Resectoscopic treatment of ectopic pregnancy in previous cesarean ...

CASE REPORT
Resectoscopic treatment of ectopic pregnancy in
previous cesarean delivery scar defect with
vasopressin injection
Yu Chang, M.D., a Nari Kay, M.D., b Yung Hung Chen, M.D., c Hung Sheng Chen, M.D., a and Eing Mei Tsai, Ph.D. a
a Department of Obstetrics and Gynecology, Kaohsiung Medical University Hospital, Graduate Institute of Medicine, College of
Medicine, Kaohsiung Medical University, b Department of Obstetrics and Gynecology, E-Da Hospital, I-Shou University,
and c Department of Obstetrics and Gynecology, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung Medical University,
Kaohsiung, Taiwan
Objective: To describe resectoscopic treatment with vasopressin injection as an effective surgical intervention for
ectopic pregnancy in previous cesarean delivery scar (PCDS) defect.
Design: Case report.
Setting: University hospital.
Patient(s): Two women with ectopic pregnancy in PCDS defect.
Intervention(s): The patients underwent transvaginal ultrasound examination, followed by operative hysteroscopy
with vasopressin injection for evacuating the ectopic pregnancy in PCDS defect.
Main Outcome Measure(s): Conservation of the uterus.
Result(s): Successful resectoscopic treatment of ectopic pregnancy in PCDS defect.
Conclusion(s): Resectoscopic treatment of ectopic pregnancy in PCDS defect is a safe and efficient technique that
has the advantage of a rapid return to normal levels of b-hCG. Intracervical vasopressin administration could
decrease intraoperative bleeding and provide a clear view during the operation. (Fertil SterilÒ 2011;96:e80–2.
Ó2011 by American Society for Reproductive Medicine.)
Key Words: Cesarean delivery scar defect, ectopic pregnancy, hysteroscopy, vasopressin
An ectopic pregnancy developing in a previous cesarean delivery
scar (PCDS) defect is a rare event, and there is little information concerning
the adequacy of management strategies (1–3). Management
of ectopic pregnancy in PCDS defect carries a risk of uncontrollable
bleeding (4). With the increasing rate of cesarean deliveries, the
incidence of PCDS defect has been more than expected. This
emerging condition needs technique improvement in the treatment
of ectopic pregnancy in PCDS defect.
Hysteroscopic removal of ectopic pregnancy in PCDS defect has
been reported to be safe and effective in a small case series (2, 5).It
offers a short operative time, short postoperative stay, and rapid
return of levels of b-hCG to normal. To date, there have been only
a few cases in the literature reporting hysteroscopic treatment
success for ectopic pregnancy in PCDS defect (2, 6, 7). To our
knowledge, this will be the first report in an English-language journal
of hysteroscopic management with paracervical vasopressin
injection for this increasingly common problem.
Received March 30, 2011; revised May 6, 2011; accepted May 9, 2011;
published online June 12, 2011.
Y.C. has nothing to disclose. N.K. has nothing to disclose. Y.H.C. has
nothing to disclose. H.S.C. has nothing to disclose. E.M.T. has nothing
to disclose.
Reprint requests: Eing Mei Tsai, Ph.D., Department of Obstetrics and
Gynecology, Kaohsiung Medical University Hospital, Graduate Institute
of Medicine, College of Medicine, No. 100, Tzyou 1st Road, Kaohsiung
807, Taiwan (E-mail: tsaiem0510@gmail.com).
e80
CASE REPORT
Case 1
A 29-year-old woman, gravida 3, para 2, was referred to our hospital
at 7 weeks’ gestation with complaint of painless vaginal bleeding for
3 days. She had a history of 2 lower-segment transverse cesarean
deliveries. Transvaginal ultrasound (TVU) demonstrated a wellformed,
2.1-cm diameter gestational sac with a crown-rump length
of 8.1 mm and fetal cardiac activity in the PCDS defect. Laboratory
analysis showed a serum b-hCG level of 51,775 mIU/mL.
Case 2
A 29-year-old woman, gravida 2, para 1, with a previous history of
a cesarean delivery was referred to our hospital at 9 weeks’ gestation
for possible ectopic pregnancy in PCDS defect. TVU confirmed
a 1.94-cm diameter gestational sac in PCDS defect. The TVU findings
were compatible with an ectopic pregnancy in PCDS defect.
The serum level of b-hCG was 28,673 mIU/mL.
MATERIALS AND METHODS
A prospective study was undertaken at a tertiary referral obstetric
unit. Between October 2009 and September 2010, the previously
mentioned patients were diagnosed with ectopic pregnancy in
PCDS defect using TVU (Fig. 1). The two patients had a gestational
sac in the PCDS defect, an empty uterine cavity without a view of
the sac, and a clearly visible empty cervical canal. Before the
Fertility and Sterility â Vol. 96, No. 2, August 2011 0015-0282/$36.00
Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc. doi:10.1016/j.fertnstert.2011.05.032

FIGURE 1
Longitudinal view of ectopic pregnancy in PCDS defect (case 1).
The gestational sac is located in the PCDS defect and separated
from the cervical canal and endometrial cavity. PCDS ¼ previous
cesarean delivery scar.
