古谷 菜摘, 長谷川 潤一, 上嶋 佳織, 三浦 彩子, 倉崎 昭子, 近藤 春裕, 鈴木 直

Natsumi FURUYA, Junichi HASEGAWA, Kaori UWAJIMA, Ayako MIURA, Akiko KURASAKI, Haruhiro KONDO, Nao SUZUKI

聖マリアンナ医科大学産婦人科学

Department of Obstetrics and Gynecology, St. Marianna University School of Medicine

キーワード : Caesarean scar pregnancy, Potter syndrome, amniotic fluid infusion, oligohydramnios

26歳，5妊2産（3回自然流産，1回帝王切開，1回帝王切開後経腟分娩）．妊娠9週，帝王切開瘢痕部妊娠の疑いがあったが，前医の診察では最終的にその可能性は低いと判断され，妊娠を継続していた．妊娠19週，胎児発育は週数相当であったが，羊水量がほとんどなく当院へ紹介となった．自覚症状はなかったが，超音波検査で，胎盤は前回帝王切開瘢痕部に付着していた．腟内に破水所見はなく，腹腔内の液体貯留もなかったが，羊水腔はほとんどなく，胎児の形態評価は困難であった．入院管理として羊水注入を施行し，胎児を精査したところ，胸郭はベル状で，胃胞・両側腎臓・膀胱の描出は困難であった．一方，胎盤は前回帝王切開創部に付着し，同部分が腹側に向かって膨隆し，子宮底に内腔の拡大を認めない小さな子宮体部を認めた．以上より，帝王切開瘢痕部の癒着胎盤と児のPotter症候群による羊水過少と診断した．そこで，妊娠の継続は子宮破裂の可能性が高く，家族と協議の上で妊娠中絶の方針となったが，子宮温存の希望が強く，子宮体部下部横切開術および瘢痕部癒着胎盤部分の切除術を行った．帝王切開瘢痕部妊娠とPotter症候群は，いずれも妊娠継続の可否を熟慮すべきハイリスク妊娠であり，妊娠初期からの精密超音波検査や，診断を目的とした羊水注入の意義は高い．妊娠初期の精密超音波検査の重要性や，診断のための羊水注入の意義を再認識させられる症例であった．

The patient was a 26-year-old pregnant woman, gravida 5, para 2 (3 spontaneous abortions, 1 Caesarean section, 1 Caesarean section after transvaginal delivery). Although Cesarean section scarred pregnancy was previously suspected at 9 weeks of gestation in a private clinic, a final decision was not made. She subsequently underwent routine pregnancy checkups. At 19 weeks’ gestation, she was referred to our perinatal center due to oligohydramnios. Although she did not have any symptoms, ultrasound revealed that the placenta was attached on the previous Caesarean section scar. Although there were no findings of outflow of the amniotic fluid including the echo-free space in the abdominal cavity and rupture of membrane, the amniotic fluid cavity was almost absent. Since fetal morphological assessment was difficult, amniotic fluid injection was performed after admission to the hospital. Fetal assessment was then attempted, which showed a bell-shaped thorax, absence of gastric fluid, and absence of the bilateral kidneys and the bladder. Moreover, the placenta was adhered to the whole Caesarean section scar and bulged. A closed small uterine body was also found at the uterine fundus. Therefore, diagnoses of Cesarean scar pregnancy and Potter syndrome were made. Considering the risk of uterine rupture, we decided to perform induced abortion after consulting the patient and her family. Because she had a strong desire for uterine preservation, wedge resection of scarred pregnancy after Caesarean section and wound repair were performed. Conclusion: Amniotic fluid injection successfully led to a diagnosis of previous Caesarean scarred pregnancy with oligohydramnios due to Potter syndrome. This case suggests that ultrasound evaluation of the previous Caesarean scar in early pregnancy is important for safe management of the pregnancy.