NON TUBAL ECTOPIC PREGNANCY: CAESAREAN SECTION SCAR ECTOPIC PREGNANCY

CONTENT

-INTRODUCTION

-RISK FACTORS

-PRESENTATION

-INVESTIGATIONS

-MANAGEMENT

 

INTRODUCTION

Caesarean scar ectopic pregnancy is estimated to occur in 1:1800 to 1:2216 pregnancies and in 6 % ocf all ectopic pregnancies found in women with at least one caesarean delivery. Once deemed very rare, a gradual increment in rate has being seen as the a result of increased rate of caesarean delivery globally.

                                             Caesarean section ectopic

 

RISK FACTORS

Although clearly associated with caesarean section, it is not related to the number of previous caesarean sections nor to the number of layers of closure of the uterine wall during surgery i.e. single versus double layer closure of the incision site at the time of caesarean section. It seems to be commoner following caesarean sections for elective indications and is theorized that this may be due to impaired healing of the unlabored lower segment of the uterus.

 

PRESENTATION

Cesarean ectopic may present similar to cervical ectopic with painless vaginal bleeding. It may be symptomless until in advanced pregnancy when a sudden rupture of the uterus at the caesarean scar point presenting with an acute onset of severe abdominal pain and massive blood loss into the abdominal cavity. Other complications include increased risk of recurrence, placenta accreta and severe hemorrhage in subsequent pregnancies.

 

INVESTIGATIONS

Aside the usual history taking, examination, and a positive blood pregnancy test, definite diagnosis is usually done by ultrasound scan.

 

MANAGEMENT

As in all cases of ectopic pregnancies, this depends on the clinical presentation of the patient.

In stable patients with intact caesarean ectopic that is yet to rupture, interruption of the pregnancy is recommended, given the high risk of hemorrhage, hysterectomy and death.

In some rare occasions, live births resulting from these ectopic pregnancies have been described; however, these deliveries were associated with severe hemorrhage and emergency caesarean hysterectomy hence, expectant management is not routinely advised.

Medical management may be employed when early via the use of systemic administration of single or multiple doses of cytotoxic drugs or local injection of cytotoxic drugs into the ectopic pregnancy with or without the use of uterine artery embolization (UAE) or other surgical management such as D&C or hysteroscopy to improve the success rate. There is however a high risk of persistent trophoblastic tissue and resolution of the disease is usually prolonged.

Surgical management is employed in instances where medical management failed or when the ectopic pregnancy is detected in advanced pregnancy and or when a more rapid resolution of the ectopic pregnancy is desirous by the patient.

Surgical options are D & C, Hysteroscopic resection of caesarean scar, laparatomy with excision of the lesion and scar along with re-closure of the lower uterine segment and hysterectomy in cases of severe intractable bleeding. D & C alone is fraught with the highest risk of bleeding and ancillary initial measures to reduce bleeding which is the most dire complication encountered during the management of caesarean scar ectopic pregnancy usually include tamponade with a transcervical catheter, haemostatic cervical cerclage sutures and UAE.

Regardless of the chosen method of treatment, persistent trophoblastic tissue is a common complication to be watched out for except after hysterectomy. Therefore the serum pregnancy hormone (β-hCG) assay must be monitored till its level drops to zero to prevent its occurrence,

UAE is not currently recommended for patients desirous of getting pregnant.

 

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REFERENCES

1.  Panelli D.M, Phillips C.H, Brady P.C. Incidence, diagnosis and management of tubal and non-tubal ectopic pregnancies: a review. Fertility Research and Practice2015 1:15. DOI: 10.1186/s40738-015-0008-z

2.  Ash A, Smith A, Maxwell D. Caesarean scar pregnancy. Br J Obstet Gynecol. 2007;114:253–63.

3.  Michaels AY, Washburn EE, Pocius KD, Benson CB, Doubilet PM, Carusi DA. Outcome of cesarean scar pregnancies diagnosed sonographically in the first trimester. J Ultrasound Med. 2015;34:595–9