A Case of Complex CS Scar Ectopic

                                                                           MR/Nader Soliman        MR/Ahmed El Naggar       Miss/Nicole Pope

Objective: This case highlights the crucial importance of imaging in the diagnosis and management of Caesarean scar ectopic, MDT discussion ,the role of CT,MRI  in measuring the endometrial thickness , and whether there is myometrial/serosal  invasion as to aid in the management plan

Brief description of the case:P1,28 yrs ,Previous CS in Romania,12w pregnant 29/12/22 coming with PV bleeding and lower abdo pain,bhcg 2354, Us shows uterus contains heterogenous mass within  endometrial cavity, solid and cystic components seen, Solid component is likey possible fetalpole but is abnormal in appearance = 35x21mm, no fetal heartbeat seen.  Adjacent to this is a solid area which is infiltrating the endometrial cavity, demonstrates multiple cystic spaces = 49x13mm ?partial molar pregnancy,no vascularity seen,?complex RPOC,BHCG ON 31\12  2080,offered EVAC,Romanian language line used as pt doesn’t speak or understand English,EVAC done on 3\1\23 ,active bleeding during the procedure,us guidance ?CS scar ectopic,iv synto and txa given,rusch ballon  inflated with 45 mls inutero,bleeding settled ,EBL 100 MLS,iv atx,BHCG on 4\1 1200,us on 4\1 ?cs scar ectopic,MRI 5\1/23 HIGHLY SUSPISCIOUS OF MOLAR CS scar ectopic,loss of interface between anterior uterus&bladder,MDT with MRI gynaecology radiologist& Gyn oncologist at Sheffield GTN centrewho agreed with thesuggestion of CS scar pregnancy unlikely to be molar and these changes are related to the effect of balloon pressure, more than 50% of myometrium at CS scar involved by pregnancy tissue that might reach to bladder serosa,can wait for histopatholoigcal results of the tissues removed,plan was for methotrexate as per protocol,given on 6\1,bhcg on D 4 693 10/1,D7 465 13/ On 16\1 patient admitted with septicshock,tachycardia,hypotension,fever,CT scan was done showed 7.3x6x6.2cm gas and fluid containing collection within the endometrial cavity,admitted to ITU for 24hrs,on iv atx,bhcg on 16\1 235,then 100 on 18\1,pt improving,decision for conservative management not for laparotomy.On 23\1 BHCG 54 and discharged home,histology no molar pregnancy just RPOC.On 27\1 BHCG 53,US :anterior myometrium around the level of cs scar is bulky heterogenous hypervascular producing a mass 80x29x46 mm,plan was for weekly bhcg and repeat scan in 14 d.On 30/1 pt admitted via A&E with sepsis ,significant pv bleeding,decision was for stabilization and midline laparotomy,findings: Bulky uterus 12 weeks size,Caesarean scar ectopic occupying the entire scar is vascular and offensive +++,The caesarean scar ectopic was invading the myometrium and the serosa(confirmed by histology(percreta)),There was a loss of cleavage plane between the bladder and the lower segment with no recognizable U-V fold .Both tubes and ovaries normal.Very vascular and friable tissues.TAH+bilateral salpingectomy with ovarian conservation performed,bladder injury repaired by urology with bilateral ureteric stents,EBL 2 L,ITU admission,IV tx,4 units of PRBCS,stepdown care to the ward after 48hrs,pt recovering well

References:

-The American College of Obstetricians and Gynecologists (ACOG) and the Society of Family Planning endorse this document. The American Society for Reproductive Medicine supports this document. This document replaces SMFM Consult Series #49: Cesarean scar pregnancy (May 2020)

-RCOG GREEN TOP GUIDELINE 21 (2016)

-Cesarean Scar Ectopic Pregnancy: A Diagnostic and Management Challenge

Monitoring Editor: Alexander Muacevic and John R Adler

Koulshan Jameel,1 Gul-e-rana Abdul Mannan,1 Rabiya Niaz,1 and Durr-e-shahwar Hayat

Discussion

 Conclusion: It is clearly evident that management of CS scar ectopic should be individualized depending on the clinical presentation imaging, and it is very difficult to recommend either the medical versu