JBRA Assist. Reprod. 2021;25(1):165-167
CASE REPORT
doi: 10.5935/1518-0557.20200039
Cesarean scar ectopic pregnancy: A cause of failed first trimester surgical termination of pregnancy (case report)
1Department of Obstetrics & Gynecology - October 6th University & As-Salam International Hospital, Cairo, Egypt
CONFLICT OF INTEREST
None.
ABSTRACT
Cesarean scar (ectopic) pregnancy is due to blastocyst implantation on a
Caesarean scar. The current case presented by vaginal bleeding after a failed
surgical termination of pregnancy. The ultrasound scan revealed a cesarean scar
ectopic pregnancy managed by surgical removal. The possibility of cesarean scar
ectopic pregnancy should be considered in any case presenting with a low-lying
gestational sac.
Keywords: cesarean scar pregnancy, diagnosis, surgical management
INTRODUCTION
Cesarean scar (ectopic) pregnancy is due to blastocyst implantation on a Caesarean
scar. It is the least common type of ectopic pregnancies (Herman et al., 1995). I am presenting a case of
cesarean scar ectopic pregnancy with vaginal bleeding after failed surgical
termination of a first trimester pregnancy.
CASE REPORT
A thirty-nine year old woman Gravida 6 Para 3 - all by cesarean sections - who was 7
weeks pregnant presented to the emergency department with moderate vaginal bleeding
following a failed attempt of surgical termination of pregnancy outside the
hospital, as she was initially miss-diagnosed as a missed miscarriage. On
examination, her pulse was 110, blood pressure 100/60 and temperature of 36.6. Her
BhCG was 56,000 mIU/mL and hemoglobin of 12.4 g/dl, while her transvaginal
ultrasound revealed an empty uterine cavity and an intact gestational sac with fetal
pole but no fetal heart, implanted at the site of the scar causing ballooning of
this site (Figures 1 and 2). She was diagnosed as scar ectopic pregnancy. Considering her
condition, we decided to do a laparotomy, we cross-matched her blood and obtained a
signed informed consent form.
Figure 1.
Ultrasound picture showing ballooning of cesarean scar by a pregnancy
sac
Figure 2.
Ultrasound picture showing pregnancy sac with fetal pole
Operative technique
We did the laparotomy using the Pfannenstiel skin incision. Her urinary bladder
was adherent to the anterior surface of the uterus, near the uterine fundus. We
sharply dissected the adhesions until reaching the ballooned scar ectopic site
(Figure 3). The uterus was thoroughly
inspected for possible perforation by the failed attempt of surgical termination
of pregnancy, and then we proceeded with a segmental resection of the area
containing the pregnancy followed by suturing the edges to close the defect. We
left an intraperitoneal drain, and removed it two days later. Post-operative
hemoglobin was 9 g/dl. She made an uneventful recovery and was discharged on
hematinic.
Figure 3.
Operative picture of the ballooned scar ectopic pregnancy
DISCUSSION
Cesarean scar ectopic pregnancy has an estimated incidence between 1/1,800 and
1/2,216 pregnancies (Seow et al.,
2004). It is a serious condition, which may cause excessive bleeding and
uterine rupture.
The rising rate of caesarean sections has increased the risk of some serious
conditions as placenta previa, placental abruption, placenta accreta, percreta, and
cesarean scar ectopic pregnancies. Theories explaining this condition are blastocyst
invasion of the myometrium via a microscopic dehiscent tract resulting from previous
uterine surgery, like surgical termination of pregnancies and Cesarean sections
(Cignini et al., 2007),
and trauma caused by assisted reproductive techniques in cases with no previous
surgeries (Aich et al.,
2015).
The commonest presenting symptom of Caesarean scar ectopic pregnancy is painless
vaginal bleeding in the absence of clinical signs; however, in the current case,
there was bleeding following a failed attempt of surgical evacuation. Transvaginal
ultrasonography and color flow Doppler are helpful diagnostic tools (Fylstra et al., 2002; Jurkovic et al., 2003), because
they can differentiate between cesarean scar ectopic and low-lying intra-uterine
gestational sac, thus avoiding a faulty intervention which resulted in vaginal
bleeding and could have resulted in uterine perforation and additional morbidity in
the current case, during the failed attempt of surgical termination of pregnancy.
