Abstract
As adenomyomectomy can generate defects in the uterine muscular layer, pregnancy after adenomyomectomy is at significant risk of uterine rupture. We report a 40-year-old nulliparous woman who underwent uterine adenomyomectomy two years earlier. She underwent in vitro fertilization at an infertility clinic, resulting in pregnancy. However, at 7 weeks, the muscular layer covering the gestational sac was found to be precariously thin, and she was referred to our department. Transvaginal ultrasonography revealed that the gestational sac was localized within the muscular layer of the anterior uterine wall and a fetus was growing with heartbeat. The muscular layer over the sac was as thin as 2.4 mm and associated with marked development of blood vessels. The position of villi suggested that implantation occurred at the site of the adenomyomectomy scar. After thorough counseling, we injected methotrexate (MTX) into the sac, followed by systemic administration of the drug. However, due to the liver toxicity of MTX and re-elevation of the human chorionic gonadotropin level, we performed surgical evacuation. As it was difficult to excise the intramuscular gestational tissue by the conventional resectoscopic approach, we applied the “Transcervical Trocar Technique”, which was developed in our department. We first inserted a 12-mm camera port sheath through the uterine cervix, and then simultaneously inserted a thin diameter scope, suction/irrigation devices, and laparoscopic surgery forceps through the sheath. Through this approach, we successfully removed the residual gestation tissue within the muscular layer and spared the uterus. Our technique allows us to effectively perform transcervial surgery for lesions in the muscular layer using multiple forceps.
