Art Fougner, MD

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TRV Uterus IUCD Fragment post IUCD Removal

3D Uterus Reconstruction: Bicornuate Uterus


 Implantation in the scar of a previous Cesarean is thought to be the rarest of  ectopic pregnancies.

 With the increasing numbers of Cesareans  performed, scar implantation may become more frequent as well. We present an  illustrative case.




 Our patient is a 32 year old P 1001 who was referred for evaluation of a  continued first trimester vaginal bleeding. She had previously undergone  Cesarean delivery for dystocia. Subsequently, she developed an  incisional mass.  Surgical excision revealed endometriosis. 

 TVS and TAS were both performed. Ultrasound revealed an enlarged uterus with  blood within the uterine cavity. A gestational sac was noted implanted in the  anterior lower uterine segment in the region of the previous uterine incision.  An approximately 8 week live fetus was seen within the sac.

She underwent treatment with local injection of methotrexate  into the gestational sac. Serial titers of B-HCG progressively fell; however,  after two weeks, profuse vaginal bleeding ensued. Emergency hysterectomy was  performed.


 Although an admittedly rare entity, the rise in Cesarean births may affect its  incidence. The spate of recent articles suggests this may be the case.  Therefore, all who provide prenatal care need to be aware of this form of  ectopic pregnancy. In our case, the incisional endometriosis undoubtedly became  an additional risk factor.

 Since scar ectopic is so rare, a consensus about treatment does not exist. Most  reviews consist of case reports.

 Both medical and surgical therapies  have been utilized successfully. In our case, local injection met with initial  success. Despite falling levels of HCG, the onset of hemorrhage necessitated  emergency surgery.

 One technical note concerning the ultrasound needs mentioning. After Cesarean,  we have found the uterus often adherent anteriorly and pulled superiorly out of  the focal range of the vaginal transducer, negating the higher resolution.  Therefore, TAS, with its more panoramic field of view, can be more helpful in  demonstrating the true nature of the pathology. Moreover, with the development  of harmonic technology, diagnostic images are usually obtained without the need  for bladder-filling.

Fylstra DL Ectopic pregnancy within a Cesarean scar: a review. Obstet Gynecol Survey 2002; 57: 538-543.

Implantation in the scar of a previous Cesarean is thought to be the rarest of ectopic pregnancies. With the increasing numbers of Cesareans performed, scar implantation may become more frequent as well. We present an illustrative case.

Cesarean Scar Ectopic Pregnancy - A Case Presentation

:  "I'm Dr. Allen Worrall from Fairbanks, Alaska and  I'm an OB-GYN doctor who does a good deal of prenatal and GYN  ultrasound.  My job today is to interview Dr. Art Fougner from Forest  Hills, New York, and I'm interested in that because I was born and  raised on Long Island and used to drive by Forest Hills on the Long  Island Railroad when I went into New York City.  It used to be a big  tennis center; I remember that when I was a kid.  Art is going to talk  about       the prenatal assessment of the risk of Down's syndrome, and my  interest in this was started by several things; I'm due to give a talk  on April 21st and I chose that as my topic.  I had a very recent case  that sparked my interest even more; I scanned a thirty-four year old  woman who would be thirty-five at the time of her delivery and her  biophysical triple screen risk was something like 1 in 7,000 - very low  risk.  I scanned her at about nineteen weeks and found what I  interpreted to be echogenic bowel.  I was not sure whether the echogenic  bowel overrode the very low triple screen risk or whether an  amniocentesis was indicated or not indicated.  I decided that I should  recommend to my obstetrical colleague that he do an amniocentesis and he  did.  He is also here in Orlando at Walt Disney World but on vacation  and not coming to this meeting.  By one chance in five million, I ran  into him yesterday and he told me that the amniocentesis revealed a  mosaic for 46-XY and 45-X.  I don't know what that's got to do with  echogenic bowel but, Art, tell us how do you integrate these two  findings - the age of the patient and the triple screen and, of course,  the triple screen includes the age of the patient and the ultrasound  risk?  We could talk about lowering the risk and raising the risk."
       
       