Chang. Resectoscopy for cesarean scar pregnancy. Fertil Steril 2011.
operation, both patients were asked to sign an informed consent
approved by the institutional review board of Kaohsiung Medical
University, Kaohsiung, Taiwan.
The operation was performed by Y.C. using a 30-degree hysteroscope
with a 10-mm external diameter continuous flow sheath,
bipolar electrical current, and normal saline as a medium of
distension. Under general anesthesia, the patient was placed in the
dorsolithotomy position. After a speculum was placed inside the vagina,
a tenaculum was applied to the cervix and 10 mL of a diluted
vasopressin solution (0.4 U/mL; 20 units diluted into 50 mL) was
injected in equal amounts into the cervical stroma at the 4 and
8 o’clock positions. The cervix was then carefully dilated by Hegar
dilators to 11 mm.
The intervention began by identifying the implantation of the
ectopic sac. The gestational tissue was located in the PCDS defect
(Fig. 2) and removed under direct vision with cold resection by
a 90-degree wire-loop electrode. For dissection of the gestational
tissue and anterior uterine wall, a 180-degree rotation of the loop
electrode is recommended.
RESULTS
The operating time was 20 and 18 minutes for cases 1 and 2, respectively.
Vaginal bleeding was minimal throughout the operation. The
patients had an unremarkable postoperative course and were both
discharged the next day. Quantitative b-hCG levels declined to
normal with a return time of 35 and 32 days for cases 1 and 2, respectively.
The depth of PCDS defect, measured by TVU after the first
menses post the hysteroscopic treatment, was 9.7 mm for case 1
and 6.5 mm for case 2.
DISCUSSION
The incidence of ectopic pregnancy in PCDS defect is unknown;
however, the estimated prevalence has been reported to be between
1 in 1,800 and 1 in 2,226 (6, 8). PCDS defect represents the most
Fertility and Sterility â
FIGURE 2
Hysteroscopic view of ectopic pregnancy in PCDS defect. The
pregnancy is located in the right side of the PCDS defect. os ¼
ostium.
Chang. Resectoscopy for cesarean scar pregnancy. Fertil Steril 2011.
important factor for this kind of ectopic pregnancy. However, the
etiopathogenesis, incidence, and prevalence of PCDS defect
remain unknown (3).
Diagnosis of ectopic pregnancy in PCDS defect is most often obtained
by TVU, with a sensitivity of 86.4% (2, 9). We propose this
modified sonographic diagnosis criteria for this condition: 1) the
trophoblast is located between the cervical canal and the anterior
uterine wall; 2) fetal parts are not present in the uterine cavity;
3) on a sagittal uterine view that runs through the amniotic sac, no
myometrium is seen between the gestational sac and the urinary
bladder, as illustrated by the lack of continuity of the anterior
uterine wall (10).
From our past experience, PCDS defects are most often located
directly underneath the endocervical ostium (os) and most often inside
of the cervical canal. Therefore, we assumed that some of the
cervical pregnancy diagnoses from the past could have been ectopic
pregnancies in PCDS defect. Postmenstrual abnormal uterine bleeding
is the most significant clinical presentation in patients with
PCDS defect (3). With that in mind, if the patient had a previous cesarean
delivery and presented with postmenstrual abnormal uterine
bleeding, there is a possibility of PCDS defect ectopic pregnancy.
The management of ectopic pregnancy in PCDS defect has varied,
and only a few centers have significant experience to date. Uterineconserving
treatment is preferred, and expectant management is not
recommended because of a high risk of uterine rupture (2, 11).Past
approaches have included systemic and/or local injection with
methotrexate, aspiration, local potassium chloride injection,
curettage, open scar resection, hysterectomy, laparoscopic scar
resection, embolization, and hysteroscopy (2, 4, 7, 8). However,
some of these approaches do not have good outcomes. For
example, dilation and curettage has been associated with a failure
rate of 70% (6, 12). It is because the ectopic pregnancy in PCDS
defect is not within the normal uterine cavity that attempts to treat
with dilation and curettage can potentially rupture the cesarean
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scar, leading to severe hemorrhage. As mentioned, methotrexate is
commonly used to treat ectopic pregnancy in PCDS defects.
According to published case reports of treatment with
methotrexate, the success rate is 71% to 80%, but it only appears
to be effective in women with b-hCG levels less than 5,000 mIU/
mL (6, 13).
Hysteroscopy is a minimally invasive operative technique that offers
direct visualization, low morbidity, and high primary success
rates to date, although numbers are small and further experience
would be helpful to determine the safest and most appropriate technique.
However, a double setup of laparoscopy and hysteroscopy is
necessary in patients suspected of having ectopic pregnancy in
PCDS defect. In the literature to date, the success rate of hysteroscopy
treatment is 14 of 14 (2, 5, 7, 14). Our 2 cases increase this
number to 16, with a 100% success rate and minimal associated
morbidity.
Vasopressin has been widely used for bleeding control in gynecologic
surgeries because of its potent vasoconstrictive effect, but it
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e82 Chang et al. Resectoscopy for cesarean scar pregnancy Vol. 96, No. 2, August 2011