Author
Information
Mehta D*,
Parulekar SV*.
(* First Year Resident, ** Professor and Head,
Department of Obstetrics and Gynecology, Seth G S Medical College and KEM
Hospital, Mumbai, India.)
Abstract
Cesarean scar
ectopic pregnanacy is one of the rarest form of ectopic pregnancy. it is
presumed as a result of migration of embryo through defect in scar. Here we
present Such a case managed conservatively. It ended in formation of a lithokelyphos. This is the first case of
Introduction
Ectopic
pregnancy in cesarean section (LSCS) scar is the rarest form of ectopic
pregnancy.[1] It is characterized by the gestational sac being completely
separated from the uterine cavity and completely surrounded by myometrium and
LSCS scar. Its incidence seems to be on the rise, either because of an increase
in rate of cesarean sections or an increase in evaluation of early pregnancy by
transvaginal ultrasonography(USG).[2] Its clinical presentation varies a lot -
painless or painful vaginal bleeding, lower abdominal pain, or severe
hemorrhagic shock. Some cases may be asymptomatic. If not treated, there can be
complications like rupture and severe hemorrhage. In some cases the pregnancy
may continue to grow and the placenta maybe morbidly adherent in the lower
segment.[3,4] There are different modes of management of LSCS scar ectopic pregnancies, medical or
surgical.[5,6,7,8,9] We present a case that was successfully managed by
observation alone. It progressed to formation of a lithokelyphos.
Case Report
A 24 year old
woman, married for 3 years, para presented with a complaint of 3 months of
amenorrhea and spotting per vaginum for 1.5 months. There was no history of
abdominal pain. She had undergone a cesarean section in past. Her medical and
surgical history was not contributory. She was not using any contraception. She
gave a history of consumption of mifepristone and misoprostol for achieving a
medical abortion 1.5 months ago. She had not passed any products of conception
after that. Her vital parameters were normal. Her general and systemic
examination revealed no abnormality. Abdominal examination showed a
Pfannenstiel scar but no tenderness, guarding, rigidity or lump. Bimanual
examination showed the uterus to be mildly enlarged and soft. There was no
tenderness or vaginal bleeding. She had reports of transvaginal ultrasonography
(USG) and magnetic resonance imaging (MRI) performed 5 and 4 prior to
presenting at our hospital. The USG showed a 4x3 cm mass without any fetal pole
with decidual reaction reaching up to serosa. The MRI showed a 48x44x21 mm
irregular gestational sac in lower uterine segment with diffuse thinning of
anterior myometrium and decidual reaction reaching up to serosa. USG performed
in our hospital showed a heterogenous mass measuring 3.5x25x3.1 cm in lower
uterine segment, with scar thickness 3.5 mm. A diagnosis of cesarean section
(LSCS) scar ectopic pregnancy was made. Her hemoglobin was 8.5 g/dl. Remaining
hemogram, urinalysis, liver and renal function tests were normal. Serum βhCG
level was 3867 mIU/ml. It fell to 2711
mIU/ml after 8 hours. She was counselled about various treatment options. She
opted for observation for spontaneous resolution of the LSCS scar ectopic
pregnancy. She was give a transfusion of two units of packed red blood cells.
Then she was discharged from the hospital with instructions to report
immediately in the event of vaginal bleeding or acute pain in abdomen. Serum
βhCG levels were 427, 127, 47, and not detectable 1, 2, 3, and 7 weeks later. However her pelvic USG did not show any resolution of the lesion in this period. The mass remained of a size 3.5x25x3.1 cm. It showed deposition of calcium in its walls during the last of the three USG scans performed on her. She was prescribed hematinics
for a month and counseled about the risk of rupture of the scar in a future pregnancy at the site of the ectopic pregnancy with litokelyphos formation. She opted not to undergo any surgical treatment for its removal and not to have any more pregnancies.
Figure 1. MRI
showing LSCS scar ectopic pregnancy (arrow).
Discussion
The first
case of LSCS scar ectopic pregnancy was reported by Larsen and Solomon.[10] The
risk of it development is increased further by past myomectomy, manual removal
of placenta, dilatation and curettage, in vitro fertilization and embryo
transfer, and adenomyosis.[11] Early evaluation by transvaginal USG of a woman
with previous LSCS is important in making an early diagnosis of LSCS scar
ectopic pregnancy. Diagnostic features include absence of trophoblastic tissue
in the uterine cavity and cervical canal, presence of a gestational sac between
the anterior wall of the uterus and adjacent wall of the urinary bladder, and
thin or absent myometrial layer between the urinary bladder and the gestational
sac. If it is less than 8 weeks’ size, a triangulas mass fills the niche of the
scar. If it is more than 8 weeks’ size, the shape is rounded. Trophoblastic
activity is confirmed by Doppler study.[11]
Medical
treatment is preferred so as to preserve fertility. It is with systemic or
local methotrexate administration. Surgical treatment options include rapid cervical
dilatation and evacuation by suction and curettage, hysteroscopic removal,
laparoscopic removal, and uterine artery embolization, and removal by
laparotomy. Use of high energy focused ultrasound combined with curettage has
also been reported.[12] Abdominal hysterectomy may have to be performed as a
last resort in some cases to control hemorrhage in an advanced, ruptured LSCS
scar ectopic pregnancy. In our case the patient had ingested mifepristone and
misoprostol without medical prescription and supervision. Fortunately the
ectopic gestation did not rupture and cause a life threatening hemorrhage.
These drugs must have caused fetal demise. So her serial serum βhCG levels were
found to be falling. That suggested that her ectopic pregnancy might resolve without
and intervention. However that did not happen. The mass remained of the same size, and its walls got calcified, forming a lithokelyphos. A problem with observation or medical
treatment is that the defect in the lower segment scar remains, and is likely
to rupture in a future pregnancy. With the formation of a lithokelyphos, the risk is possibly increased further. Since cesarean scar ectopic pregnancy and its treatment conservatively are relatively recent, follow up of patients so treated is essential
over a few years to see if this risk is real.
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Citation
Mehta D, Parulekar SV. Conservative Management Of Cesarean Section Scar Ectopic Gestation And Lithokelyphos Formation. JPGO 2015. Volume 3 No. 5. Available from: http://www.jpgo.org/2016/05/conservative-management-of-cesarean.html
Mehta D, Parulekar SV. Conservative Management Of Cesarean Section Scar Ectopic Gestation And Lithokelyphos Formation. JPGO 2015. Volume 3 No. 5. Available from: http://www.jpgo.org/2016/05/conservative-management-of-cesarean.html