FERTILITY AND STERILTTYQ Vol 65, No. 2.

February 1997
Copyright 1997 American Society for Reproductive Medicine

An ectopic pregnancy developing in a previous caesarian section scar

Pierre-Arnaud Godin, M.D.

Salim Bassil, M.D.
Jacques Donnez, M.D., Ph.D.*

Catholic University of Louvain, Department of Gyn.ecology, St. Luc University Clinics, Brussels, Belgium

Objective: To report the diagnosis and management of an ectopic pregnancy (EP) developing
in a caesarean section scar.
Design: Case report.
Setting: University medical school.
Patient(s): A patient with a previous history of two caesarean sections developing an EP.
Intervention(s): Methotrexate (MTX) was administered locally under ultrasonographic
guidance.
Main Outcome Measure(s): Weekly screening of blood hCG levels and yolk sac resorption
by endovaginal sonography.
Result(s): The diagnosis was suspected by vaginal echography and confirmed by magnetic
resonance imaging. Local injection of KC1 and MTX provoked a progressive resorption of the
pregnancy. Human chorionic gonadotropin was undetectable on day 82.
Conclusion(s): To prevent uterine rupture in cases of an EP developing in a caesarean
section scar, a medical approach can be proposed. Fertil Steril@ 1997;67:398-400

Key Words: Ectopic pregnancy, myometrium, caesarean section scar

Myometrial pregnancy developing in a previous CASE REPORT

caesarean section scar is the rarest of all ectopic
pregnancies (EP) and probably one of the most dan- A 33-year-old woman, gravida 3 para 2, with a
gerous because of the risk of rupture and hemor- previous history of two caesarean sections was ad-
rhage (l-3). This entity must be distinguished mitted complaining of a painless pin.k vaginal dis-
clearly from cervical pregnancy. Since the advent charge. The patient reported 6.5 weeks of amenor-
of endovaginal ultrasound and magnetic resonance rhea. The pregnancy test was positive. The ultra-
imaging (MRI), this condition, which previously re- sound demonstrated a gestational sac implanted in
quired hysterectomy in most cases for extensive the anterior isthmic wall of the uterus. This sac con-
uterine disruption, can be diagnosed earlier in the tained an embryo with fetal cardiac activity and a
gestation and treated more conservatively, main- crown-rump length corresponding to 7 weeks of
taining fertility. Here we describe the first case of an amenorrhea (Fig. 1A). The gestation was surrounded
EP developing in the myometrial scar of a previous by myometrium bulging from the serosal surface of
caesarean section diagnosed by echography and MRI the uterus. Only 1.2 mm of myometrium could be
and treated successfully by a conservative medical visualized between the sac and the bladder wall.
therapy. There was no fluid in the cul-de-sac. The diagnosis
of a gestation in the scar of a previous caesarian
section was made. Because the patient was asymp-
tomatic, an expectative management was proposed
Received June 3, 1996; revised and accepted September 17, in order to confirm the diagnosis. The patient was
1996.
* Reprint requests: Jacques Donnez, M.D., Ph.D., Catholic Uni- examined weekly by vaginal echography.
versity of Louvain, Department of Gynecology, 10 Avenue Hippoc- At 9 weeks of amenorrhea, the embryo had a
rates, B-1200 Brussels, Belgium (FAX: 32-2-764-95-07). crown-rump length of 24 mm with persistent cardiac

398 Godin et al. Communications-in-brief Fertility and Sterility”

 injected directly into the fetal thorax to cease cardiac
motion, and 60 mg of MTX was injected into the sac
and the surrounding myometrium.
The subsequent course was characterized by a
steady progressive resorption of the pregnancy as
demonstrated by the decrease in the hCG level. The
hCG levels were, respectively, 62,000, 39,800,
11,900, 552, and 114 mIU/mL (conversion factor to
SI unit, 1.00) on days 0, 5, 12, 23, and 4-5. It finally
was undetectable on day 82. Sonograplnic findings
showed a rapid disappearance of the fetal pole, with
persistent amorphous echoes. On day 96, an ultra-
sound examination demonstrated a normal non-
gravid uterus and cervix.
There was no change in either liver function or
bone marrow suppression. Bleeding and uterine
cramps were intermittent and minimal.
The patient experienced menstrual lbleeding 16
weeks after the MTX injection. A hysterosalpingog-
raphy was performed and demonstrated a dehiscent
caesarean section scar. Because of the very low risk
of recurrence of an EP in this site, it was decided
that the natient could attempt to conceive.

