European Journal of Obstetrics & Gynecology and Reproductive Biology
ReviewSuccessful direct bipolar resection of 6th week cesarean scar pregnancy: case report and literature review
Introduction
First described in 1978 [1], ectopic pregnancy implantation in a previous cesarean scar (cesarean scar pregnancy [CSP]) is a rare but extremely perilous condition. Currently, CSP is estimated to occur in about 1:2226 of all pregnancies [2], and this incidence continues to rise owing to the increasing number of cesarean deliveries reported worldwide [3].
The pathogenesis of CSP is not clearly understood; however, some authors have reported correlations with history of uterine surgery, in vitro fertilization, and previous dilatation and curettage [4]. Development beyond the first trimester could cause uterine rupture, serious hemorrhage, and invasion of other abdominal organs. A significant number of cases do not show any symptoms [5], and only 39% of women present with painless vaginal spotting as an early clinical manifestation [6].
The gestational age at diagnosis ranges from 5+0 to 12+4 weeks (mean, 7.5 ± 2.5 weeks) [6]. In the majority of cases, a transvaginal ultrasound (TVS-US) scan is the first imaging technique used in CSP diagnosis, showing the highest diagnostic accuracy. Typically, CSP is characterized by the following features: gestational sacs inserted in the anterior part of the uterine isthmus, an empty uterine and cervical cavity, and an absence of or a defect in the myometrial tissue between the bladder and the gestational sac [2], [7]. The use of color Doppler and/or three-dimensional (3D) ultrasound is also useful for diagnosis [8], [9].
Currently, there is no clear evidence regarding the treatment and management of CSP. The majority of cases presented in the literature show different approaches. We report our experience about this issue, illustrating a case of CSP treated in our institute with direct bipolar hysteroscopic resection.
Section snippets
Case report
A 40-year-old woman was admitted to our Hospital (Dipartimento di Neuroscienze, Scienze Riproduttive ed Odontostomatologiche Federico II University of Naples, Italy) at 6 weeks of amenorrhea, presenting a plasma β-human chorionic gonadotropin (βHCG) value of 7000 mUI/mL and an ultrasound scan showing a suspected cervical pregnancy.
The general physical examination was normal and obstetric history revealed that a single lower segment cesarean section was performed in 2009. The patient was
Discussion
Although CSP is considered a rare condition, the worldwide increase in cesarean sections could raise its incidence. This type of gestation could cause uterine rupture and abnormal placental adherence with related maternal morbidity and mortality [10]. Moreover, epidemiological data suggested that CSP seems to be even more common than cervical pregnancy [8].
Early recognition and well-timed treatment are associated with a lower rate of complications and preservation of fertility.
Improvements in
Conflict of interest
None of the authors have conflicts of interest to declare.
Acknowledgments
The authors would like to thank Federico II University theatre workforce for their assistance during surgery.
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