CASE REPORT | https://doi.org/10.5005/jp-journals-10006-1777 |
Conservative Management of Cesarean Scar Ectopic Pregnancy: A Case Series
1,2Department of Obstetrics and Gynaecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3Department of Anatomy, Banaras Hindu University, Varanasi, Uttar Pradesh, India
Corresponding Author: Raghunath S More, Department of Anatomy, Banaras Hindu University, Varanasi, Uttar Pradesh, India, Phone: +91 8808628696, e-mail: psychiatry.more@gmail.com
How to cite this article Rai S, Anu V, More RS. Conservative Management of Cesarean Scar Ectopic Pregnancy: A Case Series. J South Asian Feder Obst Gynae 2020;12(3):192–195.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Cesarean scar ectopic pregnancy (CSEP) is on the rise with increasing rate of cesarean section and better diagnostic modalities. Therefore, prompt and correct diagnosis and decision about treatment modality are important to reduce mortality and morbidity. Expertise of both gynecologist and radiologist is needed. High index of suspicion should be kept in mind, and any delay in management can lead to detrimental consequences. Here is a case series of three cases with CSEP and their conservative line of management. Diagnosis was made through history,clinical examination, serum beta-human chorionic gonadotropin (β-hCG) levels, ultrasound and hysteroscopy, and confirmed with histopathology also. Methotrexate was the primary treating modality in all the three cases, and the future fertility was preserved. The follow-up was by serum β-hCG and ultrasound scans.
Keywords: Caesarean, Ectopic pregnancy, Methotrexate..
INTRODUCTION
Cesarean scar pregnancy is the rarest form of ectopic pregnancy.1 It has been estimated that incidence 1/1,800–1/2,500 of all cesarean deliveries performed.2 Obliviously, very less data are available regarding its incidence and natural history. As there is increased incidence of cesarean section worldwide, so more number of cases are diagnosed and reported.1 Ectopic pregnancy is a life-threatening condition; in majority cases, it leads to complications such as uterine rupture, massive hemorrhage, hypovolemic shock, and maternal death.3 The outcome is dependent on early diagnosis and timely intervention. Transvaginal ultrasound and color flow Doppler provides a high diagnostic accuracy.4 Choice of treatment depends on the case presentation and usually managed by medically with methotrexate or surgically.5
The outmost aim of this present case series is that as cesarean scar ectopic pregnancies are a rarest presentation so difficult to diagnose and for which a management option may be hard to choose. This present case series patients diagnosed with transvaginal ultrasound (TVUS) confirmed with histopathology and successfully treated conservatively with methotrexate.
CASE DESCRIPTION
Patients Profile
The present study was retrospective case series of three patients (patients 1, 2 and 3) referred to the Department of Obstetrics and Gynaecology at Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, since 2018–2019. All three patients presented to us with per vaginal bleeding prior one week to 15 days at outpatient. Detailed obstetric history and clinical diagnosis of all patients done with TVUS, hysteroscopy, and in patient 3 confirmed with histopathology also. All patients underwent conservative treatment with multidose regimen of methotrexate. Clinical data and findings are presented in the Table 1.
Maternal age of all three cases ranged from 29 to 39 years. Patient 1 and patient 3 have per vaginal (PV) bleeding for past 15 days and 7 days, respectively, but both wished medical termination and took MTP kit on advice of a local doctor. Thereafter, they had continuous PV bleeding. Patient 2 came with chief complaint of PV spotting and pain abdomen for 1 week in antenatal clinic. On admission, all the patients investigated for their routine biochemical parameters that were within normal limit. At the time of admission, Patients 1 and 2 were hemodynamically stable. But for patient 3, on examination, pulse was 106 minutes and blood pressure was 110/70 mm Hg. She had severe pallor, Resuscitation was done, and three units of PRBC was transfused. After initial stabilization proceed to management.
MANAGEMENT
Clinical management for patients 1, 2, and 3 done conservatively with multidose regimen of methotrexate and serial ultrasonography (USG) and serum beta-human chorionic gonadotropin (β-hCG) were done. Findings are shown in Table 2 and Figures 1 to 3.
