子宮鏡取胚胎,婦產科醫師蔡鋒博表示，這名31歲婦人，經人工受孕懷雙胞胎，但妊娠第6周時，發現有一個胚胎不當著床於剖腹產傷口上 2010年08月28日蘋果日報: 子宮鏡取胚胎 長庚創首例-- 婦產科醫師蔡鋒博表示，這名31歲婦人，經人工受孕懷雙胞胎，但妊娠第6周時，發現有一個胚胎不當著床於剖腹產傷口上，因此轉診。 
2010年08月28日蘋果日報: 子宮鏡取胚胎 長庚創首例-- 婦產科醫師蔡鋒博表示，這名31歲婦人，經人工受孕懷雙胞胎，但妊娠第6周時，發現有一個胚胎不當著床於剖腹產傷口上，因此轉診。 http://tw.nextmedia.com/applenews/article/art_id/32771723/IssueID/20100828 http://www.flickr.com/photos/85944727@N00/4932636241/ 2010年08月28日蘋果日報新聞快訊列印轉寄(0)引用(0)點閱(0) 放大圖片 上一張 1 / 1 下一張圖為超音波檢查，1指在子宮內著床的胚胎，2是跑到傷口著床的胚胎。 蔡鋒博醫師提供 【高麗玲╱台北報導】一名婦人懷了雙胞胎，卻是複合性懷孕，亦即一個胚胎正常在子宮內孕育，另一胚胎卻不當著床於上胎剖腹產傷口上，隨著胚胎長大，隨時可能撐破傷口、引發大出血，危及母體性命，林口長庚醫院創新使用子宮鏡，經陰道取出此不當著床胚胎，成功保住另一個正常胚胎與母親性命。此個案報告已獲美國《生育與不孕期刊》刊登，報告上指此手術方法是醫界首例。婦產科醫師蔡鋒博表示，這名31歲婦人，經人工受孕懷雙胞胎，但妊娠第6周時，發現有一個胚胎不當著床於剖腹產傷口上，因此轉診。婦產科醫師王錦榮指，醫界以往對複合性懷孕不當著床的胚胎，多採注射毒物氯化鉀，或用剖腹、腹腔鏡手術等將該胚胎取出，但此婦人懷雙胞胎，擔心做侵襲性手術，危及另一正常胚胎。 過程短無傷口他改運用子宮鏡經陰道取出不當著床胚胎，過程僅15分鐘、無傷口。 台北市立聯合醫院婦幼院區婦產科主任林陳立表示，有剖腹產史婦女再度懷孕時，產檢時應先檢查胚胎有無在剖腹產傷口著床。 複合性懷孕小檔案定義 ．同時發生子宮內懷孕和子宮外孕，若其中一個胚胎是著床於剖腹產傷口上，也算是一種複合性懷孕 發生率 ．在孕婦中約佔0.2%至1% 風險 ．若未及處理外孕或位於剖腹產傷口的胚胎，胚胎長大，可能造成大出血 治療 ．可將毒物氯化鉀注射在外孕或剖腹產上傷口的胚胎讓其死亡，或是進行腹腔鏡等手 資料來源：蔡鋒博醫師、王錦榮醫師 
http://www.flickr.com/photos/85944727@N00/4933269494/ 
http://www.fertstert.org/article/S0015-0282(10)00332-8/fulltext Articles in Press ABSTRACT FULL TEXT FULL-TEXT PDF (415 KB) RELATED ARTICLES EXPORT CITATION EMAIL TO A COLLEAGUE DOWNLOAD IMAGES BOOKMARK ARTICLE Hysteroscopic management of heterotopic cesarean scar pregnancy Chin-Jung Wang, M.D.a, Fengpo Tsai, M.D.b, Chaowen Chen, M.D.b, Angel Chao, M.D., Ph.D.a Received 2 November 2009; received in revised form 13 February 2010; accepted 17 February 2010. published online 29 March 2010. Corrected Proof Objective To report a cesarean scar pregnancy (CSP) with a coexistent viable intrauterine pregnancy. Design Case report. Setting Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, Taiwan. Patient(s) A 31-year-old woman, with previous cesarean delivery, presented with vaginal bleeding, was transferred to our hospital at 7 weeks' gestation for heterotopic pregnancy after an IVF–embryo transfer. A diagnosis of intrauterine pregnancy combined with CSP was made by ultrasonography. Intervention(s) Hysteroscopic-directed evacuation of CSP. Main Outcome Measure(s) Good hemostasis at cesarean site and ongoing intrauterine pregnancy. Result(s) A healthy baby was delivered by cesarean delivery at term. Conclusion(s) With the increasing number of IVF–embryo transfers, the amount of heterotopic pregnancies is also increasing. Hysteroscopic management of CSP is a minimally invasive procedure that leads to successful obstetric outcomes in the corresponding intrauterine pregnancies. Key Words: Cesarean scar, heterotopic, hysteroscopy, pregnancy, assisted reproductive technology Article Outline • Abstract • Case report • Discussion • References • Copyright With the increasing use of assisted reproductive technologies (ART), more cases of heterotopic pregnancies were being diagnosed. The incidence of heterotopic pregnancies in ART is 0.2%–1% (1). Management of cesarean scar pregnancy (CSP) itself carries risk of uncontrollable bleeding, not to mention the salvage of the concomitant intrauterine pregnancy. In our previous report, successful removal of CSP using operative hysteroscopy was demonstrated 2, 3, 4. We report here a case of heterotopic pregnancy of intrauterine and cesarean after IVF–embryo transfer and close monitoring of early pregnancy and prompt removing of the CSP to preserve the intrauterine pregnancy. Case report A 31-year-old Vietnamese woman, gravida 2, para 1, had a history of bilateral tubal occlusion and one lower segment transverse cesarean delivery. She underwent IVF–embryo transfer at a local IVF clinic. Four embryos were transferred into the uterus under transabdominal ultrasound guidance. A positive pregnancy test was noted 14 days after embryo transfer. Three weeks later, she presented with vaginal spotting and transabdominal ultrasound revealed two intrauterine gestational sacs, one in the middle of the uterine cavity and the second