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Ectopic pregnancy in a cesarean-section scar The 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 rise Nontubal ectopic pregnancies remain a significant treatment challenge. Cases of cesarean scar ectopic pregnancies (CSP) have increased significantly; this may be related to the growing number of cesar- ean deliveries that are being performed or to improved diagnosis. 1 No standard treatment protocol has yet been estab- lished. Adverse sequelae for both un- treated and treated CSPs include uter- ine rupture, severe hemorrhage, and hysterectomy. 2,3 A 27-year-old woman, G4P2012, had complaints of spotting and a missed pe- riod. Her history was notable for 2 cesar- ean deliveries and a dilation and curettage for a spontaneous abortion. Ultrasound imaging was suspicious for an ectopic pregnancy that was 6 weeks 3 days and lo- cated between the uterus and bladder at the site of the cesarean scar (Figure 1). Three-dimensional ultrasound imaging confirmed the extrauterine location (Fig- ure 2). Fetal cardiac activity was 120 beats per minute. The patient’s serum beta-hu- man chorionic gonadotropin level was 32,673 mIU/mL. Given the advanced presentation and lo- cation, local therapy was chosen over sys- temic treatment or a potentially difficult surgical approach. In the operating room, under transvaginal ultrasound guidance, the gestational sac was drained with a 17- gauge needle (Video clip). Methotrexate (50 mg/mL) was then instilled. The needle was subsequently used to mechanically disrupt 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 hemostasis was documented. Blood loss was negligi- ble, and the patient recovered unevent- fully. Serum beta- human chorionic go- nadotropin levels were followed to ensure complete resolution. Given the relative rarity of CSPs, no series have evaluated the best treatment technique. As the number of cesarean deliveries increases, this condition will likely be encountered more frequently. Our case illustrates diagnosis and the feasibility of local therapy as a minimally invasive management plan. This allows fertility preservation in patients with ad- vanced CSP, especially with the presence of fetal heart tones. f From the Division of Reproductive Medicine and Infertility, Department of Obstetrics and Gynecology, Alpert Medical School, Brown University, Providence, RI. The authors report no conflict of interest. Presented at the American Association of Gynecologic Laparascopists’ 38th Global Congress 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 VIDEO Click Supplementary Content under the article title in the online Table of Contents FIGURE 1 Ultrasound imaging indicated the presence of an ectopic pregnancy at the site of the cesarean scar. Frishman. Ectopic pregnancy in a cesarean-section scar. Am J Obstet Gynecol 2012. Cesarean scar ectopic pregnancies may be difficult to diagnose and may result in uterine rupture or hysterectomy. Based on location and vascularity, especially in the presence of fetal cardiac activity, local treatment with transvaginal ultrasound-guided injection of methotrexate is an excellent option which also optimizes the chance for fertility preservation. Key words: cesarean scar pregnancy, ectopic pregnancy, methotrexate Cite this article as: Frishman GN, Melzer KE, Bhagavath B. Ectopic pregnancy in a cesarean-section scar: the patient, 6 weeks into an ectopic pregnancy, underwent local treatment. Am J Obstet Gynecol 2012;207:238.e1-2. Surgeon’s Corner www. AJOG.org 238.e1 American Journal of Obstetrics & Gynecology SEPTEMBER 2012
