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CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 270-272

A rare case report of scar ectopic pregnancy


Department of Obstetrics and Gynaecology, Gandhi Medical College/Gandhi Hospital, Secunderabad, Telangana, India

Date of Submission27-Aug-2015
Date of Acceptance23-Oct-2015
Date of Web Publication6-Jan-2021

Correspondence Address:
Dr. Shobha Gumdal
Department of Obstetrics and Gynaecology, Gandhi Medical College/Gandhi Hospital, Secunderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.306120

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  Abstract 


Caesarean scar ectopic pregnancy is a rare form of ectopic pregnancy where gestational sac is implanted in the myometrium at the site of previous caesarean scar. Incidence of scar pregnancy is increasing due to the rise in caesarean section (CS) rate. A 26-year-old female [G1P1L0 with 3MA, prev. lower segment CS (LSCS)] came with acute abdomen and hypovolemic shock. Caesarean scar pregnancy was diagnosed. The patient was resuscitated and emergency laparotomy and resection of ectopic mass was done. In women with a history of caesarean scar pregnancy, early ultrasound should be performed in subsequent pregnancies in order to establish the location of implantation, and make early diagnosis so that conservative management is initiated to avoid severe maternal morbidity and spare fertility in patients with cesarean scar pregnancy.

Keywords: Caesarean section (CS), scar ectopic pregnancy, ultrasound


How to cite this article:
Gumdal S, Lakavath RD. A rare case report of scar ectopic pregnancy. J NTR Univ Health Sci 2020;9:270-2

How to cite this URL:
Gumdal S, Lakavath RD. A rare case report of scar ectopic pregnancy. J NTR Univ Health Sci [serial online] 2020 [cited 2021 Jan 17];9:270-2. Available from: https://www.jdrntruhs.org/text.asp?2020/9/4/270/306120




  Introduction Top


The first case of caesarean scar (CS) ectopic was reported in 1978. Incidence varies from 1:1,800 to 1:2,226 of all pregnancies, with increasing incidence attributed to increased number of CS. CS ectopic is one of the rarest forms of ectopic pregnancy where the gestational sac is implanted in the myometrium at the site of previous CS scar.[2] CS pregnancy rate accounts for 6% of ectopic pregnancies among women with a prior caesarean delivery.[2] The mechanism for implantation in this location is believed to be migration of the embryo through either the wedge defect in the lower uterine segment or a microscopic fistula within the scar.[2]

Associated risk factors are previous CS and procedures that cause endometrial damage such as myomectomy, adenomyosis, in vitro fertilization (IVF) and embryo transfer, dilation and curettage (D&C), and manual removal of placenta.

Complications such as uterine rupture and hypovolemic shock may be life-threatening. If diagnosed early, arrangements for resuscitation with blood and emergency laparotomy done simultaneously or conservative management with systemic or local methotrexate,[3] or uterine artery embolization (UAE) can be made to prevent hemorrhage is possible, if the patient is hemodynamically stable.


  Case Report Top


A 26-year-old female [G2P1L0 with 3MA with 1 prev. lower segment CS (LSCS)] presented with severe lower abdominal pain, radiating to chest and shoulder tip, not relieved with medication, associated with vomiting. She had previously undergone caesarean delivery for abruptio placenta with intrauterine death (IUD) 9 months back.

O/E patient was pale, P/R 110/min, BP 96/60, on P/A tenderness in hypogastrium noted, on P/V uterus bulky, cervical movements tenderness+, culdocentesis done –altered blood aspirated, confirmed hemoperitoneum and ruptured ectopic pregnancy.

Ultrasonography findings

Bulky uterus with slightly increased endometrium (13 mm) in the upper portion with fluid echoes and in the lower portion of the cavity and scar area appear irregular with an irregular shaped gestational sac of about 25 mm mean sac diameter (MSD) (7 weeks 2 days) showing a fetal node of about 5 mm (6 weeks 2 days).

Large irregular mass of about 86 mm × 97 mm × 48 mm sitting on the uterus – clot, significant free fluid in pouch of Douglas (POD). Both adnexa were normal.

