案例報告：試管嬰兒子

宮內外複合受孕，以子
宮鏡刮除剖腹 外孕，
保 留內孕，生下健康
寶寶
蔡鋒博 1 　王錦榮 2 　 1
1. 彰化市博元婦產科試管嬰兒中心
2. 林口長庚醫院婦產部內視鏡手術中
心

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
Hysteroscopic management of heterotopic cesarean
scar pregnancy with 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).
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.
figure 2:The ultrasound scan before hysteroscpic
treatment :the c/s scar pregnancy showed by the arow
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.
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

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.