Review
Successful direct bipolar resection of 6th week cesarean scar pregnancy: case report and literature review

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Abstract

Cesarean scar pregnancy is a specific ectopic pregnancy implanted in the scar tissue of a previous cesarean section. To date, no clear consensus exists regarding its management and treatment. Timely diagnosis of this condition is fundamental, owing to the high rate of life-threatening complications and massive hemorrhage. The use of high-definition transvaginal ultrasound is strongly recommended as a first-line diagnostic approach. A wide range of medical and surgical strategies has been described in the literature, including methotrexate administration, local injection of embryocides, uterine curettage, and laparoscopic surgery. The treatment goal should be complete and efficient without compromising the chance of future pregnancies. Recently, many cases were successfully treated through the hysteroscopic route. Illustrating the case of an early detected cesarean scar pregnancy originally treated in our institution with direct bipolar resection, we reviewed the literature regarding the advantages and efficacy of the hysteroscopic approach in terms of fertility preservation, rapid recovery, and safety. In conclusion, the use of a direct hysteroscopic approach could represent a valuable strategy in the first stage of cesarean scar pregnancy.

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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