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Laparoscopic management of heterotopic cesarean scar pregnancy with preservation of intrauterine gestation and delivery at term: case report
CASE REPORT Laparoscopic management of heterotopic cesarean scar pregnancy with preservation of intrauterine gestation and delivery at term: case report L. Cem Demirel, M.D., Harika Bodur, M.D., Belgin Selam, M.D., Arda Lembet, M.D., and Tolga Ergin, M.D. Department of Obstetrics and Gynecology, Acibadem Health Group, Istanbul, Turkey
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. (Fertil Steril 2009;91: 1293.e5–e7. 2009 by American Society for Reproductive Medicine.) Key Words: Heterotopic cesarean scar pregnancy, laparoscopy
The incidence of heterotopic cesarean scar pregnancy during spontaneous cycles is extremely low. The frequency of spontaneous heterotopic pregnancy is reported as 1:10,000 to 1:50,000 (1, 2). Despite lack of a standard treatment protocol, medical and surgical treatment modalities have recently been suggested. Urgent hysterectomy may be required in patients with uncontrolled hemorrhage and uterine rupture. To the best of our knowledge this is the first case report on heterotopic cesarean scar pregnancy managed successfully by a laparoscopic approach under ultrasound guidance. We also report alternative management options and discuss the surgical challenges. CASE REPORT A 34-year-old woman, gravida 2, para 1, who had a menstrual delay of 7 weeks, presented with a dark reddish-brown vaginal Received November 27, 2007; revised January 15, 2008; accepted January 17, 2008; published online March 18, 2008. L.C.D. has nothing to disclose. H.B. has nothing to disclose. B.S. has nothing to disclose. A.L. has nothing to disclose. T.E. has nothing to disclose. Presented at the 61st Annual Meeting of the American Society for Reproductive Medicine, October 14–19, 2005, Montreal, Quebec, Canada. Reprint requests: L. Cem Demirel, M.D., Reproductive Endocrinology, IVF Division, Acibadem Hospital, Tekin Sk. 8, Istanbul 34718, Turkey (FAX: 90-216-326-71-67; E-mail: [email protected]).
0015-0282/09/$36.00 doi:10.1016/j.fertnstert.2008.01.067
discharge. She had previously undergone a lower segment transverse cesarean section. We observed two gestational sacs with fetal cardiac activity by transvaginal ultrasound at 6 weeks and 5 days of pregnancy. One of the gestational sacs was located in the uterine cavity, whereas the other was within the previous cesarean scar (Fig. 1A). The heterotopic sac was implanted in the vicinity of the anterior cervicoisthmic wall. We informed the patient about the pathology and discussed the management options of heterotopic pregnancy. After informed consent had been obtained, operative laparoscopy was performed. Initially we were not able to visualize the heterotopic pregnancy during laparoscopy. We used transvaginal ultrasonographic guidance to determine the exact site of the ectopic gestation and proper line of incision. We dissected the vesicoperitoneal reflection over the anterior isthmic wall separating the lower uterine segment from the bladder by sharp, blind, and hydro-dissections to gain access to the site of heterotopic pregnancy at the previous cesarean scar. We palpated the bulging part of the ectopic gestational sac by the tip of the aspirator. Trophoblastic tissue was observed to be protruding from the heterotopic gestational sac after incision with unipolar electrocautery (Fig. 1B). There was profuse bleeding from the vascular bed after evacuation of the ectopic pregnancy by
Fertility and Sterility Vol. 91, No. 4, April 2009 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc.
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FIGURE 1 (A) Ectopic gestational sac located at the previous cesarean scar. (B) Incision to the heterotopic gestational sac with unipolar electrocautery was demonstrated. (C) Profuse bleeding observed during evacuation of the heterotopic cesarean scar pregnancy.
