Case of cesarean scar ectopic pregnancy

A report describes a case of a 29-year-old woman who presented from an outside facility with vaginal bleeding and discharge; but without any abdominal pain or discomfort. She gave a history of 3 cesarean deliveries in the past due to hypertension in her first pregnancy and two subsequent scheduled cesarean deliveries after normal pregnancies. Her last pregnancy was three years before the presentation. 

She gave no other significant medical history other than a body mass index of 38. She described having regular menses and no history of sexually transmitted infections. Three weeks before presentation, a transvaginal ultrasound suggested an intrauterine pregnancy at seven weeks and five days with a gestational sac envisioned in the lower uterine segment.

At the presentation, she showed normal and stable vitals. The physical examination showed moderate clear-white discharge in the vaginal vault without blood and a closed cervix on speculum evaluation. Her hemoglobin and hematocrit, and white blood cell count were within normal limits. The basic metabolic panel, wet prep, KOH, and STIs were negative. Her quantitative Beta-hCG was 67,142 IU/L. Her previous transvaginal ultrasound showed a single live intrauterine pregnancy low in the left uterine segment with a 1.9 × 1.3 × 1.0 cm perigestational hemorrhage present to the right of the gestational sac. 

A fresh transvaginal ultrasound demonstrated a gestational sac (dated at ten weeks and four days) located at the level of the internal cervical os; and a fetal pole with the presence of fetal cardiac motion. The location of the gestational sac was in an anterior position toward the anterior lower uterine segment at the level of the prior cesarean scar, with little visible myometrium present before the gestational sac in the lower uterine segment. The gestational sac showed communication with the endometrial cavity while being located in the lower uterine segment of the uterus and was without the involvement of the cervix. 

The concern for cesarean scar ectopic pregnancy, the possibility of implantation on the prior cesarean scar compared to within the scar with lower risk of morbidity, and limitations of the ultrasound given the maternal BMI of 38 prompted conducting an MRI. MRI of the abdomen and pelvis without contrast showed a gestational sac located in the anterior aspect of the lower uterine segment superior to the internal cervical os at the site of the prior cesarean scar. Disruption of the myometrium was likely between the gestational sac and bladder, with only intact uterine serosa suspected, most consistent with implantation into the prior cesarean scar.

The patient received education regarding her imaging findings, potential complications of continuation of cesarean scar pregnancy, and reproductive goals and finally decided on permanent sterilization. She underwent an uncomplicated total laparoscopic hysterectomy with removal of the cesarean scar pregnancy, bilateral salpingectomy, and cystoscopy. She received a discharge on postoperative day one and was scheduled for a close follow-up with obstetrics and gynecology.

Brancazio S, Saramago I, Goodnight W, McGinty K Cesarean scar ectopic pregnancy: Case report☆. Radiology Case Reports. 2019;14(3):354-359. https://doi.org/10.1016/j.radcr.2018.12.001.