Management of a cesarean section scar niche ectopic Preeti Sandhu1 , Francisco Garcia Rocha1 , Veluppillai Vathanan1

 

40-year-old, BMI 22 • G4P1 • 1 x Medical Termination Of Pregnancy at 22/40 for foetal abnormality • 1 x Early Miscarriage - surgically managed • 1 x Cesarean section • Past Medical History: Sjogren’s syndrome • Drug History: Hydroxychloroquine Management of a cesarean section scar niche ectopic Preeti Sandhu1 , Francisco Garcia Rocha1 , Veluppillai Vathanan1 1 Wexham Park Hospital, Frimley Health Foundation Trust, UK Treatment Follow-up Early Pregnancy Unit Presentation • Attended with PV bleeding and abdominal pain at approximately 5/40 pregnancy • Had a TV US showing pregnancy at cesarean section scar site; Gestational Sac 4.8 x 3.7 x 5.1mm, Mean Sac Diameter 4.5mm, CRL 2.7mm, foetal heart rate seen • Repeat TV US 3 days later as per patient’s wishes – same findings (Figure 1) • Risks of continuing pregnancy discussed • Underwent ultrasound guided surgical evacuation of products of conception with less than 30ml blood loss • Discharged home same day as procedure Figure 1. TV US pre-op: Pregnancy located at caesarean section scar site Figure 2. TV US post-op: Measurements of cesarean section scar • TV US repeated 6 weeks after procedure mid-cycle to measure cesarean section scar • Myometrial scar thickness 3.2mm, niche measurement 4.9mm x 4mm (Figure 2) • As scar thickness >3mm, decision not for scar repair surgery Discussion • Cesarean niche can be defined as ‘indentation at the site of a cesarean section with depth of at least 2mm’ diagnosed on US1 • Osser2 et al found a 61% scar defect 6-9 months post-op. • Unclear cause, hypothesis include method of uterine closure and cervical tissue incision1 • Symptoms include postmenstrual spotting, secondary infertility and pain1 • No current agreed management guidelines Treatment options depending on myometrium thickness range from hormonal to surgery including hysteroscopic resection, laparoscopic repair and vaginal repair1 • Further studies are required to develop an evidence-based approach in managing cesarean section scar ectopic pregnancies.