A case report of caesarean section scar pregnancy: novel approach to acute management

doi:10.21203/rs.3.rs-4117288/v1

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Case Report

A case report of caesarean section scar pregnancy: novel approach to acute management

https://doi.org/10.21203/rs.3.rs-4117288/v1

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Introduction:

This case report presents the clinical journey of a 41-year-old woman who was diagnosed with caesarean section ectopic pregnancy, which is the rarest form of ectopic pregnancy, but who presented as an emergency because of default to planned management.

Case presentation:

A 41-year-old woman who had two previous caesarean sections at a 10-week period of amenorrhea presented to our hospital gynaecology clinic with mild abdominal pain without bleeding per vagina for five days.

A transvaginal scan was performed, and a caesarean scar pregnancy was diagnosed.

The diagnosis was explained to the patient, and scar ectopic removal either by hysteroscopy or laparoscopy was scheduled in two days.

The patient did not undergo the procedure as scheduled but experienced severe abdominal pain and vaginal bleeding after four days.

On examination, she was haemodynamically stable with a soft abdomen. The vaginal speculum showed period-like bleeding with an opened cervical os.

A transvaginal scan revealed a caesarean section ectopic with a foetal pole and heartbeat.

Since the cervical os was opened, successful suction curettage was performed. Beta hCG became undetectable 11 days after curettage.

Conclusion:

This case demonstrates the current knowledge of the application of transvaginal scanning for managing the acute presentation of caesarean scar pregnancy, and the correct application of minimally invasive appropriate tailor-made surgical procedures will provide cost -effective and safer outcomes for individual patients.

Obstetrics & Gynecology

caesarean scar pregnancy

diagnosis

ectopic pregnancy

suction curettage hysteroscopy

laparoscopy

surgical management

The first reported case of a caesarean scar pregnancy (CSP) was in 1978(1). Due to the increasing frequency of caesarean sections worldwide, the incidence of caesarean scar ectopic has been on the rise (2). The reported incidence of CSP ranges from 1:1800 to 1:2200 pregnancies (3).

This case report describes the clinical course of a 41-year-old woman who was diagnosed with CSP but who defaulted to planned management.

A 41-year-old woman with a 10-week period of amenorrhea presented to our hospital gynaecology clinic with mild abdominal pain without bleeding per vagina for five days.

This was her third pregnancy. She had two previous caesarean sections and a miscarriage.

The physical examination was unremarkable. Her urine pregnancy test was positive five days prior.

A transvaginal scan revealed a gestational sac measuring 13.3 mm and a yolk sac measuring 4.7 mm in the lower uterine segment in the region of the previous caesarean scar. The myometrium tissue was located between the gestational sac and the urinary bladder (Fig. 1)

The diagnosis of CSP was explained to the patient, and scar ectopic removal either by hysteroscopy or laparoscopy was scheduled in two days.

The patient did not undergo the procedure as scheduled but experienced severe abdominal pain and vaginal bleeding after four days.

On examination, she was haemodynamically stable with a soft abdomen. The vaginal speculum showed period-like bleeding with an opened cervical os.

Diagnostic workup:

A transvaginal scan revealed a gestational sac containing a fetal pole measuring 4.9 mm with a positive colour doppler, in the lower uterine segment in the region of the previous caesarean scar. The myometrium tissue was observed between the gestational sac and the urinary bladder (Fig. 2). Her serum beta-hCG concentration was 15391 mIU/mL.

Surgical intervention:

The diagnosis was explained to the patient. Since the cervical os was opened, suction curettage was planned under ultrasound guidance. The hysteroscopy and laparoscopy approaches were put in place as fallback methods. Suction curettage under ultrasound guidance was successful, and the estimated blood loss was 100 ml (Fig. 3).

Outcome:

The patient's recovery was uncomplicated. Three days later, the beta-hCG concentration decreased to 401 mIU/mL and was undetectable after 11 days.

Histopathology revealed extensive haemorrhagic decidua containing blood vessels with thick muscularized wall fibrinous necrosis. Endometrial glands lined by hypersecretory-type epithelium with Arias Stella reactions were observed.

