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The Wayward Seed: An Ectopic Gestation in a Cesarean Section Scar

Paula Patricia P. Perez, MD; Regta L. Pichay, MD, FPOGS, FPSGE
Department of Obstetrics and Gybecology, Manila Central University

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.