1. Obstetrics and Gynaecology
Emergency Abdominal Hysterectomy for Caesarean Scar Ectopic pregnancy unresponsive to conservative surgical management.
Authors: Mian Khurshid, Ahmed Elhadidy, Kanna Jayaprakasan
CASE Report
Patient was admitted in A&E Resuscitation as an emergency with haemorrhage and shock after three weeks of conservative surgical management / suction evacuation of Caesarean ectopic pregnancy under ultrasound guidance.
Background and Objectives
Incidence of Caesarean scar ectopic pregnancy is increasing possibly due to an increase in the number of Caesarean sections. Generally, Caesarean scar ectopic pregnancies are managed with conservative medical and surgical treatment including ultrasound guided intra-amniotic methotrexate, and also ultrasound guided surgical evacuation of pregnancy combining with modified shirodkar cervical sutures. Our objective is to describe a case of caesarean scar ectopic pregnancy, initially treated with conservative surgical methods and subsequently presented with massive vaginal bleeding requiring emergency abdominal hysterectomy. Follow up with measurement of gestation sac volume and degree of vascular activity may predict failure of conservative management and risk of complications.
Diagnosis
Patient was seen in pregnancy advisory clinic for termination of pregnancy. She was 35 years old and had LSCS previously. A diagnosis of Caesarean scar ectopic pregnancy was made incidentally on ultrasound. The patient did not have any symptoms. The gestation sac was measures 21 x 12 mm with fetal pole 9.5 mm with no cardiac embedded in scar. Her BHCG was IU/L. There was minimal myometrium between bladder and gestational sac and also absent sliding sign. Prominent vascular pattern was seen in area of Caesarean scar.
Medical Treatment
Patient had transvaginal ultrasound guided aspiration of gestation sac and intra amniotic injection of methotrexate after appropriate counselling in Derby Teaching Hospital. Patient was subsequently followed up conservatively. While BHCG dropped significantly to 300 IU/L over a period of about 5 weeks, gestation sac persisted with significant Doppler flow around the gestational sac indicating dilated veins and ? AV malformation. She had MRI as well
Conservative Surgical Management in UCL London:
Patient was referred to UCL London for further opinion as significant vascular activity and no change in size of gestational sac on follow up USG / MRI. Uterine artery embolization was unlikely to helpful as it was a big AV malformation. Patient had suction evacuation under Ultrasound guidance with removal of gestational sac. Intraoperative blood loss was 2000 ml and patient had 4 units blood transfusion.
Emergency Hysterectomy
Patient was discharged from UCL hospital London as whole gestational sac was removed but admitted three weeks later with haemorrhage and shock in A&E Resuscitation. She had 3 units blood transfusion and emergency Laparotomy with Total Abdominal Hysterectomy. Preoperative findings showed ballooned, friable cervix with gestational sac embedded in myometrium.
Cervix ballooned with gestational sac embedded in scar and reaching to serosa.
Conclusions
Caesarean scar ectopic pregnancies are not uncommon due to increase number of LSCS. Early diagnosis of Caesarean ectopic pregnancy can be made with transvaginal USG with the diagnostic criteria explained early. (1)
Caesarean scar pregnancies carries significant complication rate. In one study complication rate after treatment was 44.1% and many patient need hysterectomies, laparotomies and uterine artery embolization as an emergency. Treatment with systemic methotrexate, D&C and Uterine artery embolization has increase no. of complications. (2)
Minimal complication are associated with intra gestational injection of methotrexate. It can be done with transvaginal route. Monitoring and follow up is very important. It include serial serum HCG, gestational sac volume and vascular activity in gestational sac. Complication can happen even if HCG is dropping or even undetectable due to separation of gestational sac from scar. Successful treatment will reduce the size of gestational sac, and also reduce vascular activity.
Increase degree of vascular activity point towards AV malformation and increase complication rate. These patient may be treated with Uterine artery embolization initially.
Suction evacuation of gestational sac with application of modified shirodkar suture may offer as a conservative surgical option with less risk of complication as shown in this study involving 232 patients. (3)
Diagnosis of Caesarean ectopic in early pregnancy with TVS
Empty Uterus, gestational sac embedded in caesarean scar
Minimal myometrium between sac and bladder
Degree of vascular / Doppler flow around gestational sac in scar
Follow up MRI scan ( signs of failed medical management )
Persistent of gestational sac and increase vascularity
MRI pelvis with Angiography
Extensive AV malformation in follow up pints towards failed medical
Management and increase risks of complications
References:
(1) Kirk E, Bourne T, Diagnosis of ectopic pregnancy with ultrasound, Best
Practice & Research Clinical Obstetrics and Gynaecology (2009), doi: /j.bpobgyn
(2) Timor-Tritsch IE, Monteagudo A, Santos R, et al. The diagnosis, treatment, and follow-up of cesarean scar pregnancy. Am J Obstet Gynecol 2012;207:44.e1-13
(3) Surgical treatment of Cesarean scar ectopic pregnancy: efficacy and safety of ultrasound-guided suction curettage.
Jurkovic D1, Knez J1, Appiah A2, Farahani L2, Mavrelos D1, Ross JA2 2016