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by Rukhsana Afzal   Similarity by Source
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sources:

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7% match ()
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6% match (Internet from 26-Jan-2022)

3
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5% match ()
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5
https://www.ncbi.nlm.nih.gov/pubmed/31007806

2% match (publications)
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Sophia Brancazio, Israel Saramago, William Goodnight, Katrina McGinty. "Cesarean scar
ectopic pregnancy: Case report☆", Radiology Case Reports, 2019

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https://ecommons.aku.edu/pakistan_fhs_mc_radiol/113

1% match (publications)
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Anjali Gupta, Daya Sirohiwal, Nirmala Duhan, Sarita Bishnoi. "Lower Segment Cesarean Scar
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 1% match (Internet from 12-Dec-2021)
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1% match (Internet from 19-Oct-2021)

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1% match (publications)
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Michèle Hoffmann, Julian Schardt, Codruta Ionescu, Ute E. Wolf-Schnurrbusch et al. "Long
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< 1% match (publications)

15
Sumaya Al Gadeeb, Mohammed Al Gadeeb, Jumana Al Matrouk, Zainab Faisal, Afnan
Mohamed. "Cesarean Scar – Unusual Site of Ectopic Pregnancy: A Case Report", Cureus,
2019

paper text:

15Cesarean scar ectopic pregnancy:case report

7Abstract: Cesarean scar pregnancy (CSP) is the rarest location for an ectopic
pregnancy.The incidence is

increasing because of increase in rate of cesarean section.Delay in diagnosis can lead to significant
maternal morbidity and mortality.

2Fortunately,the use of first trimester ultrasound imaging has led to a

significant number of the pregnancies being diagnosed and managed early

5This study presents the case of a cesarean scar ectopic pregnancy in a

patient with previous 2 cesarean
sections.The lady presented at 12 weeks gestation with acute abdomen.The diagnosis was suspected on
transvaginal ultrasound and on laparotomy,active bleeding was seen from previous scar,placenta was seen
protruding through the previous scar and gestational sac and fetus was removed and ruptured scar
repaired,hence preserving the uterus and future fertility. Key words:

6Cesarean scar ectopic Obstetrics Ectopic pregnancy Introduction: An

ectopic pregnancy is a pregnancy that occurs outside the uterine cavity 1

.Over 90% implant in the fallopian tube2.Rarely, pregnancy

12can implant in the ovary,cervix,abdominal cavity or

in cesarean section scars.

5Ectopic pregnancy accounts for 9% of pregnancy related deaths and is

an important cause of maternal morbidity and mortality3.Cesarean scar ectopic pregnancy occurs
approximately 1 in 2000 pregnancies4.The first case was reported in 1978 and todate 161 cases have been
reported3.It

2may follow previous hysterotomy,uterine manipulation and

invitro fertilization4.

2There are two types of scar ectopic pregnancies.Type 1 develops in the

myometrium and grows inside towards the uterine cavity and type 2 progresses
outside towards uterine serosa4.Type 2 scar ectopic pregnancies have poor
prognosis because they result in uterine rupture,hemorrhage and maternal
death

2Symptoms include pelvic pain and vaginal bleeding in the first

trimester4.

2The investigation of choice is transvaginal ultrasound

.In equivocal cases MRI may be needed to confirm the diagnosis4. This is

14a case report and review of literature

3of a rare case of first trimester cesarean scar pregnancy

with rupture of uterus where uterine repair was done,preserving the future fertility. Case

10presentation: A 28 years old,Gravida 4 Para 2 with previous 2 cesarean

sections

presented at 12 weeks gestation with acute abdomen.Her first cesarean was an emergency cesarean
section due to failure to progress in first stage of labour and second delivery was by elective repeat
cesarean section two years ago.She had a 1st trimester spontaneous miscarriage three years ago.She
presented to emergency department with pain lower abdomen since morning.On examination,her pulse was

9100/min,blood pressure 100/60 mm Hg,she was

afebrile and clinically pale.Abdominal examination showed generalized tenderness with signs of
peritonitis.Her hemoglobin was 7 g/dl.Her urgent abdominopelvic ultrasound by radiologist was done which
showed intrauterine foetus of 6.7cm CRL in lower uterine segment with normal foetal cardiac activity and
movements with marked free fluid seen in Morrison s pouch as well as in pelvis. Right adnexal region
showed possibility of clots and there was hemoperitoneum on ultrasound with suspicion of ruptured right
adnexal hemorrhagic cyst/ectopic pregnancy. Due to acute abdomen,emergency laparotomy proceeded.On
laparotomy,500 cc clots removed from the abdomen.Active bleeding was seen from previous scar,placenta
was seen protruding through the previous scar,removed piecemeal.Gestational sac and foetus was
removed.Hemostasis secured by taking hemostatic sutures.Uterus was

13closed in two layers.Intraperitoneal drain was placed.Abdomen was

closed in reverse order.Three units of blood transfused one per operatively and two post operatively.Patient
s post operative hemoglobin was 7.9 g/dl on which five doses of parenteral iron were given.Patient s serum
beta HCG report came out tobe 5230 mIU/ml. Her

