tltih

Surgeon’s Corner www.AJOG.org

Ectopic pregnancy in a cesarean-section scarThe patient �6 weeks into an ectopic pregnancy, underwent local treatment

Gary N. Frishman, MD; Katherine E. Melzer, MD; Bala Bhagavath, MD

Problem: prevalence likely to riseNontubal ectopic pregnancies remain asignificant treatment challenge. Cases ofcesarean scar ectopic pregnancies (CSP)have increased significantly; this may berelated to the growing number of cesar-ean deliveries that are being performedor to improved diagnosis.1 No standardreatment protocol has yet been estab-ished. Adverse sequelae for both un-reated and treated CSPs include uter-ne rupture, severe hemorrhage, andysterectomy.2,3

A 27-year-old woman, G4P2012, hadcomplaints of spotting and a missed pe-riod. Her history was notable for 2 cesar-ean deliveries and a dilation and curettagefor a spontaneous abortion. Ultrasoundimaging was suspicious for an ectopicpregnancy that was 6 weeks 3 days and lo-cated between the uterus and bladder atthe site of the cesarean scar (Figure 1).Three-dimensional ultrasound imagingconfirmed the extrauterine location (Fig-ure 2). Fetal cardiac activity was 120 beatsper minute. The patient’s serum beta-hu-man chorionic gonadotropin level was32,673 mIU/mL.

Giventheadvancedpresentationandlo-cation, local therapy was chosen over sys-temic treatment or a potentially difficultsurgical approach. In the operating room,

From the Division of Reproductive Medicineand Infertility, Department of Obstetrics andGynecology, Alpert Medical School, BrownUniversity, Providence, RI.

The authors report no conflict of interest.

Presented at the American Association ofGynecologic Laparascopists’ 38th GlobalCongress of Minimally Invasive Gynecology,Orlando, FL, Nov. 15-19, 2009.

0002-9378/$36.00© 2012 Mosby, Inc. All rights reserved.doi: 10.1016/j.ajog.2012.03.009

VIDEOClick Supplementary Content underthe article title in the online Table ofContents

238.e1 American Journal of Obstetrics & Gynecolo

under transvaginal ultrasound guidance,the gestational sac was drained with a 17-gauge needle (Video clip). Methotrexate(50 mg/mL) was then instilled. The needlewas subsequently used to mechanicallydisrupt the pregnancy. Color Doppler ul-trasound imaging was performed at base-line and at the end of the procedure to con-firm the absence of fetal cardiac activity.Ultrasound confirmation of hemostasiswas documented. Blood loss was negligi-ble, and the patient recovered unevent-fully. Serum beta- human chorionic go-

FIGURE 1

ltrasound imaging indicated the presence of anrishman. Ectopic pregnancy in a cesarean-section scar. Am J

Cesarean scar ectopic pregnancies may berupture or hysterectomy. Based on location acardiac activity, local treatment with transvaginan excellent option which also optimizes the c

Key words: cesarean scar pregnancy, ecto

Cite this article as: Frishman GN, Melzer KE, Bhascar: the patient, �6 weeks into an ectopic prGynecol 2012;207:238.e1-2.

gy SEPTEMBER 2012

nadotropin levels were followed to ensurecomplete resolution.

Given the relative rarity of CSPs, noseries have evaluated the best treatmenttechnique. As the number of cesareandeliveries increases, this condition willlikely be encountered more frequently.Our case illustrates diagnosis and thefeasibility of local therapy as a minimallyinvasive management plan. This allowsfertility preservation in patients with ad-vanced CSP, especially with the presenceof fetal heart tones. f

opic pregnancy at the site of the cesarean scar.tet Gynecol 2012.

cult to diagnose and may result in uterineascularity, especially in the presence of fetalltrasound-guided injection of methotrexate isce for fertility preservation.

pregnancy, methotrexate

ath B. Ectopic pregnancy in a cesarean-sectionancy, underwent local treatment. Am J Obstet

U ectF Obs

diffind val uhan

pic

gavegn

www.AJOG.org Surgeon’s Corner

SEPTEMBER 2012 Americ

REFERENCES1. Rotas MA, Haberman S, Levgur M. Cesareanscar ectopic pregnancies: etiology, diagnosis,and management. Obstet Gynecol 2006;107:1373-81.2. Herman A, Weinraub Z, Avrech O, MaymonR, Ron-El R, Bukovsky Y. Follow-up and out-come of isthmic pregnancy located in a previ-ous caesarean scar. BJOG 1995;102:839-41.3. Michener C. Dickinson JE. Caesarean scarectopic pregnancy: a single centre case series.Aust N Z J Obstet Gynaecol 2009;49:451-5.

FIGURE 2

The extrauterine location of the pregnancy was clearly confirmed by 3-dimensional ultrasound imaging.Frishman. Ectopic pregnancy in a cesarean-section scar. Am J Obstet Gynecol 2012.

an Journal of Obstetrics & Gynecology 238.e2