It was an ordinary day in July, another day for outpatient visits.
Looking at the bustling obstetrics and gynecology waiting room, I knew it would be another busy and tiring day, but everything was proceeding in an orderly manner.
At that moment, a Ms. Zhang entered the consultation room. I looked at her medical record; she was 34 years old.
"Hello, is there anything wrong?" I greeted her gently.
She looked distressed and pulled out her medical report, telling me, "For the past four days, I've had some vaginal bleeding, and my stomach has been aching intermittently. I went to the local hospital yesterday, and the doctor said it might be a cesarean section pregnancy. They all said it's a complicated condition to treat, with risks of uterine rupture and severe bleeding, and suggested I come to a higher-level hospital. So I came here today for further examination..."
As she spoke, Ms. Zhang suddenly burst into tears.
After calming the patient down, I communicated with her carefully and learned that she had a history of cesarean section and was currently breastfeeding with a child who was only 1 year and 2 months old.
Previously, her menstrual cycle and period were regular, but based on her last menstrual period, she has now stopped menstruating for 41 days.
I arranged for her to undergo a vaginal ultrasound and blood hCG test. The color Doppler ultrasound showed a cystic echo in the lower segment of the uterine cavity, partially embedded in the myometrium, and abundant blood flow signals were detected in the lower segment of the anterior wall, so cesarean scar pregnancy could not be ruled out; the blood hCG level was as high as 8430 mIU/ml.
My heart skipped a beat; this was the third case of cesarean scar pregnancy I'd encountered today.
The diagnosis of cesarean scar pregnancy is now clear, and the gestational sac is close to the cesarean section incision, with part of it embedded in the uterine muscle layer, much like tree roots deeply embedded in the soil. Furthermore, the high serum hCG level indicates that the gestational sac is highly active.
After the discussion, Ms. Zhang agreed to be hospitalized for further treatment.
What is a keloid pregnancy?
With the increasing cesarean section rate in my country, the incidence of scar pregnancy is on the rise, and more and more people are now paying attention to this disease.
Cesarean scar pregnancy (CSP) refers to a pregnancy in which a woman who has previously undergone a cesarean section becomes pregnant again and the new life implants on the cesarean scar on the uterus, which is limited to the early stages of pregnancy.
The cause remains unclear, but it may be related to poor healing of the uterine incision after cesarean section, or it may be related to damage to the endometrium and myometrium at the scar site caused by repeated induced abortions after cesarean section.
Alternatively, it may be related to inflammation causing tiny openings in the scar tissue, through which a fertilized egg can enter the muscle layer and implant if it travels too fast or develops too slowly.
CSP has different forms of expression:
One possibility is that the gestational sac implants at the scar site and grows in the isthmus and uterine cavity, which can develop into an intrauterine live fetus and even a full-term delivery, but there are risks of placenta previa and placenta accreta.
Another scenario is that the gestational sac implants in the cesarean section scar and grows into the muscle layer, which can develop into placenta previa with severe complications or even uterine rupture.
CSP can lead to life-threatening massive bleeding, rupture of scar tissue, uterine rupture, and hemorrhagic shock, and is a type of ectopic pregnancy.
Simply put, it means the fetus is growing in an inappropriate place, which is just as dangerous as an ectopic pregnancy and is considered a relatively dangerous obstetric emergency.
Transvaginal ultrasound is an important tool for diagnosing CSP. Meanwhile, hysteroscopy can directly examine lesions within the uterine cavity and clarify the location of the gestational sac. Patients also have higher satisfaction with the treatment results than with traditional curettage.
Since most cases of CSP have a poor prognosis, once diagnosed, it is generally recommended to terminate the pregnancy as soon as possible, and the treatment plan should be individualized.
Current treatment methods include drug therapy and surgical treatment.
Methotrexate is the first-line drug for conservative treatment;
Surgical treatments include ultrasound-guided curettage, hysteroscopic removal of CSP pregnancy tissue, and transabdominal, laparoscopic, or transvaginal lesion resection and repair; among these, uterine artery interventional embolization is an important adjunctive treatment.
Scar pregnancy is not a terrible thing; early treatment is key. Specific treatment methods can be chosen based on the patient's age, ultrasound classification, and fertility requirements.
Based on Ms. Zhang's condition, including a history of one cesarean section, this pregnancy is 14 months after her last pregnancy and she is currently breastfeeding. Her uterus is large and soft, and her blood hCG level is high. The color Doppler ultrasound showed abundant blood flow signals around the pregnancy tissue, indicating that the pregnancy tissue is highly active and embedded in the myometrium.
Such scar pregnancies are relatively difficult to treat. If a curettage is performed blindly, it may lead to rupture of the weak scar tissue, massive bleeding, or even hemorrhagic shock.
Later, with the assistance of uterine artery embolization and color Doppler ultrasound, Ms. Zhang was able to completely remove the small gestational sac that was growing in an incorrect location.
After 24 hours of postoperative observation, Ms. Zhang experienced minimal vaginal bleeding and was discharged smoothly.
Before being discharged from the hospital, Ms. Zhang held my hand and kept expressing her gratitude.
Seeing the long-lost smile on her face, my heart was filled with both joy and sorrow. I was happy that she was discharged from the hospital safely, but I was also deeply worried about the increasing incidence of cesarean scar pregnancy.
With the relaxation of the national two-child policy, the cesarean section rate has gradually increased, which has sounded an alarm for women of childbearing age. It is hoped that women who do not want to have children will choose reasonable contraceptive methods.
For women with a history of cesarean section, it is recommended to strictly use contraception for more than 2 years to reduce the occurrence of scar pregnancy and minimize harm to their health.
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