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 　 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
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 The intervention began by an overview of the uterine cavity.
pregnancy was an extremely rare event in the past, it's One gestation sac was implanted in endometrial cavity and the
increasingly being diagnosed since the rate of ART gestations other sac was implanted in a niche located in anterior
increased. Due to the serious consequences, delayed diagnosis endocervical wall, compatible with prior caesarean section scar.
should be prevented in order to salvage the intrauterine fetus's The sac was pushed toward the fundal direction via wire loop
viability and avoid maternal morbidity and mortality. electrode and blood vessels in the implantation site were
Nevertheless, early diagnosis is difficult .This case report identified. These vessels were coagulated by loop electrode and
demonstrate the importance of close monitoring of early the resectoscope was then withdrawn. A placenta forceps
pregnancies following IVF treatment and prompt treatment to followed by a vacuum curette were used to remove the partial
preserve the intrauterine pregnancy. detached gestational tissue under the ultrasound guidance.
Thereafter, the resectoscope attached with a rollerball was
Case Report introduced again to achieve haemostasis. The operating time
was 15 minutes. Vaginal bleeding was minimal at the end of the
The 31 year-old Vietnamese woman, gravida 2, para 1, visited
our IVF unit because of secondary infertility due to bilateral tubal procedure. The patient had an unremarkable post-operative
course and was discharged on the next day.
occlusion. She received IVF treatment since
Nov.5, 2008. Four embryos were transferred smoothly via Figure 3: The ultrasound scan after hyeteroscopic treatment
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 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 Disscussion
by Hegar dilators to 12 mm and a continuous flow 26F
hysteroscopic resectoscope (Karl Stortz, Tuttlingen, Germany) In pregnancies following IVF-ET, heterotopic
with a 900 wire loop electrode was introduced under ultrasound pregnancies should particularly be considered in cases
control. Uterine distension was achieved using distilled with abdominal pain or vaginal bleeding. Ultrasound
water propelled by simple gravity. An Aspen Excalibur (Aspen examination may lead to early diagnosis even in
Labs, Englewood, Colorado) electrosurgical generator was used asymptomatic cases. In most cases, removal of the
on a setting of 80 W of cutting waveform current and 100 W of ectopic gestation will allow the intrauterine pregnancy to
coagulation current. 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.