It has been hypothesized that the scar ectopic is linked to deficient and poorly healed caesarean scars secondary to poor vascularisation of the lower uterine segment, with subsequent fibrosis. Furthermore, patients with multiple previous caesarean sections have a greater scar surface area, thus increasing the chance of an embryo being implanted into the scar(4).

There is no evidence to suggest a positive correlation between the risk of caesarean section scar implantation and the number of prior caesarean sections(2) or between single-layer and double-layer closure(4).

The diagnosis of CSP is primarily by ultrasound examination. The transvaginal approach is better than the transabdominal approach (3). This patient had subtype I CSP according to the three subtypes of CSP described by the family planning group et al. (Fig. 2) (5).

Among the surgical methods of managing CSP, laparotomy or laparoscopy with wedge and hysteroscopy resection are more popular than curettage (6).

Tang et al suggested that dilation and curettage success depend on the subtype of the CSP; accordingly, gynaecologists can choose dilation and curettage as safer methods (7). Jurkovic et al. concluded that ultrasound-guided suction curettage is an effective method for the treatment of CSP and is associated with a low risk of blood transfusion and hysterectomy (8). Blind procedures without ultrasound guidance are associated with a greater risk of complications(9).

This case study highlights a unique scenario of an acute presentation of a previously diagnosed CSP where we deviated from the 2 most popular surgical methods (6) of managing CSP and tailor-made cost-effective management best suited to the woman's health.

As the cervical os was opened in this patient, there was no additional risk of reaching the gestational sac with suction curette.

Current knowledge about CSP and its subtypes, skills in correct ultrasound diagnosis, and the application of such knowledge and skills are key to successful, safer, cost-effective patient management.

Consent for publication- Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review with me.

Larsen JV, Solomon MH (1978) Pregnancy in a uterine scar sacculus–an unusual cause of postabortal haemorrhage. A case report. S Afr Med J 53(4):142–143
Rotas MA, Haberman S, Levgur M (2006) Cesarean scar ectopic pregnancies: etiology, diagnosis, and management. Obstet Gynecol 107(6):1373–1381
Jurkovic D, Hillaby K, Woelfer B, Lawrence A, Salim R, Elson C (2003) First-trimester diagnosis and management of pregnancies implanted into the lower uterine segment Cesarean section scar. Ultrasound Obstet Gynecology: Official J Int Soc Ultrasound Obstet Gynecol 21(3):220–227
Maymon R, Halperin R, Mendlovic S, Schneider D, Herman A (2004) Ectopic pregnancies in a Caesarean scar: review of the medical approach to an iatrogenic complication. Hum Reprod Update 10(6):515–523
Family Planning Group O, Gynecology Branch CMAs (2016) Expert consensus on diagnosis and treatment of uterine scar pregnancy after cesarean section (2016). Chin J Obstet Gynecol 51:568–572
Ban Y, Shen J, Wang X, Zhang T, Lu X, Qu W et al (2023) Cesarean Scar Ectopic Pregnancy Clinical Classification System With Recommended Surgical Strategy. Obstet Gynecol 141(5):927–936
Tang Y, Zhang Y, Tang H, Che J, Feng H, Yao X, Chen Q (2021) A Comparison of Ultrasound Guided Curettage With and Without Uterine Artery Embolization on Controlling Intraoperative Blood Loss for a Cesarean Scar Pregnancy Treatment: Study Protocol for a Randomized Clinical Trial. Front Endocrinol (Lausanne) 12:651273
Jurkovic D, Knez J, Appiah A, Farahani L, Mavrelos D, Ross JA (2016) Surgical treatment of Cesarean scar ectopic pregnancy: efficacy and safety of ultrasound-guided suction curettage. Ultrasound Obstet Gynecol 47(4):511–517
Birch Petersen K, Hoffmann E, Rifbjerg Larsen C, Svarre Nielsen H (2016) Cesarean scar pregnancy: a systematic review of treatment studies. Fertil Steril 105(4):958–967

The authors declare no competing interests.

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A case report of caesarean section scar pregnancy: novel approach to acute management

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Abstract

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Introduction

Case presentation

Diagnostic workup:

Surgical intervention:

Outcome:

Discussion

Conclusion

Declarations

References

Additional Declarations

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