A rare case report of heterotopic cesarean scar pregnancy in the 8th week of gestation that was managed successfully by exploratory laparotomy with dilation and curettage

Abstract

Key clinical message: Swift and precise identification of heterotopic cesarean scar pregnancy, coupled with standardized treatment approaches for handling possible serious complications, form an essential component in reaching favorable outcomes for patients experiencing this rare type of pregnancy.

Abstract: Heterotopic pregnancy (HP) denotes a form of multiple gestation where intrauterine and ectopic pregnancies coexist. Cesarean scar ectopic pregnancy, on the other hand, involves the implantation of a fetus over the previous cesarean scar. This condition poses a significant risk of uterine rupture, which may lead to serious health complications, and even death. We report a case of a fit 37-year-old woman with two previous cesarean deliveries who was diagnosed with a heterotopic cesarean scar pregnancy at 8 weeks gestation following symptoms of lower abdominal pain and delayed menstruation. Both pregnancies demonstrated cardiac activity and the portion of the myometrium located between the bladder wall and the gestational sac was noted to exhibit considerable thinness. The patient underwent an exploratory laparotomy coupled with dilation and curettage and recovered uneventfully. The proper management of a HCSP requires timely diagnosis through ultrasonography. Early diagnosis allows for immediate intervention to prevent complications such as uterine rupture or potentially lethal bleeding.

Keywords: dilation and curettage; heterotopic cesarean scar pregnancy; laparotomy; ultrasonography.

FIGURE 1

Dichorionic diamniotic pregnancy, with one sac implanted at the cesarean scar. Transvaginal ultrasonography; sagittal view showing two separate intrauterine gestational sacs with two yolk sacs and alive embryos; the upper twin (UT): normally implanted in the endometrial cavity; the lower twin (LT): abnormally implanted at the site of the previous cesarean section scar.

FIGURE 2

Magnified TVS sagittal view shows the ectopic gestational sac at the lower uterine segment at the site of the cesarean scar (CS) with a yolk sac (YS) and a fetal pole (FP) with cardiac activity and a crown‐rump length (CRL) of 1.38 cm with estimated gestational age (GA) of 7 weeks and 5 days. The ectopic gestational sac extends into the cesarean scar (CS), occupying more than one‐half thickness of the lower uterine segment. The overlying myometrium is thinned out (between cursors).

FIGURE 3

Transvaginal color Doppler ultrasonography shows rich vascularity at the implantation site of the lower twin within the previous cesarean scar.