within the isthmic area of the lower anterior wall of the uterus. A diagnosis of heterotopic CSP was highly suspected. Because of the patient's strong desire to preserve her normal pregnancy, she was transferred to our endoscopic division. Transvaginal ultrasonography (TVUS) confirmed the diagnosis (Fig. 1). After counseling, the couple opted for conservative treatment with operative hysteroscopy, which is approved by the Institutional Review Board (IRB no.98-3535B) of the Chang Gung Memorial Hospital. View Large Image Download to PowerPoint Figure 1. Transvaginal ultrasonography shows the intrauterine pregnancy and the cesarean scar pregnancy at 7 weeks' gestation. GS = gestational sac; CX = cervix; CSP = cesarean scar pregnancy; CDS = cul-de-sac. The operative hysteroscopy was performed at 7 weeks' gestation. 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 carefully dilated by Hegar dilators to 11 mm, not beyond the endocervical canal, 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. The height of the intravenous bag was positioned approximately 100 cm above the patient's uterus 5, 6. An Aspen Excalibur (Aspen Labs, Englewood, CO) electrosurgical generator was used on a setting of 80 W of cutting waveform current and 100 W of coagulation current. The intervention began by identifying the implantation of the ectopic sac. The electric loop of the resectoscope was used to push the gestational sac, exposing the vessel bed of the implantation site. A coagulation current of 100 W was used for hemostasis. A placenta forceps was then used to pull out the gestational sac under sonographic guidance, and suction curettage was used to clear the residual gestational tissue. Finally, a hysteroscopic rolling ball was used to stop the bleeding point. The operating time was 15 minutes. Vaginal bleeding was minimal at the end of the procedure. Postoperative ultrasound showed a normal intrauterine pregnancy with complete disappearance of the ectopic gestational sac (Fig. 2). The patient had an unremarkable postoperative course and was discharged the next day. She recovered with no vaginal spotting and the remaining intrauterine pregnancy proceeded until 39th week of gestation. A healthy male baby, weighed 3,250 g, was delivered by cesarean section. View Large Image Download to PowerPoint Figure 2. Hysteroscopic management of heterotopic cesarean scar pregnancy under ultrasound guidance. (A) Before hysteroscopic treatment, cesarean scar pregnancy with fetal heart beat (FHB) is seen. Arrow shows cesarean scar site. (B) Gestational villi are seen through the distension medium. (C) After hysteroscopic treatment, only one viable fetus is left. (D) Clear cervical area after the evacuation. Discussion Hysteroscopic removal of the CSP provides an alternative treatment to preserve the viable intrauterine gestation. To our knowledge, this is the first case report of a successful conservative treatment of heterotopic CSP after IVF–embryo transfer using hysteroscopy. Suspicion on heterotopic pregnancies should be particularly considered in women with abdominal pain or vaginal bleeding after IVF–embryo transfer. Transvaginal ultrasonographic examination is a tool that makes early diagnosis possible, even in asymptomatic cases. Different types of heterotopic pregnancies were noted that include cervical, tubal, and cornual, where removal of the ectopic gestation usually allow the intrauterine pregnancy to proceed to term 7, 8. At present there is no standard treatment protocol for heterotopic pregnancy involving CSP. Conservative management that has been reported sporadically included laparoscopic excision, fetal reduction by potassium chloride, or embryo aspiration 9, 10, 11, 12,13. Successful management of heterotopic CSP relied on either fetal reduction with gestational tissue in situ or removal of ectopic gestational tissue (Table 1). Table 1. Review of English literature describing successful management of heterotopic cesarean scar pregnancy. Reference Case no. Age (y) Gravity and parity Previous LSCS (n) Mode of conception Gestation (wk) Fetal heart beat Pre-op β-hCG level (mIU/mL) Management Operating time (min) Post-op stay (d) Outcome Salomon et al. (9) 1 36 G4, P1 1 IVF 8 + N/K TVS guidance, potassium chloride-directed injection N/K N/K CS at 36 wk due to premature rupture of the membranes Live female 2,800 g Hsieh et al.