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Management of embedded products of conception in a previous caesarean scar by hysteroscopy and curettage

A multiparous 32-year-old woman presented to the early pregnancy unit 18 months after a caesarean section with vaginal bleeding. A transvaginal scan at the time showed findings consistent with an incomplete abortion. A gestational sac adherent to the old caesarean scar was also noted at scan. Tissue suggestive of products of conception in the vagina was removed and sent for histology. Her bleeding settled and she was discharged from the unit in accordance with our protocol for expectant management of miscarriages. She was well at subsequent follow-up 10 days later with the histology of the removed tissue showing decidualised endometrium and not confirming products of conception. She then presented to her general practitioner 6 weeks later with persistent vaginal bleeding. A diagnosis of endometritis was made on clinical grounds and she was commenced on antibiotics. There was no response to antibiotics, thus she was referred back to the hospital. Genital swabs done were negative for chlamydia or any other common pathogens. She had a negative urinary beta-human chorionic gonadotrophin (bhCG) but her serum bhCG was reported as 5 IU/l. Transvaginal and transabdominal scans revealed a mass seen in close proximity to the scar. In view of the patient’s continued bleeding and scan report a magnetic resonance imaging (MRI) study was requested to characterise the pathology and location of the mass. MRI reported the presence of an abnormal non-vascular 4 cm mass within the anterior myometrium, extending through the myometrium to the serosal margin and internally to the endometrial cavity that it had partly obliterated. A differential diagnosis of haemorrhage within a fibroid, focal uterine tumour or retained products of conception were entertained. However, based on the clinical history the latter was favoured. She underwent an inpatient hysteroscopy with findings of retained products in an aneurysmal dilatation of the anterior wall. This was curetted and confirmed to be products of conception on histology. Two months later, the patient was well, her bleeding had resolved and she had returned to a normal menstrual cycle.