hematocrit values were 11.5 g/dL, 34.4% and 9.6 g/dL, 28.3%, respectively. Postoperative follow-up was uneventful. Results from pathologic examination of the tissue removed were reported as trophoblastic tissue proliferation and chorion villus, consistent with ectopic pregnancy. Ongoing intrauterine pregnancy ended with a live birth by cesarean delivery at 38 weeks’ gestation. We did not observe any pathology other than healed previous cesarean scar on site of repair at the time of repeat cesarean section. DISCUSSION Management of heterotopic cesarean scar pregnancy is a challenge, especially when the woman desires preservation of the concurrent intrauterine pregnancy. Ectopic pregnancy located within the cesarean section scar tissue has a high risk of rupture and bleeding. The early diagnosis of an ectopic component of the heterotopic pregnancy may be overlooked, especially with the presence of an intrauterine pregnancy. Ectopic trophoblasts are embedded into repaired myometrium in close proximity to the bladder. High-resolution transvaginal ultrasonography is an important diagnostic tool in such cases. Doppler sonography also reveals the trophoblastic vessels for confirmation of diagnosis. The second conceptus might be implanted heterotopically to the uterine incision in case of an existing scar defect or microscopically, through a tract from the endometrial canal up to the scar tissue (3). Treatment options for cesarean scar pregnancy include transvaginal embryo aspiration, potassium chloride injection, and local or systemic methotrexate therapies (4, 5). Placentatoxic agents may affect the intrauterine fetus with possible side effects. Salomon et al. (4) reported the results of potassium chloride injection into the heterotopic cesarean scar pregnancy. They found an amorphous bulging mass along the embryo reduction site when they performed cesarean section for the viable fetus. Pathologic examination demonstrated residual placental and deciduous tissues, which could be predisposing factors for uterine rupture during uterine contractions. Potassium chloride or hyperosmolar glucose may be used for selective termination of ectopic gestation (2, 4).
Demirel. Heterotopic cesarean scar pregnancy. Fertil Steril 2009.
the suction–irrigation and grasping forceps (Fig. 1C). Unipolar scissors were used to trim the incisional edge. Myometrial defect was repaired by intracorporeal interrupted 2/0 mattress polyglactin sutures. The procedure was completed within 45 minutes. Preoperative and postoperative hemoglobin and 1293.e6
Demirel et al.
The major problem after medical approaches may be the difficulty of getting a strong lower segment in the presence of a concurrent intrauterine pregnancy. Seow et al. (3) reported the results of 12 cesarean scar pregnancies. Nine patients were treated with local and/or systemic methotrexate, and the interval for disappearance of the ectopic mass ranged from 2 months to 1 year after the procedure. One patient had a uterine rupture at 38 weeks and 3 days of gestation during the follow-up of the intrauterine pregnancy (3). We preferred surgical removal of the placental tissue and repair of the myometrium, considering the side effects of medical treatment. Wang et al. (6) suggested an endoscopic approach as a firstline treatment option for non-heterotopic cesarean scar
Heterotopic cesarean scar pregnancy
Vol. 91, No. 4, April 2009
pregnancy. Laparoscopic treatment was used in four women. The major problem during laparoscopy was the risk of hemorrhage. The mean (SD) value for operative time of laparoscopy was 113.8 32 minutes, and blood loss was 200 108 mL in these cases. The operative time in our case was much shorter, and we did not have any postoperative complications. The intrauterine pregnancy ended uneventfully. Surgical removal of the ectopic mass by a laparoscopic approach may be offered in heterotopic cesarean scar pregnancy as in the presented case. Laparoscopic excision of the cesarean scar pregnancy gives the opportunity to preserve the viable intrauterine gestation while constituting a strong lower uterine segment. Ultrasound is an adjunctive tool that helps for precise localization of the ectopic sac during the procedure in these rare cases.
Fertility and Sterility
REFERENCES 1. Barrenetxea G, Rementeria LB, Larruzea AL, Agirregoikoa JA, Mandiola M, Carbonero K. Heterotopic pregnancy: two cases and comparative review. Fertil Steril 2007;87:417. e9–15. 2. Goldenberg JM, Bedaiwy MA. Transvaginal local injection of hyperosmolar glucose for the treatment of heterotopic pregnancy. Obstet Gynecol 2006;107:509–10. 3. Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol 2004;23:247–53. 4. Salomon LJ, Fernandez H, Chauveaud A, Doumerc S, Frydman R. Successful management of a heterotopic Caesarean scar pregnancy: potassium chloride injection with preservation of the intrauterine gestation: case report. Hum Reprod 2003;18:189–91. 5. Hsieh BC, Hwang JL, Pan HS, Huang SC, Chen CY, Chen PH. Heterotopic caesarean scar pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for selective embryo reduction: case report. Hum Reprod 2004;19:285–7. 6. Wang CJ, Chao AS, Yuen LT, Wang CW, Soong YK, Lee CL. Endoscopic management of cesarean scar pregnancy. Fertil Steril 2006;85:494. e1–4.
