Ruptured Ectopic Pregnancy in Cesarean Section Scar

Pregnancy implantation within previous caesarean scar is one of the rarest locations for an ectopic pregnancy. Incidence of caesarean section is increasing worldwide and with more liberal use of transvaginal sonography, more cases of caesarean scar pregnancy are being diagnosed in early pregnancy thus allowing preservation of uterus and fertility. We are reporting a rare case of first trimester caesarean scar pregnancy with viable fetus in the process of rupture, where uterine repair could be done, thus preserving the future fertility.

A 24-year gravida 2, para 1, live 1 with confirmed pregnancy of 10-week 3-days gestation presented with acute abdomen. Her obstetric history was notable for one caesarean delivery two years back. In present pregnancy, she neither had any antenatal checkup nor any ultrasonography. On examination she had tachycardia and hypotension with moderate pallor. Abdomen was distended with evidence of free fluid and signs of peritonitis. Speculum examination revealed slight bleeding through cervical os. On bimanual examination uterus seemed enlarged; however, exact size could not be made out due to gross free fluid. She was resuscitated with fluids. 

Uterine rupture during first trimester of pregnancy is an extremely rare, but life-threatening cause of intraperitoneal haemorrhage. The ectopic pregnancy within the scar of a previous caesarean delivery is best diagnosed by transvaginal ultrasound. However, a delay in either diagnosis or treatment can lead to uterine rupture, hysterectomy, and significant maternal morbidity. Though a rare event, the incidence of caesarean scar pregnancy seems to be on the rise due to increasing caesarean section rate. Hence, an obstetrician is likely to encounter this entity in his or her lifetime. Heightened awareness amongst obstetricians regarding the possibility of scar pregnancy in those with prior caesarean section and early ultrasound in these women may lead to early diagnosis and hence a chance of conservative management.