1 Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, 2 School of Medicine, Fu Jen Catholic University, Taipei and 3 Department of Obstetrics and Gynecology, Taipei Medical University, Taipei, Taiwan
4 To whom correspondence should be addressed at: Department of Obstetrics and Gynecology, Shin Kong Wu Ho-Su Memorial Hospital, No. 95, Wen Chang Road, Shin Lin District, Taipei, Taiwan. e-mail: m004407{at}ms.skh.org.tw
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Abstract |
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Key words: Caesarean scar pregnancy/embryo aspiration/heterotopic pregnancy/selective embryo reduction
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Introduction |
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Case report |
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Ultrasound was repeated 2 weeks later and revealed that the gestational sac in the Caesarean scar had shrunk to a small echogenic area. Six weeks later, transvaginal ultrasound showed normal uterine anatomy with complete disappearance of the gestational sac. The two intrauterine pregnancies proceeded without further complication until the 32nd week gestational age, when emergency delivery was performed due to preterm labour.
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Discussion |
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The first report of CSP was by Larsen and Solomon (1978); laparotomy was required to evacuate the gestational tissue. Medical treatment with systemic or local injection of methotrexate (MTX), potassium chloride (KCl) and hyperosmolar glucose has been reported (Godin et al., 1997
; Ravhon et al., 1997
; Roberts et al., 1998
; Seow et al., 2000
; Shufaro and Nadjari, 2001
). Godin et al. (1997
) reported successful transvaginal aspiration in a CSP with intrathoracic KCl followed by MTX. Recently, Nawroth et al. (2001
) also described the combined effect of local and systemic MTX administration.
There are few case reports in the literature of heterotopic CSP. Some reports suggested that MTX treatment may be associated with spontaneous abortion and may cause congenital abnormality (Feldenkamp et al., 1993; Timor-Tritsch et al., 1998
). Salomon et al. (2003
) described a heterotopic CSP with one embryo implanted into the uterine cavity, and the other located in the anterior isthmus wall which was successfully managed with KCl injection into the area of the embryo to terminate the CSP at 8 weeks gestation. As we know, during injection of KCl, the fetus is sometimes pushed away from the needle and KCl diffuses into the amniotic sac, consequently it may diffuse to the adjacent sac. Toxic effects of KCl on the remaining fetuses have been reported by Tabsh et al. (1990
) and Wapner et al. (1990
). Our patient received IVF treatment and successfully conceived two intrauterine pregnancies coexisting with a CSP. This patient emphasized the need for preserving the intrauterine twin pregnancy and we opted for a more conservative treatment approach. Because of the teratogenic effect of MTX and the potentially toxic effect of KCl on the remaining fetus, the treatment was more complicated. Ravhon et al. (1997
) used i.m. MTX to treat a CSP at 8 weeks of gestation and aspiration of the fluid in the gestational sac was performed 9 weeks later after the MTX injection due to prolonged vaginal bleeding. They proposed that because the placenta is implanted mainly on fibrous tissue, absorption of the gestational sac is extremely slow and fine needle aspiration of the remaining fluid in the sac may be required. In this case, the CSP was in the 6th gestational week; the small embryonic size at this early stage of gestation makes the embryo more fragile, thus the chance of successful aspiration without the use of cardiotoxic agents may be higher. We used a technique of embryo aspiration of the CSP under vaginal sonography and successfully preserved the intrautrerine twin pregnancy. If the treatment were delayed to later gestational age, it is hard to say if this technique would still work or alternatively cause a catastrophic event, because the risk of rupture and haemorrhage directly correlated with the duration of pregnancy (Lam et al., 2002
). In conclusion, it is important to perform transvaginal ultrasound
56 weeks gestation to rule out the possibility of an abnormal pregnancy for the patient.
In view of the increasing use of Caesarean section and of assisted reproduction techniques, obstetricians should be aware of the possibility of this type of heterotopic pregnancy. This case suggests that when the diagnosis of CSP with additional intrauterine pregnancies is made at an early gestational age, fetal reduction of the CSP by embryo aspiration without any other rescue may be an effective alternative which does not result in undue risk of trauma to the intrauterine pregnancy.
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References |
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Submitted on July 15, 2003; accepted on October 19, 2003.