasonographic examination there was no suspicion of pregnancy tissue remaining in the uterus. A diagnosis of atonic bleeding was made, and the patient was treated with an intrauterine gauze pack, high-dose uterotonic therapy for 2 days, and iron tablets against anemia. Blood loss was estimated at 1200 mL. The patient was discharged home 5 days after admission. The patient had intermittent vaginal bleeding until the seventh postoperative week, when an acute hemorrhage with severe noncrampy abdominal pain occurred. A solid and painful tumor was palpated approximately 3 cm above the closed external cervical os, extending from the anterior and left
0020-7292/$ - see front matter D 2006 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2006.06.019
Cesarean section scar pregnancy
51
Figure 1 (A) Magnetic resonance imaging (T2-weighed, sagittal view) shows a discontinuity in the isthmic area of the lower anterior wall of the uterus, with a bulging mass measuring approximately 4 3 2 cm and containing several serpentine and nonhomogenous areas and no evidence of retained tissue. (B) Macroscopic photograph of the surgically removed uterus with the tumor in the region of the cesarean scar; the corpus and cervix were opened through the anterior wall. A normal-sized uterine corpus with normal bilateral adnexa was located above a large pelvic tumor arising from the uterine isthmus. (C) Microscopic view of the tumor tissue (hematoxylin and eosin; original magnification 100). The tumor consisted of progressively transformed trophoblastic cells invading the fibrous scar.
lateral cervix to the pelvic wall. The result of a human chorionic gonadotropin test was negative but magnetic resonance imaging revealed a bulging mass in the cervicoisthmic region of the uterus (Fig. 1A). No blood was found in the abdominal cavity on emergency laparotomy, and the serosa was intact. The uterus was removed en bloc with the tumor (Fig. 1B). A microscopic examination led to the diagnosis of denatured placenta increta embedded in a cesarean section scar (Fig. 1C). The patient was discharged on the 10th postoperative day after an uneventful recovery. Cesarean section scar pregnancies have become more common because of the increasing rate of cesarean deliveries [2,4]. This patient’s history, tumor size, low titer of urine human chorionic gonadotropin, and histologic findings—which revealed regressively transformed chorionic villi—are similar to patients’ histories in other reports [3]. Prognosis is good and the risk of hysterectomy is low when the proper diagnosis is made in the first trimester [1]. This information should alert the
sonographer to look for scars in the pregnant uterus and verify the integrity of the uterine wall, especially in the presence of an anterior gestational sac close to the cesarean section scar.
References [1] Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson C. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol 2003;21:220 – 7. [2] 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. [3] Einenkel J, Stumpp P, Kosling S, Horn L, Hockel M. A misdiagnosed case of caesarean scar pregnancy. Arch Gynecol Obstet 2005;271:178 – 81. [4] Lam P, Lo K, Lau T. Unsuccessful medical treatment of cesarean scar ectopic pregnancy with systemic methotrexate: a report of two cases. Acta Obstet Gynecol Scand 2004;83:108 – 11.