RESUMEN
Cesarean scar pregnancy (CSP) is a very serious complication of a prior cesarean delivery. The major risks associated with CSP are uncontrolled hemorrhage and uterine rupture, potentially leading to future infertility. Management of CSP remains a major obstetric challenge without a well-defined therapeutic procedure. Dilation & curettage is a commonly used procedure for the treatment of CSP. However, it can be ineffective and often leads to definite infertility. Therefore, we present a case of the successful use of an alternative procedure, Myosure® hysteroscopy, in the treatment of CSP. We herein report the case of a 32-year-old G5P3013 woman who presented with vaginal bleeding and past history of three cesarean sections. She was found to have a CSP with fetal pole and cardiac activity at 6 weeks 2 days. The patient was initially treated with a systemic methotrexate injection, but there was persistence of cardiac activity. A second course of methotrexate was administered into the gestational sac, which systemically led to successful fetal cardiac arrest and downtrend of beta-human chorionic gonadotropin (HCG) level. A dilation & curettage procedure was not successful in removing products of conception. A Myosure hysteroscopy procedure, however, was successful in removing products of conception. The patient was discharged after a negative ultrasound and beta-HCG level. In our review of the literature, we found that there is no general consensus on the management of cesarean scar ectopic pregnancies. To date, there is no literature cited about the use of Myosure for cesarean scar ectopic pregnancies. However, our case suggests that Myosure can be effective for CSP and this warrants a larger-scale controlled study to better evaluate this as a treatment for this condition.
RESUMEN
Instream biogeochemical process measurements are often short-term and localized. Here we use in situ sensors to quantify the net effects of biogeochemical processes on seasonal patterns in baseflow nitrate retention at the river-reach scale. Dual-station high-frequency in situ nitrate measurements, were coupled with high-frequency measurements of stream metabolism and dissolved inorganic carbon, in a tributary of the Buffalo National River, Arkansas. Nitrate assimilation was calculated from net primary production, and combined with mass-balance measurements, to estimate net nitrification and denitrification. The combined net effects of these instream processes (assimilation, denitrification, and nitrification) removed >30-90% of the baseflow nitrate load along a 6.5 km reach. Assimilation of nitrate by photoautotrophs during spring and early summer was buffered by net nitrification. Net nitrification peaked during the spring. After midsummer, there was a pronounced switch from assimilatory nitrate uptake to denitrification. There was clear synchronicity between the switch from nitrate assimilation to denitrification, a reduction in river baseflows, and a shift in stream metabolism from autotrophy to heterotrophy. The results show how instream nitrate retention and downstream delivery is driven by seasonal shifts in metabolic pathways; and how continuous in situ stream sensor networks offer new opportunities for quantifying the role of stream biota in the dynamics, fate, and transport of nitrogen in fluvial systems.