罕見案例:剖腹產傷口外孕.內孕( 子宮內外複合受孕)，以子宮鏡手術切除外孕，保留內孕

案例報告： 試管嬰兒子宮內孕合併剖腹產疤痕異位妊娠，以子宮鏡成功 治療剖腹產疤痕內之異位妊娠，保留子宮內孕，生下健康寶 寶 蔡鋒博 1 　王錦榮 2 　

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1. 彰化市博元婦產科試管嬰兒中心 手術中心

2. 林口長庚醫院婦產部內視鏡

Hysteroscopic management of heterotopic cesarean scar pregnancy with 彰化市博元婦產科不孕症試管嬰兒中心 : 蔡鋒博醫師 , 陳昭雯醫師 http://www.babymaker.com.tw preservation of intrauterine gestation following IVF treatment Fengpo Tsai(*), Chin-Jung Wang(**) Chaowen Chen *IVF center, Poyuan Women Clinic.Changhua, Taiwan **Department of Obstetrics and Gynecology, Division of Gynecologic Endoscopy, Chang Gung Memorial Hospital, Linkou Medical Center and Chang Gung University College of Medicine, Kwei-Shan, Tao-Yuan, Taiwan

Introduction Although spontaneous simultaneous intrauterine and ectopic pregnancy was an extremely rare event in the past, it's increasingly being diagnosed since the rate of ART gestations increased. Due to the serious consequences, delayed diagnosis should be prevented in order to salvage the intrauterine fetus's viability and avoid maternal morbidity and mortality. Nevertheless, early diagnosis is difficult .This case report demonstrate the importance of close monitoring of early pregnancies following IVF treatment and prompt treatment to preserve the intrauterine pregnancy.

Case Report The 31 year-old Vietnamese woman, gravida 2, para 1, visited our IVF unit because of secondary infertility due to bilateral tubal occlusion. She received IVF treatment since Nov.5, 2008. Four embryos were transferred smoothly via transabdominal ultrasound guidance on Nov. 20. A positive urine pregnancy test was noted and serum hCG revealed 373.4mIU/ml on Dec. 3. Three weeks later, patient presented with vaginal spotting and transabdominal ultrasound revealed one intrauterine gestation sac and the other gestation sac was located anterior to uterine isthmus with only a thin layer between uterus and bladder(fig.1). A diagnosis of heterotopic cesarean scar pregnancy combined with intrauterine gestation was made. After extensive counseling, the couple decided to take surgical treatment at CGMH. figure 1:transabdominal ultrasound revealed an intrauterine viable gestation and another gestational sac located anterior to the uterine isthmus (arrow).

The intervention began by an overview of the uterine cavity. One gestation sac was implanted in endometrial cavity and the other sac was implanted in a niche located in anterior endocervical wall, compatible with prior caesarean section scar. The sac was pushed toward the fundal direction via wire loop electrode and blood vessels in the implantation site were identified. These vessels were coagulated by loop electrode and the resectoscope was then withdrawn. A placenta forceps followed by a vacuum curette were used to remove the partial detached gestational tissue under the ultrasound guidance. Thereafter, the resectoscope attached with a rollerball was introduced again to achieve haemostasis. The operating time was 15 minutes. Vaginal bleeding was minimal at the end of the procedure. The patient had an unremarkable post-operative course and was discharged on the next day. Figure 3: The ultrasound scan after hyeteroscopic treatment

The patient recovered well and the intrauterine pregnancy (figure 4) proceeded until 39th week. A healthy boy ,weight 3250g, was born via cesarean delivery. Figure 4: The intrauterine gestation proceeded smoothly following previous treatment.

Under the impression of heterotopic cesarean scar pregnancy(fig.2) ,the patient was admitted for hysteroscopic treatment at CGMH . Under spinal anesthesia, the patient was placed in the dorsolithotomy position. After a speculum was placed inside the vagina, a tenaculum was applied to the cervix and gentle traction was exerted to align the uterus. The cervix was dilated by Hegar dilators to 12 mm and a continuous flow 26F hysteroscopic resectoscope (Karl Stortz, Tuttlingen, Germany) with a 900 wire loop electrode was introduced under ultrasound control. Uterine distension was achieved using distilled water propelled by simple gravity. An Aspen Excalibur (Aspen Labs, Englewood, Colorado) electrosurgical generator was used on a setting of 80 W of cutting waveform current and 100 W of coagulation current.

Disscussion In pregnancies following IVF-ET, heterotopic pregnancies should particularly be considered in cases with abdominal pain or vaginal bleeding. Ultrasound examination may lead to early diagnosis even in asymptomatic cases. In most cases, removal of the ectopic gestation will allow the intrauterine pregnancy to proceed to term. Svare J et al. Hum Reprod.1993Jan;8(1):116-8

figure 2:The ultrasound scan before hysteroscpic treatment :the c/s scar pregnancy showed by the arow

The management of cesarean scar pregnancy varied from laparotomy, laparoscope to fetal reduction by KCL , MTX injection or embryo aspiration. There are few case reports in the literature of heterotopic cesarean scar pregnancy. Larsen and Solomon. S Afr Med J 1978 53,142-143 Hsieh et al. Hum Reprod. 2004 Feb;19(2),285 Wang et al. Fertil Steril. 2007 Sep;88(3):706 e13-6 Demirel LC et al. Fertil Steril 2009 April;91(4):1293 e5-7 Hysteroscopic removal of the cesarean scar pregnancy gives the opportunity to preserve the viable intrauterine gestation while maintaining a strong lower uterine segment .To our knowledge, this is the first case report of successful hysteroscopic treatment of heterotopic cesarean scar pregnancy.