Scar pregnancy treated with double cervical balloon, with the guide of peak of systolic velocity at colorDoppler examination

Dear editor,

We recently read with interest the article published in March 2021 in the Journal of Maternal, Fetal and Neonatal Medicine by Timor Tritsh et al. titled “Extreme enhanced myometrial vascularity following cesarean scar pregnancy: a new diagnostic entity” [1]. The authors stratified the risk of patients affected by a scar pregnancy on patient clinical condition, vaginal bleeding entity and the peak of systolic velocity (PVS) in the hyper-vascularized myometrium. This conduct could guide the management; specifically, Timor-Tritsch and Timmerman [1–2] suggested the possibility of an expectant management in case of asymptomatic patient, with a PSV <50–60 cm/s.

The possible management in case of scar pregnancy is the use of double cervical balloon with the aim to avoid surgery, that is associated with the risk of a massive hemorrhage and consequently hysterectomy.

Considering these indications, we would like to share our experience in the management of a scar pregnancy occurred to our department and treated with double cervical balloon. A Caucasian woman of 40 years old. Gravida 3 Para 0, 2 previous cesarean section, without other abdominal surgery or disease comes at 6 gestational weeks requiring a pregnancy interruption.

At the first trimester ultrasound, a scar pregnancy was suspected and the patient, who was asymptomatic, was posed under observation. At 7.5 weeks, a combined vaginal and abdominal ultrasound was performed: a ventro-fixed uterus with normal adnexa were visualized; a gestational sac was identifiable close to the previous cesarean section scars (with 2 mm of residual myometrium) with a single embryo corresponding to gestational age (Figure 1(A–C)). An enhanced myometrial vascularity was detected at color Doppler and PSV was measured in different sites. The highest PSV was 45 cm/s (Figure 1(D–F))

Figure 1. Ultrasound evaluations of each step of scar pregnancy management and follow-up. (A) Transvaginal US which demonstrated a gestational sac close to the previous cesarean section scars; (B) a single embryo corresponding to gestational age; (C) a 2 mm residual myometrium. (D–F) Color-Doppler examination which detected a enhanced myometrial vascularity with different PSV mensuration. (G,H) Transabdominal and transvaginal views of intrauterine and vaginal double baloon; (I) Transabdominal US which demonstrated the compacted pregnancy after intrauterine baloon filling. (L) Doppler examination which highlighted an immediate reduction of vascularization after double baloon placement. (M) The 16 Gy foley baloon posed intrauterine after hysterosuction to preventive reduce the risk of bleeding. (N,O) Ultrasound follow-up one week later with a persistent dishomogeneous and not vascularized intrauterine material of 2.6 cm and the absence of the previous hypervascularization of the myometrium.

Considering the PSV value under 50 cm/s in an asymptomatic patient with a viable pregnancy, we opted for a not surgical management by using a double cervical ripening balloon (DCRB), as proposed by other colleagues [3–5].

After a counseling with the couple, we perform a cervical instillation of local anesthesia and dilated the stenotic cervical canal. We introduce the DCRB under ultrasound view. We present difficulties to place the intrauterine balloon cranially the gestational sac, due to the ventro-fixed uterus and the gestational sac diameters; for this reason, we decided to place it close to the gestational sac. The intrauterine balloon was filled with 20 mL of physiologic solution, and the vaginal one with 18 mL. After the filling of the uterine balloon the fetal heartbeat disappear and the gestational sac was no more visible with an immediate reduction of myometrial flow (Figure 1(G–I,L)). Subsequently, the patient present an abdominal pain well managed with ibuprofen and morphine. The DCRB was removed 24 h later. The patient did not present a spontaneous expulsion of pregnancy with the removal of the balloon. Thus, we opted for an hysterosuction (specifically an uterine aspiration after cervical dilatation by Hegar number 10), which was conduct easily, considering that the gestational sac detachment was already obtained with the double cervical balloon. The total blood loss was 300 mL. We administered prophylactic tranexamic acid after procedure, to minimize the bleeding. To reduce the risk of bleeding a 16 Gy foley balloon was placed in the uterus (Figure 1(M)) and removed 12 h later. At discharged the patient presented a minimal intrauterine dishomogeneous material and weak vaginal bleeding. One week later, at clinical and ultrasound evaluations, the patient was in wellbeing, with low quantity vaginal bleeding, a persistent dishomogeneous and not vascularized intrauterine material of 2.6 cm (Figure 1(N)); the previous hypervascularization of myometrium was no more present (Figure 1(O)). We opted to wait the spontaneous menstrual period and we obtained a linear endometrial rime after it.

We would like to share our experience to underline the utility of doppler evaluation guiding the conduct in case of scar pregnancy and we also would like to pose the attention on the possibility to a not surgical and not invasive management with DCRB, well tolerated by the patient. In addition, we also underlined that, even if we presented difficulties to pose the DCRB over and cranially to the gestational sac, we however have obtained a detachment of the pregnancy sac and a reduction of myometrial vascularization. This probably allow to perform a “gentle” hysterosuction with a reduction of bleeding.

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Funding

The author(s) reported there is no funding associated with the work featured in this article.