Emergency laparotomy along with arrangement of blood transfusions were done. Operative findings were as follows: Hemoperitoneum of about 1,500 mL, rent in the lower uterine segment at previous scar [Figure 1], products of conception partly inside and partly outside the rent [Figure 2] and [Figure 3]. Excised scar tissue sent for HPE, which is consistent with pregnancy. Rent repair was done.
Figure 1: (a) Product of conception seen through Ruptured scar with gestational sac (b) Product of conception seen through ruptured scar

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Figure 2: Ruptured scar with gestational sac1

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Figure 3: Ruptured scar with gestational sac2

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  Discussion Top


CS pregnancy should be diagnosed as early as possible in order to avoid severe complications and to provide conservative treatment. Most of the cases that have been reported were diagnosed early in the first trimester. The most common symptom is painless vaginal bleeding that may be massive. The patients of scar ectopic pregnancy commonly present with painless, sometimes heavy vaginal bleeding. Uterine tenderness may be elicited if the ectopic is in process of rupture. Unlike adherent placenta where the placenta invades the myometrium at the scar site but the pregnancy is uneventful, scar ectopic is more aggressive in its behavior because of its early invasion which can lead to rupture and massive hemorrhage.

When the pregnancy is not localized by ultrasonography, either laparoscopy or laparotomy can be used for the to confirm the diagnosis.

Diagnosis is made by USG and Doppler; and magnetic resonance imaging (MRI) is confirmatory. The diagnostic criteria on Doppler to differentiate from cervical ectopic pregnancy are as follows:[3]

  1. Gestational sac located between bladder wall and anterior isthmic portion of uterus.
  2. No trophoblastic tissue in uterine cavity or cervical canal.
  3. Clearly visible circular blood flow surrounding the sac.


Jurkovic has described a negative “sliding organ sign” as diagnostic of scar ectopic – The inability to displace the gestational sac from its position at the level of the internal os by gentle pressure applied by the transabdominal probe.[4]

The mode of treatment depends on the presentation as rupture and severe hemorrhage may warrant hysterectomy. However, several types of conservative treatment[1] have been used, which are as follows:

  1. D&C and excision of trophoblastic tissues through hysterolaparoscopy or laparotomy. However, D&C should not be done as the first-line treatment due to risk of perforation and catastrophic hemorrhage.
  2. Local and/or systemic methotrexate (MTX) administration, and intragestational injection of methotrexate is preferable.
  3. Bilateral hypogastric artery ligation, associated with dilatation and evacuation under laparoscopic guidance with Foley balloon tamponade.
  4. Selective UAE in combination with curettage and/or MTX injection. UAE appears to prevent excessive bleeding and spare fertility.[5]


Long-term outcomes after conservative treatment include concerns about future fertility and recurrence of CS ectopic. As uterine rupture can occur in the next pregnancy, the scar should be evaluated hysteroscopically before the next pregnancy and by USG during the subsequent pregnancies.[5]


  Conclusion Top


Ectopic pregnancy within the scar of a previous caesarean delivery can lead to uterine rupture and life-threatening intraperitoneal hemorrhage during the first trimester of pregnancy. Though a rare event, the incidence of CS pregnancy seems to be on the rise. Every obstetrician is likely to encounter this entity in his or her lifetime. In women with a history of CS pregnancy early ultrasound should be performed in subsequence pregnancies in order to establish the location of implantation, to establish the diagnosis so that conservative management is initiated to avoid severe maternal morbidity and spare fertility in patients with CS pregnancy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tulpin L, Morel O, Malartic C, Barranger E. Conservative management of a Cesarean scar ectopic pregnancy: A case report. Cases J 2009;2:7794.  Back to cited text no. 1
    
2.
Nankali A, Ataee M, Shahlazadeh H, Daeichin S. Surgical management of the cesarean scar ectopic pregnancy: A case report. Case Rep Obstet Gynecol 2013;2013:525187.  Back to cited text no. 2
    
3.
Khadkikar R, Wakchaure G, Prasad M, Chauhan AR. Cesarean scar ectopic pregnancy. JPGO 2014;1.   Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
Rotas MA, Haberman S, Levgur M. Caesarean scar ectopic pregnancies: Etiology, diagnosis, and management. Obstet Gynecol 2006;107:1373-81.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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Discussion
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