Resectoscopic treatment of ectopic pregnancy in previous cesarean ...

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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 e81
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 REFERENCES 1. Wang CJ, Yuen LT, Yen CF, Lee CL, Soong YK. Three-dimensional power Doppler ultrasound diagnosis and laparoscopic management of a pregnancy in a previous cesarean scar. J Laparoendosc Adv Surg Tech A 2004;14:399–402. 2. Deans R, Abbott J. Hysteroscopic management of cesarean scar ectopic pregnancy. Fertil Steril 2010;93: 1735–40. 3. Chang Y, Tsai EM, Long CY, Lee CL, Kay N. Resectoscopic treatment combined with sonohysterographic evaluation of women with postmenstrual bleeding as a result of previous cesarean delivery scar defects. Am J Obstet Gynecol 2009;200:370.e1–4. 4. Wang CJ, Tsai F, Chen C, Chao A. Hysteroscopic management of heterotopic cesarean scar pregnancy. Fertil Steril 2010;94:1529.e15–8. 5. 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. 6. Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. BJOG 2007;114:253–63. 7. Robinson JK, Dayal MB, Gindoff P, Frankfurter D. A novel surgical treatment for cesarean scar pregnancy: laparoscopically assisted operative hysteroscopy. Fertil Steril 2009;92:1497.e13–6. 8. 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. 9. Einenkel J, Stumpp P, Kosling S, Horn LC, Hockel M. A misdiagnosed case of caesarean scar pregnancy. Arch Gynecol Obstet 2005;271:178–81. 10. Vial Y, Petignat P, Hohlfeld P. Pregnancy in a cesarean scar. Ultrasound Obstet Gynecol 2000;16: 592–3. 11. Rotas MA, Haberman S, Levgur M. Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 2006;107:1373–81. 12. Arslan M, Pata O, Dilek TU, Aktas A, Aban M, Dilek S. Treatment of viable cesarean scar ectopic pregnancy with suction curettage. Int J Gynaecol Obstet 2005;89:163–6. 13. Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ. First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment cesarean section scar. Ultrasound Obstet Gynecol 2003;21:220–7. 14. Wang CJ, Yuen LT, Chao AS, Lee CL, Yen CF, Soong YK. Caesarean scar pregnancy successfully treated by operative hysteroscopy and suction curettage. BJOG 2005;112:839–40. 15. Ugur M, Yesilyurt H, Soysal S, Gokmen O. Prophylactic vasopressin during laparoscopic salpingotomy for ectopic pregnancy. J Am Assoc Gynecol Laparosc 1996;3:365–8. 16. Tulandi T, Beique F, Kimia M. Pulmonary edema: a complication of local injection of vasopressin at laparoscopy. Fertil Steril 1996;66:478–80. 17. Shimanuki H, Takeuchi H, Kitade M, Kikuchi I, Kumakiri J, Kinoshita K. The effect of vasopressin on local and general circulation during laparoscopic surgery. J Minim Invasive Gynecol 2006; 13:190–4. has toxicity, resulting in adverse effects such as bradycardia (mild decreases in pulse rate of 5 to 15 beats/min), transient hypertension, and pulmonary edema (15–18). Although a local vasopressin injection into the uterus during gynecologic surgery is safe, intraoperative myocardial infarction has been reported of a paracervical injection of 5 mL of diluted vasopressin (4.29 U/mL) (17, 19–21). Some researchers have reported severe complications after the administration of vasopressin, which was suspected to have been intravascular injections of concentrated vasopressin (0.5–0.6 U/mL) (16, 20, 22, 23). Several investigators have used more diluted solutions (range, 0.05–0.4 U/mL), delivering up to a maximum of 4 U with no side effects (24, 25). Therefore, one must be cautious about the concentration when using vasopressin. 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Nezhat F, Admon D, Nezhat CH, Dicorpo JE, Nezhat C. Life-threatening hypotension after vasopressin injection during operative laparoscopy, followed by uneventful repeat laparoscopy. J Am Assoc Gynecol Laparosc 1994;2:83–6. 23. Deschamps A, Krishnamurthy S. Absence of pulse and blood pressure following vasopressin injection for myomectomy. Can J Anaesth 2005;52:552–3. 24. Corson SL, Brooks PG, Serden SP, Batzer FR, Gocial B. Effects of vasopressin administration during hysteroscopic surgery. J Reprod Med 1994;39:419–23. 25. Phillips DR, Nathanson HG, Milim SJ, Haselkorn JS, Khapra A, Ross PL. The effect of dilute vasopressin solution on blood loss during operative hysteroscopy: a randomized controlled trial. Obstet Gynecol 1996;88:761–6. e82 Chang et al. Resectoscopy for cesarean scar pregnancy Vol. 96, No. 2, August 2011
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