DISCUSSION

Pregnancy developing in a previous caesarean sec-

tion scar is the rarest kind of all EPs and must he
distinguished from cervicoisthmic implantation,
sometimes resulting in term delivery (2,3). The risk
involved in a pregnancy developing in a previous
caesarean section scar is that of uterine rupture and
hemorrhage, requiring an emergency h;ysterectomy
(l-4). As an explanation for this, the most reason-
able hypothesis is that the conceptus enters the myo-
Figure 1 CA), The gestation (7 weeks of amenorrhea) was sur- metrinm through a microscopic dehiscent tract of
rounded by myometrium (1.2 mm) (long white arrow:) bulging
from the serosal surface of the uterus. Short white arrow, endocer-
vical canal; B, bladder. (B), At 9 weeks of amenorrhea, the embryo
had a crown-rump length of 24 mm. No myometrium (long white
arrow J was individualized between the sac and the bladder. Short
white arrow, endocervical canal; B, bladder.

activity. No myometrium was visible between the

bladder and the sac, which obviously bulged in a
“prerupture” stage (Fig. 1B). The uterine cavity re-
mained empty. To confirm the diagnosis, MRI was
carried out. The uterine cavity was empty, although
trophoblastic tissue and an embryo were seen on a
transversal section picture in the anterior portion of
the cervix (Fig. 2) outside the endocervical canal, in
a previous caesarean section scar.
Because of the risk of uterine rupture, it was de-
cided to interrupt the pregnancy. Under the guid-
Figure 2 Magnetic resonance imaging. Transverse section pic-
ance of endovaginal sonography, a 22-gauge needle
ture clearly demonstrated the pregnancy implanted in the ante-
was introduced transvaginally into the gestational rior portion of the cervix, outside the endocervical canal. *Preg-
sac through the cervix, 8 MEq KC1 (2 MEq/mL) was nancy, arrow, endocervical canal. R, rectum; B, bladder.

Vol. 67, No. 2, February 1997 Godin et al. Communications-in-brief 399

the caesarean section scar. In 1993, a case was diag- of KC1 and MTX to treat an EP implanted in a previ-
nosed by echography and required a hysterectomy ous caesarean section scar. This minimally invasive
due to rupture and extensive bleeding at week 24 nonsurgical approach can preserve fertility without
of gestation (1). In 1995, another case was treated any major risk to the mother. In view of the increas-
conservatively by MTX but laparotomy was required ing rate of caesarean deliveries, medical personnel
2 weeks after injection because of extensive bleed- should be aware of the possibility of this type of EP.
ing (5).
Since the advent of endovaginal echography and REFERENCES
MRI, it has been possible to assess the diagnosis 1. Wehbe A, Ioan A, Allart JP, Fontanie P, Assemekang B, Azou-
earlier in the gestation and to use a more conserva- lay M, et al. A case of cervico-isthmic pregnancy with delayed
tive approach. Strict imaging criteria must be used development. Rev Fr Gynecol Obstet 1993:,88:439-44.
to assess the diagnosis: empty uterus, empty cervical 2. Jelsema RD, Zuidema L. First-trimester diagnosed cervico-
isthmic pregnancy resulting in term delivery. Obstet Gynecol
canal, development of the sac in the anterior part
1992;80:517-9.
of the isthmic portion, and an absence of healthy 3. Herman A, Weinraub Z, Avrech 0, Mayrnon R, Ron-El R,
myometrium between the bladder and the sac. This Bukovsky Y. Follow-up and outcome of isthmic pregnancy
last criterion allows us to differentiate a pregnancy located in a previous caesarean section scar. Br J Obstet Gyn-
implanted in a caesarean section scar from cervical aecol 1995; 102:839-41.
4. Rempen A, Albert P. Diagnosis and therapy of an in the cae-
or cervicoisthmic pregnancy.
sarean section scar implanted early pregnancy. Geburtshilfe
To our knowledge, this is the first report of a preg- Perinatol 1990;194:46-8.
nancy implanted inside a previous caesarean section 5. Lay YM, Lee JD, Lee CL, Che TC, Soong YK. An ectopic
scar diagnosed by vaginal echography and MRI. It pregnancy embedded in the myometrium of a previous cesar-
is also the first report of the successful local injection ean section scar. Acta Obstet Gynecol Stand 1995;74:573-6.

Godin et al. Communications-in-brief Fertility and Sterility@

400