8postoperative course was uneventful and was discharged in good condition

on her 6th post operative day with advice of follow up in gynae OPD after 7 days with report of serum beta
HCG levels.
 3Discussion: Cesarean scar ectopic pregnancies are rare,comprising less
than 1% of all pregnancies5.In recent years,the incidence

of scar ectopic pregnancies

3has increased due to the increase in rate of cesarean section.The center for
disease control and prevention(CDC) reported a cesarean section rate of
20.7% in 1996,which has increased to 32% in 2017 in United States5.This
increase in rate of cesarean scar pregnancy detection may also be due to
improvements in image quality of transvaginal ultrasound

1Establishing a diagnosis of CSEP canbe difficult and the preferred method of

establishing a definitive diagnosis is transvaginal ultrasound with colour,spectral
and power Doppler imaging6.The sensitivity of TVUS is quite satisfactory and
has been reported tobe 84.6%.Another diagnostic tool used in CSEP is three
dimensional ultrasonography.It is now being increasingly used as it allows
surgeons to study a confined area in better

detail6.MRI

1and diagnostic laparoscopy may also be used to confirm the diagnosis.

Several criteria for the

diagnosis of CSEP are

1proposed by Timor-Tritsch as follows.(1) an empty uterine cavity and empty

endocervical canal (2) a gestational sac located in the anterior portion of the
lower uterine segment corresponding to the scar site of the previous
cesarean (3) demonstration of functional trophoblatic tissue by Doppler
ultrasound at the site of implantation at the scar,(4) in early gestation,less
than 8 weeks,a triangular shaped gestational sac filling the scar niche(after 8
weeks of gestation, a rounded or an oval sac could be observed) (5) cervical
canal that is closed and empty.(6) observation of foetal pole and/or yolk sac
 with or without heart activity and (7) absence or deficiency of a healthy
myometrium between the bladder and the gestational sac6. The

11exact pathogenesis of cesarean scar ectopic pregnancy is unclear

4Blastocyst invades the myometrium through a microscopic uterine desiscent

tract which is related to a previous uterine surgery(eg cesarean
section).However this hypothesis doesnot explain the occurance of scar
ectopic pregnancy in previous uterine surgry absence7.For such cases, it is
suggested that scar pregnancy may occur due to trauma occurring during
manual removal of placenta or during assisted

reproductive techniques7.

4In our case,patient had two previous cesarean sections which predisposed
her for scar ectopic pregnancy. The principles of

treatment for CSEP are to diagnose early,to manage early and keep reproductive function as much as
possible8. Conservative treatment

1of CSEP has a significant risk of bleeding and is not recommended6.Systemic

therapy with methotrexate is also not as effective for CSEP as for tubal
ectopic pregnancy.However, an intralesional methotrexate injection,either
through transvaginal or transabdominal route is quite

successful6.

1Uterine artery embolization is another option for treatment for treatment of

CSEP.In recent years,UAE along with intralesional methotrexate injection was
reported with high success rates

.
 1Suction curettage could be a safe option after UAE and methotrexate
treatment in which vaginal bleeding persists6. Surgical intervention is another
reliable treatment option for CSEP.Conventionally,a laparotomy and
resection of ectopic sac along with the previous scar tissue have been
used.In expert hands, a laparoscopic excision alone is sufficient for complete
treatment of

CSEP6.

1In conclusion,individualized treatment options based on gestational

age,foetal viability,severity of symptoms,serum HCG levels and
ultrasonographic findings are necessary for successful treatment of CSEP6.An
early and timely diagnosis increases the success rate and decreases

the complications6. Referrences: (1) Brancazio S, Saramago I, Goodnight W, McGinty K.,Cesarean scar
ectopic pregnancy: Case report. Radiology case reports. 2019 Mar 1;14(3):354-9. (2)Kenny L, Bickerstaff H,
editors. Gynaecology by Ten Teachers. CRC Press; 2017 May 8. (3)Hummeida ME, Rahman EA, Ahmed A.
Case Report Caesarean scar ectopic pregnancy Case report and literature review. Sudan Med J. 2015
Dec;50(3). (4) Majangara R, Madziyire MG, Verenga C, Manase M. Cesarean section scar ectopic
pregnancy-a management conundrum: a case report. Journal of medical case reports. 2019 Dec
1;13(1):137.. (5) Hoffman T, Lin J. Cesarean Scar Ectopic Pregnancy: Diagnosis With Ultrasound. Clinical
Practice and Cases in Emergency Medicine. 2020 Feb;4(1):65. (6) Koplay M, Dogan NU, Sivri M, Erdogan
H, Dogan S, Celik C. Ectopic pregnancy in a Cesarean section scar: successful management using vacuum
aspiration under laparoscopic supervision—mini review of current literature. Case reports in surgery. 2016
Jan 1;2016. (7) Al Gadeeb S, Al Gadeeb M, Al Matrouk J, Faisal Z, Mohamed A. Cesarean Scar– Unusual
Site of Ectopic Pregnancy: A Case Report. Cureus. 2019 Oct;11(10). (8) Fu LP. Therapeutic approach for
the cesarean scar pregnancy. Medicine. 2018 May;97(18). (9)Jayaram PM, Okunoye GO, Konje J.
Caesarean scar ectopic pregnancy: diagnostic challenges and management options. The Obstetrician
&Gynaecologist. 2017 Jan;19(1):13-20. (10) Najam S, Malik SE, Aqeel S, Rizwan N, Haider AR. Viable
Caesarean Scar Pregnancy: A Case Report. Biomedica. 2020 Mar 1;36(1).