:  "In order to do that, we almost have to  go back to the beginning.  Amniocentesis was first used to diagnose Down  syndrome in the older woman.  It was first used prenatally in the  1970's and the situation used to be very easy, the counseling and risk  assessment simply consisted of asking a woman - how old are you and that  was it.  If you were over a certain age you were offered amniocentesis,  and if you were under a certain age you weren't.  That's the way it  stood until Merkatz in the eighties serendipitously discovered four  fetuses with Down syndrome whose maternal serum AFP's were much lower  than the medium.  Then this progressed rapidly into using other analytes  to nail down and make the test even more sensitive without sacrificing  specificity so now by serum screen we have Down syndrome detection rates  of conservatively around 60%-70%.  Subsequently several investigators,  most notably the group out of Massachusetts headed by Dr. Beryl       Benacerraf, reported on several ultrasound findings which might  also be used to rule in or rule out or I should say modify risks for  Down's such as nuchal folds and then later certain characteristics of  the fetal hand and the fetal heart.  It's almost gotten to the point now  that there are so many markers - I counted over twenty the last time I  looked - for Down's syndrome that one could almost justify an  amniocentesis on virtually every pregnant woman simply based on the  presence or absence of markers.  One of the problems with risk  assessment is you have to know what the individual relative risk is of  the individual finding.  You bring up echogenic bowel, for example,  what's not well appreciated is that the most common correlate with  echogenic bowel and probably the most common cause is bleeding into the  amniotic fluid and subsequent fetal swallowing that let's you get some  bio breakdown and that shows up as inspissated meconium and echogenic  material.  The second thing is that the equipment over the years is  getting better and so the transducer frequencies are getting higher and  higher and produce more and more false-positives.  Now we can detect  things that we never saw previously so the first thing we need to know  is relative risk of the individual findings.  The reason that's  important is if you want to modify risks you have to know by how much  does this finding contribute to a risk.  That's not well defined in  various populations, as a matter of fact, in any population and the  problem with jumping in using markers right now is that all these things  were first described in populations that were already considered to be  at high risk because the original use of ultrasound was not to rule in  an amniocentesis, it was to tell which patient was truly reluctant -  actually your risks are probably lower because your fetus really doesn't  have any of these findings.  Now it's gone completely the opposite  where we're taking       young women who are very happy with their pregnancy and all of a  sudden you see the jaws begin to drop and now they're rapidly becoming  scared to death.  Yesterday it was announced that there's going to be a  consensus panel over the summer to address many of these issues.  In  answer to your question, I'm not sure that really answers your question  because we're all kind of stuck so the best you can do is what you did -  you present the findings to your patient, you have to tell her that  these things have been associated with things, and ultimately the final  choice is up to her.  I think if this were a cancer-screening test, we  wouldn't be doing any of these things because the yield is so poor.  No  cancer detections test would pass muster if a positive finding consisted  of 1 in 300, it just wouldn't pass muster which leaves me to believe  that, perhaps, the only thing our society tolerates less than cancer is  Down syndrome.  Now whether that's a positive or negative can be debated  but that seems to be what the facts are right now."
       
       

:  "Is it true that you can reduce a woman's risk between the ages of 35 and 40 by a negative ultrasound?"
       
       

:  "Yes, I believe that you can.  You can  probably reduce it conservatively by a factor of 75%, 3 out of 4 and  some centers aggressively claim that their detection rates are around  90%.  I'm always leery of that because my own personal bias is that if  you want to see the chromosomes you have to do a specific test that's  for chromosomes.  As of yet, ultrasound hasn't gotten down to the high  frequency necessary to visualize chromosomes so, therefore, you almost  have to look but I do believe that you could at least modify the risks."
       
       

:  "Now how about the woman under 35,  let's say, a low risk woman who has a triple screen that indicates a  risk of 1 in 200 but a negative ultrasound.  How would you advise her?"
       
       

:  "Again, the trick is given the practice  environment in which we live, you can't advise anybody to do anything.   What you can do is you can say - these are your risks and ultimately  it's your pregnancy, you need to talk to people.  This is a decision  that I can't make for you, you need to make that decision that your  risks have to be reduced but they're not zero.  A common analogy I use  is that in our neighborhood we have Queen's Boulevard, it's easily one  of the widest thoroughfares in the world, and people get killed  periodically crossing the street so the risk of getting killed on  Queen's Boulevard given the number of people that cross the street is  very low but it's not zero.  I think this is an analogous situation."
       
       

:  "We do expect a paper, I believe, this  afternoon from Dr. Nyberg.  He has some interesting new information I  think about the independence of ultrasound and biochemistry.  This is a  field that is important and we know that we're overusing these minor  markers, and Doctors Filly and Benacerraf have written recent papers on  this subject that stimulated the AIUM to call a consensus panel so we  all will know how to use these things.  I think it takes a good deal of  courage to find a soft marker in an otherwise low risk patient and just  ignore it and not even mention it because       any baby can be born with Down syndrome, and if that one is born  with Down syndrome and the patient gets it to a lawyer, and the lawyer  finds that the baby had an echogenic focus that you didn't mention - why  you might be in trouble so that's the problem."

OBGYN.net Conference CoverageFrom 45th Annual Conference of the AIUM - Orlando, FL 2001

Author | Art Fougner, MD

Articles

TRV Uterus IUCD Fragment post IUCD Removal

3D Uterus Reconstruction: Bicornuate Uterus

Cesarean Scar Ectopic Pregnancy - A Case Presentation

The Prenatal Ultrasound Assessment for the Risk of Down's Syndrome