Pregnancy implantation within the scar of a previous caesarean delivery is the rarest location for an ectopic pregnancy. With increasing incidence of cesarean section worldwide, more and more cases are diagnosed and reported.
A 36 years of age, Gravida 3 Para 1 (1-0-1-1) with a CS delivery and one completion curettage for abortion presented with hypogastric pain and vaginal spotting. She was admitted with an impression of Missed Abortion at eleven weeks age of gestation. Initial scan showed embryonic fetal demise, eight weeks and two days by crown to rump length (CRL) for which completion curettage was planned. On her 3rd hospital day, evacuation curettage was attempted. It was aborted when profuse vaginal bleeding ensued upon the insertion of the hysterometer. Carbetocin 100 mcg/IV and Tranexamic acid 1gm/IV were given to control the bleeding. Repeat scan showed Abortion in progress eight weeks and one day by CRL; Abortus was noted at the lower uterine segment and cervical canal. On her 4th hospital day, evacuation curettage was rescheduled with anesthesia assist, however the profuse bleeding that resulted when a piece of tissue was grasped with an ovum forceps, cautioned the operator not to proceed further. Hemorrhage was controlled with an intrauterine balloon tamponade, antifibrinolytics and carbetocin. Suspicious of the presence of an ectopic gestation, emergency ultrasound was requested showing features of CS scar pregnancy. She underwent medical management with methotrexate and exhibited a successful outcome.
The case presented aims to highlight the difficulty of diagnosing CS scar pregnancy clinically and by sonography. The importance of having a high index of clinical suspicion in women with risk factors, the pathophysiology, appropriate methods of diagnosis and timely intervention are likewise emphasized. A delay in diagnosis and/or treatment of this rare event can lead to serious maternal morbidity and even death.

 

Human ; Female ; Adult ; Tranexamic Acid ; Antifibrinolytic Agents ; Abortion, Missed ; Carbetocin ; Pregnancy, Ectopic ; Cesarean Section ; Abortion, Induced ; Oxytocin ; Uterine Hemorrhage ; Fetal Death

Postpartum hemorrhage is a preventable event in abdominal and vaginal seliviries. Conventional incremental dosing or continous infusion of oxytocin has been employed for these. Carbetocin, as an anlogue is associated with longer half-life and has clinical benefits.

OBJECTIVE: The objective was to compare the effectiveness of carbetocin and oxytocin when administered after elective uncomplicated cesarean section (CS) for the prevention of postpartum hemorrhage.

DESIGN: Randomized single blind controlled trial of patients admitted at Rizal Medical Center from June to October 2012.

PARTICIPANTS AND METHODS: A total of 70 patients were randomized to carbetocin (n=35) and oxytocin (n=35) for the prevention of postpartum hemorrhage and analyzed by intention-to treat. Baseline demographic and obstetric profile, indications for CS, estimated blood loss, hematocrit, hemoglobin, need for uterine massage, additional uterotonics, uterine tone and involution were compared immediate post-operative and 24 hours after.

RESULTS: Baseline profiles were similar between the two groups. Post-operatively, hemoglobin and hematocrit levels in the carbetocin in group were statistically significant and were associated with lesser need for additional uterotonic agents, uterine massage and a well contracted uterus immediate post-operative and 24 hours thereafter. The estimated blood loss was significantly lower in the carbetocin group however , the two groups did not significantly differ in terms of blood transfusion requirements and post-op blood pressure.

CONCLUSION: Carbetocin as a uterotonic agent is an acceptable alternative for the prevention of postpartum bleeding in elective cesarean section. A cost-benefit analysis is mandated. 

Human ; Female ; Carbetocin ; Oxytocin ; Postpartum Hemorrhage ; Blood Pressure ; Half-life ; Hematocrit ; Oxytocics ; Cesarean Section ; Postpartum Period

PURPOSE: The objective of this study was to compare the efficacy and safety of carbetocin, a long oxytocin analogue, with oxytocin in preventing postpartum hemorrhage.

METHODS: Sixty women eligible for the study were enrolled on this prospective, double-blinded randomized controlled trial. They were randomized to receive either a single dose of 100-microgram intravenous carbetocin or oxytocin infusion (a mixture of 10 IU oxytocin and 1 liter of D5 containing intravenous fluid) upon delivery of the anterior shoulder of the baby. The primary outcome measure was a difference in hemoglobin drop measure 242 hours postpartum.

RESULTS: A significant drop of hemoglobin level 24 hours  postpartum was observed in the oxytocin group (-1.1) compared to the carbetocin (-0.6). The incidence of additional uterotonic agents and average estimated blood loss were lower with carbetocin. Uterine massage was needed in almost all patients who received oxytocin compared to a negligible number of those in the carbetocin group. Blood pressure and pulse rate of the patients were logged though no statistical difference was observed. The onset and duration of action was rapid and longer, respectively with carbetocin. There was no difference in the incidence of side effects between the two groups.

CONCLUSION: Carbetocin appears to be more effective than a continuous infusion of oxytocin with similar safety profile, thus a good alternative to conventional  uterotonic agents.

Human ; Female ; Carbetocin ; Oxytocin ; Postpartum Hemorrhage ; Blood Pressure ; Parturition ; Delivery, Obstetric ; Postpartum Period ; Hemoglobins