Cesarean Scar Pregnancy Successfully Managed to Term: When the Patient Is Determined to Keep the Pregnancy

Abstract

Cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy, defined as the implantation of the gestational sac at the uterine incision scar of the previous cesarean section. This condition is associated with severe maternal and fetal/neonatal complications, including severe bleeding, rupture of the uterus, fetal demise, or preterm delivery. In view of these, early diagnosis allows the option of termination of pregnancy. In this case report, we present a patient with a cesarean scar pregnancy who was diagnosed at the sixth week of gestation but declined early termination of the pregnancy and was managed to the 38th week. Placenta previa was confirmed in the second trimester. A planned cesarean section was performed that resulted in the birth of a live full-term neonate. Intraoperatively, placenta percreta was diagnosed, and due to uncontrollable bleeding, a hysterectomy was performed. The postoperative course was uneventful. In cases where an early diagnosis of CSP is made, women should be counseled that this will almost certainly evolve to placenta previa, and the associated risks should be explained. Close follow-up of CSP is mandatory if expectant management is selected. Further studies are needed for definitive conclusions and to determine the risks of expectant management.

Keywords: High-Risk; cesarean section; complication; ectopic; pregnancy.

Figure 1

Transvaginal ultrasound examination of a cesarean scar pregnancy (CSP) at the sixth postmenstrual week showing an empty uterine cavity with a 9 mm endometrial strip (E) and a triangular gestational sac (10 mm in diameter) located within the isthmic part of the anterior uterine wall filling the niche of the scar, with a yolk sac inside covered with a thin myometrial layer 2 mm in diameter (arrow); the cervical channel (Cx) is empty; according to the presence of cross over sign (COS), this gestational sac could be identified as COS-1; according to the implantation of the gestation sac it is implanted in the niche of the scar (ultrasound sign reported by Kaelin Agten et al.); according to the position of the center of the gestational sac it could be classified as implantation bellow the uterine midline (classification proposed by Timor-Tritsch et al.) (explanation in Discussion).

Figure 2

Cesarean scar pregnancy: A gestational sac (GS) containing an embryo with heart action and a crown–rump length (CRL) of 9.6 mm, which corresponded to 7 weeks and 1 day of gestation.