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Cesarean scar pregnancy associated with an impending uterine rupture diagnosed with 3-dimensional ultrasonography

Published:February 16, 2017DOI:https://doi.org/10.1016/j.ajog.2017.02.023
      A 30-year-old woman having had 2 cesarean deliveries presented with vaginal spotting with dull lower abdominal pain that had been ongoing for 2 months. Transvaginal sonography revealed a gestational sac located within the anterior lower uterine segment with a 12-week-sized fetus. An empty uterus with a clear visualization of the endometrium and an empty cervical canal were also noted. A typical hourglass-shaped uterus with marked color Doppler flow around the sac and nearly absent myometrium between the gestational sac and the urinary bladder suggested a cesarean scar pregnancy (Figure 1). Three-dimensional sonographic examination showed a defect at the cesarean scar adjacent to the gestational sac and free blood in Douglas pouch suggestive of an impending uterine rupture (Figure 2). It was decided to terminate the pregnancy, and the patient underwent laparoscopic surgery 1 hour after the ultrasonographic examination. A highly vascularized mass bulging out from the lower segment of the uterus with bleeding from the top of the mass was noted (Figure 3, A and B ). Touching and suctioning out the gestational sac caused the fetus to pop out (Figure 3, C). Massive bleeding from the implantation site was controlled by a continuous running suture with barbed suture material. A new uterine closure was made, and the patient was discharged on the third postoperative day with an uneventful recovery.
      Figure thumbnail gr1
      Figure 1Typical sonographic features of cesarean scar pregnancy
      A, Transvaginal sonography revealed gestational sac (G) located within anterior lower uterine segment with head shadow of 12 weeks’ fetus (F). Empty uterus with clear visualization of endometrium (En) and empty cervical canal (Cx) were also noted. B, Marked color Doppler flow around G and nearly absent myometrium (arrow) between G and urinary bladder (Bl) were noted. Free fluid in Douglas pouch (*) suggested hemoperitoneum. C, Transabdominal sonography revealed typical hourglass-shaped uterus with G bulging toward Bl suggesting cesarean scar pregnancy.
      Lee. Cesarean scar pregnancy impending uterine rupture diagnosed with 3D ultrasonography. Am J Obstet Gynecol 2017.
      Figure thumbnail gr2
      Figure 2Three-dimensional sonographic images
      Cesarean scar dehiscence (arrow) and gestational sac (G) in lower uterine segment bulging toward urinary bladder (Bl) suggesting cesarean scar pregnancy. Empty cervical (Cx) canal and fetus are clearly visible in 3-dimensional sonography.
      Lee. Cesarean scar pregnancy impending uterine rupture diagnosed with 3D ultrasonography. Am J Obstet Gynecol 2017.
      Figure thumbnail gr3
      Figure 3Laparoscopic findings
      A, Typical hourglass-shaped uterus with bleeding from top of cesarean scar (arrow). B, Magnification of highly vascularized mass bulging out from lower segment of uterus revealed spillage of tissues (arrow) from scar dehiscence. C, Fetus popped out of gestational sac.
      Lee. Cesarean scar pregnancy impending uterine rupture diagnosed with 3D ultrasonography. Am J Obstet Gynecol 2017.
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