RARE PRESENTATION OF A RARE CASE: TYPE 2 CAESAREAN SCAR ECTOPIC PREGNANCY

Dr. Alisha Singh (Primary Author/Presenter), Dr. Sai Sruti, Dr. Ishita Sinha

 Introduction

Scar ectopic is the rarest form of ectopic pregnancy, but its diagnosis has been increasing worldwide. It is the abnormal implantation of embryo within the myometrium and fibrous tissue in a previous scar on uterus. Early and accurate diagnosis with timely management can prevent life threatening complications such as Hemorrhage and uterine rupture1. Exact mechanism is not known but thought to be due to migration of blastocyst through a wedge-shaped myometrial scar defect, a scar dehiscence or through a microscopic tract within the scar 2,3

Case

A 30-year-old G3P2+0 (previous 2 caesarean section) female with history of amenorrhea for 2 month (at home UPT twice negative) presented with painless bleeding and spotting for 14 days .

UPT Positive in OPD and beta hCG 1966mIU/ml

Management Diagnosis

The initial tool is USG (TVS) .The following signs would be present

MRI can also be used.

 Treatment

The best management for caesarean scar ectopic has not yet been defined. Medical management include systemic or local injection of methotrexate or KCl. Surgical management include Dilatation and curettage ( with or without hysteroscopy),UAE, excision of tissue by laparotomy or laparoscopy, Hysterectomy.Treatment for our patient consisted of Laparotomy. Intraoperatively, there was a soft, vascular mass of 3x3 cm seen at the site of previous scar. Scar excision and repair under spinal anesthesia was done with minimal intraoperative blood loss. Histopathology confirmed ectopic pregnancy

Discussion

With increasing caesarean section rates there has been increase in scar ectopic . It is approx.6% of all ectopic pregnancy in women with prior caesarean delivery and 0.15% in women with previous    caesarean 4,5,6 .The number has increased dramatically in last 20 years. 2 Types : 1. Implantation in the previous scar and progression towards cervicoisthmic  space or uterine cavity .Type 2: deep implantation with infiltrating growth into uterine serosa which could lead to uterine rupture and hemorrhage which could be fatal.

Conclusion

With higher rates of caesarean sections ,rarity of occurrence, risk of life-threatening complications ,difficulty in diagnosis and varied management, scar ectopic pregnancy becomes one of the important condition in modern day obstetrics.

 References