Caesarean Scar Ectopic Pregnancy—A case report; Successfully managed with Medical Treatment

 

Objective:  To discuss medical treatment as a management option in  Caesarean scar ectopic pregnancy (CSEP) in a background of increasing number of cases and their serious consequences.

 

Case report:

25 years old G₄P₃ (Previous 3 lower segment Caesarean section (LSCS)) at 6⁺⁶ weeks of pregnancy presented with moderate vaginal bleeding associated with crampy abdominal pain. On admission, Transvaginal scan was done which revealed an intrauterine gestational sac embedded in the CS scar with a yolk sac, but no fetal pole. Patient’s  beta hCG was noted to be 5652 IU/L. Patient was vitally stable and bleeding had stopped , so initially a conservative management was planned with a repeat  scan and β-hCG in 48 hours which had dropped to 3261 IU/L when it was decided for methotrexate administration  which led to a further drop of β-hCG to 660 IU/L within 48 hrs. Patient was discharged home then and called for subsequent repeat β-hCG and scans. Her β-hCG had returned to normal within almost 5 weeks. Her recovery was uneventful.

Discussion:

CSEP can be defined as implantation into the myometrial defect caused by a previous uterine incision.

Prompt early diagnosis of CSEP is necessary to avoid the serious consequences including maternal bleeding and uterine rupture .¹

Due to the rarity of the condition, CSEPs are primarily documented through case reports or series, lacking consensus on optimal treatment. Tailored approaches are essential, considering factors like future fertility desire, gestational age, and hemodynamic stability. Treatment options encompass medical, uterine artery embolization (UAE), surgical, or combined modalities.¹

Conservative medical treatment is suitable for an asymptomatic patient, <8 weeks of gestation, with β-hCG levels <5000 and a myometrial thickness of <2 mm between the CSP and the bladder.²

 

Conclusion:

CSEP is a rare with variable presentation and challenging diagnosis that needs high suspicion and ultrasound expertise. Different treatment modalities can be used with this case report focussing on medical management as a treatment option.

References:

1.Morente, L. S., León, A. I. G., Reina, M. P. E., Herrero, J. R. A., Mesa, E. G., & López, J. S. J. (2021). Cesarean scar ectopic pregnancy-case series: Treatment decision algorithm and success with medical treatment. Medicina (Kaunas), 57(4), 362. https://doi.org/10.3390/medicina57040362

 

2. Zhuang, Y., & Huang, L. (2009). Uterine artery embolization compared with methotrexate for the management of pregnancy implanted within a cesarean scar. American Journal of Obstetrics & Gynecology. DOI: 10.1016/j.ajog.2009.04.038.