(10) 2 38 G4, P2 2 IVF 6 + N/K TVS guidance, embryo aspiration, preserving twin pregnancy N/K 1 CS at 32 wk due to preterm labor Live twin Yazicioglu et al. (11) 3 23 G2, P1 1 Spontaneous 6 + N/K TVS guidance, potassium chloride-directed injection N/K N/K CS at 30 wk due to abruptio placenta Live male 1,530 g Wang et al. (12) 4 38 G4, P3 3 IVF 10 + N/K TVS guidance, potassium chloride-directed injection N/K N/K CS delivery at 35 wk due to preterm labor Live male 1,820 g Immediate PPH managed by hypogastric artery ligation Demirel et al. (13) 5 34 G2, P1 1 Spontaneous 6 + N/K Laparoscopic removal of cesarean scar pregnancy 45 N/K Unremarkable pregnancy CS at 38 wk Live singleton Present case 6 31 G3, P1 1 IVF 7 + 99,544 Hysteroscopic-directed evacuation + D&C 15 1 Unremarkable pregnancy CS at 39 wk Live male 3,250 g Note: Pre-op = preoperative; Post-op = postoperative; N/K = not known; TVS = transvaginal sonography; PPH = postpartum hemorrhage; D&C = dilatation and curettage; CS = cesarean section. For fetal reduction with gestational tissue in situ, although four patients with heterotopic CSP received this procedure under TVUS guidance ended with live births by cesarean deliveries, these pregnant courses were not uneventful (Table 1). All babies were born prematurely due to various causes (premature rupture of the membranes, abruptio placentae, or preterm labor). Immediate postpartum hemorrhage was even encountered in one pregnancy and bilateral hypogastric arteries ligation was necessary to stop the bleeding and preserve the uterus (Table 1). Furthermore, the retained gestational tissues might affect the muscle strength of the uterine lower segment in the ongoing pregnancy. Consequently, the residual placenta and deciduous tissues in a weak myometrium might predispose to early uterine premature contraction. Instead, surgical removal of heterotopic CSP carries uneventful prenatal courses and the pregnant women delivered live births at term. Laparoscopic removal of ectopic mass in heterotopic CSP with good pregnancy outcome has been reported (13). However, to follow the principles of laparotomy (12), proper anatomic dissection, trim of unhealthy tissues, and repair of the uterine defect should be performed at the same time by laparoscopy. Massive operative blood loss is another main concern. Thus, laparoscopic management is not suitable for an inexperienced laparoscopic surgeon. We previously reported the management of the first trimester CSP using hysteroscopy (4). Accumulating experiences from this approach we chose this minimally invasive method to remove the heterotopic CSP. Although the uterine pregnancy was uneventful, the possibility of complications involving uterine defects after removal of gestational tissue by hysteroscopic surgery should be considered. Complications with advanced pregnancy of the intrauterine embryo, such as increased the possibility of intermittent antepartum spotting or uterine rupture before cesarean section, should be watched for. Different from the management of single CSP, hysteroscopic manipulation should be reduced to as much a minimum as possible because the intrauterine embryo might be disturbed by the upward force of the distended medium during hysteroscopy. After identifying the location of the CSP and coagulating the vessel beds of the implantation site, the hysteroscope should be withdrawn immediately and replaced by placenta forceps and suction curettage to remove the gestational tissues under sonographic guidance. Caution with avoidance of damaging the embryo should be strictly followed. Based on the reported cases