帝王切開瘢痕部妊娠に対しMTX全身投与、UAE、子宮鏡下妊卵除去術を行い、 腹腔鏡下子宮形成術後、生児を得た一例

抄録

  A cesarean scar pregnancy (CSP) is one of the most dangerous forms of ectopic pregnancy. We report a case of a 33-year-old gravida 5 para 3 who was referred to our hospital at 6 weeks, 2 days of gestation from another facility with a diagnosis of CSP. A sagittal view of a transvaginal ultrasonogram imaged a gestational sac 32 mm in diameter in the anterior wall of the uterine isthmus, a fetus with a fetal heart beat, and abundant vascular flow around the gestational sac. The serum hCG level was 64,999 IU/l. It increased for a short interval to 125,512 IU/l after the systemic administration of methotrexate (MTX). We performed uterine artery embolization (UAE). Subsequently, the serum hCG level gradually declined, and we identified the disappearance of the fetal heart beat and vascular flow around the gestational sac. After another UAE, we performed a hysteroscopic resection when the serum hCG level declined to < 10,000 IU/l. The serum hCG level showed a negative conversion 60 days after the first MTX administration. During the follow-up period the thickness of the muscular layer of the uterine isthmus became remarkably thin; therefore, we performed a laparoscopic repair of the uterine scar. The patient subsequently achieved a normal pregnant and delivered a live infant at 30 weeks, 0 days of gestation by cesarean section. We stress that it is extremely important to avoid situations such as hemorrhage or rupture during treatment of a CSP. Therefore, we must carefully employ a combination of MTX administration, UAE, and hysteroscopic resection. This case suggests that laparoscopic repair of a uterine scar is a useful procedure, which leads to a better prognosis for future pregnancy, particularly in cases in which the muscular layer is extremely thin. Further study of CSPs is needed.