Ectopic intramural pregnancy developing at the site of a cesarean section scar: a case report

Abstract

Introduction: Cesarean section scar pregnancy is a rare but serious complication. It occurs in women with previous uterine scar when implantation takes place at the site of this scar. If early diagnosis is missed the woman's future fertility and eve her life are at risk. Earlier reports on the condition suggesting different management approaches have been described.

Case presentation: A 37 year-old woman gravida 4, para 3, was referred to our emergency department, as a case of missed miscarriage following 14 weeks amenorrhea. Ultrasound examination revealed a picture suggestive of intramural pregnancy near the Cesarean section scar. The case was managed by laparotomy evacuation of products of conception and repair of the scar.

Conclusion: The diagnosis of ectopic intramural pregnancy in a cesarean section scar is possible with ultrasound and high level of suspicion. This serious complication must be suspected in a pregnant woman with previous uterine scar when early ultrasound show a gestational sac that is implanted anteriorly in the lower uterine segment, near the uterine scar. Ultrasound criteria for diagnosis include empty uterus, empty cervical canal and a discontinuity on the anterior wall of the uterus demonstrated on a sagittal plane of the uterus running through the amniotic sac. Early intervention is recommended to avoid serious consequences in such cases.

Figure 1

Abdominal ultrasound, transverse scan showing a gestational sac measuring 4.57 × 4.36 cm between the uterus and the urinary bladder.

Figure 2

Abdominal ultrasound, longitudinal scan showing a gestational sac pushing itself towards the urinary bladder. An 8 mm layer of fibro-muscular tissue separates the sac from the bladder.

Figure 3

Operative view a gestational sac bulging into the anterior uterine wall after dissection of the urinary bladder.

Figure 4

Operative view the bluish gestational sac bulging out of the dehiscent scar after the fibro-muscular layer was gently incised.