Delayed Hysteroscopic Management of Persistent Cesarean Section Scar Ectopic Pregnancy (CSSEP) Following Transvaginal Ultrasound-Guided, Trans-Myometrial Needle Fetal Aspiration and Intra-Amniotic Administration of Methotrexate.
CANSAGE ePoster Library. Michael E. 09/26/19; 275262; eP-129
Essam Michael
Essam Michael
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Introduction:Cesarean section scar ectopic pregnancy (CSSEP) is a rare form of ectopic pregnancy that occurs at an incidence of 0.05% of all pregnancies. The increase in frequency can be attributed to an increase in cesarean section rates and an increase in assisted reproductive treatments. Diagnosis of this rare entity is usually made by transvaginal ultrasound. CSSEP should not be confused with low implanting cervico-isthmic pregnancy or a cervical ectopic pregnancy. CSSEP can lead to significant morbidity and mortality, including uterine rupture and bleeding-related complications. Early diagnosis and treatment of CSSEP offers the best outcomes and, importantly, permits fertility preservation.Material and Methods:We had two cases of viable, confirmed CSSEP at 7-8 weeks gestational age with beta-hCG above 10,000. Both were successfully treated with transvaginal ultrasound-guided needle aspiration of the fetus through the myometrium. Methotrexate (25mg) was injected into the amniotic sac after fetal extraction. The patients were followed by serial beta-hCG and frequent ultrasound assessments. In the first case, complete resolution of beta-hCG occurred. In the second case, the beta- hCG plateaued at 6 weeks post methotrexate administration. As a result, we elected to perform hysteroscopic assessment of the CSSEP using a mini hysteroscope under sedation. Degenerated chorionic villi were removed from the cervical niche using a 5 French hysteroscopic grasper. No cauterization was required as no bleeding was encountered. Dramatic and complete resolution of her beta-hCG levels followed this procedure. There were no complications in either case.Conclusion:For early CSSEP (less than 9 weeks gestational age), transvaginal needle guided fetal aspiration with concomitant intra-amniotic administration of methotrexate results in rapid resolution of beta-hCG levels. If the CSSEP persists, delayed hysteroscopic removal of the products of conception is a very effective and safe management option.
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