Cesarean Scar Pregnancy: A Case Report on an Increasingly Common Condition with Limited Management Options

INTRODUCTION

Cesarean scar pregnancy (CSP), where the product of gestation implants into the myometrial defect of a previous uterine incision, is the most uncommon form of ectopic pregnancy and is difficult to both diagnose and treat.^1,2 The estimated prevalence of CSP is 1 in 2,000 pregnancies, and up to 1 in 530 women with a prior cesarean section.³ This increasing incidence is because of the doubling of cesarean sections over the past 20 years. These pregnancies can lead to severe maternal complications like rupture of the uterus, excessive blood loss, and morbidly adherent placenta that can lead to iatrogenic preterm termination of pregnancy or obstetric hysterectomy. The ultrasound characteristics are missed if the clinical suspicion is not high and can lead to a delay in beginning the appropriate management. Cesarean scar pregnancy is categorized as type I when half of the gestational sac (G Sac) extends toward the uterine cavity or cervix. Cesarean scar pregnancy is stamped as type II when the placenta implants into a lower segment cesarean sections (LSCSs) scar, and the G Sac protrusion is half or less.³ We explore a specific case of type II CSP where the diagnosis was initially missed.

CASE PRESENTATION

A woman in her mid-forties presented to us with two months of amenorrhea and severe abdominal pain for the past 12 hours. She was a multigravida who had two vaginal deliveries followed by two LSCSs due to labor not progressing in both instances. She had been experiencing lower abdominal pain for five days and, before visiting our hospital, she consulted two physicians who treated her with painkillers. She possessed a self-administered urine pregnancy test kit, which indicated a positive result. Additionally, she had self-medicated with an over-the-counter medical termination of pregnancy kit (MTP Kit) three days prior. A transvaginal scan with Doppler testing was promptly conducted. The G Sac was located at the level of the internal OS, implanted at the site of a previous LSCS. The myometrium thickness between the bladder and G Sac was significantly reduced and virtually absent, and minimal free fluid was also noticed in the pouch of Douglas (POD). Color Doppler imaging showed prominent placental circulation, and an empty endocervical canal was present. Considering the clinical presentation, the history of two previous LSCSs, a positive pregnancy test, and characteristic ultrasound markers, a diagnosis of CSP was established. The patient and her husband received comprehensive counseling regarding the diagnosis, the risks associated with her current condition, and the available management options. After considering and understanding all the risks and benefits, the patient opted for the surgical removal of the uterus and cervix. The patient was re-counseled regarding conservative options, such as laparoscopic removal of the ectopic tissue followed by uterine repair, but she declined. Written consent was obtained, and an urgent preoperative assessment was conducted due to the severe abdominal pain she was experiencing, along with the discovery of free fluid in the POD, which indicated the possibility of an impending rupture. Her laboratory results were within normal limits, except for a random blood sugar level of 345 mg/dL and an HbA1c of 8.9%. The patient’s blood glucose levels were regulated in coordination with the general medicine specialist, and she was shifted to the operation theatre for a laparoscopic hysterectomy.

General anesthesia was administered, the patient was catheterized under aseptic conditions, and the surgery began following proper preoperative preparation. A uterine manipulator was carefully placed vaginally. The primary trocar insertion was performed through Palmer’s point due to the anticipated adhesions from two previous LSCS. After confirming intraperitoneal entry, a pneumoperitoneum was created, and two accessory trocars were inserted. Extensive omental adhesions were noticed. The omentum was adherent to the anterior and posterior surface of the uterus, the left fallopian tube, and the left ovary. The right ovary and fallopian tube were grossly normal (Fig. 1).

Figs 1A to F: Intraoperative pictures demonstrating extensive omental adhesions: (A) The omental adhesions to the inner surface of the anterior abdominal wall, and the omental adhesions to the posterior surface of the uterus; (B) The points to the right fallopian tube and the points to the right ovary; (C) The omental adhesions to the anterior uterine wall; (D) The omental adhesions attached to the left fallopian tube and ovary; (E) The adhesiolysis of the omental adhesions attached to the left fallopian tube; (F) The omental adhesions attached to the left fallopian tube, while the left fallopian tube itself

The sigmoid colon adhered to the left lateral pelvic wall, and the bladder was notably advanced on the anterior side of the uterus. All adhesions were carefully dissected. The round, ovarian, and uterosacral ligaments were bilaterally coagulated and severed. The bladder had formed dense adhesions to the site of the prior hysterotomy incision, necessitating careful sharp dissection. The ureters were meticulously identified on both sides, and the pedicles of the uterine vessels were coagulated and severed at their origins on both sides as well. The cervix was separated from the vagina and the vaginal vault was secured with sterile synthetic absorbable sutures (Fig. 2). Complete hemostasis was attained, the peritoneal cavity was irrigated with normal saline, and subsequently, the pneumoperitoneum was released. The patient remained stable during the postoperative period. In addition to the routine postoperative care, regular insulin was administered on a sliding scale for 24 hours before transitioning her to a subcutaneous insulin regimen before discharge. The histopathology report revealed a G Sac implanted within an LSCS scar, surrounded by the myometrium and regions of hemorrhage.

Figs 2A to I: The hysterectomy in progress: (A) The arrow indicates the dissection of the left ovary from the omental adhesions. Both ovaries were preserved while both fallopian tubes were removed; (B) The arrow marks the coagulation of the left uterine vessel pedicle at its origin, a procedure that was similarly executed on the right side; (C) The arrow marks the dense bladder adhesions anteriorly; (D and E) The arrows in both figures indicate the dense fibrous bladder adhesions and their dissection; (F) The arrow marks the complete separation and retraction of the bladder; (G) The arrow marks the separation of cervix from the vagina; (H) The arrow marks the endosuturing of the vaginal vault; (I) The arrow marks the complete closure of the vaginal vault

DISCUSSION

Cesarean scar pregnancy is the most uncommon type of ectopic pregnancy, but the incidence has been increasing over the recent years both due to an increase in the number of LSCS and also due to a wider availability of imaging modalities. In type II CSP, there is a heightened risk of morbid hemorrhage towards the end of the first trimester if prompt treatment is not provided. Transvaginal ultrasound (TVUS) often provides a reliable diagnosis by demonstrating a G Sac placement below the mid-sagittal line, unlike an intrauterine pregnancy, and magnetic resonance imaging (MRI) is a helpful adjunct for preoperative planning as it shows the extent of myometrial invasion and bladder involvement.^4,5 The treatment options available are expectant management, injection of methotrexate either through the intramuscular route or via local infiltration at the implantation site, careful dilation and evacuation (D&E), interventional radiological techniques like uterine artery embolization, minimally invasive procedures like hysteroscopy, and laparoscopy, and finally hysterectomy.⁶ Detailed counseling is necessary to inform women about the risks associated with pregnancy and the available management options. Deciding whether to terminate or continue a pregnancy is important, but it is equally crucial for women to receive ongoing monitoring and follow-up.

CONCLUSION

Cesarean scar pregnancy is a form of uterine ectopic pregnancy, as per the 2020 recommendations of the ESHRE.⁷ Ultrasound remains the primary modality of diagnosis. While expectant management has been tried in certain types of type II CSP, data from case series support the termination of such pregnancies once accurately diagnosed. More such case reports and series have to be studied and analyzed to establish clear and standard guidelines for early recognition and optimal management of this condition.

ORCID

Keeranmayee Mishra https://orcid.org/0000-0001-9265-2169

Chirag Doshi https://orcid.org/0009-0000-3413-227X

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