Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Hsin Street, Kwei-Shan, Tao-Yuan, Taiwan
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Abstract |
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Key words: Caesarean section scar/ectopic pregnancy/hysteroscopy/laparoscopy
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Introduction |
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Case report |
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Diagnostic and possible operative laparoscopy was arranged. Under general endotracheal anaesthesia, the patient was placed in the 15 degree Trendelenburg position. A Foley catheter was inserted pre-operatively in order to enable continuous monitoring of urine output during the operation. The Veress needle was inserted through a small incision just inferior to the umbilicus. Pneumoperitoneum was created by insufflating carbon dioxide at a maximal pressure of 15 mm Hg. After the Veress needle was removed, an operative 10 mm trocar was inserted into the abdomen. A laparoscope with an attached camera was inserted through the cannula to visualize the intra-abdominal organs. Two additional 5 mm trocars were inserted at the level of the anterior superior iliac spine, lateral to the epigastric blood vessels. The uterus was anteverted and normal in size, but a bulging mass was seen, measuring 5 cm in diameter arising from serosa of the previous Caesarean section scar (Figure 1). The jejunum was adherent over the mass but without evidence of fistula. Bilateral adnexae were normal. Free fluid in the pouch of Douglas was not visualized. The adhesion caused by the anterior uterine mass was removed carefully and completely. Surgical laparoscopy began but with equipment and staff prepared for immediate laparotomy if required. An incision was made over the most prominent area of the mass (Figure 2
). Dark reddish tissue suggestive of the products of conception was noted and removed using grasping forceps. Homeostasis was achieved using Wolf bipolar forceps at 20 W. One layer of continuous endoscopic sutures along the affected uterine wall was made with 10 Prolene (Figure 3
). The gestational tissue was removed in an endobag. The total operative time was 110 min. Blood loss was limited and no blood transfusion needed. Histopathology revealed blood clots with necrotic villi which was consistent with ectopic pregnancy. The patient was discharged on the third postoperative day after an uneventful recovery. No subsequent abnormal uterine bleeding was noted during regular follow-up for 1 year.
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Discussion |
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In our patient, the concentration of ß-HCG did not appear to be associated with the trophoblastic activity. ß-HCG has been reported to indicate abnormal progression in patients with eroding vessels or existing haematoma. Therefore, the return of ß-HCG to normal values might reflect residual trophoblastic activity. Although it was difficult to determine the size and status of the ectopic pregnancy pre-operatively, careful ultrasound examination might be of use in making the diagnosis of early ectopic gestation. The appearance of an anterior bulging mass outside the contour of the uterus during pregnancy should raise the suspicion of ectopic pregnancy, especially when the patient has received a prior Caesarean section. Nevertheless, the diagnosis is sometimes not made until the uterus ruptures and the patient develops haemoperitoneum and hypovolaemic shock. In these circumstances, a hysterectomy is usually required, as described previously (Huang et al., 1998).
Dilatation and curettage is one of the contraindications in ectopic pregnancy in a previous Caesarean section scar; this procedure may cause uterine perforation inducing intractable bleeding, and laparotomy or even hysterectomy is often required. Thus, both ultrasonography and hysteroscopy provide useful information for an early and accurate diagnosis. The hysteroscope allows the cervix and the uterine cavity to be distended with relatively little trauma. The hysteroscopic findings of a normal uterine cavity, together with gestation tissue at the lower corpus, were further evidence of the likelihood of ectopic pregnancy.
There is still a lack of information concerning the adequacy of management strategies for previous Caesarean section scar pregnancy including local injections of potassium chloride (KCl), methotrexate (MTX) or abdominal hysterectomy. No modality is entirely reliable, and none can guarantee uterine integrity. The effectiveness of operative laparoscopy in the treatment of the reproductive and gynaecological lesion is well established. In our hospital, laparoscopic hysterectomy is now employed in the vast majority of hysterectomies. In cases of intractable bleeding during operative laparoscopy, laparoscopic hysterectomy can serve as an immediate alternative. In our patient, the absence of a viable fetus, and the lack of significant flow on Doppler sonography, enabled us to perform operative laparoscopy as a diagnostic modality. Therefore, in addition to its value as a diagnostic tool, laparoscopy enabled the successful treatment of an unruptured ectopic pregnancy in a previous Caesarean scar, making it possible to avoid unnecessary exploratory laparotomy and to preserve the patient's reproductive capability.
In short, pregnancy in a previous Caesarean section scar is the rarest kind of all ectopic pregnancies and probably one of the most dangerous because of the risk of rupture and haemorrhage. No treatment modality is entirely reliable, and none can guarantee uterine integrity. In this case, hysteroscopy together with laparoscopy proved to be a reliable method for diagnosing and managing ectopic pregnancy in a previous Caesarean section scar and it enabled uterine preservation.
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Notes |
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References |
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Submitted on October 6, 1998; accepted on February 2, 1999.