Case notes
A 30 year old patient was admitted with a complaint of irregular vaginal bleeding for 1 month and acute abdominal pain for 1 day. She had a regular menstrual cycle (30 days) with 6 days of duration. The patient had 2 full-term pregnancies, both ending with a caesarean delivery. She also had 4 pregnancies that ended by induced abortion in the first trimester. Her serum levels of β-human chorionic gonadotropin was 20,626 mIU/mL.
Pelvic examination revealed an enlarged uterus that was approximately 20 gestational weeks in size. Ultrasound revealed an intrauterine mass of 12.4 cm × 6.5 cm × 6.8 cm in size without abundant blood flow ( Figure 1 ). Magnetic resonance imaging (MRI) showed a stratified, miscellaneous-signal mass of 11 cm × 7.3 cm × 16.4 cm in size having no clear boundary with the anterior wall of isthmus and thin myometrium ( Figure 2 ).
The patient underwent an emergency laparotomy following an acute intractable vaginal bleeding (approximately 2500 mL) a day after her admission. At surgery, the uterus appeared to be 20 gestational weeks in size with a 6 cm lower uterine segment. A hysterectomy was performed. On cut sections, large clots and a vessel occupied the scar of the anterior isthmus ( Figure 3 A). Pathological examination revealed the presence of gestational cells and villi in the myometrium at the anterior isthmus ( Figure 3 B), which confirmed the nature of cesarean scar pregnancy (CSP). Three days after surgery, her serum levels of β-human chorionic gonadotropin dropped to 904 mIU/mL.