In patient 1, we planned to administer multidose regimen of methotrexate (0.1 mg/kg) on outpatient basis. Intramuscular methotrexate was administered on day 1, 3, 5, and 7 alternate with leucovorin (0.1 mg/kg) on day 2, 4, 6, and 8. In follow-up visits, patient had complaint of on and off PV spotting but was managed conservatively on tranexamic acid. Reassurance regarding prolonged duration and follow-up of such cases were given. Barrier contraception was advised for the next 6 months.
| Clinical history | Patient 1 | Patient 2 | Patient 3 |
|---|---|---|---|
| Maternal age (years) | 39 | 29 | 32 |
| Gravidity/parity | G3P1 | G3P1 | G4p3 |
| Presenting symptoms | Per vaginal bleeding for past 15 days | P/V spotting and pain abdomen for 1 weeks | Per vaginal bleeding for 1 week |
| Obstetric history | 1 previous preterm LSCS | 1 previous LSCS, indication-Beech, | 3 previous LSCS |
| 1 spontaneous abortion with D and C | 8 years old for meconium aspiration amniotic fluid | ||
| On maternal request | |||
| Due to 2 previous LSCSs | |||
| Gestational age at diagnosis (weeks) | 7 weeks | 6 weeks | 13 weeks |
| Pretreatment β-hCG level (IU/L) | 7850 mIU/L | 35,836 mIU/mL | 2086.20 mIU/mL |
| USG finding | Missed scar ectopic pregnancy with adherent retained product of conception | Gravid uterus with well-defined gestational sac in myometrial region below the scar in the anterior lower uterine segment | Failed scar ectopic pregnancy (7.7 × 5.9 cm) with deep myometrial invasion without any extrauterine extension. Vascularity is poor within the tissue |
| Days | Parameters | Patient 1 methotrexate (0.1 mg/kg) | Patient 2 multidose methotrexate (6 mL with 20% KCl intraamniotic) | Patient 3 methotrexate (50 mg/m2) single dose followed by curettage |
|---|---|---|---|---|
| Admission Day | β-hCG | 7850 mIU/mL | 35,836 mIU/mL | 2086.20 mIU/mL |
| USG findings | Missed scar ectopic with adherent retained product of conception | Gravid uterus with well-defined gestational sac in myometrial region below the scar in the anterior lower uterine segment | Failed scar ectopic pregnancy (7.7 × 5.9 cm) with deep myometrial invasion without any extrauterine extension. Vascularity is poor within the tissue | |
| Day 4 | β-hCG | 6739.90 mIU/mL | 53365 mIU/mL | — |
| USG findings | — | — | — | |
| Day 7 | β-hCG | 14180.16 mIU/mL | 3151 mIU/mL | 209.86 mIU/mL |
| USG findings | Missed scar ectopic with adherent rpoc. In comparison with the previous scan there is increased size of the lesion. However, the vascularity has significantly reduced | residual lesion (1.4 × 1.6 × 2.5 cm) in LSCS scar with prominent peripheral vascularity and central cavity showing low level echogenicity. | 4.28 × 3.61 cm trophoblastic tissue seen without any internal vascularity. No evidence of invasion | |
| Day 14 | β-hCG | 79.78 mIU/mL | — | — |
| USG findings | Missed scar ectopic with adherent retained product of conception in comparison with previous scan there is reduction of size of the lesion. Vascularity is significantly reduced | — | — | |
| Day 17 | β-hCG | — | 941.98 mIU/mL | 2.92 mIU/mL |
| USG findings | — | — | Normal scan | |
| Day 24 | β-hCG | 5.91 mIU/mL | — | — |
| USG findings | FUC of missed scar ectopic pregnancy residual scar tissue lesion seen with any obvious echogenic trophoblastic tissue and showing central liquefactive area suggesting necrosis in response to pharmacology | — | — | |
| Day 31 | β-hCG | 5.65 mIU/mL | — | |
| USG findings | Normal USG scan | — |
Figs 1A and B: (A) Transvaginal sonography scan showing anteriorly ectopic tissue with empty uterine cavity and cervical canal; (B) Hysteroscopic view showing anteriorly hanging in ectopic tissue (A, anterior; P, posterior; U, uterine cavity)
Figs 2A and B: (A) Transvaginal sonography scan scan showing anteriorly tented uterine wall with implanted gestational sac (G sac); (B) Ultrasonography-guided aspiration of amniotic fluid which was followed by KCl administration
Figs 3A and B: (A) Large adherent echogenic retained product of conception (RPOC); (B) Histopathology showing decidual tissue and chorionic villi
Hospitalized patient 2 was given intra-amniotic KCl (embryocide) and multidose methotrexate and were given 6 mL intra-amniotic infusion of 20% KCl after transvaginal sonography (TVS)-guided intra-amniotic aspiration. It was followed by intramuscular methotrexate (1 mg/kg) and was given on days 1, 3, 5, and 7 and alternated with Leucovorin (0.1 mg/kg). Patient 2 came with on and off PV bleeding in follow-up after 1 month but managed conservatively. Through counseling and explanation of course of treatment was a boot in recovery. Barrier contraception was advised for next 6 months to avoid teratogenic effect of methotrxate.
