1. Ectopic Pregnancy On Serosal Surface Of C/Section Scar
Ajibade F ,Garcia F& Barnor E.
Royal Berkshire Hospital, Reading, UK
INTRODUCTION
Ectopic pregnancy is a common problem of early pregnancy causing maternal morbidity and occasional mortality.
Transvaginal ultrasound in early pregnancy & minimal access surgery have contributed to improved management of ectopic pregnancy.
Ectopic pregnancy on C/section scar is nowadays a more common pathology, partly due to increase in C/section rate.
Various reasons have been suggested for this abnormal implantation of pregnancy, on or within the caesarean section scar. One is a possible defect of the uterine wall within the C/section scar, another has been the presence of ectopic endometrium .
Management option includes conservative, medical, embolisation & surgical management.
Surgical management includes hysteroscopic, laparoscopic & open surgery.
CASE STUDY
We present the case of a 39 year old woman with history of 3 normal vaginal deliveries and one caesarean section for twin pregnancy in the past.
She presented to our Unit with an unwanted pregnancy, requesting termination. A transvaginal ultrasound scan was performed and did not confirm any intra or extrauterine pregnancy.
Serum BHCG levels were requested with a result of 2789 u/l.
A diagnostic laparoscopy was performed showing a 2 cm lesion lying on the surface of the lower aspect of the uterus. The visceral peritoneum was intact and there was no hemoperitoneum.
The lesion was excised and sent for histological analysis. The integrity of the bladder was confirmed with injecting methylene blue through urethra.
The histology report confirmed chorionic villi and serial serum BHCG levels fell over four weeks to less than 10 u/l.
Laparoscopic view of a lesion on the serosal
surface of lower part of uterus
CONCLUSION
This case illustrates the possible appearances of a Caesarean ectopic at laparoscopy and the successful laparoscopic excision without bladder injury.
It raises as well, the possibility of other routes for ovum transportation leading to abnormal implantation over a C/section scar, e.g. the abdominal route.
At the same time it continues to question the contributory factors accountable for this implantation on the outer serosa surface of the c/section scar, and the place for ectopic endometrial tissue in abnormal implantation / ectopic pregnancy?
Appearance of the lower aspect of
the uterus after excision
REFERENCES
Caesarean scar Pregnancy; A. Ash, A. Smith, D Maxwell. BJOG 2007;114:
Laparoscopic Mx Of an ectopic pregnancy in a previous C/section Scar; Chyi-long Lee et al. Human Reproduction vol 14 no5 pp
Laparoscopic Mx of an ectopic pregnancy within a previous C/section. Gynaecological surgery 2007, Vol 4 No 2,
Caesarean Scar Pregnancy; A Diagnosis to consider Carefully in Pts with Risk factors. Ann Acad Med Singapore 2005 :34: 216-9