Service de Gynécologie-Obstétrique, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris (AP-HP), 157 rue de la Porte-de-Trivaux, 92140 Clamart, France 1 To whom correspondance should be addressed. e-mail: herve.fernandez{at}abc.ap-hop-paris.fr
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Abstract |
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Key words: Caesarean scar pregnancy/heterotopic pregnancy/selective embryo reduction
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Introduction |
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We report here the first case of a heterotopic pregnancy in which the ectopic pregnancy implanted into the previous Caesarean scar and was successfully treated with potassium chloride under sonographic guidance. We discuss the management options and review the literature.
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Case report |
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Routine check-up found no evidence of abnormalities to explain her secondary infertility. She underwent a successful IVF cycle, with three embryos transferred. Her ß-hCG values were normal, and she had no signs or symptoms of an ectopic pregnancy. Routine vaginal ultrasonographic (US) examination at six weeks revealed two gestational sacs (Figure 1). One embryo was normally implanted into the uterine cavity, and the other appeared to be located in the anterior isthmic wall. Both had cardiac activity, crownrump length and yolk sac that were normal for gestational age. The US examination was repeated at 8 weeks and confirmed a heterotopic pregnancy with one ongoing pregnancy in a normally implanted sac and one in a sac located in the previous Caesarean scar (Figure 1). The cervix was normal, and the pelvic examination unremarkable.
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Premature rupture of the membranes occurred at 36 weeks. A healthy girl weighing 2800 g, was delivered by Caesarean section. Surgical exploration of the scar revealed no sign of uterine rupture, but found an amorphous bulging mass, 3 x 3 cm in area, along the lower segment. This mass was removed for pathological examination, which found placental and deciduous tissues but no remaining elements consistent with an embryo.
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Discussion |
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From a strictly theoretical point of view, a CSP might be considered either intrauterine or ectopic, but in practice it appears to be very rare (Neiger et al., 1998). Little information is available about its exact incidence or pathogenesis. Diagnosis is usually made by US examination, but laparoscopy (Roberts et al., 1998
), hysteroscopy (Lee et al., 1999
) or even magnetic resonance imaging (Godin et al., 1997
) can also be helpful. CSP carries with it a high risk of bleeding and rupture (Godin et al., 1997
; Lee et al., 1999
), which may necessitate hysterectomy (Marcus et al., 1999
; Huang et al., 1998
).
To our knowledge, this is the first reported case of twin gestation with one intrauterine pregnancy and one CSP. It was a particularly challenging case for us because we had to try to conserve our patients fertility and at the same time maintain the intrauterine pregnancy. Various management options for CSP have been described in the literature. Herman et al. experimented with expectant management to try to carry the CSP to term, but an emergency Caesarean delivery was finally necessary (Herman et al., 1995). Planned and emergency surgery for acute symptoms have been reported (Lee et al., 1999
; Valley et al., 1998
) but uncontrolled bleeding may require hysterectomy (Marcus et al., 1999
; Huang et al., 1998
). Successful medical treatment has generally used local and/or systemic methotrexate, because of its reported efficacy in tubal pregnancies (Stovall et al., 1991
; Fernandez et al., 1993
). It can be combined with a feticidal agent (Roberts et al., 1998
) such as potassium chloride, as described for other heterotopic pregnancies (Monteagudo et al., 1996
; Fernandez et al., 1993
; Benifla et al., 1996
).
In this case, the mother reported no symptoms, such as abdominal pain or bleeding, that might have required a surgical approach. Furthermore, such treatment would necessarily have exposed the intrauterine pregnancy to serious risks. Because the diagnosis was confirmed at an early gestational age and the patient was asymptomatic, conservative management was possible. We considered methotrexate to halt trophoblast proliferation and to reduce to the minimum the risk of bleeding and uterine rupture, but these effects were outweighed by its potential teratogenicity (Jordan et al., 1977; Timor-Tritsch, 1998
). We therefore decided to inject potassium chloride selectively into the CSP. This action successfully terminated the CSP and prevented further development. The intrauterine pregnancy was not affected and remained uneventful. Moreover, to our knowledge, the minimum thickness of the remaining scar tissue to warrant a safety successful intrauterine pregnancy is unknown and cannot be used to improve the indication of the medical management in these rare cases.
In conclusion, potassium chloride can be injected under US guidance to terminate CSP. It should be the first-line treatment when an asymptomatic patient presents a CSP associated with a normal intrauterine pregnancy.
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References |
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Submitted on June 26, 2002; accepted on September 9, 2002