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• W2999692092 abstract "Cesarean scar pregnancy (CSP) is becoming more common with the increasing Cesarean section rate1. Among the various treatment modalities reported, local injection of therapeutic agents, either transabdominally or transvaginally, is a minimally invasive option that targets the lesion while minimizing systemic side effects2. Nevertheless, transvaginal access is not always possible, and a CSP hidden underneath the maternal pubic symphysis or maternal bowel loops makes transabdominal access challenging. In such cases, an unconventional transvesical approach may be helpful. We report two cases in which transvesical injection was used to treat CSP. In the first case, a 35-year-old woman with two previous Cesarean deliveries presented with vaginal bleeding and abdominal pain at 7 weeks of amenorrhea. Ultrasound examination revealed a single viable pregnancy outside of the uterine cavity at the site of the Cesarean scar, with a serosal bulge. The crown–rump length (CRL) measured 3.7 mm. Maternal bowel loops were overlying the CSP. Maternal serum human chorionic gonadotropin (hCG) was 37 728 IU/L. Treatment options, including medical therapy (systemic and/or local), embolization and surgery were discussed. The woman opted for combined local and systemic medical therapy. A vaginal needle guide was not available, so transvaginal injection could not be performed. After the maternal bladder was filled, bowel loops overlying the CSP were displaced (Figure 1). Potassium chloride 14.9% solution was injected transabdominally into the gestational sac by passing a 22-G needle through the distended maternal bladder under local anesthesia. Immediate fetal heart beat cessation was observed. One dose of systemic methotrexate (50 mg/m2 of body surface area) was also administered. Maternal serum hCG dropped to 21 923 IU/L on day 4, to 14 555 IU/L on day 7, and returned to normal by 2 months. Normal menstruation returned in 4 months, followed by sonographic resolution of CSP at 7 months. In the second case, a 42-year-old woman presented with vaginal bleeding at 7 weeks of amenorrhea. She had a previous Cesarean delivery and two terminations of pregnancy. Ultrasound examination showed a viable CSP with CRL of 9.8 mm. Maternal serum hCG level was 89 227 IU/L. After a detailed discussion of the management options, the woman opted for combined local and systemic medical therapy. Maternal bowel loops were obscuring the CSP, and a vaginal needle guide was not available. After the maternal bladder was filled, bowel loops overlying the CSP were displaced and a window for access became apparent. Dextrose 10% solution (total, 8 mL) was injected transabdominally into the gestational sac via a 22-G needle through the distended maternal bladder under local anesthesia (Figure 2). Fetal asystole was observed. A dose of systemic methotrexate was also administered. Maternal serum hCG was 102 978 IU/L and 84 288 IU/L on days 4 and 7 respectively, and returned to normal by 2 months. Transvesical access is an established surgical approach in urology3, 4. It is also used in exceptionally difficult cases of chorionic villus sampling5. Despite a lack of reports in the literature, a transvesical approach renders transabdominal injection feasible in CSPs that would otherwise be inaccessible by this route. The method is well tolerated by women. Neither of our two patients experienced significant hematuria or urinary symptoms after the procedure, nor did they experience any complications. Using a transvesical approach enables more CSPs to become accessible for local treatment." @default.
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• W2999692092 date "2020-10-01" @default.
• W2999692092 modified "2023-09-24" @default.
• W2999692092 title "Transvesical injection to treat Cesarean scar pregnancy" @default.
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• W2999692092 doi "https://doi.org/10.1002/uog.21966" @default.
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