Cesarean section scar pregnancy

Abstract

Introduction: Cesarean section scar pregnancy (CSSP) occurs due to implantation of the gestational sac over the previous cesarean section or hysterotomy scars. Case description: A 40-year-old woman referred to our hospital with a missed period for 5 weeks +3 days, mild vaginal spotting and β-hCG 5770 mIU/ml as a case of ectopic pregnancy. The repeated β-hCG was 8797 mIU/ml and the transvaginal ultrasound (TVS) showed the gestational sac located in the lower anterior quadrant of the uterus behind the urinary bladder (only a thin layer of myometrium separating it from the bladder), close to the internal cervical os and the site of the previous scars. The case was diagnosed as CSSP and managed according to the hospital protocol by systemic multi-dose methotrexate (MTX) with follow-up using β-hCG, TVS and complete blood count (CBC). When the β-hCG result was found to be 60.66 mIU/ml, and the repeated weekly TVS showed a progressive decrease in the size of the gestational sac, the studied woman was discharged from the hospital for follow-up in the outpatient department (OPD). Conclusions: There is no single best treatment to terminate the CSSP, and the procedure with the fewest complications should be selected. Several authors support systemic multi-dose MTX treatment for CSSP with follow-up using TVS, β-hCG and CBC.

Primary hepatic pregnancy

“… Multidisciplinary team management includes senior obstetrician, anesthetist, surgeon, hepatologist, and radiologist, with blood bank and neonatal supports, which is crucial before termination of pregnancy (TOP) in such cases Preoperative magnetic resonance imaging (MRI) defines the regional anatomy and is crucial in identification of placental implantation; therefore, it can help in the decision of whether or not to remove the placenta during laparotomy Preoperative intragestational ultrasound-guided methotrexate (MTX) to destroy active trophoblastic tissue, to facilitates placental involution and decreases the bleeding risks, which has been reported in some cases of cesarean section scar pregnancies, interstitial ectopic pregnancies, and morbidly adherent placenta (MAP)[ 2 3 ] The preoperative insertion of arterial catheters for intraoperative embolization if needed. The arterial embolization has been reported in cases of MAP successfully[ 4 ] Intraoperatively, the placenta should be kept in place without any attempt of removal unless was separated spontaneously, because any attempt to remove the placenta will precipitate uncontrollable massive bleeding[ 5 ] The intraoperative massive bleeding from the placenta site can be controlled by interlocking sutures and/or packing which removed 48 h or removal of the placenta with its attached structure, if this structure is removable and less vascular (omentum or adnexa)[ 5 6 ] The packing or the placenta if left in situ associated with risks of ileus, peritonitis, and abscess formation necessitating a second laparotomy[ 6 ] Postoperatively, MTX systemic alternating with leucovorin (active folic acid) can be used to help placental involution.…”

“…The arterial embolization has been reported in cases of MAP successfully[ 4 ] Intraoperatively, the placenta should be kept in place without any attempt of removal unless was separated spontaneously, because any attempt to remove the placenta will precipitate uncontrollable massive bleeding[ 5 ] The intraoperative massive bleeding from the placenta site can be controlled by interlocking sutures and/or packing which removed 48 h or removal of the placenta with its attached structure, if this structure is removable and less vascular (omentum or adnexa)[ 5 6 ] The packing or the placenta if left in situ associated with risks of ileus, peritonitis, and abscess formation necessitating a second laparotomy[ 6 ] Postoperatively, MTX systemic alternating with leucovorin (active folic acid) can be used to help placental involution. [ 2 ] …”

“…Preoperative intragestational ultrasound-guided methotrexate (MTX) to destroy active trophoblastic tissue, to facilitates placental involution and decreases the bleeding risks, which has been reported in some cases of cesarean section scar pregnancies, interstitial ectopic pregnancies, and morbidly adherent placenta (MAP)[ 2 3 ]…”

“…Postoperatively, MTX systemic alternating with leucovorin (active folic acid) can be used to help placental involution. [ 2 ]…”