Cesarean scar ectopic pregnancy should also be differentiated from cervical
pregnancies, which are characterized by absence of myometrium between the
gestational sac and bladder, because the gestational sac grows into the anterior
wall of the isthmus (Fylstra, 2012). To
determine whether a Cesarean Scar Pregnancy (CSP) has occurred, one can use an
ultrasound scan in the sagittal view to indicate a clear uterine cavity and an empty
cervical canal (Rizk et al.,
2013), as shown in Figure 1.
Rizk et al. (2013) studied
the use of intramuscular and intra-gestational methotrexate in twenty-six cases of
suspected ectopic pregnancies - nineteen of them were Caesarean scar ectopic - with
successful outcome. After treatment, there was an initial rise in the human
chorionic gonadotropin serum level, the volume of the gestational sac and it’s
vascularization, followed by a fall in the level of serum human chorionic
gonadotropin after a variable period of time; however, this treatment option was not
used in the current case, considering the amount of bleeding and high human
chorionic gonadotropin level.
Surgical options were used in several case reports even in the absence of bleeding
(Aich et al., 2015). One
of those options is laparotomy and excision of the gestational mass as the one used
in the current case, this option decreases the risk of recurrence and a shorter
follow-up period as the old scar is resected with a new uterine closure (Jurkovic et al., 2003; Fylstra, 2012; Maymon et al., 2004).
CONCLUSION
Cesarean scar ectopic pregnancy should be excluded in any case with a low-lying
intra-uterine pregnancy sac before performing surgical termination of a first
trimester pregnancy as this avoids faulty interventions, which can increase both
morbidity and mortality.
REFERENCES
Aich R, Solanki N, Kakadiya K, Bansal A, Joshi M, Nawale A. Ectopic
Pregnancy in caesarean section scar: A case report. Radiol Case Rep.
2015;10:68-71.
Medline Crossref
Cignini P, Giorlandino M, Caserta L, Dominici L, Giorlandino C. The
importance of early diagnosis in cesarean scar pregnancy. J Prenat Med.
2007;1:29-31.
Medline
Fylstra DL, Pound-Chang T, Miller MG, Cooper A, Miller KM. Ectopic
pregnancy within a cesarean delivery scar: a case report. Am J Obstet Gynecol.
2002;187:302-4.
Medline Crossref
Fylstra DL. Ectopic pregnancy not within the (distal) fallopian
tube: aetiology, diagnosis, and treatment. Am J Obstet Gynaecol.
2012;206:289-99.
Medline Crossref
Herman A, Weinraub Z, Avrech O, Maymon R, Ron-El R, Bukovsky Y.
Follow up and outcome of isthmic pregnancy located in a previous caesarean
section scar. Br J Obstet Gynaecol. 1995;102:839-4.
Medline Crossref
Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson CJ.
First-trimester diagnosis and management of pregnancies implanted into the lower
uterine segment Cesarean section scar. Ultrasound Obstet Gynecol. 2003;21:220-7.
Medline Crossref
Maymon R, Halperin R, Mendlovic S, Schneider D, Herman A. Ectopic
pregnancies in a Caesarean scar: review of the medical approach to an iatrogenic
complication. Hum Reprod Update. 2004;10:515-23.
Medline Crossref
Rizk B, Holiday CP, Owens S, Abuzeid M. Cervical and Cesarean scar
ectopic pregnancies: Diagnosis and management. Middle East Fertil Soc J.
2013;18:67-73.
Crossref
Seow KM, Hwang JL, Tsai YL, Huang LW, Lin YH, Hsieh BC. Subsequent
pregnancy outcome after conservative treatment of a previous cesarean scar
pregnancy. Acta Obstet Gynecol Scand. 2004;83:1167-72.
Medline Crossref