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• W2010570550 abstract "Wedge-shaped defects of the uterine incision following Cesarean section are a well-known phenomenon1-8. Though the relevance of these defects is still uncertain, they have been associated with severe complications including spontaneous or instrumental rupture, abnormal placentation, menorrhagia and dysmenorrhea1. Implantation of the conceptus within a Cesarean section scar is considered to be the rarest and one of the most dangerous types of ectopic pregnancy. We report the case of a heterotopic twin pregnancy with one fetus located at the fundus uteri and the other within the Cesarean section scar in the cervico-isthmic region. A 23-year-old woman, gravida 2 para 1, with a previous Cesarean delivery was referred because of the abnormal location of one of the two gestational sacs of a twin pregnancy. She had conceived without any kind of infertility therapy. There was scant bleeding, but no pelvic pain since the last menstrual period. Standard blood counts and a routine urine analysis were in the normal range. Transvaginal examination (GE Logiq 400 MD, 5-MHz transvaginal probe, GE Medical Systems, Milwaukee, WI, USA) revealed a diamniotic, dichorionic, twin pregnancy. Both fetuses had normal fetal cardiac activity and crown–rump length measurements (4.8 and 4.9 mm) in accordance with 6 + 2 weeks' gestation. One gestational sac was in the upper fundus, whereas the second one was located in a large tent-shaped incisional defect just above the gaping (7 mm) internal cervical os (Figure 1). The heterotopic placenta at the Cesarean section scar was in close proximity to the maternal bladder. The cervical canal was funnel-shaped and 37 mm in length. The patient opted for a selective termination of the abnormally located fetus, which was accomplished at 7 + 2 weeks' gestation by intrathoracic injection of 0.5 mL 7.5% potassium chloride (KCl) via a 22G 20-cm needle inserted transvaginally. On follow-up, persistence of placental vascularization and even some growth of the placental mass was noted despite the disappearance of the tiny fetal mass. At 26 + 6 weeks' gestation a detachment of the abnormally located placenta from its bed without any bleeding was noted. At 30 + 3 weeks' gestation a sudden rupture of membranes was followed by minimal vaginal bleeding and preterm labor. The baby was delivered by Cesarean section. The placenta at the uterine incision site was completely detached without any significant bleeding from the placental bed. There was no sign of abruption of the normally located placenta. The male baby weighing 1530 g with Apgar scores of 7 and 9 at 1 and 5 min, respectively, was taken to the neonatal intensive care unit for the first 8 days, was discharged from hospital in good condition and at the time of writing is doing well at home. The mother was discharged 2 days after the operation without any complications. Ultrasound image showing a heterotopic twin pregnancy with one gestational sac located in the fundus uteri and the other within the Cesarean section scar. Ectopic pregnancy in a previous Cesarean section scar is a rare phenomenon. A recent review has identified only 19 cases reported in the English language scientific literature since 19662. Cesarean section scar pregnancy may result in heavy blood loss controllable by drastic measures such as uterine artery ligation, embolization or emergency hysterectomy3-5. Consequently, early detection of Cesarean section pregnancy usually necessitates some kind of intervention to prevent a dramatic course. Though interventions such as laparoscopic evacuation5 or bilateral uterine artery embolization3, 4 have been undertaken in some cases of Cesarean scar pregnancy, the current standard is a medical approach usually comprising a full course of maternal methotrexate therapy6-8, which unfortunately is not an option in heterotopic pregnancy. There are few cases of cervical heterotopic pregnancy treated by conservative measures. Elective feticide with KCl in one case was shown to be successful in terminating the heterotopic fetus but placental vascularization remained intact, necessitating a full course of methotrexate in the immediate postpartum period9. Jozwiak et al. attempted a novel approach using hysteroscopic removal followed by roller-ball coagulation of the bleeding sites. The pregnancy then continued successfully to be terminated by a near-term Cesarean section without any abnormal bleeding10. Obviously this approach needs an intact internal cervical os to keep the intrauterine part unaffected. In this first case of heterotopic Cesarean section scar pregnancy, selective feticide with KCl proved to be a successful conservative mode of management. In this era of increasing Cesarean section rates throughout the world, many Cesarean section scar pregnancies will inevitably follow. Consequently we think that the standard informed consent form should list Cesarean section scar pregnancy as a remote but serious complication of Cesarean section. H. F. Yazicioglu*, S. Turgut , R. Madazli , M. Aygün*, Z. Cebi*, S. Sönmez*, * Department of Perinatology, Süleymaniye Maternity Hospital for Research and Training, Süleymaniye Egitim ve Arastirma Hastanesi, Prof. Siddik Sami Onar Cad. 45/1, Eminönü, Istanbul, Turkey, Meltem Private Maternity Hospital, Istanbul, Turkey, Department of Perinatology, Cerrahpasa Faculty of Medicine, Istanbul, Turkey" @default.
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• W2010570550 date "2004-04-20" @default.
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• W2010570550 title "An unusual case of heterotopic twin pregnancy managed successfully with selective feticide" @default.
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