A 38-year-old woman was admitted to our emergency gynecologic unit referring amenorrhea lasting 9 weeks, inconstant pelvic pain, and vaginal bleeding that started 2 days earlier.
She had three previous deliveries, all performed by at-term CS: the first one in 2004 for a twin pregnancy, and the other two in 2009 and 2011. All CS occurred successfully and without any complications. Her family and personal histories were negative for any disease.
General physical examination was unremarkable and vital signs were within normal limits, with a heart rate of 90 bpm and a blood pressure of 105/60 mmHg.
The abdomen was treatable by superficial palpation and painful on the deep one at the hypogastric site. The uterus had a pasty consistency, and the cervix was closed; no adnexal tenderness or pelvic swelling during the bimanual visit was appreciable; the speculum examination did not show blood loss from the uterine cervix.
TVUS was carried out showing a uterus with a higher size (longitudinal diameter = 96 mm; latero-lateral diameter = 61 mm; and antero-posterior diameter = 48 mm). Uterine adnexa were regular in location and size with the presence of corpus luteum in the left ovary of 25 mm x 20 mm. No free fluid in Douglas' pouch was detected. In the cervico-isthmic site, inside the thickness of the uterine wall, a GS of 16 mm (corresponding to six gestational weeks) was detected with no embryonic echoes suggestive of heartbeat (Figure 1).
The dosage of beta-human chorionic gonadotropin (beta-hCG) was 12,770 mU/mL, lower than the normal range for nine gestational weeks, ranging from 22,075 to 227,000 mU/mL. Considering the following findings: implantation on the site of previous cesarean wounds, stop of GS growth at six gestational weeks, absence of embryonic heartbeat on TVUS, and lower beta-hCG values, a diagnosis of CSP was done.
First, spinal anesthesia was carried out, and the patient was placed in a gynecological position with a sterile operating field. Cleaning and disinfection of the surgical site were done. By a transvaginal way, after visualizing the cervix and putting the tenacula, we started the procedure by performing bladder retraction, considering the multiple previous CS. A 2-cm horizontal incision was made in the anterior cervix about 1 cm beneath the estimated vaginocervical fold, and the bladder was retracted using a swab on a stick. The uterus was pulled towards the contralateral side of the intended ligature, to allow for ample working space and visualization of the vessel bundle. Thus, permanent bilateral ligature of the cervical branch of the uterine artery was performed using a synthetic absorbable thread (Vicryl, CT2, 2-0, Ethicon, Johnson & Johnson, Spreitenbach, Switzerland). An eight-distal loop-shaped stitch on each side of the late absorbable thread was applied, under the guidance of the index finger placed in the cervical canal and lower uterine segment, allowing the uterine artery pulsation. The whole procedure was then repeated with the contralateral vessel bundle (Figure 2).
The anterior vaginal wall and anterior cervical lip were reunited with a few interrupted stitches. A progressive dilation of the cervix up to 10 Hegar dilatators was carried out. A Foerster ring forceps was inserted into the cervico-isthmic cavity, and the entire GS was identified under ultrasound guidance and pulled out. Blood loss was negligible owing to the previous uterine ligation. Curettage of the uterine cavity ended the procedure. Finally, an utero-vaginal package was inserted.
The patient was kept under observation, and the postoperative course was uneventful. Slight blood loss was observed after removing the package the following day. On the third day, beta-hCG was 223 mU/mL, and the patient was discharged following a TVUS control that showed a regular uterus, with normal endometrial thickness and cervix, absence of intrauterine blood clots or necrotic areas, and no free fluid in the Douglas pouch. The trophism of the cervix was found to be regular at follow-up.
A week after discharge, the blood test was normal and beta-hCG values were 89 mU/mL. Four weeks later, beta-hCG was unremarkable and menstruation resumed regularly. One year later, she delivered a healthy female newborn by elective and uneventful CS.