Resectoscopic treatment of ectopic pregnancy in previous cesarean ...

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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