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Abstract: A 29-year-old woman who planned to prepare for her second child after a cesarean delivery was unexpectedly conceived before a preparation test. After pregnancy, she developed abnormal vaginal bleeding, and ultrasound examination suggested that no gestational sac was seen in the uterine cavity, and there was a diverticular ventricle at the uterine scar with a mixed echogenic mass visible at the diverticulum, which was diagnosed as cesarean scar pregnancy and scar diverticulum, a special type of ectopic pregnancy with a very dangerous condition. She was treated with laparoscopic surgery to remove and repair the scar tissue at the diverticulum, and her condition was controlled.
Basic information】Female, 29 years old
Type of disease】Cesarean section scar pregnancy, scar diverticulum
Hospital】Jiangbin Hospital of Guangxi Zhuang Autonomous Region
Date of consultation】September 2021
Treatment plan】Uterine scar excision and repair + MTX embryo killing treatment + medication (cefuroxime sodium for injection + metronidazole injection + tranexamic acid injection)
Treatment Period】6 days of inpatient treatment and regular outpatient review
Effectiveness of treatment】Surgical termination of pregnancy and repair of scar diverticulum, and control of the disease
I. Initial consultation
A 29-year-old woman reported that she had two abortions and one cesarean section in 2017, and she was planning to prepare for her second child, but she had not yet undergone a pregnancy preparation test. On September 18, she went to the hospital and underwent ultrasound examination, which showed that there was no gestational sac in the uterine cavity, and there was a diverticulum with extra-diverticular convexity at the uterine scar, and there was a mixed echogenic mass at the diverticulum.
II. Treatment history
On admission, body temperature: 36.8℃, blood pressure: 94/65mmHg, clear, no abdominal pressure pain, small amount of vaginal blood stain on gynecological examination, mild painful cervical elevation, slightly enlarged uterus with light pressure pain, no obvious abnormalities in both adnexa. Based on the history, gynecological examination and ultrasound findings, the current diagnosis is cesarean scar pregnancy and scar diverticulum. On September 19, she underwent laparoscopic excision and repair of the uterine scar under general anesthesia in the operating room, and MTX embryo-killing treatment. A mass of about 15 mm in diameter was seen in the lower part of the anterior uterine wall, so the uterine scar was excised, the incision was re-sutured and repaired, and MTX was injected locally to kill the embryos. After the operation, the patient was returned to the ward and given intravenous anti-inflammatory treatment with cefuroxime sodium and metronidazole injection, and hemostatic treatment with tranexamic acid injection.
III. Treatment effect
After the operation, the patient was given regular blood sampling to recheck the routine blood and blood HCG status. On the 6th day of hospitalization, the patient was seen to be recovering well after surgery, with normal vital signs, no abdominal pain and abdominal distension, and a small amount of vaginal bleeding, which was normal. The pathological results returned villi tissue at the scar diverticulum, which was consistent with the clinical diagnosis. The routine blood tests were normal, and the blood HCG: 328mIU/ml, which was significantly lower than before, was discharged, and regular outpatient review was recommended.
IV. Precautions
After surgical treatment, the patient’s cesarean scar pregnancy was properly treated, and the following precautions need to be noted after discharge.
1. after discharge, the patient is advised to recheck the blood HCG status at the outpatient clinic weekly until the blood HCG turns negative.
2.A good contraception is recommended after surgery, because it takes 2 years to conceive again after removing part of the scar tissue of the atomic uterus, so during this period, good contraception must be done to avoid getting pregnant again too early.
3, it is recommended to take more rest, increase nutrition appropriately, but do not eat food that activates blood, pay attention to hygiene and avoid infection.
4. Due to the influence of the disease and multiple uterine surgeries, it is easy for patients to have a fear of pregnancy and surgery. It is recommended that family members give more love and care to help patients come out of the shadow of the disease as soon as possible, adjust their mindset and face life positively.
V. Personal insight
With the increase of cesarean delivery, pregnancy at the scar of cesarean delivery is gradually becoming more common, but this patient had a diverticulum at the scar and was neglected because she did not do pregnancy preparation examination, which led to the accidental implantation of the fertilized egg near the diverticulum after conception, thus causing this special type of ectopic pregnancy, which is easy to rupture with the increase of the mass and the weakness of the diverticulum, and it is easy to produce hemorrhage, which is very dangerous. It is very dangerous, so once this condition is detected, it should be treated by surgery as soon as possible to avoid serious consequences.