and our own experience we suggest surgical removal of the ectopic mass for the management of first trimester heterotopic CSP. For experienced hysteroscopists, this case report offers an important alternative treatment for heterotopic pregnancy involving CSP with a short operative time and minimum blood loss. Early diagnosis is warranted to preserve the viability of the intrauterine fetus and avoid maternal morbidity. References 1. Dor J, Seidman DS, Levran D, Ben-Rafael Z, Ben-Shlomo I, Mashiach S. The incidence of combined intrauterine and extrauterine pregnancy after in vitro fertilization and embryo transfer. Fertil Steril. 1991;55:833–834. MEDLINE 2. Wang CJ, Yuen LT, Chao AS, Lee CL, Yen CF, Soong YK. Caesarean scar pregnancy successfully treated by operative hysteroscopy and suction curettage. BJOG. 2005;112:839–840. MEDLINE | CrossRef 3. Chao A, Wang TH, Wang CJ, Lee CL, Chao AS. Hysteroscopic management of cesarean scar pregnancy after unsuccessful methotrexate treatment. J Minim Invasive Gynecol. 2005;12:374–376. Abstract | Full Text | Full-Text PDF (138 KB) | CrossRef 4. Wang CJ, Chao AS, Yuen LT, Wang CW, Soong YK, Lee CL. Endoscopic management of cesarean scar pregnancy. Fertil Steril. 2006;85:494;e1–4. 5. Loffer FD, Bradley LD, Brill AI, Brooks PG, Cooper JM. Hysteroscopic fluid monitoring guidelines. The ad hoc committee on hysteroscopic training guidelines of the American Association of Gynecologic Laparoscopists. J Am Assoc Gynecol Laparosc.2000;7:167–168. Full-Text PDF (107 KB) | CrossRef 6. Munro MG, Brill AI, Parker WH. Gynecologic endoscopy. In: Berek JS editors. Berek & Novak's Gynecology. Philadelphia: Lippincott Williams & Wilkins; 2006;p. 749–804. 7. Svare J, Norup P, Grove Thomsen S, Hornnes P, Maigaard S, Helm P, et al. Heterotopic pregnancies after in-vitro fertilization and embryo transfer—a Danish survey. Hum Reprod. 1993;8:116–118. MEDLINE 8. Jozwiak EA, Ulug U, Akman MA, Bahceci M. Successful resection of a heterotopic cervical pregnancy resulting from intracytoplasmic sperm injection. Fertil Steril. 2003;79:428–430. Abstract | Full Text | Full-Text PDF (63 KB) | CrossRef 9. Salomon LJ, Fernandez H, Chauveaud A, Doumerc S, Frydman R. Successful management of a heterotopic Caesarean scar pregnancy: potassium chloride injection with preservation of the intrauterine gestation: case report. Hum Reprod. 2003;18:189–191.MEDLINE | CrossRef 10. Hsieh BC, Hwang JL, Pan HS, Huang SC, Chen CY, Chen PH. Heterotopic Caesarean scar pregnancy combined with intrauterine pregnancy successfully treated with embryo aspiration for selective embryo reduction: case report. Hum Reprod. 2004;19:285–287. MEDLINE | CrossRef 11. Yazicioglu HF, Turgut S, Madazli R, Aygun M, Cebi Z, Sonmez S. An unusual case of heterotopic twin pregnancy managed successfully with selective feticide. Ultrasound Obstet Gynecol. 2004;23:626–627. MEDLINE | CrossRef 12. Wang CN, Chen CK, Wang HS, Chiueh HY, Soong YK. Successful management of heterotopic cesarean scar pregnancy combined with intrauterine pregnancy after in vitro fertilization–embryo transfer. Fertil Steril. 2007;88:706;e13–6. 13. Demirel LC, Bodur H, Selam B, Lembet A, Ergin T. Laparoscopic management of heterotopic cesarean scar pregnancy with preservation of intrauterine gestation and delivery at term: case report. Fertil Steril. 2009;91:1293;e5–7. a Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou and Chang Gung University College of Medicine, Kwei-Shan, Tao-Yuan b Poyuan Women Clinic, Changhua, Taiwan Reprint requests: Angel Chao, M.D., Ph.D., Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou, Taiwan (FAX: 886-3-3288252). C.-J.W. has nothing to disclose. F.T. has nothing to disclose. C.C. has nothing to disclose. A.C. has nothing to disclose. Supported by Chang Gung Memorial Hospital, Linkou, Taiwan, Grant CMRPG340753. PII: S0015-0282(10)00332-8 doi:10.1016/j.fertnstert.2010.02.039 © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved. 博元婦產科不孕症試管嬰兒中心:蔡鋒博醫師,陳昭雯醫師
留言列表
