輿石 太郎, 馬場 一憲, 木下 二宣, 斎藤 麻紀, 大久保 貴司, 斉藤 正博, 林 直樹, 竹田 省

Taro KOSHIISHI, Kazunori BABA, Kazunori KINOSHITA, Maki SAITO, Takashi OOKUBO, Masahiro SAITO, Naoki HAYASHI, Satoru TAKEDA

埼玉医科大学総合医療センター産婦人科

Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University

キーワード : cesarean scar pregnancy, Doppler ultrasound , chemotherapy, uterine artery embolism

帝王切開創部妊娠は子宮破裂, 大量出血の原因となり, 早期の診断, 治療が重要であるが, 未だ治療法は確立されていな い. 当科では妊娠初期に診断し, メソトレキセート(MTX) 投与や子宮動脈塞栓術(uterine artery embolism：UAE) を 併用して子宮内容除去術(dilatation and curettage：D&C) で妊卵除去を行う方法を用い, 良い治療成績を上げている. しかし, 今回, D&C で治療を完結できずに開腹手術を行った1 症例を経験した. 症例は31 歳2 経妊1 経産. 前置胎盤 による帝王切開術の既往がある. 前医で妊娠8 週稽留流産の診断で流産処置を試みるも出血多量のため処置中止となり, 外来フォローとなっていた. 約6 週間後, 出血多量によるプレショック状態で当科に緊急入院となり, 帝王切開創部妊娠 と診断された. 創部内は凝血塊と思われる腫瘤で占められ, そこに流入する動脈性の血流も確認された. MTX の経静脈 投与とUAE を施行した後にD&C を施行したが, 子宮筋層の菲薄化のために治療を完結できなかった. その後, 腫瘤は 縮小し動脈性の血流も消失したが, 出血が続くために開腹手術による腫瘤摘出術を行った. 術後は経過順調であった. 帝 王切開創部妊娠における管理, 治療指針について, 当院での治療経験に文献的考察を加え再検討するとともに, この症例 における超音波ドプラ法の所見について検討した.

Cesarean scar pregnancy causes uterine rupture and hemorrhage. If diagnosed early, treatment options are capable of preserving the uterus and subsequent fertility. In this center, early diagnosis is achieved by transvaginal scan. Upon decreasing the blood human chorionic gonadotropin (hCG) level by methotrexate (MTX), and uterine artery embolism (UAE), we were able to remove pregnancy tissue with little blood loss by dilatation and curettage (D&C) in many cases. We encountered a case in which we were not able to remove pregnant tissue by D&C, despite having decreased the blood hCG level. A 31-year-old woman, gravida 2, para 1, had a history of lower segment cesarean section. Eight-week missed abortion was diagnosed and D&C performed at another hospital, but the procedure was terminated with insufficient treatment, due to massive blood loss. She left that hospital after the operation, although the hemorrhage continued. Afterwards, she was admitted to our hospital for diagnosis of a pre-shock state. At admission, blood hCG level was 387 mIU/m. A transvaginal scan confirmed that a mass suspected of being pregnancy tissue with abundant blood supply was a caesarean scar. Cesarean scar pregnancy was diagnosed, and systemic MTX was administered resulting in a decrease in blood hCG level to 142 mIU/ml. We attempted to remove the pregnancy tissue by D&C with uterine artery embolism. However, the procedure was not successful, because the cesarean scar was very thin, and there was a possibility of uterine perforation. Afterwards, the mass got smaller, and the blood supply for the pregnancy tissue vanished. However, bleeding continued. Laparotomy was done 13 days after D&C. The cesarean scar adhered to the bladder, and the uterine muscle layer was very thin. After we lysed the adhesions between the bladder and the uterus, the pregnancy tissue was resected via a vertical incision into the anterior wall of the lower uterine segment, and the uterine defect was repaired. We examine the medical guidelines for cesarean scar pregnancy and the Doppler ultrasound findings in this case.