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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. (Fertil Steril 2009;91: 1293.e5–e7. 2009 by American Society for Reproductive Medicine.) Key Words: Heterotopic cesarean scar pregnancy, laparoscopy
The incidence of heterotopic cesarean scar pregnancy during spontaneous cycles is extremely low. The frequency of spontaneous heterotopic pregnancy is reported as 1:10,000 to 1:50,000 (1, 2). Despite lack of a standard treatment protocol, medical and surgical treatment modalities have recently been suggested. Urgent hysterectomy may be required in patients with uncontrolled hemorrhage and uterine rupture. To the best of our knowledge this is the first case report on heterotopic cesarean scar pregnancy managed successfully by a laparoscopic approach under ultrasound guidance. We also report alternative management options and discuss the surgical challenges. CASE REPORT A 34-year-old woman, gravida 2, para 1, who had a menstrual delay of 7 weeks, presented with a dark reddish-brown vaginal Received November 27, 2007; revised January 15, 2008; accepted January 17, 2008; published online March 18, 2008. L.C.D. has nothing to disclose. H.B. has nothing to disclose. B.S. has nothing to disclose. A.L. has nothing to disclose. T.E. has nothing to disclose. Presented at the 61st Annual Meeting of the American Society for Reproductive Medicine, October 14–19, 2005, Montreal, Quebec, Canada. Reprint requests: L. Cem Demirel, M.D., Reproductive Endocrinology, IVF Division, Acibadem Hospital, Tekin Sk. 8, Istanbul 34718, Turkey (FAX: 90-216-326-71-67; E-mail: [email protected]).
0015-0282/09/$36.00 doi:10.1016/j.fertnstert.2008.01.067
discharge. She had previously undergone a lower segment transverse cesarean section. We observed two gestational sacs with fetal cardiac activity by transvaginal ultrasound at 6 weeks and 5 days of pregnancy. One of the gestational sacs was located in the uterine cavity, whereas the other was within the previous cesarean scar (Fig. 1A). The heterotopic sac was implanted in the vicinity of the anterior cervicoisthmic wall. We informed the patient about the pathology and discussed the management options of heterotopic pregnancy. After informed consent had been obtained, operative laparoscopy was performed. Initially we were not able to visualize the heterotopic pregnancy during laparoscopy. We used transvaginal ultrasonographic guidance to determine the exact site of the ectopic gestation and proper line of incision. We dissected the vesicoperitoneal reflection over the anterior isthmic wall separating the lower uterine segment from the bladder by sharp, blind, and hydro-dissections to gain access to the site of heterotopic pregnancy at the previous cesarean scar. We palpated the bulging part of the ectopic gestational sac by the tip of the aspirator. Trophoblastic tissue was observed to be protruding from the heterotopic gestational sac after incision with unipolar electrocautery (Fig. 1B). There was profuse bleeding from the vascular bed after evacuation of the ectopic pregnancy by
Fertility and Sterility Vol. 91, No. 4, April 2009 Copyright ª2009 American Society for Reproductive Medicine, Published by Elsevier Inc.
1293.e5
FIGURE 1 (A) Ectopic gestational sac located at the previous cesarean scar. (B) Incision to the heterotopic gestational sac with unipolar electrocautery was demonstrated. (C) Profuse bleeding observed during evacuation of the heterotopic cesarean scar pregnancy.