Comparatively, patient 3 was critical; therefore, after initial stabilization on third day of hospitalization, a single dose of intramuscular methotrxate was given (50 mg/m2) (BMI = 21.42). Patient complained of heavy p/v bleeding. Patient and attendants were explained the risk, and under high risk consent, careful curettage was done on the fourth day of admission for dislodgement of content. Tissue was sent for HPE. Biopsy showed decidual products and chorionic villi shown Figure 3B. Patient was relieved of PV bleeding and discharged on day of admission sixth day. Contraception was advised in follow-up. Patient opted for vasectomy.
DISCUSSION
CSEP is a type of ectopic pregnancy implanted completely or partially outside the uterine cavity into the previous scar within the myometrium. Risk factors that may contribute: deficient cesarean scar, pouch, diverticulum or niche (hinting to poorly healed scar), Retroflexion of uterus, prior uterine surgery, ectopic pregnancy, adenomyosis, IVF, previous cesarean for prematurity or breech presentation, emergency cesarean section, and single layer closure. Although a few studies have shown relation between the number of cesarean section and occurrence of CSEP, our case series has not concluded the same. The main pathophysiology seems poor wound healing.6 Low oxygen tension after implantation leads to increased invasion of cytotrophoblast up to myometrium and beyond. This in turn divides CSEP into two broad types. Type 1 grows toward the uterine cavity and is more common. This type progresses to viable pregnancy and involves significant risk of vaginal hemorrhage. Second type grows toward pelvis and bladder and/or the abdominal cavity with extremely high risk of uterine rupture.7 It is possible to diagnose 84.6% cases with help of of TVUS.8
Timor-Tritsch and Monteagudo2 studied the different therapeutic approaches of the CSEP.
Some of them are surgical approach with hysteroscopy, cervical dilation, and curettage (DandC), excision of the CSP, hysterectomy or embolization of the uterine arteries, and other exclusively medical approaches with methotrexate. There are different modalities with highest complications were those involving the use of MTX alone (62%), DandC (62%), and the administration of intramuscular MTX combined with DandC (86%).2 But in present study, patient 1 and patient 2 treated with Methotrexate only and patient 3 treated a combined approach single-dose methotrexate and DandC and results are in contrast to previously reported data by Timor-Tritsch and Monteagudo.2
Surgical option includes visually guided suction curettage, hysteroscopic removal, isthmic excision, and reconstruction abdominally or vaginally. UAE or Foley’s balloon catheter for reducing procedure associated risk. A non-viable pregnancy has not shown to cause uterine rupture. Hence, local administration of embryocidal drug followed by multidose regimen of methotrexate can prove as viable option. Patient should be carefully watched for side effects and weekly complete blood count and liver and kidney function test should be sent. Following conservative management, subsequent pregnancies have good outcomes, but there is risk of placenta accrete and recurrent CSEP. AV malformation is a potential long-term risk.9
CONCLUSION
First-trimester PV bleeding with previous scar can have dangerous consequences. Therefore, as early as possible, correct diagnosis and decision about treatment modality is important to reduce mortality and morbidity. Proper counseling and regular follow-up is required. Expertise of both gynecologist and radiologist is needed. High index of suspicion should be kept in mind, and any delay in management can lead to detrimental consequences. The management protocol majorly includes medical, surgical, or combined approach. Selection of which may depend on patient’s presenting complaint, fertility needs, type of CSEP, initial β-hCG levels, and expertise available. Hysteroscopy is a good tool for diagnostic as well as therapeutic purpose in cases of Type 1 CSEP. A standard protocol for management should be developed. Further research into risk stratification and management are needed to guide clinician and patient decision making.
ETHICAL CLEARANCE
Taken from institutional committee.
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