hematocrit values were 11.5 g/dL, 34.4% and 9.6 g/dL, 28.3%, respectively. Postoperative follow-up was uneventful. Results from pathologic examination of the tissue removed were reported as trophoblastic tissue proliferation and chorion villus, consistent with ectopic pregnancy. Ongoing intrauterine pregnancy ended with a live birth by cesarean delivery at 38 weeks’ gestation. We did not observe any pathology other than healed previous cesarean scar on site of repair at the time of repeat cesarean section. DISCUSSION Management of heterotopic cesarean scar pregnancy is a challenge, especially when the woman desires preservation of the concurrent intrauterine pregnancy. Ectopic pregnancy located within the cesarean section scar tissue has a high risk of rupture and bleeding. The early diagnosis of an ectopic component of the heterotopic pregnancy may be overlooked, especially with the presence of an intrauterine pregnancy. Ectopic trophoblasts are embedded into repaired myometrium in close proximity to the bladder. High-resolution transvaginal ultrasonography is an important diagnostic tool in such cases. Doppler sonography also reveals the trophoblastic vessels for confirmation of diagnosis. The second conceptus might be implanted heterotopically to the uterine incision in case of an existing scar defect or microscopically, through a tract from the endometrial canal up to the scar tissue (3). Treatment options for cesarean scar pregnancy include transvaginal embryo aspiration, potassium chloride injection, and local or systemic methotrexate therapies (4, 5). Placentatoxic agents may affect the intrauterine fetus with possible side effects. Salomon et al. (4) reported the results of potassium chloride injection into the heterotopic cesarean scar pregnancy. They found an amorphous bulging mass along the embryo reduction site when they performed cesarean section for the viable fetus. Pathologic examination demonstrated residual placental and deciduous tissues, which could be predisposing factors for uterine rupture during uterine contractions. Potassium chloride or hyperosmolar glucose may be used for selective termination of ectopic gestation (2, 4).
Demirel. Heterotopic cesarean scar pregnancy. Fertil Steril 2009.
the suction–irrigation and grasping forceps (Fig. 1C). Unipolar scissors were used to trim the incisional edge. Myometrial defect was repaired by intracorporeal interrupted 2/0 mattress polyglactin sutures. The procedure was completed within 45 minutes. Preoperative and postoperative hemoglobin and 1293.e6
Demirel et al.
The major problem after medical approaches may be the difficulty of getting a strong lower segment in the presence of a concurrent intrauterine pregnancy. Seow et al. (3) reported the results of 12 cesarean scar pregnancies. Nine patients were treated with local and/or systemic methotrexate, and the interval for disappearance of the ectopic mass ranged from 2 months to 1 year after the procedure. One patient had a uterine rupture at 38 weeks and 3 days of gestation during the follow-up of the intrauterine pregnancy (3). We preferred surgical removal of the placental tissue and repair of the myometrium, considering the side effects of medical treatment. Wang et al. (6) suggested an endoscopic approach as a firstline treatment option for non-heterotopic cesarean scar
Heterotopic cesarean scar pregnancy
Vol. 91, No. 4, April 2009
pregnancy. Laparoscopic treatment was used in four women. The major problem during laparoscopy was the risk of hemorrhage. The mean (SD) value for operative time of laparoscopy was 113.8 32 minutes, and blood loss was 200 108 mL in these cases. The operative time in our case was much shorter, and we did not have any postoperative complications. The intrauterine pregnancy ended uneventfully. Surgical removal of the ectopic mass by a laparoscopic approach may be offered in heterotopic cesarean scar pregnancy as in the presented case. Laparoscopic excision of the cesarean scar pregnancy gives the opportunity to preserve the viable intrauterine gestation while constituting a strong lower uterine segment. Ultrasound is an adjunctive tool that helps for precise localization of the ectopic sac during the procedure in these rare cases.
Fertility and Sterility
REFERENCES 1. Barrenetxea G, Rementeria LB, Larruzea AL, Agirregoikoa JA, Mandiola M, Carbonero K. Heterotopic pregnancy: two cases and comparative review. Fertil Steril 2007;87:417. e9–15. 2. Goldenberg JM, Bedaiwy MA. Transvaginal local injection of hyperosmolar glucose for the treatment of heterotopic pregnancy. Obstet Gynecol 2006;107:509–10. 3. Seow KM, Huang LW, Lin YH, Lin MY, Tsai YL, Hwang JL. Cesarean scar pregnancy: issues in management. Ultrasound Obstet Gynecol 2004;23:247–53. 4. Salomon LJ, Fernandez H, Chauveaud A, Doumerc S, Frydman R. Successful management of a heterotopic Caesarean scar pregnancy: potassium chloride injection with preservation of the intrauterine gestation: case report. Hum Reprod 2003;18:189–91. 5. Hsieh BC, Hwang JL, Pan HS, Huang SC, Chen CY, Chen PH. Heterotopic caesarean scar pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for selective embryo reduction: case report. Hum Reprod 2004;19:285–7. 6. Wang CJ, Chao AS, Yuen LT, Wang CW, Soong YK, Lee CL. Endoscopic management of cesarean scar pregnancy. Fertil Steril 2006;85:494. e1–4.
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